OPINION
Opinion By
After Raymond Kettle (Kettle) died, his survivors (the Kettles) brought this wrong *836 ful death and survival action alleging medical negligence by Baylor Medical Center at Garland (Baylor), Cardiology Consultants of North Dallas, P.A. (Cardiology), Abdul Kader Ezeldin, M.D. (Ezeldin), Kanti Lai Agrawal, M.D. (Agrawal), and Michael Motta, D.O. (Motta). The trial court dismissed the Kettles’ claims with prejudice under the Medical Liability and Insurance Improvement Act of Texas (MLIIA) (former Tex.Rev.Civ. Stat. art. 4590i, § 13.01) for failure of the Kettles’ pre-trial expert reports to satisfy its requirements. In two groups of eight issues addressing each defendant, the Kettles argue thе court abused its discretion in (i) dismissing the claims and (ii) refusing to grant an extension under MLIIA § 13.01(g) to file amended reports meeting the statutory requirements. We affirm in part and reverse in part and remand.
BACKGROUND
Kettle had chronic obstructive pulmonary disease (COPD). The Kettles allege that two days after he was implanted with a cardiac pacemaker he suffered “cardiac tamponade” and died. They generally allege (i) inadequate and non-timely assessment and reporting by Baylor nurses of his condition and symptoms to physicians for prompt treatment and (ii) inadequаte and non-timely diagnosis and treatment by Drs. Ezeldin, Agrawal, and Motta. They allege Cardiology and Baylor are liable through actual or ostensible agents or employees in the course and scope of employment. They filed curricula vitae and expert reports from cardiologist/internist Dr. Marc Cohen (Cohen) and registered nurse Debra L. Pugh (Pugh); both experts stated they reviewed the medical records.
Expert Report Requirements
The parties agree that the Texas Medical Liability and Insurance Improvement Act at former Tex.Rev.Civ. Stat. art. 4590i (MLIIA) (current version at Tex. Crv. PRAC. & Rem.Code ch. 74) applies and governs the Kettles’ health care liability claims, because they filed suit before it was repealed. MLIIA § 13.01(d)(1) requires health care liability claimants to furnish an expert report with the expert’s curriculum vitae within 180 days of filing suit “for each physician or health care provider” sued. “Expert report” is defined as a written
fair summary of the expert’s opinions as of the date of the report regarding applicable standards of care, the manner in which the care rendered by the physician or health care provider failed to meet the standards, and the causal relationship between that failure and the injury, harm, or damages claimed.
MLIIA § 13.01(r)(6).
The supreme court has outlined the standard governing sufficiency of MLI-IA expert reports.
See Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios,
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Conclusory reports do not satisfy MLIIA.
Bowie Memorial Hosp. v. Wright,
Under MLIIA §§ 13.01(e)(3), (Z), on motion a trial court shall dismiss a suit with prejudice either where a report is untimely or where a timely report, after a hearing, appears to the court to not adequately represent a good faith effort to comply with the expert report definition at MLIIA § 13.01 (r)(6). MLIIA § 13.01(g) mandates granting one 30-day grace period to meet its expert report deadline if after a hearing the trial court finds that failure to do so was not intentional or consciously indifferent but accidental or mistaken. The grace period is available to cure inadequate but timely filed reports.
Walker v. Gutierrez,
Standard of Review
We review both a dismissal under MLI-IA and refusal to grant a grace period to cure expert report deficiencies for abuse of discretion.
Jernigan v. Langley,
In evaluating a report’s sufficiency, wе are confined to its four corners.
Pa-lacios,
Discussion
Drs. Ezeldin and Agrawal
For liability of Drs. Ezeldin, Agrawal, and Motta (and vicarious liability of Cardiology), the Kettles rely on Dr. Cohen’s report. Motta is discussed separately below as he abandoned any standard of care, breach, and causation challenges to Cohen’s report in the trial court and in his brief to this Court and argues only that Cohen did not demonstrate he was qualified to opine. Ezeldin аnd Agrawal do not object to Cohen’s qualifications. Though the Kettle’s petition alleges Dr. Rolando Solis (Solis) negligently implanted a pacemaker in Kettle when there was “no indication for one,” and though Cohen includes Solis with the other physician-defendants in discussing their conduct, Solis’s conduct is not at issue as he is not a party to this appeal.
Dr. Cohen’s report. 1 The report’s “case summary” states Kettle’s COPD was advanced but far from end stage; notes a CAT scan and echocardiogram showed a new pericardial effusion; and notes pro *838 gressive hypotеnsion for about a seven hour period before he arrested. The substance of his opinion on standard of care, breach, and causation on the two courses of conduct alleged to be negligent may be summarized in pertinent part:
• Documenting indication for a pacemaker implant. Cohen opines that Drs. Solis, Ezeldin, 2 and Agrawal, and Cardiology, all collectively owed a duty to “fully document” a “clear cut” indication for implanting a pacemaker. He states Kettle “[was] referred for” a pacemaker and opinеs that Solis, Ezeldin, Agrawal, and Cardiology all collectively breached the standard of care because a pacemaker “was implanted” without “adequate” indication. He opines that the implantation “resulted in pericardial tamponade and death.”
