ÿWPC5 ÏE‡A.I úÁ9S9íÇêNø–Î:¹5û÷­}Œï„pìÑZ'Eò,¶PØ{¤~CÎhø™Ù~k‚òS?hœqD1¾hš²¡Sûcyúný¥lò ‹'­Ë#ŠÓsüšÐ‡ š5FW:èÕ/5ÎRÏ¥f“~–,gv’Ùí×|«bhOz«(†Ž Ü›Î;j’¸| fb‹_yÕ‚uÒJ:/b!{DWÇL¨Xüþr裠ۨêI¤è¦œÍ­o±[ÙmàÒ4öÔKfF¾r¹OÉMÁ„ŠÙ24Îôïë ™È£"†®I“VŒ†%»k„ÓÁ·ºÀF•uEÙ<%éI@r5芥ËYžjÌì1®«FÃ3pîknµ‚>|ñ™akTüXB@® ô«[™ù‹¹É¼yaüVøOÖ+¤¶ÿÉiN×w! ,0¶mCšÊ7YÒ²Õèø-"gX3‚n}É1{TŽ cò®CbˆˆY°ˆÞÃL×°”+ÈŸ:Œå.l 'h_v±ü>‰{<}ªcf™gKˆ¬EÙ¦9ÆoMú[Dé6Û =øÞ³I»¦32LcHP;–cP'õêÊÌ'+ý]-s€{h ¿øÐ^§ ÌËþ`{`# @UNK %™ 0(Ÿw@Ç4  V* € bˆ :  Ê 0P× 0 ”' 0D» ÿ  ª ^ ¶Â mÄNÛ 1‡Ý 1md 0cÑ 0w4 0Š« 0 5 0´Õ 0lj 0ÛP B+ 0ïH 1‹7 1‡Â 1‡I 1‡Ð W ` i# AQl&ƽ&ÿƒ' 0D‚+ 0DÆ+À , D/Ê0 Bù01 D32U:M2‡2U:‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3‹3 0DÅ3Å3Å3Å3Å3Å3Å3Å3Å3 A 4 D?ˆ4 BGÇ4˜HP LaserJet 4SiHPPCL5MS,ü,,,,,ü0nLhÎ(ÖÃ9 Z ‹6Times New Roman RegularX($¡¡ ¦ § ª  « D¬ U­ ® ¯ Ó€¹ º ©yË&tttttt3|x» waiver HendersonvilleVanderbilt- ù- 0Ñ#€O@Xÿÿd#ÑÑ € Ñ Ý ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú1Ú  ÚóóÝ  ÝE.€W.€Carmack,€Editorial,€Nashville€Tennessean,€Nov.€9,€1908,€òòquoted€inóó€òòCooper€v.Ð ° ÐStateóó,€138€S.W.€826,€832€(Tenn.1911).€((3/Q$««Ý ƒ!ÝÝ  ÝÔ d Ô(D(2ÿ$¤¤Ý ƒ!ÝÝ  ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú0Ú  Úóó(#Ã$òòÚ  Ú0Ú  Úóó úÝ ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú2Ú  ÚóóÝ  ÝJudge€Koch,€in€dissent,€asserts€in€effect€that€the€majority€opinion€grants€partialÐ ° Ðsummary€judgment€to€Dr.€Case€on€two€out€of€three€theories€of€liability€asserted€by€plaintiffs.€ÏWe€disagree.€€The€defendant€Case€neither€sought€in€the€trial€court€nor€was€granted€by€the€trialÏjudge,€partial€summary€judgment€on€any€asserted€theories.€€The€motion€for€summary€judgmentÏis€a€general€one,€addressing€the€entire€case€asserted€by€plaintiffs,€and€the€order€grantingÏsummary€judgment€is€general€and€not€issue€specific.€€This€general€order€granting€summaryÏjudgment€is€herein€reversed.€€Appellate€review€of€trial€on€the€merits€is€for€the€future. ÿÝ ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú2Ú  ÚóóÝ  ÝJudge€Koch,€in€dissent,€asserts€in€effect€that€the€majority€opinion€grants€partialÐ ° Ðsummary€judgment€to€Dr.€Case€on€five€out€of€six€theories€of€liability€asserted€by€plaintiffs.€ÏThis€is€incorrect.€€The€defendant€Case€neither€sought€in€the€trial€court€nor€was€granted€by€theÏtrial€judge,€partial€summary€judgment€on€any€asserted€theories.€€The€motion€for€summaryÏjudgment€is€a€general€one,€addressing€the€entire€case€asserted€by€plaintiffs,€and€the€orderÏgranting€summary€judgment€is€general€and€not€issue€specific.€€This€general€order€grantingÏsummary€judgment€is€herein€reversed.€€Appellate€review€of€trial€on€the€merits€is€for€the€future. dispositiveT.C.A. ARDSKilpatrickHustedEchols Jennings.draftFrazorGrubinProothWallschGraddy affdStansburyBacardiHundley i]nProsserC.J.S.ShmerlingBarksdaleReubinPrimmWickespulselessness Volz symptomatologysymptomologyunrefuted SavsHardawayPeete Sys"¨¬&ˆÿU‹ÿÀÀÀ(5hCEKQW]cioAutoList11.1.1.1.1.1.1.1.!#6,37=CIQYag­­1.a.i.(1)(a)(i)1)a)(;s±$´´Ô26,ÔÚ  Ú0Ú  Ú.Ô3  Ôà0  à(O÷{$µµà0  àÔ26,ÔÚ  ÚaÚ  Ú.Ô3  Ôà0` (#(#à(b¾Ä$¶¶à0  àà0` (#(#àÔ26,ÔÚ  ÚÚ  Ú.Ô3  Ôà0¸ ` (#` (#à(x…ò$··à0  àà0` (#(#àà0¸ ` (#` (#àÔ26,Ô(Ú  Ú0Ú  Ú)Ô3  Ôà0¸ (#¸ (#à(Œø‚$¸¸à0  àà0` (#(#àà0¸ ` (#` (#àà0¸ (#¸ (#àÔ26,Ô(Ú  ÚaÚ  Ú)Ô3  Ôà0h(#(#à(Ÿ†$¹¹à0  àà0` (#(#àà0¸ ` (#` (#àà0¸ (#¸ (#àà0h(#(#àÔ26,Ô(Ú  ÚÚ  Ú)Ô3  Ôà0Àh(#h(#à(³Ï4$ººà0  àà0` (#(#àà0¸ ` (#` (#àà0¸ (#¸ (#àà0h(#(#àà0Àh(#h(#àÔ26,ÔÚ  Ú0Ú  Ú)Ô3  Ôà0À(#À(#à d(Çû$»»à0  àà0` (#(#àà0¸ ` (#` (#àà0¸ (#¸ (#àà0h(#(#àà0Àh(#h(#àà0À(#À(#àÔ26,ÔÚ  ÚaÚ  Ú)Ô3  Ôà0p(#(#à!p·–Gaekosw{Bullet ListBullets ListA:)š½CEKQW]cioAutoList2A.A.A.A.A.A.A.A. ª½CEKQW]cioAutoList3A.A.A.A.A.A.A.A. º½CEKQW]cioAutoList4A.A.A.A.A.A.A.A. ÿÝ ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú2Ú  ÚóóÝ  ÝJudge€Koch,€in€dissent,€asserts€in€effect€that€the€majority€opinion€grants€partialÐ ° Ðsummary€judgment€to€Dr.€Case€on€five€out€of€six€theories€of€liability€asserted€by€plaintiffs.€ÏThis€is€incorrect.€€The€defendant€Case€neither€sought€in€the€trial€court€nor€was€granted€by€theÏtrial€judge,€partial€summary€judgment€on€any€asserted€theories.€€The€motion€for€summaryÏjudgment€is€a€general€one,€addressing€the€entire€case€asserted€by€plaintiffs,€and€the€orderÏgranting€summary€judgment€is€general€and€not€issue€specific.€€This€general€order€grantingÏsummary€judgment€is€herein€reversed.€€Appellate€review€of€trial€on€the€merits€is€for€the€future. ÿÝ ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú2Ú  ÚóóÝ  ÝJudge€Koch,€in€dissent,€asserts€in€effect€that€the€majority€opinion€grants€partialÐ ° Ðsummary€judgment€to€Dr.€Case€on€five€out€of€six€theories€of€liability€asserted€by€plaintiffs.€ÏThis€is€incorrect.€€The€defendant€Case€neither€sought€in€the€trial€court€nor€was€granted€by€theÏtrial€judge,€partial€summary€judgment€on€any€asserted€theories.€€The€motion€for€summaryÏjudgment€is€a€general€one,€addressing€the€entire€case€asserted€by€plaintiffs,€and€the€orderÏgranting€summary€judgment€is€general€and€not€issue€specific.€€This€general€order€grantingÏsummary€judgment€is€herein€reversed.€€Appellate€review€of€trial€on€the€merits€is€for€the€future. ùÝ ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú2Ú  ÚóóÝ  ÝJudge€Koch,€in€dissent,€asserts€in€effect€that€the€majority€opinion€grants€partialÐ ° Ðsummary€judgment€to€Dr.