                        COURT OF APPEALS
                         SECOND DISTRICT OF TEXAS
                              FORT WORTH


                               NO. 2-09-216-CV


DANIEL L. FOSTER, D.O.                                              APPELLANT

                                        V.

MARY RICHARDSON                                                       APPELLEE

                                    ------------

          FROM THE 17TH DISTRICT COURT OF TARRANT COUNTY

                                    ------------

                                   OPINION

                                    ------------

      In this interlocutory appeal concerning the adequacy of an expert report

filed in a health care liability claim under chapter 74 of the civil practice and

remedies code (chapter 74),1 appellant Daniel L. Foster, D.O. contends in one

issue that the trial court erred by denying his motion to dismiss. We affirm in

part and reverse and remand in part.




      1
     … See Tex. Civ. Prac. & Rem. Code Ann. §§ 74.001–.507 (Vernon
2005 & Supp. 2009).
                                Background Facts

Facts alleged in Richardson’s petition

      Appellee Mary Richardson injured her left leg while working for an airline

in December 2006. Hospital personnel immobilized her knee, initially told her

that she had sustained a knee sprain, and instructed her to see her primary

physician for treatment. Richardson’s primary physician referred her to Dr.

Angelo Otero for an orthopedic consultation.2 On January 22, 2007, Dr. Otero

diagnosed Richardson with tears of her anterior cruciate ligament (ACL) and

lateral meniscus in her left knee.       On February 15, Dr. Otero surgically

reconstructed that knee; he then released her for light duty at work on February

26 and for full duty on May 14.

      On June 21, because she was still experiencing pain in her leg,

Richardson saw Dr. Foster,3 who diagnosed her as having complex regional pain

syndrome in her left leg and recommended that she participate in physical

therapy. However, on July 27, Richardson saw an orthopedic surgeon whose



      2
       … “Orthopedics” (or “orthopaedics”) is the “medical speciality concerned
with the preservation, restoration, and development of form and function of the
musculoskeletal system, extremities, spine, and associated structures by
medical, surgical, and physical methods.” Stedman’s Medical Dictionary 1383
(28th Ed. 2006).
      3
          … The record does not indicate who referred Richardson to Dr. Foster.


                                         2
diagnostic tests revealed that Richardson had a partially-healed ankle fracture.

To treat the fracture, the surgeon had to rebreak Richardson’s ankle and insert

metal hardware into it. Richardson asserts that her leg is disfigured and that

her ankle will never function normally because of Dr. Otero’s and Dr. Foster’s

failures to timely diagnose and treat the fracture.

Procedural history

      Dr. Foster and Dr. Otero 4 answered Richardson’s allegations, and then

Richardson served both defendants with the expert report and curriculum vitae

of Bryan S. Drazner, M.D. concerning their alleged deficiencies in providing

Richardson’s care, as required by section 74.351 of the civil practice and

remedies code. See Tex. Civ. Prac. & Rem. Code Ann. § 74.351. Dr. Foster

filed a motion to dismiss under chapter 74, claiming that Dr. Drazner’s report

is deficient. After the trial court heard arguments from the parties, it denied Dr.

Foster’s motion. Dr. Foster filed his notice of this interlocutory appeal. See id.

§ 51.014(a)(9) (Vernon 2008); Lewis v. Funderburk, 253 S.W.3d 204, 207–08

(Tex. 2008).




      4
       … The claims against Dr. Otero are still pending and are not at issue in
this appeal.

                                        3
                 The Adequacy of Dr. Drazner’s Expert Report

      In one issue, Dr. Foster asserts that the trial court erred by denying his

motion to dismiss and concluding that Dr. Drazner’s expert report complies with

chapter 74.

Standard of review

      We review a trial court’s denial of a motion to dismiss under section

74.351 for an abuse of discretion. See Am. Transitional Care Ctrs. of Tex.,

Inc. v. Palacios, 46 S.W.3d 873, 875 (Tex. 2001); Collini v. Pustejovsky, 280

S.W.3d 456, 461 (Tex. App.—Fort Worth 2009, no pet.) (op. on remand);

Moore v. Gatica, 269 S.W.3d 134, 139 (Tex. App.—Fort Worth 2008, pet.

denied) (op. on remand). We also review a trial court’s decision on whether a

physician is qualified to offer an expert opinion in a health care liability claim

under an abuse of discretion standard. Collini, 280 S.W.3d at 461; Moore, 269

S.W.3d at 139.