• Treating pericardial tamponade. Cohen opines that Drs. Solis, Ezel-din, Agrawal, and Motta, and Cardiology and Baylor, 3 all collectively owed a duty to “promptly consider, diagnose, and then treat,” with “peri-cardiocentesis,” Kettle’s “pericardial tamponade” that was causing his “progressive hypotension.” He states all defendants collectively breached the standard of care because “[m]ore than six hours passed before any intervention related to the diagnosis of effusion ... was entertained.” He states Kettle was “not in imminent danger of dying from his COPD,” opines that failing to “promptly” perform pericardiocentes-is caused Kettle’s death, and opines that “earlier” pericardiocentesis would have “stabilized [his] blood pressure and saved his life.”
A standard of care that only requires physicians tо “fully document” indications for implanting a pacemaker is at best ambiguous. For example, the report does not explain how documenting relates to recommending or ordering; i.e., it does not link documenting to implanting. It is silent on who recommended or ordered the implant, stating only that Kettle “[was] referred for” it. It is silent on the implanting physician. It does not state what must be documented, what is sufficient, to whom it must be directed, explain how its insufficiency led to wrongful implantation, or describe its intended purpose or effect. Moreover, it does not state the indications for pacemaker implants and is silent on the standard for assessing them. It does not opine that the implantation itself was negligently performed or explain how this implant caused the complications alleged. We conclude this portion of the opinion identifies no discernible standard of care satisfying
Palacios
and does not explain causation as the supreme court required in
Bowie,
Cohen’s opinion that all the physician-defendants collectively shared the same duty to diagnose and treat Kettle’s condition “promptly” or “earlier” is also too vague and general to satisfy
Palacios.
It
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could be stated that
every
physician has a general duty to diagnose or treat medical conditions timely but that truism does not inform the physician-defendants what the standard specifically required them to do. It is conclusory.
Cf. Whitworth v. Blumenthal,
This report states: “More than six hours passed before any intervention related to the diagnosis of effusion ... was entertained.” This is just a statement of an occurrence that does not specify who had a duty to do what and when. The report does not specify the steps that should have been taken to diagnose Kettle’s condition for timely intervention аnd does not specify a standard for determining what intervention is timely. In other words, there is no breach alleged that relates to a defined standard of care. Merely stating a particular condition should be timely treated with a particular procedure is insufficient to meet
Palacios. Cf. Eichelberger v. St. Paul Med. Ctr.,
Reports Lumping Defendants Inadequate
Cohen’s report is independently deficient in lumping all the physician-defendants together, without describing their individual roles in Kettle’s care. The report identifies no practice specialty of any defendant. The report does not opine but requires us to infer that the same standard applies to each of them and that they all breached it in the same way.
MLILA expressly requires submitting a report “for each physician or health care provider” sued. MLIIA § 13.01(d)(1). Reports must “notify[] each defendant of the specific conduct called into question....”
See Whitworth v. Blumenthal,
Plainly, different specialists may be involved in a given patient’s care. While it is certainly
possible
an identical standard of care governs different providers, a generalized statement without explanation that a uniform standard applies “can reasonably be deemed conclusory” and deficient.
Gray v. CHCA Bay shore, L.P.,
Dr. Motta
Motta’s only objection to cardiologist Cohen’s report is that it does nоt show he is qualified to testify on Motta’s conduct as a pulmonologist. A report may be challenged for failing to sufficiently detail why the expert is qualified.
See Hansen v. Starr,
Cohen states he is a licensed, practicing physician, board certified in internal medicine, cardiovascular diseases, and interven-tional cardiology. He states he has “knowledge of the accepted standards of medical care for the diagnosis, care and treatment of pacemaker insertion and peri-cardial tamponade” and is qualified based on his “training, education, and experience regarding” those standards. His curriculum vitae recites extensive cardiological expertise, which Motta does not challenge. But his report describes no pulmonology-related expertise and the Kettles point to nothing in his curriculum vitae reflecting any pulmonology-related expertise. The Kettles counter that the report is sufficient because it adequately shows qualification to opine on the standard governing diagnosis/treatmеnt of the “condition involved in the[ir] claim,” Kettle’s cardiac condition. See MLIIA § 14.01(a)(2).
MLIIA section 14.01(a)(l)-(3) provides that in suits against physicians an expert may qualify to opine on breach of the applicable standard of care if the expert
(1) “practices] medicine”;
(2) has knowledge of accepted “medical care” standards “for the diagnosis, care, or treatment of the illness, injury, or condition involved in the claim”; and
(3)is qualified based on “training or experience” to opine on those standards.
