In the case of Carolyn Stovall v. Lois E. Clarke, M.D. et al., the Court of Appeals of Tennessee addressed a medical malpractice claim resulting from the death of Gerald D. Stovall due to coronary heart disease, which the plaintiff alleged was misdiagnosed and untreated by the defendant physicians. The court affirmed in part and reversed in part the Circuit Court's dismissal of the case on summary judgment grounds, ruling that there were no disputed issues of fact and that defendants were entitled to judgment as a matter of law, primarily due to the disqualification of the plaintiff’s expert witnesses under the locality rule.
Carolyn Stovall, the plaintiff and widow of the deceased, claimed that Dr. Clarke, the primary physician, failed to diagnose Gerald's heart condition despite his significant risk factors, including a history of smoking, high cholesterol, and family heart disease. Notably, an EKG in 1992 indicated potential heart issues, yet subsequent consultations in 1996 and 1997 resulted in misdiagnoses of reflux disease and upper respiratory infections. The plaintiff argued that proper diagnostic testing would have identified the coronary heart disease, which ultimately led to Gerald's death on March 11, 1997.
Dr. Clarke denied any negligence, asserting in her motion for summary judgment that her treatment met the local standard of care, supported by her affidavit and that of another physician, Dr. Summers Chaffin. Similarly, Dr. McCain, who also faced allegations of negligence regarding his treatment of the decedent, filed a motion for summary judgment, maintaining that no genuine issues of material fact existed. Both physicians presented affidavits and other materials to support their claims.
Dr. McCain examined the decedent, Mr. Stovall, on February 26, 1997, following a referral from Dr. Clarke. Stovall reported previously good health, but had recently developed a rattling chest and cough, without any complaints of chest pain. Dr. McCain's evaluation revealed normal cardiac and lung function, diagnosing bronchitis exacerbated by smoking history.
In response to Motions for Summary Judgment, the plaintiff presented testimonies from Drs. Clarke, McCain, Ronald Krone, and Jack Uhrig, along with affidavits from Drs. Uhrig and Krone. Dr. Uhrig served as a standard of care expert for both defendants, while Dr. Krone focused on causation issues against Dr. Clarke. In his deposition, Dr. Uhrig, who is experienced in coronary heart disease and has reviewed Stovall's medical records, asserted that the standard of care in Franklin, Tennessee, aligns with that of Marshall, Missouri, despite never having visited Franklin. He stated both Dr. Clarke and Dr. McCain deviated from the required standard of care during 1996-1997, detailing these opinions in Rule 26 disclosures attached to his affidavit. Dr. Uhrig emphasized his familiarity with care standards for patients with coronary disease, derived from 18 years of practice in a similar community, and involvement in the Missouri Patient Care Review Foundation.
Dr. Krone, a board-certified cardiologist and professor at Washington University, did not address the standard of care but limited his testimony to causation.
Mr. Stovall's testimony indicated that bypass surgery would have extended his life. Following the granting of summary judgment motions without detailed reasoning, the plaintiff filed a Rule 59 Motion to Alter or Amend, supported by three affidavits, including one from Dr. Krone regarding the standard of care. This Rule 59 Motion was denied, prompting the plaintiff's appeal. Central to the appeal is the disqualification of the plaintiff’s expert witnesses due to their lack of familiarity with the applicable standard of care in Williamson County, Tennessee. A secondary issue concerns the proper consideration of affidavits submitted with the Rule 59 Motion.
In evaluating the existence of a genuine issue of material fact for summary judgment, the court must adopt the strongest legitimate view of the evidence in favor of the nonmoving party, allowing reasonable inferences and disregarding opposite evidence. If any material fact is disputed or if there is any doubt about the conclusions drawn, the motion must be denied. The court cannot weigh evidence at this stage, as summary judgment cannot replace a trial on disputed factual issues.
Tennessee Code Annotated § 29-26-115 outlines that in a malpractice action, the claimant must prove the following: the standard of acceptable professional practice in the relevant community, that the defendant acted with less than ordinary care, and that the plaintiff suffered injuries as a direct result of the defendant's negligence.
The "locality rule" requires that an expert in a medical malpractice case demonstrate knowledge of the standard of care in the same or similar community where the alleged malpractice occurred. While the expert does not need to be from the same specialty as the defendant, they must be familiar with the local standard of care to provide relevant testimony. Past cases have established that a lack of knowledge about local medical resources undermines the ability to testify on the standard of care, which is essential to proving a breach of duty.
Mabon argues that he has fulfilled the burden of proof regarding the standard of care applicable in Jackson, Tennessee, distinguishing his case from Ayers and Osler based on the differing standards of care in those cases. He claims that once Dr. Shane asserted the national standard of care was equivalent to that in Jackson, the burden shifted to Dr. Thomas to demonstrate a different standard. However, it is determined that the plaintiff bears the burden of proving the standard of care in the relevant community, as stated in T.C.A. 29-26-115(a)(1). Mabon must show that any similar community is indeed comparable to Jackson. The burden cannot shift to the defendant without contradicting the statute's language.
