(just a quick synopsis)
In an 11-day medical malpractice trial, the court found that an emergency medicine physician and general surgeon both met the standard of care. When providing care to a patient with perianal pain, their examinations and discharge instructions were appropriate, and they were not required to order imaging in the circumstances.
(your key takeaways)
- Choose your standard of care experts carefully. Match specialty, geographical location, and practice setting (e.g., community vs. tertiary) as best as possible.
- Good documentation is important. Contradictions between oral testimony and the written record can negatively affect a witness’ credibility; as can poor memory.
- This is a great case for any lawyer looking for an overview of the law on:
- The standard of care of a physician and specialist;
- Distinction between standard of care and clinical judgment;
- Impact of sympathetic circumstances on the onus of proof;
- Best practices in selecting an expert witness; and,
- Principles in establishing causation.
(links to the full judicial reasons)
Facts
The plaintiff alleged that the defendant physicians, Dr. Benjamin Lee (emergency medicine) and Dr. Arthur Chiu (general surgery), provided negligent care to Helen Martindale on November 21, 2014 and December 31, 2014. The matter proceeded to trial.1
On November 21, 2014, Ms. Martindale attended at a community hospital’s emergency department complaining of perianal pain 7/10. Dr. Lee assessed Ms. Martindale, performed an incision and drainage (I&D) procedure, and found signs of an early infection. Ms. Martindale was discharged with instructions to follow-up with a physician and nursing wound care.
On December 28, 2014, she was told to go to the hospital for a possible prolapsed mucosa.
On December 31, 2014, Ms. Martindale was, again, told to go to the hospital. She subsequently attended at the community hospital’s emergency department, complaining of rectal pain 3/10. An emergency room physician requested a consult from Dr. Chiu for a possible prolapsed mucosa. Dr. Chiu assessed Ms. Martindale and diagnosed her with a prolapsed mucosa and hardened area where Dr. Lee had performed the I&D. Ms. Martindale was discharged with instructions for home care and follow-up at his office.
Ms. Martindale did not seek medical treatment until April 8, 2015, when she attended at a tertiary hospital, complaining she was passing stool through her vagina. Within the next five months, she was diagnosed with recto-vaginal fistula, underwent an ileostomy, was diagnosed with anal cancer, and had chemotherapy and radiation.
The patient passed away on March 6, 2022, for reasons unrelated to the issues in this case.
IssueS
- Did either of the defendant physicians breach the standard of care?
- If so, did the breach cause the plaintiff’s injuries?
Held
No. Justice C.J. Brown found that Dr. Lee and Dr. Chiu both met the standard of care. As such, she found it unnecessary to determine the issue of causation.
REASONS
Comments on Credibility
Before discussing liability, Brown J found that Ms. Martindale was unreliable because her evidence was inconsistent with the medical records and displayed poor memory. Brown J conversely found Dr. Lee and Dr. Chiu to be both credible and reliable because their evidence was candid and forthright, without contraindications or inconsistencies.
Standard of care
Brown J preferred the defendants’ standard of care experts over the plaintiff’s. She affirmed that where experts do not have experience in the same geographical area, care setting, or specialty, their opinion may carry less weight. In this case, Brown J found that the defendants’ experts’ backgrounds, experiences, training, and/or geographical locations were more similar to that of Dr. Lee and Dr. Chiu. This made them better suited to opine on the appropriate standard of care.
Dr. Lee met the standard of care on November 21, 2014. Brown J weighed the evidence and found that Dr. Lee’s examination, treatment, and discharge instructions were appropriate. She also found that Dr. Lee was not required to order imaging based on Ms. Martindale’s clinical presentation. Nothing suggested cancer as the potential cause of the symptoms.
Dr. Chiu similarly met the standard of care on December 31, 2014. Based on the outcome of the examinations, assessments, and observations, Dr. Chiu had no reason to order imaging. His examination and discharge instructions were appropriate. Nothing suggested cancer as the potential cause of the symptoms.
Causation
Brown J did not determine causation because there was no breach of the standard of care.
comments in obiter dicta
In obiter , Brown J noted that the plaintiff’s causation experts did not connect any alleged breach to Ms. Martindale’s ileostomy or “delayed” cancer diagnosis. Brown J also stated that she would have found Ms. Martindale 40% contributorily negligent because she failed to follow her practitioners’ instructions and attend the hospital in a timely manner.
- The hospital and several other physicians were also named as defendants, but were released from the action before trial. ↩︎