AFFIRM; and Opinion Filed April 30, 2019.




                                             In The
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                      No. 05-18-00833-CV

                  SUJEET ACHARYA, M.D., TEXAS ONCOLOGY, P.A.,
                   AND TEXAS UROLOGY SPECIALISTS, Appellants
                                      V.
                         BERNICE MARIE GOMEZ, Appellee

                      On Appeal from the 160th Judicial District Court
                                   Dallas County, Texas
                           Trial Court Cause No. DC-17-12969

                             MEMORANDUM OPINION
                          Before Justices Myers, Osborne, and Nowell
                                  Opinion by Justice Osborne
       In this interlocutory appeal, we consider whether an expert report filed by appellee Bernice

Marie Gomez to support a healthcare liability claim against appellants Sujeet Acharya, M.D.,

Texas Oncology, P.A., and Texas Urology Specialists meets the requirements of section 74.351 of

the civil practice and remedies code. TEX. CIV. PRAC. & REM. CODE § 74.351. We conclude that it

does, and we affirm the trial court’s order overruling appellants’ objections to the report and

denying appellants’ motion to dismiss.

                                         BACKGROUND

       Gomez was diagnosed with a malignant tumor in her left adrenal gland that was causing

her abdominal pain. Dr. Acharya performed surgery on Gomez on November 14, 2016, to remove

the cancerous adrenal gland. But a post-surgical pathology report revealed that only benign tissue
from Gomez’s pancreas had been removed, not the cancerous adrenal tissue. In the following

weeks, Gomez required treatment for her injured pancreas. She continued to suffer from worsening

abdominal pain and had not received further treatment for her malignant adrenal tumor as of June

1, 2017.

          Gomez sued appellants,1 alleging that Dr. Acharya was negligent in the care provided to

her. She served an expert report as required under Chapter 74 of the civil practice and remedies

code. TEX. CIV. PRAC. & REM. CODE §§ 74.001–74.507 (“Chapter 74”). Richard E. Link, M.D.,

Ph.D prepared the report on Gomez’s behalf. Appellants filed a motion to dismiss Gomez’s claims,

arguing that the report did not meet Chapter 74’s requirements. An associate judge granted the

motion and gave Gomez an opportunity to amend the report as permitted under Chapter 74. Dr.

Link revised his report and appellants filed a motion to dismiss that addressed the revised report.

The trial court heard the motion, overruled appellants’ objections to Dr. Link’s revised report, and

denied the motion to dismiss by order signed June 20, 2018.

          In five issues, appellants contend the trial court erred by overruling their objections to

Gomez’s Chapter 74 expert report and denying their motion to dismiss. They allege:

          1.         Dr. Link is not qualified to opine regarding causation;

          2.         The report “ignored the facts” regarding Dr. Acharya’s communications with

                     Gomez after the surgery;

          3.         The report does not “accurately report the facts of the case” regarding the care Dr.

                     Acharya exercised during surgery;

          4.         The report fails to specify a clear standard of care; and

          5.         The report fails to explain the causal connection between the alleged breaches of

                     the standard of care and the alleged injuries.


   1
       Gomez alleges that appellants Texas Oncology, P.A. and Texas Urology Specialists are vicariously liable for Dr. Acharya’s medical care.

                                                                    –2–
                                       STANDARD OF REVIEW

        We review a trial court’s ruling on the sufficiency of an expert’s report for abuse of

discretion. Van Ness v. ETMC First Physicians, 461 S.W.3d 140, 142 (Tex. 2015) (per curiam);

Nexion Health at Terrell Manor v. Taylor, 294 S.W.3d 787, 791 (Tex. App.—Dallas 2009, no

pet.). A trial court abuses its discretion if it acts arbitrarily, unreasonably, or without reference to

any guiding rules or principles. Jelinek v. Casas, 328 S.W.3d 526, 539 (Tex. 2010). The trial court

has no discretion in determining what the law is or applying the law to the facts. Sanchez v. Martin,

378 S.W.3d 581, 587 (Tex. App.—Dallas 2012, no pet.). A clear failure by the trial court to analyze

or apply the law correctly will constitute an abuse of discretion. Walker v. Packer, 827 S.W.2d

833, 840 (Tex. 1992) (orig. proceeding). But a trial court does not abuse its discretion merely

because it decides a discretionary matter differently than an appellate court would under similar

circumstances. Taylor, 294 S.W.3d at 791.

