Court Opinion

ID: 9962116
Source: CourtListenerOpinion
Date Created: 2024-04-22 19:09:51.558935+00
Date Added: 2024-06-11T08:19:52.401345
License: Public Domain

[Cite as Horseman v. Mercy Health-Lorain Hosp., 2024-Ohio-1518.]

STATE OF OHIO                   )                       IN THE COURT OF APPEALS
                                )ss:                    NINTH JUDICIAL DISTRICT
COUNTY OF LORAIN                )

ZACHARY HORSEMAN                                        C.A. Nos.     22CA011894
                                                                      22CA011898
        Appellee

        v.
                                                        APPEAL FROM JUDGMENT
MERCY HEALTH-LORAIN HOSPITAL,                           ENTERED IN THE
et al.                                                  COURT OF COMMON PLEAS
                                                        COUNTY OF LORAIN, OHIO
        Appellants                                      CASE No.   19CV199157

                               DECISION AND JOURNAL ENTRY

Dated: April 22, 2024

        FLAGG LANZINGER, Judge.

        {¶1}    In Case No. 22CA011894, David M. Yin, M.D. appeals from the judgments of the

Lorain County Court of Common Pleas. In Case No. 22CA011898, Mercy Health – Regional

Medical Center, LLC dba Mercy Regional Medical Center (“Mercy Health”) appeals from the

same judgments. This Court consolidated the parties’ appeals for purposes of the record, oral

argument, and decision. For the following reasons, this Court reverses and remands the matter for

further proceedings.

                                                   I.

        {¶2}    This appeal involves a medical malpractice case that centered around whether Dr.

Yin, an emergency room physician at Mercy Health, breached the standard of care, and whether

such breach proximately caused the death of Carole Horseman. While the record in this case is

voluminous, this Court will limit its recitation of the facts and procedural history to those relevant

to the disposition of this appeal.
                                                  2

        {¶3}   The record reflects that Ms. Horseman had a history of chronic and severe neck

pain for which she received treatment. Relevant to this appeal, Ms. Horseman presented to the

emergency room at Mercy Health four times in early September 2018: once on September 7th,

once on September 9th, and twice on September 11th. On September 7th and 9th, Ms. Horseman

presented with complaints of neck pain. On September 11th, Ms. Horseman presented with

complaints of vomiting, nausea, and continued neck pain. Ms. Horseman was discharged after

each visit.

        {¶4}   On the morning of September 12, 2018, Ms. Horseman collapsed in her home while

getting dressed. Her son, Zachary Horseman, called 911. EMS transported Ms. Horseman to the

hospital, and she died that morning. An autopsy subsequently confirmed that Ms. Horseman died

of community-acquired MRSA pneumonia. The death certificate listed the “Approximate Interval

Onset and Death” as “DAYS[.]”

        {¶5}   Zachary Horseman (individually and in his capacity as the administrator of Ms.

Horseman’s estate) (“Plaintiff”) sued Mercy Health and Dr. Yin for wrongful death and

negligence. In short, Plaintiff alleged that Dr. Yin breached the standard of care by failing to order

certain tests that would have confirmed that Ms. Horseman had pneumonia and sepsis while she

was in the ER on September 11th, which could have been successfully treated with MRSA

antibiotics. Conversely, Dr. Yin argued that he did not breach the standard of care because there

was no indication that Ms. Horseman had pneumonia or sepsis (and, therefore, no reason to order

certain tests) while she was in the ER on September 11th, and that Ms. Horseman acquired MRSA

pneumonia after her discharge from the ER. Additionally, Dr. Yin argued that, even if Ms.

Horseman had been diagnosed with pneumonia and sepsis while in the ER, she would not have

survived.
                                                  3

        {¶6}    Relevant to this appeal, the record reflects that Plaintiff’s counsel filed motions in

limine two weeks before trial, including a motion in limine to exclude any evidence related to its

infectious disease expert, John J. Cascone, M.D.’s, history of substance abuse from 2009. Plaintiff

asserted that, in September 2010, the Missouri Board of Registration for the Healing Arts placed

Dr. Cascone’s medical license on probation, which ended in September 2014. Plaintiff asserted

that Dr. Cascone admitted to his past issues with substance abuse, and that it was not relevant to

his qualifications or bias in this case.

        {¶7}    Dr. Yin responded in opposition, arguing that Dr. Cascone’s past unlawful acts of

fraud and dishonesty that led to his medical license being put on probation directly related to his

credibility and character for truthfulness. Dr. Yin argued that this evidence was admissible under

Evid.R. 608(B) and that its probative value was not substantially outweighed by the danger of

unfair prejudice. As a result, Dr. Yin argued, he should be allowed to rely on such evidence to

impeach Dr. Cascone at trial. Dr. Yin also argued that Plaintiff’s assertions regarding Dr.

