Court Opinion

ID: 9546948
Source: CourtListenerOpinion
Date Created: 2023-08-07 17:38:28.941756+00
Date Added: 2024-06-11T15:17:05.010248
License: Public Domain

BISTLINE, Justice,
specially concurring.
I
Chief Justice Bakes in dissent claims that there was not a sufficient foundation for Dr. Friedman’s testimony because “[a] careful review of Dr. Friedman’s testimony ... demonstrates that Dr. Friedman did not establish the Handbook of Standards for ob-gyn doctors required either a biomedical profile or an ultrasound in cases of suspected macrosomia.”
In support of that statement, it is argued that “there was never any testimony ... that the Handbook of Standards even addressed biophysical profiles.” However, Dr. Rufi stated that the local standard of care, with one minor exception, was the same as the national standard of care. He also testified that the national standard was set out in the Handbook.
Q. Do you believe you have knowledge of what the local standard of practice for board certified obstetricians and gynecologists was in 1985 in Pocatello?
A. Yes.
Q. You obviously got that by practicing here.
A. Right.
Q. And you are also a board certified specialist and you are supposed to be familiar with the national standards of people who have your certification.
A. Yes.
Q. And are you?
A. Yes.
Q. In relation to the local standard of practice for board certified obstetricians as it existed at that time frame ... was that standard in any respect lower in this community than it was for board certified physicians practicing elsewhere, i.e., using the national standards?
A. No.
Q. Did you have occasion from time to time to look at the handbook of suggested practices which was presented and published by the National College—
A. American College.
Q. Thank you. Are you familiar with the Handbook of Standards by the American College of Obstetricians and Gynecologists?
A. Yes.
Q. And is that reflective of what the standard of practice was in this community in 1985?
A. Yes.
Rufi Deposition, 6-8.
Dr. Friedman testified that the national standards are the ones set forth in the Handbook.
Q. Doctor, are there standards, written standards of any type which would have in 1985 applied to the standard of practice for Dr. Rush’s behavior as a board certified obstetrician?
A. Yes.
Q. And what are those standards, sir? A. There are a number of different published standards. The one most commonly referred to are a list of standards published by the American College of Obstetricians and Gynecologic Services. This is the Sixth Edition dated 1985 and was published and distributed in April of 1985 to all members of the college, all fellows of the American College of Obstetricians and Gynecologists, and to obstetric services in the country.5
*835Q. Dr. Friedman, what facts did you obtain from Dr. Rufi’s deposition which have assisted you in coming to conclusions about the local standard of practice?
A. He specifically stated that he knew the local standards for Pocatello and that he knew the national standards and that basically the local standards were the national standards, and they went by the. American College of Obstetricians and Gynecologists standards. Those guidelines were the guidelines for local practice ____
Tr., Vol. VII, 1101-02, 1112.
Dr. Friedman’s testimony that Dr. Rush’s treatment fell below the standard of care by failing to conduct a biophysical profile, established that Dr. Rush did not follow the procedures set out in the Handbook. And if Dr. Rush did not follow the procedures set forth in the Handbook regarding biophysical profiles, then he was not following the local standard of care in Pocatello in 1985, as those standards then existed according to Dr. Rufi’s testimony.
Likewise, when Dr. Friedman testified that Dr. Rush fell below the standard of care by failing to use ultrasound, he was referring to the standards as embodied in the Handbook, which Dr. Rufi testified set forth the standard of care in Pocatello in 1985, with one irrelevant exception.
The Chief Justice is entitled to his view that the evidence was insufficient to establish that ultrasound or biophysical testing was required under the then applicable national standard of care. However, such testimony read in context establishes that biophysical testing and ultrasound were part of the national standard of care in 1985. And, if they were reflection of the national standard of care, it follows that they were also part of the local standard of care.
II
Justice Boyle’s dissent takes a different approach by arguing that Dr. Rufi’s deposition does not support the conclusion that ultrasound was part of the local standard of care, although he apparently concedes it was part of the national standard of care.
It is first argued that other doctors in Pocatello, specifically Dr. DeSano and Dr. Rush, did not believe the use of ultrasound was part of the local standard of care. Of course, it is not surprising that Dr. Rush, being one of the defendants, would deny he gave substandard care to Zofia and Stephanie. Little, if any, weight needs to be given to his opinion because the legislature could not have intended to allow Dr. Rush to defeat the claim against him by his own self-serving testimony. Such a result would be absurd, to say the least!
As to Dr. DeSano’s statement, Dr. Friedman noted that it did not make any sense:
He indicated to me that the use of ultrasound was available and being used for assessing gestational age and fetal size, but specifically did not say that it was being used for macrosomic infants. And I have already testified yesterday that that didn’t make any sense to me since the technique for fetal size was the technique for fetal size regardless of the size of the baby, it’s the same technique.
Tr., Vol. VII, 1177.
