                IN THE COURT OF APPEALS OF TENNESSEE
                           AT KNOXVILLE
                               December 6, 2011 Session

  WILLIAM MISE, ET. AL. V. METHODIST MEDICAL CENTER OF OAK
                           RIDGE, ET. AL.

                 Appeal from the Circuit Court for Anderson County
                  No. B0LA0014 Hon. Donald R. Elledge, Judge




                No. E2011-01325-COA-R3-CV-FILED-APRIL 23, 2012




This is an appeal from the grant of summary judgment in a medical malpractice case.
Virginia Mise was admitted to Methodist Medical Center of Oak Ridge following complaints
of abdominal pain, nausea, and vomiting. She was diagnosed with chronic renal failure.
Several days later, she died following a medical procedure. Her sons filed suit, alleging that
Virginia Mise’s treating physicians and nurses failed to comply with the requisite standard
of care, causing her death. Methodist Medical Center of Oak Ridge and the treating
physicians filed motions for summary judgment. The trial court granted the motions for
summary judgment. We affirm the grant of the motions for summary judgment.

        Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Circuit Court
                            Affirmed; Case Remanded

J OHN W. M CC LARTY, J., delivered the opinion of the court, in which, H ERSCHEL P. F RANKS,
P.J., and D. M ICHAEL S WINEY, J., joined.

Michael S. Shipwash, Knoxville, Tennessee, for the appellants, William Mise and Michael
Cantrell.

F. Michael Fitzpatrick and Rachel Park Hurt, Knoxville, Tennessee, for the appellee,
Methodist Medical Center of Oak Ridge.

Edward G. White, II, and B. Chase Kibler, Knoxville, Tennessee, for the appellee, Bradley
Strnad, M.D.
Libba Bond and R. Scott Durham, Knoxville, Tennessee, for the appellee, Charles Mascioli,
M.D.

                                               OPINION

                                         I. BACKGROUND

      On November 25, 2008, Virginia Mise (“Decedent”) was taken to the emergency
room at Methodist Medical Center of Oak Ridge (“MMC”), complaining of abdominal pain,
nausea, vomiting, and diarrhea. Randy Lovelace, M.D. evaluated Decedent and initially
diagnosed her as suffering from “profound bradycardia, chronic acute renal failure,
metabolic/lactic acidosis, hyperkalemia, and possible cardiogenic or septic shock.” Ali
Yaqub, M.D. subsequently examined Decedent and diagnosed her with hyperkalemia
secondary to acute renal failure. A plan was developed to treat Decedent’s renal failure, and
she was fitted with a temporary pacemaker. Decedent underwent dialysis on December 1.

        Decedent’s renal function worsened the next day, and she experienced “extremity
swelling with concern for central venous obstruction.” Decedent was scheduled to undergo
central venograms and CO2 arteriograms. Bradley Strnad, M.D., a radiologist,1 inserted a
needle and guide wire into the femoral artery and attempted to guide a catheter into the renal
arteries in an effort to obtain diagnostic imaging of the renal arteries and to open the renal
arteries, reestablishing blood flow to the kidneys. Dr. Strnad performed the procedures at
approximately 8:30 a.m. Dr. Strnad took the diagnostic images and attempted to improve the
blood flow to the left kidney. He found that the left renal artery stent that had been placed
in an earlier procedure was occluded, impeding his ability to reestablish blood flow to the
kidney through that artery. He was unable to view the right renal artery. Following the
procedure, he used manual compression to close the femoral artery because he had difficulty
with the Angio-Seal closure device. At 10:45 a.m., Decedent returned to the critical care
unit, where her vital signs were periodically checked and recorded by Stephanie Carmichael,
R.N. (“Nurse Carmichael”) per Dr. Strnad’s instructions. Charles Mascioli, M.D., an
intensivist,2 examined Decedent at 2:00 p.m. Decedent complained of increased abdominal
pain, and Dr. Mascioli noticed that Decedent’s abdomen was tender. He ordered a CT scan




1
 “[ A] physician specializing in the use of radiant energy for diagnostic and therapeutic purposes.” Merriam-
Webster Online Dictionary (2012) (www.merriam-webster.com (derived from Merriam-Webster’s Collegiate
Dictionary (11th Ed.))).
2
 “[A] physician who specializes in the care and treatment of patients in intensive care.” Merriam-Webster
Online Dictionary (2012) (www.merriam-webster.com (derived from Merriam-Webster’s Collegiate
Dictionary (11th Ed.))).
                                                    -2-
with contrast of Decedent’s abdomen and pelvis. The CT scan was taken at 4:19 p.m., and
Decedent returned to her room shortly before 5:00 p.m.

        At approximately 5:13 p.m., Decedent’s blood pressure dropped. A “code blue” was
called, and Dr. Mascioli responded and began emergency efforts to resuscitate Decedent.
Decedent had recovered and developed a blood pressure for a limited time when the CT scan
was returned. The CT scan revealed a collection of blood in the abdominal cavity, most
commonly referred to as an “acute retro peritoneal hemorrhage.” Decedent’s blood pressure
dropped a second time, and her heart beat slowed. At 5:58 p.m., Dr. Lovelace arrived and
assisted in a second attempt to resuscitate Decedent. The physicians were unable to
resuscitate her, and she was pronounced dead at 6:08 p.m.

        Decedent’s sons, William Mise and Michael Cantrell (collectively “Plaintiffs”), filed
suit against MMC, Dr. Lovelace, Dr. Strnad, Dr. Mascioli, and unknown nurses at MMC
(collectively “Defendants”). Plaintiffs contended that Defendants “breached the standard of
care for medical providers in Anderson County, Tennessee,” causing Decedent’s death.
Plaintiffs asserted that MMC was liable pursuant to the doctrine of respondeat superior.

