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Court Reverses Trial Court Decision that Nephrology and Urology Are Not Related Medical Specialties

Red bandaid.jpgUnder Maryland law, one of the requirements for taking a medical malpractice case to court is that a qualified health professional in the same or a related specialty must state that the standard of care has been violated. Maryland's courts continue to grapple with the question of what medical specialties are related. In Donnell Nance v. David A. Gordon, et al., the Court of Special Appeals recently held that nephrology and urology are related specialties.

Donnell Nance filed a complaint in circuit court in May 2009. Nance said negligent care in 2005 caused his kidney failure. Nance first went to Sinai Hospital in Baltimore in 2005, complaining of blood in his urine. Tests taken at the hospital confirmed that blood and protein were present in his urine. Nance was prescribed antibiotics for what was diagnosed as a urinary tract infection and sent home. He returned the next month. Two years later, he went back to the emergency room, complaining that he was splitting up blood. Tests revealed that his kidneys had shut down, while a renal biopsy revealed that he had a late-stage kidney disease requiring hemodialysis three times a week. Doctors concluded that the kidney disease had progressed too long without treatment.

Nance sued David A. Gordon, M.D., Larry Waskow, P.A. and Chesapeake Urology Associates, P.A. Gordon is a board-certified urologist, Waskow is a urology physician's assistant and Chesapeake is the professional association employing both Gordon and Waskow.

Before the lawsuit, however, Nance filed a Statement of Claim with the Health Care Alternative Dispute Resolution Office (HCADRO). As required under Maryland law, Nance filed a Certificate of Qualified Expert from Stanley C. Jordan, M.D. Jordan said that the doctors deviated from the standard of care by failing to include nephritis on the differential diagnosis for Nance when he went to the emergency room and that those deviations caused Nance's injuries. Nance obtained a waiver of arbitration. HCADRO issued an Order of Transfer from its office to the circuit court.

The doctors asked the court to throw the case out, arguing that Jordan was not a qualified expert under the Health Care Malpractice Claims Act (Act) because Dr. Jordan, a board certified nephrologist, was not in a related specialty. The Circuit Court for Baltimore City agreed.

Urology involves the study, diagnosis and treatment of diseases of the genitourinary tract. Nephrology involves medical diseases of the kidneys. Nephritis, the condition that Nance developed, is an inflammation of the kidneys.

But, the appeals court disagreed with the trial court, reversing the decision and sending the case back to that court.

A certifying or testifying expert witness in a medical malpractice case does not have to be the same kind of health care provider as the defendant. An expert need only satisfy certain professional qualifications in the same or a related specialty to submit a valid certificate.

Nance contended that Jordan was qualified under the Act to express an opinion. Nance argued that that Jordan's certificate, supporting report and deposition testimony established that nephrology and urology are related specialties because nephrology and urology share the kidney as a common focus.

In response, the defendant doctors argued that the plain language of the Act and the court's earlier decided cases demonstrated that, for Dr. Jordan's certificate to have been valid, Nance had to show that Jordan's specialty -- pediatric nephrology -- overlapped with the defendant healthcare providers specialty - urology -- with regard to the diagnosis of nephritis in the emergency room setting. The defendants claimed that the evidence before the circuit court showed that no such overlap existed because nephrologists diagnose and treat nephritis, while urologists do not.

The dispute centers on whether nephrology and urology are related fields under the circumstances of this case, the court observed. The word "related" embraces board certification specialties that, in the context of the treatment or procedure in a given case, overlap, the court said. Where medical specialties overlap with regard to a particular treatment or procedure, there also is an overlap of knowledge of the treatments and procedures among those health chare providers certified in either specialty, the court pointed out, relying on an earlier decided case.

Jordan is board certified in nephrology, pediatric nephrology, pediatrics and diagnostic laboratory immunology.

The court agreed that nephrology and urology shared a common focus on kidneys. But, merely sharing an organ isn't enough by itself to compel the conclusion that nephrology and urology are related specialties for purposes of qualifying Jordan as an expert under the Act. "We conclude that nephrology and urology are 'related' in the case . . . because the treatment rendered (a differential diagnosis at the time the patient presents to the emergency room) is performed by both specialists (both Dr. Jordan and appellees)," the court said.

A differential diagnosis requires the physician to consider the diseases that are possibly responsible for the patient's illness. Thus, Dr. Jordan opined, in effect, that the defendants breached the standard of care by failing to consider nephritis as a disease that was "possibly responsible" for the blood and protein in Nance's urine, the court said.

The record revealed that Dr. Jordan participated in the same kinds of "on call services for emergency departments" as the treatment Nance received from the defendants. The court also noted that Dr. Jordan's testimony revealed that he had experience with consults for emergency room patients with medical issues of the kidney and with urinary tract obstructions and surgical kidney diseases. In other words, the court said, Dr. Jordan is familiar with the medical conditions and diseases normally treated by nephrologists and urologists that may be presented in an emergency room setting.

Most significantly, the court said, Dr. Jordan testified about his familiarity with emergency room consults for patients who presented with blood and protein in the urine. The defendants, however, argued that there was no overlap because nephrologists diagnose and treat nephritis and urologists do not. "This argument is without merit, because the particular procedure or treatment at issue in the instant case is the preparation of a differential diagnosis from an emergency room consult involving a patient who presents with blood and protein in his or her urine and not the final diagnosis and treatment of nephritis," the court said.

As a result, the court concluded that, under the circumstances of the case, nephrology and urology are related specialties under the act and that the trial court made a mistake when it ruled that Dr. Jordan was not qualified to testify as an expert.

Baltimore, Maryland-based Belsky, Weinberg & Horowitz has been fighting for clients who have been the victims of medical malpractice, negligence and personal injury for many years. Call us at 410-234-0100 or email us for a free consultation and let us help you.

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