OPINION
Appellee Oscar Padilla was struck by a
The question in this case is whether an expert report certifying merit, in which the Padillas’ medical expert alleged that Drs. Sandberg, Gonzalez, and their respective employers breached the standard of care, was- sufficient to allow the Padillas to survive a motion to dismiss. We agree with the trial court that the Padillas’ expert report was made in good faith and sufficiently demonstrated that the pleaded health care liability claims were- not wholly frivolous. As such, we affirm the trial court’s denial of the Appellants’ motions to strike and dismiss.
BACKGROUND
As required by the Texas Medical Liability Act, the Padillas-timely filed an expert report from Dr. Rathel Linwood “Skip” Nolan, a Mississippi-licensed, board certified infectious disease specialist and professor of medicine at the University of Mississippi Medical Center. In his report, Dr. Nolan stated that he had reviewed Padilla’s medical records and understood the course of Padilla’s treatment to be as follows.
On September 8, 2011, Padilla was struck on his motorcycle and taken to UMC with a broken leg and a de-gloved heel. At UMC:
[H]e underwent open reduction external fixation surgery of the compound, com-minuted fracture he suffered to his lower right leg. The procedure was a success and a ‘halo type’ fixation device [was] placed around the leg to hold the bones in place as the fracture healed.
Among other medications, UMC placed Mr. Padilla on IV antibiotics. These antibiotics included Gentamicin and Ce-fazolin (Ancef).[sic], Mr. Padilla received multiple doses of IV Gentamicin on September 8 and 9, 2011 and multiple doses of IV Cefazoline on September 9,12 and 13, 2011. At the time of his transfer from UMC on September 16, 2011, Mr. Padilla was prescribed IV Oefazolin for a 10 day period from September 12, 2011 through September 22, ■
UMC discharged Padilla into the care of Highlands for follow-up rehabilitative care on September 16, 2011. At that time, he had been .treated with daily wound care treatments and twice daily doses of Ancef. Padilla was in “fair” condition, and UMC
Highlands’ medical records show that Padilla received topical antibiotics, but not oral antibiotics or the IV antibiotics prescribed by UMC. He also received wound care treatment with a “wound vac.” On September 28, 2011, twelve days after being admitted to Highlands, Padilla was transferred to Kindred’s Triumph facility
There is no indication in the Triumph medical records that Triumph timely put in place or implemented a comprehensive. treatment plan for Mr. Padilla. The first, attempt to do so took place very shortly before Mr. Padilla’s release from Triumph. However, due to Mr. Padilla’s release, Triumph madе no attempt to implement the treatment plan. No effort was made to have him seen by a wound care specialist physicians or plastic surgeon prior to his return to UMC although his wound was high risk for development of an infection.
Padilla received home health care after leaving Triumph. Nine days after his discharge, on October 12, 2011, Padilla’s home health care service recommended he seek emergency room treatment for his leg. The emergency room physician at East El- Paso Physician’s Medical Center diagnosed a “serious infection in the leg and instructed Mr. Padilla to return to UMC for treatment.” Padilla returned to UMC, “where efforts were made to save his leg. However, due to the presence of gangrene Mr. Padilla’s leg could not be saved and on October 21, 2011, Mr. Padilla’s right leg was amputated below the knee.” '
Dr. Nolan’s expert report then contains five sections containing his findings, entitled “Standard of Care,” “Breach of the Standard of Care,” “Proximate Cause,” “Damages Proximately Caused by Breaches of the Applicable Standard of Care in the Treatment of Mr.-Padilla,” and “Summary.” In brief, Dr. Nolan accused Appellants of-failing to create a comprehensive treatment plan and failing to follow up. All Appellants objected to the report on various grounds, and requested' that the report be struck and the case dismissed with prejudice as a sanotion for the Padil-las’ failure to file a complaint expert report in good faith. After a hearing, the trial court denied Appellants’ request for relief. This appeal followed. We have interlocutory jurisdiction. Tbx.Civ.PRAc. & Rem. Code Ann. § 51.014(a)(8)(West Supp.2015).
DISCUSSION
The four Appellants in this case have collectively brought multiple issues before this Court, many with subparts. Appellants also, to a сertain extent, incorporate each'óther’s briefs by reference. Their complaints can be broadly grouped into attacks on Dr. Nolan’s qualifications and assertions that his report was brought in bad faith and is too vague to give them or the trial e'ourt adequate notice- of what conduct Padilla specifically cdntends was
A.
