Paetsch v. Spokane Dermatology Clinic, PS

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IN CLERKS O'PICI ~ This opinion was filed for record
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MAR 1 2 Z0151
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DATE
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Supreme Court Clark
IN THE SUPREME COURT OF THE STATE OF WASHINGTON
PHYLLIS PAETSCH, )
)
Petitioner, ) No. 89866-9
)
v. ) En Bane
)
SPOKANE DERMATOLOGY CLINIC, P.S., )
as a Washington Corporation; and ) Filed _ _MA_R_1_2_20_15__
WILLIAM P. WERSCHLER, M.D., )
individually, )
)
)
Responden~. )
)
WIGGINS, J.-The plaintiff in this medical malpractice case asks us to decide
that a physician-patient relationship is formed when a patient enters into a written
contract with a clinic and that written contract names a specific physician as the
patient's doctor. We do not reach this issue because the jury instructions allowed the
plaintiff to argue her theory of the case and the jury found that the defendant was not
negligent.
Several novel issues lurk in the question brought by the plaintiff, including
questions about the liability of a physician for actions undertaken by a certified
physician's assistant and whether the plaintiff in a medical malpractice action must
Paetsch v. Spokane Dermatology Clinic
No. 89866-9
prove a physician-patient relationship in order to prevail in a medical malpractice suit
under chapter 7.70 RCW. 1 We do not opine on these issues because they were not
raised by the parties and are not presented here. 2
FACTS
I. Factual history
Plaintiff Phyllis Paetsch was referred to Spokane Dermatology Clinic for Botox
injections to smooth facial wrinkles. Paetsch had never heard of the clinic, had never
been there before, and was not aware of the staff or medical reputation of the clinic.
She made an appointment for treatment and was told that her appointment would be
with Dan Rhoads.
Spokane Dermatology Clinic is a professional services company owned solely
by Dr. William Werschler. The clinic also employed Dr. Scott Smith as a dermatologist
and three certified physician's assistants (PA-Cs): 3 Julia Bowan, Frank McCann, and
Dan Rhoads. The clinic's business card listed each individual by name and title.
1 We denied review of the petitioner's informed consent claim and therefore do not address it
in this opinion.
2 Phyllis Paetsch arguably preserved her challenge to the validity of the "exercise of judgment"
jury instruction, the propriety of which is affirmed in Fergen v. Sestero, No. 88819-1 (Wash.
Mar. 12, 2015). Assuming that Paetsch's challenge was preserved, Paetsch does not raise
any new claims that are distinguishable from those decided in Fergen. Thus, under Fergen,
Paetsch's challenge fails.
3 WAC 246-918-005(1): "'Certified physician assistant' means an individual who has
successfully completed an accredited and commission approved physician assistant program
and has passed the initial national boards examination administered by the National
Commission on Certification of Physician Assistants." Certified physician assistants' duties
and responsibilities are identical to those of physician's assistants; WAC 246-918-050
requires all physician assistants to be certified effective July 1, 1999.
2
Paetsch v. Spokane Dermatology Clinic
No. 89866-9
Paetsch arrived at the clinic for treatment on February 26, 2007. She was
presented with a medical history form and a patient profile form. This paperwork stated
that her doctor was "Wm. Philip Werschler, M.D." and asserted that "Dr. Werschler
and/or Dan Rhoads" had informed her of the risks of the procedure. Paetsch
completed and signed the forms, was escorted to her appointment room, and was told
that "the doctor" would be in soon.
Shortly thereafter, a man in scrubs entered and introduced himself as "Dan."
Rhoads injected Paetsch with both Botox and Restylane. He injected Restylane into
Paetsch's forehead, not knowing that the federal Food and Drug Administration did
not approve the use of Restylane in the forehead as it increased the risk of necrosis. 4
Pleased and excited by her appearance, Paetsch left the clinic.
Later that evening, Paetsch developed a headache. This headache continued
throughout the next several days. In addition, she noticed bruising and swelling on her
forehead. Three days after the procedure, Paetsch's eye swelled up until nearly
closed. She called Rhoads, who told her to ice it. Four days after surgery, her eyes
remained swollen shut and her forehead was covered in a green sheen. She
contacted Rhoads multiple times and twice visited him at the clinic as her symptoms
worsened. Rhoads misdiagnosed her condition as an infection and prescribed
antibiotics and anti-inflammatories to control it. These treatments were ineffective, and
Paetsch's condition continued to deteriorate.