Cascone’s past substance abuse downplayed Dr. Cascone’s past misconduct, which–per publicly

available documents from the Missouri Division of Professional Registration and/or the Missouri

State Board of Registration for the Healing Arts–included: (1) possessing and using controlled

substances, including cocaine, methamphetamine, and other prescription drugs without a valid

prescription; (2) failure to “document the suppliers’ or recipients’ DEA number and date of receipt

on his controlled substances receipt records and did not maintain complete controlled substance

receipt records[;]” (3) failure to maintain a record of all controlled substances prescriptions; (4)

prescribing “controlled substances in the absence of good faith, in the absence of properly

established physician-patient relationship;” and (5) discovering in February 2008 that his wife

“had been purchasing controlled substances and billing them to his account[,]” but failing to
                                                  4

“report the loss or diversion” to the appropriate board. Dr. Yin also asserted that Dr. Cascone

violated the terms of his probation by using controlled substances and cocaine, which resulted in

further disciplinary action and an additional term of probation. Dr. Yin argued that “Dr. Cascone’s

misconduct regarding controlled substances and fraudulent record keeping practices is directly

relevant to his credibility, qualifications, and character for truthfulness as a purported medical

expert witness * * *.” (Emphasis omitted.) Dr. Yin also argued that the probative value of such

evidence was not substantially outweighed by the danger of unfair prejudice, and that the jury

should be permitted to evaluate the impeachment evidence and weigh Dr. Cascone’s testimony

accordingly.

        {¶8}    The trial court granted Plaintiff’s motion in limine regarding Dr. Cascone’s past

misconduct and licensure issues prior to trial without explaining its reasoning.

        {¶9}    Additionally, two weeks before the scheduled trial date, Dr. Yin filed numerous

motions in limine, including a motion in limine to exclude Dr. Cascone’s report and testimony

during Plaintiff’s case-in-chief at trial.1 Dr. Yin based his motion on the fact that Plaintiff only

identified Dr. Cascone as an expert after Dr. Yin had identified his experts, rendering Dr.

Cascone’s expert report untimely under the trial court’s scheduling order. Dr. Yin also based his

motion on the fact that neither the trial court’s scheduling order nor the court’s local rules provided

for rebuttal reports.

        1
        Several months before trial, the record also reflects that Dr. Yin moved to strike Dr.
Cascone’s expert report and to exclude Dr. Cascone from testifying at trial, which the trial court
denied.
                                                   5

            {¶10} Trial began as scheduled on March 28, 2022. According to Dr. Yin, the trial court

denied his motion in limine on the morning of the start of trial.2 Then, on the third day of trial,

prior to Plaintiff calling Dr. Cascone as a witness, Dr. Yin renewed his objection to Dr. Cascone

testifying during Plaintiff’s case-in-chief. Dr. Yin argued that Plaintiff “named Dr. Cascone late

as witness” and switched him from being its rebuttal witness, to being its sole case-in-chief

causation expert (as opposed to Plaintiff’s previously identified causation expert) on the first day

of trial. The trial court overruled Dr. Yin’s objection and permitted Dr. Cascone to testify during

Plaintiff’s case-in-chief as Plaintiff’s sole causation expert.

            {¶11}   Immediately prior to Plaintiff calling Dr. Cascone as a witness, defense counsel

proffered the fact Dr. Cascone “lost his license3 due to the reasons that were set forth in our

motions, back from 2009 to 2012, for narcotics issues, substance abuse issues, and then the three-

year probation.” The trial court noted defense counsel’s objection to its ruling on Plaintiff’s motion

in limine regarding Dr. Cascone’s past substance abuse and licensure issues but concluded that it

would not allow defense counsel to cross-examine Dr. Cascone regarding those issues.

            {¶12} With that procedural history in mind, we now turn to some of the testimony adduced

at trial.

          Dr. Yin has not directed this Court to the portion of the record containing the trial court’s
            2

ruling in this regard on the morning of the start of trial. See App.R. 16(A)(7). Presumably, the
trial court’s ruling occurred off the record. The record reflects that the trial court journalized its
ruling on Dr. Yin’s pre-trial motions in limine on April 5, 2022 (i.e., while the trial was still in
process and after Dr. Cascone had testified on March 30, 2022). In doing so, the trial court held
that “Defendant Yin’s motion in limine to exclude testimony of Dr. John Cascone is denied. The
rebuttal report was timely in light of the circumstances.”
        3
          On appeal, the parties do not dispute that Dr. Cascone’s license was put on probation, not
“lost[.]”
                                                   6

                                        Dr. Yin’s Testimony

        {¶13} At trial, Plaintiff called Dr. Yin (as on cross-examination) as a witness. Dr. Yin

testified that Ms. Horseman presented to the ER on September 11, 2018, around 9:00 a.m. with

complaints of nausea, vomiting, and continued neck pain. Dr. Yin testified that he examined Ms.

Horseman, and that she presented with no cough or fever, and that her lung exam was

“[c]ompletely normal.” After examining her, Dr. Yin gave Ms. Horseman fluids, a muscle

relaxant, and an anti-inflammatory medication. Dr. Yin also entered certain orders, including an

order for bloodwork and a CAT scan of Ms. Horseman’s neck. The bloodwork was completed

within an hour and showed that Ms. Horseman had an elevated white blood cell count of 15.9 (i.e.,

15,900).

