HECHT, Justice.
In this case, we are asked to review a summary judgment ruling dismissing a wrongful death action because it was commenced later than is allowed under Iowa Code section 614.1(9) (2011), a statute of repose limiting the time allowed for commencing medical negligence cases. The plaintiffs contend their case should not have been dismissed because the defendants fraudulently concealed the fact that a tissue specimen harvested from the plaintiffs' decedent more than six years before the filing of this action was not evaluated by a board-certified pathologist. In the alternative, the plaintiffs contend the continuum-of-negligent-treatment doctrine precludes the summary dismissal of this case notwithstanding the statute of repose. For the reasons expressed below, we affirm the district court's grant of summary judgment.
When viewed most favorably to the plaintiffs, the summary judgment record would support the following findings of fact. In September 1996, Erika Herren Anderson sought care from Dr. Charles
When Erika returned to Dr. Love's office on January 2 and February 15, 1997, Dr. Love's examination revealed that pigmentation had returned to the biopsied area. Dr. Love treated the area with liquid nitrogen to freeze the tissue and remove the coloration. Erika returned to Dr. Love's office on June 3, 1997; July 8, 1997; and January 27, 1998, each time complaining that the brown pigmentation had returned. Each time, Dr. Love examined the area and applied liquid nitrogen.
As the pigmentation in the residual tissue had not been permanently eliminated from the biopsy site by the five previous liquid nitrogen treatments, Dr. Love took another tissue specimen on February 28, 1998. Dr. Love sent this specimen to Iowa Pathology Associates, but not for evaluation. Instead, Iowa Pathology Associates mounted the specimen on a slide and returned it to Dr. Love for his analysis. Dr. Love concluded this specimen, like the earlier one, was noncancerous. It was thereafter inadvertently destroyed.
Dr. Love took additional tissue specimens from the same area of Erika's neck on September 4, 1998; April 1, 1999; April 9, 1999; and April 15, 1999, and sent them to Iowa Pathology Associates for evaluation. Upon evaluation of the April 1 tissue sample, Dr. Scupham observed "mitotic figures"
Erika continued to consult Dr. Love for her dermatological concerns after April 15, 1999. Dr. Love harvested additional tissue specimens from parts of Erika's body other than her neck on September 26, 2000; September 10, 2002; March 15, 2004; June 14, 2006; and September 6, 2007.
Erika discovered a lump on her chin in March 2008, and she consulted an ear, nose, and throat physician at the Iowa Clinic. The lump was ultimately removed and evaluated by a pathologist. The pathologist diagnosed Erika with melanoma on August 19, 2008. Following the diagnosis, pathologists evaluated each of the tissue samples previously examined by Dr. Scupham. The evaluations revealed each of the specimens harvested by Dr. Love on September 18, 1996; April 1, 1999; and April 9, 1999, contained microscopic evidence supporting a diagnosis of melanoma. The plaintiffs' experts further opined the February 28, 1998 specimen evaluated by Dr. Love before it was inadvertently destroyed also would have shown microscopic evidence of the presence of melanoma consistent with specimens taken before and after that date.
The cancer ultimately took Erika's life in November 2009. The plaintiffs — Erika's estate, her husband, and her children — brought this medical malpractice action on August 11, 2010. The plaintiffs' petition alleged multiple specifications of negligence against Dr. Love, Iowa Dermatology Clinic, and Iowa Pathology Associates.
Dr. Love and Iowa Dermatology Clinic filed a motion for partial summary judgment, and Iowa Pathology Associates filed a motion for summary judgment. The motion of Dr. Love and Iowa Dermatology Clinic asserted the statute of repose barred the plaintiffs' claims of negligence arising out of conduct occurring more than six years before the filing of the petition on August 11, 2010. The motion filed by Iowa Pathology Associates claimed entitlement to summary judgment as to the entirety of the plaintiffs' claims because it provided no medical services or treatment during the six years prior to the commencement of this action.
The plaintiffs resisted the motions, asserting the defendants were equitably estopped from asserting the statute of repose as a defense under the doctrine of fraudulent concealment. The plaintiffs asserted Erika and her husband had a right to know a pathologist did not evaluate the February 28, 1998 slide and that the defendants concealed this material fact. The plaintiffs also urged the district court to overrule the defendants' motions pursuant to the continuum-of-negligent-care doctrine.