€Case€on€five€out€of€six€theories€of€liability€asserted€by€plaintiffs.€ÏWe€disagree.€€The€defendant€Case€neither€sought€in€the€trial€court€nor€was€granted€by€the€trialÏjudge,€partial€summary€judgment€on€any€asserted€theories.€€The€motion€for€summary€judgmentÏis€a€general€one,€addressing€the€entire€case€asserted€by€plaintiffs,€and€the€order€grantingÏsummary€judgment€is€general€and€not€issue€specific.€€This€general€order€granting€summaryÏjudgment€is€herein€reversed.€€Appellate€review€of€trial€on€the€merits€is€for€the€future.*,T-/Cþÿ<< CÿÿƒLevel 1Level 2Level 3Level 4Level 5 õÝ ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú3Ú  ÚóóÝ  ÝÔ_Ô€Ô€ôYÙ ôXXÔ€Ô‡X&X ôôYÙÔThe€validity€of€this€principle€is€made€clear€in€the€instant€case.€€Because€of€the€natureÐ ° Ðof€Dr.€Stewartððs€statements,€no€evidence€exists€which€could€be€used€to€directly€rebut€thoseÏstatements.€€What€Dr.€Stewart€believes€he€would€have€done€in€a€hypothetical€situation€isÏincapable€of€being€disproved€by€anyone€else.€€The€best€Plaintiff€can€do,€and€what€she€has€done,Ïis€present€expert€testimony€that€her€prior€symptoms€should€have€made€a€difference€under€theÏapplicable€standard€of€care.€€Thus,€there€is€a€fundamental€problem€with€dismissing€PlaintiffððsÏclaims€against€Dr.€Case€on€the€basis€of€Dr.€Stewartððs€statements€that€he€would€have€doneÏnothing€different€in€aÔ#†ôYÙ ôXX&œ#ÔÔ‡X&X ôôYÙÔ€situation€which€never€occurred.Ô#†ôYÙ ôXX&“#Ô(3¯$¢¢Ý ƒ!ÝÝ  Ý($$””ò òÚ  Ú1Ú  Úó ó ¶Ý ƒÿ$ÝÒ¼°ÒÒ„°ÒÓ  Óà  àòòÚ  Ú4Ú  ÚóóÝ  ÝJudge€Koch€in€dissent€asserts€that€there€is€no€objective€basis€for€the€trier€of€fact€toÐ ° Ðdisbelieve€Dr.€Stewart's€testimony€that€the€clinical€notes€of€Dr.€Case€would€have€had€no€effectÏon€his€subsequent€treatment€of€her.€€The€dissent€further€asserts€that€Dr.€Stewart's€testimony€onÏthis€point€is€against€his€own€interest.€€These€statements€by€the€co„defendant€Dr.€Stewart€areÏdoubtless€helpful€to€Dr.€Case€but€not€necessarily€against€the€interest€of€Dr.€Stewart.€€AnyÏstatement€by€Dr.€Stewart€attributing€diagnostic€value€to€him€of€clinical€notes€and€informationÏnot€disclosed€by€Dr.€Case€would€tend€to€detract€from€his€own€treatment€of€Mrs.€Jennings.€€HisÏtestimony€is€self„serving€as€well€as€serving€the€interest€of€Dr.€Case.€€This€is€summary€judgmentÏand€he€is€a€party€in€interest€to€the€outcome€of€the€case.€€This€alone€makes€his€credibility€aÏquestion€for€the€jury.€€òòPoole€v.€First€Nat'l€Bank€of€Smyrnaóó,€196€S.W.2d€563,€568„69;€òòPrice€v.Ð ü L  ÐAllstate€Ins.€Co.óó,€614€S.W.2d€377,€379;€and€òòCole€v.€Cliftonóó,€833€S.W.2d€75,€77.Ð è 8  Ð00'÷ÿ dxdüÿP Pd úÝ ƒ,¯"ÝÝ  ÝÔ€3XÔ'XXXÔÔ€3KX3XÔ'ÔÓ  Óò òÔ Ad ÔFILEDÔ€3XÔ'X3KÔÐ  ÐÌAugust€18,€1999ÌÌCecil€Crowson,€Jr.ÌAppellate€Court€ClerkÔdAhÔó ó 'ÿÿdxd,c½¬AZ‹"Arial Regular úÝ ƒ,¯"ÝÝ  ÝÔ€5XÔ'XXXÔÔ€5KX5XÔ'ÔÓ  Óò òÔ Ad ÔFILEDÔ€5XÔ'X5KÔÐ  ÐÌAugust€12,€1999ÌÌCecil€Crowson,€Jr.ÌAppellate€Court€ClerkÔdAhÔó ó,c½¬AZ‹"Arial Regular(3¯$££Ý ƒ!ÝÝ  ÝTyúÿ  <<= 8fæÿÿÿÿÿÿÿÿÿÿCÿÿ____3 TripledxdCTriple 1+| d d dÝ ƒ!ÝÝ  ݛҀ°ÒÒ„°ÒÔ‡¼Œ¼XXÔÑTR[¤ AØ'ÿ Legal3Ø' AØ'ÿ Legalÿ3Ø'TÑÑ  ÑÑ€ foÑÓ'€Ð‡X®è“X°œX'Óœñ¹ ññ¯ ñßr€)12<,(j 8` `€€@Eô±` 8ttxP,°ð  rßñ¯ ññ¹ ññ¹ ññ¹ ñGLENDA›€JENNINGS,€et€virà 8 àà ® à)Ð ° Ðñº ñœßt€)42>.*jxþš` `€€@EòZ` 8ttxP*À‚ š tßñº ñ›ñº ñßt€)12>.*jxþš` `€€@EòZ` 8ttxP*À‚ š tßñ¹ ñœñ¹ ññº ññ¹ ññ¹ ñKEITH€JENNINGS,à à àà 8 àà ® à)Ð À Ðà Ø àà 0 àà ˆ àà à àà 8 àà ® à)ÌÓ6€ü(‚X®˜‘X€Ð‡X®è“X6Óà Ø àPlaintiffs/Appellants,à ® à)à  àAppeal€No.Ð à0 Ðà Ø àà ® à)à  à01„A„01„9804„CV„00192Ð ð@ Ðv.à Ø àà ® à)Ð  P Ðà Ø àà ® à)à  àSumner€CircuitÐ  ` ÐKENNETH€CASE,€M.D.;€€à ® à)à  àNo.€16129„CÐ  p Ðand€CASE€MEDICAL€CLINIC,€P.C.;à ® à)Ð 0 € ÐP.C.;€W.€DAVID€STEWART,€M.D.;à ® à)Ð @  Ðand€ASSOCIATED€SURGEONS,à ® à)€à  àÐ P   Ðà Ø àà ® à)Ìà Ø àDefendants/Appellees.à ® à)Ð pÀ  Ðà Ø àà ® à)ÌÌÌÔ#†X¦pX¼¼Œ8#ÔÔ‡» »XX¦pÔÓ  ÓCOURT€OF€APPEALS€OF€TENNESSEEÐ ° ÐÌÌAPPEAL€FROM€THE€CIRCUIT€COURT€FOR€SUMNER€COUNTYÌÌAT€GALLATIN,€TENNESSEEÌÌÌTHE€HONORABLE€TOM€E.€GRAY,€JUDGEÌÓ9°,X‚Xì“X€ü(‚X®˜‘X9ÓÌÌÌÓ  ÓROBERT€J.€SHOCKEYÌ2400€Crestmoor€Road,€Suite€307ÌNashville,€Tennessee€€37215ÌÌJAMES€E.€MOFFITTÌ1013€Vista€CircleÌFranklin,€Tennessee€€37067ÌÔ#†X¦pX»» t#ÔÔ‡¼Œ¼XX¦pÔà Ø àATTORNEYS€FOR€PLAINTIFFS/APPELLANTSÐ à)0%# ÐÌÌÌROSE€P.€CANTRELLÌGEORGE€A.€DEANÌParker,€Lawrence,€Cantrell€&€DeanÌ200€Fourth€Avenue€NorthÌ5th€Floor,€Noel€PlaceÌNashville,€Tennessee€€37219Ìà Ø àATTORNEYS€FOR€DEFENDANTS/APPELLEESÌÌÓ  ÓÌREVERSED€AND€REMANDEDÌÌñ¯ ñÑ foÑÑ7€¦pXXdìXXdì7ÑÑ€ ÑÑ  ÑÑ foÑÑ#€O@Xÿÿd#ÑÑ € ÑÑ  Ññ¯ ñÌÓ  Óà @ àà @ì àWILLIAM€B.€CAIN,€JUDGEÐ à:063d ÐÑ foÑÑ7€¦pXXdìXXdì7ÑÑ€ ÑÑ  Ññ¯ ñÑ foÑÑ7€&#XXdìXXdì7ÑÑ€ ÑÑ  Ññ¯ ñÓÓÓ  ÓòòÔ#†X¦pX¼¼Œ¢#ÔÔ‡°?°XX¦pÔOPINIONóóÐ ° ÐÓ  ÓÔ#†X¦pX°°? #ÔÓ€ÓÓ9°,X°4ì“X°,X‚Xì“X9ÓÔ€¼Œ¼XX¦pÔà  àThis€is€a€medical€malpractice€action€in€which€the€trial€court€grantedÐ T¤ Ðsummary€judgment€to€both€defendant€physicians.€€The€plaintiff€has€appealedÏarguing€that€there€existed€genuine€issues€of€material€fact.€€We€agree€with€theÏplaintiff€and€reverse€the€decision€of€the€trial€court.ÌÌà  àDefendant€Kenneth€Case,€M.D.€was€an€employee€of€Sanders€and€CaseÏMedical€Clinic,€P.C.€and€at€all€times€relevant€was€acting€within€the€scope€of€hisÏemployment.€€Defendant€W.€David€Stewart,€M.D.€was€board€certified€in€generalÏsurgery.€€Plaintiff€Linda€Jennings€was€initially€a€patient€of€Dr.