Hohenberger v. United States , 660 F. App'x 637 ( 2016 )

FILED
United States Court of Appeals
UNITED STATES COURT OF APPEALS Tenth Circuit
FOR THE TENTH CIRCUIT September 7, 2016
_________________________________
Elisabeth A. Shumaker
Clerk of Court
EVELYN HOHENBERGER, individually
and as representative of the estate of
Thomas Hohenberger,
Plaintiff - Appellant,
v. No. 15-1494
(D.C. No. 1:14-CV-00337-CBS)
UNITED STATES OF AMERICA, (D. Colo.)
Defendant - Appellee.
_________________________________
ORDER AND JUDGMENT*
_________________________________
Before MATHESON, McKAY, and O’BRIEN, Circuit Judges.
_________________________________
Thomas Hohenberger had been receiving medical care from the Department of
Veterans Affairs (VA) when he died from coronary artery disease that had not been
diagnosed or treated. His widow, Evelyn Hohenberger, acting individually and as the
representative of his estate, sued the United States for medical malpractice under the
Federal Tort Claims Act (FTCA). After a bench trial, the district court found in favor
*
After examining the briefs and appellate record, this panel has determined
unanimously to honor the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
submitted without oral argument. This order and judgment is not binding precedent,
except under the doctrines of law of the case, res judicata, and collateral estoppel. It
may be cited, however, for its persuasive value consistent with Fed. R. App. P. 32.1
and 10th Cir. R. 32.1.
of the United States, and Mrs. Hohenberger appeals. Exercising jurisdiction under
28 U.S.C. § 1291, we affirm.
BACKGROUND
Mr. Hohenberger, born in 1946, was a Vietnam veteran who received medical
care from a VA facility in Grand Junction, Colorado. Between 1998 and July 2011,
his primary care physician was Paul Preston, M.D. While under Dr. Preston’s care,
Mr. Hohenberger was treated for several conditions, including chronic obstructive
pulmonary disease (COPD), osteoarthritis, low testosterone, and post-traumatic stress
disorder (PTSD). He was a smoker and considered to be an alcoholic. Dr. Preston’s
last exam of Mr. Hohenberger was in February 2011.
In July 2011, Kathleen Ono, D.O., replaced Dr. Preston as Mr. Hohenberger’s
primary care physician. Dr. Ono, however, never saw Mr. Hohenberger in person.
On September 24, 2011, he died suddenly at home. The cause of death was ischemic
heart disease due to coronary artery atherosclerosis. Mr. Hohenberger had not been
diagnosed with or treated for coronary artery disease.
Mrs. Hohenberger, on behalf of herself and her husband’s estate, filed an
administrative tort claim and then this FTCA suit. She alleged that Dr. Preston failed
to properly diagnose and treat Mr. Hohenberger’s coronary artery disease, leading to
his death. The parties consented to have a magistrate judge preside over the case and
then filed several pre-trial motions.
Mrs. Hohenberger moved for summary judgment as to liability and moved to
exclude the United States’ expert witness. The district court denied both of those
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motions. The United States filed a motion to exclude Mrs. Hohenberger’s expert
witness, which the district court also denied. The United States was more successful
with its motion to preclude Mrs. Hohenberger’s expert witness from testifying about
Dr. Ono’s performance. The district court granted that motion because the complaint
focused on Dr. Preston’s negligence and Mrs. Hohenberger had never moved to
amend to include allegations about Dr. Ono. Thus, the court concluded, Dr. Ono’s
performance was not relevant to the case as Mrs. Hohenberger had framed it and
testimony about Dr. Ono would not assist the court in deciding the issues before it.
The district court conducted a three-day bench trial. In addition to hearing
testimony from Mrs. Hohenberger, the court heard testimony from three medical
witnesses: (1) Dr. Preston, who is board-certified in internal medicine and who
testified both as a fact witness and as an expert in primary care medicine; (2) the
United States’ expert witness, John Johnson, M.D., who is board-certified in family
medicine; and (3) Mrs. Hohenberger’s expert witness, Michael Jones, M.D., who is
board-certified in cardiovascular medicine and was board-certified in internal
medicine from 2000 to 2010. The medical records showed that over the years
Mr. Hohenberger presented with various complaints, including shortness of breath,
fatigue, and lightheadedness. The medical witnesses differed on the proper
interpretation of those complaints and the appropriate standard of care for a primary
care physician.
Dr. Preston reviewed his treatment of Mr. Hohenberger. He testified that
Mr. Hohenberger had no symptoms of coronary artery disease. He did not present
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with the primary symptom, angina, and the symptoms he reported were more
consistent with other conditions, such as COPD and low testosterone. Dr. Preston
opined that the standard of care for an asymptomatic patient was to conduct a yearly
cardiovascular risk assessment and to treat modifiable risk factors for coronary artery
disease. He testified that it was his practice to do a cardiovascular risk assessment at
every primary care visit. He identified smoking as Mr. Hohenberger’s only
modifiable risk factor, and he testified that he consistently advised Mr. Hohenberger
to stop smoking or at least to cut down on his smoking.