      To determine whether a trial court abused its discretion, we must decide

whether the trial court acted without reference to any guiding rules or

principles; in other words, we must decide whether the act was arbitrary or

unreasonable. Downer v. Aquamarine Operators, Inc., 701 S.W.2d 238, 241–

42 (Tex. 1985), cert. denied, 476 U.S. 1159 (1986); see Collini, 280 S.W.3d

at 461. Merely because a trial court may decide a matter within its discretion

                                        4
in a different manner than an appellate court would in a similar circumstance

does not demonstrate that an abuse of discretion has occurred. Downer, 701

S.W.2d at 242; Collini, 280 S.W.3d at 461. A trial court does not abuse its

discretion if it commits a “mere error in judgement.”      See E.I. du Pont de

Nemours & Co. v. Robinson, 923 S.W.2d 549, 558 (Tex. 1995); Collini, 280

S.W.3d at 461.

The statutory requirements of expert reports

      A plaintiff must serve an expert report that addresses liability and

causation on each defendant no later than the 120th day after the plaintiff files

a health care liability claim. Tex. Civ. Prac. & Rem. Code Ann. § 74.351(a), (j).

If an expert report has not been served on a defendant within the 120-day

period, then on the motion of the affected defendant, the trial court must

dismiss the claim with prejudice and award the defendant reasonable attorney’s

fees and costs. Id. § 74.351(b). A report “has not been served” under the

statute when it has physically been served but a court finds it deficient. See

id. § 74.351(c); Leland v. Brandal, 257 S.W.3d 204, 207 (Tex. 2008); Lewis,

253 S.W.3d at 207–08.

      A report is deficient (therefore subjecting a claim to dismissal) when it

“does not represent an objective good faith effort to comply with the [statute’s]

definition of an expert report.” Tex. Civ. Prac. & Rem. Code Ann. § 74.351(l);

                                       5
Collini, 280 S.W.3d at 461–62. While the expert report “need not marshal all

the plaintiff’s proof,” it must provide a fair summary of the expert’s opinions as

to the applicable standards of care, the manner in which the care rendered by

the physician failed to meet the standards, and the causal relationship between

that failure and the injury, harm, or damages claimed. Tex. Civ. Prac. & Rem.

Code Ann. § 74.351(r)(6); Palacios, 46 S.W.3d at 878; Collini, 280 S.W.3d at

462.

          To qualify as a good faith effort, the report must “discuss the standard

of care, breach, and causation with sufficient specificity to inform the

defendant of the conduct the plaintiff has called into question and to provide

a basis for the trial court to conclude that the claims have merit.” Palacios, 46

S.W.3d at 875; Benish v. Grottie, 281 S.W.3d 184, 194 (Tex. App.—Fort

Worth 2009, pet. denied). A report does not fulfill this requirement if it merely

states the expert’s conclusions or if it omits any of the statutory requirements.

Palacios, 46 S.W.3d at 879; Benish, 281 S.W.3d at 194.

          The information in the report “does not have to meet the same

requirements as the evidence offered in a summary-judgment proceeding or at

trial.”     Palacios, 46 S.W.3d at 879.       The expert report must “contain

sufficiently specific information to demonstrate causation beyond mere




                                          6
conjecture.” Farishta v. Tenet Healthsystem Hosps. Dallas, Inc., 224 S.W.3d

448, 453 (Tex. App.—Fort Worth 2007, no pet.).

The facts alleged in Dr. Drazner’s report

      According to his report, Dr. Drazner physically evaluated Richardson on

July 26, 2007, and he became concerned about aspects of her prior care at

that time. During his examination of Richardson, he noticed a “profound range

of motion deficit of the left ankle, left ankle edema, and left calf pain prior to

the receipt of diagnostic testing.”    He also reviewed Dr. Foster’s and Dr.

Otero’s records of Richardson’s treatment.

      Dr. Drazner’s report recites that after Richardson’s initial injury in

December 2006, hospital personnel examined her left foot, ankle, and knee,

and they “inexplicably opined” that she had a knee sprain or strain, without

“any positive findings about the knee objectively.”         Dr. Otero examined

Richardson about a month later by taking x-rays that, although resulting

negative, led Dr. Otero to conclude that there was an “acute tear of the [ACL].”

Dr. Otero ordered an MRI scan, but the scan did not reveal signs of an ACL

tear, and it only showed minor abnormalities about the knee’s meniscus that

existed because of knee surgery that Richardson had previously received. Thus,

the report alleges that Dr. Otero operated on Richardson’s knee without an




                                        7
adequate medical basis and despite Richardson’s complaints to him about pain

in her ankle.

