J. JONES, Justice.
This is a medical malpractice case arising from a cataract operation performed by Dr. Scott Pressman on plaintiff-appellant Franz Suhadolnik. The Suhadolniks appeal the district court's summary judgment order in favor of Respondents based on its determination that the Appellants' expert, Dr. Hofbauer, failed to adequately inform himself on the local standard of care. We affirm.
Appellant Franz Suhadolnik argues that his cataract surgeon, Dr. Pressman, failed to adequately inquire about his prior use of the prescription drug Flomax,
Suhadolnik met with Dr. Pressman at The Eye Associates in Boise, in October of 2005, to discuss the possibility of cataract surgery. During this visit, Dr. Pressman performed an eye exam, and informed Suhadolnik that he would need cataract surgery at some point in the future. Suhadolnik completed a medical history form during the visit, which did not list Flomax as a current medication. Suhadolnik testified that this description was accurate because he started taking the medication in December of 2005 (two months after the October visit), pursuant to a prescription from his personal care physician, Dr. Paris. After experiencing several ill side effects, Suhadolnik quit taking Flomax in approximately January of 2006, but resumed use of the prescription in a lesser dosage after the cataract surgery with Dr. Pressman.
Suhadolnik elected to forgo cataract surgery until May of 2006, when he contacted The Eye Associates and was informed he needed a clearance for surgery from his physician. Dr. Paris performed this exam on May 25, 2006, and cleared him for surgery. The first page of the document created during this exam lists "current medications" taken by Suhadolnik as: Simvastatin, Cyclocort, Lisinopril, and "FLOMAX 0.4MG, 1 TAB QD-days, 30, Ref: 11." Flomax is also separately identified as a prescription on the second page. Dr. Pressman testified that this document was in his file, and presumably available to him prior to the surgery, but that he had no recollection of reviewing it prior to Suhadolnik's surgery.
On May 30, 2006, Suhadolnik went to The Eye Associates for a pre-operation visit. During this visit, Suhadolnik completed another medical history form, and signed consent forms. The medical history form asked the patient to "List all meds and dosages you use," and only Zocor and Lisinopril were identified in response. The additional paperwork completed during this visit included an informed consent form for the cataract surgery, which warned that: 1) the results of the surgery could not be guaranteed; 2) complications of the surgery to remove the cataract could make vision in the eye worse; and 3) lens implantation may include loss of corneal clarity, infection, an inability to dilate the pupil, and dislocation of the lens and retina. Yet another form identified the risks of anesthesia.
Dr. Pressman performed the cataract surgery on May 31, 2006. During the surgery, Suhadolnik's lens capsule came out of position allowing vitreous fluid to come into the anterior chamber of the eye. Pressman removed the fluid and placed an intraocular lens in the anterior portion of the eye; however,
Franz and Betty Suhadolnik filed this action in May of 2008, alleging that the defendants provided negligent care in the performance of Suhadolnik's cataract surgery. They also allege that the defendants failed to obtain Suhadolnik's informed consent as required by I.C. §§ 39-4501 through 39-4507. The defendants moved for summary judgment arguing that: 1) Dr. Pressman's affidavit was sufficient to shift the burden to the plaintiff to demonstrate that a material fact existed regarding a breach of the local standard of care; and 2) Dr. Pressman obtained the requisite consent from Suhadolnik prior to surgery because the risks of Flomax were inconclusive at the time of the surgery. In response, the Suhadolniks submitted the affidavit of Dr. Hofbauer in support of their argument that Dr. Pressman failed to meet the local standard of care and failed to obtain Suhadolnik's informed consent. However, the district court determined that Dr. Hofbauer's affidavit was inadmissible because he failed to demonstrate actual knowledge of the local standard of care and, therefore, granted summary judgment to the defendants on both counts. The Suhadolniks appealed to this Court.
Before determining whether there is sufficient evidence to raise a genuine issue of material fact to preclude summary judgment, this Court must first address the admissibility of expert testimony. Dulaney v. St. Alphonsus Reg'l Med. Ctr., 137 Idaho 160, 163, 45 P.3d 816, 819 (2002).