                                             DISCUSSION

        An expert report under section 74.351 must represent a good-faith effort to provide a fair

summary of the expert’s opinions. See Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46

S.W.3d 873, 878–79 (Tex. 2001). The report need not marshal all the plaintiff’s proof, but must

include the expert’s opinion on each of the elements identified in the statute. Id. To constitute a

good-faith effort, the report must (1) inform the defendant of the specific conduct the plaintiff has

called into question, and (2) provide a basis for the trial court to conclude the claims have merit.

Id. at 879. In addition, “the expert report must make a good-faith effort to explain, factually, how

proximate cause is going to be proven,” although the report need not use the words “proximate

cause,” “foreseeability,” or “cause in fact.” Columbia Valley Healthcare Sys., L.P. v. Zamarripa,

526 S.W.3d 453, 460 (Tex. 2017). “‘[T]he expert must explain the basis of his statements to link

his conclusions to the facts.’” Id. (quoting Earle v. Ratliff, 998 S.W.2d 882, 890 (Tex. 1999)).

                                                  –3–
“[C]ourts must view the report in its entirety, rather than isolating specific portions or sections, to

determine whether it includes” the required information. Baty v. Futrell, 543 S.W.3d 689, 694

(Tex. 2018).

       A.      Expert’s qualifications

       In their first issue, appellants argue that Dr. Link is not qualified to opine about causation

because “he is not a gastroenterologist and claims no special knowledge of pancreatic injury or the

sequelae of pancreatic injury.” Appellants argue that even though Dr. Link states he is “familiar

with the entity of necrotizing pancreatitis which can be a sequalae of untreated pancreatic injury,”

he does not have the expertise to connect necrotizing pancreatitis to the alleged cause of Gomez’s

injury. Appellants’ challenge focuses on Dr. Link’s alleged lack of expertise regarding injuries to

the pancreas. But as we discuss, Dr. Link opines that the injury to Gomez’s pancreas occurred as

a result of Dr. Acharya’s negligent surgical procedures on Gomez’s adrenal gland. At issue are Dr.

Link’s expertise—and Dr. Acharya’s alleged negligence—in the surgical procedures for removal

of a cancerous adrenal gland, not the occurrence or treatment of pancreatic injury.

       Gomez contends that Dr. Link’s report demonstrates he has the requisite expertise to opine

about causation of her injury. Section 74.403 of Chapter 74 sets out the criteria necessary for an

expert to opine on causation. Id. § 74.403(a). To qualify as expert on the causal relationship

between an alleged departure from accepted standards of care and a plaintiff’s injury, the person

must be a physician and “otherwise qualified to render opinions” on causation under the Texas

Rules of Evidence. Id. Rule of evidence 702 permits “[a] witness who is qualified as an expert by

knowledge, skill, experience, training, or education” to testify in the form of an opinion if the

testimony would “help the trier of fact to understand the evidence or to determine a fact in issue.”

TEX. R. EVID. 702. The party offering the witness as an expert must establish that the witness is

qualified to testify under rule 702 by demonstrating the witness has expertise concerning the actual

                                                 –4–
subject matter about which the party is offering an opinion. Mem’l Hermann Healthcare Sys. v.

Burrell, 230 S.W.3d 755, 762 (Tex. App.—Houston [14th Dist.] 2007, no pet.).

       In determining whether a witness is qualified on the basis of training or experience, the

court shall consider whether, at the time the claim arises or at the time testimony is given, the

witness is “board certified or has other substantial training or experience in an area of medical

practice relevant to the claim” and is “actively practicing medicine in rendering medical care

services relevant to the claim.” CIV. PRAC. & REM. § 74.401(c). The trial court should focus on the

medical expert’s “knowledge, skill, experience, training, or education” concerning the specific

issue before the court which would qualify the expert to give an opinion on that particular subject.

