             If this opinion indicates that it is “FOR PUBLICATION,” it is subject to
                  revision until final publication in the Michigan Appeals Reports.




                             STATE OF MICHIGAN

                             COURT OF APPEALS


ESTATE OF HENRY GEROW, JR., by MARIE                                  UNPUBLISHED
GEROW, Personal Representative,                                       July 2, 2020

               Plaintiff-Appellant,

v                                                                     No. 348221
                                                                      St. Clair Circuit Court
RONALD L. THIES, JR., M.D. and EMERGENCY                              LC No. 17-001458-NH
MEDICINE SPECIALISTS, PC,

               Defendants-Appellees,
and

ST. JOHN RIVER DISTRICT HOSPITAL,

               Defendant.


Before: GLEICHER, P.J., and SAWYER and METER, JJ.

GLEICHER, J. (dissenting).

        This medical malpractice case arises from the death of Henry Gerow. An autopsy revealed
that Gerow died as a result of pneumonia and sepsis. Three days before his death, Gerow presented
in the emergency department of defendant St. John River District Hospital and was evaluated by
defendant Ronald L. Thies, Jr., M.D. Plaintiff alleges that the standard of care required Dr. Thies
to obtain a chest x-ray, and that a chest x-ray would have revealed pneumonia. With proper
treatment, plaintiff contends, Gerow would have survived.

        The circuit court granted summary disposition to defendants under MCR 2.116(C)(10),
ruling that plaintiff failed to present evidence of causation. In the circuit court’s view, it was
“purely speculative” whether a chest x-ray would have demonstrated a treatable pneumonia. The
majority affirms this ruling, citing a carefully selected and legally irrelevant portion of the expert
testimony. The majority opinion inexplicably omits even a bare mention of the expert testimony
directly supporting plaintiff’s causation claim.




                                                 -1-
       Contrary to the majority’s recitation of the facts, plaintiff’s experts clearly and
unequivocally testified that a chest x-ray likely would have revealed pneumonia, and that treatment
would have saved Gerow’s life. I respectfully dissent.

                                                 I

        The majority’s causation analysis fails to adhere to a core summary disposition principle:
the evidence presented at summary disposition must be viewed in the light most favorable to the
nonmoving party. Kemp v Farm Bureau Gen Ins Co of Mich, 500 Mich 245, 251; 901 NW2d 534
(2017). A court must credit competent evidence presented by the nonmoving party and draw all
reasonable inferences supported by that evidence. A court may not make findings of fact or assess
the credibility of witnesses. White v Taylor Distrib Co, Inc, 482 Mich 136, 142-143; 753 NW2d
591 (2008).

       Nor may a court simply ignore testimony supporting the nonmovant’s claim.

                                                II

        On November 7, 2013, Henry Gerow sought care in the River District Hospital emergency
room. He complained of back pain. This was Gerow’s third visit to the emergency department in
five days. On November 7, Gerow complained that his pain was exacerbated by breathing—a new
symptom. He also reported that the pain radiated to the upper right quadrant of his abdomen.

        Plaintiff’s emergency medicine expert, Dr. Marc Eckstein, explained that the standard of
care required a chest x-ray because this was Gerow’s third visit within a short time, the character
of his pain had changed to include pain with respiration, and the pain involved a new area (the
upper right abdomen). The differential diagnosis included an abdominal dissection, a cardiac
event, “lower lung pathology, pneumonia, pulmonary embolism, a musculoskeletal problem of the
back,” and other processes, Dr. Eckstein opined. “[A]t the very least,” Dr. Eckstein maintained,
Dr. Thies “should have gotten a chest x-ray at that point.”

        Dr. Eckstein was closely questioned regarding whether a chest x-ray would have
demonstrated the presence of pneumonia. The majority holds that Dr. Eckstein’s testimony failed
to create a material fact question on this score. Here is the snippet of testimony on which the
majority relies for its conclusion:

             Q. How do you know [a chest x-ray] would have shown a pneumonia when
       [Gerow] doesn’t have any of the signs of symptoms that are consistent and
       compatible with pneumonia?

               A. I can’t say for certain.

                                             * * *

             A. I can’t say with certainty . . . that the x-ray would have shown a
       pneumonia, correct.




                                                -2-
Note that Dr. Eckstein’s answer was phrased in terms of “certainty.” It did not address the actual
standard: probability.