Id. (internal citations omitted).
McDaniel v. Inland Northwest Renal Care Group-Idaho, LLC, 144 Idaho 219, 221-22, 159 P.3d 856, 858-59 (2007) (internal citations omitted).
A precondition to the admission of testimony by a medical expert in a malpractice
Respondents argue that Dr. Hofbauer failed to demonstrate how he familiarized himself with the local standard of care, pointing out that Dr. Pressman's deposition did not provide sufficient information regarding any relevant standard of care. Respondents also argue that there is no evidence that a local standard has been replaced by state or federal regulatory standards such that Dr. Hofbauer's knowledge of the national standards would be sufficient to define the local standard of care. Finally, Respondents argue that resolution of the question of the admissibility of expert testimony is a precursor to applying the liberal construction rules pertaining to a summary judgment motion, and that the district court did not improperly weigh conflicting evidence.
The district court determined that the defendants met their initial summary judgment burden by providing Dr. Pressman's affidavit, wherein he testified that he was familiar with the local standard of care for ophthalmology and cataract surgery in May of 2006 and that he did not breach that standard.
In order to avoid summary judgment in a medical malpractice case, a plaintiff must provide expert testimony that the defendant doctor, or other health care provider, "negligently failed to meet the applicable standard of health care practice." Dulaney, 137 Idaho at 164, 45 P.3d at 820. In order for expert testimony to be admissible in a medical malpractice claim, the party must demonstrate:
Id. (citing I.C. § 6-1013) (emphasis added). Additionally, I.C. § 6-1012 defines the community standard of care as:
Dulaney, 137 Idaho at 164, 45 P.3d at 820 (citing I.C. § 6-1012) (internal citations omitted).
In addition to these foundational requirements, I.R.C.P. 56(e) requires that affidavits submitted on a motion for summary judgment must "set forth such facts as would be admissible in evidence, and shall show affirmatively that the affiant is competent to testify to the matters stated therein." I.R.C.P. 56(e). The affiant must have personal knowledge of the facts contained within the affidavit and statements within it cannot be conclusory or speculative. Dulaney, 137 Idaho at 164, 45 P.3d at 820. Therefore, in a medical malpractice action, an expert must show that he or she is familiar with the local standard of care for the relevant timeframe and specialty, and "must also state how he or she became familiar with that standard of care." Id.
An out-of-area expert can meet the foundational requirement of personal knowledge by inquiring of a local specialist regarding the standard of care. Id. (citing Perry v. Magic Valley Reg'l Med. Ctr., 134 Idaho 46, 51, 995 P.2d 816, 821 (2000)). Additionally, when consulting with a local specialist, that specialist need not have practiced in the same field as the defendant, so long as the consulting specialist is sufficiently familiar with the defendant's specialty. See Newberry v. Martens, 142 Idaho 284, 292, 127 P.3d 187, 195 (2005). The plaintiff's expert can also make inquiries to another out-of-area specialist, so long as that specialist has had sufficient contacts with the area in question to demonstrate personal knowledge of the local standard. See Shane v. Blair, 139 Idaho 126, 130, 75 P.3d 180, 184 (2003).
