Woodman v. United States
| Decision Date | 06 May 2022 |
| Docket Number | Civil No. 18-cv-156-LM |
| Parties | Kasey WOODMAN & Mark Foley v. UNITED STATES of America |
| Court | U.S. District Court — District of New Hampshire |
Robert F. Oberkoetter, Pro Hac Vice, Dartmouth, MA, Rosario M. F. Rizzo, Rizzo Law Offices, Concord, MA, for Kasey Woodman & Mark Foley.
Terry L. Ollila, US Attorney's Office, Concord, NH, for United States of America.
Landya McCafferty, United States District Judge In January 2015, Kasey Woodman suffered a severe laceration of her vagina, perineum, and anus while giving birth at Madigan Army Medical Center, Joint Base Lewis-McChord, Washington. United States Army physicians repaired the laceration, but, as the laceration healed, Woodman developed a rare but fixable complication known as a rectovaginal fistula. Even the government's expert agreed that, if performed properly, the success rate for this surgery was higher than 90%. Here, however, the surgery was unsuccessful. Over the next three years, Woodman underwent seven subsequent surgeries, including a highly invasive surgery to divert her fecal matter called an ileostomy, until the fistula was ultimately successfully repaired. Following the repair, Woodman underwent an eighth surgery—plastic surgery to improve the disfigurement she had suffered as a result of the prior surgeries.
In this suit, Woodman alleges that Army physicians should have prevented her perineal laceration (that occurred during childbirth), failed to properly repair the perineal laceration, and failed to properly repair her rectovaginal fistula (that developed following childbirth). Woodman alleges that had Army physicians followed the standard of care, she would not have needed the follow-up surgeries. She also alleges that the physicians who first attempted to repair the rectovaginal fistula were unqualified to perform the surgery. Woodman's ex-husband, Mark Foley, brings a loss of consortium claim premised on Woodman's injuries.
Woodman and Foley bring their suit against the United States under the Federal Tort Claims Act ("FTCA"), 28 U.S.C. § 1346(b)(1). The court held a bench trial in October 2021. This opinion constitutes the court's findings of fact and conclusions of law. See Fed. R. Civ. P. 52(a).
In brief, Woodman has not demonstrated that the United States's medical providers breached the standard of care as to preventing or repairing her fourth-degree perineal laceration. Woodman has shown, however, that they breached the applicable standard of care by attempting to repair her rectovaginal fistula before her tissue was healthy enough to perform the surgery. The failure to properly perform the first fistula repair transformed a complication with a highly favorable prognosis into a complex, recurring medical problem that took years and many additional surgeries to resolve.
As a result, Woodman endured several years of considerable pain, suffering, and mental anguish. The repeated surgeries left Woodman with scars and deformities. Her marriage devolved. And even though the fistula was eventually repaired, Woodman is likely to require future surgeries to correct urinary and fecal incontinence. For those reasons and more discussed below, the court awards damages to Woodman in the sum of $5,000,000, and damages to Foley in the sum of $150,000.
"In an action tried on the facts without a jury or with an advisory jury, the court must find the facts specially and state its conclusions of law separately." Fed. R. Civ. P. 52(a)(1). Here, the court is the trier of fact; when facts are in dispute the court weighs the evidence and makes findings of credibility. See Sawyer Bros., Inc. v. Island Transporter, LLC, 887 F.3d 23, 31 (1st Cir. 2018). Because the events that give rise to this case occurred in the State of Washington, the substantive law of Washington governs. See Gonzalez-Rucci v. U.S. I.N.S., 539 F.3d 66, 69 (1st Cir. 2008).
By agreement of the parties, the court held this FTCA bench trial by videoconference. See doc. nos. 29, 37. The parties agreed to abide by several conditions to ensure the integrity of a trial conducted remotely. See doc. no. 29-2. Trial took place between October 21 and October 28, 2021. Following the presentation of evidence, the court heard oral argument from Woodman and the United States and took the matter under advisement. The court also requested and received supplemental briefs from the parties on several issues. Doc. nos. 40, 42.
