Plaintiffs Markina Westmoreland et al. appealed the summary dismissal of their medical malpractice claims against three physicians: an orthopedic surgeon, Dr. William Bacon, and two hematologists, Dr. Wichai Chinratanalab and Dr. Chukwuemeka Ikpeazu. The case stems from the death of their mother, Dorris Dennis, following a hip replacement surgery on December 13, 2004. Dennis, who had several medical conditions, including a blood disorder diagnosed by Dr. Chinratanalab, experienced a decline in health nine days post-surgery and died from severe pulmonary and gastrointestinal hemorrhage.
The Plaintiffs alleged that the physicians breached their respective standards of care. Each physician filed a motion for summary judgment supported by expert witness affidavits, while the Plaintiffs submitted an affidavit from their expert. The trial court found the Plaintiffs' expert unqualified under Tenn. Code Ann. § 29-26-115, leading to the granting of summary judgment for the defendants. On appeal, the court affirmed the trial court's ruling, agreeing that the Plaintiffs' expert was not qualified to testify, thus upholding the dismissal of their claims. The opinion was delivered by Judge Frank G. Clement Jr., with a dissenting opinion filed by Judge Richard H. Dinkins.
Dr. Bacon treated Ms. Dennis on December 14, 2004, ordering red blood cells but not platelets due to a normal platelet count. He ordered platelets on December 15 and additional red blood cells on December 16. Dr. Chinratanalab, consulted on December 16 for low potassium, recommended tests and intravenous potassium, aiming to keep Ms. Dennis's platelet count above 50,000 and hematocrit over 50 percent. He ordered more red blood cells and a dosage reduction of Lovenox on December 17, and discontinued Bextra on December 18, noting acceptable platelet and hematocrit levels. On December 20, he suggested a formal hematology consult and the discontinuation of Lovenox. Dr. Ikpeazu conducted the hematology consult that day, recommending more platelets and an alternative to Lovenox, marking his only involvement. Following this, Dr. Bacon ordered additional platelets and Epogen on December 20, then two more units on December 22. Ms. Dennis's condition deteriorated later that evening, leading to her admission to the ICU and subsequent death from internal bleeding on December 23, 2004.
On December 7, 2005, Ms. Dennis's children filed medical malpractice claims against Dr. Bacon, Meharry Medical College, and Metro Hospital, later dismissing the latter. An amended complaint on November 29, 2007, included Dr. Chinratanalab and Dr. Ikpeazu as defendants. In April 2009, all three doctors filed motions for summary judgment, asserting they did not breach the standard of care. Dr. Bacon highlighted his long-standing certification and practice in orthopedic surgery, while Dr. Chinratanalab detailed his extensive training and board certifications in hematology and oncology, claiming adherence to the recognized standard of care and denying responsibility for Ms. Dennis's injuries or death.
Dr. Ikpeazu, in his motion for summary judgment, highlighted his qualifications, including his medical license in Tennessee since 1995, board-certification in internal medicine and medical oncology, and position as Chief of Hematology/Oncology at Nashville General Hospital during Ms. Dennis’s hospitalization in 2004. He asserted compliance with the relevant professional standards and denied any causation of Ms. Dennis’s injuries or death.
In response, Plaintiffs presented Dr. Richard M. Sobel, an emergency room physician from Atlanta, as their sole expert to argue that the defendants breached the standard of care. The defendants contended that Dr. Sobel’s affidavit was inadmissible under Tennessee law due to his specialty not being relevant to the case, as well as his failure to demonstrate competence under the Tennessee Medical Malpractice Act for the specialties involved.
After a hearing, the trial court granted summary judgment to the defendants, finding their affidavits sufficient to shift the burden to the plaintiffs, who failed to present competent evidence of a genuine issue of material fact. The court ruled Dr. Sobel was not qualified to testify regarding hematology and orthopedics, leading to a lack of expert proof for the plaintiffs. A subsequent Rule 59 motion by the plaintiffs, supported by a supplemental affidavit from Dr. Sobel, was denied by the court as it did not establish his qualifications.