Furthermore, where an expert demonstrates that a local standard of care has been replaced by a statewide or national standard of care, and further demonstrates that he or she is familiar with the statewide
Although Kozlowski and Perry are cited in subsequent decisions by this Court as providing a standard for the admissibility of expert testimony based on review of deposition testimony alone, this is an inappropriate characterization of the cases. See, e.g., Grover, 137 Idaho at 251, 46 P.3d at 1109 ("An out-of-state expert can become familiar with the local standard of care ... by `review of a deposition stating that the local standard does not vary from the national standard, coupled with the expert's personal knowledge of the national standard." (citing Perry, 134 Idaho at 51-52, 995 P.2d at 821-22)). In Kozlowski, the out-of-area expert reviewed not only deposition testimony, but also contacted a local practitioner to become familiar with the local standard of care. "In an effort to determine the local area standard of care, [plaintiff's expert] read the deposition of [defendant ob-gyn] Rush, the depositions of several nurses, spoke to a board certified ob-gyn who was practicing in Pocatello at the same time Stephanie was born, and read the deposition of Dr. V. Gene Rufi who is another board-certified ob-gyn practicing in Pocatello." 121 Idaho at 829, 828 P.2d at 858. Additionally, in Perry, the plaintiff's expert "reviewed the depositions of three Hospital nurses; reviewed a standard nursing text...; talked with the executive director of the Idaho Board of Nursing; and spoke with nursing faculty members at two Idaho nursing schools to determine whether the Twin Falls standard for administering intramuscular injections differed in any way from the national or state-wide standard." 134 Idaho at 51, 995 P.2d at 821. Therefore, the experts in Kozlowski and Perry clearly reviewed more than the defendant's deposition testimony in order to become familiar with the local standard of care.
While this Court has never affirmed the admissibility of expert testimony based solely on an expert's review of deposition testimony, we have stated that this may be sufficient. "[I]t may be possible for an expert to become familiar with the local standard of care by reviewing the defendant doctor's deposition...." Rhodehouse v. Stutts, 125 Idaho 208, 212, 868 P.2d 1224, 1228 (1994) (emphasis added). See also Newberry, 142 Idaho at 292, 127 P.3d at 195 ("Inquiring with a local specialist is `one method' an expert witness may obtain such knowledge, but it is not the only method.") (internal citation omitted). In Rhodehouse, the plaintiff's expert based his knowledge of the local standard of care on the defendant's deposition, 35 mm films, and hospital records. Id. at 212, 868 P.2d at 1228. Although the Court acknowledged that such a review might provide an adequate foundation for an expert's knowledge of the local standard of care, it found the deposition in that case to be insufficient because the deposition "never stated that the local standard of care was the same as the national standard, nor in fact did [the defendant-doctor] make any direct reference to the local standard of care."
In this case, the Suhadolniks' expert, Dr. Hofbauer, stated that the local standard of care for cataract surgery in Boise, Idaho, in May of 2006, required an ophthalmologist to: (1) be current on medical literature and FDA advisories; (2) take an adequate medical history; and (3) advise patients of risks and complications thereby allowing them to make an informed decision. Dr. Hofbauer also stated that "[t]hese standards of care are very basic standards of ophthalmologists. In my opinion the standards of care relevant to Dr. Pressman's treatment of Mr. Suhadolnik do not vary by locale and thus could be considered the same as national standards."
Dr. Hofbauer is a board-certified ophthalmologist currently practicing in Beverly Hills, California, with a multitude of experience in ophthalmology and cataract surgeries. Therefore, he is presumed to be knowledgeable of the class of specialists of which Dr. Pressman is a member. However, he must also demonstrate knowledge of the local standard of care in order for his testimony to be admissible.
Dr. Hofbauer stated in his affidavit that his knowledge of the local standards was derived from the following sources:
While the district court acknowledged that an out-of-area expert can demonstrate knowledge of a local standard of care by reviewing deposition testimony, the court held that Dr. Pressman's deposition did not contain sufficient evidence of the local standard to render Dr. Hofbauer's affidavit admissible. Specifically, the court noted that: (1) Dr. Pressman testified that he was not aware of the standard of practice in 2006 for patients who were, or had been, on Flomax because the medical evidence was inconclusive at the time; and (2) Dr. Pressman never testified that the local standard was the same as the national standard. This determination is not an abuse of discretion because reliance on deposition testimony alone is already at the outer bounds of adequate foundational evidence, and because Dr. Pressman's testimony is too inconclusive to provide a sufficient basis of knowledge for Dr. Hofbauer's conclusions.
