Frаnk Joyce and Kelly Anne Joyce appeal from an order entered in the Court of Common Pleas of Philadelphia County granting appellees’ motion for nonsuit. We reverse.
While working on the roof of the Franklin Mills Mall in Philadelphia, Frank Joyce slipped and injured his right knee. After experiencing frequent buckling of the knee, Joyce sought care at Franklin Hospital. At the hospital his knee was placed in an immobilizer and he was instructed to see Dr. Randall Smith, an orthopedic surgeon. Dr. Smith provided care to Joyce, but was unable to make a conclusive diagnosis. He did, however, instruct Joyce to continue to wear the immobilizer and prescribe a regimen of physical therapy treatment which he recommended should be undertaken at Boulevard Physical Therapy and Rehabilitation, P.C. (“Boulevard”). Although Dr. Smith noted in Mr. Joyce’s medical file that he was not to remove the immobilizer, this file was not sent to Boulevard. Moreover, the prescription sheet neither mentioned a diagnosis, nor did it contain an instruction prohibiting a physical therapist from removing the knee immobilizer or an instruction to the physical therapists at Boulevard to contact him (Dr. Smith) prior to removing the immobilizer from Joyce’s knee.
Approximately one week later, Joyce commencеd his treatment at Boulevard under the supervision of physical therapist Karen Gentry. Unaware of any instructions to the contrary, Ms. Gently removed the immobilizer during treatment and replaced it at its conclusion. After his third treatment, Ms. Gentry instructed Joyce to refrain from wearing the immobilizer altogether, because she felt that his knee was improving. Upon arriving home from his third treatment, and eager to further the progress which he thought he was making, Joyce performed exercises without his immobilizer as directed by Ms. Gentry. During the exercises, however, his knee buckled, and he fell, striking his head and right knee upon the floor. Joyce was subsequently taken to the hospital
Joyce initiated a lawsuit against Dr. Smith and Boulevard alleging that Dr. Smith was negligent in failing to contact Boulevard either in writing or orally to explain that Joyce was required to wear the immobilizer until further notice.
1.Did the trial court not [sic] err in granting the motion for nonsuit after the defendants had marked and introduced exhibits raising elements of their defenses in the plaintiffs’ case-in-ehief, thereby eliminating the court’s ability to consider only the plaintiffs’ evidence for purposes of non-suit?
2. Did the trial court not [sic] err when, after plaintiffs’ expert orthopedic surgeon explicitly testified that, based on the standard of care in the community as known to him through his years of experience in the specialty, the defendant breached the standard of care, the court nonetheless struck all of the expert’s testimony as being the expert’s personal opinion, even after the expert expressly stated that his opinion was not mere personal opinion?
3. Did the trial court not [sic] err when it required that written medical literature must be relied on as a basis for a medical expert’s opinion that a defendant surgeon breached the standard of care?
4. Did the trial court not [sic] err when it dеtermined that the doctor-patient relationship between the defendant and the plaintiff was severed when the doctor ordered the plaintiff to be given physical therapy, when the doctor negligently omitted instructions to the therapist and the therapist was working under the doctor’s orders?
5. Did the trial court not [sic] err in refusing to permit plaintiffs to present expert testimony on causation, although plaintiffs in pretrial expert discovery set forth the opinion that the negligence of defendants caused plaintiff’s injuries?
Our standard of review in determining the propriety of an entry of nonsuit is that it is proper only if the factfinder, viewing all the evidence in favor of the plaintiff, could not reasonably conclude that the essential elements of a cause of action have been established. Biddle v. Johnsonbaugh,
The Joyces first contend that the trial court could not properly enter a nonsuit, because the appellees had already entered evidence before the motion for nonsuit was brought. Specifically, the Joyces point to the appellees’ entrance into evidence of their affirmative defense, as well as certain exhibits during the cross-examinations of Dr. Ratner and Dr. Hume, as preclusive on the trial court from entering a nonsuit.
Pennsylvania Rule of Civil Procedure 230.1 governs compulsory nonsuits аt trial. The Rule states, “In a case involving only one defendant, at the close of plaintiffs case on liability and before any evidence on behalf of the defendant has been introduced ... the court ... may enter a non-suit.” Pa.R.C.P. 230.1, 42 Pa.C.S.A. (emphasis added). Courts have applied Rule 230.1 strictly, and have held that they are without power to grant nonsuits where a defendant has offered evidence either during or immediately after plaintiffs case. See Atlantic Richfield Co. v. Razumic,
Here, appellees offered defense exhibits during appellant’s case and the trial court had the exhibits before it when it evaluated the motion for compulsory nonsuit. The express language of Rule 230.1 and the above-cited authorities compel us to conclude that the trial court was not empowered to enter a nonsuit because appellee had offered evidence. Where, however, a court enters a nonsuit in violation of these rules, reversal is not mandated if the admission of some defense evidence is harmless error. See Bowser v. Lee Hospital,
In Storm, supra, a case procedurally identical to the present case, our court found that although the trial court had erred in entering a nonsuit, since the defense had entered exhibits during the plaintiffs case, that such an error was harmless in light of the fact that plaintiffs had failed to offer the proper standard of care. Storm,
Our paramount objective is, therefore, determining whether the trial court’s error in entering a nonsuit was reversible or merely harmless error. Bowser, supra; Storm, supra. In determining whether the entry of nonsuit was harmless, we must first ascertain if the trial court properly concluded that the Joyces failed to establish the essential element of standard of care.