4At trial, Dr. Jon Wilenski described necrosis as the death of cells due either to disease or to
a lack of blood supply. In this case, the necrosis was caused by a lack of blood supply.
3
Paetsch v. Spokane Dermatology Clinic
No. 89866-9
Paetsch sought treatment from her primary care provider, the Christ Clinic, on
March 9, 2007. The clinic properly diagnosed the condition as necrosis caused by the
use of Restylane in the forehead; the Restylane had expanded throughout the
forehead, cutting off the only flow of blood to the skin. This diagnosis was too late to
treat the condition, and the provider could only scrape the dead tissue from Paetsch's
face. The necrosis resulted in deep, permanent scarring to Paetsch's forehead.
Rhoads never consulted with a doctor during his treatment of Paetsch. While
Dr. Werschler owned the clinic and was listed as the plaintiff's doctor on her patient
profile form, he was not present at the clinic while Paetsch was a patient of the clinic.
Dr. Werschler never saw Paetsch, never advised Rhoads on her treatment or on her
condition, and never spoke with her.
II. Trial and appellate proceedings
Paetsch filed suit under RCW 7.70.030(1 ), .030(3), and .050 against Spokane
Dermatology Clinic and against Dr. Werschler personally for the failure to obtain her
informed consent to treatment and for medical malpractice by Dr. Werschler and Dan
Rhoads. Dr. Werschler moved for summary judgment of dismissal. He argued that he
did not owe Paetsch any duty because she was a patient of Spokane Dermatology
Clinic (and thus not his patient) and that he was not PA-C Rhoads' supervising
physician. The court denied the motion for summary judgment but clarified that the
only cause of action against Dr. Werschler was whether he established a physician-
patient relationship with Paetsch and whether he was thus directly negligent for failing
to intervene and provide follow-on care to Paetsch after her complications arose.
Paetsch does not challenge this summary judgment ruling on appeal.
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Paetsch v. Spokane Dermatology Clinic
No. 89866-9
During the trial, Paetsch presented evidence that Dr. Werschler presented
himself as her doctor through the use of consent forms, that he owed her a duty of
care, and that he breached that duty. Paetsch also presented evidence that as a PA-C,
Rhoads was an agent of the physician and that Dr. Werschler's failure to adequately
supervise Rhoads breached the standard of care. Dr. Werschler presented expert
testimony that the standard of care was not breached and that Dr. Smith, not Dr.
Werschler, was the supervising physician responsible for the actions of PA-C Rhoads.
After the close of evidence, the trial court granted Dr. Werschler's motion for
judgment as a matter of law under CR 50, dismissing Dr. Werschler from personal
liability on the ground that no jury could find that he breached a duty to Paetsch under
the evidence. Following this motion, Spokane Dermatology Clinic was the only
remaining named defendant.
Despite dismissing Dr. Werschler personally, the court instructed the jury that
the clinic could be held liable for Dr. Werschler's medical negligence, as he was an
employee of Spokane Dermatology Clinic. The jury was never told that Dr. Werschler
was dismissed as a defendant, and the majority of the jury instructions remained
unchanged. These instructions specifically framed the duty owed by Dr. Werschler as
a duty owed to "patients." No exception was taken to the court's framing of this duty.
The jury returned a verdict in favor of defendants, and the Court of Appeals
affirmed. Paetsch v. Spokane Dermatology Clinic, PS, noted at 178 Wn. App. 1032(2013). We granted review. Paetsch v. Spokane Dermatology Clinic PS, 180 Wn.2d
1020 (2014).
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Paetsch v. Spokane Dermatology Clinic
No. 89866-9
ANALYSIS
I. Standard of review
We review judgments as a matter of law de novo. Faust v. Albertson, 167 Wn.2d
531, 539 n:2, 222 P.3d 1208 (2009). Judgment as a matter of law is appropriate only
when no competent and substantial evidence exists to support a verdict. Guijosa v.
