P Estate of Lamarr Green v. Bashar Yaldo Md

If this opinion indicates that it is “FOR PUBLICATION,” it is subject to
revision until final publication in the Michigan Appeals Reports.
STATE OF MICHIGAN
COURT OF APPEALS
JULIE BRESKO, Personal Representative of the UNPUBLISHED
ESTATE OF LAMARR GREEN, May 25, 2023
Plaintiff-Appellee,
v No. 357931
Oakland Circuit Court
BASHAR YALDO, MD, LC No. 2020-179077-NH
Defendant,
and
SHAHRZAD ABBASSI-RAHBAR and ST JOSEPH
MERCY-OAKLAND,
Defendants-Appellants.
Before: CAVANAGH, P.J., and K. F. KELLY and GARRETT, JJ.
GARRETT, J. (concurring in part and dissenting in part).
In a medical malpractice case, a “specialist” is “a physician whose practice is limited to a
particular branch of medicine or surgery, especially one who, by virtue of advanced training, is
certified by a specialty board as being qualified to so limit his practice.” Woodard v Custer, 476
Mich 545, 561; 719 NW2d 842 (2006), quoting Dorland’s Illustrated Medical Dictionary (28th
ed). A general surgery resident is not transformed into a “specialist” in surgical critical care simply
by virtue of participation in a brief required rotation in the surgical intensive care unit (SICU).
Therefore, I respectfully dissent from the majority’s conclusion that defendant Shahrzad Abbassi-
Rahbar (Dr. Abbassi) was a “specialist” in surgical critical care at the time of the alleged
malpractice. Instead, I would conclude that Dr. Abbassi was a “specialist” in general surgery.
Nevertheless, I am constrained to agree that plaintiff’s proposed expert, Dr. Jason Nirgiotis, is not
qualified to provide standard-of-care testimony against Dr. Abbassi under MCL 600.2169(1)(b),
as interpreted by Woodard, because Dr. Nirgiotis spent the majority of his time practicing the
distinct specialty of pediatric surgery in the year before the alleged malpractice in this case. For
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that reason, I concur in the majority’s ultimate conclusion that defendants1 were entitled to
summary disposition on plaintiff’s claims arising out of Dr. Abbassi’s treatment of the decedent,
LaMarr Green. I also concur in the majority opinion in all other respects.
I. BASIC FACTS
Dr. Abbassi began her general surgery residency at St. Joseph Mercy-Oakland (SJMO) in
2015. The SJMO general surgery residency program requires residents to participate in several
rotations in different specialties related to the practice of general surgery. On February 1, 2018,
Dr. Abbassi began a scheduled two-month-long rotation in the SICU. The next day, Dr. Bashar
Yaldo, a general surgeon, performed a hernia repair on Green, and Green was discharged the same
day. Three days later, on February 5, 2018, Green presented to the emergency room at SJMO,
reporting that he was vomiting and experiencing abdominal pain after the hernia operation. Green
was admitted to the hospital and soon transferred to the SICU as his health declined.
During Green’s nearly two-week stay in the SICU, he was cared for by several residents
and attending physicians, including Dr. Abbassi. Dr. Yaldo also saw Green throughout his stay in
the SICU and was listed as his attending physician on all progress notes. Dr. Yaldo performed a
second surgery on Green on February 12, 2018, during which he discovered and addressed a small
bowel obstruction. Throughout Dr. Abbassi’s care of Green in the SICU, Dr. Abbassi worked
directly with supervising physicians who were specialists in surgical critical care. Dr. Abbassi
treated Green on at least six days during Green’s time in the SICU until his unfortunate passing on
February 19, 2018. According to Dr. Nirgiotis, Green’s death certificate listed his causes of death
as aspiration pneumonia, sepsis, and a small bowel obstruction due to an internal hernia.2
In bringing suit against Dr. Abbassi, plaintiff alleged in relevant part that Dr. Abbassi
breached the applicable standard of care when: (1) on February 8, 2018, she cut back on Green’s
antibiotics when he was in septic shock; (2) on February 10, 2018, she started Green on tube feeds
when he had a bowel obstruction; and (3) on February 15, 2018, she stopped Green’s intravenous
therapy (IV) antibiotics when Green was at high risk for redeveloping sepsis. Attached to
plaintiff’s complaint was an affidavit of merit from Dr. Nirgiotis, a physician board-certified in
general surgery and pediatric surgery.3 After discovery, defendants moved for summary
1
Any reference to “defendants” refers to Dr. Abbassi and St. Joseph Mercy-Oakland.
