Related Specialty: Nance v. Gordon

The Baltimore Medical Malpractice Lawyer Blog examines issues in medical malpractice cases from Maryland appellate court opinions. In this post, the issue is whether a board-certified nephrologist is qualified under the Health Care Malpractice Claims Act to certify standard of care violations against a board-certified urologist and a physician’s assistant. This question involved the related specialty qualification for an expert witness in a Maryland medical malpractice case. The case is Nance v. Gordon, 210 Md. App. 26, 61 A.3d 1263 (2013). The Court of Special Appeals of Maryland (now the Appellate Court) issued this reported opinion.

Factual Background on Related Specialty Qualification of Expert Witness

A fifteen-year-old minor presented to a hospital emergency department with gross hematuria and proteinuria. Medical staff diagnosed a urinary tract infection, prescribed antibiotics, and discharged the minor patient. Seven weeks later, the minor patient returned to the emergency department. He was complaining of persistent hematuria, fever, sore throat, and flank pain. A physician’s assistant evaluated the patient and consulted with a board-certified urologist by phone. Neither provider conducted an in-person examination by a doctor that day. The medical team again discharged the patient with antibiotics for a urinary tract infection.

Nearly two years later, the minor patient returned to the emergency department throwing up blood. Diagnostic testing revealed late stage IgA nephropathy, a severe kidney disease. Because the condition advanced too long without proper medical treatment, the patient suffered total and permanent kidney failure needing ongoing hemodialysis.

The plaintiff filed a medical malpractice action in HCADRO under the Maryland Health Care Malpractice Claims Act. The plaintiff filed a Certificate of Qualified Expert signed by a board-certified pediatric nephrologist. The expert witness opined that the defendants breached the standard of care by failing to include nephritis in their differential diagnosis when evaluating the patient’s symptoms.

Parties’ Arguments

The defendants filed a Motion to Dismiss or, in the Alternative, for Summary Judgment. They argued that the plaintiff’s expert witness lacked proper qualifications under section 3-2A-02(c)(2) of the Courts and Judicial Proceedings Article. Specifically, the defendants argued that pediatric nephrology is not a “related specialty” to urology. They claimed that nephrologists diagnose and treat medical kidney diseases, whereas urologists handle surgical issues of the genitourinary tract. Because urologists do not treat nephritis, the defense argued no overlap existed between the fields regarding emergency department care.

Conversely, the plaintiff argued that nephrology and urology are related specialties under the statute because both fields share the kidney as a primary focus. The plaintiff argued that the expert witness had extensive experience handling emergency room consults for patients presenting with blood and protein in their urine. Because developing a differential diagnosis for these initial symptoms is a task performed by both specialties, the plaintiff maintained the statute requirements were satisfied.

Court’s Ruling on Related Specialty Qualification of Expert Witness

The Circuit Court for Baltimore City granted summary judgment for the defendants, ruling that the nephrologist was unqualified to testify against a urologist. On appeal, The Court of Special Appeals of Maryland reversed this ruling and sent the case back to the trial court.

The appellate court stated that medical experts do not need to practice in the exact same field as a defendant. Instead, specialties are related under the statute when their expertise overlaps regarding the specific procedure or treatment in question. The appellate court identified the core procedure at issue as making a differential diagnosis for a patient presenting to an emergency room with hematuria and proteinuria.

Because a differential diagnosis requires a provider to consider all potential causes before making a final conclusion, it necessarily spans medical and surgery kidney conditions. The record showed that the plaintiff’s expert frequently provided emergency room consults for patients showing these exact symptoms. Consequently, the appellate court ruled that nephrology and urology are related specialties under these facts, making the expert fully qualified to submit a certificate.

Commentary by Baltimore Medical Malpractice Lawyer Mark Kopec on Related Specialty Qualification of Expert Witness

This decision interprets Maryland statute law and protects injured medical malpractice victims. The Health Care Malpractice Claims Act seeks to eliminate meritless lawsuits by requiring early expert verification. However, the legislature never intended to create artificial procedural barriers that bar legitimate claims.

The trial court made an error by analyzing the specialty overlap based on the final diagnosis of nephritis rather than the initial clinical presentation. A provider making an emergency room evaluation cannot limit their diagnosis thinking to their preferred surgery scope. When a patient arrives with blood and protein in the urine, the standard of care demands a broad differential diagnosis. Both urologists and nephrologists regularly evaluate these symptoms on the front line.

Requiring an exact specialty match in every instance would allow specialists to hide behind narrow sub-specialty definitions when they fail to perform basic diagnosis workups. The appellate court recognized that differential diagnosis is a shared medical task. By focusing on the broad diagnosis process rather than narrow treatment boundaries, the court ensured that qualified medical experts can hold practitioners liable when basic screening steps are ignored.

Risk

This case shows the risk of choosing an expert that is in a different specialty from the defendant doctor. Even when the related specialty qualification is satisfied, a defendant doctor frequently will argue that it is not, and see if a trial court will agree. Here, the trial court did agree. While the appellate court ultimately remedied the issue, the plaintiff lost over two years and associated costs in the process.

You can read additional Blog posts on issues involving Expert Testimony, including:

• Related Specialty: Reid v. BACE 1
• Related Specialty: Otto v. UPMC 1
• Related Specialty: Street v. UPMC 1

Mark Kopec is a top-rated Baltimore medical malpractice lawyer. Contact us at 800-604-0704 to speak directly with Attorney Kopec in a free consultation. The Kopec Law Firm is in Baltimore and helps clients throughout Maryland and Washington, D.C. Thank you for reading the Baltimore Medical Malpractice Lawyer Blog.