€Case€andÏsubsequently€of€Dr.€Stewart.€€ÌÌà  àOn€April€2,€1996,€Glenda€Jennings€went€to€the€hospital€emergency€roomÏcomplaining€of€left€arm€pain€from€her€elbow€to€her€hand.€€On€April€5,€1996,€sheÏvisited€Dr.€Case€complaining€of€the€same€symptoms.€€Dr.€Case€diagnosedÏrepetitive€use€syndrome€and€tendinitis,€thereupon€prescribing€Motrin€800Ïmilligrams€three€times€per€day€along€with€"no€work"€for€one€week.€€Dr.€CaseÏagain€saw€Plaintiff€on€April€10,€1996,€and€approved€her€return€to€work€theÏfollowing€Monday.€€Plaintiff€returned€to€see€Dr.€Case€on€April€19,€1996.€€HerÏcomplaints€on€that€date€were€continuing€left€arm€pain€and€blue€nail€beds.€€Dr.ÏCase,€suspecting€thoracic€outlet€syndrome,€referred€Plaintiff€to€Dr.€David€Stewart,Ïand€Dr.€Case's€office€immediately€scheduled€for€her€an€appointment€with€Dr.ÏStewart€on€April€23,€1996.€€In€all,€Dr.€Case€saw€and€evaluated€Plaintiff€for€her€leftÏarm€symptoms€three€times€in€the€two€week€period€from€April€5€through€April€19,Ï1996,€and€promptly€referred€her€to€an€appropriate€specialist€when€he€first€notedÏthe€blue€nail€beds,€suggestive€of€a€vascular€abnormality.ÌÌà  àDefendant€Dr.€Stewart€examined€Plaintiff€on€April€23,€1996€andÏconcluded€that€thoracic€outlet€syndrome€remained€a€possibility€but€also€that€herÏproblem€might€be€carpal€tunnel€syndrome.€€He€ordered€nerve€conduction€studiesÏwhich€were€reported€to€him€on€April€29,€1996€as€being€normal.€€Though€PlaintiffÏwas€scheduled€to€return€to€Dr.€Stewart€for€a€follow€up€visit,€she€did€not€see€himÏagain€after€the€April€23€examination.Ð ¼9 5@ Їà  àThe€symptoms€of€Glenda€Jennings€continued€with€increased€severity,Ïand€she€visited€Dr.€Verne€Allen€in€early€to€mid„May.€€Diagnostic€studies€atÏNashville€Memorial€Hospital€indicated€embolus€or€thrombus€in€the€left€subclavianÏartery.€€She€underwent€a€series€of€vascular€surgeries€beginning€on€May€13,€1996,Ïand€her€left€forearm€with€elbow€was€amputated€on€May€17,€1996€by€Dr.€LawrenceÏPass.ÌÌà  àOn€November€1,€1996,€Plaintiff€and€her€husband€Keith€Jennings€filedÏsuit€against€Drs.€Case€and€Stewart€alleging€conduct€by€both€doctors€which€fellÏbelow€the€applicable€standard€of€care.€€Drs.€Case€and€Stewart€denied€liability€inÏtheir€own€affidavits€and€presented,€in€support€of€their€motion€for€summaryÏjudgment,€additional€affidavits€from€Dr.€James€B.€Atkinson,€a€pathologist€atÏVanderbilt€University€Medical€Center,€who€had€microscopically€examinedÏspecimens€of€the€thrombus€removed€from€Plaintiff,€and€Dr.€Anthony€B.€Dallas,ÏJr.,€a€medical€doctor€in€Hendersonville,€Tennessee.€€The€record€on€summaryÏjudgment€also€includes€the€deposition€of€Dr.€Stewart€taken€May€22,€1997.€€ToÏrebut€the€summary€judgment€motion,€Plaintiff€presented€the€affidavit€of€Dr.ÏJoseph€W.€Rubin,€professor€of€surgery€at€the€Medical€College€of€Georgia€inÏAugusta,€Georgia€dated€January€29,€1998€and€a€supplemental€affidavit€from€Dr.ÏRubin€dated€March€2,€1998.€€The€trial€judge€granted€summary€judgment€to€allÏdefendants€without€factual€comment€on€March€20,€1998.€€Plaintiffs€timelyÏappealed.ÌÌà  àThe€following€familiar€rules€of€law€are€not€in€dispute:ÌÓ<€ü(€ ä è“X°,X°4ì“X<Óà  à1.à ä àThe€standard€of€care€in€a€medical€malpractice€action€and€theÐ ð*@&0 Ðdeviation€from€such€standard€of€care€along€with€proximate€cause€must€beÏestablished€by€expert€testimony€in€all€cases€not€within€the€experience€orÏknowledge€of€a€layman.€€Tenn.€Code€Ann.€ðð€29„26„115€(1980);€òòGerman€v.Ð ¸/+6 ÐNichopoulosóó,€577€S.W.2d€197,€202€(Tenn.App.1978);€òòStokes€v.€Leungóó,€651Ð P1 ,8 ÐS.W.2d€704,€706€(Tenn.App.1982).ÌÌà  à2.à ä àThe€trial€court€must€take€the€strongest€legitimate€view€of€theÐ 6h1> Ðevidence€in€favor€of€the€nonmoving€party€on€summary€judgment€and€allow€allÏreasonable€inferences€in€favor€of€that€party,€discarding€all€countervailing€evidence.€Ð H9˜4B ÐòòByrd€v.€Hallóó,€847€S.W.2d€208€(Tenn.1993).Ð ° ÐÌà  à3.à ä àAfter€applying€this€rule,€if€€"there€does€exist€a€dispute€as€to€factsÐ à0 Ðwhich€are€deemed€material€by€the€trial€court,€.€.€.€or€.€.€.€there€is€uncertainty€as€toÏwhether€there€may€be€such€a€dispute,"€the€summary€judgment€motion€must€beÏoverruled.€€òòEvco€Corp.€v.€Rossóó,€528€S.W.2d€20,€25€(Tenn.1975).Ð ¨ ø  ÐÌà  à4.à ä àThe€question€to€be€resolved€is€whether€or€not€the€two€affidavits€ofÐ Ø(  ÐPlaintiffs'€qualified€expert,€Dr.€Rubin,€are€sufficient€to€preclude€summaryÏjudgment.ÌÌI.à  àTHE€DUTY€ANALYSISÐ 8ˆ Ðà  àThis€court€has€held:€€"Whether€there€is€a€duty€owed€by€one€person€toÏanother€is€a€question€of€law€to€be€decided€by€the€court.€€However,€once€a€duty€isÏestablished,€the€scope€of€the€duty€or€the€standard€of€care€is€a€question€of€fact€to€beÏdecided€by€the€trier€of€fact."€€òòDooley€v.€Everettò ò,€óóó ó805€S.W.2d€380,€384Ð ˜è Ð(Tenn.App.1990).€€Like€the€Rule€Against€Perpetuities,€it€is€easy€to€say€but€difficultÏto€apply.€€This€"duty€as€law„scope€of€duty€as€fact"€has€produced€a€plethora€ofÏreported€cases€in€every€context€imaginable,€blurring€the€line€of€demarcation€to€theÏpoint€that€one€is€compelled€to€wonder€how€long€the€courts€can€make€"soda€andÏvinegar€to€dwell€placidly€in€the€same€bottle."׃ ×Ý ƒ%ÃÝòòÚ  Ú1Ú  ÚóóÝ  Ý×  ×Ð “$ã( ÐÌà  àThis€is€a€medical€malpractice€case€wherein€the€physician„patientÏrelationship€existed€between€Glenda€Jennings€as€patient€and€Kenneth€Case€and€W.