Josephine Wilson v. P.B. Patel, M.D., P.C., and Rohtashav Dhir, M.D.

CourtMissouri Court of Appeals
DecidedJune 21, 2016
DocketWD78538
StatusPublished

This text of Josephine Wilson v. P.B. Patel, M.D., P.C., and Rohtashav Dhir, M.D. (Josephine Wilson v. P.B. Patel, M.D., P.C., and Rohtashav Dhir, M.D.) is published on Counsel Stack Legal Research, covering Missouri Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Josephine Wilson v. P.B. Patel, M.D., P.C., and Rohtashav Dhir, M.D., (Mo. Ct. App. 2016).

Opinion

IN THE MISSOURI COURT OF APPEALS WESTERN DISTRICT

JOSEPHINE WILSON, ) ) Appellant, ) ) WD78538 v. ) ) OPINION FILED: ) June 21, 2016 P.B. PATEL, M.D., P.C., and ) ROHTASHAV DHIR, M.D., ) ) Respondents. )

Appeal from the Circuit Court of Buchanan County, Missouri The Honorable Weldon C. Judah, Judge

Before Division IV: Alok Ahuja, Chief Judge, Presiding, Mark D. Pfeiffer, Judge, and J. Dale Youngs, Special Judge

Ms. Josephine Wilson (“Wilson”) appeals the judgment, following a jury trial, of the

Circuit Court of Buchanan County, Missouri (“trial court”), in favor of defendants P.B. Patel,

M.D., P.C., and Rohtashav Dhir, M.D. (collectively, “Dhir”), on Wilson’s medical malpractice

claim. On appeal, Wilson claims instructional, evidentiary, jury venire, and closing argument

errors by the trial court. We affirm. Factual and Procedural Background

Wilson had a history of acid reflux and trouble swallowing; she had been treated for these

conditions since about 2000. She underwent balloon dilation of her esophagus for her reflux in

2004 and again in 2005, which provided some long-term relief.

In the fall of 2009, Wilson saw Dr. Scott Knappenberger, an ear, nose, and throat

specialist. Dr. Knappenberger diagnosed chronic pharyngitis (inflammation of the throat lining),

and globus sensation (subjective feeling of something stuck in the throat, resulting in difficulty

swallowing, but without physical findings to suggest an abnormality). He referred her to Dhir, a

gastroenterologist, for consultation and evaluation.

Dhir saw Wilson in his office on December 2, 2009, and prescribed Kapidex, a

medication for her reflux. He scheduled an appointment for Wilson to undergo an

esophagogastroduodenoscopy (“endoscopy”) on December 8, 2009, at an outpatient clinic. His

notes from the December 2 appointment state, “An [endoscopy] will be performed. The

procedure was discussed with the patient today. The patient voices understanding. She might

need dilation of the esophagus depending on the findings.” Wilson understood after this visit

that Dhir “was going to go in and do a scope like Dr. McCormick had done” in 2004 and 2005

and that “if there was any problem, that he would fix it like Dr. McCormick had done in the

past.”

On December 8, 2009, Dhir performed the endoscopy, through which Dhir was able to

visualize Wilson’s esophagus and stomach down to her duodenum. The endoscope revealed

“nothing in the duodenum that would stimulate any further action on my part or important to be

noted.” Dhir found gastritis in her stomach and a single polyp near the top of Wilson’s

2 esophagus, which he removed with forceps. Dhir’s operative report stated that Wilson’s “GE

junction [where the stomach meets the esophagus] and the esophagus seem to be normal.”

Despite the normal findings of the endoscopy, Dhir decided to perform an esophageal

dilation procedure, or a stretching of Wilson’s esophagus, using a large, rubbery bore dilator. As

the dilator was manually pushed down the esophagus, Dhir felt for resistance of the dilator going

through a narrowing. Dhir testified that the “dilation went smooth,” and he felt nothing other

than an expected mild resistance.

Upon withdrawal of the dilator, Dhir observed that the guidewire was kinked. Dhir

performed another endoscopy and observed a tear in the esophageal lining that he concluded had

been caused by the dilation. One of the risks of dilation is tearing or perforating the esophagus.

Dr. Robert Zink, a cardiothoracic surgeon, repaired the esophageal tear. The repair

required Dr. Zink to open Wilson’s chest wall, spread her ribs, and collapse one of her lungs to

reach the esophagus. During the repair, Dr. Zink observed no esophageal abnormalities other

than the tear. He noticed no fibrous tissues or otherwise abnormal tissues. Following the repair,

Wilson has experienced pain in her chest “all the time. It’s not just the ribs. It’s the nerves. It’s

the muscles . . . .” Her pain feels like “a huge knife that’s on fire and it’s just stabbing me and it

just burns.”

Wilson’s argument of malpractice was that the esophageal dilation was medically

unnecessary and below the standard of care because she had a normal esophagus without signs or

findings of a stricture or other abnormality, and there was no reason to stretch it. Wilson’s

expert, Dr. Richard Dwoskin (“Dwoskin”), testified that the established and relevant standard of

care at the time of the procedure was, “Don’t dilate unless you see a structural abnormality.”

