Opinion
Maria Del Carmen Mejia (plaintiff) appeals from a judgment of nonsuit in favor of Community Hospital of San Bernardino (respondent or respondent hospital), one of several defendants in her medical malpractice complaint. Plaintiff argues that there was sufficient evidence that the negligent physician was the ostensible agent of respondent to survive the motion for a nonsuit. We agree and reverse, concluding that a nonsuit on the issue of ostensible agency was improper because plaintiff sought treatment at respondent hospital and there was no evidence that she should have known that the negligent physician was not an agent of respondent.
Statement of Facts
In April 1997, plaintiff heard something pop in her neck when she bent over to move some boxes. Her neck immediately became stiff, and she suffered neck pain and stiffness off and on for a couple of weeks. Nevertheless, plaintiff went about her business, using acetaminophen to control the pain, until May 3, 1997, when she awoke with severe neck pain and her head was twisted to onе side. That night, plaintiff’s mother convinced plaintiff to go to the emergency room (hereinafter sometimes ER).
*1451 A neighbor took plaintiff, her mother, and her cousin to the ER at respondent hospital and dropped them off. Around 3:00 a.m., plaintiff was examined by an ER physician. The ER physician prescribed hydrocodone and acetaminophen for the pain and a tranquilizer to relax the muscles, and ordered X-rays of plaintiff’s neck. The ER physician sent at least one X-ray to the on-call radiologist for an evaluation. The radiologist reported that he saw a congenital fusion, but nothing else. Based in part on the radiologist’s report, the ER physician discharged plaintiff, telling her that she had a twisted neck, but was otherwise all right.
When a nurse came in to escort plaintiff and her family out, plaintiff began to feel nauseous from the medication and vomited several times. The last time she vomited, her family had to lift her head out of the toilet and put her in a wheelchair. When they left respondent hospital, plaintiff tried to get into her sister’s car, but was unable, so her family lifted her into the car. After taking plaintiff home, her family put her in bed. Plaintiff slept all day and all night. When she awoke the next morning, she could feel the pain in her neck again, but could not move her arms or legs and felt numb throughout her body. Plaintiff was taken by an ambulance to another hospital, where it was determined that her neck was actually broken and she was paralyzed. 1
Plaintiff filed a medical malpractice suit against respondent, the ER physician, the radiologist, Emergency Physicians Medical Group (the company that contraсted to run the ER for respondent and employed the ER physician), and MSB Radiology Medical Group (the company that contracted to run the radiology department for respondent and employed the radiologist). The case proceeded to trial, where respondent successfully moved for a nonsuit immediately after the close of plaintiff’s case. Regarding the remaining defendants, the jury found that the radiologist and his employer, MSB Radiology, were negligent, but the ER physician and his employer, Emergency Physicians Medical Group, were not.
Discussion
On appeal, plaintiff argues that respondent was not entitled to a nonsuit because there was a triable issue as to whether the negligent radiologist was the ostensible agent of respondent. We agree.
a. National Trend
For the last century, courts throughout the country have struggled with the issue of whether hospitals are liable for the negligence of physicians. In *1452 doing so, they have confronted and cast aside two major impediments to liability.
The first impediment overcome was that of charitable immunity. Early cases endowed hospitals with charitable immunity based on the theory that their funds should not be diverted from charitable purposes to pay tort damages.
(Silva v. Providence Hospital of Oakland
(1939)
Fortunately for all concerned, however, hospitals evolved. “Today, hospitals compete aggressively in providing the latest medical technology and the best facilities, as well as in attracting patients and physicians who will funnel patients to them. Hospitals not only strive to be a source of pride in the local community, but they also seek to avoid operating at a financial loss. Regardless of whether they are profit-seeking enterprises, they are run much like any large corporation and must operate in a fiscally responsible manner. Like any business dependent upon attracting individual people as customers, hospitals in the aggregate spend billions to advertise their facilities and services in a variety of media, from newspapers and billboards to television and the Internet.”
(Simmons, supra,
533 S.E.2d at pp. 316-317.) As a result of this evolution, courts withdrew the protections of charitable immunity.
(Silva, supra,
The second impediment overcome was that created by the application of the traditional rules of respondeat superior to skilled professionals, such as physicians. “For many years the majority of courts followed the rule . . . that physicians, because of their skill and training in a highly technical field, were not subject to control by hospital lay boards and thus could not be servants or employees in the sense required by the doctrine of respondeat superior. Rather, physicians were classified as independent contractors with the result that the hospitals in whiсh they labored could not be held
*1453
vicariously liable for their medical mistakes.”