      The report continues by describing Richardson’s attempt to get a second

opinion about her pain from Dr. Foster after Dr. Otero’s surgery. It states in

relevant part,

      Although Dr. Foster noted that Ms. Richardson’s left calf was
      smaller than her right calf, and superficial tenderness to palpation,
      Dr. Foster did not perform a range of motion on Ms. Richardson’s
      left ankle or identify the ligaments that he examined. Dr. Foster
      diagnosed Ms. Richardson’s problem as “complex regional pain
      syndrome of the left lower extremity.” Dr. Foster arrived at his
      opined diagnosis, failing to document the hallmarks of the
      condition, well delineated in the [American Medical Association]
      Guide, Fifth Edition, to include hypersensitivity to light touch,
      withdrawal behavior, hyperhidrosis, hyperfusion, mottling and hair
      and nail bed changes.

      The Standard of Care Applicable to both Dr. Otero and Dr. Foster:

            It is the standard of care for a physician who is examining a
      patient’s leg injury to perform a thorough [orthopedic] examination
      in order to determine the nature and extent of the injury. It is also
      the standard of care when examining a leg injury, to perform full
      range of motion testing regarding the injured leg, including the
      knee, the ankle, and the foot, and to detail the findings of the
      examination. . . .

      Breach of Standard of Care:

            From their records, neither Dr. Otero nor Dr. Foster performed
      a thorough examination of Ms. Richardson’s left leg, including her
      ankle and foot. . . . Without a complete [orthopedic] examination,
      including full range of motion testing, and the obtainment of
      appropriate objective diagnostic tests on Ms. Richardson’s ankle

                                       8
     and foot, an accurate diagnosis was not possible. . . . Although
     Ms. Richardson may have sprained her knee, it was later
     discovered (not by Dr. Otero or Dr. Foster) that Ms. Richardson had
     fractured her left distal fibula. Nevertheless, . . . Dr. Foster had
     ignored the patient’s complaints of calf pain and tenderness, . . .
     attributing her complaints as a complication of the knee surgery
     performed by Dr. Otero.

     Results of Defendants’ Breach of the Standard of Care:

           . . . If Dr. Otero and Dr. Foster had performed a complete
     examination of Ms. Richardson’s left leg, including her tibula/fibula,
     ankle and foot, and/or if they had referred Ms. Richardson for a
     second opinion, while treating her conservatively to determine the
     true nature of her injury, an unnecessary knee surgery would not
     have been performed. Moreover, due to the physicians’ failure to
     correctly diagnose Ms. Richardson’s injury, her fracture went
     completely undetected for over seven months and the patient was
     subjected to . . . a prolonged period of pain and requirement for
     exhaustive narcotic enalyens, usage of a bone growth stimulator
     and another surgery to remove painful surgical hardware, a
     prolonged period of disability, and . . . loss of hind foot motion, . . .
     as well as moderate chronic pain. As a result, it is my opinion that
     Ms. Richardson will suffer from impairments that could have been
     prevented had her injury been properly and timely diagnosed and
     treated before the fracture had healed incorrectly failed to heal,
     moved to non-union, and required further exhaustive care. 5




     5
      … The words “failed to heal, moved to non-union, and required further
exhaustive care” are hand written.

                                        9
The adequacy of Dr. Drazner’s report as to causation

      In the first part of his only issue, Dr. Foster contends that Dr. Drazner’s

report is deficient because Dr. Drazner’s statements related to the cause of

Richardson’s injuries are factually unsupported and inadequately explained and

because the report does not differentiate Dr. Foster’s and Dr. Otero’s actions

that allegedly contributed to Richardson’s injuries. 6

      The factual explanation of causation

      Dr. Foster asserts that Richardson’s allegedly unnecessary knee surgery

cannot have any causal link to Dr. Foster’s diagnosis because Richardson’s

petition and Dr. Drazner’s report establish that Dr. Foster first saw Richardson

about four months after the surgery. Dr. Foster also argues that Dr. Drazner’s

report “makes no attempt to explain how Dr. Foster’s alleged breach—the one

month delay in diagnosis that occurred six months after the injury—had any

causal relationship with the corrective [ankle] surger[ies] performed a little over

one month later.”