ÏDavid€Stewart€as€physicians.€€òòOsborne€v.€Frazoróó,€425€S.W.2d€768€œ(Tenn.App.Ð ó*C&0 Ð1968);›€òòBass€v.€Barksdaleóó,€671€S.W.2d€476€(Tenn.App.1984).Ð ‹,Û'2 ÐÓ€Óà8  àà ä àProfessionals€are€judged€according€to€the€standard€ofÏcare€required€by€their€profession.€€In€òòDelmar€Vinyards€v.Ð 3/ƒ*5 ÐTimmonsóó,€486€S.W.2d€914,€920€(Tenn.App.1972),€the€CourtÐ C0“+6 Ðstated:€€"The€standard€of€care€applicable€to€the€conduct€ofÏaudits€by€public€accountants€is€the€same€as€that€applied€toÏdoctors,€lawyers,€architects,€engineers,€and€others€furnishingÏskilled€services€for€compensation€and€that€standard€requiresÏreasonable€care€and€competence€therein."€€òòSee€Cleckner€v.Ð “5ã0; ÐDaleóó,€719€S.W.2d€535€(Tenn.App.1986)€(Attorney€mustÐ £6ó1< Ðexercise€the€degree€of€care€and€diligence€which€is€commonlyÏpossessed€and€exercised€by€attorneys€practicing€in€the€sameÏjurisdiction.);€òòTruan€v.€Smithóó,€578€S.W.2d€73€(Tenn.1979)Ð Ð  Ð(Physicians€must€exercise€reasonable€and€ordinary€careÏcommensurate€with€his€skill€and€knowledge.).Ð  Ð  Ð  ÐÌòòDooleyóó,€805€S.W.2d€at€384„85€(Tenn.App.1990).€€Ó€ÓIn€this€case€the€duty€analysisÐ  ` Ðmust€be€made€in€the€context€of€the€admitted€physician„patient€relationship€and€notÏon€principles€of€duty€to€foreseeable€third€persons.€œòò€See,›€e.g.óó€òòBradshaw€v.€Danielóó,Ð @  Ð854€S.W.2d€865€(Tenn.1993);€òòPittman€v.€Upjohn€Co.óó,€890€S.W.2d€425€œ(Tenn.Ð Ø(  Ð1994).›ÌÓ€ÓÓ?€ü(€ ä @’X€ü(€ ä è“X?Óà8  àà8ä  Ð  Ð àà  àThe€relationship€of€physician€or€surgeon€andÏpatient€is€one€arising€out€of€a€contract,€express€orÏimplied.€€70€C.J.S.€Physicians€&€Surgeons,€s€37.Ð ä ðä ð Ðà8  àà8ä  Ð  Ð àà  àThe€relation€of€"physician€and€patient"€isÏcreated€when€the€professional€services€of€aÏphysician€are€accepted€for€a€purpose€of€medical€orÏsurgical€treatment,€the€relation€being€a€contractualÏone,€wherein€patient€knowingly€seeks€assistance€ofÏa€physician€and€physician€knowingly€accepts€himÏas€a€patient.€€òòFindlay€v.€Board€of€Supervisorsóó,€72Ð ˜è ÐAriz.€58,€230€P.2d€526,€24€A.L.R.2d€841€(1951).Ð ä ðä ð Ðà8  àà8ä  Ð  Ð àà  àThe€Hippocratic€Oath€by€which€every€doctor€isÏmorally€bound,€assumes€a€preexisting€relationshipÏwith€patient€and€physician,€which€relationship€in€itsÏinception€is€basically€contractual€and€whollyÏvoluntary,€created€by€agreement,€express€orÏimplied,€and€by€its€terms€may€be€general€or€limited.€ÏòòAgnew€v.€Parks,óó€172€Cal.App.2d€756,€343€P.2d€118Ð %h ! Ð(1959).Ð ä ðä ð ÐÌòòOsborneóó,€425€S.W.2d€at€771.Ð H(˜#$ ÐÌÌII.à  àKENNETH€CASE,€M.D.€and€SANDERS€&€CASE€MEDICALÐ x+È&' ÐÓ€Óà  àCLINIC,€P.C.Ìà  àDr.€Case€does€not€dispute€his€contractual€physician„patient€relationshipÏto€Mrs.€Jennings.€€He€asserts,€however,€that€his€referral€of€her€to€Dr.€Stewart€onÏApril€19,€1996€ended€his€obligations€to€her.€€This€court€has€held€relative€to€theÏduty€of€referral:ÌÓ€Óà8  àà ä àIn€132€A.L.R.€392€is€found€the€following€generalÏstatement:Ð  Ð  Ð  ÐÌà8  àà8ä  Ð  Ð àà  à"It€may€be€stated€as€a€general€rule€that,€as€a€partÏof€the€requirements€which€the€law€exacts€of€generalÏpractitioners€of€medicine€and€surgery,€or€otherÐ Ð9 57 Ðschools€of€healing,€if,€in€the€exercise€of€the€careÏand€skill€demanded€by€those€requirements,€such€aÏpractitioner€discovers,€or€should€know€or€discover,Ïthat€the€patient's€ailment€is€beyond€his€knowledgeÏor€technical€skill,€or€ability€or€capacity€to€treat€withÏa€likelihood€of€reasonable€success,€he€is€under€aÏduty€to€disclose€the€situation€to€his€patient,€orÏadvise€him€of€the€necessity€of€other€or€differentÏtreatment."Ð ä ðä ð Ðà8  àà ä àThe€many€cases€analyzed€under€this€annotation€supportÏthe€insistence€of€the€plaintiff,€the€admission€of€the€defendant,Ïand€the€testimony€of€the€defendant's€witnesses€that€theÏchronic,€persistent€condition€of€the€patient€in€this€caseÏrequired€the€defendant€to€recommend€treatment€by€specialist.Ð  Ð  Ð  Ðà8  àà ä àSince€defendant's€duty€to€refer€his€patient€to€moreÏcompetent€specialized€medical€authority€was€clearlyÏestablished,€the€question€remains,€did€the€defendant€performÏthat€duty?Ð  Ð  Ð  ÐÌœòòOsborneóó,›€425€S.W.2d€at€773.Ð à0 ÐÌÓ€ÓÌà  àIn€support€of€his€motion€for€summary€judgment,€Dr.€Case€filed€theÏaffidavit€of€Anthony€V.€Dallas,€Jr.,€M.D.,€which€states€in€part:€ÌÓ€Óà8  àMore€specifically,€Dr.€Case€alertly€and€promptly€reacted€onÏApril€19,€1996€with€regard€to€the€patient's€new€symptom€ofÏblue€nail€beds.€€Suspecting€a€vascular€or€neurologicalÏinsufficiency,€Dr.€Case€referred€Glenda€Jennings€to€a€surgeonÏwho€could€appropriately€evaluate,€provide€surgicalÏintervention,€or€make€further€referrals€for€the€patient'sÏproblem,€whether€it€proved€to€be€neurological€or€vascular.Ð  Ð  Ð  ÐÌÓ€ÓThe€undisputed€testimony€of€Dr.€Stewart€reveals:ÌÓ€Óà8  àBY€[PLAINTIFFS'€LAWYER]:Ð  Ð  Ð  ÐÌÓB€ü(€ ä ¦@’X€ü(€ ä @’XBÓà8  àà ä àQ.à ¦ à.€.€.€You€first€saw€the€plaintiff€on€April€the€23rd;€isÐ ,P'' Ðthat€correct,€Glenda€Jennings?Ð  Ð  Ð  Ðà8  àà ä àA.à ¦ àYes,€sir,€I€believe€that€is€right.Ð .p)) Ð  Ð  Ðà8  àà ä àQ.à ¦ àAll€right.€€Now,€prior€to€you€seeing€her€in€yourÐ 0/€** Ðoffice,€did€you€have€any€information€about€why€she€wasÏcoming€to€see€you?€€Dr.€Case€evidently€made€a€referral;€is€thatÏcorrect?Ð  Ð  Ð  Ðà8  àà ä àA.à ¦ àHe€made€a€referral,€and€the€referral€was€madeÐ p3À.. Ðthrough€my€personnel.