JUAN R. SÁNCHEZ, District Judge.
In November 2008, following a routine employee tuberculosis screening, Greater Philadelphia Health Action (GPHA) employee Elaine Booker (Ms. Booker) was prescribed a drug to treat latent tuberculosis, which ultimately led to her acute liver failure and death. In this Federal Tort Claims Act (FTCA) action, Ms. Booker's daughter, Brandi Booker, in her capacity as administratrix of her mother's estate,
Following a bench trial, and for the reasons discussed herein, the Court concludes Plaintiff failed to show by a preponderance of the evidence that Dr. Mallory-Whitmore owed a duty of care to Ms. Booker or that Dr. Ruddock breached her duty of care to Ms. Booker. The Court further finds that GPHA's Employee Health Program was not defectively designed, and GPHA was not negligent in its supervision or monitoring of its health care providers. Pursuant to Federal Rule of Procedure 52(a), the Court issues the following findings of fact and conclusions of law.
Plaintiff, as administratrix of her mother's estate, seeks damages for her mother's wrongful death. Specifically, she asserts Dr. Ruddock and Dr. Mallory-Whitmore breached the duty of care owed to Ms. Booker by failing to take a health history or conduct a physical examination prior to prescribing INH, and by failing to monitor Ms. Booker's liver function after prescribing INH. Plaintiff also asserts GPHA was negligent in defectively designing the EHP and in failing to supervise or monitor Dr. Ruddock and Dr. Mallory-Whitmore.
Pursuant to this Court's March 31, 2014, decision, this is an action under the FTCA against the United States of America, as sole Defendant. The FTCA operates as a partial waiver of the federal government's sovereign immunity for claims against the Government for money damages caused by "the negligent or wrongful act or omission of any employee of the Government while acting within the scope" of his or her employment. See 28 U.S.C. § 1346(b)(1). In an FTCA action, the Government is liable to the extent that a similarly situated private person would be liable, "in accordance with the law of the place where the act or omission occurred." Id. The relevant acts and omissions in this case occurred in Philadelphia, Pennsylvania, and as such, the law of Pennsylvania is controlling.
In Pennsylvania, a decedent's estate may bring an action to recover damages for the decedent's death caused by the wrongful conduct, including negligence, of another. See 42 Pa. Cons. Stat. § 8301(a). To prove a medical malpractice claim under Pennsylvania law, a plaintiff must establish four elements: (1) a duty owed to the patient by the physician; (2) the physician's breach of that duty; (3) that the breach was the proximate cause of the patient's injury, or alternatively, a substantial factor in bringing about the patient's injury; and (4) damages suffered by the patient directly resulting from that harm. See Mitzelfelt v. Kamrin, 584 A.2d 888, 891 (Pa. 1990). The duty owed by a physician to a patient is a duty to "[p]ossess and [e]mploy . . . the skill and knowledge usually possessed by physicians in the same or a similar locality" when treating the patient, in addition to exercising "the care and judgment of a reasonable [person]." Incollingo v. Ewing, 282 A.2d 206, 213 (Pa. 1971). In a medical malpractice case, the court must first determine the accepted standard of care, and then must determine whether the defendant's conduct adhered to that standard. See Toogood v. Rogal, 824 A.2d 1140, 1149 (Pa. 2003). Plaintiff bears the burden of proving by a preponderance of the evidence that the conduct of the physician or health care facility did not meet the applicable standard of care. See Brannan v. Lankenau Hosp., 417 A.2d 196, 199 (Pa. 1980); Hamil v. Bashline, 392 A.2d 1280, 1284 (Pa. 1978). To meet this burden, the plaintiff is generally required to present medical expert testimony that the physician's conduct fell below the applicable standard of care and that the physician's breach was the proximate cause of the patient's injury, particularly when the standard is outside of "common knowledge or experience." See Donaldson v. Maffuci, 156 A.2d 835, 838 (Pa. 1959) (quoting Robinson v. Wirts, 127 A.2d 706, 709 (Pa. 1956)). Where a physician may undertake more than one option in treating a patient, and both options are within the standard of care, it is not negligent for the physician to choose either of such equally appropriate treatment methods. See Donaldson, 156 A.2d at 838 (collecting cases).