Dwoskin opined that Wilson’s difficulty swallowing, or dysphagia, was caused by her reflux and

3 that it could have been treated with the Kapidex medication alone. Dwoskin, who relied upon

guidelines issued from the American Society for Gastrointestinal Endoscopy (“ASGE”), testified

that empiric dilation (dilation without findings of stricture or abnormality) fell out of favor no

later than 2006 because medical research failed to establish any benefit to dysphagia patients that

outweighed the risk of esophageal perforation, and medication was effective and less risky.

Dwoskin opined that Dhir should have continued treating Wilson with medication, set a

follow-up appointment, and re-evaluated her progress at that time.

Dhir contended that he exercised sound professional judgment in deciding to perform the

dilation, despite the normal endoscopy findings, because he thought it would help her with her

dysphagia, and because sometimes abnormal esophageal tissues occurred in outer layers of the

esophagus that were not visible with endoscopy. Dhir also had an expert, Dr. Ginsburg, testify

on his behalf. Dr. Ginsburg opined that the ASGE guidelines that counseled against empiric

dilation did not apply in every case and that sometimes empiric dilation was appropriate, as it

was in Wilson’s case. Dr. Ginsburg opined that his conclusion was supported by the fact that

Wilson had a history of esophageal strictures, dysphasia, and the absence of a condition called

eosinophilic esophagitis. Dr. Ginsburg opined that Dhir had employed the appropriate standard

of care in treating Wilson.

At trial, Wilson did not present a claim for failure to provide informed consent. Her only

theory at trial was that Dhir was negligent in performing the dilation absent abnormal findings

during the endoscopy. Nonetheless, Dhir’s counsel mentioned during opening statement that

Wilson signed an “informed consent” that stated that the risks and benefits of the endoscopy had

been explained to her and “that my doctor may choose to do other procedures if necessary.”

Wilson’s counsel did not object to the mention of the “informed consent” in opening statements.

4 Dhir’s counsel also cross-examined Wilson about the “informed consent.” Again, Wilson’s

counsel did not object but on redirect used the informed consent documentation to question

Wilson about whether the form was just one of many forms that she was asked to sign

immediately before the endoscopy, forms that Wilson claimed she had not had the time to read

closely before signing them.

Dhir’s counsel later asked Dhir on his direct examination whether his patients are asked

to sign an “informed consent” document. At this point, Wilson’s counsel finally objected to the

“informed consent” line of questioning on the basis of relevancy. This objection was overruled,

and Wilson does not challenge that ruling on appeal.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Wright v. Kaye
593 S.E.2d 307 (Supreme Court of Virginia, 2004)
Nelson v. O'Leary
291 S.W.2d 142 (Supreme Court of Missouri, 1956)
Swartz v. Gale Webb Transportation Co.
215 S.W.3d 127 (Supreme Court of Missouri, 2007)
State v. Grondman
190 S.W.3d 496 (Missouri Court of Appeals, 2006)
Joy v. Morrison
254 S.W.3d 885 (Supreme Court of Missouri, 2008)
Stewart v. Sioux City & New Orleans Barge Lines, Inc.
431 S.W.2d 205 (Supreme Court of Missouri, 1968)
State v. Powell
286 S.W.3d 843 (Missouri Court of Appeals, 2009)
Fleshner v. Pepose Vision Institute, P.C.
304 S.W.3d 81 (Supreme Court of Missouri, 2010)
Heshion Motors, Inc. v. Western International Hotels
600 S.W.2d 526 (Missouri Court of Appeals, 1980)
Storm v. NSL ROCKLAND PLACE, LLC
898 A.2d 874 (Superior Court of Delaware, 2005)
Hayes v. Camel
927 A.2d 880 (Supreme Court of Connecticut, 2007)
Sampson v. Missouri Pacific Railroad
560 S.W.2d 573 (Supreme Court of Missouri, 1978)
Kelly v. St. Luke's Hospital of Kansas City
826 S.W.2d 391 (Missouri Court of Appeals, 1992)
Carla Gleason v. Bendix Commercial Vehicle Systems, LLC
452 S.W.3d 158 (Missouri Court of Appeals, 2014)
Brady, M. v. Urbas D.P.M., W., Aplt.
111 A.3d 1155 (Supreme Court of Pennsylvania, 2015)
Tiffany K. (Mahaffey) Brizendine v. Bartlett Grain CO., LP
477 S.W.3d 710 (Missouri Court of Appeals, 2015)
Matranga v. Parish Anesthesia of Jefferson, LLC
170 So. 3d 1077 (Louisiana Court of Appeal, 2015)
Baird v. Owczarek
93 A.3d 1222 (Supreme Court of Delaware, 2014)
Peterson v. Progressive Contractors, Inc.
399 S.W.3d 850 (Missouri Court of Appeals, 2013)
Warren v. Imperia
287 P.3d 1128 (Court of Appeals of Oregon, 2012)

Cite This Page — Counsel Stack

Bluebook (online)
Josephine Wilson v. P.B. Patel, M.D., P.C., and Rohtashav Dhir, M.D., Counsel Stack Legal Research, https://law.counselstack.com/opinion/josephine-wilson-v-pb-patel-md-pc-and-rohtashav-dhir-md-moctapp-2016.