        {¶14} Plaintiff’s counsel questioned Dr. Yin regarding the Systemic Inflammatory

Response Syndrome (“SIRS”) criteria utilized at Mercy Health, which is used for evaluating

whether a patient may be septic. The SIRS criteria utilized at Mercy Health include: (1) a

respiratory rate of greater than or equal to 204; (2) a white blood cell count over 12; (3) a fever

over 100.4 degrees; and (4) a heart rate over 90. Dr. Yin acknowledged that the medical records

indicate that if a patient meets two of the four SIRS criteria and there is a suspicion for an infection,

then the patient is presumed to be septic. Dr. Yin also acknowledged that Mercy Health’s

electronic records system displays best practice advisory alerts (“BPAs”) when a patient meets the

SIRS criteria, which alert providers that a patient “may be septic.” Dr. Yin further acknowledged

that Ms. Horseman met two of the four SIRS criteria (i.e., white blood cell count over 12 and a

        4
        Dr. Yin maintained that the SIRS criteria generally include a respiratory rate of over 20,
but acknowledged that the SIRS criteria utilized at Mercy Health includes greater than or equal to
20. He also acknowledged that, even without considering Ms. Horseman’s respiratory rate, she
otherwise met at least two of the SIRS criteria during each visit on September 11th.
                                                  7

heart rate over 90), and that he received BPAs indicating that she “may be septic” during her first

visit to the ER on September 11th.

       {¶15} Dr. Yin testified that Ms. Horseman responded well to the pain medication and was

discharged from the ER on September 11th around 11:30 a.m. While waiting for a ride home, Ms.

Horseman complained that she felt dizzy and like she was going to “pass out[.]” Ms. Horseman

was then re-admitted to the ER, and Dr. Yin examined her again.

       {¶16} During the second visit, Ms. Horseman presented with a flat affect and three out of

the four SIRS criteria, i.e., an elevated heart rate, respiratory rate, and white blood cell count. Dr.

Yin ordered Ms. Horseman pain medication, fluids, and anti-nausea medication, and diagnosed

her with dizziness. Dr. Yin acknowledged that he received BPAs indicating that Ms. Horseman

may be septic at 2:34 p.m. during her second visit to the ER on September 11th, and that he

discharged her from the ER around the same time. Dr. Yin also acknowledged that a nurse took

Ms. Horseman’s vitals at discharge (around 3:00 p.m.), and that Ms. Horseman continued to have

three out of the four SIRS criteria at that time. Dr. Yin testified that he called Ms. Horseman after

her discharge (possibly around 6:00 p.m.), and that Ms. Horseman told him she felt much better.

Dr. Yin acknowledged, however, that there was no record of that phone call.

       {¶17} When questioned by his own counsel on direct examination, Dr. Yin explained that

Ms. Horseman denied having any cough, shortness of breath, or chest pain on September 11th, and

that he examined her lungs, which were normal. Dr. Yin also explained that Ms. Horseman

presented with no signs or symptoms of an infection during her first or second visit to the ER on

September 11th, and that Ms. Horseman had no physical findings of pneumonia. Dr. Yin further

explained that BPAs are “merely suggestions[,]” and that when he received them for Ms.

Horseman, his job was to “reassess the patient and dive further[,]” which he did. Dr. Yin explained
                                                  8

that Ms. Horseman’s SIRS criteria (i.e., her elevated white blood cell count, respiratory rate, and/or

heart rate) could be explained by causes other than an infection, such as Ms. Horseman’s

medications, pain, anxiety, COPD, history of smoking, and/or her recent steroid use. Dr. Yin

explained that he, therefore, ruled out the possibility of an infection based upon Ms. Horseman’s

history and physical exams. Dr. Yin ultimately opined that he met the standard of care.

       {¶18} When cross-examined by Plaintiff’s counsel, Dr. Yin acknowledged that medical

literature advises that, if a patient meets two SIRS criteria plus there is a suspicion of infection,

then providers should consider a chest x-ray. Dr. Yin also acknowledged that he did not order a

chest x-ray for Ms. Horseman on September 11th.

                                   Plaintiff’s Expert Testimony

       {¶19} Plaintiff presented testimony from Richard Zane, M.D., an emergency medicine

physician, who opined that Dr. Yin failed to meet the standard of care on September 11, 2018. Dr.

Zane explained that, if a patient (like Ms. Horseman) meets the SIRS criteria, then the next step is

to consider whether there is an infectious source for those criteria. Dr. Zane explained that, if an

infectious source cannot be ruled out, then the next step is to treat the patient as though they have

sepsis, or to perform more tests. Dr. Zane opined that a reasonably skilled, prudent emergency

room doctor presented with Ms. Horseman’s circumstances should have suspected an infection

and either treated Ms. Horseman as though she had sepsis or should have ordered a lactate test

(which is a blood test) and a chest x-ray, which Dr. Yin failed to do. Dr. Zane explained that if

either the lactate was elevated or the chest x-ray showed pneumonia, the next step would be to

administer antibiotics. Dr. Zane also explained that, if a patient does not improve after receiving

antibiotics, then the patient “can’t go home.”
                                                9

       {¶20} Additionally, Dr. Zane explained that the fact that Dr. Yin documented a normal

chest exam on physical examination did not change his opinion because patients presenting with

normal chest exams can still have pneumonia. Dr. Zane also explained that, while there could be

reasonable, non-sepsis explanations for certain symptoms, taken together in Ms. Horseman’s case,

“you must consider sepsis.”

       {¶21} On cross-examination, Dr. Zane acknowledged that he was not offering an opinion

as to what a chest x-ray or lactate test would have shown had they been performed on September

11th; he was only opining that the standard of care required Dr. Yin to order those tests. Dr. Zane

also acknowledged that he did not know whether Ms. Horseman would have survived had she been

admitted to the hospital on September 11th and treated for pneumonia.