       An affidavit provided by Dr. Robert R. Boyd was attached to the complaint. The
affidavit provided that Dr. Boyd was “familiar with the recognized standards of acceptable
professional practice for physicians in Oak Ridge, Tennessee . . . at all times material to this
case.” (Emphasis added). Dr. Boyd stated that Defendants “failed to conform with the
recognized standards of acceptable professional practice for physicians in Oak Ridge,
Tennessee . . . by not taking precautions and closely monitoring [Decedent] after they failed
to close the renal artery which was punctured during surgery,” causing Decedent’s death.
(Emphasis added).

        Each doctor answered the complaint individually and denied responsibility for
Decedent’s death. MMC denied responsibility on behalf of the unknown nurses and on its
own behalf in response to the respondeat superior claim. Dr. Lovelace subsequently filed a
motion for summary judgment, and by agreement of the parties, Dr. Lovelace was dismissed
from the suit. MMC filed a motion for partial summary judgment on behalf of the nurses,
alleging that Dr. Boyd’s affidavit did not provide that he was familiar with the standard of
care relevant to nurses or that the nurses breached the applicable standard of care. MMC
further argued that there was no “genuine issue as to any material fact regarding the care and
treatment” provided by the nurses because the care provided was consistent with the
applicable standard of care. In support of its motion, MMC presented Nurse Carmichael’s
affidavit in which she stated that the treatment provided to Decedent by the nursing staff
“was in accordance with the standard of care for registered nurses providing care to critically
ill patients in the Anderson County community at that time.”

                                              -3-
       Following MMC’s motion for partial summary judgment, Dr. Boyd filed a second
affidavit in which he stated, “I am familiar with the recognized standards of acceptable
professional practice for physicians and nurses in Oak Ridge, Tennessee . . . in light of my
active clinical practice and instruction.” (Emphasis added). Dr. Boyd further stated that
Defendants “failed to conform with the recognized standards of acceptable professional
practice for physicians and nurses in Oak Ridge, Tennessee . . . by not taking precautions and
closely monitoring [Decedent] after they failed to close the renal artery which was punctured
during surgery,” causing Decedent’s death. (Emphasis added).

        On March 14, 2011, the deposition of Dr. Boyd was taken. Dr. Boyd was licensed in
Tennessee in 1999 or 2000 and maintained his Tennessee license. Through September 2004
to 2006, he was affiliated with the University of Tennessee Family Practice Center in
Jackson, Tennessee. Through that affiliation, he presented lectures to residents and allowed
residents to accompany him while reviewing surgical cases. Relative to his experiences
testifying as an expert, the following colloquy occurred:

       Q:     In all of your prior expert work in medical malpractice, have you
              always testified in the area of surgery expertise?

       A:     Yes.

       Q:     Have you ever testified in any other medical field, other than surgery?

       A:     No, sir.

       Q:     Is that the only area of medical expertise that you maintain you hold
              expertise?

       A:     Yes.

       Q:     As a surgeon only?

       A:     That’s correct.

       Q:     You do not claim to hold expertise as a hospitalist-physician?

       A:     That’s correct.

       Q:     You do not claim to hold expertise as a radiology physician?



                                             -4-
       A:     That’s correct.

       Q:     You do not claim to hold expertise as a radiology technologist or
              technician?

       A:     That’s correct.

       Q:     You do not claim to hold expertise as a nurse?

       A:     That’s correct.

        Dr. Boyd admitted that he had never performed a venogram or a renal arteriogram.
He related that he had performed extremity angiograms, which were different than the
procedures performed on Decedent. He had accessed the femoral artery with a needle more
than 20 times, but it had been “about a year ago” since he had accessed the femoral artery.
He opined that the needle used in the procedure performed on Decedent would have been
larger than the needle he used for his procedures. He had personally stopped the flow of
blood from the femoral artery using manual pressure, but he had also observed physicians
who had closed the femoral artery surgically. He had never used Angio-Seal or observed the
use of Angio-Seal but had spoken to cardiologists and radiologists who used Angio-Seal.

       Dr. Boyd admitted that Dr. Strnad did not commit any blatant errors in the attempt to
access the renal artery. He opined that while he did not observe any errors, Dr. Strnad failed
to open the renal artery. Additionally, Decedent suffered from a retro peritoneal hematoma,
which was most likely caused by an injury to the renal artery. He said that the bleeding in
the back of the abdominal cavity started when Decedent complained “of the additional back
pain and the monitors starting going off, alarming[] things of that nature.” He believed that
Dr. Strnad was negligent in performing the procedure itself, in failing to close the femoral
artery, and in failing to stress the importance of monitoring Decedent following the
procedure. He also believed that Dr. Mascioli and unknown nurses took an excessive amount
of time to evaluate Decedent and to perform the CT scan once evaluated.

       Relative to Dr. Boyd’s ability to testify regarding each particular standard of care, the
following colloquy occurred:

       Q:     Now, you are not a nurse, never been a nurse, agreed?

       A:     That’s correct.

       Q:     You cannot testify as to the standard of care for nurses, can you?

                                              -5-
A:   That’s correct.

Q:   The only physicians that you can testify about the standard of care is a
     surgeon, agreed?

A:   That’s correct.

Q:   So that in terms of your affidavits, either Affidavit 1 or Affidavit 2,
     you’re not offering any standard of care opinions with regard to the
     nurses who provided care to [Decedent], are you?

A:   My opinions will be based on a physician that’s in practice and who
     practices with nurses.

Q:   My question was: You’re not going to offer standard of care opinions
     with regard to nursing staff, though, are you?

A:   No more than what I’ve discussed.

Q:   Well, you’re not qualified to offer any standard of care opinions with
     regard to nurses, are you?

A:   I’m not a nurse, I do not work as a nurse; but I do work with nurses
     with my patients.

Q:   All right. You work with lawyers, too, don’t you?

A:   Yes.