The facts of this case are similar to Rhodehouse, wherein an expert attempted to rely on deposition testimony without speaking to a local specialist, because Dr. Hofbauer did not rely on a conversation with a local practitioner in order to familiarize himself with the local standard of care. Although Idaho case law does not specifically require such a discussion, this fact alone distinguishes this case from Kozlowski (expert reviewed defendant's deposition, the depositions of several nurses and spoke to a local specialist), Perry (expert reviewed the deposition testimony of three nurses and spoke to the executive director of the state nursing board, as well as several faculty members at Idaho schools), Hayward (expert spoke to local pharmacist, reviewed depositions of defendant-pharmacists, and reviewed plaintiff's medical records), Grover (expert spoke to several local dentists, administered and observed state licensing exams and was familiar with national standards adopted in the state), and Shane (expert spoke to another out-of-area expert familiar with the standard of care), wherein all of the experts spoke to local specialists, or persons knowledgeable of the local standard, in order
Furthermore, this case is also similar to Rhodehouse, where the reviewed deposition failed to identify the local standard of care or the existence of a national standard, because Dr. Pressman's deposition gives no indication that the local standard had been replaced by a national standard and makes only vague references to a local standard of care.
(emphasis added). Review of this testimony indicates that Dr. Pressman had no personal knowledge of a local standard of care regarding precautions to take with patients who had used Flomax or as to what information to provide such patients regarding the increased risks resulting from prior use of Flomax. Furthermore, although Dr. Pressman states that he personally would have
The Suhadolniks argue that the district court erred in narrowing the standard of care to Flomax in particular, rather than allowing the general standard testified to in Dr. Pressman's deposition regarding "adequate patient history" and "staying informed on medical journals" to be a sufficient basis for the local standard.
In his deposition, Dr. Pressman stated:
Dr. Hofbauer used these general admissions as a basis for his standards regarding adequate patient histories and reviewing medical journals in paragraph 6(a), (b), and (d) of his affidavit. However, the district court identified the local standard of care as "concerning precautions due to past use of the medication Flomax" specifically and did not address Dr. Hofbauer's reiteration of the more general standards of care.
The district court's narrowing of the standard of care to Flomax particularly is not an abuse of discretion because this Court generally identifies the standard of care in terms of the major facts appurtenant to the case. See Perry, 134 Idaho at 51, 995 P.2d at 821 (identifying the relevant standard of care as the administration of intramuscular injections); Kozlowski, 121 Idaho at 829, 828 P.2d at 858 (identifying the standard as requiring ob-gyns to "conduct a biophysical profile or use ultrasound to determine fetal size");
Finally, the Suhadolniks argue that even if Dr. Pressman's deposition testimony is inadequate to establish a standard of care for taking a patient's medical history, this standard is a statewide standard that has replaced the local standard of care. They argue that, like in Grover, where statewide dental standards replaced any local standard for taking a patient's medical history, I.C. §§ 54-1811 through 54-1834 similarly require an adequate patient history regardless of what is customary in a particular locale. The Suhadolniks fail to cite any text from these statutory provisions and fail to provide any argument as to how these provisions have replaced the local standard for taking a patient's medical history. Rather, they cite to Grover as establishing a statewide mandate in every profession requiring an adequate patient history. However, the Court in Grover emphasized the power of the state licensing board of dentistry to implement statewide standards, specifically addressed the act adopted by the Legislature in implementing these standards, and identified the expert's familiarity with these standards because of his administration and observation of the state licensing exam, in order to support the determination that the local standard of care had been replaced by a statewide standard of care.