       {¶22} Plaintiff also presented expert testimony from Dr. Cascone, an internal medicine

and infectious disease specialist, as the causation expert. Dr. Cascone opined that Ms. Horseman

had pneumonia and sepsis when she presented to the ER on September 11th. Dr. Cascone opined

that, if Dr. Yin had ordered a chest x-ray, it would have shown pneumonia on September 11th. Dr.

Cascone explained that Ms. Horseman would have then been admitted to the hospital and treated

with penicillin-like antibiotics, that she would have continued to decline, and that she would have

then been treated with MRSA antibiotics, such as Vancomycin. Dr. Cascone opined that, had Ms.

Horseman been admitted to the hospital and treated with MRSA antibiotics, she would have

survived.

       {¶23} During his testimony, Dr. Cascone indicated that he agreed with the death

certificate indicating that Ms. Horseman’s cause of death was acute bronchopneumonia, and that

the “Approximate Interval Onset and Death” was “DAYS[.]” Dr. Cascone explained that the
                                                  10

autopsy report showed an overwhelming MRSA infection that went untreated in Ms. Horseman’s

lungs, spread into her blood, and then spread to the rest of her body, which caused her death.

                                    Dr. Yin’s Expert Testimony

       {¶24} Dr. Yin, on the other hand, presented testimony from Michael Dick, M.D., an

emergency medicine physician, who opined that Ms. Horseman did not have pneumonia and was

not septic during her ER visits on September 11th, and that Dr. Yin met the standard of care. Dr.

Dick explained that Ms. Horseman had no signs or symptoms consistent with pneumonia or an

infection, and that nothing in Ms. Horseman’s history or on her physical exam would have required

Dr. Yin to obtain a chest x-ray or order a lactate test.

       {¶25} On cross-examination, Plaintiff’s counsel asked Dr. Dick whether it was a

coincidence that Ms. Horseman died of MRSA pneumonia 20 hours after her discharge from the

ER. Dr. Dick responded that there were alternative, appropriate explanations for Ms. Horseman’s

symptoms, and that Ms. Horseman did not have pneumonia or sepsis while in the ER on September

11th. Regarding the BPAs, Dr. Dick explained that they “did not apply because [Ms. Horseman]

did not have an indication of infection * * *.”

       {¶26} Dr. Yin also presented testimony from Marin Kollef, M.D., a pulmonary critical

care specialist, who opined that Dr. Yin met the standard of care. Dr. Kollef explained that nothing

required Dr. Yin to order a chest x-ray or lactate test, and that–even if he had–those results would

have been normal (except for signs of emphysema on the x-ray). Dr. Kollef explained that there

was nothing to indicate that Ms. Horseman had pneumonia, an infection, or sepsis while at the ER

on September 11th, and that Dr. Yin should not have suspected pneumonia or sepsis. Dr. Kollef

opined that the MRSA pneumonia occurred after Ms. Horseman left the ER on September 11th,

and the fact that she had been in the ER the day prior to her death was a “coincidence[.]” In doing
                                                11

so, Dr. Kollef disagreed with the death certificate indicating that the interval from onset to death

was “DAYS[.]” Dr. Kollef also opined that nothing Dr. Yin did or did not do proximately caused

Ms. Horseman’s death, and that Ms. Horseman would have died whether she had been admitted

to the hospital on September 11th or not.

       {¶27} Lastly, Dr. Yin presented testimony from Robert Citronberg, M.D., an infectious

disease physician, who opined that Ms. Horseman did not have pneumonia or sepsis while in the

ER on September 11th. Dr. Citronberg explained that Ms. Horseman had no signs or symptoms

of pneumonia on September 11th, and that it would be “virtually impossible” not to have signs or

symptoms of pneumonia at the time of presentation. Dr. Citronberg also explained that, while Ms.

Horseman met the SIRS criteria, the most important part of diagnosing sepsis is a known or

suspected infection, neither of which Ms. Horseman had on September 11th. Dr. Citronberg

explained that, even if admitted to the hospital, patients with community-acquired pneumonia with

no MRSA risk factors (like Ms. Horseman) would not initially be treated with MRSA antibiotics.

Dr. Citronberg explained that MRSA can cause death within hours and opined that–even if Ms.

Horseman would have been admitted to the hospital–she would not have survived.

       {¶28} Additionally, like Dr. Kollef, Dr. Citronberg testified that Ms. Horseman’s

pneumonia began after she was discharged from the ER on September 11th. He testified that,

while he agreed with the coroner’s conclusion that Ms. Horseman died of community-acquired

MRSA pneumonia, he disagreed with the conclusion that the interval between onset and death was

“DAYS[.]” On cross-examination, Dr. Citronberg admitted that part of his opinion was based

upon Dr. Yin’s claim that he called Ms. Horseman after her discharge from her ER, and that Ms.