Q:   You know the standard of care for lawyers?

A:   No.

Q:   So you can’t testify as to the standard of care for a nurse.

A:   Correct.

Q:   You cannot testify as to the standard of care for a radiologist, correct?

A:   I’m not a radiologist.

                                    -6-
       Q:     Answer the question.

       A:     No.

       Q:     Meaning, you cannot testify to the standard of care for a radiologist.

       A:     That’s correct.

       Q:     You cannot testify as to the standard of care for a hospitalist –

       A:     Correct.

       Q:     – such as Dr. Mascioli or Dr. Lovelace?

       A:     Correct.

       Q:     You can’t testify as to the standard of care for Dr. [Strnad], correct?

       A:     He’s a radiologist, I’m not; therefore, I cannot – only based on what
              we’ve already discussed.

       Q:     You cannot offer testimony as to the standard of care for unknown
              nurses, either, can you?

       A:     By me not being a nurse, no.

Later in the deposition, Dr. Boyd was questioned regarding his ability to testify concerning
the standard of care applicable to intensivists. The following colloquy occurred:

       Q:     And you have never worked full-time in an ICU as an intensivist, have
              you?

       A:     No.

       Q:     Okay. On occasion, have you had the opportunity to refer or consult
              with an intensivist on care of one of your patients?

       A:     Frequently.




                                             -7-
       Q:     And is that because they have specialized training in managing
              critically ill patients?

       A:     Medical issues.

       Q:     Okay. And I believe you testified earlier that you do not know the
              standard of care for an intensivist, is that correct?

       A:     That’s correct.

       During the examination by Plaintiffs’ counsel, Dr. Boyd testified that he was familiar
with the recognized standards of acceptable professional practice for each applicable
speciality. The following colloquy occurred:

       Q:     Well, then can you please help me understand? Because I could have
              sworn in response to one of [defense counsel’s] questions, you said that
              you were not familiar with the standard of care of hospitalists and
              nurses. Can you please explain that?

       A:     I can. I recall [defense counsel] asking, was I a radiologist? Do I
              perform radiology? Am I qualified to speak as an expert in interpreting
              x-rays? Am I a radiologist? The answer to that is no. However, as a
              practicing surgeon, I do - - and I did state this, as well - - I do read CT
              scans. And I do know what the standard of care is with regard to that
              within the scope of my surgical practice.

       Q:     And in this case, are you able to testify that Nurse Carmichael breached
              the standard of care for nurses in Oak Ridge, Tennessee?

       A:     I can, yes.

                                             ***

       Q:     And are you comfortable testifying that Dr. Mascioli breached the
              standard of care in this case?

       A:     Yes.

       Q:     Are you comfortable testifying that Dr. [Strnad] breached the standard
              of care in this case?

                                              -8-
      A:     I am.

      Q:     And that’s so, even though in previous testimony, I wrote down and I
             thought you said that you were not familiar with the standard of care of
             radiology.

      A:     What I meant by saying that is that I am not a radiologist. If anyone
             were to ask me, am I a radiologist, the answer would be no. Do I work
             with a radiologist, do I read films, do I communicate with them, do I
             interact with them with regard to surgical patients? Yes. Therefore,
             with regard to that, I am qualified to make that statement.

      Q:     Okay. And briefly, . . . can you please tell the [c]ourt how Nurse
             Carmichael breached the standard of care as it relates to [Decedent] in
             this case.

      A:     Yes. The individual aggressive attention was not there for [Decedent].

Upon further questioning by defense counsel, the following colloquy occurred:

      Q:     Are you recanting all of your earlier testimony?

      A:     No.

      Q:     Are you standing by your opinions?

      A:     I’m standing by - - yes, I am.

      Q:     And are you standing by all of your testimony in this case?

      A:     With - - well, obviously, there has been some discrepancy with regard
             to me stating that I’m not an - - I’m not able to give the standard of
             care; and I would like to think that I qualified that.

      Q:     Qualified it or recanted?

      A:     Well, I like the word qualified.

      Q:     All right. You would agree that you are not an expert nurse, agreed?



                                              -9-
A:   I am not a nurse.

                                    ***

Q:   And you would agree, you cannot testify as to the standard of care for
     nurses?

A:   I can testify to the standard of care of the nurses with regard to caring
     for patients.

Q:   Just because you’ve worked with them?

A:   I think that means quite a bit.

                                    ***

Q:   So you can’t offer opinions with regard to radiology technologists in
     this case, can you?

A:   I have had patients that have had problems similar to [Decedent];
     therefore, I feel that I can offer an opinion with regard to that.

                                    ***

Q:   Doctor, earlier, you told me that you do not know the standard of care
     for an intensivist in Oak Ridge, Tennessee. And it sounds like you’ve
     changed your mind on that . . .

A:   I’d like to qualify. Am I going to say that I am an intensivist if I’ve had
     training in that? The answer is no. Have I worked with, had interaction
     with, worked closely with hospitalists, intensivists with regard[] to care
     of my patients or a patient similar to [Decedent] that’s had a procedure
     and a potential surgical problem? The answer to that is yes.

Q:   Tell me . . . what do you mean by that?

A:   Well, we work as a team. I have a surgical patient who’s got medical
     issues. I consult them. They have patients with medical issues that so
     happen to have a surgical problem, they consult me. And together, we
     come up with a treatment plan to get the patient better.

                                       -10-
       Q:     Do you round on patients in the ICU?

       A:     Of course.

                                            ***

       Q:     Okay. But you would agree that Dr. Mascioli, his speciality is critical
              care medicine. He is strictly an intensivist, correct?

       A:     I agree.

       Q:     He’s not a pulmonologist, correct?

       A:     I agree. But they do have - - they have knowledge in every facet of
              internal medicine. That’s part of their training.

       Q:     Do you have that training?