Standard of Review and Applicable Law
We review a trial court’s decision to dismiss a case on inadequate expert report grounds for abuse of discretion. Tenet Hosps., Ltd. v. Barajas,
A plaintiff who brings a health care liability claim must serve each defendant with “one or more expert reports, with a curriculum vitae of each expert listed in the report for each physician or health care provider against whom a liability claim is asserted” within 120 days of defеndant’s original answer. Tex.Civ.PRac. & .Rem.Code Ann. § 74.351(a)(West Supp. 2015). The filing of this expert report is procedurally required, and failure to timely file the report will result in dismissal of the claim with prejudice. Tex.Civ.PRAc. & Rem.Code Ann. § 74.351(b)(2). Where a timely-filed expert report is deficient, the trial court may grant one thirty-day extension to cure the deficiencies, unless it is objectively shown that the report was not filed in good faith, at which point, dismissal is required. Tex.Civ.PRAC. & Rem.Code Ann. § 74.351(c).
An expert must meet certain qualifications, discussed at length later in this opinion, in order to render an acceptable report. Tex.Civ.Prac. & Rem.Code Ann. § 74.351(r)(5). “A valid expert report has three elements: it must fairly summarize the applicable standard of care; it must explain how a physician or health care provider failed to meet that standard; and it must establish the causal relationship between the failure and the harm alleged.” Certified EMS, Inc. v. Potts,
“A court shall grant a motion challenging the adequacy of an expert report only if it appears to the court, after hearing, that the report does not represent an objective good faith effort to comply with the [statutory] definition of an expert report[.]” Tex.Civ.Prac. & Rem.Code Ann. § 74.351(7). A good-faith effort requires the report to contain sufficient information to (1) “inform the defendant of the specific conduct the plaintiff has called into question,” and (2) “provide a basis for the trial court to conclude that the claims have merit.” Jelinek v. Casas,
In reviewing the adequacy of an expert report, we bear in mind that in passing the TMLA, “[t]he Legislature’s goal was to deter baseless claims, not to block earnest ones.” Certified EMS, Inc.,
B.
Was the Padillas’ expert qualified?
As a threshold matter, we address challenges to Dr. Nolan’s qualifications brought solely by Appellant Dr. Sandberg in his brief. In Dr. Sandberg’s Issue One
At issue here are two sets of expert qualifications set by the Texas Medical Liability Act: those necessary to opine on a physician’s standard of care and breach,Tex.Civ.PRAC. & Rem.Code Ann. §§ 74.351(r)(5)(A) & 74.401(a)(West 2011), and those necessary to opine on causation. Tex.Civ.Prac. & Rem.Code . Ann. § 74.351(r)(5)(C).
(1) is practicing medicine at the time such testimony is given or wаs practicing medicine at the time the claim arose;
(2) has knowledge of accepted standards of medical care for the diagnosis, care, or treatment of the illness, injury, or condition involved in the claim; and
(3) is qualified on the basis of training or experience to offer ah expert opinion regarding those accepted standards of medical care. •
Tex.Civ.Prac. & Rem.Code Ann. § 74.401(a).
To opine on causation, a physician must be “otherwise qualified to render opinions on such causal relationship under the Texas Rules of Evidence.” Tex.Civ.Prac. & Rem.Code Ann. § 74.351(r)(5)(C).
Dr. Sandberg argues that Dr. Nolan is not qualified to serve as an expert in this case because neither his report nor his CV indicate that he has experience overseeing patients in a rehabilitation facility, and there is nothing to show he can speak to issues that would bear on a physical medicine or rehabilitatiоn specialist.. We note that an expert physician is not required to have experience practicing in a specific kind of facility to render an opinion, so long as his general work experience and knowledge establishes an ability to offer a sufficient opinion on proper practices. IHS Acquisition No. 131, Inc., v. Crowson,
“[T]he care and treatment of open wounds and the prevention of infection are subjects common to and equally recognized and developed in all fields of practice, thus any physician familiar with and experienced in the subject may testify as to the standard of care.” Legend Oaks—South San Antonio, L.L.C., v. Molina on Behalf of Estate of Rocamontes, No. 04-14-00289-CV,
Dr. Nolan’s report and C.V. are beyond sufficient to establish that the trial court did not abuse its discretion in implicitly determining he was qualified. Dr. Nolan received his medical degree from the University of Mississippi in 1982, he is certified as a diplomat in both internal medicine and infectious diseases, he is licensed to practice, medicine in Mississippi, is a member of multiple professional organizations, has multiple years of hospital experience, and has served as a professor of medicine. Nothing in the record casts doubt as to Dr. Nolan’s ability to provide ah opinion in this case.