Roberts v. Williamson, 111 S.W.3d 113, 122 (Tex. 2003) (trial court did not abuse discretion by

admitting expert’s testimony on plaintiff’s neurological issues; although doctor was not

neurologist, he had experience and expertise regarding the specific causes and effects of plaintiff’s

injuries). The trial court’s focus should not necessarily be on the specialty of the medical expert.

Pediatrix Med. Servs. Inc. v. De La O, 368 S.W.3d 34, 39 (Tex. App.—El Paso 2012, no pet.).

       Dr. Link is a medical doctor licensed in Texas, is board certified by the American Board

of Urology, has “advanced fellowship training in Endourology and Minimally Invasive Uruologic

Surgery,” and has been performing and teaching minimally invasive retroperitoneal and pelvic

surgery, including adrenalectomies (the surgery at issue here), since 2005. Dr. Link attached his

curriculum vitae to his affidavit showing that he currently holds numerous faculty positions in the

Department of Urology at Baylor College of Medicine, including Director of the Division of

Endourology and Minimally Invasive Surgery, a position he has held for more than a decade.

       Appellees argue Dr. Link does not have the expertise to opine about the injuries caused to

Gomez’s pancreas. But Dr. Link explained his experience in both teaching and performing the

surgery at issue, and when doing so, preserving the patient’s pancreas:

                                                –5–
       Throughout my career as a urologist with a focus on minimally invasive
       retroperitoneal surgery, I have routinely monitored and cared for patients with
       suspicious adrenal lesions found on radiographic studies. I have specific advanced
       training in both laparoscopic and robotic adrenalectomy procedures and have
       regularly evaluated and treated similar patients with adrenal masses during my
       career. Over the past 13 years of practice, I have performed more than 1,500
       minimally invasive retroperitoneal procedures, including laparoscopic and robotic
       nephrectomy, partial nephrectomy, pyeloplasty, ureterolysis, ureteral
       reconstruction and adrenalectomy. I have served as faculty for multiple national
       courses through the American Urological Association to teach these techniques to
       other surgeons. I have extensive experience performing laparoscopic and robotic
       adrenalectomy for both benign and malignant tumors, having performed more than
       100 adrenalectomies in the past. Over this time interval, I have also performed more
       than 800 laparoscopic left donor nephrectomy procedures. In each donor
       nephrectomy, the left adrenal gland and tail of the pancreas must both be identified
       and dissected free of surrounding tissue so that these important structures can be
       preserved. In summary, I am currently performing minimally invasive procedures
       multiple times a week that involve identification and preservation of the left adrenal
       gland and tail of the pancreas. My advanced subspecialty training and experience
       in this specific area over 13 years of practice provides me with the necessary
       perspective to comment on the technical issues that led to a misidentification of the
       pancreas as the adrenal gland and the subsequent pancreatic injury (and omission
       of adrenalectomy) during this case that resulted in significant morbidity for Ms.
       Bernice Gomez.

       Dr. Link also explained his familiarity “with the endocrine and exocrine functions of the

pancreas and the effects of injury to the pancreatic duct and leakage of pancreatic enzymes,”

injuries he explained that Gomez suffered as a result of Dr. Acharya’s misidentification and

removal of a portion of her pancreas. He continued, “[t]his is a basic requirement of medical

training and is particularly emphasized in surgical residency training, fellowship and urologic

surgical practice,” in all of which he provided details of his experience. We conclude the trial court

did not abuse its discretion by determining that Dr. Link was qualified to provide an opinion on

causation. See Baylor Univ. Med. Ctr. v. Rosa, 240 S.W.3d 565, 572 (Tex. App.—Dallas 2007,

pet. denied) (concluding expert’s causation opinions provided sufficient basis for trial court to

conclude that plaintiff’s claims had merit). We decide appellants’ first issue against them.




                                                 –6–
        B.      Factual disputes

        In their second and third issues, appellants argue that Dr. Link “ignored the facts actually

cited in the report itself” regarding whether Dr. Link communicated with Gomez after the surgery

about the injury, and “failed to accurately report the facts of the case as to whether Dr. Acharya

exercised care in identifying anatomical landmarks in the surgery to avoid injury to non-target

organs.” They argue that Dr. Link’s report “gets fundamental facts simply wrong.” They assert

that because the report “fail[s] to account for the facts in the records it relies upon,” it also fails to

“give fair notice of criticisms.” They conclude that these factual errors “depriv[e] the Report of

any basis for opinions about th[ese] issue[s].”