€€And€a€note€was€made€that€he€wasÏsending€her€to€me€to€consider€the€possibility€of€a€thoracicÏoutlet€syndrome.€€That€was€the€only€information€I€had.Ð  Ð  Ð  Ðà8  àà ä àQ.à ¦ àDid€he€send€you€a€copy€of€his€records?а732 Ð  Ð  Ðà  àà ä àA.à ¦ àNo,€sir.Ð À843 Ðà8  àà ä àQ.à ¦ àOf,€you€know,€her€visits€to€him€in€the€precedingÐ Ð9 54 Ðseveral€weeks€about€arm€pain?Ð  Ð  Ð  Ðà  àà ä àA.à ¦ àNo,€sir.Ð À Ðà8  àà ä àQ.à ¦ àAll€right.€€Did€you€talk€to€him€on€the€telephone?ÐÐ  Ð  Ð  Ðà  àà ä àA.à ¦ àNo,€sir.Ð à0 Ðà8  àà ä àQ.à ¦ àAll€right.€€So€without€belaboring€this,€you€didn'tÐ ð@ Ðhave€any€information€that€was€contained€in€his€records€whichÏindicated€that€he€or€his€nurse€a€week€prior€„„€that's€not€a€weekÏprior€„„€I€guess€four€days€prior€in€examining€the€left€arm€notedÏthat€her€nail€beds€were€blue?Ð  Ð  Ð  Ðà  àà ä àA.à ¦ àNo,€sir.Ð @  ÐÌÓ€ÓDr.€Rubin,€in€his€affidavit€in€support€of€the€plaintiff,€states€in€part:ÌÓ€Óà8  à2.à ä àDr.€Case€violated€the€applicable€standard€of€care€inÐ øH  Ðfailing€to€provide€Dr.€Stewart€with€his€(Dr.€Case's)€records,Ïwhich€contained€important€information€concerning€Mrs.ÏJennings€condition€relative€to€her€left€upper€extremity.€€HeÏalso€violated€the€standard€of€care€in€failing€to€discuss€the€caseÏwith€Dr.€Stewart€after€the€nerve€conduction€studies€virtuallyÏruled€out€carpal€tunnel€syndrome€or€thoracic€outlet€syndromeÏinvolving€serious€nerve€injury€or€problems,€and€in€failingà @¼ àà @¼ à€toÏinitiate€vascular€testing.€€Furthermore,€in€her€deposition€Mrs.ÏJennings€relates€that€she€told€Dr.€Case€about€her€hand€beingÏcold,€and€difficulty€in€finding€a€pulse.€€If€this€testimony€isÏaccurate,€Dr.€Case's€failure€to€inform€Dr.€Stewart€of€theseÏreported€signs€and€symptoms,€and€the€fact€that€her€nail€bedsÏwere€blue,€was€a€violation€of€the€standard€of€care.Ð  Ð  Ð  Ð̛̜Ó€Óà  àœPlaintiffððs›€theory€is€that€this€slip€between€the€two€doctors€is€a€cause€ofÏher€injuries.€This€theory€has€a€basis€in€the€law€of€Tennessee€:ÌÓ€Óà8  àà8ä  Ð  Ð àWhen€two€or€more€physicians€treat€a€patient,€theyÏare€required€to€coordinate€their€evidence€andÏcommunicate€ð ðin€a€manner€that€best€serves€theirÏpatientððs€well„being.ðð€€The€ð ðextentðð€of€theÏphysicianððs€ð ðinvolvementðð€decides€what€effort€heÏmust€take€to€satisfy€his€obligation€to€communicate.€ÏThis€is€a€question€of€fact€which€depends€upon€theÏstandard€of€care€in€the€community.€€Dr.ÏShmerlingððs€testimony€is€that€he€was€Mrs.€BassððÏprimary€physician€and€that€the€standard€of€care€inÏthe€community€required€him€to€know€what€drugsÏMrs.€Bass€was€taking.€€If€the€jury€believed€Dr.ÏShmerlingððs€contention€that€he€had€turned€theÏpatient€over€to€the€public€health€department€forÏtreatment,€it€was€necessary€to€communicate€inÏorder€to€determine€the€type€of€drugs€that€were€to€beÏprescribed€for€her€treatment€of€tuberculosis€underÏwhat€he€admits€is€his€standard€of€care€in€theÏcommunity.ÐH9˜43ä ðä ð ЇòòBass€v.€Barksdaleóó,€671€S.W.2d€476€(Tenn.€App.€1984).Ð ° ÐÌÓ€Óà  àÌà  àœPlaintiff›€has€the€burden€of€proving€that€the€specific€breach€of€theÏstandard€of€care€alleged€as€to€Dr.€Case€was€a€cause€in€fact€of€her€injury.€€To€beÏsuccessful€at€trial€in€her€claim€against€Dr.€Case,€she€must€prove,€by€aÏpreponderance€of€the€evidence€that€as€a€result€of€Dr.€Caseððs€omission€toÏcommunicate€her€symptoms€to€Dr.€Stewart,€she€suffered€injuries€which€ð ðwouldÏnot€otherwise€have€occurred.ðð€€Tenn.€Code€Ann.€ðð€29„26„115(a)(3).€€In€òòKilpatrickÐ `°  Ðv.€Bryantóó,€868€S.W.2d€594€(Tenn.€1993),€the€Supreme€Court€reiterated€that€theÐ øH  Ðstandard€for€causation€in€medical€malpractice€cases€is€whether€the€physicianððs€actÏor€omission€more€likely€than€not€was€the€cause€in€fact€of€the€harm.€ExpressedÏanother€way,€the€test€is€whether€the€injury€would€not€have€occurred€but€for€theÏdefendantððs€negligence.€òòVolz€v.€Leedsóó,€895€S.W.2d€677,€679€(Tenn.€œ1995).Ð X¨ ЛÌà  àIn€òòKilpatrickóó,€the€Court€found€it€determinative€that€the€Plaintiffððs€expertÐ ˆØ Ðdid€not€state€that€the€delay€in€diagnosis€ð ðcaused€Mrs.€Kilpatrick€to€sufferÏirreparable€damage.€€It€merely€states€that€there€is€a€likelihood€or€probability€thatÏthe€delay€would€cause€irreparable€damage.ðð€€òòKilpatrickóó,€868€S.W.2d€at€597.€Ð P  " ÐPlaintiffððs€expert€evidence€herein€suffers€from€no€such€ð ðprobabilityðð€problem.€€Dr.ÏRubin,€in€his€affidavits,€testified:ÌÓ€Óà8  àà8ä  Ð  Ð àIf€Dr.€Stewart€or€Dr.€Case€had€made€a€timely€andÏaccurate€diagnosis€of€Mrs.€Jenningsðð€condition,€it€isÏmore€likely€than€not€that€prompt€and€appropriateÏtreatment€would€have€prevented€not€only€the€needÏfor€amputation€but€also€the€ARDS€suffered€by€Mrs.ÏJennings;Ð ä ðä ð Ðà@YY,êà.€.€.ˆÌÌà8  àà8ä  Ð  Ð àGenerally€speaking,€most€competent€vascularÏsurgeons€believe€that€expeditious€diagnosis€andÏtreatment€is€of€paramount€importance€in€casesÏinvolving€vascular€occlusion€of€an€upper€extremity.€ÏThe€viability€of€the€extremity€will€depend€upon€theÏspeed€with€which€the€diagnosis€is€made€andÏappropriate€care€instituted.€€We€know€that€earlyÏdetection€and€subsequent€repair€of€the€underlyingÏstenotic€lesion€will€result€in€dramatically€improvedÏpatency€and€salvage€rates.€€Excellent€limb€salvageÏrates€are€obtainable€when€delayed€diagnosis€andÏdelayed€treatment€are€avoided;ÐH9˜4;ä ðä ð Ðà@YY,êà.