Dr. Sandberg’s Issue One (Subpart Á) is overruled.
C.
Formal requirements
All Appellants challenge various formal aspects of Dr. Nolan’s report, complaining generally that he failed to parse out responsibility to each party individually, that he failed to set out the requisite information related to each element of negligence with sufficient specificity, and that the premises underlying his report are demonstrably flawed. We address these issues in partial reverse order, beginning with the purported evidentiary issue.
1.
Scope of Review
In Dr. Sandberg’s Issues One (Subpart C) and Two (adopted by reference into Highlands’ brief) and Dr. Gonzalez’s Issue A (Subpart One)(adopted by reference into Highlands’ and'Kindred’s briefs), Appellants maintain that in deciding whether Dr. Nolan’s expert report is adequate, we may look beyond the four corners 'of the report and consider extrinsic evidence, or at the very least the actual records he relied on, to determine if his opinion was worthy of credencе. They then assert that we should direct dismissal of this case because Padilla’s medical records conclusively contravene the main factual premises underlying Dr. Nolan’s report. For example, although Dr. Nolan attested that Appellants breached the standard of care by failing to follow up or consult with other doctors, Appellants point to medical report excerpts purportedly showing that Padilla met with two plastic surgeons at Kindred, that he had follow-up appointments scheduled with the plastic surgeons and an orthopedic surgeon, and that wound management was transferred fróm Dr. Gonzalez to one of the plastic surgeons, .thereby absolving him of liability.
In support of their contention that we should consider extrinsic evidence or medical reports, Appellants cite two memorandum opinions from our sister court in Beaumont. See Baptist Hosps. of Se. Tex. v. Carter, No. 09-08-067-CV,
The Beaumont cases regarding consideration of “parole evidence” are inconsistent' with this Court’s previous approach to scope of review at this stage of litigation. We have previously stated that “[a]s the ‘statute focuses' on what the report discusses, the only information relevant to the inquiry is within the four comers of the document.’ ” Barajas,
Appellants’ points on apparent conflicts between the medical records and the assumptions Dr. Nolan makes are'well-taken. But “[w]hether' an expert’s opinions are correct is an issue for summary judgment, not a'motion to dismiss under Chapter 74.” Tenet Hospitals, Ltd. v. Boada,
In showing restraint as to scope of review, we mirror the moves of the Texas Supreme Court, which post-Palacios has declined' to expand the scope of review to consider anything outside the scope of the four corners 'of the expert report. See Horizon/CMS Healthcare Corp., Inc. v. Fischer,
*246 Principal among the Legislature’s stated purposes in enacting the Medical Liability Act was decreasing the cost of health care liability claims without unduly restricting a claimant’s rights. But disagreements over the Act’s expert report requirement, which is merely intended to weed out frivolous claims early on, have resulted in protracted pretrial proceedings and multiple interlocutory appeals, threatening to defeat the Act’s purposе by increasing costs and delay that do nothing to advance claim resolution. [Footnotes omitted].
Loaisiga v. Cerda,
Adding an additional stage for the parties to argue about fact questions apart from summary judgment and trial would subvert the balance the Legislature struck between protecting doctors from the financial burden of defending against facially meritless allegations, and allowing an injured patient to pursue a colorable malpractice claim without having to marshal them proof three times before recovering damages. Id. We also question the wisdom of endorsing an expanded, extra-statutory scope of appellate review of expert report sufficiency given that a plaintiff is largely barred from conducting discovery until the expert report is deemed statutorily sufficient. See Tex.Civ.PRAc. & Rem. Code Ann. § 74.351(s)(setting out discovery restriсtions); In re Lumsden,
In short, we will not open the door to more litigation absent further legislative directive. Precedent dictates that we look only to the text of the report to determine its adequacy, and exрanded factual review in the expert report stage is inconsistent with the plain language of the statute and with the stated intent of the Legislature to reduce costs and simplify procedures.