        In determining whether the expert report represents an objective good faith effort to comply

with the statutory requirements, the court’s inquiry is limited to the four corners of the report.

Fortner v. Hosp. of the Sw., LLP, 399 S.W.3d 373, 379 (Tex. App.—Dallas 2013, no pet.); see

also Jelinek, 328 S.W.3d at 539 (to determine whether expert report complies with section 74.351,

courts consider the information “found within the four corners of the expert report, which need not

marshal all the plaintiff’s proof but must include the expert’s opinion on each of the three main

elements: standard of care, breach, and causation”) (internal quotation omitted). Statements in an

expert report that are “in tension with” other statements may not preclude a trial court from finding

the report sufficient. See Van Ness, 461 S.W.3d at 144 (expert’s conflicting statements did not

render report insufficient where report also set out opinion explaining how and why timely

treatment would have prevented child’s death). “[T]he trial court had discretion—indeed it was

incumbent on the trial court—to review the report, sort out its contents, resolve any inconsistencies

in it, and decide whether the report demonstrated a good faith effort to show that the [plaintiffs’]

claims had merit.” Id.




                                                  –7–
       As appellants argue, Dr. Link and Dr. Acharya have differing opinions on “whether Dr.

Acharya exercised care” in his treatment of Gomez. As required at this stage, however, Dr. Link

has explained his opinions and the basis for them. See Jelinek, 328 S.W.3d at 539. He has opined

that Dr. Acharya failed to meet the standard of care by failing to remove the adrenal gland

containing the tumor, misidentifying the tail of the pancreas and “stapling across” it, and failing to

be “oriented to the anatomy of the procedure,” among other problems. The report informs Dr.

Acharya of the specific conduct Gomez has called into question, and provides a basis for the trial

court to conclude the claims have merit. See Palacios, 46 S.W.3d at 878–79. The existence of

factual disputes does not preclude Dr. Link’s report from meeting Chapter 74’s requirements. See

CIV. PRAC. & REM. § 74.351(r)(6) (“expert report” must provide “fair summary” of expert’s

opinions on standards of care, manner in which care rendered failed to meet standards, and

causation). We decide appellants’ second and third issues against them.

       C.      Standard of care

       In their fourth issue, appellants argue that Dr. Link’s report “failed to specify a clear

standard of care for the surgery other than dressed up versions of ‘do no harm.’” They assert that

“stating the unfortunate result is not stating the breach of the standard.” Gomez disagrees, citing

Dr. Link’s opinions that the standard of care required Dr. Acharya (1) to notice and realize that he

removed the wrong organ during surgery, and (2) to consult specialists during the operation as

soon as he became aware of the problem. Dr. Link discusses what Dr. Acharya should have noticed

during the surgery that would have led him to discover that he had removed the wrong tissue. Dr.

Link also states:

       The standard of care in treating an adrenal malignancy with adrenalectomy is
       absolutely clear: the adrenal gland containing the tumor should be removed. The
       standard of care during an adrenalectomy requires that that the surgeon be oriented
       to the anatomy of the procedure. The standard of care requires that the surgeon
       identify the correct organ for removal and identify and preserve adjacent organs
       that are not the targets of this procedure.
                                                 –8–
Dr. Link also explains that the standard of care required Dr. Acharya to “articulate a clear and

cogent plan for further management of Ms. Gomez’s malignant tumor” after the failed surgery. In

paragraph 25 of his report, Dr. Link lists additional failures by Dr. Acharya to meet the “standard

of minimum care and treatment required of a prudent urologist under like circumstances and

similar surroundings.” We conclude that Dr. Link provided more detail than “do no harm” as the

applicable standard of care, and that Dr. Link’s report informed appellants of the specific conduct

that Gomez has called into question. See Palacios, 46 S.W.3d at 879. We decide appellants’ fourth

issue against them.