The key issue on appeal is whether the trial court erred in determining that Dr. Sobel did not meet the qualifications necessary to testify as a medical expert under Tennessee law. The trial court has broad discretion in assessing expert qualifications, and its decisions regarding the admission or exclusion of evidence fall within that discretion.
The court reviews discretionary decisions from trial courts using the abuse of discretion standard. A trial court is deemed to have abused its discretion if it applies an incorrect legal standard, makes a decision contrary to logic, or causes injustice. An appellate court will only overturn such a decision if the trial court misapplies legal principles or acts against the substantial weight of the evidence. To evaluate a trial court's discretionary decision, the appellate court assesses: (1) whether the factual basis is supported by evidence, (2) whether the applicable legal principles were identified and applied, and (3) whether the decision falls within acceptable alternatives. Reasonable judicial differences in opinion will uphold the trial court's decision.
Under the Tennessee Medical Malpractice Act, a plaintiff must prove the following to establish a medical malpractice claim: (1) the recognized standard of care for the defendant's profession at the time of the alleged malpractice, (2) the defendant's failure to act with reasonable care, and (3) that this failure caused the plaintiff's injuries. Competent expert evidence is required for these elements. Expert witnesses must be licensed in Tennessee or a bordering state and have practiced in the relevant field within the year preceding the alleged incident. In this case, it is established that Dr. Sobel was licensed in Georgia and practiced there during the relevant time. The key issue is whether his qualifications as an emergency room specialist make his testimony relevant under the statute, which does not require the expert to share the same specialty as the defendant but does demand familiarity with the standard of care in the relevant field.
Expert testimony in Tennessee can be accepted as competent proof even if the expert specializes in a different field, provided they have a sufficient basis for familiarity with the defendant's field of practice. This principle, known as the fungibility of experts, is recognized under Tennessee’s Medical Malpractice Act. However, an expert must be familiar with the specific standards of care in the relevant field; otherwise, generalized evidence is inconsistent with the Act's provisions. Courts have consistently rejected attempts to establish a general standard of care applicable to all medical doctors, as this undermines established competency requirements.
The case at hand requires an evaluation of Dr. Sobel's qualifications to testify regarding the standards of care for hematology and orthopedic surgery in Nashville, Tennessee. Plaintiffs submitted two affidavits from Dr. Sobel: the first opposing the defendants' summary judgment motions and the second supporting a motion to alter or amend a dismissal order. In his initial affidavit, Dr. Sobel asserts his qualifications, noting his prior practice in emergency medicine in Georgia and his familiarity with the standards of care in a community similar to Nashville. He emphasizes his training, experience, and knowledge of local medical practices, as well as his awareness of Nashville's healthcare landscape, which includes major medical institutions and a large population.
Dr. Sobel’s affidavit outlines the credentials and operational details of Nashville General Hospital, emphasizing its accreditation, services, and emergency care capabilities. He asserts that the hospital is comparable to those in the Greater Atlanta and Greater Nashville areas. Dr. Sobel critiques the care provided by Drs. Chinratanalab, Bacon, and Ikpeazu to Ms. Dennis in December 2004, claiming they fell below the standard of care. He notes Ms. Dennis exhibited signs of hypotension and a deteriorating condition on December 22, 2004, without adequate evaluation or management from her physicians.
He highlights significant drops in hemoglobin and hematocrit levels during her hospitalization and notes the increased risk of hemorrhage due to Ms. Dennis's medical history, including Hepatitis C, alcohol abuse, and anticoagulant treatment. Dr. Sobel contends that the sudden decline in her hemoglobin levels should have prompted thorough investigation for potential bleeding, which he claims was not conducted. He criticizes the lack of routine monitoring for gastrointestinal hemorrhage, indicating this failure constituted a breach of medical standards.
