Wilson v. Bodian

130 A.D.2d 221, 519 N.Y.S.2d 126, 1987 N.Y. App. Div. LEXIS 46218
CourtAppellate Division of the Supreme Court of the State of New York
DecidedAugust 10, 1987
StatusPublished
Cited by61 cases

This text of 130 A.D.2d 221 (Wilson v. Bodian) is published on Counsel Stack Legal Research, covering Appellate Division of the Supreme Court of the State of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Wilson v. Bodian, 130 A.D.2d 221, 519 N.Y.S.2d 126, 1987 N.Y. App. Div. LEXIS 46218 (N.Y. Ct. App. 1987).

Opinion

OPINION OF THE COURT

Spatt, J.

This case presents for our consideration the admissibility of physicians’ office records pursuant to the "business records” exception to the hearsay rule.

THE TRIAL

The plaintiff Helen Wilson consulted a Dr. Hyman, an ophthalmologist, in late 1979 and early 1980 with complaints concerning a growth on her left eyelid. This growth had existed for approximately three years prior to that time and had grown larger. Dr. Hyman saw the plaintiff a number of times before referring her to Dr. Colebrenner, a dermatologist, and to the defendant Dr. Martin Bodian, an ophthalmological plastic surgeon. The plaintiff acknowledged that, prior to seeing Dr. Bodian, another doctor had recommended that the growth be removed. She first saw Dr. Bodian in April 1980 [223]*223and he diagnosed the growth on the plaintiffs eyelid to be either cancerous or precancerous and recommended that it be surgically removed. According to Dr. Bodian, he did not consider taking a biopsy of the growth because it was his opinion, from his visual inspection, that it would have to be surgically removed regardless of the results of the biopsy, and he did not wish to subject this patient of advanced years to the trauma of the biopsy procedure. He did concede, however, that if the growth was not malignant, the surgery would have been less radical.

The surgery to remove the growth was performed by Dr. Bodian at the Brookdale Hospital Medical Center on June 6, 1980. After the initial operation, three additional corrective surgical procedures were performed on the plaintiffs left eyelid; two by Dr. Bodian and one by a Dr. Hornblass. Following the surgical procedures and after Dr. Bodian’s involvement ceased, the plaintiff continued to see Dr. Hyman, the original treating ophthalmologist.

In this medical malpractice action against Dr. Bodian and the Brookdale Hospital Medical Center, the plaintiff alleged, essentially, that Dr. Bodian was negligent in failing to perform certain presurgical diagnostic procedures which would have avoided what the plaintiff contended was unnecessary surgery. She maintained that as a result of the medical malpractice, namely, the unnecessary surgery, she suffered needless mutilation, has constant tearing in her left eye, and is unable to completely close the eye. The plaintiff’s theory at trial was that the initial surgery was unnecessary because the growth was not cancerous but was a condition known as actinic keratosis, a premalignant ailment which was allegedly susceptible to conservative treatment rather than the radical surgery performed. Her principal contention was that Dr. Bodian was negligent in failing to perform a biopsy or in discovering whether one had previously been performed which would have revealed a condition not requiring surgery. Crucial to the plaintiffs case was her contention that had he performed a biopsy prior to surgery, Dr. Bodian would have discovered the nature of the growth to be actinic keratosis rather than a malignancy, and, with this knowledge, he should not have performed such extensive surgery.

In support of this contention, the plaintiff called Dr. Vivian Boniuk, an ophthalmologist, who testified that accepted medical practice required that a "definitive tissue diagnosis must be made before the contemplated surgery is done”. She fur[224]*224ther stated that if a diagnosis of actinic keratosis is made, the accepted method of treatment is to burn it off or by local excision, which would have prevented the radical surgery resulting in the mutilation and injury to the eye caused by Dr. Bodian’s operation. On the other hand, Dr. Bodian testified that even if a biopsy had been done which revealed the condition to be actinic keratosis, this knowledge would not have affected his decision to surgically remove the growth. He conceded, however, that if he knew the tumor was benign he would have removed less tissue.

Another disputed issue material to the plaintiff’s case on damages was whether and to what extent the plaintiff had suffered from tearing in her left eye prior to the surgery. As a major item of her damages, she contended that the unnecessary surgery caused the tearing, while it was Dr. Bodian’s position that the plaintiff’s tearing condition predated the surgery. Thus, two key issues of fact presented were (1) whether a biopsy should have been performed on the growth on the plaintiff’s eyelid prior to the initial surgery, and (2) whether the plaintiff suffered from tearing in the affected eye prior to the surgery. Dr. Hyman was a material witness with regard to both issues and did not testify.

At the trial, the plaintiff sought to introduce into evidence the office records of Dr. Hyman. When the trial court inquired as to why Dr. Hyman was not available to testify in person, the plaintiff’s counsel stated, "I’ve subpoenaed him, Your Honor, and he has not shown”. Neither the process server nor any other witness nor any affidavit of service was produced to verify the unavailability of Dr. Hyman. Through Bernice Sorkin, an employee of Dr. Hyman whose specific duties were not revealed, the plaintiff’s counsel attempted to lay a foundation for the introduction of Dr. Hyman’s records into evidence as business records. Although the testimony of Ms. Sorkin did not follow the required statutory litany as set forth in CPLR 4518 (a), no objection was made by Dr. Bodian’s counsel on the ground of an inadequate foundation. Therefore, the defendant Bodian waived the "foundation” objection (see, Flynn v Manhattan & Bronx Surface Tr. Operating Auth., 61 NY2d 769; Horton v Smith, 51 NY2d 798; Sanchez v Kato, Inc., 115 AD2d 646; CPLR 4017; 4 Weinstein-Korn-Miller, NY Civ Prac ¶ 4017.05). The objections to the introduction of Dr. Hyman’s office records were (1) that the records were irrelevant, and (2) that "[tjhere are conclusions and statements contained in those records, the jury is going to be asked to [225]*225make inferences from that, and I cannot cross-examine those records”, which was, in effect, a hearsay objection.

Dr. Hyman’s office records consisted of five pages, of which the first page was partially typewritten and the balance was in handwritten notations and sketches. As previously noted, the gravamen of the plaintiffs case against Dr. Bodian was that the growth on her eyelid was a condition known as actinic keratosis rather than a malignancy, which condition did not require radical surgery but was susceptible to more conservative treatment. Since Dr. Bodian conceded that he did not seek to have the growth biopsied, a significant issue arose during the trial as to whether a biopsy had previously been performed at Dr. Hyman’s request. The plaintiff also contended that if Dr. Bodian had consulted with Dr. Hyman, he would have learned that a biopsy had indeed been performed and that a diagnosis of actinic keratosis had been made. The plaintiffs case was, therefore, enlarged to include the theory that a biopsy had been taken which revealed the condition to be actinic keratosis, and that, therefore, conservative treatment rather than surgery would have been the accepted standard.

Dr. Hyman’s office records contained the following entry dated April 15, 1980: "BX nose lesion—keratosis”. The plaintiffs attorney sought to elicit testimony as to the meaning of this abbreviation and term. He did not attempt to obtain an interpretation of this term by his own medical expert but, rather, did so by questioning the defendant Dr. Bodian and Dr. Bernard Kronenberg, the appellant’s medical expert. During cross-examination of Dr.

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Bluebook (online)
130 A.D.2d 221, 519 N.Y.S.2d 126, 1987 N.Y. App. Div. LEXIS 46218, Counsel Stack Legal Research, https://law.counselstack.com/opinion/wilson-v-bodian-nyappdiv-1987.