           D.         Causation

           In their fifth issue, appellants argue that Dr. Link’s report does not meet Chapter 74’s

requirement to “explain the causal connection between the alleged breaches in the standard of care

and the injuries in question in a nonconclusory manner.” They contend that Dr. Link’s report fails

to describe any injury or harm “at all, beyond the injury to the pancreas,” does not explain the

significance of the injury to the pancreas, and “fails to give any connection at all between the

alleged breaches and alleged consequences.”2

           To establish a causal relationship between the injury and the defendant’s negligent act or

omission, the expert report must show the defendant’s conduct was a substantial factor in bringing

about the harm, and, absent this act or omission, the harm would not have occurred. Mitchell v.

Satyu, M.D., No. 05–14–00479–CV, 2015 WL 3765771, at *4 (Tex. App.—Dallas June 17, 2015,

no pet.) (mem. op.). Causation is generally established through evidence of a “reasonable medical

probability” that the injury was caused by the negligence of the defendant, meaning that it is more

likely than not that the ultimate harm or condition resulted from such negligence. See id. “An



    2
      The parties also dispute whether the doctrine of res ipsa loquitur, a rule of evidence by which a jury may infer negligence, applies here. See
Haddock v. Arnspiger, 793 S.W.2d 948, 951–55 (Tex. 1990) (discussing application of res ipsa loquitur doctrine in medical malpractice cases).
Because we conclude that Dr. Link’s report adequately addresses causation, we pretermit discussion of these arguments.

                                                                       –9–
expert may show causation by explaining a chain of events that begins with a defendant doctor’s

negligence and ends in injury to the plaintiff.” Id.; see also McKellar v. Cervantes, 367 S.W.3d

478, 485–86 (Tex. App.—Texarkana 2012, no pet.). The report must explain “to a reasonable

degree, how and why the breach [of the standard of care] caused the injury based on the facts

presented.” Mitchell, 2015 WL 3765771, at *4 (quoting Jelinek, 328 S.W.3d at 539–40); Quinones

v. Pin, 298 S.W.3d 806, 814 (Tex. App.—Dallas 2009, no pet.) (to satisfy Chapter 74’s

requirement of a showing of causation, expert report must include fair summary of expert’s opinion

regarding causal relationship between breach of standard of care and injury, harm, or damages

claimed). “We determine whether a causation opinion is sufficient by considering it in the context

of the entire report.” Mitchell, 2015 WL 3765771, at *4 (citing Ortiz v. Patterson, 378 S.W.3d

667, 671 (Tex. App.—Dallas 2012, no pet.)); Bakhtari v. Estate of Dumas, 317 S.W.3d 486, 496

(Tex. App.—Dallas 2010, no pet.).

       As we have discussed, Dr. Link explained that Dr. Acharya breached the standard of care

by failing to remove the adrenal gland containing the tumor, failing to be “oriented to the anatomy”

of the adrenalectomy procedure, failing to identify the correct organ for removal, and failure to

“identify and preserve adjacent organs that are not the targets of this procedure.” Dr. Link

explained that a few days after the surgery, Gomez “underwent an ERCP with pancreatic

sphincterotomy and pancreatic ductal stent placement” and received an abdominal drain,

procedures required as “a direct result of injury to the pancreas by Dr. Acharya.” Dr. Link also

explained, in some detail, the proper procedure for an adrenalectomy and how Dr. Acharya

deviated from the proper procedure. After discussing the procedure, Dr. Link concluded, in part:

       (a) Dr. Acharya did not remove the left adrenal gland and tumor, which was the
       sole indication for Ms. Gomez’s surgery. For an operation with the sole goal of
       removing the left adrenal gland containing a tumor, it appears that Dr. Acharya did
       not even identify the correct organ for removal during this case. The pathologist
       reported that the surgical specimen submitted as the adrenal gland actually
       represented pancreatic tissue.
                                               –10–
       (b) Dr. Acharya removed the wrong organ (a portion of the pancreatic tail) and
       caused a serious pancreatic ductal injury resulting in major postoperative morbidity
       for Ms. Gomez. Critical and relatively straightforward clues (such as the
       requirement to staple a “thick vascular pedicle”) were ignored during surgery.
       These clues should have led a reasonable and prudent surgeon to suspect a
       pancreatic injury, the injury and complications of which would have been lessened
       by consulting the appropriate surgical specialist (a general or pancreatic surgeon)
       intraoperatively. Failure to consult the appropriate surgical specialist
       intraoperatively to address the pancreatic injury was below the standard of care.