Horseman told Dr. Yin that she was doing better.
                                                  12

                                         The Jury’s Verdict

          {¶29} Six of the eight jurors ultimately returned a verdict in favor of Plaintiff, awarding

$6.5 million in damages. In the jury interrogatories, the jury indicated that: (1) it found Dr. Yin

negligent by a preponderance of the evidence by “[i]gnoring the BPAs and not ordering the chest

x-ray and lactase [sic] tests[;]” (2) it found by a preponderance of the evidence that Dr. Yin’s

negligence proximately caused Ms. Horseman’s death; and (3) Ms. Horseman’s two adult children

were entitled to $500,000 each for the loss of services and society of their mother suffered to date,

$500,000 each for mental anguish suffered to date, $1,750,000 each for the loss of services and

society of their mother likely to be suffered in the future, and $500,000 each for mental anguish

likely to be suffered in the future.

          {¶30} After the trial, Dr. Yin and Mercy Health (collectively, “Defendants”) moved for a

new trial or, in the alternative, for judgment notwithstanding the verdict, which the trial court

denied.

                                          Issues on Appeal

          {¶31} On appeal, Dr. Yin and/or Mercy Health challenge numerous rulings by the trial

court, including the trial court’s decision to: (1) allow Dr. Cascone to testify during Plaintiff’s

case-in-chief; (2) prevent Dr. Yin from impeaching Dr. Cascone with certain evidence; (3)

preclude Dr. Yin from presenting evidence or referencing the “many suspect circumstances

surrounding” Ms. Horseman’s death; (4) instruct the jury that Mercy Health had stipulated that it

was responsible for the conduct of Dr. Yin; and (5) deny Dr. Yin’s motion for directed verdict and

judgment notwithstanding the verdict. Dr. Yin and/or Mercy Health also challenge the weight and

sufficiency of the evidence, as well as the amount of the jury’s damages award. Lastly, Defendants

argue that the cumulative effect of the trial court’s errors warrants a new trial. This Court will
                                                 13

address Dr. Yin’s third assignment of error and Mercy Health’s second assignment of error

together, and first.

                                                 II.

                            DR. YIN’S ASSIGNMENT OF ERROR III

        THE TRIAL COURT ABUSED ITS DISCRETION IN PREVENTING DR. YIN
        FROM IMPEACHING PLAINTIFF’S REBUTTAL EXPERT, DR. CASCONE,
        WITH EVIDENCE OF HIS PAST UNLAWFUL ACTS OF FRAUD,
        DISHONESTY AND DECEIT.

                       MERCY HEALTH’S ASSIGNMENT OF ERROR II

        THE TRIAL COURT ERRED WHEN IT EXCLUDED EVIDENCE RELEVANT
        TO THE CREDIBILITY, BIAS, AND WEIGHT OF DR. CASCONE AND HIS
        OPINIONS, SPECIFICALLY DR. CASCONE’S PAST UNLAWFUL ACTS OF
        FRAUD, DISHONESTY, AND DECEIT–IN CONNECTION WITH HIS
        MEDICAL PRACTICE–WHICH LED TO (AMONG OTHER THINGS) A
        THREE-YEAR HIATUS FROM PRACTICING MEDICINE AND THE
        PROBATION OF HIS MEDICAL LICENSE FOR SEVERAL YEARS.

        {¶32} In Dr. Yin’s third assignment of error and Mercy Health’s second assignment of

error, Defendants argue that the trial court erred by preventing Dr. Yin from impeaching Dr.

Cascone with evidence regarding Dr. Cascone’s past misconduct, which led to the probation of his

medical license. In support of their argument, Defendants rely, in part, on Evid.R. 608(B). In

response, Plaintiff argues that this evidence was not admissible under Evid.R. 608(B) and that,

even if it was, any relevance was substantially outweighed by the danger of unfair prejudice. For

the following reasons, this Court determines that Dr. Yin’s third assignment of error and Mercy

Health’s second assignment of error have merit.

        {¶33} Evid.R. 608(B) provides:

        Specific Instances of Conduct. Specific instances of the conduct of a witness, for
        the purpose of attacking or supporting the witness’s character for truthfulness, other
        than conviction of crime as provided in Evid.R. 609, may not be proved by extrinsic
        evidence. They may, however, in the discretion of the court, if clearly probative of
        truthfulness or untruthfulness, be inquired into on cross-examination of the witness
                                                14

       (1) concerning the witness’s character for truthfulness or untruthfulness, or (2)
       concerning the character for truthfulness or untruthfulness of another witness as to
       which character the witness being cross-examined has testified.

       {¶34} Regarding Evid.R. 403(A), this Court has explained:

       Evidence that falls within the scope of Evid.R. 608(B) is subject to Evid.R. 403(A),
       which provides that “[a]lthough relevant, evidence is not admissible if its probative
       value is substantially outweighed by the danger of unfair prejudice, of confusion of
       the issues, or of misleading the jury.” * * * The exclusion of relevant evidence
       under Evid.R. 403(A) rests within the discretion of the trial court. * * * When
       considering a trial court’s decision to exclude evidence under Evid.R. 403(A), this
       Court is “mindful that ‘the exclusion of evidence under Evid.R. 403(A) is even
       more of a judgment call than determining whether the evidence has logical
       relevance in the first place.’”

State v. Vugrinovich, 9th Dist. Medina No. 19CA0067-M, 2020-Ohio-3541, ¶ 22.