2
Aspiration pneumonia is an “infection of the lungs caused by inhaling saliva, food, liquid, vomit
and even small foreign objects,” and sepsis is a “life-threatening medical emergency caused by
[the] body’s overwhelming response to an infection.” Cleveland Clinic, Aspiration Pneumonia,
(accessed May 2,
2023); Cleveland Clinic, Sepsis,
(accessed May 2, 2023). Dr. Nirgiotis opined that the aspiration pneumonia ultimately led to
sepsis.
3
Specifically, Dr. Nirgiotis is board-certified in the specialty of general surgery, with a certificate
of special competency in the subspecialty of pediatric surgery. This certificate of special
competency also constitutes a board certificate under MCL 600.2169(1)(a). See Woodard, 476
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disposition. With respect to Dr. Abbassi, defendants argued that Dr. Nirgiotis was not qualified to
offer expert testimony on her alleged malpractice because Dr. Abbassi was practicing as a
“specialist” in surgical critical care, and Dr. Nirgiotis does not specialize in that field. The trial
court denied summary disposition to Dr. Abbassi, but the majority reverses that decision,
concluding that binding precedent “compel[s] the conclusion that Dr. Abbassi was a specialist
practicing in surgical critical care at the time of the alleged malpractice.” I depart from the majority
on that holding.
II. LEGAL BACKGROUND AND ANALYSIS
The proper determination of the standard of care applicable to Dr. Abbassi’s alleged
conduct in this case turns on inconsistent caselaw interpreting the expert qualification statute for
medical malpractice cases. Relying on Woodard, Gonzalez v St John Hosp & Med Ctr (On
Reconsideration), 275 Mich App 290; 739 NW2d 392 (2007), and Reeves v Carson City Hosp (On
Remand), 274 Mich App 622; 736 NW2d 284 (2007), the majority concludes that surgical critical
care is the applicable standard of care to Dr. Abbassi.
In Woodard, our Supreme Court undertook a comprehensive review of MCL 600.2169(1),
the statute governing the required qualifications of an expert witness in a medical malpractice
action. In relevant part, the statute provides:
(1) In an action alleging medical malpractice, a person shall not give expert
testimony on the appropriate standard of practice or care unless the person is
licensed as a health professional in this state or another state and meets the
following criteria:
(a) If the party against whom or on whose behalf the testimony is offered is
a specialist, specializes at the time of the occurrence that is the basis for the action
in the same specialty as the party against whom or on whose behalf the testimony
is offered. However, if the party against whom or on whose behalf the testimony
is offered is a specialist who is board certified, the expert witness must be a
specialist who is board certified in that specialty.
(b) Subject to subdivision (c), during the year immediately preceding the
date of the occurrence that is the basis for the claim or action, devoted a majority
of his or her professional time to either or both of the following:
(i) The active clinical practice of the same health profession in which the
party against whom or on whose behalf the testimony is offered is licensed and, if
that party is a specialist, the active clinical practice of that specialty.
Mich at 565. One must become certified by the American Board of Surgery in general surgery
before undergoing the required training for pediatric surgery certification. The American Board
of Surgery, Pediatric Surgery,
(accessed April 27, 2022).
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(ii) The instruction of students in an accredited health professional school
or accredited residency or clinical research program in the same health profession
in which the party against whom or on whose behalf the testimony is offered is
licensed and, if that party is a specialist, an accredited health professional school or
accredited residency or clinical research program in the same specialty. [MCL
600.2169.]
Beginning with § 2169(1)(a)’s “same specialty” requirement, Woodard explained that “if
a defendant physician is a specialist, the plaintiff’s expert witness must have specialized in the
same specialty as the defendant physician at the time of the alleged malpractice.” Woodard, 476
Mich at 560-561. Turning to the dictionary, the Court approvingly cited a definition of “specialist”
as “a physician whose practice is limited to a particular branch of medicine or surgery, especially
one who, by virtue of advanced training, is certified by a specialty board as being qualified to so
limit his practice.” Id. at 561, quoting Dorland’s Illustrated Medical Dictionary (28th ed).
Considering this definition and the plain language of § 2169(1)(a), the Court concluded that a
“specialist” did not have to be board certified. Id. at 561. Thus, the Court described a “specialty”
as a “particular branch of medicine or surgery in which one can potentially become board
certified.” Id. (emphasis added). “Accordingly, if the defendant physician practices a particular
branch of medicine or surgery in which one can potentially become board certified, the plaintiff’s
expert must practice or teach the same particular branch of medicine or surgery.” Id. at 561-562.
The Court also held that “[a] subspecialty, although a more particularized specialty, is nevertheless
a specialty,” and that the “same specialty” requirement similarly applied to subspecialties. Id. at
562. Recognizing that a defendant physician may specialize in multiple areas, Woodard
additionally held that “the plaintiff’s expert witness must match the one most relevant standard of
practice or care—the specialty engaged in by the defendant physician during the course of the
alleged malpractice.” Id. at 560.
