                           PUBLISHED

UNITED STATES COURT OF APPEALS
              FOR THE FOURTH CIRCUIT


WILLIAM COOPER,                          
                  Plaintiff-Appellant,
                  v.
SMITH & NEPHEW, INCORPORATED,
              Defendant-Appellee,
              and
SMITH & NEPHEW RICHARDS,
INCORPORATED; ABRAHAM ROGOZINSKI;
CHAIM ROGOZINSKI; JAMES WALT
SIMMONS; AMERICAN ACADEMY OF
ORTHOPAEDIC SURGEONS; NORTH
AMERICAN SPINE SOCIETY; SCOLIOSIS
RESEARCH SOCIETY; ACROMED
CORPORATION, CHARTER NUMBER
614043; ACROMED CORPORATION,                No. 00-2556
CHARTER NUMBER 816942; ACROMED
INCORPORATED, CHARTER NUMBER
811415; ACROMED INCORPORATED,
CHARTER NUMBER 816943; ACROMED
HOLDING CORPORATION, CHARTER
NUMBER 811416; ACE MEDICAL
COMPANY; ADVANCED SPINE FIXATION
SYSTEMS, INCORPORATED; CROSS
MEDICAL PRODUCTS; DEPUY-MOTECH,
INCORPORATED; SYNTHES; SYNTHES,
INCORPORATED; SYNTHES NORTH
AMERICA, INCORPORATED; SYNTHES
A.G. CHUR; DANEK MEDICAL,
INCORPORATED; SOFAMOR,
INCORPORATED; SOFAMOR-DANEK
                                         
2                 COOPER v. SMITH & NEPHEW, INC.


GROUP, INCORPORATED; SOFAMOR,          
S.N.C.; YOUNGWOOD MEDICAL
SPECIALTIES, INCORPORATED, formerly
known as Stuart Medical Specialty,
Incorporated, formerly known as        
National Medical Specialty,
Incorporated; ZIMMER,
INCORPORATED,
                         Defendants.
                                       
            Appeal from the United States District Court
             for the District of Maryland, at Baltimore.
              J. Frederick Motz, Chief District Judge.
                         (CA-97-2578-JFM)

                       Argued: May 9, 2001

                       Decided: July 9, 2001

    Before WILKINSON, Chief Judge, NIEMEYER, Circuit Judge,
        and Arthur L. ALARCON, Senior Circuit Judge of the
         United States Court of Appeals for the Ninth Circuit,
                        sitting by designation.



Affirmed by published opinion. Chief Judge Wilkinson wrote the
opinion, in which Judge Niemeyer and Senior Judge Alarcon joined.


                            COUNSEL

ARGUED: Frederick Steven Longer, LEVIN, FISHBEIN, SEDRAN
& BERMAN, Philadelphia, Pennsylvania, for Appellant. Terri Stein-
haus Reiskin, HOGAN & HARTSON, L.L.P., Washington, D.C., for
Appellee. ON BRIEF: Arnold Levin, Scott Levensten, LEVIN,
FISHBEIN, SEDRAN & BERMAN, Philadelphia, Pennsylvania; Ste-
                    COOPER v. SMITH & NEPHEW, INC.                       3
ven M. Pavsner, JOSEPH, GREENWALD & LAAKE, Greenbelt,
Maryland, for Appellant. James B. Irwin, David O’Quinn, IRWIN,
FRITCHIE, URQUHART & MOORE, L.L.C., New Orleans, Louisi-
ana, for Appellee.


                               OPINION

WILKINSON, Chief Judge:

   This case is one of several thousand involving the promotion, sale,
and use of pedicle screw fixation devices to treat spinal injuries.
Appellant William Cooper brought this lawsuit against Smith &
Nephew, Inc., claiming that its defective device was responsible for
his failed back surgeries and the accompanying deleterious side
effects. The district court dismissed Cooper’s claims after determin-
ing that Cooper had no admissible medical evidence indicating that
Smith & Nephew’s device was the proximate cause of his injuries.
Because the district court did not abuse its discretion in excluding the
testimony of Cooper’s expert on medical causation, we affirm the
judgment.