The United States’ expert, Dr. Johnson, testified similarly to Dr. Preston. He
opined that the standard of care for a primary care physician was focused on
prevention, identifying a patient’s risk factors and attempting to modify them. His
calculations put Mr. Hohenberger in the intermediate range. Treatment for
asymptomatic patients, whether low, intermediate, or high risk, was to modify risk
factors. Dr. Johnson considered Mr. Hohenberger to be asymptomatic for coronary
artery disease because his symptoms were not characteristic of coronary artery
disease. Accordingly, Dr. Johnson opined that Dr. Preston met the standard of care.
In contrast, Mrs. Hohenberger’s expert, Dr. Jones, opined that
Mr. Hohenberger’s complaints were symptoms of coronary artery disease. He
therefore did not consider Mr. Hohenberger to be an asymptomatic patient. In light
of Mr. Hohenberger’s age, his status as a smoker, and his medical history, Dr. Jones
testified that the standard of care required more aggressive evaluation for cardiac
disease. At the least, Dr. Preston should have ordered an exercise stress test. Then,
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depending on results, the initial test could be followed by other treatments such as an
angiogram. When questioned about persons considered to be an intermediate risk,
Dr. Jones reaffirmed that the appropriate treatment was an exercise stress test. He
further opined that had Dr. Preston ordered the additional testing, Mr. Hohenberger
probably would have lived longer.
The district court found in favor of the United States. It credited
Dr. Johnson’s and Dr. Preston’s opinions over Dr. Jones’s opinion, finding that
Mr. Hohenberger’s complaints were not symptoms of coronary artery disease.
Having found that Mr. Hohenberger was asymptomatic, it further found that the
applicable standard of care was for Dr. Preston to identify risk factors and attempt to
modify them, which he did. It concluded that Mrs. Hohenberger had failed to
demonstrate by a preponderance of the evidence that Dr. Preston breached the
standard of care by not performing further testing for and treatment of coronary
artery disease.
DISCUSSION
I. Summary Judgment
Mrs. Hohenberger first argues that the district court erred in denying her
pre-trial motion for summary judgment. She acknowledges that Dr. Jones and
Dr. Johnson offered different opinions regarding the standard of care. She argues,
however, that summary judgment was appropriate because (1) Dr. Johnson’s opinion
did not sufficiently oppose Dr. Jones’s opinion at the time of the motion’s filing, and
(2) Dr. Johnson’s opinion was not supported by the undisputed facts. In response,
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the United States points to the rule that “the denial of a motion for summary
judgment is not reviewable on an appeal following the entry of final judgment after a
trial where the district court’s decision on the motion was based on its determination
that there were genuine issues of material fact in dispute.” Stump v. Gates, 211 F.3d
527, 532 (10th Cir. 2000); see also Whalen v. Unit Rig, Inc., 974 F.2d 1248, 1251
(10th Cir. 1992) (“[S]ummary judgment was not intended to be a bomb planted
within the litigation at its early stages and exploded on appeal.” (internal quotation
marks omitted)).
The district court denied summary judgment because it found the existence of
a factual dispute:
I cannot find, as a matter of law, that . . . there are no facts that the
defendant could not offer at trial that would support the defendant’s
position. I mean, this is fundamentally a dispute between experts, and,
folks, you might as well just accept that reality. Your expert says A and
their expert says B, that’s what experts do. But fundamentally, since I have
to draw all inferences in favor of the non-moving party, since I cannot draw
any conclusions with respect to credibility, I do not see how, in the context
of this motion, I can find that one expert is right and the other expert is
wrong.
Aplt. App., Vol. 3 at 471-72. Mrs. Hohenberger attempts to frame her challenges as
involving questions of law, but as the district court recognized, this case
fundamentally turned on the facts. We therefore agree with the United States that the
summary judgment decision is not reviewable on appeal.
II. Exclusion of Testimony
Mrs. Hohenberger next argues that the district court erred in granting the
government’s pre-trial motion to preclude testimony about Dr. Ono’s performance.
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The government filed that motion after Mrs. Hohenberger moved for summary
judgment on liability, arguing that both Dr. Preston and Dr. Ono were negligent.
Concluding that the complaint pleaded only a claim based on Dr. Preston’s
negligence, the district court held that evidence about another doctor’s performance
was not relevant to the case, see Fed. R. Evid. 401, and would not assist the court in
deciding the issues before it, see id. 702(a). “The district court’s decision to admit or
exclude evidence generally, including expert testimony, is typically reviewed under
an abuse of discretion standard.” Ralston v. Smith & Nephew Richards, Inc.,
275 F.3d 965, 968 (10th Cir. 2001) (Rule 702); see also Tanberg v. Sholtis, 401 F.3d
1151, 1162 (10th Cir. 2005) (Rule 401).1 Under this standard, “[a] trial court’s
decision will not be disturbed unless this Court has a definite and firm conviction that
the trial court has made a clear error of judgment or exceeded the bounds of
permissible choice in the circumstances.” Ralston, 275 F.3d at 968-69 (brackets and
internal quotation marks omitted).
