Gala v. Hamilton
552 Pa. 466, 715 A.2d 1108, 1998 Pa. LEXIS 1475 (1998)
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Rule of Law:
To establish the 'two schools of thought' defense in a medical malpractice action, a defendant is not required to present medical literature; expert testimony alone, based on practitioners' experience, training, and professional knowledge, can sufficiently demonstrate that a considerable number of recognized and respected professionals advocate the chosen course of treatment.
Facts:
- In December 1987, Hiren S. Gala's wife noticed a lump on his neck.
- In March 1988, Hiren S. Gala underwent surgery for the removal of a schwannoma, a benign tumor on a nerve in his neck, performed by plastic surgeon Ralph Hamilton, M.D., and neurosurgeon Michael O’Connor, M.D.
- Prior to the surgery, Drs. Hamilton and O’Connor did not know which nerve was involved in the schwannoma, but suspected it might be the vagus nerve or a branch of the spinal accessory nerve.
- The surgical plan was to operate under local anesthesia, allowing for a stimulus response from the patient during surgery to identify the nerve involved.
- During the procedure, Drs. Hamilton and O’Connor observed that the schwannoma had grown completely around what they believed to be a branch of the spinal accessory nerve, and realized they would have to cut the nerve to remove the tumor.
- They determined that repairing the nerve damage would not be feasible due to the crowded area at the base of the skull, which contains the carotid artery, jugular vein, and numerous nerves.
- Following surgery, Hiren S. Gala was unable to speak, and it was determined the schwannoma had grown around the vagus nerve, not the spinal accessory nerve as initially believed.
- Hiren S. Gala eventually regained his voice.
Procedural Posture:
- Hiren S. Gala filed a medical malpractice suit against Ralph Hamilton, M.D. and Michael O’Connor, M.D. in the Court of Common Pleas of Philadelphia County (trial court), alleging negligence for permanent injury to his vagus nerve.
- The trial court instructed the jury on the 'two schools of thought' doctrine.
- The jury returned a verdict in favor of Drs. Hamilton and O’Connor.
- Hiren S. Gala appealed to the Superior Court of Pennsylvania (intermediate appellate court) as appellant; Drs. Hamilton and O’Connor were appellees.
- The Superior Court affirmed the trial court's judgment.
- Hiren S. Gala, as appellant, sought and was granted allocatur by the Supreme Court of Pennsylvania (highest court) to address the specific issue of whether medical literature must exist to support a two schools of thought jury instruction; Drs. Hamilton and O’Connor were appellees.
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Issue:
Does a defendant in a medical malpractice action need to present medical literature to justify a 'two schools of thought' jury instruction?
Opinions:
Majority - Newman, Justice
No, a defendant does not need to present medical literature to justify a 'two schools of thought' jury instruction. The Court referenced Jones v. Chidester, which uses general terms like 'competent medical authority' and 'factual reasons to support [the expert’s] claim,' and determined these terms do not restrict the type of evidence to medical literature. Limiting evidence to medical literature would prevent expert witnesses from testifying based on their experience as practitioners, medical training, and knowledge gained from lectures and educational programs. Such a restriction would be particularly problematic in cases where medical literature is silent on certain techniques or treatments, making the defendant's burden 'burdensome,' contrary to the standard set in Jones. The Court distinguished Tesauro v. Perrige, clarifying that the defense was rejected there not due to a lack of literature, but because the experts lacked personal experience with the procedure in question. The Court also noted that prior cases like Jones and Sinclair v. Block relied on medical expert testimony to establish the existence of two schools of thought. Since the 'two schools of thought' doctrine has existed for over 75 years in Pennsylvania without requiring medical literature, and expert testimony alone can establish a factual basis, allowing juries to receive such an instruction without literature is prudent. Plaintiffs remain free to challenge the basis of the expert’s testimony, including the lack of supporting literature, during cross-examination.
Dissenting - Nigro, Justice
Yes, medical literature should be required to establish a 'two schools of thought' defense. Justice Nigro argued that a 'school of thought' implies a more formal mode of practice, system, or discipline with a theoretical basis, medical principles, and protocol, which must be communicated to others. This shared knowledge must be memorialized to constitute a 'school' in a legal sense, rather than just a spontaneous agreement among colleagues. Without professional literature describing and supporting the defendant's course of treatment, there is inadequate factual support to establish that 'competent medical authority is divided.' In this specific case, neither Appellee had performed a vagal tumor resection under local anesthetic before, and their expert witnesses offered limited examples (like a missionary doctor in India) and cited no medical literature advocating the use of local anesthetic for this type of operation. One expert even declined to state it was 'accepted practice.' Therefore, the Appellees failed to establish a second school of thought, and the jury was improperly instructed, warranting a new trial.
Concurring - Cappy, Justice
No, medical literature is not the only competent evidence. Justice Cappy agreed with the majority, acknowledging the 'enticing simplicity' of the dissent's position but stating that it fundamentally misunderstands how medical information is conveyed. Unlike the legal community, where acceptance often requires written documentation, a significant amount of valid medical information is passed along orally, such as during hospital rounds or conferences. Imposing a requirement for medical literature would exclude a substantial amount of relevant evidence and thus distort the process of determining whether a certain medical practice constitutes a recognized 'second school of thought.' Therefore, the majority's approach is more sound.
Analysis:
This case significantly clarifies the evidentiary standard for the 'two schools of thought' defense in medical malpractice actions in Pennsylvania, affirming that expert testimony based on clinical experience, training, and informal professional discourse is sufficient, even in the absence of supporting medical literature. This broadens the scope of admissible evidence for defendants, making the defense less burdensome in areas where formal literature may not extensively cover every recognized practice. The decision reinforces the value of practical, real-world medical knowledge and consensus among professionals, ensuring that the legal standard aligns more closely with actual medical practice. Future cases will allow defendants to more readily establish this defense through expert testimony, while plaintiffs will need to meticulously challenge the basis and extent of such unwritten 'schools of thought' through vigorous cross-examination.
