March 11, 2013

162017_132140396847214_292624_nIn an appeal decided by the Court of Special Appeals of Maryland (“Appellate Court”) on March 1, 2013, the issue was whether nephrology and urology are “related” fields under the circumstances of the case before it, as that term is used in subsubparagraphs §§ 3-2A-02(c)(2)(ii)1A and 1B of the Health Care Malpractice Claims Act (“the Act”),  so that a board-certified nephrologist was qualified under the Act to testify that a urologist, a physician’s assistant, and their employer violated the standard of care in treating the medical malpractice plaintiff.

The Revelant Provisions Of  The Act

Subparagraph 3-2A-02(c)(2)(ii) of the Act provides:

1. In addition to any other qualifications, a health care provider who attests in a certificate of a qualified expert or testifies in relation to a proceeding before a panel or court concerning a defendant’s compliance with or departure from standards of care:

A. Shall have had clinical experience, provided consultation relating to clinical practice, or taught medicine in the defendant’s specialty or a related field of health care, or in the field of health care in which the defendant provided care or treatment to the plaintiff, within 5 years of the date of the alleged act or omission giving rise to the cause of action; and

B. Except as provided in subsubparagraph 2 of this subparagraph, if the defendant is board certified in a specialty, shall be board certified in the same or a related specialty as the defendant.

2. Subsubparagraph 1B of this subparagraph does not apply if:

A. The defendant was providing care or treatment to the plaintiff unrelated to the area in which the defendant is board certified; or

B. The health care provider taught medicine in the defendant’s specialty or a related field of health care.

The Underlying Facts Alleged In The Maryland Medical Malpractice Claim

On June 2, 2005, the then 15-year-old medical malpractice plaintiff arrived at a Maryland hospital’s emergency department, complaining of blood in his urine. Urinalysis taken at the hospital verified the teenager’s gross hematuria (blood in urine), as well as proteinuria (protein in urine), for which he was prescribed antibiotics for what was diagnosed as a urinary tract infection and sent home.

On July 27, 2005, the medical malpractice plaintiff returned to the same hospital emergency department, complaining about blood in his urine plus a fever, sore throat, and right flank pain. A physician’s assistant examined him and spoke with the urologist by telephone about the examination, evaluation, and treatment plan. However, no physician examined the teenager that day. Once again, he was provided with antibiotics to treat a urinary tract infection.

On May 28, 2007, the medical malpractice plaintiff again returned to the same emergency department, complaining that he was spitting up blood. Tests conducted at the hospital revealed that the teenager’s kidneys were no longer functioning. A renal biopsy revealed that he had late-stage IgA nephropathy, a severe kidney disease that requires him to undergo hemodialysis three times a week. It was determined that the kidney disease had progressed too long without treatment and that the failure of his kidneys was irreversible.

The Medical Malpractice Claims

The plaintiff’s medical malpractice lawsuit was filed on April 17, 2009. Pursuant to the requirements of the Act, the medical malpractice lawsuit was accompanied by a certificate of qualified expert, a board certified pediatric nephrologist, in which it was stated that the medical malpractice defendants “departed from the standards of practice among members of the same health professions with similar training and experience situated in the same or similar communities” when they treated the teenager in June and July 2005. In his report, which was attached to the Certificate, the pediatric nephrologist specifically stated that, in his professional opinion, the medical malpractice defendants committed malpractice by “[f]ailing to include nephritis on the differential diagnosis for [the teenager]” when he presented to the hospital emergency department in June and July 2005, and that the deviations from standards of care proximately caused the teenager’s injuries and damages.

The medical malpractice defendants filed a Motion to Dismiss, or in the Alternative, for Summary Judgment, arguing that the plaintiff’s medical expert, the pediatric nephrologist, was not a “qualified” expert because he is not a board-certified urologist, and because he did not have relevant clinical or teaching experience in a “related field of health care” to urology. The trial court granted the motion and the plaintiff’s appeal followed.

The Appellate Court noted that “related” is not defined in the Act and therefore looked to dictionary definitions of the word and concluded that, as used throughout the Act, “related” means “‘being connected; associated.’” The Appellate Court phrased the issue before it as whether the specialties of nephrology and urology are “related” under the Act in the context of developing a differential diagnosis for a patient who presents to the emergency department with blood and protein in his or her urine.

The Appellate Court stated that it must review the circumstances of the case before it and determine whether nephrology and urology “overlap” in the context of “the treatment or procedure” at issue. The Appellate Court concluded that nephrology and urology are “related” in the case before it because “the treatment rendered” (a differential diagnosis at the time the patient presents to the emergency room) is “performed by both specialists.” Defining differential diagnosis as “the determination of which of two or more diseases with similar symptoms is the one from which the patient is suffering, by a systematic comparison and contrasting of the clinical findings,” the Appellate Court noted that a differential diagnosis requires the physician to consider the diseases “that are possibly responsible for the patient’s illness.”

The Appellate Court noted that the pediatric nephrologist’s opinion was that the defendants breached the standard of care by failing to consider nephritis as a disease that was “possibly responsible” for the blood and protein in appellant’s urine. The Appellate Court further noted that the pediatric nephrologist was actively involved in emergency room consults and as such, was a “front line health care provider,” and that the pediatric nephrologist has experience with consults for emergency room patients who present both with medical issues of the kidney and with urinary tract obstructions and surgical kidney diseases. In other words, the expert was familiar with the medical conditions and diseases normally treated by nephrologists and urologists that may be presented in an emergency room setting, and the pediatric nephrologist has seen “patient[s] in an emergency department setting with a presentation of hematuria and proteinuria,” and that at least some of these patients  have presented “without a diagnosis,” which makes them similar to appellant in the present case.

The Appellate Court stated that the procedure at issue in the instant case – preparing a differential diagnosis of a patient who presents with blood and protein in his or her urine – “is one which both healthcare providers … have experience with;” such differential diagnosis must take into consideration possible medical conditions or diseases treated by both nephrologists and urologists.

Therefore, the Appellate Court concluded that under the circumstances of the case it was deciding, nephrology and urology are “related specialt[ies]” pursuant to section 3-2A-02(c)(2) of the Act and the trial court erred in ruling that the pediatric nephrologist was not qualified to testify as an expert under the Act.

Nance v. Gordon, et al., Court of Special Appeals of Maryland, No. 1574, decided March 1, 2013.  Click here to read the appellate opinion.

If you or a loved one were injured as a result of medical malpractice in Maryland or in another U.S. state, you should promptly seek the advice of a Maryland medical malpractice attorney or a medical malpractice attorney in your state who may agree to investigate your medical malpractice claim for you and file a medical malpractice case on your behalf, if appropriate.

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