       {¶35} “Given the broad discretion accorded to trial courts to admit or exclude evidence,

this Court ‘will not disturb evidentiary rulings absent an abuse of discretion ‘that produced a

material prejudice’ to the aggrieved party.’” Somerick v. YRC Worldwide Inc., 9th Dist. Summit

No. 29239, 2020-Ohio-2916, ¶ 6, quoting In re I.W., 9th Dist. Wayne Nos. 07CA0056 and

07CA0057, 2008-Ohio-2492, ¶ 8. An abuse of discretion is more than an error of judgment; it

means that the trial court was unreasonable, arbitrary, or unconscionable in its ruling. Blakemore

v. Blakemore, 5 Ohio St.3d 217, 219 (1983). When applying the abuse of discretion standard, an

appellate court may not substitute its judgment for that of the trial court. Pons v. Ohio State Med.

Bd., 66 Ohio St.3d 619, 621 (1993). “Material prejudice exists when, after weighing the prejudicial

effect of the errors, the reviewing court is unable to find that without the errors the fact finder

would probably have reached the same decision.” In re Moore, 9th Dist. Summit No. 19217, 1999

WL 1215294, *17 (Dec. 15, 1999); Estate of Cushing v. Kuhns, 9th Dist. Lorain No. 97CA006981,

1999 WL 74626, *3 (Feb. 9, 1999).
                                                 15

       {¶36} Even if a trial court makes an improper evidentiary ruling, such ruling “constitutes

reversible error only when the error affects the substantial rights of the adverse party or the ruling

is inconsistent with substantial justice.” Beard v. Meridia Huron Hosp., 106 Ohio St.3d 237, 2005-

Ohio-4787, ¶ 35. “Generally, in order to find that substantial justice has been done to [a party] so

as to prevent reversal of a judgment for errors occurring at the trial, the reviewing court must not

only weigh the prejudicial effect of those errors but also determine that, if those errors had not

occurred, the jury or other trier of the facts would probably have made the same decision.”

(Alteration sic.) Id., quoting O’Brien v. Angley, 63 Ohio St.2d 159, 164-165 (1980).

       {¶37} As discussed above, the record reflects that Plaintiff’s counsel filed motions in

limine two weeks before trial, including a motion in limine to exclude any evidence of Dr.

Cascone’s history of substance abuse and related probation of his medical license. Dr. Yin

responded in opposition, arguing that Dr. Cascone’s past unlawful acts directly related to his

credibility and character for truthfulness, and that he should be allowed to rely on such evidence

to impeach Dr. Cascone at trial. Specifically, Dr. Yin pointed to the following misconduct: (1)

possessing and using controlled substances, including cocaine, methamphetamine, and other

prescription drugs without a valid prescription; (2) failure to “document the suppliers’ or

recipients’ DEA number and date of receipt on his controlled substances receipt records and did

not maintain complete controlled substance receipt records[;]” (3) failure to maintain a record of

all controlled substances prescriptions; (4) prescribing “controlled substances in the absence of

good faith, in the absence of properly established physician-patient relationship;” and (5)

discovering in February 2008 that his wife “had been purchasing controlled substances and billing

them to his account[,]” but failing to “report the loss or diversion” to the appropriate board. In

support of his argument, Dr. Yin relied, in part, on Evid.R. 608(B). As noted, the trial court granted
                                                 16

Plaintiff’s motion in limine regarding Dr. Cascone’s past misconduct prior to trial without

explaining its reasoning.

       {¶38} At trial, immediately prior to Plaintiff calling Dr. Cascone as a witness, defense

counsel proffered the fact Dr. Cascone “lost his license due to the reasons that were set forth in

our motions, back from 2009 to 2012, for narcotics issues, substance abuse issues, and then the

three-year probation.” In addressing the issue, the trial court stated:

       With respect to his treatment for substance abuse, I mean, that’s an issue that the
       Courts deal with in all kinds of – in all kinds of cases, and we’re trying to help
       people rehabilitate themselves and get themselves back as productive citizens. For
       that reason, the fact that he had difficulty with substance abuse, I’ve already ruled
       that that would not be something we would discuss. And the fact that that affected
       his license prior to his review of anything in this case, I think – would be unfairly
       prejudicial, and we’re not going to get into the fact that he did not have a license
       for a period of a few years because that was entirely related to his treatment for
       substance abuse. And that would just allow you to open that door, and I’ve said
       that that would be unfairly prejudicial.

       Had this been a situation where the expert was reviewing and coming up with his
       opinion in the midst of substance abuse treatment, then I might have a different
       feeling about his credibility as a witness, because it might have affected his
       judgment. But there being no – we’re not getting into that at this point. This is
       something he dealt with in the past, and I just think it would be inappropriate.

       {¶39} Defense counsel then reminded the trial court that the “loss” of Dr. Cascone’s

license for three years was for recordkeeping issues. The trial court responded:

       I understood that the link to the recordkeeping may have been related to his
       substance abuse at the time[.] * * * I saw it all as once we * * * open that door, it’s
       a mess, and I think it’s unfairly prejudicial.

       {¶40} The trial court did not cite an evidentiary rule when making its ruling. The trial

court’s language regarding the evidence being “unfairly prejudicial[,]” however, indicates that the

trial court relied–at least in part–upon Evid.R. 403(A).

       {¶41} Consistent with the trial court’s ruling, defense counsel did not question Dr.