Dr. Sandberg’s Issues One (Subpart C) and Two and Dr. Gonzalez’s Issue A (Sub-part One) and those portions of Highlands’ Issue One and Kindred’s Issue One incorporating those arguments by reference are overruled.
2.
Standard of Care and Breach
Having established that we must only look to the four corners of the expert report in assessing sufficiency, we next turn to Appellants’ complaints that various aspects of Dr. Nolan’s report are inadequate or conclusory.
i.
Proper Parties
In Issues Two and Three of its brief, Kindred claims that Dr. Nolan’s ex
Even if this were not the case, we find that Dr. Nolan sufficiently implicated Kindred by specifying that all references he made to Dr. Gоnzalez in his report also referred to Kindred. This incorporation by reference is sufficient to bring Kindred within the scope of parties encompassed by Dr. Nolan’s report. See In re Stacy K. Boone, P.A.,
Kindred’s Issues Two and Three are overruled.
ii
Applying a Collective Standard of Care to All Parties
All Appellants
“When a plaintiff sues more than one physician, the expert report, in order to constitute a good faith effort, must set forth the standard of care applicable to each physician and explain the causal relationship between each physician’s individual acts and the injury.” Clapp v. Perez,
Appellants cite Clapp as proof that Dr. Nolan’s assignment of a collective standard of care to both doctors is legally inadequate. Clapp is distinguishable. In that case, a woman aspirated during an emergency surgery aimed at correcting complications from a previous gastric bypass and eventually died. Id. at 257. Her heirs sued the surgeon and the anesthesiologist who performed the surgery. Id. The plaintiffs’ expert stated in his report that the standard of care required certain measures be taken, such as the insertion of a nasal-gastric tube, in order to prevent aspiration, but the report never made clear whether that standard applied to the surgeon, the anesthesiologist, or both. Id. at 259-60. Because the report never made clear to which physician the standard of care applied, because the report never delineated why two doctors with different roles in the surgery owed the same standard of care, and because it was unclear
In contrast to Clapp, which dealt with the divided 'responsibilities of two specialist physicians performing separate tasks in the context of a surgical procedure, here, Dr. Nolan’s report goes toward the general issue of wound care and infection prevention. As we noted previously, both Wound care and infection prevention are subjects common to all fields of medical practice. Legend Oaks—South San Antonio, L.L.C.,
Dr. Nolan’s grouping of Drs. Sandberg and Gonzalez under the same standard of care meets the requirements we set out in Clapp for collectivization. Reversal on that ground would be improper.
Dr. Sandberg’s Issue. One (Subpart E) and Dr. Gonzalez’s Issue C are overruled. Highlands’ Issue One and Kindred’s Issue One incorporating those arguments by reference are also overruled.:
in.
Specificity of Standard of Care , and Breach Allegations
All Appellants
“Identifying the standard of care is critical: Whether a defendant breached his or her duty to a patient cannot be determined absent specific information about what the defendant should have done differently.” Palacios,
Appellants generally limit' their discussion of the stаndard of care to the bullet point summaries Dr. Nolan made in his report under the section subtitled “Standard of Care,” asserting that the following statements, standing alone, are legally insufficient to set out the standard of care and the coordinate breaches (bolding and italics in original):
STANDARD OF CARE:
• Mr. Padilla’s attending physicians, Dr. Sandberg and Dr. Gonzalez had the final responsibility, legally and otherwise, for Mr. Padilla’s care — During all of these time periods, Mr.*249 Padilla had a large, open, unhealed wound on hi^ heel with a high risk of developing a very serious infection that could rpsult in the loss of his leg.
• The applicable standard of care as to Dr. Sandberg and Dr. Gonzalez in the' treatment of Mr. Padilla, as ordinary reasonably prudent attending physicians under similar circumstances, requires that the patient be protected from developing infections, especially under high risk conditions.
• The applicаble standard of care as to Dr. Sandberg and Dr. Gonzalez in the treatment of Mr. Padilla, as ordinary reasonably prudent attending physicians under similar circumstances, requires than an adequate and comprehensive plan" of care must be established and implemented oh a timely basis to meet the patient’s anticipated needs, including for the •prevention of infection: and for the timely diagnosis, and treatment of infection.
• The applicable standard of care as to Dr. Sandberg and Dr. Gonzalez in the treatment of Mr. Padilla, as ordinary reasonably prudent attending physicians under .similar circumstances, requires that patients with large, open, unhealed wounds who are at high risk of developing a very serious limb-threatening infection, be closely monitored and followed with urgency. .
