Nickerson v. Lee
Decision Date | 27 January 1997 |
Docket Number | No. 95-P-1245,95-P-1245 |
Citation | 674 N.E.2d 1111,42 Mass.App.Ct. 106 |
Parties | Carol M. NICKERSON & another 1 v. Yhu H. LEE. |
Court | Appeals Court of Massachusetts |
Edward Fegreus, Boston, for plaintiffs.
Leslie M. Tector, Boston, for defendant.
Before BROWN, GREENBERG and LAURENCE, JJ.
Aggrieved by the final judgment dismissing her medical malpractice claim against the defendant, Dr. Yhu H. Lee, the plaintiff, Carol M. Nickerson, appeals. A medical malpractice tribunal 2 found her offer of proof deficient because a letter from a podiatrist, Dr. Jeffrey R. Coen, did not provide an explicit statement that the defendant departed from the applicable standard of care. The plaintiff's motions for reconsideration and to supplement the offer of proof were denied. We conclude that the plaintiff's offer of proof, if substantiated at trial, is sufficient to raise a legitimate question of liability.
The tribunal, without passing on the weight or credibility of any of the evidence, see Gugino v. Harvard Community Health Plan, 380 Mass. 464, 468, 403 N.E.2d 1166 (1980), could have found the following facts. On August 8, 1990, the plaintiff went to the East Boston Neighborhood Community Health Center (Center), 3 for treatment of a painful foot. When she first consulted with the defendant, a podiatrist, he took a medical history from her in which she mentioned that several weeks before--while she was having her toe nails cut--another podiatrist scraped a piece of skin underneath the third toe of her right foot. She also told the defendant that she was diabetic. Physical examination of her toe revealed that it was red and swollen. The defendant noted that she had "an infected lesion over the tip" and that pus was draining from the toe. He diagnosed the plaintiff's condition as cellulitis, prescribed medication, and instructed her to soak her toe in a quarter strength Betadine solution followed by application of Bacitracin ointment.
The plaintiff continued to receive treatment of the infected toe at the Center from the defendant and other staff members. On August 16, 1990, a wound culture was ordered. 4 On August 29, the defendant's examination revealed that the plaintiff had no drainage from the toe and lacked sensation. The defendant ordered an X-ray of the plaintiff's toe, which the radiologist reported as showing "no radiographic evidence of osteomyelitis but if that is a clinical concern, bone scan is advised."
On October 8, 1990, the plaintiff returned to the Center complaining of a sore on her right lower leg. She was seen by a physician who noted a sore on her right lower leg that was warm to the touch. She then began to receive fairly regular treatment for the wound on her leg. On her final visit to the Center, October 16, 1990, the defendant made a note in the plaintiff's record that the wound on the right lower leg had decreased substantially and that it appeared as a superficial ulceration with no cellulitis and no lymphangitis. Notes from an earlier office visit on October 11 made by another physician, available to the defendant, suggest that the defendant perhaps ought to have been less certain about whether the infection was clearing up.
Less than a month later, the plaintiff was hospitalized at Massachusetts General Hospital with a diagnosis of diabetic septic foot. A button toe amputation of the third toe of her right foot was performed on the day of her admission. She remained in the hospital for seventeen days and was discharged on November 28, 1990.
Now we bear down on matters related to arguments about the tribunal's decision. During the hearing, the judicial member of the panel suggested that the report of the plaintiff's expert medical witness, Dr. Coen, did not recite, "magic words or a sufficient statement of liability, i.e., the failure to conform to the standard of care." Then, he added:
Under § 60B of G.L. c. 231, a plaintiff is required to adduce an "offer of proof" that persuades the tribunal "that a legitimate question of liability ha[s] been raised." Little v. Rosenthal, 376 Mass. 573, 578-579, 382 N.E.2d 1037 (1978). The standard governing the tribunal's determination is the same as that applicable to a motion for a directed verdict, ibid., that is, the offer of proof is viewed in a light most favorable to the plaintiff. Blake v. Avedikian, 412 Mass. 481, 484, 590 N.E.2d 183 (1992). The statute specifies a wide range of possible sources of admissible evidence to determine whether the defendant failed to conform to good medical practice. 6 However, the critical allegations are usually set forth in an opinion letter describing a "failure to conform to good medical practice." Gugino v. Harvard Community Health Plan, 380 Mass. at 468, 403 N.E.2d 1166. See Kapp v. Ballantine, 380 Mass. 186, 190 n. 4, 402 N.E.2d 463 (1980). Cf. Ward v. Levy, 27 Mass.App.Ct. 1101, 1102, 534 N.E.2d 308 (1989) ( ).
The only question presented by the plaintiff's appeal is whether the plaintiff's expert opinion letter was sufficient to show that the defendant's failure to diagnose the extent of the plaintiff's diabetic neuropathy fell below the applicable standard of care.
Dr. Coen's opinion letter states that on the plaintiff's visit to the Center on August 8, 1990, she was treated by the defendant. He then notes:
The defendant asserts that Dr. Coen's letter did not state that the defendant failed to adhere to accepted medical practice or establish a reference point by which to evaluate the defendant's performance. We do not agree. Parts of Dr. Coen's letter which are reproduced in the margin, show that the defendant's conservative treatment of the plaintiff's infected toe, in light of her diabetic condition, fell below the applicable standard of care. 7
Supreme Judicial Court found that although the opinion letter of the plaintiff's expert did not provide a direct statement on the standard of care, the expert's statements concerning treatment that should have been rendered constituted an "opinion on the course of action that one reasonably exercising the care and skill of an average vascular surgeon should have followed." Id. at 207 n. 6, 613 N.E.2d 82. This was held sufficient to meet the directed verdict standard on the issue of that doctor's negligence.
We added gloss to the Bradford court's formulation in Rahilly v. North Adams Regional Hosp., 36 Mass.App.Ct. 714, 718 n. 6, 636 N.E.2d 280 (1994), holding that a plaintiff's expert need not state his opinion in formulaic terms. Moreover, the tribunal may not refuse to accept an expert's opinion unless the plaintiff's offer of proof is so deficient that as a matter of law it...
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