Cascone about his prior license probation and disciplinary history during cross-examination.
                                                 17

During his direct examination, however, Dr. Cascone testified regarding his training, education,

and experience as a medical doctor.

       {¶42} This Court concludes that the trial court abused its discretion by precluding defense

counsel from cross-examining Dr. Cascone regarding the fact that his medical license had been

put on probation for a period of time. “Courts have found that a physician-witness’s licensure is

a matter that affects the weight to be given to their testimony.” Cleveland v. St. Elizabeth Health

Ctr., 7th Dist. Mahoning No. 10-MA-151, 2012-Ohio-1472, ¶ 50 (addressing Evid.R. 601); see

State v. Awkal, 76 Ohio St.3d 324, 332 (1996) (acknowledging that an expert’s licensure goes to

the weight of the expert’s testimony). When a medical expert testifies as to his training, education,

and experience, the expert is “building up his credentials in front of the jury so that, presumably,

they would give more weight to his medical opinion * * *.” Id. at ¶ 49. As a result, that expert

puts his professional credentials at issue, and a trial court should allow that expert to be cross-

examined regarding certain licensure issues. Id. Otherwise, the jury is given “the impression that

his professional credentials were untarnished when this was not the case.” Id. While “counsel

cannot challenge a witness’s credibility with evidence of bad moral character[,] * * * [c]ounsel

may, however, impeach a witness on cross-examination by questions about prior misconduct

which relate directly to truthfulness.” Weidner v. Blazic, 98 Ohio App.3d 321, 327 (12th

Dist.1994), citing State v. Shields, 15 Ohio App.3d 112, 113 (8th Dist.1984) and Evid.R. 608(B).

       {¶43} Here, the trial court emphasized the fact that Dr. Cascone’s license probation

related to his issues with substance abuse, and that courts are “trying to help people rehabilitate

themselves and get themselves back as productive citizens.” The trial court stated that, “[f]or that

reason, the fact that [Dr. Cascone] had difficulty with substance abuse, I’ve already ruled that that

would not be something we would discuss[,]” and later concluded that such evidence would be
                                                18

“inappropriate.” But that is not the standard under Evid.R. 403(A), nor does it account for the

other misconduct that led to Dr. Cascone’s license probation (e.g., his problematic recordkeeping).

       {¶44} While drug use does not necessarily affect a witness’s character for truthfulness,

the probation of an expert witness’s medical license due to deceptive and/or dishonest acts is

probative of that witness’s character for truthfulness and is admissible under Evid.R. 608(B). State

v. Everson, 7th Dist. Mahoning No. 12 MA 128, 2016-Ohio-87, ¶ 35 (“Drug use does not

necessarily affect a witness’s character for truthfulness” for purposes of Evid.R. 608(B)); see

Weidner at 327-328. Additionally, while the trial court did note that evidence of Dr. Cascone’s

license probation would be unfairly prejudicial, it provided no analysis as to whether the danger

of unfair prejudice “substantially outweighed” any probative value of that evidence under Evid.R.

403(A). See Haynal v. Nordonia Hills City School Dist. Bd. of Edn., 9th Dist. Summit No. 25242,

2011-Ohio-3191, ¶ 17 (concluding, in part, that the trial court misapplied Evid.R. 403(A) because

the trial court never concluded that the danger of unfair prejudice substantially outweighed the

probative value of the evidence).

       {¶45} As noted, an expert’s licensure is a matter that affects the weight of the expert’s

testimony. St. Elizabeth Health Ctr. at ¶ 50. This case hinged upon which set of experts the jury

chose to believe, yet Dr. Cascone was able to “give the jury the impression that his professional

credentials were untarnished when this was not the case.” Id. at ¶ 49. Given the facts of this case,

had the trial court allowed defense counsel to cross-examine Dr. Cascone regarding his past

licensure issues, this evidence may have affected the weight the jury gave to Dr. Cascone’s medical

opinions and–in turn–the outcome of the case. Id. at ¶ 51, 53 (holding that the trial court abused

its discretion by not allowing the defendant/medical expert to be cross-examined regarding certain

licensure issues, which could have affected the weight the jury gave to his medical opinions); see
                                                   19

Weidner 98 Ohio App.3d at 328 (holding that the trial court did not err by allowing plaintiff’s

counsel to cross-examine the defendant/dentist regarding his probationary status with the Ohio

State Dental Board). As a result, the trial court committed reversible error by precluding defense

counsel from cross-examining Dr. Cascone regarding his past licensure issues. See Beard, 2005-

Ohio-4787, at ¶ 35 (explaining that an improper evidentiary ruling “constitutes reversible error

only when the error affects the substantial rights of the adverse party or the ruling is inconsistent

with substantial justice.”). Dr. Yin’s third assignment of error and Mercy Health’s second

assignment of error are sustained on that basis.

                            DR. YIN’S ASSIGNMENT OF ERROR I

       THE TRIAL COURT ERRED IN ALLOWING PLAINTIFF TO CALL HIS
       REBUTTAL EXPERT, DR. JOHN CASCONE, IN HIS CASE-IN-CHIEF.

                            DR. YIN’S ASSIGNMENT OF ERROR II

       THE TRIAL COURT ERRED IN DENYING DR. YIN’S MOTIONS FOR
       DIRECTED VERDICT AND JUDGMENT NOTWITHSTANDING THE
       VERDICT.