€.€.ˆÌÌà8  àà8ä  Ð  Ð àProper€examination,€testing€and€intervention€wouldÏhave€saved€her€arm.Ð ä ðä ð Ðà@YY,êà.€.€.ˆÌÌÓ€Óà  àFor€purposes€of€resolving€the€issue€of€the€grant€of€summary€judgment,Ïwe€are€required€to€take€the€strongest€legitimate€view€of€Dr.€Rubinððs€affidavit€inÏfavor€of€œMrs.›€Jennings,€allow€all€reasonable€inferences€in€her€favor,€and€discardÏall€countervailing€evidence.€€òòByrd€v.€Hallóó,€847€S.W.2d€208,€210„11€(Tenn.€œ1993).ñ¤ ñÐ Ø(  Ðñ“ ñ›ñ“ ññ¤ ññ“ ññ¥ ññ¦ ññ§ ññ® ñ׃×ñ® ññ® ñ׃(×ñ® ññ§ ññ§ ñ׃'×ñ§ ññ¦ ññ¦ ñ׃&×ñ¦ ññ¥ ññ¥ ñ׃×ñ¥ ñÝ ƒ%ÃÝòòÚ  Ú2Ú  ÚóóÝ  Ý×  ×›ñ“ ñÐ Ø(  ÐImplicit€in€Dr.€Rubinððs€causation€statements€is€the€conclusion€that€properÏexamination€would€have€included€review€of€œMrs.›€Jenningsðð€medical€historyÏincluding€signs€and€symptoms€observed€by€Dr.€Case.€€Regarding€these€records,ÏDr.€Rubin€stated:ÌÓ€Óà8  àà8ä  Ð  Ð àDr.€Case€violated€the€applicable€standard€of€care€inÏfailing€to€provide€Dr.€Stewart€with€his€(Dr.€Caseððs)Ïrecords,€which€contained€important€informationÏconcerning€Mrs.€Jenningsðð€condition€relative€to€herÏleft€upper€extremity.Ð ä ðä ð ÐÌà@““-êà...ˆÌÌà8  àà8ä  Ð  Ð àFurthermore,€in€her€deposition€Mrs.€JenningsÏrelates€that€she€told€Dr.€Case€about€her€hand€beingÏcold,€and€difficulty€in€finding€a€pulse.€€If€thisÏtestimony€is€accurate,€Dr.€Caseððs€failure€to€informÏDr.€Stewart€of€these€reported€signs€and€symptoms,Ïand€the€fact€that€her€nail€beds€were€blue,€was€aÏviolation€of€the€standard€of€care;Ð ä ðä ð ÐÌà@““-êà...ˆÌà  àÌÓ€Óà  àThus,€Plaintiff€has€provided€expert€testimony€to€the€effect€that€the€failureÏof€Dr.€Case€to€provide€information€about€œMrs.›€Jenningsððs€signs€and€symptoms€wasÏa€cause€of€the€failure€to€timely€and€accurately€diagnose€and,€therefore,€a€cause€ofÏthe€injuries€suffered€by€œPlaintiff.̛РP1 ,0 Ðà  àœDr.›€Stewartððs€statements€that€Dr.€Caseððs€records€would€have€made€noÏdifference€in€the€examination€procedures€he€adopted€were€in€response€to€questionsÏregarding€only€one€symptom:€blue€nail€beds.€€While€Plaintiffððs€expert,€Dr.€Rubin,Ïdiscusses€blue€nail€beds,€he€also€specifically€states€that€Plaintiffððs€report€to€Dr.ÏCase€of€cold€hand€and€pulselessness€should€have€been€conveyed€to€Dr.€Stewart.€ÏNowhere€in€his€deposition€does€Dr.€Stewart€state€that€knowledge€of€those€twoÏsigns€and€symptoms€would€have€made€no€difference.€€To€the€contrary,€aÏreasonable€fact€finder€could€conclude€from€Dr.€Stewartððs€full€testimony€thatÏknowledge€of€those€earlier€symptoms€would€have€made€a€difference€in€the€actionsÏDr.€Stewart€œtook.Ì›Ìà  àIn€his€deposition,€Dr.€Stewart€discusses€the€symptoms€and€signs€ofÏvascular€occlusion,€which€he€did€not€include€in€his€initial€diagnosis€as€a€possibleÏcause€of€œMrs.›€Jenningsððs€problems.€Dr.€Stewart€is€of€the€opinion€that€œMrs.›ÏJennings€had€two€different€conditions:€thoracic€outlet€syndrome€at€the€time€he€sawÏher€and,€later,€vascular€occlusion.€His€position€is€that€she€developed€symptoms€ofÏvascular€occlusion€after€her€only€appointment€with€œhim.›ÌœÓ€Óà8  àA.›à8ä  Ð  Ð àMy€opinion€is€ð!ð€and€this€is€absolute€ð!ð€is€that€sheÐ È" Ðhad€dramatic€changes€in€her€findings€and€herÏsymptoms€after€I€saw€her€that€one€time,€and€on€theÏbasis€of€that,€yes,€I€believe€that€she€developed€herÏvascular€occlusion€after€I€saw€her€on€the€morningÏof€that€single€visit.Ð ä ðä ð ÐØØÓL€ #š½(#!LÓœà8  àQ.à8ä  Ð  Ð àWhat›€were€the€dramatic€changes€in€herÐ (&x!( Ðsymptomatology€that€youððre€talking€about€thatÏoccurred€after€you€saw€her?€€List€those€for€me.Ð ä ðä ð ÐÓL€ $ª½((#LÓœà8  àA.›à8ä  Ð  Ð àThey€are€the€ones€that€are€related€in€Dr.€VerneÐ X)¨$+ ÐAllenððs€record.Ð ä ðä ð ÐÓL€ %º½(($LÓœà8  àQ.›à8ä  Ð  Ð àWhat?€€Name€them€for€me.€€Severe€pain?Ðx+È&-ä ðä ð Мà8  àA.›à8ä  Ð  Ð àShe€had€severe€pain.€€She€had€discoloration.€€SheÐ ˆ,Ø'. Ðhad€ò òcoldness,ó ó€and€she€had€anò ò€absent€radial€pulseó ó.И-è(/ä ðä ð ÐÓ€±_Óà  àœÌà  àWhen›€asked€specifically€what€symptoms€would€be€present€in€a€patientÏsuffering€from€an€upper€extremity€arterial€occlusion€but€would€not€be€present€inÏa€patient€with€thoracic€outlet€syndrome,€Dr.€Stewart€stated€that,€ð ðcoldness€orÏcoolness€would€be€the€one€that€would€come€to€my€mind€that€would€be€specificallyÏnot€to€be€looked€at€in€the€thoracic€outlet€syndrome.ðð€€Similarly,€at€one€point,€Dr.ÏStewart€was€asked€whether€it€would€have€made€a€difference€if€œMrs.›€Jennings€hadÏpresented€the€same€symptoms€when€he€examined€her€as€she€had€apparentlyÐ Ô9$5> Ðpresented€the€night€before€at€the€emergency€room.€€ð ðThe€symptomology€that€wasÏpresented€the€night€before€about€diminished€pulse€in€the€left€hand,€about€patchyÏblue€areas€.€.€.€would€you€have€had€vascular€occlusion€in€your€differentialÏdiagnosis?ðð€€Dr.€Stewart€answered€œyes.Ì›Ìà  àœThus,›€Dr.€Stewart€provides€testimony€that€can€be€interpreted€to€meanÏthat€the€symptoms€of€cold€hand€and€pulselessness€would€have€been€relevant€to€hisÏdiagnostic€procedures€had€he€known€about€them.€Therefore,€his€testimony€doesÏnot€provide€unrefuted€evidence€of€the€lack€of€causation€in€Dr.€Caseððs€failure€toÏtransmit€œMrs.›€Jenningsðð€signs€and€œsymptoms.Ì›Ìà  àEven€Dr.€Stewartððs€statement€that€the€records€regarding€ð ðblue€nail€bedsððÏwould€not€have€changed€his€approach€œcannot›€form€the€basis€for€dismissal€of€œMrs.