       A:     No. Have I had training in the ICU? Yes, I have.

                                            ***

       A:     Well, I have had training during my surgical residency in ICU
              management with regard to surgical patients.

        Following the deposition, Plaintiffs filed their response to MMC’s motion for partial
summary judgment and attached a second affidavit. MMC filed a motion to strike the second
affidavit, alleging that Dr. Boyd had given “contradictory testimony regarding his ability to
provide expert testimony relative to the standard of care of nurses in Anderson County,
Tennessee.” Plaintiffs argued that Dr. Boyd’s testimony at the deposition was not contrary
to the affidavits and that Dr. Boyd presented a plausible explanation for his testimony.

       On April 1, 2011, a hearing was held on MMC’s motion for partial summary judgment
regarding the claim filed against the nurses. The court held that Dr. Boyd had given
inconsistent testimony on his ability to testify concerning the relevant standard of care for
nurses. The court further found that the affidavit filed by Nurse Carmichael “negated the
essential claim” that the nurses had failed to comply with the requisite standard of care and
shifted the burden of proof to Plaintiffs to rebut Nurse Carmichael’s affidavit. In its order
granting the motion for summary judgment, the court found



                                            -11-
       that the testimony of Dr. Boyd in his discovery deposition is not sufficient to
       overcome the motion for summary judgment and Dr. Boyd clearly
       acknowledged that he was not acquainted with the standard of care for nurses
       and that he could not offer testimony on that subject. His attempts to explain
       why he should be allowed to express opinions regarding nurses is insufficient
       under Tennessee law.

Plaintiffs filed a motion to revise or alter or amend the judgment.

       Dr. Strnad and Dr. Mascioli then filed motions for summary judgment. Each doctor
alleged that Plaintiffs had not offered competent expert proof in support of their claim
because Dr. Boyd was not qualified to render opinions regarding the applicable standard of
care. Attached to each motion was a statement of material facts, denying liability. Each
motion also included an affidavit in which each doctor stated that he was familiar with the
requisite standard of care and that he did not breach that standard of care. MMC filed a
second motion for summary judgment, asserting that the respondeat superior claim against
it should be dismissed if the claims against Dr. Strnad and Dr. Mascioli were dismissed.

       Plaintiffs responded with a third affidavit from Dr. Boyd in which he attempted to
further explain his deposition testimony. Dr. Boyd opined that he was “led down the
‘primrose path’ [by defense counsel] and, unfortunately, gave testimony that [he] was
confused on; and for which looking back, was clearly erroneous.” Dr. Boyd recounted the
relevant testimony before finally stating,

       In summary, although I thought I clarified the confusion I experienced during
       my deposition, please allow this Affidavit to clear up any additional concerns:
       I am able to testify as to the standard of care in this case as to all the
       Defendants[.]

In response to each assertion contained in each doctor’s statement of undisputed material
facts, Plaintiffs responded that it was “[u]ndisputed that [Dr. Strnad or Dr. Mascioli] makes
this statement in his self-serving Affidavit.”

       On May 9, 2011, the court held a hearing on the motions for summary judgment filed
by Dr. Strnad, Dr. Mascioli, and MMC. Following the hearing, the court granted the motions
for summary judgment and dismissed the claim against Defendants. Plaintiffs declined
argument on the motion to revise or alter or amend the court’s judgment. The court stated,

       This [c]ourt specifically finds that [P]laintiffs’ proffered testimony of [Dr.
       Boyd] is not sufficient to overcome the motions for summary judgment

                                            -12-
       because his testimony, by three (3) affidavits and one (1) deposition, regarding
       the applicable standards of care is contradictory and therefore negates his
       testimony. Furthermore, the [c]ourt finds that Dr. Boyd is not qualified to
       testify as to the standard of care for the various defendants in this case. As a
       third and independent ground for the grant of summary judgment as to
       defendants [Dr.] Strnad and [Dr.] Mascioli, this [c]ourt finds that [P]laintiffs
       did not dispute any material issue of fact which [D]efendants [Dr.] Strnad and
       [Dr.] Mascioli filed in support of their [m]otions for [s]ummary [j]udgment,
       showing that there was no genuine issue for trial.

Relative to MMC, the court held,

       All claims of independent negligence against [MMC] have been dismissed
       pursuant to an [o]rder entered April 18, 2011; however[,] the [c]ourt has ruled
       that the applicable time for filing an appeal from that ruling will be from the
       date this [o]rder is approved by the [c]ourt. As this [c]ourt has dismissed the
       claims against defendants [Dr.] Strnad and [Dr.] Mascioli, [MMC] is entitled
       to summary judgment as a matter of law on the remaining claim of agency
       pursuant to the law of respondeat superior.

       Plaintiffs timely filed their appeal to the trial court’s ruling.

                                          II. ISSUES

       We consolidate and restate the issues raised on appeal by Plaintiffs as follows:

       A. Whether the trial court erred in disregarding Dr. Boyd’s affidavits pursuant
       to the cancellation rule.

       B. Whether the trial court erred in holding that Dr. Boyd was not qualified to
       testify concerning the relevant standard of care for each defendant.

       C. Whether the trial court erred in ruling that Plaintiffs failed to dispute the
       statements of material facts filed by Dr. Strnad and Dr. Mascioli.

                              III. STANDARD OF REVIEW

       Summary judgment is appropriate where: (1) there is no genuine issue with regard to
the material facts relevant to the claim or defense contained in the motion and (2) the moving
party is entitled to judgment as a matter of law on the undisputed facts. Tenn. R. Civ. P.