Dr. Thomas’ motion for summary judgment included an affidavit stating he adhered to the standard of care in Jackson, which shifted the responsibility back to Mabon to provide specific facts indicating a failure to meet that standard. Dr. Shane’s testimony lacked familiarity with Jackson's standard of care, and his claim that the standard is uniformly applied nationwide was insufficient. Consequently, Mabon failed to establish a breach of duty, as he did not provide evidence of the standard of care in Jackson or a similar community, leading to the conclusion that no material fact issues existed. Thus, the trial court correctly granted summary judgment in favor of Dr. Thomas.
After the summary judgment, Mabon filed a Motion to Alter or Amend the Judgment, supported by affidavits from Drs. Tuteur, Krone, and Golusinski. Dr. Tuteur, a Missouri pulmonologist, testified about his familiarity with the standard of care in Franklin, Tennessee, asserting it is similar to that in other counties where he practices. He opined that Dr. McCain deviated from the required standard by inadequately documenting a patient's history and failing to conduct a thorough evaluation of the causes of the patient's symptoms, noting that Dr. McCain's examination was alarmingly brief.
The short consultation time during Dr. McCain's initial pulmonary visit for Mr. Stovall was insufficient for diagnosing the causes of his shortness of breath and cough, violating the standard of care. Dr. McCain failed to consider potential cardiac disease as a cause of Mr. Stovall's symptoms, despite having access to relevant medical history, including an equivocal EKG from 1992. Proper differential diagnosis and investigation would likely have revealed Mr. Stovall's underlying cardiac issue, which is causally linked to his subsequent death. Had Dr. McCain complied with the standard of care in February 1997, it is probable that Mr. Stovall would have been diagnosed and successfully treated, potentially saving his life.
Dr. Clarke, the family practitioner, similarly violated the standard of care by not thoroughly investigating an abnormal EKG in a smoker with elevated lipids, failing to treat these conditions over five years, and neglecting to refer Mr. Stovall for cardiological evaluation despite symptoms indicative of heart failure. Her inaction is also causally connected to Mr. Stovall's death, as adherence to the standard of care could have led to a diagnosis of coronary artery disease and possible surgical intervention, likely resulting in his survival. "Reasonable degree of medical certainty" is defined as more probable than not, and Dr. Krone provided an additional affidavit regarding Dr. Clarke's standard of care.
Testimony established that Dr. Clarke failed to meet the standard of care required for family practitioners treating patients like Gerald Dewayne Stovall in Franklin, Tennessee. Dr. Clarke was aware of Mr. Stovall's equivocal EKG from 1992, his history of smoking, elevated lipid levels over five years, and abnormal EKG findings in 1996. Given this information, she had an obligation to investigate further for signs of congestive heart failure or ischemia, or alternatively, refer Mr. Stovall to a cardiologist. Her failure to do so constituted a violation of the standard of care, which the expert opined was causally linked to Mr. Stovall's death. If Dr. Clarke had adhered to the standard of care in 1996 and 1997, it is believed that Mr. Stovall’s coronary artery disease would have been diagnosed, likely leading to coronary bypass surgery and possibly saving his life.
Additionally, a Rule 59 Motion was filed on February 26, 2001, to amend a summary judgment favoring Dr. Clarke, based on the claim that the trial court had indicated the plaintiff could submit new expert opinions within thirty days after the judgment. The court recognized the defendants' objections to late affidavits but still considered them, concluding that they did not alter the appropriateness of the summary judgment. The resolution of such motions is guided by criteria from Harris v. Chern, which includes factors like the movant’s evidence-gathering efforts, the importance of new evidence, reasons for its late submission, potential prejudice to the opposing party, and other relevant facts. The trial judge’s decision to consider the late-filed affidavits was affirmed, given the circumstances.
Dr. Krone's affidavit asserts that coronary by-pass surgery would have extended Mr. Stovall's life, emphasizing the availability of cardiologists and cardiac surgeons in Franklin, Tennessee. He contends that the standard of care in Franklin is equivalent to that in St. Louis, asserting that community-specific standards do not exempt Franklin from general expectations for cardiac work-ups and referrals. Dr. Uhrig supports this by stating his familiarity with the standard of care in Franklin, likening it to Marshall, Missouri.
Key points from the legal analysis include:
1. An expert does not need to know all medical statistics of a specific county but must understand the local standard of care or that of a similar community.
2. The plaintiff must prove that the standard of care in Marshall is akin to that in Franklin or a comparable area.
3. If defendants demonstrate adherence to the standard of care in Franklin, the burden shifts to the plaintiff to show specific facts of deviation from that standard.
The court found Dr. Uhrig's testimony to sufficiently indicate knowledge of the standard of care, leading to the conclusion that the trial court erred in granting summary judgment to Dr. Clarke, while affirming the summary judgment for Dr. McCain due to insufficient evidence of causation. The judgment against Dr. Clarke is reversed, and the case is remanded for trial, with costs split between the plaintiff and Dr. Clarke.
