Court: Connecticut Appellate Court; August 23, 2005; Connecticut; State Appellate Court
In the medical malpractice case involving plaintiffs Nancy B. Farrell and Cynthia B. Grocki against defendants David M. Bass and his medical practice, the trial court ruled in favor of the defendants after a jury found that Bass had not deviated from the standard of care. The appeal raises two main issues: whether the court abused its discretion by excluding expert testimony from two of the plaintiffs’ witnesses who were not specialists in the same field as Bass, and whether the court improperly limited cross-examination and direct examination regarding certain medical literature.
The plaintiffs alleged that Bass deviated from the standard of care by failing to communicate with the decedent’s internist or cardiologist before altering her anticoagulant medication, improperly directing her to interrupt anticoagulation, and neglecting to explain alternative methods and the risks associated with the surgical procedure performed without medication interruption. These alleged deviations contributed to the decedent suffering an embolic stroke post-surgery, ultimately leading to her death.
Defendants moved to exclude the testimony of two of the plaintiffs' proposed expert witnesses, Stanley Bernstein and John Miller, arguing they were not “similar health care providers” as defined under General Statutes 52-184c, which governs expert testimony in medical malpractice cases. The plaintiffs also presented James Shearer, a board-certified plastic surgeon, who was allowed to testify on the applicable standard of care. The court affirmed the trial court's judgment, indicating that the evidence presented did not meet the statutory requirements for expert testimony.
Defendants contended that the key issue was whether a plastic surgeon must personally communicate with a patient's primary care physician regarding the discontinuation of blood thinning medication before performing a facial biopsy, or if it suffices for the surgeon to instruct the patient to initiate that communication. Plaintiffs countered that the standard of care for any healthcare provider mandates personal communication with the prescribing physician, irrespective of specialty. Defendants highlighted that their witness, Miller, acknowledged a lack of knowledge about customary practices among plastic surgeons regarding such communications in April 1999, a sentiment echoed by plaintiff witness Bernstein.
Plaintiffs further asserted that the standard of care applicable to the defendant, Bass, should extend to all physicians when interrupting another physician’s medication regimen. Alternatively, they claimed Bass was practicing outside his specialty by discontinuing Coumadin, a decision typically within cardiology or internal medicine. They argued that under statute 52-184c, this practice justified treating Bass as a cardiologist or internist, thereby allowing the testimony of Bernstein and Miller.
The court granted defendants' motion in limine, prohibiting Miller and Bernstein from commenting on the standard of care Bass should have followed. The jury ultimately ruled in favor of defendants, concluding that Bass did not deviate from the standard of care for plastic surgeons. Plaintiffs attempted to overturn the verdict, but the court denied their motion, leading to an appeal. The court's decision on evidentiary matters, including the exclusion of expert testimony, is reviewed under an abuse of discretion standard, which emphasizes the trial court's broad latitude in such rulings.
The admissibility of expert witness opinions hinges on the expert's understanding of the applicable standard of care and their ability to evaluate the defendant's conduct accordingly. While trial courts have discretion in evidentiary matters, their legal interpretations regarding admissibility are subject to plenary review. Reversal of a judgment due to evidentiary errors requires proof of both an error and resulting harm. In medical malpractice cases, plaintiffs must prove the standard of care, a deviation from that standard, and a causal link to the injury, typically necessitating expert testimony due to the specialized nature of medical treatment.
In this case, Bass testified that discontinuing Coumadin without consulting the prescribing physician would violate a plastic surgeon's standard of care, which is met if the surgeon advises the patient to contact the prescribing physician. The plaintiffs sought to introduce testimony from Miller and Bernstein, arguing their expertise was relevant since the treatment involved a decision outside Bass's specialty. However, the court ruled their testimony inadmissible, stating Bass's actions were consistent with his role as a plastic surgeon and that the standard of care is not uniform across specialties. The court found insufficient evidence to support the claim that all physicians share the same standard regarding medication prescribed by other doctors.
Following this ruling, the court permitted testimony from Shearer, another plastic surgeon, who opined that failing to communicate with the prescribing physician before discontinuing Coumadin constituted a deviation from the standard of care. He emphasized that such communication is crucial for patient safety, as the prescribing physician understands stroke risks while the surgeon is aware of bleeding risks, highlighting the need for collaborative medical decision-making.