The trial court found that the Joyces had failed to offer any competent evidence in the form of expert testimony as to the proper standard of care under which Dr. Smith should have conducted himself and in what way his actions deviated from that standard. Thus, the trial court concluded that as a matter of law, the Joyces had failed to meet their burden of proof, warranting the entry of a nonsuit. The Pennsylvania Supreme Court in Donaldson v. Maffucci,
The standard of care required of a physician or surgeon is well-settled_ A physician who is not a specialist is required to possess and employ in the treatment of a patient the skill and knowledge usually possessed by physicians in the same or a similar locality, giving due regard to the advanced state of the profession at the time of the treatment; and in employing the required skill and knowledge he is also required to exercise the care and judgment of a reasonable man. However, a physician or surgeon is not bound to employ any particular mode of treatment of a patient, and, where among physicians or surgeons of ordinary skill and learning more than one method of treatment is recognized as propеr, it is not negligence for the physician or surgeon to adopt either of such methods.
Donaldson,
Generally, a plaintiff must introduce expert testimony to show that a defendant-doctor’s conduct varied from accepted medical practice. Brannan v. Lankenau Hospital,
The trial court concluded that the expert testimony provided by Dr. Ratner did not address the course of conduct the average orthopedic surgeon would undertake during the course of Mr. Joyce’s treatment, but rather what Dr. Ratner personally thought was the standard of care. The trial court and appellees rely heavily upon Maurer, supra, in supporting this conclusion. We believe that this reliance upon Maurer is misplaced.
In Maurer, the plaintiff suffered a severe brain injury which left him comatose and hospitalized at the Hospital of the University of Pennsylvania (HUP) for approximately six months. Two months after his arrival at HUP, plaintiff awoke and was treated by one of the defendants, a neurosurgeon. During his stay, plaintiff experienced heterotropic ossification, a disorder that causes a person’s joints to harden, rendering them inflexible. Plaintiff also developed a decubitis ulcer, commonly known as a bedsore. Plaintiff filed suit against the neurosurgeon alleging that his failure to administer a drug entitled Didronel to the plaintiff caused the hardening of the joints, as the medicine would have prevented the disorder. Plaintiff also filed suit against his doctor in charge of physical therapy for failure to provide more frequent exercise, thus, permitting his joints to harden more than they should have. Both doctors were found equally liable. An appeal followed in which our court, sitting en banc, held that plaintiff’s expert was unable to articulate a standard of сare with regard to the administering of Didronel. Maurer,
Presently, the trial court read Maurer as standing for the proposition that an expert’s personal oрinion as to the standard of care is improper. Specifically, the trial court reasoned that because the plaintiff’s expert testified in the first person when articulating the standard of care, and because he did not provide concrete support for his opinion, that he was testifying as to his personal opinion, rather than the objective standard of care articulated in Donaldson and its progeny.
While we agree that the standard of care is objective, we cannot agree that merely because some of Dr. Ratneris testimony was in the first person transforms his elicitation of the standard of care into his personal opinion. We explained in Maurer that merely because the expert elicited the standard of care in the first person does not equate to the rendering of a personal opinion. Id, at 518-20,
In the present ease, an orthopedic surgeon testified to the applicable standard of care in referring patients to physical therapists. The Joyces’ expert testified that Dr. Smith either should have discussed Mr. Joyce’s case with the physical therapist or specified written instructions on the referral sheet. This is not a matter, as in Maurer, of whether to administer an experimental medication. Rather, this is simply a matter of routine procedure. Most, if not all orthopedic surgeons prescribe patients to physical therapists. It is well within the knowledge of an orthopedic surgeon, such as Dr. Ratner, to articulate an opinion upon the standard of care when referring patients to physical therapists. We do not feel that it was necessary to have Dr. Ratner cite to treatises and medical periodicals to support his articulation of the standard of care. As explained by our supreme court in Collins v. Hand,
The trial court reasons, hоwever, that as a matter of law, an orthopedic surgeon’s duty to his patient is severed upon the transcription of the prescription for physical therapy. Accordingly, the trial court explains, the entry of non-suit was nonetheless proper. We disagree.