                                    I.

                                    A.

   Appellee Smith & Nephew, Inc., ("S&N"), manufactures the
Rogozinski Spinal Rod System. The Rogozinski System is a medical
device consisting of connectors, rods, bone screws, and hooks. Ortho-
pedic surgeons use the Rogozinski System to aid them in performing
spinal fusion surgeries. This type of surgery stabilizes the spine by
fusing two or more vertebrae together into a single bone. The Rogoz-
inski System is used to promote a successful fusion between vertebrae
by providing stability for the spine.

   Since June 25, 1990, the FDA has cleared the Rogozinski System
for sale for some spinal applications. Prior to the initiation of this law-
suit, the Rogozinski System had not been approved for pedicle fixa-
tion. The pedicles are two pieces of bone on each side of the spinal
4                  COOPER v. SMITH & NEPHEW, INC.
vertebrae. Pedicle fixation is the process by which bone screws are
inserted through the pedicles in order to provide increased spinal sta-
bility, thereby promoting fusion.

   Once the FDA has cleared a device for introduction into the stream
of commerce, physicians may use the device in any manner they
determine to be best for the patient, regardless of whether the FDA
has approved the device for this usage. This practice by physicians is
known as "off-label" usage. See Buckman Co. v. Plaintiffs’ Legal
Comm., 121 S. Ct. 1012, 1018 (2001). Although the FDA had not
approved the Rogozinski System for pedicle fixation prior to 1998,
many physicians engaged in the off-label usage of the Rogozinski
System for this purpose. Indeed in 1998, the FDA adjusted its assess-
ment of devices capable of lumbar pedicle screw fixation, stating that
"FDA believes that there is reasonable assurance that pedicle screw
spinal systems are safe and effective for certain intended uses." See
63 Fed. Reg. 40,025, 40,035-36 (July 27, 1998).

                                  B.

   On January 28, 1990, appellant William Cooper slipped on a patch
of ice, resulting in lower back and leg pain. An MRI performed on
Cooper in March 1990 revealed herniated disks between lumbar ver-
tebrae positions 3 and 4 ("L3-L4"), 4 and 5 ("L4-L5"), and lumbar
position 5 ("L5") and sacral region 1 ("S1"). The MRI also revealed
a compression of the L4 nerve root sheath. Cooper subsequently
underwent two procedures in order to alleviate his pain. The hospital
records from these surgeries revealed that Cooper had smoked one
pack of cigarettes per day for 25 years.

   Following his second surgery, Cooper experienced worsening pain
in his lower back and legs. After further diagnosis, an orthopedic sur-
geon, James Murphy, M.D., determined that there was instability in
Cooper’s lumbar spine. On June 19, 1991, Dr. Murphy performed spi-
nal fusion surgery on Cooper, inserting the Rogozinski System
between the L3-L4, L4-L5, and L5-S1 vertebrae. The goal of the sur-
gery was to obtain a fusion at all three levels of vertebrae.

   Following this surgery, Cooper continued to experience back and
leg pain. By May 1992, Dr. Murphy believed that there likely was a
                    COOPER v. SMITH & NEPHEW, INC.                          5
nonunion at all three levels of vertebrae. Subsequent X rays revealed
that the right S1 pedicle screw appeared to have loosened. During this
time, Dr. Murphy continued to urge Cooper to stop smoking.

   On October 15, 1992, a second fusion surgery on Cooper revealed
that fusion had indeed occurred at L3-L4 and L4-L5. Dr. Murphy
removed the pedicle screws from these levels. The surgery also
revealed, however, that there was a nonunion at the L5-S1 level. Dr.
Murphy attempted to refuse L5-S1, using the same bone screws, but
attaching new rods and cross-links. After this surgery, Cooper contin-
ued to experience pain. An X ray taken on June 15, 1993, revealed
that a screw had cracked on the left side of S1. In addition, a fusion
failed to occur at L5-S1 following the second surgery. In preparation
for yet another surgery, Dr. Murphy wrote in Cooper’s medical
records: "I think the most important function if we are going to re-
operate on [Cooper] is that he stop smoking because that is going to
really have a great deal of effect on the success or failure of the proce-
dure."