We are not persuaded that the district court abused its discretion in excluding
testimony about Dr. Ono’s performance. The record is clear that Mrs. Hohenberger
was focused on Dr. Preston’s performance when she initiated her case. Her
1
The parties disagree on the appropriate standard of review for this issue. We
reject both parties’ proffered standards. Mrs. Hohenberger approaches the issue as
one of pleading, which would involve de novo review. Her discussion of Fed. R.
Civ. P. 12(b)(6) is misplaced, however, because the district court relied on Fed. R.
Evid. 401 and 702. In contrast, the United States urges plain error review because
Mrs. Hohenberger did not make an offer of proof. See Fed. R. Evid. 103(a)(2). But
we agree with Mrs. Hohenberger that the substance of Dr. Jones’s testimony
regarding Dr. Ono’s performance “was apparent from the context,” as allowed by
Rule 103(a)(2).
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administrative claim names as witnesses only Mrs. Hohenberger and Dr. Preston.
The complaint names as defendants the United States and Dr. Preston, and identifies
only Dr. Preston by name as a negligent actor.2 Further, in her initial discovery
responses, Mrs. Hohenberger failed to identify Dr. Ono as a medical practitioner that
allegedly was negligent. Apparently Dr. Ono came to Mrs. Hohenberger’s attention
during discovery. But Mrs. Hohenberger did not supplement her initial discovery
responses or her initial expert report until after she filed her motion for summary
judgment, and she never moved to amend her complaint to discuss Dr. Ono as well as
Dr. Preston.
Mrs. Hohenberger points to allegations in the complaint referring to “[t]he
government,” “[t]he employees of the VA who treated Mr. Hohenberger,” and “[t]he
VA and its employees,” which would encompass Dr. Ono as well as Dr. Preston.
Aplt. Br. at 21-22 (internal quotation marks omitted). This general language,
however, must be read in context with the remainder of the complaint and in light of
other events in the case (such as Mrs. Hohenberger’s initial disclosures and the
United States’ scope-of-employment certification, which was limited to Dr. Preston).
In the circumstances, these general references do not demonstrate that the district
court abused its discretion in concluding that Mrs. Hohenberger had framed her case
2
Mrs. Hohenberger dismissed Dr. Preston as a defendant after the
United States certified that he was acting within the scope of his employment. The
United States is the only proper defendant in an FTCA case. See Smith v.
United States, 561 F.3d 1090, 1099 (10th Cir. 2009).
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as focusing on Dr. Preston’s performance, and therefore Dr. Ono’s performance was
not relevant to the issues before the court.
III. Verdict for the United States
Finally, Mrs. Hohenberger challenges the district court’s verdict in favor of the
United States. When the district court has conducted a bench trial, we review
conclusions of law de novo and findings of fact for clear error. See United States v.
Estate of St. Clair, 819 F.3d 1254, 1264 (10th Cir. 2016). “A finding is clearly
erroneous when the reviewing court has a definite and firm conviction that it is
mistaken, even though there may be some evidence to support it.” Id. (internal
quotation marks omitted).
Mrs. Hohenberger takes issue with the district court’s evaluation of Dr. Jones’s
testimony, arguing that the court “was clearly erroneous when [it] held that
Dr. Jones’ opinion was not supported by the medical literature and the [United States
Preventive Services Task Force].” Aplt. Br. at 28. But that is not what the district
court stated. In evaluating the witnesses’ testimony, it stated that “Dr. Jones’s
opinions are not as consistent with the [United States Preventive Services Task
Force] and medical literature as are the opinions of Dr. Preston and Dr. Johnson.”
Aplt. App., Vol. 2 at 457 (emphasis added). Mrs. Hohenberger fails to show that the
district court’s actual finding is clearly erroneous.3 Further, the district court gave
other reasons for not crediting Dr. Jones’s testimony, including that his opinions
3
We decline Mrs. Hohenberger’s invitation to take judicial notice of materials
that were not introduced in the district court.
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were based on hindsight and on a number of symptoms that were not present in the
record, and that he was not aware of all of Mr. Hohenberger’s medical conditions.
Mrs. Hohenberger does not challenge these other reasons.
Mrs. Hohenberger also asserts that “the record is ripe with evidence that
Mr. Hohenberger suffered cardiac symptoms.” Aplt. Br. at 29. But whether his
complaints were symptoms of coronary artery disease or of other conditions was a
question for trial, and the district court found that the symptoms were not symptoms
of coronary artery disease. Mrs. Hohenberger’s adamant belief to the contrary does
not establish that the district court’s finding was clear error.
CONCLUSION
The judgment of the district court is affirmed. Mrs. Hohenberger’s unopposed
Renewed Motion to Seal Documents is granted.4 Mrs. Hohenberger’s opposed
Motion to Supplement the Record is denied. The court did not consider the material
contained in the proposed supplemental record.
Entered for the Court
Monroe G. McKay
Circuit Judge
4
At the court’s order, Mrs. Hohenberger filed a redacted version of
Appendix Volume 5, which is publicly accessible. The originally filed, unredacted
Appendix Volume 5 shall remain sealed.
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