                                              -13-
56.04. A properly supported motion for summary judgment “must either (1) affirmatively
negate an essential element of the nonmoving party’s claim; or (2) show that the nonmoving
party cannot prove an essential element of the claim at trial.” Hannan v. Alltel Publ'g Co.,
270 S.W.3d 1, 9 (Tenn. 2008). When the moving party has made a properly supported
motion, the “burden of production then shifts to the nonmoving party to show that a genuine
issue of material fact exists.” Id. at 5; see Robinson v. Omer, 952 S.W.2d 423, 426 (Tenn.
1997); Byrd v. Hall, 847 S.W.2d 208, 215 (Tenn. 1993). The nonmoving party may not
simply rest upon the pleadings but must offer proof by affidavits or other discovery materials
to show that there is a genuine issue for trial. Tenn. R. Civ. P. 56.06. If the nonmoving party
“does not so respond, summary judgment, if appropriate, shall be entered.” Tenn. R. Civ.
P. 56.06.

        On appeal, this court reviews a trial court’s grant of summary judgment de novo with
no presumption of correctness. See City of Tullahoma v. Bedford County, 938 S.W.2d 408,
412 (Tenn. 1997). In reviewing the trial court’s decision, we must view all of the evidence
in the light most favorable to the nonmoving party and resolve all factual inferences in the
nonmoving party’s favor. Luther v. Compton, 5 S.W.3d 635, 639 (Tenn. 1999); Muhlheim
v. Knox. Cnty. Bd. of Educ., 2 S.W.3d 927, 929 (Tenn. 1999). If the undisputed facts support
only one conclusion, then the court’s summary judgment will be upheld because the moving
party was entitled to judgment as a matter of law. See White v. Lawrence, 975 S.W.2d 525,
529 (Tenn. 1998); McCall v. Wilder, 913 S.W.2d 150, 153 (Tenn. 1995).

        “‘In general, questions regarding the admissibility, qualifications, relevancy and
competency of expert testimony are left to the discretion of the trial court.”’ Helderman v.
Smolin, 179 S.W.3d 493, 501 (Tenn. Ct. App. 2005) (quoting McDaniel v. CSX Transp., Inc.,
955 S.W.2d 257, 263 (Tenn. 1997)). Likewise, questions regarding a party’s compliance
with Rule 56.03 of the Tennessee Rules of Civil Procedure are left to the discretion of the
trial court. Owens v. Bristol Motor Speedway, Inc., 77 S.W.3d 771, 774-45 (Tenn. Ct. App.
2001). “A trial court abuses its discretion only when it ‘applie[s] an incorrect legal standard
or reache[s] a decision which is against logic or reasoning that cause[s] an injustice to the
party complaining.’” Eldridge v. Eldridge, 42 S.W.3d 82, 85 (Tenn. 2001) (quoting State v.
Shirley, 6 S.W.3d 243, 247 (Tenn. 1999)). If a discretionary decision is within a range of
acceptable alternatives, we will not substitute our judgment for that of the trial court simply
because we may have chosen a different alternative. White v. Vanderbilt Univ., 21 S.W.3d
215, 223 (Tenn. Ct. App. 1999).

                                     IV. DISCUSSION




                                             -14-
        Medical malpractice claims are a specialized type of negligence action. Such actions
in this state are controlled by the medical malpractice statute, which provides, in pertinent
part,

       (a) In a malpractice action, the claimant shall have the burden of proving by
       evidence as provided by subsection (b):

              (1) The recognized standard of acceptable professional practice
              in the profession and the specialty thereof, if any, that the
              defendant practices in the community in which the defendant
              practices or in a similar community at the time the alleged injury
              or wrongful action occurred;

              (2) That the defendant acted with less than or failed to act with
              ordinary and reasonable care in accordance with such standard;
              and

              (3) As a proximate result of the defendant’s negligent act or
              omission, the plaintiff suffered injuries which would not
              otherwise have occurred.

Tenn. Code Ann. § 29-26-115(a). The three elements listed in subsection (a) of the statute
must be proven by the testimony of a qualified expert. Williams v. Baptist Mem’l Hosp., 193
S.W.3d 545, 553 (Tenn. 2006).

                                             A.

        Plaintiffs argue that the trial court erred in finding that Dr. Boyd’s deposition
testimony merited the rejection of his affidavits. Plaintiffs note that any inconsistencies in
the testimony were explained and did not present an unequivocal and irreconcilable conflict,
that medical doctors are not expected to speak with precision on legal matters, and that Dr.
Boyd’s testimony was corroborated. Defendants respond that Dr. Boyd’s testimony was
properly discarded because it was contradictory. They argue that Dr. Boyd’s subsequent
failure to offer a plausible explanation for his contradictory statements merited the
application of the cancellation rule, warranting the grant of the motions for summary
judgment. MMC notes that Dr. Boyd never presented any evidence in support of his later
assertions that he was familiar with the requisite standard of care.

       “Tennessee follows the rule that contradictory statements by the same witness
regarding a single fact cancel each other out.” Church v. Perales, 39 S.W.3d 149, 169-70

                                             -15-
(Tenn. Ct. App. 2000) (citing State v. Matthews, 888 S.W.2d 446, 449 (Tenn. Crim. App.
1993); Gambill v. Middle Tenn. Med. Ctr., 751 S.W.2d 145, 149-50 (Tenn. Ct. App. 1988)).
“If determined by the trial court to be contradictory, the statements by the witness are
considered to be ‘no evidence’ of the fact sought to be proved.” Helderman, 179 S.W.3d at
501 (quoting Wilson v. Patterson, 73 S.W.3d 95, 103-04 (Tenn. Ct. App. 2001)). “[I]n order
to be disregarded under the so-called cancellation rule, the allegedly contradictory statements
must be unexplained and neither statement can be corroborated by other competent
evidence.” Perales, 39 S.W.3d at 170 (citing Matthews, 888 S.W.2d at 450; Gambill, 751
S.W.2d at 151). “When the cancellation rule is invoked at the summary judgment stage to
challenge evidence opposing the motion, the courts must view the challenged evidence in the
light most favorable to the opponent of the motion.” Id. Additionally, “there should not be
a dismissal for inconsistency in testimony of a witness unless it represents an unequivocal
and irreconcilable conflict.” Gambill, 751 S.W.2d at 151-52.