   In February 1995, Dr. Murphy performed a final surgery on Coo-
per, in which he attempted to fuse L5-S1. Dr. Murphy also removed
the broken screw at left S1, and inserted new Rogozinski screws and
rods at L4 and S1. Although Cooper suffered some complications, the
surgery resulted in a fusion at L5-S1.

                                     C.

   On August 12, 1997, Cooper filed a nine-count complaint against
S&N and several other defendants. Cooper asserted claims for fraud,
civil conspiracy, concert of action, fraudulent marketing and promo-
tion, negligent misrepresentation, strict liability in tort, liability per se,
negligence, and breach of implied warranty of merchantability. Pursu-
ant to 28 U.S.C. § 1407, the suit initially was transferred to the mul-
tidistrict litigation in the United States District Court for the Eastern
District of Pennsylvania. While in the multidistrict litigation, Coo-
per’s conspiracy claims were dismissed. See In re Orthopedic Bone
Screw Prods. Liab. Litig., 193 F.3d 781 (3d Cir. 1999). On August 11,
1999, the case was transferred back to the district court, with only the
claims against S&N remaining.
6                   COOPER v. SMITH & NEPHEW, INC.
   In the present litigation, Cooper retained William Mitchell, M.D.,
and Harold Alexander, Ph.D., to present expert testimony that the
Rogozinski System was the proximate cause of Cooper’s injuries. Dr.
Alexander is an expert in the field of biomedical engineering. He is
not a medical doctor. For this reason, Dr. Alexander was found
unqualified in the multidistrict litigation to opine as to causation in
any individual plaintiff or to testify outside the area of orthopedic
bioengineering. See In re Orthopedic Bone Screw Prods. Liab. Litig.,
MDL No. 1014, 1997 WL 39583 (E.D. Pa. Jan 23, 1997).

   Cooper retained Dr. Mitchell to serve as his medical expert on spe-
cific causation. Dr. Mitchell has been a practicing orthopedic surgeon
for approximately 38 years, and regularly examines spinal patients.
Dr. Mitchell has performed numerous spinal fusion surgeries through-
out his career. While Dr. Mitchell has been trained in the use of spinal
implants, he has never implanted them in his patients. It was Dr.
Mitchell’s opinion that the Rogozinski System was incapable of bear-
ing the stress to which it was subjected in Cooper’s body. Dr. Mitch-
ell claimed that, as a result of this defect, the left S1 pedicle screw
fractured. This in turn caused the non-union at L5-S1. Dr. Mitchell’s
ultimate conclusion was that all of Cooper’s injuries were the result
of the Rogozinski System’s failure to provide spinal stability.

   On November 20, 2000, the district court granted S&N’s motion
to exclude all of Dr. Mitchell’s testimony on medical causation. The
court assumed that Dr. Mitchell was qualified as an expert under Fed.
R. Evid. 702. Nonetheless, the court agreed with the numerous other
district courts that had excluded Dr. Mitchell’s testimony as unreli-
able in similar bonescrew lawsuits. Because all of Cooper’s claims
required expert medical testimony that the Rogozinski System was
the proximate cause of his injuries, and because Dr. Alexander was
unqualified to opine as to specific causation, the court granted S&N’s
motion for summary judgment on all claims. Cooper now appeals.

                                    II.

   Under Federal Rule of Evidence 702, trial judges act as gatekeep-
ers to "ensure that any and all scientific testimony . . . is not only rele-
vant, but reliable." Daubert v. Merrell Dow Pharmaceuticals, Inc.,
                      COOPER v. SMITH & NEPHEW, INC.                         7
                              1
509 U.S. 579, 588 (1993). While Rule 702 was intended to liberalize
the introduction of relevant expert evidence, courts "must recognize
that due to the difficulty of evaluating their testimony, expert wit-
nesses have the potential to ‘be both powerful and quite misleading.’"
Westberry v. Gislaved Gummi AB, 178 F.3d 257, 261 (4th Cir. 1999)
(quoting Daubert, 509 U.S. at 595). Therefore, a trial judge, faced
with a proffer of expert scientific testimony, must conduct "a prelimi-
nary assessment of whether the reasoning or methodology underlying
the testimony is scientifically valid and of whether that reasoning or
methodology properly can be applied to the facts in issue." Daubert,
509 U.S. at 592-93. The proponent of the testimony must establish its
admissibility by a preponderance of proof. See id. at 592 n.10.