        Sadly, the majority has mischaracterized the record regarding Dr. Eckstein’s proximate
cause testimony by focusing only on irrelevant statements about “certainty.” I turn to the testimony
that the majority ignores, and which establishes a material question of fact regarding causation.

       The question and answer immediately before the text quoted by the majority speaks directly
to causation, but the majority fails to cite it. Here it is:

             Q. Is it your belief that somehow a chest x-ray would have shown these
       microabscesses in the lungs?

                 A. It would have shown pneumonia, but not the microabscesses. [Emphasis
       added.]

       Why did the majority omit this testimony? I have no explanation for this error. I also have
no explanation for the majority’s failure to cite Dr. Eckstein’s additional testimony addressing
causation. Here is what the majority elected not to include in its opinion, or to even confront:

              Q. Well, with what you saw in the autopsy, would you believe that a lower
       lobe pathology would be noted in the chest x-ray?

                 A. Yes.

                                                * * *

               A. I think, based upon the autopsy, I think it’s within medical probability
       the x-ray . . . would have been helpful.

                                                * * *

              Q. I think you said that you couldn’t say with certainty that a chest x-ray
       would have shown pneumonia, but you can say - - with what degree of probability
       can you say a chest x-ray would have shown some pneumonia?

                 MR. WULFMEIER: Again, object to form.

                 A. I think it’s within medical probability.

                 Q. So more probable than not.

                 A. Yes. [Emphasis added.]

        Dr. Eckstein testified without equivocation that in his view, a chest x-ray probably would
have revealed Gerow’s fatal pneumonia. He was not “certain” of this—and who could be, since
the x-ray wasn’t obtained? He had no such reluctance in affirming that more probably than not,
the x-ray would have shown pneumonia. That testimony created a material fact question regarding
“but for” causation. Nothing more was required.


                                                  -3-
        In a tort case such as this, a court must determine whether the defendant’s negligence was
the cause in fact of the plaintiff’s injuries. Ray v Swager, 501 Mich 52, 65; 903 NW2d 366 (2017).
Evidence supporting “a logical sequence of cause and effect” suffices. Skinner v Square D Co,
445 Mich 153, 159-160; 516 NW2d 475 (1994). Once a plaintiff produces the factual support
establishing a logical sequence of cause and effect, the plaintiff must also come forward with
evidence supporting that the actual cause was proximate, meaning that it created a foreseeable risk
of the injury the plaintiff suffered. Id. at 160, 163; Lockridge v Oakwood Hosp, 285 Mich App
678, 684; 777 NW2d 511 (2009). In a medical malpractice case, circumstantial evidence may
suffice to demonstrate but-for causation, as long as it leads to “a reasonable inference of causation
and [is] not mere speculation.” Ykimoff v Foote Mem Hosp, 285 Mich App 80, 87; 776 NW2d 114
(2009).

        Dr. Eckstein’s testimony was not “speculative,” hypothetical, or otherwise inadmissible.
Rather, it supported a causal link between a breach of the standard of care (failure to obtain a chest
x-ray) and the injury (untreated pneumonia that progressed to sepsis and death). Had the x-ray
been obtained, Dr. Eckstein asserted, it was “more probable than not” that the pneumonia would
have been diagnosed. The testimony of plaintiff’s second expert witness, Dr. James Gordon,
supplied the next link in the causation chain: treatment with antibiotics on November 7 likely
would have saved Gerow’s life.

        The majority’s reliance on Dr. Eckstein’s lack of “certainty” represents a second, and
equally egregious error. Certainty has never been required to establish causation. See Falcon v
Mem Hosp, 436 Mich 443, 451; 462 NW2d 44 (1990) (“All this is simply to say that the more
probable than not standard, as well as other standards of causation, are analytic devices-tools to be
used in making causation judgments. They do not and cannot yield ultimate truth. Absolute
certainty in matters of causation is a rarity.”); Harrison v Lorenz, 303 Mich 382, 391-392; 6 NW2d
554 (1942) (“The testimony of this witness was not rendered incompetent because he could not
state with positive certainty as to the exact location of the leak.”); Wood v Vroman, 215 Mich 449,
461; 184 NW 520 (1921) (“The plaintiff was not required to prove to an absolute certainty that the
infection was caused by the introduction of the germs in the pus.”); Birou v Thompson-Brown Co,
67 Mich App 502, 510; 241 NW2d 265 (1976) (“It is not necessary for an expert witness to state
an opinion in terms of absolute certainty for it to be admissible.”).