Additionally, he points out that Ms. Dennis was prescribed Bextra (valdecoxib), a medication known to increase bleeding risk, despite her known conditions that heightened this risk. He asserts that prescribing and not discontinuing Bextra was negligent and significantly contributed to her adverse health outcomes.
The autopsy of Ms. Dennis identified hemorrhage as the cause of her death. The hip replacement she underwent was a high-risk elective procedure, and it is unclear if adequate informed consent detailing the associated risks was provided, despite a consent form being signed. Her post-operative care required intensive monitoring for bleeding risks, contraindicating non-essential medications that could exacerbate this risk. Proper maintenance of platelet counts was essential, and there should have been active investigation into any hemorrhage occurrences. Optimal prophylactic medication to prevent gastrointestinal bleeding was necessary, and recurrent drops in hemoglobin and hematocrit needed prompt evaluation and treatment. Continuing anti-coagulation on December 20, 2004, was inappropriate. The actions or inactions of the responsible medical personnel constituted breaches of accepted medical standards. Had these standards been adhered to, it is likely Ms. Dennis would not have succumbed to hemorrhage and shock on December 23, 2004.
Following the filing of an affidavit opposing the defendants' motions for summary judgment, Dr. Sobel's qualifications to testify on the relevant standards of care were challenged. The trial court ruled that his affidavit did not sufficiently establish his competency, particularly regarding hematology and orthopedics in the Nashville medical community, leading to the dismissal of the plaintiffs' claims due to the lack of a qualified expert witness. The plaintiffs subsequently filed a motion to amend this ruling, supported by Dr. Sobel's supplemental affidavit. In this affidavit, Dr. Sobel claimed familiarity with the standard of care for prescribing Lovenox and asserted his qualifications in both emergency and orthopedic medicine, despite lacking hematology training. He emphasized his experience in evaluating and managing various orthopedic issues as an emergency physician.
Dr. Sobel claimed familiarity with the knowledge typically held by orthopedic physicians regarding anti-inflammatory agents and anti-coagulants. However, the trial court concluded that Dr. Sobel's supplemental affidavit failed to demonstrate his qualifications to testify about the accepted professional standards of care related to orthopedic surgery and hematology, specifically regarding Dr. Bacon and hematologists Drs. Chinratanalab and Ikpeazu. The court found no new information in Dr. Sobel's affidavit that would establish his expertise in these specialties, which is necessary under T.C.A. 29-26-115 (a) and (b). While Dr. Sobel showed knowledge of a general standard of care for Lovenox, the court emphasized that a general understanding is inadequate for medical malpractice claims. His affidavits revealed a lack of specialized training and experience in hematology and orthopedic surgery, as he had not performed relevant surgeries or managed complex post-surgical patients with conditions like pancytopenia, thrombocytopenia, and liver disease. This situation mirrors the case of McDaniel v. Rustom, where an expert in internal medicine was deemed unqualified to testify on pediatric emergency medicine due to insufficient familiarity with the relevant standards of care.
The court upheld the trial court's decision that the plaintiffs' expert witness, Dr. Sobel, was not competent to testify regarding the standard of care for emergency room physicians. The court found that Dr. Sobel failed to demonstrate sufficient familiarity with the specific standards of care for the relevant medical specialties involved in the case, particularly hematology and orthopedic surgery. Although he is an accomplished emergency room physician with a general understanding of various specialties, he lacked the requisite education and experience to provide relevant testimony on the specific medical issues concerning the patient’s hip replacement surgery and related post-surgical care. The court emphasized that the Medical Malpractice Act requires an expert to be adequately familiar with the standard of care applicable to the specific specialty in question, and simply being an expert in one area does not qualify one to testify about another. The ruling also clarified that the court applies an abuse of discretion standard when reviewing evidentiary decisions, affirming that the trial court acted within reasonable bounds. Consequently, since the plaintiffs did not provide other evidence to create a genuine issue of material fact, summary judgment was deemed appropriate. The trial court's judgment was affirmed, and costs were assessed against the appellants.
