Conn v. United States

Brief Fact Summary.

John Conn (Plaintiff) was treated and released at the Veterans Administration (VA) hospital (“United States” or “VA”) (Defendant).  Afterwards he suffered a massive heart attack and sued the VA (Defendant) for medical malpractice.

Synopsis of Rule of Law.

In a medical malpractice lawsuit, clinical practice guidelines do not by themselves establish the standard of care.

Facts.

John Conn (Plaintiff) suffered from chest pains and visited the Veterans Administration hospital (“United States” or “VA”) (Defendant).  He received testing and was there overnight.  Following Plaintiff’s release, he went back to the hospital after suffering a massive heart attack.  Conn and his wife (Plaintiffs) filed suit against the VA (Defendant) for medical malpractice.  Dr. Mark Strong was retained as a defense expert in the Plaintiffs’ lawsuit.  Dr. Strong indicated that the Defendant’s doctors did not diagnose Plaintiff’s condition appropriately and, in particular, did not treat Plaintiff according to the practice guidelines of the American College of Cardiology Foundation, American Heart Association.  Defendant’s motion for summary judgment was granted by the trial court based on Dr. Strong’s failure to state the standard of care, that Defendant breached that standard, and that Plaintiff’s injury was caused by any breach.  Plaintiffs then appealed.

Issue.

In a medical malpractice lawsuit, can clinical practice guidelines by themselves establish the standard of care?

Held.

(Reeves, J.)  No.  In a medical malpractice lawsuit, clinical practice guidelines do not by themselves establish the standard of care.  The success of a plaintiff in establishing a medical malpractice case is a burden placed on the medical expert who must articulate an objective standard of care.  If the expert does not do this, then summary judgment must be granted in the defendant’s favor.  The Defendant moved for summary judgment and argued Dr. Strong’s report failed on three points: (1) it does not offer a standard of care; (2) it does not show that Defendant breached the standard of care; and (3) it does not prove that Plaintiff’s injuries were caused by the breach.  Because the first argument is dispositive, this opinion does not reach the second and third arguments.
  The Federal Tort Claims Act controls negligence suits against the federal government and they are evaluated in accordance with the law where the act or omission occurred.  This suit, therefore, is governed by the state’s view of medical malpractice.  In this state, a plaintiff in a medical malpractice case must prove, among other things, that the actions of his doctor were governed by a standard of care.  The standard of care must be specific, and at its core, it is a requirement that a doctor be minimally competent in his practice.
  [The court concluded that Dr. Strong’s report failed to state that the decisions of the VA (Defendant) physicians were not those of a minimally competent physician, instead of listing them only as actions not taken.  Dr. Strong’s personal recommendations did not establish the standard of care with particularity.]
  Dr. Strong’s report leaves only his claim that Plaintiff was not treated with what the American College of Cardiology Foundation, American Heart Association (ACCF/AHA) recommend for his type of heart condition.  Defendant claims that this statement does not establish a national standard of care.  Research shows that the American Heart Association and the American College of Cardiology Foundation together publish a series of Guidelines for different aspects of cardiac medicine.  The breadth of the Guidelines series and depth of each publication raise two obvious issues with Dr. Strong’s claims.  First, Dr. Strong does not identify a specific publication within the Guidelines series.  Therefore, there is no way to tell which set of recommendations he claims the Defendant failed to live up to.  Second, even if Dr. Strong had named one particular publication, it is doubtful that he would satisfy the state law.  An enunciated standard of care must be specific, and each Guidelines publication contains possibly dozens, or even hundreds, of recommendations.
  More fundamentally however, the Plaintiff’s reliance on the Guidelines implicates an issue that has been coming up more frequently in the nation’s courts: whether the ACCF/AHA Guidelines, or any other set of published clinical practice guidelines, can establish a national standard of care in a medical malpractice lawsuit.  There is not a consensus answer, to put it mildly.  Courts are inconsistent in other jurisdictions.  One court noted that these guidelines are relevant to the question of the proper standard of care and should be admitted as substantive evidence if introduced through a witness who can lay a proper foundation.  The only guidance in this state’s case law suggests that in some situations, an expert witness can rely on clinical practice guidelines when enunciating the standard of care.  It would therefore follow that the state law would allow expert witnesses to rely on clinical practice guidelines if the conduct prescribed by those guidelines does indeed describe the specific actions a minimally competent physician would take.
  However, even under that standard, Plaintiff could not defeat the Defendant’s motion for summary judgment.  Even if Dr. Strong had been able to name a specific Guidelines’ publication, and even if he had been able to identify a specific suggestion from the publication, he would still have failed to state that the conduct recommended by the Guidelines marked the standard of care of a minimally competent physician.  Therefore, the last piece of Dr. Strong’s report, like the rest of the report, fails to establish the objective standard of care Defendant should have followed in treating Plaintiff, and the motion for summary judgment is granted.

Discussion.

The Conn case provides that clinical practice guidelines are not a substitute for expert testimony regarding the applicable standard of care.  The threshold approach to a claim of medical malpractice is that a minimally competent doctor must adhere to the basic standard of care established (and reinforced at trial) by an expert, who can reference the clinical practice guidelines and provide what should or should not be done.