When a “subject is substantially developed in more than one field, testimony cаn come from a qualified expert in
any
of those fields,” provided the offering party can establish expertise “regarding the specific issue before the court....”
Broders v. Heise,
We above held Cohen’s report deficient in lumping all the physician-defendants together without specifying what responsibility each undertook, what role each played in Kettle’s care, and what standard of care applied to each. For the same reason it is deficient in demonstrating Cohen’s qualification to opine on Motta’s conduct.
See Olveda v. Sepulveda,
Cohen may very well be qualified to opine on the services Motta performed. Motta may very well have undertaken to diagnose and treat Kettle’s specific cardiac condition within Cohen’s competence to opine. Or Motta may simply have been called in as a specialist to monitor or treat Kettle’s COPD. But we cannot tell from
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the report what role Motta played in Kettle’s care. We thus cannot conclude the trial court abused its discretion in finding Cohen’s report inadequate as to Motta.
See Hansen v. Starr,
Baylor Hospital
For Baylor’s liability from conduct of its nurses, the Kettles rely on Nurse Pugh’s report in conjunction with Dr. Cohen’s. 4 Baylor only challenges the sufficiency of the causation element, conceding sufficiency of the nursing standard and breach elements.
Nurse Pugh’s report. Pugh first opines that negligent patient monitoring and assessment and delay in reporting to physicians caused delayed treatment. She then medically opines on cause of death. The substance of her report may be summarized:
• Negligent monitoring, assessment, and reporting delayed treatment. Baylor nurses breached a duty to recognize symptoms of uncontrolled blood loss and to consider complications of Kettle’s pacemaker implant; breached a duty to reрort possible pacemaker complications and to “timely” report his unimproved vital signs, persistent symptoms, and deteriorating condition to physicians; failed to follow through to obtain results of an echocardiogram, which would have yielded “valuable insight” into the cause of Kettle’s condition; and despite monitoring decreasing blood pressure, waited five hours to call a doctor, two hours before he arrested, 5 “caus[ing] delay in treatment. ...”
• Medical causation. Delayed treatment “directly affected” Kettle’s “negative outcome” and “contributed” to his death and “earlier” physician treatment “could” have prevented it.
We first note that as a registered nurse and not a physician licensed to practice medicine, Pugh is not qualified to testify on medical causation. Because she may not render medical diagnoses
6
she is not qualified to opine that any particular treatment at any particular time would have prevented Kettle’s death.
See Costello v. Christus Santa Rosa Health Corp.,
Pugh opines that delayed reporting to physicians of Kettle’s condition in turn delayed treatment by them. Cohen’s report explicitly opines that Kettle’s COPD was not otherwise terminal and that earlier treatment “would have ... saved his lifе.” Baylor argues Cohen’s report is insufficient because it does not opine that a five hour reporting delay “prevented” earlier pericardiocentesis. Baylor also argues the report does not state the physicians would in fact have performed pericardiocentesis timely, or at all, but for the delay in conveying the specific information withheld. We do not find these arguments persuasive. Cohen specifically opined that Kettle’s death was not imminent but preventable by earlier pericardiocentesis. “[A] delay is a dеlay.”
Hillcrest,
Reports need not marshal all the plaintiffs proof or meet the formal eviden-tiary requirements of a trial or summary judgment proceeding; they need only notice the conduct called into question and give the trial court a basis to determine whether a claim has merit.
Palacios,
Cardiology Consultants
The Kettles argue the MLIIA expert report requirement does not apply to Cardiology аt all because they allege no direct negligence against it and seek only to hold it vicariously liable for Agrawal’s conduct as agent or employee in the course and scope of employment. 7
The parties agree that Cardiology is a physicians’ professional association. The supreme court has expressly held MLIIA’s protections apply to these entities.
MacGregor Med. Ass’n v. Campbell,
The Kettles next rely on Cardiology’s position in its motion to dismiss in the trial court that the Texas Medical Practice Act
8
does not provide a vehicle for a professional association to become licensed to “practice medicine.” We do not find this relevant. First, as stated MLIIA specifically requires an expert report for each “health care provider” sued, which encompasses physician professional associations. Second, the Texas Professional Association Act makes physician professional associations “jointly and severally liable with the officer or employee furnishing professional services” in the “course of his employment for the association” for professional negligence.
See
Tex.Rbv.Civ. Stat. Ann. art. 1528f, § 24 (Vernon Supp.2006). This creates “direct liability” of the professional association for the actions of a physician-principal in the course of employment because the former acts through the latter and the latter’s conduct is imputed to it.