Plaintiff first argues Dr. Mallory-Whitmore breached her duty of care to Ms. Booker by prescribing her INH without taking a medical or social history and without monitoring her liver function throughout the course of the drug. The Court disagrees. Other than the pill bottle that bears Dr. Mallory-Whitmore's name as the prescribing physician, Plaintiff presented no evidence that Dr. Mallory-Whitmore was involved in Ms. Booker's tuberculosis screening or treatment. See Hamil, 392 A.2d at 1284 (placing the burden of proof on the plaintiff in Pennsylvania medical malpractice claims). In fact, other evidence in the record demonstrates that she was not. As noted, Dr. Mallory-Whitmore credibly testified that she did not see Ms. Booker as a patient outside of an encounter relating to a dental issue, and did not write Ms. Booker a prescription for INH. Further supporting the finding that Dr. Mallory-Whitmore did not write Ms. Booker's prescription is Dr. Ruddock's testimony that she, Dr. Ruddock, in fact, wrote the prescription. While Plaintiff claims the pill bottle bearing Dr. Mallory-Whitmore's name is conclusive evidence that she was the prescribing physician, in light of the testimony of Dr. Mallory-Whitmore and Dr. Ruddock, both of whom the Court credits, the bottle is insufficient to prove Dr. Mallory-Whitmore's involvement in prescribing the drug. Having had no participation in the events surrounding Ms. Booker's tuberculosis screening and treatment, Dr. Mallory-Whitmore likewise can have no liability for her death.
Plaintiff next argues Dr. Ruddock breached her duty of care to Ms. Booker for the same reasons: she prescribed INH without taking a medical or social history and without monitoring Ms. Booker's liver function throughout the course of the drug. Consistent with Pennsylvania law regarding medical malpractice, in order to determine whether Dr. Ruddock breached the duty she owed to Ms. Booker, the Court must first establish the appropriate standard of care. See Toogood, 824 A.2d at 1149 (discussing the process for determining whether a physician breached his or her duty of care). To determine the appropriate standard of care, the Court relies upon the expert testimony presented by the parties. See Robinson, 127 A.2d at 709 (explaining the necessity of guidance from witnesses having expert qualifications in defining the appropriate standard of care in a particular medical situation). Both medical experts testified at trial that a patient who has a positive PPD followed by a negative chest x-ray has a diagnosis of latent tuberculosis. According to both Dr. Patterson and Dr. Hamilton, the benchmark standard of care for latent tuberculosis is a nine-month course of INH. The experts also agreed that a patient taking INH who is over 35 years of age should have his or her liver enzymes tested at least monthly to monitor the effect of the drug on the patient's liver. The primary issue here is whether Dr. Ruddock was responsible for undertaking this subsequent monitoring.
While Dr. Patterson agreed with Dr. Hamilton that it is within the standard of care to instruct a patient with latent tuberculosis to see his or her primary care physician for treatment and monitoring, the experts diverged on whether such an instruction is appropriate when the diagnosing physician also writes the prescription for the drug. Dr. Hamilton testified that even if the physician writes an INH prescription, the patient could still be referred to his or her primary care physician to make the ultimate determination on whether the patient should take the medication. In contrast, Dr. Patterson opined that it is the prescribing physician's responsibility to ensure that any testing necessary to monitor the safety and efficacy of the drug is undertaken. However, Dr. Patterson's testimony does not account for the circumstances in which the prescription was given, including the fact that Dr. Ruddock instructed Ms. Booker to discuss the treatment plan with her primary care physician before beginning the drug.