      6
       … Some of Dr. Foster’s contentions during oral argument regarded the
alleged vagueness of Dr. Drazner’s statements regarding Dr. Foster’s standards
of care. But Dr. Foster’s argument in his brief concerns the adequacy of Dr.
Dranzer’s report as to causation, not standards of care, and we will not
consider whether the report was adequate as to standards of care. See Tex.
R. App. P. 39.2 (explaining that the purpose of oral argument is to clarify the
written arguments in briefs); El Paso Natural Gas Co. v. Strayhorn, 208 S.W.3d
676, 681 (Tex. App.—Texarkana 2006, no pet.).

                                        10
      Richardson says that these arguments misunderstand “the nature of the

claims brought against Foster” and represents in her brief that her claims

against Dr. Foster are based on “other injuries caused by his negligence,”

specifically referring to her pain caused by Dr. Foster’s failure to properly

diagnose and treat the ankle injury. Undoubtedly, Dr. Foster is correct that he

could not have caused Richardson’s knee surgery, and Richardson has

acknowledged this fact. However, while Richardson’s petition alleges that both

doctors’ acts, “singularly or in combination, were a proximate cause” of her

damages that include expenses for medical care that could relate to the knee

surgery or the ankle surgeries (to initially treat the ankle fracture and to remove

the surgical hardware), the petition also asks for damages related to physical

pain and mental anguish suffered in the past and to be suffered in the future

and physical disability and disfigurement suffered in the past and to be suffered

in the future.

      Dr. Drazner’s report explains that Dr. Foster’s alleged misdiagnosis caused

Richardson to suffer “a prolonged period of pain” and “a prolonged period of

disability.”   Thus, assuming that Dr. Drazner correctly concluded that Dr.

Foster’s diagnosis of complex regional pain syndrome was erroneous and that

he should have diagnosed her with an ankle fracture, Dr. Drazner’s report links




                                        11
Richardson’s continued pain and disability related to the fracture 7 to Dr. Foster’s

erroneous diagnosis for as long a period—here, more than a month—until her

condition was correctly diagnosed and treated.

      Nonetheless, Dr. Foster relies on a recent San Antonio Court of Appeals

opinion to argue that Dr. Drazner’s report is still insufficient in explaining

causation even if it shows that Dr. Foster’s misdiagnosis induced Richardson’s

continued pain and disability.     See Jones v. King, 255 S.W.3d 156 (Tex.

App.—San Antonio 2008, pet. denied) (mem. op.).             In Jones, King, who

suffered from chronic pain, alleged that Dr. Jones’s allegedly improper

treatment—the placement of a morphine pump—caused her to develop several

health problems, including meningitis.          Id. at 158.        Dr. Jones, an

anesthesiologist, alleged that the expert report written by Dr. Gregory Powell

did not adequately address the causal connection between breaches of

standards of care and King’s injuries. Id. The San Antonio court explained that

the report contained “little more than a series of repetitious conclusory

statements” such as, “the failure to timely detect the meningitis and treat it for

more than forty-eight hours caused it to become worse and resulted in




      7
      … Dr. Drazner’s report alleges that Richardson complained of pain when
she saw Dr. Foster in June 2007.

                                        12
numerous additional complications and injuries including decreased vision,

diabetes insipidus, and pain.” Id. at 159. The majority opinion said,

      [A] close reading of the relevant portions of the report confirms
      Powell’s failure to link any delay in diagnosis to any additional pain
      and suffering or exacerbation of the meningitis than what would
      have occurred in the face of an earlier diagnosis.

             Stated another way, while it may be facially appealing to
      infer additional pain and suffering resulted from the alleged delay
      in diagnosis, the trial court is not permitted to rely on such
      speculation in determining the adequacy of the report. While
      Powell clearly states King suffered “extra” or “additional” pain and
      suffering due to the 48-hour delay in diagnosis, he fails to provide
      any baseline from which the trial court could conclude the delay
      caused the results. Powell does not explain what facts led him to
      his conclusions. His report does not indicate the normal or
      expected course of meningitis once treatment has begun. Does
      meningitis become more difficult to treat or take longer to resolve
      if treatment is delayed? Does the disease become more virulent
      due to lack of treatment? While Powell also states King was
      “hospitalized twice,” “lost over thirty days at work,” and “incurred
      a substantial amount of medical bills during the hospitalizations,”
      he does not attempt to explain how these results would not have
      occurred if the diagnosis of meningitis had occurred 48 hours
      earlier. . . .

            . . . Here, Powell offered no medical explanation about
      whether earlier treatment would have been effective in shortening
      the duration of the meningitis, precluding additional pain and
      suffering, or preventing other alleged injuries and damages.