In performing an incisional biopsy, it is concluded that Coumadin should not be discontinued, as doing so would violate the standard of care expected of plastic surgeons. The court ruled that Bass did not need to be treated as an internist or cardiologist for Bernstein and Miller to testify regarding the standard of care. However, it was not demonstrated that Bernstein and Miller had adequate training or experience relevant to plastic surgery to provide opinions about the standard of care regarding anticoagulant discontinuation prior to surgery. The court found the defendants' argument about the standard of care for all physicians interfering with prescriptions irrelevant, emphasizing that Coumadin was specifically related to Bass's surgical treatment of Blakely, which involved bleeding risks. The court concluded that any advice from Bass to stop Coumadin was made in his capacity as a plastic surgeon, thus limiting the applicable standard of care testimony to that field. Bernstein and Miller's testimonies were excluded correctly, as neither was a plastic surgeon. Despite potential evidentiary errors regarding expert testimony, the court determined that the plaintiffs did not demonstrate harm, as the jury did not find Bass had deviated from the standard of care despite Shearer’s testimony supporting such a claim. The plaintiffs also argued that the court improperly limited Shearer from discussing a medical article that supported their position that Coumadin did not significantly increase bleeding risk in minor surgeries. The court excluded this testimony, finding its potential prejudicial effect outweighed its probative value, as it was central to the dispute over whether Bass deviated from the standard of care. The plaintiffs asserted that there was no increased risk of bleeding with Coumadin, while the defendants countered that there was a difference in risk based on its use. The article in question appeared to align with the plaintiffs' argument and Shearer’s opinion.
Shearer was prohibited from testifying about an article that purportedly supported his opinion regarding the lack of increased bleeding risk for patients on Coumadin undergoing minor surgeries. The court's decision was based on the potential for unfair prejudice, as the article had not been disclosed or requested during discovery. Initially, Shearer indicated that his opinion was not grounded in specific medical literature. After being sent several articles post-deposition, he admitted he had not read the relevant article prior to his deposition and found no supporting literature in plastic surgery. The plaintiffs did not contest the court's discretion in determining that the article's probative value was outweighed by its prejudicial effect. They referenced Section 7-4 (b) of the Connecticut Code of Evidence, which allows experts to base opinions on facts not admissible in evidence, arguing that Shearer should have been allowed to testify about the article. However, the court found that the article's content was hearsay, as it was being offered to prove the truth of its assertions without being introduced as a full exhibit. The plaintiffs did not invoke the applicable hearsay exception for treatises under Section 8-3 (8) of the Connecticut Code of Evidence. Ultimately, the court did not abuse its discretion in excluding Shearer’s testimony regarding the article, given his acknowledgment that his opinion was not based on any specific medical literature.
The court upheld the trial court's decision to exclude Shearer's testimony regarding an article, determining that any such testimony would be inadmissible hearsay regardless of potential harm to the plaintiffs. The court noted that even if the trial court's reasoning was flawed, it could still affirm the decision if valid grounds existed. Regarding the plaintiffs’ attempt to use the article to impeach the credibility of the defendants’ expert witness, Dr. Joel Rein, the court ruled that the article's prejudicial effect outweighed its probative value. Rein did not recognize the article as authoritative and testified he did not rely on it to formulate his opinions on the applicable standard of care, which postdated the relevant surgery by four years. The court permitted inquiry into whether Rein had read the article, but prohibited questions about its content. Ultimately, the court found no abuse of discretion in excluding the article for impeachment purposes during Rein’s cross-examination. The judgment was affirmed, with other judges concurring. The case involved plaintiffs Nancy B. Farrell and Cynthia B. Grocki, executrices of Mary D. Blakely's estate, whose husband had a derivative claim for loss of consortium. The jury ruled in favor of the defendants, concluding that Bass did not violate the applicable standard of care, which was not contested regarding proximate cause. The applicable law outlines the qualifications of expert witnesses in medical malpractice cases, particularly concerning health care providers' specialties.
General Statutes 52-184c allows health care providers to testify as experts in legal actions if they qualify as a 'similar health care provider' or, if not, demonstrate sufficient training, experience, and knowledge in a related medical field to provide expert testimony regarding the professional standard of care. This expertise must result from active involvement in practice or teaching within five years preceding the incident in question. In the case involving Blakely, her cardiologist, Steven Cohen, and primary care physician, Wayne Paulekas, did not testify at trial; however, both were permitted to express their opinions that Bass’ breach of the standard of care caused Blakely’s stroke and subsequent death. Connecticut Code of Evidence 4-3 allows for the exclusion of relevant evidence if its probative value is outweighed by the risks of unfair prejudice, confusion, or undue delay. Additionally, Connecticut Code of Evidence 7-4 states that experts may base opinions on facts known to them, even if those facts are not admissible as evidence, provided they are the type typically relied upon in their field. Lastly, Connecticut Code of Evidence 8-3 establishes that statements from recognized learned treatises are admissible and not excluded by the hearsay rule, as long as they are referenced during expert testimony.