The doctor was correctly observing that it is nonsense to say that ultrasound was not being used to determine whether a fetus was macrosomic if ultrasound was being used to assess fetal size. Macrosomia is nothing more than very large fetal size which would be discovered during an ultrasound to assess fetal size. Dr. Friedman later observed that if ultrasound had been used to assess fetal size in this case, it would probably have been discovered that Stephanie was a macrosomic baby and steps could have been taken to avoid the shoulder dystocia during the delivery. Dr. Rufi also testified that ultrasound was one method of determining whether a baby is macrosomic. If anything, when Dr. DeSano said that ultrasound was being used to assess fetal size, he was supporting Dr. Friedman’s opinion that the use of ultra*836sound was part of the local standard of care.
More importantly, the fact that there is disagreement within the local medical community as to the particulars of the local standard of care does not mean an adequate foundation cannot be laid for an expert’s opinion as to what s/he thinks the standard is. A fair examination of Dr. Rufi’s deposition establishes a foundation for Dr. Friedman’s opinion.
It is next contended that Dr. Rufi’s testimony is “not time and site specific as required in Gubler v. Boe,____” because 1) it was not clear whether the local ultrasound operators were giving estimated weights in 1985, 2) that Dr. Rufi only testified that ultrasound began to be used in the “early eighties,” and 3) he did not answer the question of when it became the standard in Pocatello.
Although Dr. Rufi originally said he was not sure whether he was getting estimated weights in 1985, he later modified his testimony.
Q. As far as you could tell, your people in Pocatello were keeping up with what was being done elsewhere with the use of ultrasound in measuring fetal weights.
A. As far as the time when it was available and not available, that’s not clear in my mind. But they did provide that for us and I don't recall at this point what point it was available and wasn’t available.
Q. Was it shortly after you [moved to Pocatello in 1979]?
A. I don’t recall.
Q. Late seventies, early eighties?
A. It might have been more like early eighties.
Q. Did you routinely ultrasound gestationally diabetic patients?
A. Yes.
Q. Would it be not in accordance with good practice not to have done that?
A. I would think so, yes.
Rufi Deposition, 34-35.
This testimony establishes that Dr. Rufi was using ultrasound to determine fetal weight by 1985, by anyone’s standards the “mid-eighties.” Additionally it shows the failure to do so was not good practice in Pocatello at that time, particularly with gestationally diabetic patients like Zofia Skiba. Gestationally diabetic women are more likely to have big babies and big babies are prone to shoulder dystocia. Dr. Rufi’s testimony is corroborated by Dr. De-Sano who told Dr. Friedman that ultrasound was available and being used for assessing gestational age and fetal size in 1985.
But even if we assume that Pocatello ultrasound operators were not giving weights as late as 1985, Dr. Rufi also testified he would have sent a patient to Salt Lake City if he suspected the fetus had congenital abnormalities that local ultrasonographers were not competent to assess.
Q. Now, can you tell me what kind of information you might want to seek through the use of an ultrasound if you had a patient you regarded as high risk? And I am now speaking of the ’85 time frame.
A. Well, it would be initially important to establish a due date or at least reassure us that the due dates are accurate.
Q. Why is that important?
A. A high risk pregnancy might have to be terminated for one reason or another, and it would be very important to know the dates accurately and to know the chances for the fetus if you had to terminate a pregnancy early.
Q. Now ... are there any other reasons why you think its helpful to do ultrasound on high risk mothers?
A. Yes, and in my own office I did not assess congenital abnormalities except for gross abnormalities of the skull or the chest or heart or whatever, but to thoroughly assess the genetic or the congenital anomaly problem it would require a better machine and more expertise.
Q. Any other reasons, sir?
A. Well, that would be the main reason, is to establish dates, to evaluate the fe*837tus and reassure the patient and me that the pregnancy was normal and it was progressing normally.
Q. You had equal confidence in the local ultrasonographer as you did in those people in Salt Lake City?
A. Yes.
Q. And if you didn’t have that confidence, you would have referred the patients to Salt Lake City.
A. That’s right.
Rufi Deposition, 21-23. Later in the deposition, the doctor said:
Q. And if you had any question about [the local ultrasound operators’] competence in measuring fetal weights in ’85 and you were interested in the subject, you could clearly have sent the patient to Salt Lake.
A. Yes.
Rufi Deposition, 24.
So, even if accurate, the observation that Pocatello ultrasound operators may not have been giving fetal weights in 1985 does not show it was not the local standard of practice to have patients travel to Salt Lake City in order to have that done. Dr. Rufi’s testimony shows the opposite. In either case, Dr. Rufi’s testimony provides sufficient foundation for Dr. Friedman’s opinion that Dr. Rush violated the local standard of care by failing to order an ultrasound, whether that test would have been done in Pocatello or Salt Lake City.
Ill
To the extent that the evidence as to the local standard of care was in conflict, that is a question of the weight, not the admissibility of the evidence. It was for the jury to resolve the question of the credibility of the witnesses who testified relative to a local standard of care. It very well may be that the jury would have decided to believe the testimony of the defense experts over the testimony of Dr. Friedman. That is their right. But it is also the party’s right to have the jury hear all the competent evidence before making their decision, instead of having the district court decide for them that one doctor’s testimony is better than another’s.

. Presumably Dr. Friedman was well acquainted with the American College Standards as he was chairman of its committee on Fetal and Perinatal Medicine and was featured in *835videotapes used by the College to educate other members of the profession.