Id. at 159–60 (citations omitted and italic emphasis added).

      However, unlike the expert report at issue in Jones, which, according to

the majority opinion, did not explain how a delay in diagnosis lengthened King’s



                                       13
pain by delaying the resolution of her meningitis, Dr. Drazner’s report does

explain how Dr. Foster’s alleged failure to “determine the true nature of

[Richardson’s] injury” left her ankle fracture untreated and subjected Richardson

to prolonged pain.       Thus, we conclude that the facts in Jones are

distinguishable from those involved here.

      However, even if the Jones opinion could be read to render a report

inadequate on causation when the report sufficiently links a misdiagnosis to

pain that is prolonged until a correct diagnosis is made and the correct

treatment is given, we disagree with the opinion. Cf. Moore v. Sutherland, 107

S.W.3d 786, 791 (Tex. App.—Texarkana 2003, pet. denied) (holding that an

expert report based on a doctor’s misdiagnosis is sufficient as to causation

when it specifically states what the defendant “should have done and what

happened because he failed to do it”); see also Sullivan v. Methodist Hosps. of

Dallas, 699 S.W.2d 265, 274–75 (Tex. App.—Corpus Christi 1985) (holding

that the failure to diagnose the presence of a sponge in an abdomen sufficiently

caused the plaintiff’s injury when the plaintiff suffered from “additional physical

suffering”), writ ref’d n.r.e., 714 S.W.2d 302 (Tex. 1986). For these reasons,

we hold that, to the extent that Richardson’s claim against Dr. Foster concerns

her prolonged pain because of his alleged misdiagnosis, the trial court did not

abuse its discretion by denying Dr. Foster’s motion to dismiss based on his

                                        14
allegation that Dr. Drazner’s causation opinion is factually unsupported or

inadequately explained. See Palacios, 46 S.W.3d at 875.

      However, to the extent that Richardson’s claim against Dr. Foster asserts

that his alleged misdiagnosis caused her to require ankle surgeries and caused

the other alleged harmful conditions related to the surgeries,8 we conclude that

Dr. Drazner’s report provides a deficient explanation of causation. See Farishta,

224 S.W.3d at 453, 455 (indicating that an expert report must provide an

adequate explanation of causation as to each injury claimed by a plaintiff and

affirming the trial court’s dismissal of particular damage theories that the expert

report had not adequately addressed); see also Benson v. Vernon, No.

10-08-00271-CV, 2009 W L 2462657, at *3 (Tex. App.—Waco Aug. 12,

2009, no pet.) (citing Farishta and holding similarly). Dr. Drazner’s report says

that Richardson required “narcotic enalyens” and “usage of a bone growth

stimulator and another surgery to remove painful surgical hardware” and

suffered “loss of hind foot motion and injury to the superficial peroneal nerve,

as well as moderate chronic pain” because her ankle had “failed to heal, moved



      8
       … Despite Richardson’s statement in her brief that Dr. Foster
misunderstands the nature of her claims, Richardson claimed at trial in her
response to Dr. Foster’s dismissal motion and also claimed at oral argument on
appeal that the delay caused by Dr. Foster’s alleged misdiagnosis contributed
to the need for her two ankle surgeries. Dr. Drazner’s report also asserts such
a conclusion.

                                        15
to non-union, and required further exhaustive care.” But Dr. Drazner’s report

does not identify how Dr. Foster’s alleged misdiagnosis in June 2007, which

caused about one month’s delay in correctly diagnosing the ankle injury after

the correct diagnosis had already been delayed for about six months since the

initial injury in December 2006, contributed to the requirement of such

exhaustive care.   In other words, the report does not explain beyond mere

conjecture how the condition of Richardson’s ankle worsened from June 2007

to July so that Dr. Foster’s failure to give a correct diagnosis in June caused

the requirement of further treatment in July that would not have otherwise been

required if Dr. Foster had correctly diagnosed the injury. See Farishta, 224

S.W.3d at 453, 455. Thus, we hold that the trial court abused its discretion

to the extent that it found that Dr. Drazner’s report provided a sufficient

explanation about Dr. Foster’s actions causing Richardson’s ankle treatment.

See Palacios, 46 S.W.3d at 875. We sustain Dr. Foster’s sole issue as to that

limited basis.