       The contradictory statements at issue relate to Dr. Boyd’s ability to testify regarding
the standard of care for each defendant, nurses, an intensivist, and a radiologist. In order to
succeed on their claim, Plaintiffs needed to present an expert who was familiar with and who
was qualified to offer testimony relating to the requisite standard of care for each speciality.
Here, Dr. Boyd’s first affidavit failed to satisfy that requirement in that Dr. Boyd provided
that he was only familiar with the requisite standard of care for physicians. The second
affidavit provided that Dr. Boyd was familiar with the requisite standard of care for
physicians and nurses, while the third affidavit provided that Dr. Boyd was familiar with the
requisite standard of care for all Defendants. During the deposition, Dr. Boyd testified on
several occasions that he was unfamiliar with the requisite standard of care for each
applicable defendant. Later, he stated that he never meant to imply that he was unfamiliar
with any of the relevant standards of care but that he was merely agreeing with the fact that
he was a physician, not a radiologist, an intensivist, or a nurse.

       While we acknowledge that Dr. Boyd’s harmful statements were made while
undergoing examination by defense counsel, we cannot ignore the fact that Dr. Boyd’s
testimony on his familiarity with each applicable standard of care was inconsistent. Having
determined that Dr. Boyd’s testimony was inconsistent on this issue, we must now decide
whether the inconsistency “represents an unequivocal and irreconcilable conflict.” Id. In
Gambill, the testimony at issue was subject to two interpretations, one of which was not
inconsistent with the other testimony. Id. at 151. Here, Dr. Boyd testified at one point that
he was unfamiliar with the requisite standard of care, while he testified at another point that
he was familiar with the requisite standard of care. We believe that this contradictory
testimony presented an unequivocal and irreconcilable conflict. Indeed, either Dr. Boyd was
familiar with the requisite standard of care or he was not. While the questions posed to Dr.
Boyd by defense counsel were clear and should have been answered correctly, Dr. Boyd

                                              -16-
offered an explanation for his contradictory testimony during the deposition. Having viewed
the challenged evidence in the light most favorable to Plaintiffs, “[w]e cannot say at this
summary judgment stage that this explanation for the change in his testimony is not credible
as such a credibility determination is not appropriate at the summary judgment stage.” U.S.
Waste Atlanta, LLC v. Englund, No. E2010-01865-COA-R3-CV, 2012 WL 1116350, at *5
(Tenn. Ct. App. Apr. 3, 2012). However, this conclusion does not end our inquiry because
the court also ruled that Dr. Boyd was not qualified to offer expert testimony.

                                               B.

      A medical expert must fulfill the following requirements in order to testify in a
medical malpractice case:

       (b) No person in a health care profession requiring licensure under the laws of
       this state shall be competent to testify in any court of law to establish the facts
       required to be established by subsection (a), unless the person was licensed to
       practice in the state or a contiguous bordering state a profession or specialty
       which would make the person’s expert testimony relevant to the issues in the
       case and had practiced this profession or specialty in one (1) of these states
       during the year preceding the date that the alleged injury or wrongful act
       occurred. This rule shall apply to expert witnesses testifying for the defendant
       as rebuttal witnesses. The court may waive this subsection when it determines
       that the appropriate witnesses otherwise would not be available.

Tenn. Code Ann. § 29-26-115(b). Additionally, a medical expert relied upon by a plaintiff
“must have knowledge of the standard of professional care in a defendant’s applicable
community or knowledge of the standard of professional care in a community that is shown
to be similar to the defendant’s community.” Robinson v. LeCorps, 83 S.W.3d 718, 724
(Tenn. 2002). It is critical that expert witnesses actually be familiar with the standard of care
in the defendant’s community and not “simply assert their familiarity with the standard of
professional care in the defendant’s community without indicating the basis for their
familiarity.” Williams v. Baptist Mem’l Hosp., 193 S.W.3d 545, 553 (Tenn. 2006); see also
Stovall v. Clarke, 113 S.W.3d 715, 723 (Tenn. 2003).

       In a medical malpractice case, once a defendant physician has filed a motion for
summary judgment with an attached affidavit stating that he did not breach the applicable
standard of care, the plaintiff “cannot rest on the allegations in [the]complaint.” Kenyon v.
Handal, 122 S.W.3d 743, 758 (Tenn. Ct. App. 2003). As was the case here, the common and
practical response to such a motion and attached affidavit is to submit a contradictory
affidavit from a medical expert who satisfies the requirements of Tennessee Code Annotated

                                              -17-
section 29-26-115(b). Id. A plaintiff who is “unable to produce an expert affidavit of [his]
own face[s] almost certain dismissal of the[] complaint because the physician has effectively
negated an essential element of the[] case.” Id. Additionally, “[w]ithout an opposing expert
affidavit, [a plaintiff] cannot demonstrate the existence of a genuine factual dispute regarding
whether the physician breached the standard of professional practice in the community.” Id.
Indeed, “summary judgment in favor of [a defendant physician] in a medical malpractice
action may be appropriate where the [physician] produce[s] expert proof that completely
refutes the plaintiff’s allegations of negligence and the plaintiff does not produce rebuttal
proof by expert testimony.” Lovin v. Charles E. Nave, D.D.S., P.C., No. E2002-00686-COA-
R3-CV, 2003 WL 164281, at *4 (Tenn. Ct. App. Jan. 22, 2003). Even if the affidavit
contains sufficient rebuttal proof, summary judgment may still be appropriate if the affidavit
does not “contain sufficient information to demonstrate that the [expert] is qualified to render
an expert opinion and that the [expert]’s opinion will substantially assist the trier of fact.”
Kenyon, 122 S.W.3d at 759 (internal citations omitted).