The district court granted the motions for summary judgment. The court rejected the plaintiffs' fraudulent-concealment argument because, in its view, the summary judgment record did not contain evidence tending to prove the defendants failed to disclose to Erika that the February 28, 1998 tissue sample was not evaluated by a pathologist. The court further concluded the defendants did not have a duty to inform Erika that the slide was being evaluated by a dermatologist rather than a pathologist. The court also rejected the plaintiffs' argument that the continuum-of-negligent-treatment doctrine precluded summary judgment in favor of Dr. Love and Iowa Dermatology Clinic, PLC. The district court declined to apply the doctrine, reasoning that it would be "more prudent and judicially economical" for the question to be answered by this court on appeal. The district court then revealed that if the doctrine were recognized under
Summary judgment is appropriate
Iowa R. Civ. P. 1.981(3); Christy v. Miulli, 692 N.W.2d 694, 699 (Iowa 2005). A fact question exists "if reasonable minds can differ on how the issue should be resolved." Walker v. Gribble, 689 N.W.2d 104, 108 (Iowa 2004). The district court's ruling on a motion for summary judgment is reviewed for correction of errors of law. Christy, 692 N.W.2d at 699.
The issues before us on appeal revolve around Iowa's statute of repose for medical malpractice claims.
Iowa Code § 614.1(9)(a). Unlike the statute of limitations, under which a claim accrues for injuries caused by medical negligence when the plaintiff knew, or through the use of reasonable diligence should have known, of the injury, a statute of repose runs from the occurrence of the act causing the injury. Albrecht v. Gen. Motors Corp., 648 N.W.2d 87, 92 (Iowa 2002). Because the period of repose begins running when the injury-causing act occurs, the statute of repose can in some cases prevent a claim for medical negligence from arising before the patient even knows or should know she has been injured. Id.; Bob McKiness Excavating & Grading, Inc. v. Morton Bldgs., Inc., 507 N.W.2d 405, 408 (Iowa 1993). In the case before us, the plaintiffs seek to avoid the statute of repose under two theories: the doctrine of fraudulent concealment and the continuum-of-negligent-treatment doctrine.
A party seeking shelter under the doctrine of fraudulent concealment must plead and prove the following:
Christy, 692 N.W.2d at 702 (citation and internal quotation marks omitted). The party alleging fraudulent concealment must prove each of the elements by "a clear and convincing preponderance of the evidence." Id.
Ordinarily, the plaintiff must prove the defendant engaged in affirmative conduct to conceal the plaintiff's cause of action. Id.; Koppes, 384 N.W.2d at 386. The affirmative conduct of concealment must be independent of and subsequent to the liability-producing conduct. Christy, 692 N.W.2d at 702. However, our caselaw recognizes an exception that relaxes the requirement of affirmative concealment when a fiduciary or confidential relationship exists between the party concealing the cause of action and the party claiming fraudulent concealment. Koppes, 384 N.W.2d at 386; see also Schlote v. Dawson, 676 N.W.2d 187, 195 (Iowa 2004); Langner v. Simpson, 533 N.W.2d 511, 522 (Iowa 1995). "The close relationship of trust and confidence between patient and physician gives rise to duties of disclosure which may obviate the need for a patient to prove an affirmative act of concealment." Koppes, 384 N.W.2d at 386.
The plaintiffs contend Dr. Love should have explained to Erika that he was interpreting the February 28, 1998 slide himself rather than having it examined by a board-certified pathologist. The plaintiffs contend a board-certified pathologist is the "best qualified person" to interpret such specimens and that had Erika been informed that the specimen would not be evaluated by a pathologist she would have insisted that this be done. The plaintiffs further contend the fraudulent concealment of this information by Dr. Love also precludes Iowa Pathology Associates' reliance on the statute of repose because it participated in the "collective care" of Erika during the relevant time periods.
We conclude, as did the district court, that the plaintiffs' resistances failed to produce admissible evidence tending to prove Erika was not informed that Dr. Love evaluated that specimen.