(Adamski
v.
Tacoma General Hospital
(1978)
Courts soon realized, however, that the traditional emphasis on the master’s ability to control the servant was unrealistic in the context of the modem health care system. In an often cited passage, a New York court explained: “The conception that the hospital does not undertake to treat the patient, does not undertake to act through its doctors and nurses, but undertakes instead simply to procure them to act upon their own responsibility, no longer reflects the fаct. Present-day hospitals, as their manner of operation plainly demonstrates, do far more than furnish facilities for treatment. They regularly employ on a salary basis a large staff of physicians, nurses and internes, as well as administrative and manual workers, and they charge patients for medical care and treatment, collecting for such services, if necessary, by legal action. Certainly, the person who avails himself of ‘hospital facilities’ expects that the hospital will attempt to cure him, not that its nurses or othеr employees will act on their own responsibility.”
(Bing
v.
Thunig
(1957)
Although the cases discussing ostensible agency use various linguistic formulations to describe the elements of the doctrine, in essence, they require the same two elements: (1) conduct by the hospital that would cause a reasonable person to believe that the physician was an agent of the hospital, and (2) reliance on that apparent agency relationship by the plaintiff. (See, e.g.,
Sword, supra,
Regarding the first element, courts generally conclude that it is satisfied when the hospital “holds itself out” to the public as a provider of care.
*1454
(Butler v. Domin
(2000)
The second element, reliance, is established when the plaintiff “looks to” the hospital for services, rather than to an individual physician.
(Butler, supra,
As should be apparent to an astute observer, there is really only one relevant factual issue: whether the patient had reason to know that the physician was not an agent of the hospital. As noted above, hospitals are generally deemed to have held themselves out as the provider of services unless they gave the patient contrary notice, and the patient is generally presumed to have looked to the hospital for care unless he or she was treated by his or her personal physician. Thus, unless the patient had some reason to know of the true relationship between the hospital and the physician—i.e., because the hospital gave the patient actual notice or because the patient *1455 was treated by his or her personal physician—ostensible agency is readily inferred.
Most courts have arrived at a similar conclusion. For instance, the Indiana Supreme Court observed that “[c]entral to both of these factors—that is, the hospital’s manifestations and the patient’s reliance—is the question of whether the hospital provided notice to the patient that the treating physician was an indеpendent contractor and not an employee of the hospital.”
(Sword, supra,
This per se inference of ostensible agency actually follows logicаlly from the evolution of the modem hospital described above. As the Ohio Supreme Court explained: “In applying the traditional elements [of ostensible agency] in this way, those courts invariably recognize the status of the modem-day hospital and its role in contemporary society. Not only is the hospital of today a large, well-run business, . . . but advances in medical technology have inevitably spawned increased specialization and industrialization. Hospitals are the only place where the best equipment and facilities and a full
*1456
array of medical services are available at any time without an appointment. With hospitals now being complex full-service institutions, the emergency room has become the community medical center, serving as the portal of entry to the myriad of services available at the hospital. As an industry, hospitals spend enormous amounts of money advertising in an effort to compete with each other for the health care dollar, thereby inducing the public to rely on them in their time of medical neеd. The public, in looking to the hospital to provide such care, is unaware of and unconcerned with the technical complexities and nuances surrounding the contractual and employment arrangements between the hospital and the various medical personnel operating therein. Indeed, often the very nature of a medical emergency precludes choice. Public policy dictates that the public has every right to assume and expect that the hospital is the medical provider it purports to be.”
(Clark, supra,
b. California Law
In California, ostensible agency is defined by statute. Civil Code •section 2300 provides: “An agency is ostensible when the principal intentionally, or by want of ordinary care, causes a third person to believe another to be his agent who is not really employed by him.” (See also Civ. Code, § 2317.) Civil Code section 2334 further provides: “A principal is bound by acts of his agent, under a merely ostensible authority, to those persons only who have in good faith, and without want of ordinary care, incurred a liability or parted with value, upon the faith thereof.” Nominally, these statutes require proof of three elements: “ ‘[First] [t]he person dealing with
*1457
the agent must do so with belief in the agent’s authority and this belief must be a reasonable one; [second] such belief must be generated by some act or neglect of the principal sought to be charged; [third] and the third person in relying on the agent’s apparent authority must not be guilty of negligence.’ ”
(Stanhope v. L. A. Coll, of Chiropractic
(1942)
Ostensible agency was first applied to a hospital in California under circumstances remarkably similar to the instant case. In
Stanhope,
a large object fell on the plaintiff and he was rushed to the College of Chiropractic which was only two blocks from his home.