      The report’s collective referrals to Dr. Foster and Dr. Otero

      Next, Dr. Foster argues that Dr. Drazner “failed to explain how each

defendant specifically and individually caused or contributed to Richardson’s

injury” and that the report’s alleged “collective assertions of negligence” are

inadequate because Dr. Drazner “merely prefaces every sentence regarding

                                      16
causation with both doctors[‘] names.” He cites several cases to propose that

expert reports must differentiate the conduct of multiple defendants. See, e.g.,

Longino v. Crosswhite ex rel. Crosswhite, 183 S.W.3d 913, 917 (Tex.

App.—Texarkana 2006, no pet.) (holding that a report was deficient because

it did not contain “specific information concerning how [one doctor] breached

the standard of care apart from [another doctor’s] conduct” when the plaintiff’s

complaint concerned the doctors’ joint treatment decision while the patient

suffered from bacterial meningitis); Taylor v. Christus Spohn Health Sys. Corp.,

169 S.W.3d 241, 244–46 (Tex. App.—Corpus Christi 2004, no pet.) (holding

that a report was deficient because it did not “present the standards of care

relevant” to each defendant or distinguish among several defendants concerning

how breaches of their standards of care contributed to an alleged failure to

diagnose and treat a heart condition). 9

      Here, unlike in Longino and Taylor, the report explained that Dr. Otero’s

treatment of Richardson was independent of and attenuated in time from Dr.




      9
      … Dr. Foster also relies on the El Paso Court of Appeals opinion in
Murphy v. Mendoza, 234 S.W.3d 23, 29 (Tex. App.—El Paso 2007, no pet.).
That case is inapposite because the report did not even identify the defendants
by name when referring to their allegedly incorrect evaluations of a bladder
biopsy, so it could not have discussed the standards of care related to both
doctors “if the roles and responsibilities differed.” Id.


                                       17
Foster’s diagnosis.    Dr. Drazner’s report connects Dr. Foster’s actions to

Richardson’s delay in receiving proper treatment for her ankle fracture by

stating (in a paragraph that is independent from any discussion of Dr. Otero),

      Although Dr. Foster noted that Ms. Richardson’s left calf was
      smaller than her right calf, and superficial tenderness to palpation,
      Dr. Foster did not perform a range of motion [test] on Ms.
      Richardson’s left ankle or identify the ligaments he examined. . . .
      Dr. Foster arrived at his opined diagnosis, failing to document the
      hallmarks of the [complex regional pain syndrome] condition.

The report further states in its standard of care section of “both Dr. Otero and

Dr. Foster” that (1) orthopedic examinations should include a full range of

motion test regarding the knee, ankle, and foot, and that a doctor should detail

the results of the test, and (2) if a doctor cannot objectively diagnose the

source of pain, the doctor should refer the patient for a second opinion.

      The report then alleges that both doctors breached the standard of care

through their separate treatment of Richardson’s injury. The report refers to the

doctors collectively, in part, by stating that “neither Dr. Otero nor Dr. Foster

performed a thorough examination” because they both did not complete full

range of motion testing and they therefore failed to diagnose the ankle fracture.

It also refers to the doctors collectively by stating as to causation, “[D]ue to the

physicians’ failure to correctly diagnose Ms. Richardson’s injury, . . . [she] was

subjected to . . . a prolonged period of pain.”



                                        18
      However, we cannot agree with Dr. Foster’s assertion that the report was

required to say in a separate sentence within its standard of care section that

Dr. Foster needed to and failed to perform the range of motion test (rather than

alleging that same fact within a sentence that also mentioned Dr. Otero)

because the report had previously independently explained why Dr. Foster

should have performed the test. We also cannot agree that the report needed

to use a separate sentence to explain how Dr. Foster’s conduct delayed the

correct diagnosis of Richardson’s ankle injury and thus prolonged her pain when

that was adequately indicated by the rest of the report. Thus, we conclude

that Dr. Drazner’s report is not deficient merely because it contains some

collective statements regarding actions that both doctors should have taken

while they independently cared for Richardson.        See Barber v. Dean, No.

02-07-00353-CV, 2009 WL 3490952, at *10 (Tex. App.—Fort Worth Oct. 29,

2009, no pet. h.) (holding that a report is not deficient for grouping defendants

together when it specifically states that they all owed the same duty of care);

Livingston v. Montgomery, 279 S.W.3d 868, 873 (Tex. App.—Dallas 2009, no

pet.) (explaining that “the fact that [the report] identifies one standard of care

for more than one defendant does not render [the report] deficient”); Sanjar v.