Wai-Mart Stores, Inc., 144 Wn.2d 907, 915, 32 P.3d 250 (2001 ). We construe all facts
and reasonable inferences in favor of the nonmoving party. Yakima Fruit & Cold
Storage Co. v. Cent. Heating & Plumbing Co., 81 Wn.2d 528, 530, 503 P.2d 108(1972). A judgment as a matter of law requires the court to conclude, "as a matter of
law, that there is no substantial evidence or reasonable inferences to sustain a verdict
for the nonmoving party." Indus. lndem. Co. of Nw. v. Kallevig, 114 Wn.2d 907, 915-
16, 792 P.2d 520 (1990). The existence of a physician's duty of care is a question of
law that we review de novo. Khung Thi Lam v. Global Med. Sys., Inc., 127 Wn. App.
657, 664, 111 P.3d 1258 (2005).
Legal errors in jury instructions are reviewed de novo, but an "erroneous
instruction is reversible error only if it prejudices a party." Anfinson v. FedEx Ground
Package Sys., Inc., 174 Wn.2d 851, 860, 281 P.3d 289 (2012). "Prejudice is presumed
if the instruction contains a clear misstatement of law; prejudice must be demonstrated
if the instruction is merely misleading." /d. The party challenging an instruction bears
the burden of establishing prejudice. Griffin v. W. RS, Inc., 143 Wn.2d 81, 91, 18 P.3d
558 (2001 ). The presumption of prejudice from a misstatement of law can be
overcome only on a showing that the error was harmless. See id. at 91-92.
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Paetsch v. Spokane Dermatology Clinic
No. 89866-9
II. The jury finding that Dr. Werschler was not negligent renders harmless any
potential error in the trial court's conclusion that there was no physician-patient
relationship as a matter of law
Washington has a substantial interest in ensuring the quality of its physicians,
maintaining a quality of care for its patients, and protecting health care providers from
frivolous claims. Lam, 127 Wn. App. at 668. To balance those aims, we recognize an
evolving common law doctrine of the duties owed by physicians and have a robust
statutory scheme that carefully controls the practice of medicine by health care
providers, physicians, and physician's assistants and defines liability for medical
malpractice. See id. at 664; see a/so ch. 18.100 RCW (establishment of professional
services corporations); RCW 18. 71A.050 (supervising physician and physician
assistant responsible for any practice of medicine performed by the physician
assistant); ch. 7.70 RCW (medical malpractice); ch. 246-918 WAC (medical quality
assurance of physician assistants). 5
The elements of medical negligence brought under RCW 7.70.030(1) are duty,
breach, causation, and harm. Pedroza v. Bryant, 101 Wn.2d 226, 228, 677 P.2d 166(1984). At common law, a plaintiff could not assert a cause of action for medical
negligence absent a physician-patient relationship. See Riste v. Gen. Elec. Co., 4 7
5 Rhoads' practice plan specified that Dr. Smith was his supervisor and sponsoring physician
and that Dr. Werschler was his alternate supervisor, in compliance with chapter 246-918
WAC. Dr. Smith was available at the clinic during each of Paetsch's visits to the clinic, and
his initials appear on all of her charts. Accordingly, Dr. Smith was responsible for Rhoads'
medical actions toward Paetsch, including the injection of Restylane into her forehead, as
well as the subsequent misdiagnosis and resultant injuries for the duration of her care at the
clinic. RCW 18.71 A.050. He was not named in the suit. Paetsch did not argue that Dr.
Werschler was responsible for the patient services provided by Rhoads as a nonsponsoring
physician who knowingly used PA-C Rhoads to perform patient services. WAC 246-918-
150(2).
7
Paetsch v. Spokane Dermatology Clinic
No. 89866-9
Wn.2d 680, 682, 289 P.2d 338 (1955) (finding no cause of action for medical
malpractice absent physician-patient relationship or treatment). While our courts have
recently acknowledged that the formation of the relationship is evolving beyond merely
considering whether a face-to-face relationship existed, see, e.g., Lam, 127 Wn. App.
at 664, the disposition of this case does not require us to resolve whether a physician-
patient relationship is required to give rise to a claim for medical malpractice. 6
In this case, after the close of evidence, the trial court dismissed Dr. Werschler
from individual liability. The jury was not told that he was dismissed, and the dismissal
did not retroactively affect the evidence Paetsch was able to present at trial. The trial
court instructed the jury:
Jury instruction 3: "Spokane Dermatology Clinic, P.S. is a corporation. A
corporation can only act through its officers and employees. Any act or
omission of an officer or employee is the act or omission of the
corporation."