›ÏJenningsððs€cause€of€action€against€Dr.€Case.€€Dr.€Stewartððs€statements€that€heÏwould€not€have€done€anything€differently€even€if€he€had€received€all€Dr.€CaseððsÏinformation€regarding€the€patientððs€signs€and€symptoms€constitute€conclusions€orÏspeculation€about€what€Dr.€Stewart€would€or€would€not€have€done€in€a€situationÏwhich€never€œoccurred.Ì›Ìà  àIt€is€well€settled€that€testimony€which€amounts€to€mere€speculation€is€notÏevidence€which€can€establish€proximate€cause.€€òòPrimm€v.€Wickes€Lumber€Co.óó,€845Ð $à( ÐS.W.2d€768,€771€(Tenn.€App.€1992).€€Similarly,€ð ðthe€mere€possibility€of€a€causalÏrelationship,€without€more,€is€insufficient€to€qualify€as€an€admissible€expertÏopinion.ðð€€òòLindsey€v.€Miami€Development€Corp.óó,€689€S.W.2d€856,€862€(Tenn.Ð X)¨$. Ð1985).€€Applying€this€principle€to€expert€proof€of€proximate€cause€in€a€medicalÏmalpractice€case,€this€court€has€held€that€since€a€judgment€cannot€be€based€onÏconjecture€or€speculation,€the€probable€cause€of€an€injury€must€be€shown€to€beÏreasonably€certain,€and€not€a€mere€likelihood€or€possibility.€€òòWhite€v.€MethodistÐ ¸/+6 ÐHosp.€Southóó,€844€S.W.2d€642,€649€(Tenn.€App.€1992).€€Logic€demands€that€theÐ P1 ,8 Ðconverse€is€true:€speculation€about€a€situation€which€never€occurred€cannotÏconstitute€evidence€sufficient€to€prove€lack€of€œcausation.Ì›Ìà  àIt€is€well€settled€that€the€testimony€of€a€physician€as€to€what€he€wouldÏdo€or€his€opinion€of€what€should€have€been€done€does€not€prove€the€standard€ofÐ H9˜4B Ðcare.œ×ƒ+×Ý ƒ%ÃÝòòÚ  Ú3Ú  ÚóóÝ  Ý×  ×›€€òòRoddy€v.€Volunteer€Medical€Clinic,€Incóó.,€926€S.W.2d€572,€578€(Tenn.€App.Ð ° Ð1996);€òòLewis€v.€Hill,€óó770€S.W.2d€751,€754€(Tenn.€App.€1988);òò€Crawford€v.€FamilyÐ H˜ ÐVisionóó€òòCenter,€Incóó.,€1990€WL€177351€(Tenn.€App.€1990).€In€òòRoddyóó,€this€principleÐ à0 Ðwas€applied€to€a€physicianððs€affidavit€which€failed€to€state€that€the€plaintiff€hadÏsuffered€injuries€from€the€defendantððs€negligence€which€would€not€otherwise€haveÏoccurred,€therefore€failing€to€prove€causation.€€Inòò€Crawfordóó,€the€court€found€thatÐ ¨ ø  Ðthe€ophthalmologist„witness€did€not€testify€as€to€the€recognized€standard€ofÏacceptable€practice,€but€only€testified€as€to€the€practice€in€his€own€office.€€TheÏcourt€found€such€testimony€insufficient€to€establish€the€standard€of€practice.€ÏBased€upon€these€holdings,€Dr.€Stewartððs€statements€as€to€the€potential€effect€ofÏthe€lack€of€œMñ‘ ñrñ‘ ñs.›€Jenningsðð€prior€history€do€not€establish€the€absence€of€causation.Ìà  àœÌ›à  àEven€discounting€the€portion€of€Dr.€Rubin's€affidavit€relative€toÏdiscussion€with€Dr.€Stewart€about€the€nerve€conduction€studies€which€occurredÏafter€the€referral,€it€is€still€clear€that€according€to€Dr.€Rubin's€expert€testimony,€theÏfailure€of€Dr.€Case€to€inform€Dr.€Stewart€of€the€signs€and€symptoms€he€observedÏon€April€16,€1996,€including€the€fact€that€Plaintiff's€nail€beds€were€blue,€violatedÏthe€standard€of€care.€€This€conclusion€by€Dr.€Rubin€is€buttressed€by€the€affidavitÏof€Dr.€Dallas€that€Dr.€Case€"alertly€and€promptly€reacted"€to€the€patient's€newÏsymptom€of€blue€nail€beds€from€which€Dr.€Case€suspected€"a€vascular€orÏneurological€insufficiency."€€Dr.€Case€had€a€duty€to€refer€Mrs.€Jennings€butÏwhether€such€"referral"€can€be€accomplished€in€silence€or€must€be€accompaniedÏby€appropriate€information€provided€to€the€referee€in€order€to€meet€the€standardÏof€care€is€a€question€of€fact€raised€by€expert€testimony€and€precludes€summaryÏjudgment.ÌÌà  àœThe›€applicable€standard€of€care€is€set€by€Tennessee€Code€AnnotatedÏsection€29„26„115.€€"The€testimony€of€a€physician€as€to€what€he€would€do€or€hisÐ ¸/+6 Ðopinion€of€what€should€have€been€done€does€not€prove€the€statutory€standard€ofÏmedical€practice."€€òòLewis€v.€Hillóó,€770€S.W.2d€751,€754€œ(Tenn.App.€1988).׃.×Ý ƒ%ÃÝòòÚ  Ú4Ú  ÚóóÝ  Ý×  ×Ð H˜ ÐÌIII.›à  à€DR.€W.€DAVID€STEWARTÐ x È Ðà  àThe€physician„patient€relationship€was€established€between€GlendaÏJennings€and€Dr.€Stewart€when€he€first€examined€her€on€the€morning€of€April€23,Ï1996.€€The€affidavit€of€Dr.€Rubin€provides€in€part:ÌÓ€Óà8  à3.à ä àDr.€Stewart€violated€the€applicable€standard€of€care€inÐ Ø(  Ðfailing€to€observe€symptoms€indicative€of€arterial€obstructionÏduring€the€patient€visit€of€April€23,€1996€that€were€there€to€beÏseen€or€appreciated.€€These€signs€and€symptoms€includedÏsevere€pain€in€the€left€shoulder,€arm€and€hand;€patchy,€blueÏdiscoloration€of€the€left€hand;€and€decreased€pulse€in€the€leftÏupper€extremity.€€All€of€these€symptoms€had€been€present€inÏthe€previous€evening€at€the€Columbia/HCA€HendersonvilleÏHospital€Emergency€Room,€at€11:30€p.m.€€The€same€signs€andÏsymptoms€noted€at€the€Hendersonville€Hospital€ER€on€theÏevening€prior€to€Dr.€Stewart's€examination€of€Mrs.€JenningsÏwere€more€likely€than€not€present€when€Dr.€Stewart€examinedÏMrs.€Jennings€approximately€10€hours€after€her€ER€visit.€€Dr.ÏStewart's€failure€to€note€the€symptoms€of€left€upper€extremityÏocclusion€caused€his€failure€to€initiate€appropriate€treatment.Ð  Ð  Ð  ÐÓ€ÓÌDr.€Stewart,€in€his€deposition,€agreed€with€the€"more€likely€than€not€"€opinion€ofÏDr.€Rubin.€€Dr.€Stewart€testified€as€follows:ÌÓ€Óà8  àà ä àQ.à ¦ à.€.€.