        Aside from the caselaw, the governing statute, MCL 600.2912a(2), provides the applicable
standard: “In an action alleging medical malpractice, the plaintiff has the burden of proving that
he or she suffered an injury that more probably than not was proximately caused by the negligence
of the defendant or defendants.” (Emphasis added.) Dr. Eckstein’s inability to “say for certain”
what a chest x-ray would have shown is legally meaningless. Conclusive evidence of causation is
not required in a medical malpractice case, or any other tort action.1




1
  Nor is it necessary for an expert to state an opinion within a reasonable degree of medical
certainty. Knoper v Burton, 12 Mich App 644, 650-651; 163 NW2d 453 (1968), rev’d on other
grounds 383 Mich 62 (1970). Rather, an expert may express an opinion in probability terms, as
did Dr. Eckstein.


                                                 -4-
       The majority additionally asserts that the circuit court considered Dr. Eckstein’s testimony
“purely speculative,” and for that reason justifiably refused to consider it. There was nothing
speculative about Dr. Eckstein’s straightforward agreement that a chest x-ray likely would have
shown pneumonia. A court’s disagreement with an expert’s conclusions does not transform an
otherwise admissible opinion into speculation.

         Nor has the majority accurately presented the testimony of Dr. Gordon, plaintiff’s
infectious diseases expert. According to the majority, “the trial court was aware that Dr. Gordon
testified it was medically impossible to determine whether Gerow had pneumonia or sepsis when
Dr. Thies treated him . . . because Gerow did not present with any symptoms of pneumonia or
sepsis.” It is true that when asked whether Gerow was suffering from pneumonia on November 7,
Dr. Gordon responded: “I don’t know.” Neither the circuit court nor the majority have the luxury,
however, of selecting which expert to believe. When the evidence conflicts, the circuit court must
view the evidence in the light most favorable to the nonmoving party, draw all reasonable
inferences in favor of the nonmoving party, and refrain from making credibility determinations or
weighing the evidence. Pioneer State Mut Ins Co v Dells, 301 Mich App 368, 377; 836 NW2d
257 (2013). Here, this rule required the circuit court to credit Dr. Eckstein’s view.

        Furthermore, the majority ignores a critical part of Dr. Gordon’s testimony buttressing
plaintiff’s causation proofs:

             Q.      Doctor, within a reasonable degree of medical probability, would
       the administration of antibiotics on 11-7-2013 ED visit [have] precluded Mr.
       Gerow’s death in the time period that he died?

               MR. WULFMEIER: Object to form and foundation

               MS. CARDELLI:           I join.

               Q.      Go ahead.

               A.       So on the 7th, the patient didn’t have a fever, he didn’t have a
       leukocytosis, excuse me, he didn’t have a fever or evidence of clinical sepsis, so at
       that point in time . . . if the infection was present, it was not progressed to the point
       where treatment would not have had a significant impact on the course of disease.
       So if he would have received antibiotics on the 7th, there’s a greater than not
       chance that he would have survived this infection. [Emphasis added.]

        Regardless of whether Dr. Gordon “knew” what an x-ray would have shown on November
7, he testified that treatment of pneumonia on that date would have resulted in Gerow’s survival.
The evidence of record, viewed in the light most favorable to plaintiff, substantiated that if a chest
x-ray had been performed on November 7, it likely would have shown pneumonia. And if treated
on that day with antibiotics, Gerow likely would have survived. That evidence sufficed to defeat
summary disposition under MCR 2.116(C)(10).

        By ignoring the expert testimony supporting plaintiff’s case and judging the experts’
credibility, the majority rubber-stamps the circuit court’s errors. Neither this Court nor the circuit



                                                 -5-
court may disregard relevant and competent evidence or determine its weight. I would reverse the
circuit court’s grant of summary disposition and remand for further proceedings.



                                                           /s/ Elizabeth L. Gleicher




                                              -6-