• The applicable standard of care as to Dr. Sandberg and Dr. Gonzalez in the treatmеnt of Mr. Padilla, as ordinary reasonably prudent attending physicians under - similar circumstances, requires that patients with large, open,- unhealed: wounds who are at high risk of-developing-a very serious limb-threatening infection, not be -sent home but rather be treated promptly and effectively in an appropriate medical facility, or at a minimum be followed up on very closely and with urgency.
• -To facilitate the healing of the de- ■ gloving injury Mr. Padilla required a comprehensive plan to address said . injury including local care and further surgery to close the wound.
BREACH OF THE STANDARD OF CARE:
Dr. Sandberg and Dr. González breached the applicable standard of care in their treatment of Mr. Padilla—a patient with a large, open, unhealed wound at high risk of developing a limb-threatening infection—in numerous ways, including the following:
• Failing to accurately assess Mr. Padilla’s condition and address Mr. Padilla’s problems аnd risks;
• Failing to take adequate and reasonable .measures to protect Mr. Padilla ..from developing infection
• Failing to tipiely establish and imple- , ment an adequate and .comprehensive plan of care to meet Mr. Padilla’s medical needs, including for the .-prevention of infection and for the timely diagnosis,, and treatment of infection;
• Failing to closely monitor Mr. Padilla .for infection and follow up on Mr. . Padilla’s treatment with urgency;
• Failing to refer Mr, Padilla to .an appropriate medical facility for prompt and effective treatment of his serious, limb-threatening condition; and
• In the case of Dr. Gonzales [sic] and Triumph, ‘dumping' Mr. Padilla from - further medical treatment and sending him home rather than assuring that Mr. Padilla received prompt and*250 effective treatment in an appropriate medical facility.
While Appellants limit their discussion to those bullet points, we cannot similarly limit our review. As with any legal text, in determining whether an expеrt report sets out the applicable standard of care with sufficient detail, we consider all provisions of the entire document, and not merely the portion contained under a subheading titled “Standard of Care.” See Trisun Healthcare, L.L.C. v. Lopez, No. 13-13-00238-CV,
Assuming without 'deciding that the bullet' point summaries standing alone are legally inadequate, other portions of the report provide a gloss on Dr. Nolan’s conclusions and illuminate the reader as to what he meant in the summary section. For example, Dr. Nolan states:
Without such a skin covering it is likely that the underlying tissue will become infected if measures are not taken. These measures consist of formulating a plan on how to manage the exposed tissue to prevent infection and how to facilitate the ultimate covering of the exposed area with skin. This is often accomplished by skin grafting. Such a plan is formulated by a plastic surgeon or a physician specializing in wound care. The standard of care required his physicians at Highlands to involve such a specialist in Mr. Padilla’s care to formulate a plan and follow Mr. Padilla’s progress to assure the plan was succeeding. This did not occur. [Emphasis added].
In our review of case law regarding specificity and what constitutes a “fair summary” of the standard of care, we have found wide variation as to what is considered adequate. Some cases require a great deal of detail; others do not. Beyond admonitions that the experts provide a summary that is “fair,” “informal,” and not as stringent as that required for summary judgment, the appellate courts have not articulate a clear standard, and appear to approach these situations on a case-by-case basis.
We believe the report here is sufficiently detailed as to the standard of care so that the Padillas may proceed with suit for three main reasons. First, again, this case involves the treatment оf infection and wounds, which are subjects common to all areas of medicine, and it involves an alleged complete failure to coordinate a treatment plan between doctors. As such, the level of technical detail needed to allow a trial court to determine if a case is frivolous is less than that needed to determine if a suit involving a highly complex procedure like a surgery is frivolous. The Palacios standard, properly understood, is flexible, and the level of detail needed to provide a “fair summary” so that the trial judge can determine if a case is frivolous will necessarily vary depending on the context in which an act occurred or the technical knowledge needed to understand and
Second, when the report is read as a whole, the standard of care goes beyond general, conclusory statements that a doctor should “follow up” or “consult” with another physician. See Regent Health Care,
Third, our sister court in Corpus Christi has addressed the sufficiency of an expert report in a wound case care similar to this one, in which the plaintiffs alleged that failure to treat an open - wound on the decedent’s hand led to amputation. While Appellants have cited numerous examples of expert reports deemed insufficient, those- cases have facts that are not as similar to this case as those presented in Trisun Healthcare, L.L.C. v. Lopez. In that case, the heirs of a patient who died provided an expert report that, inter alia, alleged that a physician’s failure to follow up on a patient’s open wound and provide adequate care led to the amputation of her hand. See generally,
Trisun bolsters our conclusion that the level of detail Dr. Nolan gave in this case is sufficient to provide Appellants with notice of what the standard of care was. Only Appellant Highlands filed a reply brief, and only Highlands addressed the effect of Trisun. In its reply brief, Highlands contends that Trisun Healthcare is distinguishable because there, the expert stated that the patient should have received an order .for hyperbaric wound treatment, been placed on an air mattress with padding, and repositioned every two hours. See Trisun Healthcare L.L.C.,
Based - on our review of the report, Dr. Nolan’s statements as to the standard of care and breach were adequate. We decline to' reverse the' trial court on that basis.