Dr. Abbassi’s involvement as a defendant in this case presents a wrinkle that was not
decided in Woodard—how § 2169 applied to medical residents. This Court, in Gonzalez,
addressed that situation. This Court first read Woodard as overruling prior precedent which held
that residents are not specialists. Gonzalez, 275 Mich App at 299. But Gonzalez did not broadly
hold that residents are specialists anytime they are practicing in a specific field of medicine.
Rather, applying the definition of “specialist” from Woodard, Gonzalez explained that only those
residents who “limit their training to a particular branch of medicine or surgery and who can
potentially become board-certified in that specialty are specialists for purposes of the analysis
under MCL 600.2169(1).” Id.Reeves is the final case relied upon by the majority. As the majority notes, Reeves involved
a medical malpractice suit against a board-certified family medicine doctor who treated the
plaintiff in the emergency room at the time of the alleged malpractice. Reeves, 274 Mich App at
623. This Court explained that the defendant physician was practicing outside of her board-
certification because she was working in the emergency room. Id. at 628. As a result, this Court
determined that emergency medicine was the one most relevant standard of care applicable to the
alleged malpractice. Id. The Court summarized its conclusion: “[B]ecause [the defendant
physician] was practicing emergency medicine at the time of the alleged malpractice and
potentially could obtain a board certification in emergency medicine, she was a ‘specialist’ in
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emergency medicine under the holding in Woodard. Thus, plaintiffs would need a specialist in
emergency medicine to satisfy MCL 600.2169[.]” Id. at 630.
Relying on Reeves, the majority explains that “the fact that Dr. Abbassi was not actually
pursuing board certification in surgical critical care is irrelevant because it is a specialty in which
Dr. Abbassi could potentially obtain a board certification, as well as the specialty in which Dr.
Abbassi was practicing at the time of the occurrence.” I disagree with the majority because I would
hold that, looking beyond the label of her rotation, Dr. Abbassi was practicing as a “specialist” in
general surgery at the time of the alleged malpractice.
In opposing defendants’ motion for summary disposition, plaintiff attached a booklet on
certification for general surgery from the American Board of Surgery (ABS), the national
certifying body for surgeons practicing in the United States. The ABS defines the scope of general
surgery as “a discipline that requires knowledge of and responsibility for the preoperative,
operative, and post-operative management of patients with a broad spectrum of diseases, including
those which may require nonoperative, elective, or emergency surgical treatment.” According to
the ABS, a certified general surgeon should have broad knowledge and experience in surgical
critical care, as well as the categories of “infection and antibiotic usage” and “metabolism and
nutrition.” The ABS, which also oversees the subspecialty of surgical critical care, defines that
field as “a primary component of general surgery related to the care of patients with acute, life-
threatening or potentially life-threatening surgical conditions.”4 The allegations of malpractice
against Dr. Abbassi involve her decisions about the provision of antibiotics and tube feeding to
Green. While these tasks can fall within the practice of surgical critical care, they are also well
within the scope of knowledge of a general surgeon. For instance, Dr. Abbassi testified that, in
her training and experience, she had seen surgeons place orders for antibiotics. She also agreed
that a surgeon should know what antibiotics to give a patient who turns septic. The malpractice
allegations against Dr. Abbassi directly relate to the decision about whether to continue providing
antibiotics to Green. As for the tube feeds, Dr. Abbassi claimed that the decision to start tube feeds
was made by Dr. Amy Braddock, one of the general surgeons treating Green. This testimony is
an implicit acknowledgement that the decision to start or stop tube feeds, even on a critically ill
patient, falls within the scope of practice of a general surgeon. While Dr. Abbassi reported to
surgical critical care specialists during her rotation in the SICU, she did so as a general surgery
resident engaged in tasks common to the practice of general surgery. Neither the label of the
rotation, nor the SICU setting, changes that fact. Thus, unlike the majority, I would hold that Dr.
Abbassi was practicing as a “specialist” in general surgery during the course of the alleged
malpractice.
This conclusion is also consistent with Woodard and Gonzalez. At the time of the alleged
malpractice, Dr. Abbassi was a third-year general surgery resident on her second week of a
required rotation in the SICU, and pursuing board certification in general surgery. She limited her
training to general surgery, received “advance training” in that field, and could “potentially
become board certified” in that specialty. See Woodard, 476 Mich at 561-562 (quotation marks
4
American Board of Surgery, Specialty of Surgical Critical Care Defined,
(accessed May 2, 2023).