(Stanhope, supra,
Like the majority of the courts throughout the nation,
Stanhope
inferred ostensible agency from the mere fact that the plaintiff sought treatment at the hospital without being informed that the doctors were independent contractors. In that regard,
Stanhope
actually served as a springboard for the national trend set forth above, having been prominently cited by many of the seminal cases. (E.g.,
Grewe, supra,
*1458 c. Application to This Case
In the instant case, respondent hospital was granted a nonsuit following the plaintiff’s рresentation of evidence. Since motions for a nonsuit raise issues of law, the granting of a nonsuit is reviewed de novo on appeal, using the same standard as the trial court.
(Saunders v. Taylor
(1996)
When this standard is applied to the case law governing ostensible agency in the hospital context, it appears difficult, if not impossible, for a hospital to ever obtain a nonsuit based on the lack of ostensible agency. Effectively, all a patient needs to show is that he or she sought treatment at the hospital, which is precisely what plaintiff alleged in this case. Unless the evidence conclusively indicates that the patient should have known that the treating physician was not the hospital’s agent, such as when the patient is treated by his or her personal physician, the issue of ostensible agency must be left to the trier of fact.
Nevertheless, respondent hospital points to three facts that allegedly show that plaintiff failed to prove that the radiologist was an ostеnsible agent of the hospital. Considering each of these facts in turn, we find none of them to be relevant.
First, respondent hospital notes that plaintiff never even knew about the radiologist’s involvement in her care. Instead, the radiologist dealt solely with the ER physician who subsequently advised plaintiff without mentioning the radiologist. There actually is some authority indicating that this fact is relevant. In
Garrett v. L.P. McCuistion Community Hosp.
(Tex.App. 2000)
Furthermore, in precisely the same circumstances, the Oregon Court of Appeals recently concluded that such evidence is irrelevant. In
Jennison
v.
Providence St. Vincent Medical Center
(2001)
We agree wholeheartedly with the sentiments expressed in
Jennison,
sentiments that are reflected in the
Stanhope
holding that emergency room patients cannot be expected to inquire as to whether treating physicians are independent contractors.
(Stanhope, supra,
Second, respondent hospital notes that the radiologist was not actually selected by the hospital, but rather was scheduled by his direct employer, MSB Radiology. This fact is obviously irrelevant. As explained above, ostensible agency is based on appearances. Thus, the fact that a hospital actually contracts with an intermediary to hire and schedule physicians is only relevant if the patient had some reason to know about that arrangement. In this case, it is beyond dispute that plaintiff had no idea that the radiologist was actually employed and scheduled by MSB Radiology.
Third, respondent hospital notes that the only reason plaintiff went to this hospital was because it was the closest, not because it had a better reputation
*1460
than other hospitals. As a result, the hospital argues that plaintiff never changed her position in “reliance” on the hospital’s reputation by selecting among competing hospitals. However, this argument misconstrues the nature of the relianсe inquiry. In
Abdul-Majeed v. Emory University Hosp.
(1994)
The Illinois Supreme Court rejected a similar argument in
Petrovich, supra,
The Ohio Supreme Court was confronted with a similar argument in
Clark, supra,
In conclusion, absent evidence that plaintiff should have known that the radiologist was not an agent of respondent hospital, plaintiff has alleged sufficient evidence to get to the jury merely by claiming that she sought treatment at the hospital.
*1461 Disposition
The judgment is reversed. Plaintiff shall recover costs on appeal.
Richli, J., and Gaut, J., concurred.
Respondent’s petition for review by the Supreme Court was denied October 2, 2002. Baxter, J., Chin, J., and Brown, J., were of the opinion that the petition should be granted.
Notes
Plaintiff has made some progress with the paralysis. As of trial, she had regained some strength in her upper body and was able to move her arms.
Many courts based ostensible agency on Restatement Second of Agency, section 267, or Restatement Second of Torts, section 429.
(Clark, supra,