       Here, MMC filed a motion on behalf of the unknown nurses with an affidavit from
Nurse Carmichael, declaring that she was familiar with the requisite standard of care and that
the nurses complied with that standard. Likewise, Dr. Strnad and Dr. Mascioli filed their
own affidavits, declaring their familiarity with the standard of care and that they complied
with that standard. Once the motions and accompanying affidavits were filed, Plaintiffs were
tasked with submitting rebuttal proof by expert testimony.

                                               1. Nurses

       Relative to the claim against the nurses, Plaintiffs responded with Dr. Boyd’s second
and third affidavit filed in this case.3 In the second affidavit, Dr. Boyd expounded on his
qualifications and ability to testify concerning the applicable standard of care. Specifically,
Dr. Boyd stated, in relevant part,

        5. I am familiar with the recognized standards of acceptable professional
        practice for . . . nurses in Oak Ridge, Tennessee or similar communities at all
        times material to this case, in light of my active clinical practice and
        instruction.

Dr. Boyd also asserted that the unknown nurses failed to perform their care of Decedent
within the relevant professional standard and that their failure to take the proper precautions



3
 We acknowledge that the motion for summary judgment relative to the claim against the nurses had been
granted prior to the filing of the third affidavit. However, a motion to alter or amend that judgment was
pending prior to the filing of the final order.
                                                  -18-
and monitor Decedent caused her death. In the third affidavit, Dr. Boyd explained his
deposition testimony concerning his ability to testify regarding the standard of care for nurses
by stating,

       I was asked questions such as “am I a nurse?”; “am I a radiologist”; “am I an
       internist?”. I am not a nurse, radiologist nor an internist. Nevertheless, over
       the last 20 years I have worked with nurses; I have supervised nurses; I have
       written orders for nurses; I have viewed orders written by other physicians for
       nurses, I have trained nurses and I have observed nurses respond to monitors
       going off, as well as, observed nurses caring for patients.

Dr. Boyd finished by stating that he was “more than capable of testifying as to the standard
of care for nurses . . . as it relates to this case” and that he had worked with nurses “on a
regular and daily basis.”

       “[T]he medical malpractice statute may extend to acts of non-physicians, such as
nurses, when they are involved in the medical treatment of a patient.” Gunter v. Laboratory
Corp. of America, 121 S.W.3d 636, 640 (Tenn. 2003). A testifying expert need not practice
in the same speciality area as the defendant. Shipley v. Williams, 350 S.W.3d 527, 356
(Tenn. 2011). However, “the witness must demonstrate sufficient familiarity with the
standard of care and the testimony must be probative of the issue involved.” Cardwell v.
Bechtol, 724 S.W.2d 739, 751 (Tenn. 1987).

       In an effort to demonstrate his familiarity with the standard of care relevant to nurses,
Dr. Boyd stated that he had worked with, supervised, trained, and observed nurses. Based
upon his experience, he believed the “individual aggressive attention was not there for”
Decedent in that the nurses failed to closely monitor a high-risk patient who underwent an
“unsuccessful procedure.” While helpful, the fact that Dr. Boyd worked with nurses did not
establish that he was familiar with the relevant standard of care applicable in this case,
specifically whether the nurses were negligent in their care and observation of a patient in
chronic renal failure who had undergone central venograms and CO2 arteriograms.
Following our review, we believe that Dr. Boyd did not present sufficient information to
demonstrate that he was qualified to render an expert opinion on the standard of care relevant
to nurses. Accordingly, the trial court did not err in granting the motion for summary
judgment because Plaintiffs failed to submit sufficient rebuttal proof.

                               2. Dr. Strnad and Dr. Mascioli

      Relative to the claim against Dr. Strnad and Dr. Mascioli, Plaintiffs responded with
Dr. Boyd’s second and third affidavit filed in this case. In the second affidavit, Dr. Boyd

                                              -19-
expounded on his qualifications and ability to testify concerning the applicable standard of
care. Specifically, Dr. Boyd stated, in relevant part,

       5. I am familiar with the recognized standards of acceptable professional
       practice for physicians . . . in Oak Ridge, Tennessee or similar communities at
       all times material to this case, in light of my active clinical practice and
       instruction.

Dr. Boyd asserted that Dr. Strnad and Dr. Mascioli failed to perform their care of Decedent
within the relevant professional standard and that their failure caused Decedent’s death. In
the third affidavit, Dr. Boyd explained his deposition testimony concerning his ability to
testify regarding the standard of care for Dr. Strnad and Dr. Mascioli by stating,

       In addition, over the last 20 years I have worked with radiologists, internists,
       hospitalists and many other physicians. I have also assisted radiologists,
       internists and hospitalists in their area of practice; I have viewed orders written
       by radiologists, internists and hospitalists to nurses; I have spoken with
       radiologists, internists and hospitalists relative to their care of patients and my
       care of patients; I have observed radiologists, internists and hospitalists caring
       for their patients; and I know what the standard of care is for surgical
       procedures and post-op orders.

Dr. Boyd finished by stating that he was “more than capable of testifying as to the standard
of care for . . . radiologists, internists and hospitalists as it relates to this case” and that he had
worked with radiologists, internists, and hospitalists “on a regular and daily basis.”

        Dr. Strnad was a radiologist, while Dr. Mascioli was an intensivist. Dr. Boyd offered
testimony in his deposition regarding his familiarity with the applicable standard of care for
intensivists like Dr. Mascioli. Regarding the alleged breach of the standard of care, he stated
that he believed Dr. Mascioli was negligent in providing follow-up care to Decedent in that
Dr. Mascioli ordered a CT scan with contrast, knowing that it would not be done immediately
because Decedent would have to ingest the contrast material. He also believed that Dr.
Strnad was negligent in performing the procedure and in closing the femoral artery.