Turner, 252 S.W.3d 460, 466–67 (Tex. App.—Houston [14th Dist.] 2008, no

pet.) (holding the same and noting that nothing “forbids applying the same

                                       19
standard of care to more than one physician if . . . they all owed the same duty

to the patient”).

        Thus, we hold that the trial court also did not abuse its discretion by

denying Dr. Foster’s motion to dismiss Richardson’s claim on the basis that

portions of Dr. Drazner’s report referred to the doctors’ conduct collectively.

See Palacios, 46 S.W.3d at 875.

        Dr. Drazner’s qualifications

        In the final part of his sole issue, Dr. Foster contends that Dr. Drazner is

not qualified to submit an expert report on causation.            An expert report

authored by a person who is not qualified to testify cannot constitute an

adequate report. Collini, 280 S.W.3d at 462; see Ehrlich v. Miles, 144 S.W.3d

620, 624–26 (Tex. App.—Fort Worth 2004, pet. denied). The proper inquiry

concerning whether a doctor is qualified to testify is not his area of practice but

his familiarity with the issues involved in the claim before the court. Collini,

280 S.W.3d at 464; see Blan v. Ali, 7 S.W.3d 741, 745 (Tex. App.—Houston

[14th Dist.] 1999, no pet.).

        To be qualified to submit a report on the causal relationship between the

breach of a physician’s standard of care and harm, the reporting physician must

be “otherwise qualified to render opinions on such causal relationship under the

Texas     Rules   of   Evidence.”      Tex.   Civ.   Prac.   &   Rem.   Code   Ann.

                                         20
§ 74.351(r)(5)(C); see Tex. R. Evid. 702 (explaining that if “specialized

knowledge will assist the trier of fact to understand the evidence or to

determine a fact in issue, a witness qualified as an expert by knowledge, skill,

experience, training, or education may testify thereto in the form of an

opinion”); Collini, 280 S.W.3d at 465.10

      To be so qualified under rule 702, an expert must have knowledge, skill,

experience, training, or education regarding the specific issue before the court

that would qualify the expert to give an opinion on that particular subject.

See Helena Chem. Co. v. Wilkins, 47 S.W.3d 486, 499 (Tex. 2001); Thomas

v. Alford, 230 S.W.3d 853, 857, 860 (Tex. App.—Houston [14th Dist.] 2007,

no pet.) (holding that because the doctor who submitted an expert report did

not demonstrate knowledge of cancer treatment, he was not qualified to offer

an opinion that an earlier diagnosis could have produced a better outcome for




      10
         … The parties discuss sections 74.351(r)(5)(A) and 74.401(a) of the
civil practice and remedies code, which relate to the expert qualifications to
submit an opinion “regarding whether a physician departed from accepted
standards of medical care.” See Tex. Civ. Prac. & Rem. Code Ann. §§
74.351(r)(5)(A), 74.401(a). However, Dr. Foster has not directly challenged
Dr. Drazner’s qualifications in that regard—the heading on his qualification
challenge in his brief is “Drazner is Not Qualified to Provide Adverse Causation
Opinions,” and the analysis in his brief also focuses on causation. Thus, we
will focus on the qualification standards under section 74.351(r)(5)(C), although
we acknowledge that there may be some overlap between those standards and
the standards related to qualifications for duty of care and breach.

                                       21
the plaintiff) (citing Broders v. Heise, 924 S.W.2d 148, 153 (Tex. 1996));

Mem’l Hermann Healthcare Sys. v. Burrell, 230 S.W.3d 755, 762–63 (Tex.

App.—Houston [14th Dist.] 2007, no pet.) (deciding that a doctor was qualified

to opine about causation because his report demonstrated direct experience

with treating decubitus ulcers, which was the condition at issue). In other

words,

      there is no validity, if there ever was, to the notion that every
      licensed medical doctor should be automatically qualified to testify
      as an expert on every medical question. . . . [T]he proponent of
      the testimony has the burden to show that the expert ‘possesses
      special knowledge as to the very matter on which he proposes to
      give an opinion.’

Ehrlich, 144 S.W.3d at 625 (quoting Broders, 924 S.W.2d at 152–53).

“A medical expert who is not of the same school of medicine, however, is

competent to testify if he has practical knowledge of what is usually and

customarily done by a practitioner under circumstances similar to those

confronting the defendant.” Id.