€You're€saying€that€if€a€patient€actually€has€aÐ $à# Ðthoracic€outlet€syndrome,€the€symptomatology€that€sheÏpresented€on€the€night€of€April€22nd€and€the€findings€of€theÏ22nd€could€well€be€absent€the€next€day€when€she€saw€you.Ð  Ð  Ð  Ðà  àà ä àA.à ¦ àYes,€sir.Ð Ð( $' Ðà8  àà ä àQ.à ¦ àAll€right.€€Now,€let's€say€that€it€is€not€a€thoracicÐ à)0%( Ðoutlet€syndrome€that€is€her€problem,€that€the€pain,€theÏdiscoloration,€the€blue€discoloration,€the€weaker€pulse€in€theÏleft€hand€than€the€right,€the€patchy€blue€areas,€was€caused€byÐ -`(+ Ða€vascular€obstruction.€€If€that€was€the€case€on€April€22nd,Ï1996,€if€that€was€the€case,€would€you€have€expected€all€ofÏthese€symptoms€to€be€present€the€next€morning€when€you€sawÏher?Ð  Ð  Ð  Ðà  àà ä àA.à ¦ àMost€likely.Ð ð@ Ðà  àà ä àQ.à ¦ àAll€right.€€Most€likely,€correct?Ð  P Ðà  àà ä àA.à ¦ àYes,€sir.Ð  ` ÐÌÓ€ÓDr.€Rubin€further€asserted€that€Dr.€Stewart€failed€to€obtain€an€adequate€familyÏhistory€and€failed€to€perform€an€adequate€physical€examination€by€evaluating€allÏpulses€and€blood€pressure€in€both€arms€to€exclude€arterial€stenosis€or€obstructions.€ÏDr.€Stewart€testified€that€his€pulse€readings€and€evaluations€were€limited€to€the€leftÏextremity.ÌÌà  àIn€defense€Dr.€Stewart€presented€the€affidavit€of€Dr.€James€B.€Atkinson,ÏDirector€of€the€Laboratory€of€Surgical€Pathology€for€Vanderbilt€UniversityÏMedical€Center.€€Dr.€Atkinson€opined€that€the€thrombi€removed€from€the€leftÏsubclavian€artery€of€Glenda€Jennings€on€May€13,€1996€could€not€have€beenÏpresent€before€May€1,€1996€and€thus€would€not€have€existed€at€the€time€Dr.ÏStewart€examined€Mrs.€Jennings€on€April€23,€1996.€€Dr.€Rubin€countered€in€hisÏaffidavit€asserting€the€following:ÌÓ€Óà8  à9.à ä àDr.€Atkinson's€Affidavit€pertaining€to€the€age€of€theÐ è!8" Ðthrombi€which€occluded€the€arteries€of€Mrs.€Jennings'€left€armÏmakes€no€effort€to€address€the€question€of€whether€or€not€theÏcondition€that€òòcausedóó€the€thrombi€did€or€did€not€exist€on€orÐ %h % Ðprior€to€May€1,€1996.€€The€age€of€the€thrombi€studied€by€Dr.ÏAtkinson€is€in€no€way€dispositive€of€the€issue€of€Mrs.ÏJennings'€condition€on€and€prior€to€May€1,€1996.€€It€is€furtherÏmy€opinion€that€the€occlusive€condition€did€exist€at€thoseÏtimes,€and€timely€treatment€would€have€prevented€the€thrombiÏthat€ultimately€caused€the€loss€of€Mrs.€Jennings'€arm.€€Dr.ÏAtkinson's€Affidavit€truly€begs€the€question€of€causation.€ÏAssuming€that€his€findings€are€accurate€in€that€the€thrombiÏremoved€from€Mrs.€Jennings'€left€subclavian€artery€whichÏoccluded€"these€arteries€of€Mrs.€Jennings"€and€ultimatelyÏnecessitated€the€amputation€of€her€arm,€were€less€than€24„48Ïhours€in€age€and€in€some€cases€10„11€days€in€age,€one€couldÏwell€conclude€that€these€thrombi€were€not€present€prior€toÏMay€1,€1996.€€However,€the€essential€point€is€that€theseÏ"offending"€thrombi€would€have€been€òòpreventedóó€but€for€theÐ 5X04 Ðnegligence€of€Drs.€Case€and€Stewart€in€failing€to€diagnoseÏMrs.€Jennings'€subclavian€occlusive€problem€earlier.€€BasedÏupon€a€reasonable€degree€of€medical€and€scientific€certainty,ÏMrs.€Jennings€had€signs€and€symptoms€of€upper€extremityÐ H9˜48 Ðvascular€occlusion€well€prior€to€May€2,€1996,€which€shouldÏhave€been€observed€by€Drs.€Case€and€Stewart,€whichÏobservation€should€have€permitted€accurate€diagnosis€andÏtreatment€by€competent€physicians.€€Such€diagnosis€wouldÏhave€required€immediate€medical€treatment,€which€treatmentÏwould€more€likely€than€not€have€prevented€the€very€thrombiÏand€occlusions€discussed€by€Dr.€Atkinson.€€Drs.€Case€andÏStewart€had€the€opportunity€and€the€responsibility€to€stop€theÏdisease€progression€which€they€failed€to€do,€resulting€in€theÏthrombi€mentioned€in€Dr.€Atkinson's€Affidavit.Ð  Ð  Ð  ÐÌÓ€ÓThus,€regardless€of€the€age€of€the€thrombi,€a€question€of€fact€remains€as€to€Dr.ÏStewart's€œcompliance€with€the€applicable€standard›€of€care.ÌÌIV.à  àCONCLUSIONÐ (x Ðà  àThe€record€establishes€the€foregoing€questions€of€fact€as€to€complianceÏwith€the€applicable€standard€of€care€which€under€òòDooley€v.€Everettóó€address€theÐ X¨ Ðscope€of€the€duty€rather€than€the€duty€itself,€scope€of€duty€and€standard€of€careÏbeing€synonymous€terms€under€òòDooleyóó.€€805€S.W.2d€380,€384€(Tenn.App.1990).€Ð ˆØ ÐWhat€the€trier€of€fact€may€do€with€this€case€at€trial€remains€to€be€seen.€€What€thisÏcourt€must€do€on€summary€judgment€is€clear.€€As€to€both€defendants,€there€existsÏa€dispute€as€to€material€facts€or€at€the€very€least€"there€is€uncertainty€as€to€whetherÏthere€may€be€such€a€dispute."€€òòEvco€Corp.€v.€Rossóó,€528€S.W.2d€20,€25€œ(Tenn.Ð è!8! Ð1975).›€€The€action€of€the€trial€court€in€granting€summary€judgment€for€theÏdefendants€is€reversed€and€the€case€is€remanded€to€the€trial€court€for€trial€on€theÏmerits.€€Costs€of€this€appeal€are€assessed€equally€to€the€defendants.ÌÌœñŽ ñÌñŽ ññ’ ñ›ñ’ ñÓ€ÓÌ›€à  à€Ð ð*@&, ÐÓE€ ü(€ ä ¦˜‘X€ü(€ ä ¦@’XEÓ€€à  àà ä à€à ¦ à€€€à  à___________________________________Ð ,P'- Ðà  àà ä àà ¦ àà  àWILLIAM€B.€CAIN,€JUDGEÌÌœñª ñCONCURRING€IN€PART,€ÌDISSENTING€IN€PART€UNDER€ÌSEPARATE€OPINIONÌWILLIAM€C.€KOCH,€JR.,€JUDGEñª ññ« ñÌñ ñÌÌñ ññ« ññ ñCONCUR:ñ ñÌÌ___________________________________ÌPATRICIA€J.€COTTRELL,€JUDGEà  àñ¬ ñÐ `2°-3 ÐÌÌÌñ¬ ññ­ ñCONCURRING€IN€PART,€ÌDISSENTING€IN€PART€UNDER€ÌSEPARATE€OPINIONÌWILLIAM€C.€KOCH,€JR.,€JUDGEñ­ ñ