St. Mary's Ohio Valley Heart Care, LLC v. Derek F. Smith

Citation: 112 N.E.3d 1144Docket: 82A05-1711-PL-2594

Court: Indiana Court of Appeals; October 9, 2018; Indiana; State Appellate Court

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On October 9, 2018, the Indiana Court of Appeals issued an opinion regarding a medical malpractice case involving Derek F. Smith, who underwent lung surgery performed by Dr. Elizabeth G. Butler. During the procedure, pathologist Dr. Hongyu Yang interpreted frozen section slides as cancerous, leading to a lobectomy. However, the permanent slides later revealed the specimen was benign. Smith subsequently filed a malpractice suit against Dr. Butler and several associated medical entities, as well as Dr. Yang and Tri-State Pathology Associates. A Medical Review Panel unanimously sided with the defendants. To challenge this, Smith presented an affidavit from expert Dr. E. Allen Griggs, who claimed that Dr. Yang did not meet the pathological standard of care. The trial court denied motions for summary judgment from both groups of defendants, prompting an interlocutory appeal. The appellate court ultimately reversed the trial court's decision and remanded the case for further proceedings. The case's procedural history includes Smith's initial emergency visit for respiratory issues, subsequent evaluations by pulmonologist Dr. Victor Chavez, and the decision to refer Smith to Dr. Butler for surgery after the lung mass increased in size.

On May 31, 2012, Dr. Butler conducted a wedge resection of Smith's left lower lung lobe, sending the specimen for intraoperative pathology analysis. Dr. Yang, facing challenges in interpreting the frozen slides, ultimately deemed them highly suspicious for cancer and communicated this via intercom, although his description indicated difficulty in interpretation. Dr. Butler's operative notes stated the slides suggested bronchoalveolar carcinoma, while Dr. Yang claimed to have conveyed that the findings were suggestive of a well-differentiated adenocarcinoma. Regardless of the terminology used, Dr. Butler stated she would have proceeded with the lobectomy based on Smith's extensive clinical history, which included significant risk factors for lung cancer. The lobectomy reduced Smith's lung capacity by 20%.

The day after the procedure, Dr. Yang examined permanent slides and found them difficult to interpret, prompting him to seek a second opinion from Dr. Colby at the Mayo Clinic. Dr. Colby concluded the permanent slides were benign and highlighted the interpretative challenges of frozen sections, noting that scarring could mimic cancer. Following Dr. Colby’s report, Dr. Yang finalized his surgical pathology report on June 8, 2012, indicating no malignancy. Dr. Yang informed Dr. Butler of this discrepancy on the same day.

Smith filed a medical malpractice lawsuit in May 2014 against Dr. Butler, Dr. Yang, their practice groups, and the hospital. Under the Indiana Medical Malpractice Act, Smith submitted his complaint to a review panel, which included two cardiothoracic surgeons and one pathologist. On March 11, 2015, the panel unanimously found that the defendants met the applicable standard of care, dismissing Smith's allegations.

On August 14, 2015, Smith amended his complaint against the Surgical and Pathology Defendants, disclosing Dr. Griggs as an expert witness to counter the medical review panel's findings. Dr. Griggs provided an affidavit in January 2016 and was deposed in December 2016, stating that Dr. Yang should have postponed his diagnosis of the "unusual tumor" until he reviewed permanent section slides, though he acknowledged that the frozen slides suggested cancer. 

The Pathology Defendants filed for summary judgment on May 30, 2017, followed by the Surgical Defendants on June 29, 2017. The trial court denied both motions in September 2017 after a hearing, and later granted certification for interlocutory appeal, which was accepted by the court on December 15, 2017.

The standard for summary judgment requires no genuine issue of material fact and that the moving party is entitled to judgment as a matter of law. In Indiana, in medical malpractice cases, a unanimous opinion from a medical review panel that a physician did not breach the standard of care can establish a prima facie case for summary judgment, shifting the burden to the plaintiff to provide expert testimony to rebut this. The Surgical Defendants contend they are entitled to summary judgment, as Smith did not present expert testimony regarding Dr. Butler's standard of care or any breach thereof, claiming instead the doctrine of res ipsa loquitur absolves him of the need for such testimony.

A medical malpractice plaintiff must demonstrate that the defendant owed a duty, breached that duty, and caused an injury, with expert testimony typically required to establish the standard of care and any breach. Physicians are not obligated to provide perfect care but must exercise the skill and care expected from a reasonably competent practitioner in similar circumstances. The doctrine of res ipsa loquitur allows for an inference of negligence based on the circumstances of an injury, particularly when the injuring instrumentality is under the defendant's control and the accident would not normally occur if proper care were taken. The application of this doctrine hinges on whether the plaintiff's evidence meets its requirements, which involve a mixed question of law and fact. In medical malpractice cases, this doctrine is applicable when the defendant’s actions are so evidently substandard that a jury can recognize the breach without expert testimony, typically in clear instances like leaving a foreign object in a patient’s body. In this case, Dr. Butler's decision to perform a lobectomy was based on her evaluation of the patient's medical history and pathology consultation, indicating she would have proceeded regardless of the specifics of Dr. Yang’s report on the frozen slides.

The court agrees with the Surgical Defendants that the standard of care in this case exceeds common knowledge, necessitating expert testimony, which the plaintiff, Smith, did not provide. Consequently, the trial court's denial of the Surgical Defendants’ motion for summary judgment was erroneous, and the court directs that summary judgment be entered in favor of the Surgical Defendants. 

Regarding the Pathology Defendants, they contested the trial court's denial of their summary judgment motion, asserting that Smith's expert testimony from Dr. Griggs did not create a genuine issue of material fact. Dr. Griggs found no fault with Dr. Yang's intraoperative diagnosis and testified that Dr. Yang did not breach the standard of care in interpreting frozen slides. The Pathology Defendants further argued that Dr. Butler would have proceeded with the lobectomy regardless of Dr. Yang's diagnosis of the lesion.

Dr. Griggs acknowledged that pathologists typically provide intraoperative diagnoses based on frozen slides, which are less reliable than permanent slides. He indicated that while most cases allow for a clear diagnosis from frozen slides, inconclusive cases should defer diagnosis until permanent slides are reviewed. He criticized Dr. Yang for not deferring the diagnosis in this instance, suggesting that the slides were difficult to interpret and that had Dr. Yang deferred the diagnosis, Smith would not have lost a lung lobe.

Dr. Griggs’s deposition does not clearly establish the standard of care or that Dr. Yang breached it. Instead, Dr. Griggs expressed opinions on alternative actions he or Dr. Yang could have taken, without stating that failing to defer the diagnosis constituted malpractice. His testimony allowed for the possibility that Dr. Yang could have properly indicated that the frozen slides suggested cancer. Even if Dr. Griggs's testimony raises questions about whether Dr. Yang breached the standard of care, the Pathology Defendants provided evidence showing that Smith's injury was not caused by Dr. Yang's actions. Dr. Butler, who planned to proceed with the lobectomy unless the diagnosis was clearly non-cancerous, acknowledged the challenges in interpreting the frozen slides, which suggested cancer. Consequently, there is no evidence that Dr. Butler's decision would have differed had Dr. Yang provided a different intraoperative diagnosis. Proximate cause requires that harm would not have occurred without the defendant's actions, and the evidence does not suggest a genuine issue of fact regarding causation. Thus, the trial court is directed to grant summary judgment in favor of the Pathology Defendants. The judgment has been reversed and remanded.