   The Supreme Court in Daubert identified several factors that may
bear on a judge’s determination of the reliability of an expert’s testi-
mony. See id. at 592-94. Those factors include: (1) whether a theory
or technique can be or has been tested; (2) whether it has been sub-
jected to peer review and publication; (3) whether a technique has a
high known or potential rate of error and whether there are standards
controlling its operation; and (4) whether the theory or technique
enjoys general acceptance within a relevant scientific community. See
Daubert, 509 U.S. at 592-94.
  1
  Effective December 1, 2000, Rule 702 was amended to reflect the
Supreme Court’s recent decisions in Daubert and Kumho Tire Co. v.
Carmichael, 526 U.S. 137 (1999). Rule 702 now states:
      Testimony by Experts - If scientific, technical, or other special-
      ized knowledge will assist the trier of fact to understand the evi-
      dence or to determine a fact in issue, a witness qualified as an
      expert by knowledge, skill, experience, training, or education,
      may testify thereto in the form of an opinion or otherwise, if (1)
      the testimony is based upon sufficient facts or data, (2) the testi-
      mony is the product of reliable principles and methods, and (3)
      the witness has applied the principles and methods reliably to the
      facts of the case.
Fed. R. Evid. 702. As the Advisory Committee Notes indicate, the
amendment to Rule 702 is consistent with the district court’s gatekeeping
function as articulated in Daubert and Kumho Tire. As a result, the
amendment does not alter the standard for evaluating the admissibility of
experts’ opinions as articulated in those cases. See Nelson v. Tennessee
Gas Pipeline Co., 243 F.3d 244, 250 n.4 (6th Cir. 2001).
8                   COOPER v. SMITH & NEPHEW, INC.
   In Kumho Tire Co. v. Carmichael, 526 U.S. 137, 150 (1999), the
Supreme Court noted that the factors discussed in Daubert were nei-
ther definitive, nor exhaustive. The Court explained that particular
factors may or may not be pertinent in assessing reliability, depending
on the nature of the issue, the expert’s particular expertise, and the
subject of his testimony. See id. The Court further emphasized that
the objective of Daubert’s gatekeeping requirement is to "make cer-
tain that an expert . . . employs in the courtroom the same level of
intellectual rigor that characterizes the practice of an expert in the rel-
evant field." See id. at 152.

   Courts of appeals apply an abuse of discretion standard when
reviewing a trial court’s decision to admit or exclude expert testi-
mony. See General Electric Co. v. Joiner, 522 U.S. 136, 138-39
(1997). The Supreme Court also has emphasized that "the trial judge
must have considerable leeway in deciding in a particular case how
to go about determining whether particular expert testimony is reli-
able." See Kumho Tire, 526 U.S. at 152.

                                   III.

   As an initial matter, S&N claims that Dr. Mitchell was not quali-
fied to offer opinions as an expert in this case. Like the district court,
we assume, without deciding, that Dr. Mitchell was qualified to tes-
tify regarding the medical cause of Cooper’s injuries. However, we
must still review for abuse of discretion the district court’s determina-
tion that Dr. Mitchell’s testimony was unreliable and, therefore, inad-
missible.

   Cooper contends that Dr. Mitchell conducted a differential diagno-
sis to determine the cause of his injuries. Cooper argues that since this
court has approved differential diagnosis as a reliable methodology,
see Westberry, 178 F.3d at 263, the district court abused its discretion
in refusing to admit Dr. Mitchell’s testimony.