Crediting Dr. Ruddock's testimony, Dr. Ruddock did not intend to assume responsibility for Ms. Booker's treatment for latent tuberculosis when she met with her and wrote the prescription for INH. Rather, Dr. Ruddock intended to, and the Court finds she did, inform Ms. Booker of her results and the recommended treatment plan and, due to the type of medication, instruct Ms. Booker to discuss it with her primary care physician. While there is no documentation to corroborate Dr. Ruddock's recollection regarding the instruction to see her primary care physician, the Court finds Dr. Ruddock's trial testimony on the matter specific and persuasive that the conversation did occur. Ms. Booker and her personal physician were then to decide together, based on the entirety of her health history and current medications, whether she should take the nine-month course of INH. Both experts agreed that the monitoring associated with an INH prescription could be appropriately undertaken by either a patient's primary care physician or a consulting physician. As it was, therefore, equally appropriate for Dr. Ruddock to prescribe INH and monitor Ms. Booker's liver function herself as it was to refer her to her primary care physician, Dr. Ruddock cannot be faulted for choosing the latter of these options. See Donaldson, 156 A.2d at 838 (explaining there can be no liability for a physician who chooses one of two appropriate treatment methods). Dr. Ruddock provided the prescription only as a courtesy to Ms. Booker, so she could obtain it conveniently and at a reduced cost at the facility's on-site pharmacy, especially considering the long duration of time over which Ms. Booker may potentially be taking the drug. Dr. Hamilton, contemplating the exact sequence of events as they took place in this case, testified this was an appropriate course of action, within the standard of care.
Plaintiff also argues that Dr. Ruddock breached her duty to Ms. Booker when she prescribed INH without performing a physical examination or taking a medical or social history. This argument fails to appreciate the context of the events at issue here. Dr. Ruddock saw Ms. Booker only for purposes of tuberculosis screening as part of the EHP, and wrote the prescription for INH only for Ms. Booker's convenience. Dr. Ruddock did not intend to assume responsibility for Ms. Booker's treatment for latent tuberculosis. Furthermore, Plaintiff's expert, Dr. Patterson, conceded that a physical examination and medical and social history are recommended based on literature and guidelines, but not necessarily required prior to prescribing medication. It is also undisputed that INH was not contraindicated for Ms. Booker, such that the taking of a health history would likely not have precluded the INH prescription in any event. Plaintiff's further argument that Dr. Ruddock was overextended in her professional duties is simply irrelevant. At issue here is whether Dr. Ruddock adhered to the standard of care; the number and type of positions she held at the time she saw Ms. Booker through the EHP fails to shed light on the inquiry. Based on the foregoing, the Court finds Plaintiff failed to meet her burden of proving by a preponderance of the evidence that Dr. Ruddock breached the duty of care owed to Ms. Booker. See Hamil, 392 A.2d at 1284 (establishing that the plaintiff bears the burden of proof).
Plaintiff's contentions as to GPHA are likewise unpersuasive. Plaintiff argues GPHA should be held liable for her mother's death because GPHA defectively designed its EHP, particularly in that employees testing positive for latent tuberculosis were required to take INH as a condition of employment. The record belies this charge, as Dr. Janet Young, GPHA's Chief Medical Officer/Director, testified at trial that a patient with latent tuberculosis who had no active symptoms was not, in fact, required to take INH in order to remain employed by GPHA. Nor did the EHP require a prescription for INH to be issued to employees diagnosed with latent tuberculosis at all. Given the EHP's limited scope, the extent of care provided pursuant to the EHP was intentionally left to the professional judgment of the EHP physician involved. Once the objective of screening employees for tuberculosis was accomplished, the medical judgment of the physician controlled, and as discussed above, Dr. Ruddock exercised that judgment appropriately and within the standard of care. Plaintiff further argues that GPHA was negligent in the supervision and monitoring of its employees, but offers little support for this contention. Dr. Young testified as to GPHA's supervisory structure and Plaintiff presented no evidence that this structure was flawed or ineffective. Booker's position that GPHA is vicariously liable for her mother's death because its physicians were acting within the scope of their employment when they breached their professional duties is equally without merit. Because the Court finds no liability with respect to either of the physicians, GPHA is not vicariously liable.
For the reasons set forth above, the Court concludes Plaintiff failed to show by a preponderance of the evidence that Dr. Mallory-Whitmore, Dr. Ruddock, or GPHA is responsible for her mother's death. The Court finds Dr. Mallory-Whitmore did not owe a duty of care to Ms. Booker, Dr. Ruddock did not breach her duty of care, and GPHA's EHP was neither defectively designed nor negligently supervised or monitored. Further, as the Court finds neither of the named physicians is responsible for the death of Ms. Booker, GPHA is similarly not vicariously liable for her death.
For the foregoing reasons, judgment will be entered in favor of the Government. An appropriate Judgment follows.