Dr. Love's uncontroverted deposition testimony indicated that it was his common practice to inform his patients whether he would evaluate their biopsy specimens himself or whether he was going to send the slide to a pathologist for evaluation.
The plaintiffs have offered no admissible evidence to rebut the testimony of Dr. Love that he informed Erika that it was he who would evaluate her tissue specimen from the February 28, 1998 biopsy. Although Erika's husband averred in an affidavit that Dr. Love never told him or Erika that not all of the slides would be interpreted by a board-certified pathologist, he does not allege he was present with Erika during any of her appointments with Dr. Love or that Dr. Love communicated separately with him on any occasion. The plaintiffs do not contend Dr. Love had a separate obligation to inform Erika's husband as to the identity or qualifications of the person who evaluated the specimen in question. The plaintiffs have also not offered any evidence to rebut Dr. Love's claim that Erika would have received notice that he evaluated that tissue specimen and others through bills for the service from his office during the course of treatment. Accordingly, with only the testimony of Erika's husband, which amounts to mere speculation that Erika was not informed that Dr. Love performed the evaluation of the February 28, 1998 specimen, we conclude the plaintiffs have not engendered a fact question on whether Dr. Love concealed the fact that he, rather than a pathologist, evaluated the slide.
The plaintiffs further assert that, even if Dr. Love told Erika that he would personally evaluate the February 28, 1998 tissue specimen, he did not explain to her the differences in qualifications and training between himself and a board-certified pathologist. The plaintiffs contend this constituted a failure to disclose a material fact because, had Erika known the difference in qualifications, she would have insisted a pathologist review the slide. The plaintiffs argue we should apply an informed consent analysis to this determination — that a physician's failure to disclose a material risk in the context of informed consent constitutes a concealment of a material fact that justifies application of the fraudulent-concealment doctrine in this case.
Under the informed consent doctrine, a physician must disclose information material to a patient's decision to consent to medical treatment. Pauscher v. Iowa Methodist Med. Ctr., 408 N.W.2d 355, 360 (Iowa 1987). In Pauscher, this court endorsed the "patient rule" in determining the scope of a physician's duty to disclose information before a procedure or treatment begins. Id. at 359. Under the "patient rule," the physician's duty to disclose is "measured by the patient's need to have access to all information material to making a truly informed and intelligent decision concerning the proposed medical procedure." Id. Specifically, the plaintiff must show that "[d]isclosure of the risk would have led a reasonable patient in plaintiff's position to reject the medical procedure or choose a different course of treatment." Id. at 360.
Even assuming without deciding this test for materiality is applied to the determination of whether a material fact has been withheld from the patient for fraudulent concealment purposes, we do not conclude the plaintiffs have generated a genuine issue of material fact on this issue. Although Erika's husband averred that had Erika known some of her slides were being interpreted by a dermatologist rather than a pathologist he believes Erika would have insisted on having the slides interpreted by a pathologist or sought care elsewhere, our informed consent caselaw provides that
Id. at 360. On this issue, the plaintiffs have offered only the affidavit of Dr. Trueblood averring that "board certified pathologists... have superior training ... to recognize cellular abnormalities, including melanoma, under a microscope than do dermatologists." Importantly, Dr. Trueblood's affidavit did not address the nature of the risk arising from Dr. Love's evaluation of the February 28, 1998 biopsy slide or the likelihood of its occurrence. The importance of such expert opinion testimony at the summary judgment juncture in this case is heightened by the deposition testimony of Dr. Scupham who testified that approximately fifty percent of dermatologists evaluate biopsy slides themselves without the aid of a pathologist. Dr. Scupham further testified that, although pathologists have more formal training than dermatologists in diagnosing skin lesions, dermatologists derive "powerful" informal training and education in the course of their clinical practice aiding them in their diagnoses. We therefore conclude the evidence in the summary judgment record is insufficient to raise a genuine issue of material fact as to whether Dr. Love's failure to disclose the difference in qualifications between himself and a pathologist was a failure to disclose a material fact for purposes of our application of the fraudulent-concealment doctrine.
Accordingly, we affirm the district court's grant of summary judgment on this issue.