   In Westberry, this court explained that differential diagnosis is "a
standard scientific technique of identifying the cause of a medical
problem . . . by determining the possible causes for the patient’s
symptoms and then eliminating each of these potential causes until
reaching one that cannot be ruled out or determining which of those
                   COOPER v. SMITH & NEPHEW, INC.                       9
that cannot be excluded is the most likely." 178 F.3d at 262. A reli-
able differential diagnosis typically, though not invariably, "is per-
formed after physical examinations, the taking of medical histories,
and the review of clinical tests, including laboratory tests." Id. (inter-
nal citations omitted). Cooper is correct that Westberry held that a
reliable differential diagnosis provides a valid foundation for an
expert opinion under Rule 702. See id. at 263. However, the district
court in turn correctly held that Dr. Mitchell’s differential diagnosis
was not reliable.

   "A reliable expert opinion must be based on scientific, technical,
or other specialized knowledge and not on belief or speculation, and
inferences must be derived using scientific or other valid methods."
Oglesby v. General Motors Corp., 190 F.3d 244, 250 (4th Cir. 1999).
In this case, Dr. Mitchell asserted what amounted to a wholly conclu-
sory finding based upon his subjective beliefs rather than any valid
scientific method. Dr. Mitchell has never implanted a pedicle screw
device in his patients’ spines because he believes them to be inher-
ently dangerous. His position conflicts with that of the FDA and the
majority of his colleagues in the American Academy of Orthopedic
Surgeons who believe that the use of spinal instrumentation, including
the use of pedicle screws, is the standard of care in the profession.
See, e.g., 60 Fed. Reg. 51,946, 51,947 (Oct. 4, 1995) ("By mid-1992,
FDA discovered that the use of pedicle screw spinal systems outside
of approved IDE studies was widespread, and that pedicle screw fixa-
tion was considered to be the standard of care by the surgical commu-
nity.").

   Dr. Mitchell’s unconventional views about the overall safety and
efficacy of the use of pedicle screws in spinal surgeries is reflected
in his testimony in this particular case. He opined that since the
Rogozinski System is designed to prevent nonunion, it must stop
motion in the spine 100 percent of the time or else it is defective.
According to Dr. Mitchell, if a fusion results after implantation sur-
gery, the device is not defective; if a fusion does not result, then the
device is defective. Since a nonunion occurred in Cooper’s case, Dr.
Mitchell contended that the Rogozinski System therefore was defec-
tive and caused all of Mr. Cooper’s subsequent injuries.

  During his deposition, Dr. Mitchell explained his opinion to S&N’s
counsel as follows:
10                    COOPER v. SMITH & NEPHEW, INC.
      Q: Purely retrospective[ly] looking back, [Cooper] didn’t
      get a fusion, the screw broke, therefore it’s defective; right?

      A: Right.

      ...

      Q: Let’s assume in patient A we do not get a fusion, one of
      the screws loosens and breaks. Okay?

      A: Right.

      Q: Let’s assume in patient B we get a fusion and there’s no
      loosening and no breakage of the screw. Now, in your opin-
      ion the Rogozinski device in patient A would be defective?

      A: Right.

      Q: But the Rogozinski device in patient B would not be
      defective; right?

      A: Correct.

      ...

      Q: Your opinion is that a screw in a lumbar pedicle must
      stop motion 100 percent of the time or it’s defective.

      A: Yes. . . .

   Daubert requires more than an assertion that if there is a lack of
surgical success, there is ipso facto a product defect, and hence causa-
tion is established. Dr. Mitchell’s methodology simply failed to pro-
vide any medical evidence as to what caused Cooper’s specific
injuries. Rather, Dr. Mitchell seems to have inferred causation from
the existence of a nonunion alone. However, this basis for finding
causation makes little sense in light of Dr. Mitchell’s own concession
that a non-union is a well-known risk of spinal fusion regardless of
whether instruments are used or not.2 In addition, Dr. Mitchell
  2
   Cooper’s medical records indicate that Dr. Murphy specifically
informed Cooper of the risk of non-union before he consented to the June
                    COOPER v. SMITH & NEPHEW, INC.                       11
acknowledged that the more levels a physician attempts to fuse, the
less likely it is that the patient obtains a successful fusion. In fact, Dr.
Mitchell himself estimated Cooper’s chances of a successful fusion at
all three levels to be only 25 percent.