       Appellants assert, “[b]eyond the initial injury to the pancreas . . . the Report has little to

offer,” and they argue the report “fails to describe with clarity . . . the injury, harm, or damage[ ]

claimed by Plaintiff—apart from the fact of the result of the surgery itself.” They do not explain,

however, why an injury to Gomez’s pancreas would be insufficient for purposes of Chapter 74.

See, e.g., TTHR, L.P. v. Coffman, 338 S.W.3d 103, 109–111 (Tex. App.—Fort Worth 2011, no

pet.) (rejecting limitations on types of injuries to which Chapter 74 applies). Dr. Link describes

how Dr. Acharya’s removal of “a portion of the pancreatic tail”—“the wrong organ”—“caused a

serious pancreatic ductal injury” to Gomez. He explains that “Dr. Acharya’s failure to meet the

standard of care as described clearly resulted in the pancreatic injury that was the root cause of

[Gomez’s] subsequent complications from a pancreatic leak.” He concludes that,

       In my opinion, Dr. Acharya’s failure to remove Ms. Gomez’s left adrenal tumor
       and the resulting pancreatic injury, in reasonable medical probability, resulted in
       (a) her unnecessarily long, complicated and morbid postoperative course, (b) the
       requirement for multiple additional unanticipated invasive procedures, and
       (c) insufficiently addressed her original malignancy resulting in the potential for
       further oncologic sequelae.

       We conclude that Dr. Link’s report provides a fair summary of his opinions regarding the

causal relationship between the breaches of the standard of care he identifies and the injuries to

Gomez that he describes. See Abshire v. Christus Health Se. Tex., 563 S.W.3d 219, 225–26 (Tex.

2018) (per curiam) (expert report sufficient that linked conclusion with underlying facts); Baty,

543 S.W.3d at 698; Miller v. JSC Lake Highlands Operations, LP, 536 S.W.3d 510, 515 (Tex.

2017) (per curiam). In Abshire, Baty, and Miller, expert reports were sufficient to meet Chapter

                                                –11–
74’s causation requirements where they explained the applicable standard of care, described how

the health care provider breached that standard, and explained how that breach caused the

plaintiff’s injury. See Abshire, 563 S.W.3d at 225–26; Baty, 543 S.W.3d at 698; Miller, 536 S.W.3d

at 515. Here, Dr. Link “‘make[s] a good faith effort to explain, factually, how proximate cause is

going to be proven’” by describing how and why Dr. Acharya’s breaches of the standard of care

caused the injury to Gomez’s pancreas. See Miller, 536 S.W.3d at 515 (quoting Zamarripa, 526

S.W.3d at 460). We conclude that Dr. Link’s opinions regarding the injury to Gomez’s pancreas

“adequately explain[ ] the links in the causal chain.” See Abshire, 563 S.W.3d at 225. We decide

appellants’ fifth issue against them.

                                          CONCLUSION

       We affirm the trial court’s order denying appellants’ motion to dismiss.




                                                  /Leslie Osborne/
                                                  LESLIE OSBORNE
                                                  JUSTICE


180833F.P05




                                              –12–
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                      JUDGMENT

 SUJEET ACHARYA, M.D., TEXAS                        On Appeal from the 160th Judicial District
 ONCOLOGY, P.A., AND TEXAS                          Court, Dallas County, Texas
 UROLOGY SPECIALISTS, Appellants                    Trial Court Cause No. DC-17-12969.
                                                    Opinion delivered by Justice Osborne;
 No. 05-18-00833-CV         V.                      Justices Myers and Nowell, participating.

 BERNICE MARIE GOMEZ, Appellee

       In accordance with this Court’s opinion of this date, the trial court’s order denying
appellants’ motion to dismiss is AFFIRMED.

       It is ORDERED that appellee Bernice Marie Gomez recover her costs of this appeal from
appellants Sujeet Acharya, M.D., Texas Oncology P.A., and Texas Urology Specialists.


Judgment entered this 30th day of April, 2019.




                                             –13–
