Chudson v. Ratra
548 A.2d 172, 76 Md. App. 753, 1988 Md. App. LEXIS 201 (1988)
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Rule of Law:
A patient's failure to follow a physician's instructions to report persistent or worsening symptoms can constitute contributory negligence, which bars recovery in a medical malpractice action if the patient's negligence is a substantial contributing cause of the injury, even if the patient's negligence occurs after the physician's initial negligent act.
Facts:
- Rhoda Tzemach, who had a family history of breast cancer, began seeing Dr. Jessica Ratra for gynecological care in 1981.
- In August 1983, Tzemach discovered a hard lump in her right breast and saw Dr. Ratra on September 6.
- Dr. Ratra identified the lump as a premenstrual cyst, told Tzemach it should regress after her period, and instructed her to call if it persisted.
- By late November 1983, Tzemach noticed the lump was growing and returned to Dr. Ratra on December 13.
- Dr. Ratra referred Tzemach for a mammogram, which revealed no malignancy, and again instructed Tzemach to continue self-examinations and report any changes at once.
- From January through July 1984, Tzemach continued to feel the lump, which she noticed began growing again around April.
- By July 1984, Tzemach described the lump as 'very large and tender' and large enough to be felt through her clothes.
- Tzemach did not contact Dr. Ratra again until August 6, 1984, at which point a biopsy revealed a malignant tumor that had already metastasized to her liver, rendering it incurable. Ms. Tzemach subsequently died from the cancer.
Procedural Posture:
- Rhoda Tzemach filed a medical malpractice claim against Dr. Jessica Ratra before a health claims arbitration panel.
- The arbitration panel entered an award in favor of Dr. Ratra.
- Tzemach rejected the award and filed a malpractice action in the Circuit Court for Prince George's County, a state trial court.
- Following Tzemach's death, her personal representatives and daughter continued the lawsuit.
- A jury at the trial court found Dr. Ratra was negligent, but also found that Tzemach was contributorily negligent.
- Based on the jury's finding of contributory negligence, the trial court entered judgment for Dr. Ratra.
- Tzemach's personal representatives (appellants) appealed the judgment to the Court of Special Appeals of Maryland, an intermediate appellate court.
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Issue:
Does a patient's failure to follow a physician's instructions to report if a breast lump persisted or grew, which occurs after the physician's initial negligent failure to diagnose cancer, constitute contributory negligence sufficient to bar recovery in a medical malpractice action?
Opinions:
Majority - Wilner, Judge.
Yes. A patient's failure to follow a physician's instructions to report changes in her condition can constitute contributory negligence that bars recovery, even if that failure occurs after the physician's initial negligence. The court reasoned that to be a legal cause, the patient's negligence need not be concurrent with the physician's; rather, the test is whether the patient's negligence was a substantial factor in causing the ultimate injury. Here, the injury was not the initial existence of cancer, but its spread to an incurable and lethal stage. The evidence was sufficient for a jury to conclude that had Ms. Tzemach reported the lump's persistence and growth between January and April 1984, there was a greater than 50% chance her cancer could have been successfully treated. Her failure to follow Dr. Ratra's repeated instructions to report such changes directly contributed to the cancer becoming incurable, thus constituting contributory negligence that bars recovery.
Analysis:
This decision reaffirms Maryland's adherence to the traditional, strict doctrine of contributory negligence, under which a plaintiff's own negligence, however slight, completely bars recovery. The case clarifies that a patient's negligence does not need to be contemporaneous with the physician's; a subsequent failure to follow instructions can be a legally contributing cause if it leads to the ultimate, irreversible harm. This ruling places a significant burden on patients to diligently monitor their conditions and follow medical advice, even after a potentially reassuring but incorrect diagnosis. For future cases, it establishes that in a failure-to-diagnose scenario, the relevant 'injury' for causation purposes may be the progression of the disease to a more advanced stage, an injury to which the patient's own inaction can contribute.