Jury instruction 4: "At the time medical care and treatment was provided
to plaintiff, Dr. William Werschler and Daniel R. Rhoads[] were
employees and agents of defendant Spokane Dermatology Clinic, P.S.
Any act of either is the act or omission of Spokane Dermatology Clinic,
P.S."
Jury instruction 9: "A health care professional such as a physician or
certified physician's assistant owes to the patient a duty to comply with
6 Some courts in our state have opined that the physician-patient relationship is no longer an
element required to establish medical malpractice. See Eelbode v. Chec Med. Ctrs., Inc., 97
Wn. App. 462, 467, 984 P.2d 436 (1999) (stating that "claim of failure to follow the accepted
standard of care does not require a physician-patient relationship"); Judy v. Hanford Envtl.
Health Found., 106 Wn. App. 26,37-38,22 P.3d 81 (2001) ("chapter 7.70 RCW[] extends
malpractice liability beyond traditional physician-patient relationships"). We express no
opinion on this question.
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Paetsch v. Spokane Dermatology Clinic
No. 89866-9
the standard of care for one of the profession or class to which he
belongs .... " (Emphasis added.)Y
Having these instructions, the jury found:
Special verdict question 1: "Was there negligence by Defendant
Spokane Dermatology Clinic in the care and treatment of Plaintiff Phyllis
Paetsch?" Jury answer: "No."
Based on this verdict, we hold that it was not reversible error for the trial court
to dismiss Dr. Werschler from liability. Paetsch presented her case before a jury, and
she was able to argue that Dr. Werschler owed a duty of care. The jury had the
opportunity to consider these instructions and arguments, and the jury found that Dr.
Werschler and Rhoads were not negligent. Because Paetsch did not establish medical
negligence, it was not reversible error to dismiss Dr. Werschler from liability.
Ill. Paetsch's objection to the "exercise of judgment instruction" is controlled by
our decision in Fergen
Paetsch also argues that the trial court erred in giving the jury a variant on the
"exercise of judgment" jury instruction. Jury instruction 11 read:
A physician or certified physician's assistant is not liable for selecting one
of two or more alternative courses of treatment, if, in arriving at the
judgment to follow the particular course of treatment the physician or
certified physician's assistant exercised reasonable care and skill within
the standard of care the physician or certified physician's assistant was
obligated to follow,l 81
The propriety of this instruction is resolved against Paetsch by our decision in Fergen.
7 Paetsch did not object to jury instructions 3 or 4. Paetsch did object to jury instruction 9,
arguing that the proper standard of care is that expected by society. She did not object on the
ground that this duty was owed only to patients.
8 This is a pattern jury instruction. See 6 WASHINGTON PRACTICE: WASHINGTON PATTERN JURY
INSTRUCTIONS: CIVIL 105.08, at 612 (6th ed. 2012).
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Paetsch v. Spokane Dermatology Clinic
No. 89866-9
Fergen holds that it is within the trial court's discretion to give the exercise of
judgment instruction when the '"doctor is confronted with a choice among competing
therapeutic techniques or among medical diagnoses."' Slip op. at 14 (quoting Watson
v. Hockett, 107 Wn.2d 158, 165, 727 P.2d 669 (1986)). Paetsch argues that this
instruction is inappropriate in a case alleging medical misdiagnosis because there are
no competing, valid diagnoses in a misdiagnosis. However, Rhoads testified that he
considered both an infection and necrosis diagnosis and that he chose to treat the
patient first for an infection. He made a choice of treatment between two competing
medical diagnoses, and the trial court acted within its discretion in giving the exercise
of judgment instruction. See id. at 18-19.
Paetsch also asserts that the instruction should be abandoned because it is
harmful and improper. Fergen rejects this argument and holds that the instruction
helps juries to understand the complexity of the legal standard that they are being
asked to apply. /d. at 17. Paetsch does not raise an argument, distinguishable from
those raised in Fergen, that this instruction should be rejected. We therefore decline
Paetsch's invitation to abandon the use of the exercise of judgment instruction.
CONCLUSION
The trial court's instructions to the jury permitted Paetsch to argue her theory
of the case, and the jury found against her. Under Fergen, we also reject Paetsch's
challenge to the exercise of judgment jury instruction. Accordingly, we affirm the Court
of Appeals.
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Paetsch v. Spokane Dermatology Clinic
No. 89866-9
'
WE CONCUR.
11