The defendants urge us to reject the application of the continuum-of-negligent-treatment doctrine to the statute of repose, and in the alternative, if we conclude it does apply, the defendants contend the plaintiffs have failed to establish genuine issues of material fact on the elements of the doctrine.
We begin by clarifying that the plaintiffs have not argued for the application of the doctrine of continuous treatment but instead have asserted only the application of the continuum-of-negligent-treatment doctrine. The two doctrines are distinguishable. Under the continuing-treatment doctrine,
Ratcliff v. Graether, 697 N.W.2d 119, 124-25 (Iowa 2005) (citation and internal quotation marks omitted). In contrast, under the continuum-of-negligent-treatment doctrine, a plaintiff must establish "(1) that there was a continuous and unbroken course of negligent treatment, and (2) that the treatment was so related as to constitute one continuing wrong." Langner, 533
Dr. Love treated Erika on three occasions within the six-year statute of repose: September 15, 2004; June 14, 2006; and September 6, 2007. The motion for partial summary judgment filed by Dr. Love and Iowa Dermatology requested summary judgment for claims based on Dr. Love's conduct prior to September 15, 2004. We therefore address whether a genuine issue of material fact was engendered in the summary judgment record as to whether Dr. Love's care and treatment of Erika before that date constituted "a continuous and unbroken course of negligent treatment" that extended into the period of repose and whether "the treatment was so related as to constitute one continuing wrong." See Langner, 533 N.W.2d at 522.
The plaintiffs' petition alleged Dr. Love and Iowa Dermatology were "negligent and failed to comply with accepted standards of dermatological practice" from September 18, 1996, through September 6, 2007. The plaintiffs further alleged that Dr. Love negligently failed to diagnose and treat the melanoma in Erika's body, failed to have a qualified pathologist evaluate all of Erika's tissue samples, and otherwise failed to exercise the appropriate standard of care in his care and treatment of Erika.
We believe the plaintiffs have engendered a fact question on whether there was continuous treatment by Dr. Love of the site of the melanoma on Erika's neck within the statute of repose. Specifically, the summary judgment record indicates, in the medical records and testimony of Dr. Love himself, that Dr. Love inspected Erika's neck and the site of the excised lesion twice in 2004, once in 2006, and once in 2007. Although some of these examinations were also directed at moles or lesions on other parts of Erika's body, the record clearly raises a fact question that he regularly examined the side of Erika's neck during the repose period.
However, we cannot conclude the record engenders a fact question on whether the care that continued into the period of repose constituted negligent care, even assuming without deciding that continuing negligent care would overcome the statute of repose. The summary judgment record contains no evidence that any of the treatment provided by the defendants after April 15, 1999, fell below the applicable standard of care. Put another way, the plaintiffs have failed to provide any evidence that the applicable standard of care required defendants to do something after that date that they failed to do under the circumstances. Although the record does include evidence tending to support a finding that melanoma was detectable in the tissue samples removed from Erika's neck in 1996 through 1999, we find no expert testimony in this record establishing that, under the applicable standard of care, the defendants should have undertaken other diagnostic procedures or treatment modalities after April 15, 1999, under the circumstances of this case. Notably, Dr. Trueblood's affidavit did not address the standard of care required of Dr. Love after April 15, 1999, in his care and treatment of Erika, given the fact that the pathologist's report upon which he relied for the evaluation of the biopsy taken on that date was not positive for melanoma, nor did the affidavit state in what particulars Dr. Love's conduct after that date fell below that standard.
We conclude by noting that our decision in this case evidences the harsh consequences of statutes of repose that "reflect the legislative conclusion that a point in time arrives beyond which a potential defendant should be immune from liability for past conduct." Albrecht, 648 N.W.2d at 91 (citation and internal quotation marks omitted). Iowa Code section 614.1(9) operated in this case to "extinguish" Erika's cause of action even before she and her husband knew it had accrued. Id. at 90-91. At least under the circumstances presented here, the fraudulent-concealment doctrine and the continuum-of-negligent-treatment doctrine do not preserve the plaintiffs' causes of action, and section 614.1(9) denies the plaintiffs a remedy for negligent acts or omissions occurring more than six years prior to the commencement of this action.
For the above reasons, we affirm the decision of the district court.
All justices concur except APPEL, J., who takes no part.