Dr. Gonzalez’s Issue A, Dr. Sandberg’s Issue One (Subpart B), and those portions of Kindred’s Issue One' and Highlands’ Issue One incorporating those arguments' by reference aré overruled. ■
"2.
Proximate Cause
Finally, we turn to the issue of causation. All Appellants
“A causal relationship is established by proof that the negligent act or omission was a substantial factor in bringing about' the harm, and that, absent this act or omission, the harm would not have occurred.” Barajas,
An expert’s conclusion that % medical probability' one event caused another differs little, without an explanation tying the conclusion to the facts, from an ipse dixit, which we have consistently criticized.... Instead, the expert must go further and explain, to a reasonable degree, how and why the breach caused the injury based on the facts presented. While we have said that no ‘magical words’ need be used to meet the good-faith requirement, mere invocation of the phrase ‘medical probability’ is likewise no guarantee that the report will be found adequate.
Jelinek v. Casas,
Appellants are correct that in reading an expert report for causation, the Cоurt cannot imply or infer a conclusion on causation if the expert never actually articulates one. Barajas,
Here, Dr. Nolan’s causation assessment is not conclusory. Instead, he analytically links the negligence to the injury step-by-step. He states “[t]he negligent care provided by Dr. Sandberg and Dr. Gonzalez including the failure to timely establish an appropriate treatment plan which provided for infection prevention, resulting in the development and/or progression of the infection.” He also states' “[t]he aforementioned failures of Dr. Sandberg and Dr.
We do not see how Dr. Nolan’s causation statements were vague, nor do we find a causal break that would fail to link alleged negligent acts to Padilla’s injury. The language at bar is at the same level of specificity as language upheld by our sister courts in other wound care and infection progression cases. See generally Spitzer v. Berry,
Dr. Gonzaléz’s Issue B, Dr. Sandberg’s Issue One (Subpart D) and those portions of Highlands’ Issue One and Kindred’s Issue One incorporating' thosé arguments by reference are overruled.
CONCLUSION
■ None of Appellants’ grounds for reversal are meritorious. We overrule all appellate issues. The judgment of the trial court is affirmed.
Larsen, Senior Judge (Sitting by Assignment)
Notes
. We take this background information from the petition and the expert report in issue, noting that the factual claims have not yet been proven. Tenet Hosps., Ltd. v. Bernal,
. The record shows thát the parties 'use Kindred and Triumph interchangeably.
. As explained below, becаuse the hospitals are being sued under agency liability theories, and because -neither hospital raises' any substantive appellate points stating the Padillas were required to articulate a separate stan-. dard of care as to them, a discussion of the expert qualifications for opining on health care provider standards of care is not at issue here.
. Because we hold that review of the medical records is impermissible at this stage of litigation, we need not address any arguments related to the propriety of or preservation issues associated with Appellants’ proffer of evidence.
. Dr. Sandberg’s Issue One (Subpart E), Dr. Gonzalez’s Issue C, Highlands’ Issue One (in part), and Kindred’s Issue One incorporating other brief’s arguments by references.
. Dr. Gonzalez’s Issue A, Dr. Sandberg’s Issue One (Subpart E), Highlands’ Issue One, and Kindred’s Issue One incorporating those arguments by reference.
. Dr. Sandberg’s Issue One (Subpart D), Dr. Gonzalez’s-Issue B; incorporated into Highlands’ Issue One and Kindred’s Issue One by reference.