During trial, Woodman presented the expert testimony of urogynecologist1 Dr. Roger Lefevre, director of pelvic reconstructive surgery at Beth Israel Deaconess Medical Center in Boston, Massachusetts, and general surgeon Dr. Stephen Camer, former chief of surgery at New England Baptist Hospital. The United States presented the expert testimony of urogynecologist Dr. Patrick Culligan, director of the urogynecology department at Valley Medical Group in New Jersey. In addition, several medical providers who treated Woodman testified, including gynecologist-oncologist Dr. Jan Sunde, obstetrics and gynecology physician ("OBGYN") Dr. Shannon Renfrow, OBGYN Dr. Coleen Korzen,2 urogynecologist Dr. Christa Lewis, urogynecologist Dr. Christine Vaccaro, and nurse-midwife Judith Graham-Bilos.
Throughout this opinion, the court has included specific credibility findings pertinent to individual witnesses and expert opinions. As a general matter, the court found Dr. Lefevre's testimony most credible and therefore gives it the most weight. The court likewise found Dr. Culligan's testimony to be credible. However, Dr. Culligan's testimony was not as comprehensive and persuasive as Dr. Lefevre's testimony. Thus, the court gives Dr. Culligan's opinion significant weight but less than Dr. Lefevre's opinion.
The court gives Dr. Camer's opinions the least weight. Dr. Camer is not an obstetrician and his testimony about obstetrics issues was inconsistent with current medical practice guidance and recommendations. For example, the testimony of both Drs. Lefevre and Culligan contradicted much of Dr. Camer's testimony about the applicable standards of care. The testimony of the treating medical providers, such as Drs. Sunde, Renfrow, Lewis, and Vaccaro—all of whom have specialties or subspecialties in relevant medical fields—likewise contradicted many of Dr. Camer's assertions. Finally, many of Dr. Camer's conclusions were unexplained, particularly when compared to the thoughtful explanations offered by Drs. Lefevre and Culligan. For these reasons, the court gives Dr. Camer's opinion minimal weight.
This case involves a question about what kind of medical training is sufficient to allow a physician to perform certain medical procedures. During trial, several witnesses described the medical training process and the regulation of medical practice. The process of becoming a physician capable of working independently contains several steps: medical school; residency; board certification as a specialist; credentialing; and, sometimes, a fellowship and board certification as a subspecialist.
Medical training begins with four years of medical school. The first two years of medical school involve classroom training. The last two years involve practical training. After medical school, training continues in "residency," which also lasts four years. During this period, residents develop a specialty. These specialties include, for example, cardiology, neurology, and—as relevant in this case—obstetrics and gynecology. First-year residents, who are known as interns, interact with patients and perform procedures from their first day. As they progress through their third and fourth years of residency (and seventh and eighth years of medical training overall), residents may take on senior and supervisory roles. However, when residents perform surgical procedures, an attending physician—that is, a physician who is board certified and credentialed to perform the surgery—always supervises.
In addition to a specialty field, some physicians elect to continue training in a subspeciality through a fellowship, which can last an additional three or four years after residency. As relevant here, OBGYNs can continue their training into subspecialty fields of, among others, gynecology-oncology, urogynecology, and maternal-fetal medicine.
Specialty fields such as OBGYN and subspecialty fields such as urogynecology and gynecology-oncology have governing boards. These governing boards issue practice guidance and regulate who is "board certified" in a particular field. OBGYNs and OBGYN subspecialists obtain board certification from the American Board of Obstetricians and Gynecologists ("ABOG") and receive practice guidance from the American College of Obstetricians and Gynecologists ("ACOG"). The American Urogynecologic Society ("AUGS") also issues practice guidance in the urogynecology field.
ABOG administers examinations—known as "boards"—for each field that, if passed, allow the physician to say they are "board certified" in that field.3 In addition, these and other organizations issue guidance to practitioners in the form of practice bulletins and opinions. Physicians use this guidance to determine acceptable and best practices.
The medical knowledge and practices in different specialties and subspecialities overlap. For example, a board-certified urogynecologist, gynecologist-oncologist, or colorectal surgeon can be expected to have training and experience performing surgeries on the female pelvic anatomy. Nonetheless, the focal points of the subspecialties are different: colorectal surgeons are more familiar with rectal anatomy and approach surgeries from that perspective (e.g., a colorectal surgeon attempted to repair Woodman's fistula through a rectal route); urogynecologists are more familiar with the vagina (the urogynecologists who attempted to repair Woodman's fistula approached through the...
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