       Dr. Boyd never performed the procedures in this case. He had not even used the size
of needle that Dr. Strnad used to access the femoral artery and had never personally used
Angio-Seal to close a femoral artery. Dr. Boyd’s experience with the relevant specialists was
limited to his observation of and conversations and consultations with the specialists. While
Dr. Boyd related that he had training in the intensive care unit with regard to surgical
patients, he did not elaborate further on that training. Following our review, we believe that

                                                 -20-
Dr. Boyd failed to present sufficient information demonstrating that he was qualified to
render an expert opinion on the standard of care relevant to Dr. Strnad and Dr. Mascioli.
Accordingly, the trial court did not err in granting the motions for summary judgment
because Plaintiffs failed to submit sufficient rebuttal proof.

                                           3. MMC

        Having concluded that the trial court did not err in granting the motions for summary
judgment relative to the claims against Dr. Strnad and Dr. Mascioli, we must also conclude
that the trial court did not err in granting the motion for summary judgment relative to the
respondeat superior claim against MMC. Johnson v. LeBonheur Children’s Med. Ctr., 74
S.W.3d 338, 345 (Tenn. 2002) (“[A] principal may not be held vicariously liable under the
doctrine of respondeat superior based upon the acts of its agent . . . when the right of action
against the agent is extinguished by operation of law.”).

                                              C.

        In case of further appellate review, we will also address the trial court’s ruling that
dismissal of the claims against Dr. Strnad and Dr. Mascioli was appropriate because
Plaintiffs failed to properly respond to the statement of material facts.

       Those filing a motion for summary judgment must also file

       a separate concise statement of the material facts as to which the moving party
       contends there is no genuine issue for trial. Each fact shall be set forth in a
       separate, numbered paragraph. Each fact shall be supported by a specific
       citation to the record.

Tenn. R. Civ. P. 56.03. In return, the party opposing the motion

       must, not later than five days before the hearing, serve and file a response to
       each fact set forth by the movant either (i) agreeing that the fact is undisputed,
       (ii) agreeing that the fact is undispusted for purposes of ruling on the motion
       for summary judgment only, or (iii) demonstrating that the fact is disputed.
       Each disputed fact must be supported by specific citation to the record.

Tenn. R. Civ. P. 56.03 (Emphasis added).

       Here, Dr. Strnad and Dr. Mascioli filed statements of material facts with their motion
for summary judgment. Dr. Strnad’s statement provided,

                                              -21-
       1. Dr. Strnad performed a central venogram and CO2 arteriogram on
       December 2, 2008 on [Decedent].

       2. This procedure was indicated and appropriate, and at no time did Dr. Strnad
       puncture the renal artery.

       3. At the conclusion of the procedure, hemostasis was achieved by the well
       accepted technique of manual compression, which Dr. Strnad personally
       checked and verified.

       4. Dr. Strnad gave thorough, written postoperative orders for [Decedent’s]
       continued care and observation.

       5. Appropriate precautions were taken, and her monitoring was performed in
       accordance with the standard of care for interventional radiologists performing
       CO2 arteriograms in [Anderson County].

       6. Dr. Strnad is familiar with the recognized standards of acceptable
       professional practice for radiologists practicing in [Anderson County], having
       practiced as a radiologist in Oak Ridge since January 2008, and at all times
       material to this case.

Plaintiffs responded to each fact contained in the statement as follows:

       Undisputed that Dr. Strnad makes this statement in his self serving Affidavit.

Dr. Mascioli’s statement provided, in pertinent part,

       2. Dr. Mascioli is familiar with the standard of acceptable professional practice
       applicable to intensivists in [Anderson County].

                                            ***

       14. In providing care and treatment to [Decedent], Dr. Mascioli at all times
       met the standard of acceptable professional practice applicable to intensivists
       practicing in [Anderson County].

       15. Nothing done or omitted to be done by Dr. Mascioli caused or contributed
       to any injury to or the death of [Decedent].



                                             -22-
(Citations omitted). Plaintiffs responded to each pertinent fact contained in the statement as
follows:

       Undisputed that Dr. Mascioli makes this statement in his self serving
       Affidavit.

In the attached consolidated response to each motion, Plaintiffs alleged that there were
genuine issues of material fact remaining and further stated,

       In support of this Response, [Plaintiffs] rely on the entire record in this case,
       the Memorandum of Law, the Affidavit of Dr. Boyd attached as an Exhibit to
       the Memorandum of Law, the deposition of [Dr. Boyd], and Plaintiffs’
       Response to All Defendants’ alleged Statement of Undisputed Facts filed
       contemporaneously with this Response.

        “This [c]ourt has recognized that a nonmoving party’s failure to comply with Rule
56.03 may result in the trial court’s refusal to consider the factual contentions of the
nonmoving party even though those facts could be ascertained from the record.” Owens, 77
S.W.3d at 774. However, “a trial court, acting within its discretion, may waive the
requirements of the rule in an appropriate situation.” Id. at 774-75. If the trial court refuses
to waive the requirements, the moving party’s statement of material facts remain undisputed,
possibly meriting the grant of the motion for summary judgment. In this case, Plaintiffs
failed to comply with Rule 56.03 of the Tennessee Rules of Civil Procedure, and we do not
believe that waiver of the requirements was appropriate. Consequently, the statement of
material facts was undisputed. Accordingly, the trial court did not err in granting the motions
for summary judgment because each doctor alleged in their statement that they complied with
the applicable standard of care, leaving no issues for the trial court to consider.

                                     V. CONCLUSION

      The judgment of the trial court is affirmed, and the case is remanded for such further
proceedings as may be necessary. Costs of the appeal are taxed to the appellants, William
Mise and Michael Cantrell.


                                            ______________________________________
                                            JOHN W. McCLARTY, JUDGE




                                              -23-