   Furthermore, Dr. Mitchell failed to address S&N’s claim that the
fractured pedicle screw actually resulted from the nonunion rather
than vice-versa. The package insert for the Rogozinski System warns
that if a fusion fails to develop, the resulting motion in the spine may
cause the screw or other components to break. And Dr. Mitchell
stated that fusion usually occurs within three to six months. In this
case, the pedicle screw fractured more than six months after Cooper’s
second fusion surgery, and approximately two years after the screw
was first implanted. Dr. Mitchell’s causation theory failed to address
the possibility that the screw fracture was caused by the nonunion.
The district court properly determined that Dr. Mitchell essentially
had a set of boilerplate objections to the use of spinal implantation
devices which he asserted regardless of the specific facts of the partic-
ular case. This unscientific approach is not a reliable basis for expert
testimony.

   Furthermore, S&N’s experts provided several alternative explana-
tions for the nonunion in Cooper’s case. Primary among these was
Cooper’s smoking. The medical literature in peer-reviewed journals
indicates that smoking increases the likelihood of a nonunion. The
district court held that Dr. Mitchell’s diagnosis was unreliable in part
because Dr. Mitchell "summarily rejects evidence that Cooper’s long
history of smoking caused nonunion, even though Cooper’s medical
records contain repeated references to Cooper’s smoking habit." Coo-
per contends that the district court erroneously focused on Dr. Mitch-
ell’s ultimate conclusion that smoking was not a cause rather than his
methodology.

   We disagree. As the Supreme Court has recognized, "conclusions
and methodology are not entirely distinct from one another." Joiner,
522 U.S. at 146. A medical expert’s opinion based upon differential
diagnosis normally should not be excluded because the expert has

1991 spinal fusion surgery.
12                  COOPER v. SMITH & NEPHEW, INC.
failed to rule out every possible alternative cause of a plaintiff’s ill-
ness. See Westberry, 178 F.3d at 265 (citations omitted). In such
cases, the alternative causes suggested by a defendant normally affect
the weight that the jury should give the expert’s testimony and not the
admissibility of that testimony. See id. at 265 (citations omitted).
However, a "differential diagnosis that fails to take serious account of
other potential causes may be so lacking that it cannot provide a reli-
able basis for an opinion on causation." Id. at 265 (citations omitted).
Thus, if an expert utterly fails to consider alternative causes or fails
to offer an explanation for why the proffered alternative cause was
not the sole cause, a district court is justified in excluding the expert’s
testimony. See id. at 265-66 (citations omitted); see also In re Paoli
R.R. Yard PCB Litig., 35 F.3d 717, 758 n.27 (3d Cir. 1994).

   The record in this case reveals that the medical literature is replete
with evidence that smoking can cause nonunions to occur. Cooper’s
own medical records indicate that he has been a pack-a-day smoker
for approximately twenty-five years. And in July 1991, a month after
his first fusion surgery, Cooper’s medical records indicate that his
smoking habit had increased to two packs a day. Dr. Murphy, Coo-
per’s treating physician, wrote after the second fusion surgery that
Cooper’s "continued smoking history [ ] is probably the main etiology
of his non-union." Dr. Murphy also wrote: "I think the most important
function if we are going to re-operate on [Cooper] is that he stop
smoking because that is going to really have a great deal of effect on
the success or failure of the procedure."

   In the face of the medical literature and Cooper’s own records, Dr.
Mitchell categorically dismissed any suggestion that Cooper’s smok-
ing was the cause of the nonunion. Dr. Mitchell stated that he rejected
the medical articles as unpersuasive after he read just two of them.
When asked if he should have considered more of the articles, Dr.
Mitchell replied:

     No, for the simple reason, after I read those two articles
     years ago, they didn’t affect my prior judgment, and they
     still haven’t, that smoking doesn’t have anything to do with
     healing in spinal fusion. So even if there were ten more arti-
     cles, I’m not going to change my mind about it.
                   COOPER v. SMITH & NEPHEW, INC.                      13
In this case, Dr. Mitchell did not identify specifically how he ruled
out smoking and other potential causes of the nonunion. Simply
asserting that he read two articles on smoking and rejected them as
unpersuasive is insufficient. Such a practice offers no solid grounds
for rejecting smoking as a cause of the nonunion, and renders his
opinion that the Rogozinski System was the actual culprit little more
than speculation. As the Supreme Court has repeatedly held, "nothing
in either Daubert or the Federal Rules of Evidence requires a district
court to admit opinion evidence that is connected to existing data only
by the ipse dixit of the expert." Kumho Tire, 526 U.S. at 157 (quoting
Joiner, 522 U.S. at 146).

   In addition, Dr. Mitchell failed to conduct a physical examination
of Cooper and did not speak with any of Cooper’s treating physicians.
In certain circumstances, a physician may reach a reliable differential
diagnosis without personally performing a physical examination. See
Westberry, 178 F.3d at 262; Kannankeril v. Terminix Int’l, Inc., 128
F.3d 802, 807 (3d Cir. 1997). However, Kumho Tire emphasizes that
the purpose of Rule 702’s gatekeeping function is to "make certain
that an expert . . . employs in the courtroom the same level of intellec-
tual rigor that characterizes the practice of an expert in the relevant
field." 526 U.S. at 152.

   Dr. Mitchell admitted that his evaluation of Cooper was not consis-
tent with the diagnostic methodology he employs in his own medical
practice. With his own patients, Dr. Mitchell insists upon a physical
examination. As Dr. Mitchell explained, "you can’t go anywhere if
you don’t know what is wrong with the body. So you have to do a
hands-on exam to find out what is wrong." Dr. Mitchell had access
to Cooper, and yet, for purposes of this litigation, chose to deviate
from his traditional method of evaluation. By itself, Dr. Mitchell’s
failure to conduct a physical examination may not be grounds to
exclude his methodology as unreliable. However, the fact that Dr.
Mitchell did not employ in the courtroom the same methods that he
employs in his own practice provides further support for the district
court’s ultimate conclusion that his testimony was unreliable.

   In light of these facts, the district court properly exercised its dis-
cretion in excluding Dr. Mitchell’s testimony. And without Dr. Mitch-
ell’s testimony, Cooper could not make the requisite showing of
14                   COOPER v. SMITH & NEPHEW, INC.
            3
causation. The district court therefore properly granted S&N’s
motion for summary judgment on all claims.4

                                    IV.

     For the foregoing reasons, the judgment of the district court is

                                                             AFFIRMED.
  3
   Cooper contends that to prevail on his state-law "fraud-on-the-FDA"
claim, he needs only to show that "but for" S&N’s fraud on the FDA, he
never would have been injured. The Supreme Court, however, has
recently held that patients’ state-law fraud-on-the-FDA claims are pre-
empted by the Federal Food, Drug, and Cosmetic Act, 52 Stat. 1040, as
amended by the Medical Device Amendments of 1976, 90 Stat. 539, 21
U.S.C. § 301. See Buckman Co. v. Plaintiffs’ Legal Comm., 121 S. Ct.
1012, 1018 (2001). As a result, Cooper’s fraud-on-the-FDA claim must
be dismissed.




  4
   The district court excluded a statement of Dr. Murphy’s on the
grounds that it was actually an improper deposition and not an affidavit.
The district court noted:
      Plaintiff’s contention that the June 21 "Statement Under Oath"
      is "technically an affidavit" is without merit. Regardless of the
      heading attached to the transcript, it is clear that Dr. Murphy’s
      statements were made during the course of a deposition and not
      as part of an affidavit. The meeting between plaintiff’s counsel
      and Dr. Murphy was "a discovery device by which one party
      ask[ed] oral questions of . . . a witness for the other party."
      Black’s Legal Dictionary 396 (5th ed. 1979). Thus, plaintiff con-
      ducted a deposition and was obligated to provide defendant with
      notice pursuant to Fed. R. Civ. P. 30(b)(1).
We do not believe the district court erred in this ruling.