The Court is cognizant of the fact that outside experts may encounter difficulty in locating a local practitioner who will cooperate in providing information regarding the standard of care prevailing in the community, particularly in smaller communities where practitioners live and work in rather close proximity with one another. On the other hand, the Court is also cognizant of the fact that increased communication and availability of medical information has resulted in more standardization of practice between practitioners in urban centers and those in rural communities. As we noted in McDaniel, "Recent years have witnessed increasing standardization in the health care profession, due to a variety of factors." 144 Idaho at 224, 159 P.3d at 861. Those factors include governmental regulation, development of regional and national provider organizations, and greater access to the flow of medical information. We stated, "in the present medical care environment, there are a variety of ways that a medical malpractice plaintiff may be able to establish a local standard of care as being synonymous with a regional or national standard of care." Id. As shown above, there are various avenues by which a plaintiff may proceed to establish a standard of care, with or without the cooperation of local practitioners. The record in this case does not reflect what efforts, if any, Suhadolnik or his expert made to learn the standard of care from a local practitioner (other than from Dr. Pressman's deposition), but it isn't too much to ask of a plaintiff that some effort be made. Failing that, Suhadolnik's counsel could have made a more valiant effort to piece together a case from Dr. Pressman's deposition and affidavit but failed to do so.
Because the Suhadolniks have failed to establish Dr. Hofbauer's actual knowledge of the local standard of care pertaining to cataract surgery, the district court acted within its discretion in holding his testimony to be inadmissible. We therefore affirm that holding.
The Respondents argue that the Suhadolniks waived any argument on appeal regarding their claim for lack of informed consent because it was not separately raised or briefed before this Court. The Suhadolniks only provide argument in their opening brief regarding the foundational requirements for a medical malpractice claim and fail to separately identify their informed consent claim as an issue on appeal.
A medical malpractice claim is a cause of action separate and distinct from a claim for lack of informed consent. Foster v. Traul, 141 Idaho 890, 894-95, 120 P.3d 278, 282-83 (2005). The foundational requirements for expert testimony for an informed consent claim vary somewhat from those in I.C. §§ 6-1012 and 1013. According to I.C. § 39-4506:
In their opening briefs, the Suhadolniks make no mention of this or the other informed consent statutes, nor do they present argument as to how the district court may have erred in applying I.C. §§ 6-1012 and 1013 to the informed consent issue. Therefore, the issue is waived on appeal.
Respondents argue that they are entitled to attorney fees on appeal pursuant to civil rule 54(e)(1) and I.C. § 12-121. "Idaho Code § 12-121 permits an award of attorney fees in a civil action to the prevailing party if the court determines the case was brought, pursued or defended frivolously, unreasonably or without foundation." Newberry, 142 Idaho at 292-93, 127 P.3d at 195-96. Although Respondents prevail on appeal, the Suhadolniks' arguments are not unreasonable. As previously discussed, the case law suggests that review of deposition testimony alone can provide an appropriate foundation for expert knowledge of the local standard of care and the deposition relied on in this case identified several general standards used by Dr. Hofbauer. Although they are ultimately too general to identify the local standard of
The Court affirms the district court's exclusion of Dr. Hofbauer's affidavit for failure to meet the foundational requirements of I.C. § 6-1013. Consequently, the Court affirms the district court's grant of summary judgment in favor of the Respondents. Costs on appeal are awarded to Respondents.
Justices BURDICK, W. JONES and HORTON concur.
Chief Justice EISMANN, specially concurring.
I concur in the majority opinion, but write only to add additional thoughts as to what is required to establish the local standard of care. "How an expert becomes familiar with that standard of care is a legal issue, not a medical issue." Ramos v. Dixon, 144 Idaho 32, 37, 156 P.3d 533, 538 (2007). Thus, the medical expert needs assistance from counsel in knowing what is required to learn the applicable standard of care.
The applicable standard of care must be specific to the issues of care involved in the particular case. "The standard of care is simply the care typically provided under similar circumstances by the relevant type of health care provider in the community at the time and place of the alleged negligent act." Shane v. Blair, 139 Idaho 126, 130, 75 P.3d 180, 184 (2003).
In this case, Dr. Pressman answered "yes" to the questions of whether it was the standard of practice "to take an adequate history before you did a cataract history," "to keep current in the medical literature in your field," and to "pay attention to [what the FDA says about drugs]." General questions such as this do not establish the applicable standard of care, any more than a question such as, "It is the local standard of care not to commit malpractice?"