Because a physical therapist is akin to a pharmacist in the eyes of the law, our conclusion is guided by the dynamics surrounding the physician / pharmacist relationship. See Leidy v. Deseret Enterprises, Inc.,
We think that the relationship between an orthopedic surgeon and a physical therapist is analogous to the relationship between a physician and a pharmacist. When an orthopedic surgeon writes a prescription for his or her patient to see a physical therapist, that surgeon is charged with the same responsibilities as if he or she were writing a prescription for medication. Likewise, when a physical therapist dispenses the prescription, that physical therapist is charged with exercising due care. We will not condone the negligent conduct of one as an escape valve for the negligent conduct of the other. If we were to conclude that an orthopedic surgeon could wash his or her hands of any patient merely by asserting that he had sent his patient to a physical therapist, we would
Having concluded that Dr. Ratner properly testified as to an orthopedic surgeon’s standard of care, we must now address appellees’ claim that nonsuit was nonetheless proper because the Joyces have failed to satisfy their burden of proof on the essential issue of causation.
As previously notеd, a plaintiff must, in addition to proving that the defendant breached a duty owed to the plaintiff, establish that the breach was the proximate cause of bringing about the harm suffered by the plaintiff. Mitzelfelt, supra. Typically, in medical malpractice actions, causal connection between the care provided by a physician and the resulting injury is not amenable to proof to such a reasonable degree of medical certainty. Poleri,
Once a patient-plaintiff shows that a physician-defendant’s negligence increased thе risk of harm and that harm actually occurred, sufficient evidence has been offered to submit the case to a jury.
Mitzelfelt,
In order to complete the causal link, however, the Joyces were also required to prove that the removal of the immobilizer increased the risk that Mr. Joyce’s knee would buckle, thereby causing Mr. Joyce’s injury, severe chondromalacia. See Mitzelfelt, supra. At trial, the Joyces were precluded from questioning their experts, Doctors Ratner and Hume,
As previously discussed, where the events and circumstances of a malpractice action are beyond the knowledge of the average lay person, the plaintiff is required to present expert testimony that defendant’s negligence was a substantial factor in causing the harm suffered. Mitzelfelt,
Order reversed. Case remanded for a new trial. Jurisdiction relinquished.
Notes
. Irving Ratner, M.D. testified that Chondroma-lacia is the deterioration of the cartilage in the kneecap in which cartilage on the underside of the kneecap wears away to the point where the cap grinds against the knee joint. There are four stages of chondromalacia ranging from mild ("stage one”) to post-traumatic ("stage four”). Following his second fall Joyce was diagnosed with stage four chonrdomalacia, the effects of which include swelling and inflammation of the knee and a weakening of the thigh muscle.
. Defendants Gentry and Boulevard settled with the Joyces prior to trial for $20,000.00.
. The requisite proof required for a medical malpractice action is well settled.
In order to establish a prima facie case of malpractice, plaintiff must establish (1) a duty
Mitzelfelt v. Kamrin,
. We stated although the testimony in Maurer was articulated in the first person, when looking at the testimony as a whole, including the questions put to the expert that it was reasonable to conclude that the expert was testifying objectively. Maurer,
. We also disagree with the trial court's reasoning that because excerpts of Dr. Ratner's testimony are in the first person he merely gave his personal standard of care. As previously mentioned, we are obliged to examine an expert’s testimony as a whole, not piecemeal. See Maurer, supra. Upon examination of Dr. Ratner’s expert testimony in its entirety, it is clear that he understood the concept of standard of care аnd that he articulated the standard based upon that correct understanding.
.For these reasons we decline to characterize the relationship between a physical therapist and an orthopedic surgeon as one between a general physician and a specialist. Appellees explain that, generally, physicians cannot be held accountable for referring their patients to specialists or for other physicians covering for them. See Strain v. Ferroni,
The trial court reasons that it is impossible to hold a physician accountable for independent actions taken by a physical therapist. Utilizing the trial court's logic, then, a physician who writes an incomplete prescription for medication and upon which a pharmacist makes assumptions and fills without contacting the physician, would he releasеd from liability because of the pharmacist’s independent actions. As we explained in Riff, supra, such a result is unacceptable.
. Because it is well-settled that we may affirm an order of a trial court on any grounds, in the interests of judicial economy, we will address appellant’s causation issue.
. Appellees also assert that the action of Ms. Gentry in removing the immobilizer from Mr. Joyce’s knee was an independent intervening cause, and therefore, Dr. Smith’s actions could not have proximately caused Mr. Joyce’s injury. In light of our conclusion concerning an orthopedic surgeon’s relationship with a physical therapist, however, this argument is meritless.
. As with standard of care, рlaintiffs must usually satisfy their causation burden with expert testimony. See Cohen, supra. Such testimony must, of course, be stated with a reasonable degree of medical certainty. Id.
. Dr. Hume's testimony was elicited via a videotaped deposition, however, certain portions, including testimony concerning Dr. Hume’s opinion as to whether Mr. Joyce’s second fall increased the risk of his suffering from severe chonrdomalacia, were redacted.
. Appellees contend, however, that the trial court was correct in excluding Drs. Ratner and Hume testimony on causation, since such testimony went beyond the fair scope of their expert reports. See Pa.R.C.P. 4003.5(c) (an еxpert witness may not testify on direct examination concerning matters which are either inconsistent with or go beyond the fair scope of the matters testified to in discovery proceedings or included in a separate report); Greer v. Bryant,