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and citation omitted). Thus, Woodard and its interpretation of “specialist” support that Dr. Abbassi
was practicing as a “specialist” in general surgery. Furthermore, Gonzalez conditioned its
extension of residents as “specialists” only to those residents who “limit their training to a
particular branch of medicine or surgery and who can potentially become board-certified in that
specialty.” Gonzalez, 275 Mich App at 299. Importantly, in that case, it was “not disputed” as a
factual matter that the defendant resident “was a third-year surgical resident practicing within that
discrete specialty on the date of the occurrence.” Id. at 297. Here, of course, the parties disagree
whether Dr. Abbassi was practicing within the specialty that matched her residency program.
Consistent with Gonzalez, Dr. Abbassi could not be considered a “specialist” in surgical critical
care because she did not limit her training to that specialty. See id. at 299.
Because Dr. Abbassi was practicing as a “specialist” in general surgery, plaintiff’s
proposed expert must specialize in that field. See MCL 600.2169(1)(a). Dr. Nirgiotis is a board-
certified physician in general surgery and thus satisfies § 2169(1)(a)’s “same specialty”
requirement. That said, I agree with the majority that Dr. Nirgiotis is not qualified to offer
testimony under § 2169(1)(b)’s majority-practice requirement as interpreted by Woodard. “[I]n
order to be qualified to testify under § 2169(1)(b), the plaintiff’s expert witness must have devoted
a majority of his professional time during the year immediately preceding the date on which the
alleged malpractice occurred to practicing or teaching the specialty that the defendant physician
was practicing at the time of the alleged malpractice, i.e., the one most relevant specialty.”
Woodard, 476 Mich at 566. That means the expert must have spent more than 50% of his
professional time in the relevant specialty during the preceding year. Kiefer v Markley, 283 Mich
App 555, 559; 769 NW2d 271 (2009). Crucially, Woodard held that “one cannot devote a
‘majority’ of one’s professional time to more than one specialty.”5 Woodard, 476 Mich at 566.
Despite significant overlap in the skills used to practice general surgery and pediatric
surgery, Woodard requires that we apportion a physician’s time into separate, circumscribed
buckets. Dr. Nirgiotis’s deposition testimony definitively shows that, in the year preceding the
alleged malpractice in this case, he spent a majority of his time practicing pediatric surgery. He
admitted as much, testifying that more than 90 percent of his patients were under 18 years old, and
a majority had not reached the age of puberty. Dr. Nirgiotis is employed in the pediatric
department and works with pediatric residents; neither of the hospitals where Dr. Nirgiotis works
5
As one of my colleagues has aptly noted, this interpretation makes little sense “because in reality
there is a substantial overlap between the work of specialists and subspecialists.” Higgins v Traill,
unpublished per curiam opinion of the Court of Appeals, issued July 30, 2019 (Docket No. 343664)
(GLEICHER, J., concurring), p 8. “Woodard compels a contorted calculation of which specialty or
subspecialty consumes the majority of an expert’s time based on the notion that it is possible to
practice only one thing at a time.” Id. To that end, Dr. Nirgiotis, while primarily practicing the
specialty of pediatric surgery, undoubtedly applied many of the skills and principles learned in his
general surgery residency. Pediatric surgery is a subspecialty of general surgery, and thus,
unsurprisingly, the two areas of medicine contain significant overlap. For instance, as Dr. Nirgiotis
testified, there is often no functional difference between a surgical operation on an adolescent and
an adult: “[t]hey’re exactly the same type of surgery, the same procedure done, the same
complications, the same risks.”
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even have a general surgery residency program. Because Dr. Nirgiotis did not devote a majority
of his professional time to the practice or instruction of general surgery in the year preceding the
alleged malpractice, he is not qualified to offer standard-of-care testimony against Dr. Abbassi.
See MCL 600.2169(1)(b).
This case exemplifies why reexamination of our precedent and its interpretation of §
2169(1) is much needed. The result here—that a board-certified general surgeon with 30 years of
experience is unqualified to offer expert testimony about alleged malpractice committed by a
general surgery resident on a brief rotation in the SICU—makes little sense. Fortunately, our
Supreme Court has recently granted leave to address, among several issues, “whether Woodard v
Custer, 476 Mich 545 (2006), was correctly decided and is consistent with the requirements of
MCL 600.2169(1)” and if not, what test should apply. Selliman v Colton, 982 NW2d 396 (Mich,
2022); Stokes v Swofford, 982 NW2d 397 (Mich, 2022). It is my hope that the Court will adopt a
more workable and practical test that is consistent with the plain language of MCL 600.2169(1).
III. CONCLUSION
I respectfully dissent from the majority’s conclusion that Dr. Abbassi was practicing as a
“specialist” in surgical critical care. In all other respects, I concur in the decision to affirm in part
and reverse in part the trial court’s order.
/s/ Kristina Robinson Garrett
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