                           DR. YIN’S ASSIGNMENT OF ERROR IV

       THE TRIAL COURT ABUSED ITS DISCRETION IN PRECLUDING DR. YIN
       FROM PRESENTING RELEVANT EVIDENCE AND/OR REFERENCING
       THE MANY SUSPECT CIRCUMSTANCES SURROUNDING DECEDENT’S
       DEATH.

                            DR. YIN’S ASSIGNMENT OF ERROR V

       THE TRIAL COURT ABUSED ITS DISCRETION BY INFORMING AND
       INSTRUCTING THE JURY ON CO-DEFENDANT MERCY HEALTH’S
       STIPULATION OF AGENCY BY ESTOPPEL WITH RESPECT TO DR. YIN’S
       CARE OF DECEDENT.

                           DR. YIN’S ASSIGNMENT OF ERROR VI

       THE JURY’S VERDICT WAS AGAINST THE MANIFEST WEIGHT OF THE
       EVIDENCE.
                                               20

                         DR. YIN’S ASSIGNMENT OF ERROR VII

       THE JURY RETURNED AN EXCESSIVE VERDICT THAT WAS CLEARLY
       RENDERED UNDER THE INFLUENCE OF PASSION AND PREJUDICE AND
       WAS PUNITIVE ON ITS FACE.

                         DR. YIN’S ASSIGNMENT OF ERROR VIII

       THE CUMULATIVE EFFECT OF THE TRIAL COURT’S ERRORS DENIED
       DR. YIN A FAIR TRIAL.

                      MERCY HEALTH’S ASSIGNMENT OF ERROR I

       THE TRIAL COURT ERRED WHEN IT ALLOWED PLAINTIFF TO UTILIZE
       JOHN CASCONE, M.D. AS A “REBUTTAL” EXPERT AND FURTHER
       ERRED WHEN, ON THE FIRST DAY OF TRIAL, THE TRIAL COURT
       ALLOWED DR. CASCONE TO TESTIFY IN PLAINTIFF’S CASE-IN-CHIEF
       AND SERVE AS PLAINTIFF’S SOLE CAUSATION EXPERT.

                     MERCY HEALTH’S ASSIGNMENT OF ERROR III

       THE TRIAL COURT ERRED WHEN IT EXCLUDED EVIDENCE AND/OR
       REFERENCE TO MS. HORSEMAN’S NARCOTIC PRESCRIPTIONS AND
       THE CIRCUMSTANCES SURROUNDING HER DEATH.

                     MERCY HEALTH’S ASSIGNMENT OF ERROR IV

       THE JURY’S VERDICT IS AGAINST THE SUFFICIENCY AND MANIFEST
       WEIGHT OF THE EVIDENCE BECAUSE PLAINTIFF’S SOLE STANDARD
       OF CARE EXPERT, DR. ZANE, DID NOT TESTIFY THAT THE STANDARD
       OF CARE REQUIRED DR. YIN TO PRESCRIBE MRSA-FIGHTING
       MEDICATION TO MS. HORSEMAN–WHICH WAS A CRITICAL ASPECT TO
       PLAINTIFF’S CAUSATION THEORY.

                     MERCY HEALTH’S ASSIGNMENT OF ERROR V

       A NEW TRIAL SHOULD BE GRANTED PURSUANT TO THE CUMULATIVE
       ERROR DOCTRINE.

       {¶46} In light of this Court’s disposition of Dr. Yin’s third assignment of error and Mercy

Health’s second assignment of error, the remaining assignments of error are moot and are

overruled on that basis. See App.R. 12(A)(1)(c).
                                                21

                                                III.

       {¶47} Dr. Yin’s third assignment of error in Case No. 22CA011894 and Mercy Health’s

second assignment of error in Case No. 22CA011898 are sustained. The remaining assignments

of error are overruled on the basis that they are moot. The judgment of Lorain County Court of

Common Pleas is reversed, and the matter is remanded for further proceedings.

                                                                               Judgment reversed,
                                                                              and cause remanded.

       There were reasonable grounds for this appeal.

       We order that a special mandate issue out of this Court, directing the Court of Common

Pleas, County of Lorain, State of Ohio, to carry this judgment into execution. A certified copy of

this journal entry shall constitute the mandate, pursuant to App.R. 27.

       Immediately upon the filing hereof, this document shall constitute the journal entry of

judgment, and it shall be file stamped by the Clerk of the Court of Appeals at which time the period

for review shall begin to run. App.R. 22(C). The Clerk of the Court of Appeals is instructed to

mail a notice of entry of this judgment to the parties and to make a notation of the mailing in the

docket, pursuant to App.R. 30.

       Costs taxed to Appellee.

                                                       JILL FLAGG LANZINGER
                                                       FOR THE COURT

HENSAL, P. J.
STEVENSON, J.
CONCUR.
                                          22

APPEARANCES:

RYAN K. RUBIN, Attorney at Law, for Appellant.

DOUGLAS G. LEAK, Attorney at Law, for Appellant.

DIRK E. RIEMENSCHNEIDER and FRED A. HILOW, Attorneys at Law, for Appellant.

JUSTIN S. GREENFELDER, Attorney at Law, for Appellant.

DENNIS R. LANSDOWNE and DUSTIN B. HERMAN, Attorneys at Law, for Appellee.