      Dr. Foster argues that Dr. Drazner is not qualified as an expert on

causation in this case because although Dr. Foster is an orthopedic surgeon,

Dr. Drazner “is an internist who specializes in Physical Medicine and

Rehabilitation” and has not demonstrated “that he has had education or

experience in the diagnosis, care, or treatment of an orthopedic surgery



                                      22
patient.” Dr. Foster relies on Ehrlich and Collini. In Ehrlich, we held that a

neurologist, although skilled in the treatment of issues related to the nervous

system, was not qualified to submit an expert report on the validity of surgical

procedures used during the plaintiff’s face lift and implants. Id. at 625–26. In

Collini, we concluded that a doctor was not qualified to submit a report about

whether the prolonged prescription of a drug caused the plaintiff’s condition

because the doctor did not show that he had any knowledge, experience,

education, or training on that causal relationship or about the specific drug or

condition involved in the case. Collini, 280 S.W.3d at 465–66.

      This case is different from Ehrlich and Collini because Dr. Drazner has

shown experience with the exact issue involved in Richardson’s claim against

Dr. Foster. Dr. Drazner’s report assigns blame to Dr. Foster for failing to follow

orthopedic diagnostic procedures (such as failing to complete a range of motion

test and failing to document hallmarks of the complex regional pain syndrome)

that would have allowed him to correctly diagnose Richardson’s broken ankle

and thus avoid (among other results) the continued pain associated with an

incorrect diagnosis; it does not assess blame on Dr. Foster for processes

involved with an orthopedic surgery.

      Rather, our case is more akin to Barber v. Mercer, where we determined

that an anesthesiologist was qualified to give an expert report on a surgeon

                                       23
during orthopedic surgery regarding the proper positioning and padding of the

patient. No. 02-08-00079-CV, 2009 WL 3337192, at *8 (Tex. App.—Fort

Worth Oct. 15, 2009, no pet.).     Dr. Drazner’s report and curriculum vitae

establish his qualifications to submit a report about orthopedic diagnostic

procedures; they show that he obtained his medical degree in 1986 and that at

the time he submitted his report, he had practiced medicine in Texas for

eighteen years with a specialty in physical medicine and rehabilitation and a

secondary specialty in occupational medicine. He primarily treats patients who

have suffered orthopedic injuries, and he has “treated approximately 20,000

patients with [orthopedic] injuries and performed several hundred thousand

[orthopedic] examinations.”   Since 1995, he has practiced in the area of

“Physical Medicine and Rehabilitation, Pain Management.”

      Dr. Drazner has served as a featured speaker on several topics, including

one on “Multidisciplinary Approaches to the Management of Complex Regional

Pain Syndrome,” which is the particular condition that Dr. Foster diagnosed

Richardson as having. Dr. Drazner has also lectured on the management of

knee injuries.

      Therefore, we hold that the trial court did not abuse its discretion by

denying Dr. Foster’s motion to dismiss on the basis that Dr. Drazner is not




                                      24
qualified to provide an opinion on the causal relationship between Dr. Foster’s

actions and Richardson’s harm. See Palacios, 46 S.W.3d at 875.11




      11
        … Dr. Foster contends that Dr. Drazner was required to establish that
he is qualified to provide an opinion on the length of time it takes a bone to set
so that he could show that Richardson’s ankle fracture worsened between Dr.
Foster’s diagnosis and the later diagnosis of Richardson’s broken ankle.
Because we have already sustained Dr. Foster’s issue about the expert report’s
adequacy to establish a causal relationship between Dr. Foster’s actions and
Richardson’s ankle treatment, we will not address Dr. Drazner’s qualifications
to provide an opinion on that same issue. See Tex. R. App. P. 47.1.

                                       25
                                   Conclusion

      Having overruled the majority of Dr. Foster’s sole issue regarding

Richardson’s assertion that his alleged misdiagnosis caused her additional pain,

we affirm the trial court’s order denying his motion to dismiss as to that issue.

Having sustained a portion of Dr. Foster’s sole issue concerning Richardson’s

assertion that his alleged misdiagnosis caused her need for ankle surgeries and

having found Dr. Drazner’s report deficient as to that causal relationship, we

reverse the trial court’s decision regarding the sufficiency of the report in that

regard and remand this case to that court to consider the issue of whether to

grant Richardson a thirty-day extension to cure that deficiency. See Tex. Civ.

Prac. & Rem. Code Ann. § 74.351(c); Leland, 257 S.W.3d at 207; Collini, 280

S.W.3d at 468.




                                            TERRIE LIVINGSTON
                                            JUSTICE

PANEL: CAYCE, C.J.; LIVINGSTON and WALKER, JJ.

CAYCE, C.J. not participating.

DELIVERED: December 31, 2009




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