Battaglia v. Alexander,
Whether Cardiology’s liability is considered direct or vicarious, that liability still depends on conduct of Agrawal, to which
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MLIIA indisputably applies.
See Whitworth v. Presbyterian Healthcare Ctr.,
Extension of Time to Cure Deficiencies
In the alternative to arguing Cohen’s report on the physicians and Cardiology was sufficient, the Kettles assert that if the report is insufficient the trial court abused its discretion by failing to grant a 80-day grace period under MLIIA section 13.01(g) to amend or supplement it to cure any deficiencies. That section mandates an extension where failure to comply with MLIIA’s expert report requirements was not intentional or consciously indifferent but accidental or mistaken. The sole basis for the Kettles’ argued right to an extension is a good faith, if mistaken, belief by their counsel that the report was sufficient to satisfy MLIIA. The Kettles thus argue mistake of law.
The supreme court has rejected the Kettles’ position. It holds that some but not all mistakes of law are sufficient to negate intentional conduct or conscious indifference to excuse statutory non-compliance, entitling a claimant to a section 13.01(g) grace period.
See Walker v. Gutierrez,
The burden of showing entitlement to a section 13.01(g) grace period is on the health care liability claimant.
Yaquinto v. Britt,
The Kettles argue
Walker
is inapposite because the reports if conclusory or otherwise deficient nonetheless did not “omit” any of the required elements of duty, breach, causation, or expert qualification. They cite
In re Zimmerman,
We note
Walker
found no distinction between filing an inadequate report and filing no report in assessing compliance with MLIIA’s filing deadline. Ill S.W.3d at 61. We also note the longstanding general rule that conclusory opinion testimony is not evidence.
Coastal Transp. Co. v. Croum Cent. Petroleum Corp.,
Zimmerman
contains no analysis and only held that the trial court was “not required, as a matter of law, to find that no accident or mistake occurred” and thus did not abusе its discretion in that case to allow an extension to amend and correct deficiencies.
Conclusion
In light of the foregoing, we cоnclude the trial court did not abuse its discretion in sustaining objections by Ezeldin, Agra-wal, Motta, and Cardiology to Cohen’s report and dismissing the Kettles’ suit against them and in failing to grant them an extension to cure the report’s deficiencies. We also conclude the trial court abused its discretion in sustaining Baylor’s objection to Cohen and Pugh’s report and dismissing the Kettles suit against it. We thus reverse the trial court’s order dismissing the Kettles’ suit against Baylor and remand for further proceedings. We affirm the orders dismissing the Kettles’ suit against Ezeldin, Agrawal, Motta, and Cardiology and denying the Kettles’ requestеd extension of time to amend Cohen’s report on these defendants.
Notes
. Dr. Cohen’s report is unsigned.
. The Kettles do not appear to assert any claim against Ezeldin related to the pacemaker implantation or rely on that portion of Cohen’s report for any liability attributed to him but appear to limit their pacemaker implantation claim to Agrawal and Cardiology. This does not affect our underlying analysis of the sufficiency of the report.
. While Cohen’s report opines Baylor was collectively negligent with the physicians in diagnosing and treating a medical condition, the Kettles do not allege this and we disregard it. This portion of the report is also immaterial because medical diagnosis or treatment is practicing medicine, which hospitals are not licensed to do.
See Reed v. Granbury Hosp. Corp.,
.Nurse Pugh states she is a licensed, practicing registered nurse (RN), is board certified in operating room nursing (CNOR), has been certified in Advanced Cardiac Life Support (ACLS), has "extensive experience working as a nurse in the surgical, medical and cardiac intensive care units,” has “knowledge of the accepted standards of nursing cаre” of patients with COPD, cardiac arrhythmias, and pacemaker implants, and is qualified based on her "training, education and experience regarding” those standards.
. Dr. Cohen’s report states the time of Kettle’s arrest.
. Medical diagnosis and treatment is practicing medicine, Tex Occ.Code § 151.002(a)(13), which requires a medical license. Id. §§ 151.002(a)(12), 155.001. The Nursing Practice Act defines "nursing” as "professional or vocational nursing” and states it "does not include acts of medical diagnosis....” Tex Occ.Code Ann. § 301.002(2), (4)-(5) (Vernon Supp.2006).
. Cardiology has not challenged the course and scope of employment allegatiоn.
. Tex. Occ.Code Ann. chs. 151-165 (Vernon 2004 & Supp.2006).
. Cardiology also argues it is entitled to a dismissal of any vicarious-liability claims for conduct of agents or employees other than Agrawal. We need not address this contention because we need only address dismissal of “health care liability claims,” which require an expert report, and the Kettles submitted no report on conduct of any such other agent or employee.
. In light of our disposition on the merits, we do not reach Baylor's procedural arguments that the Kettles’ waived their motion for extension because it was heard after the court granted Baylor’s motion to dismiss.