ÿWPCH 6# UN %] 0ccU<Æw@4BV 0§e AQ  0D]¡ 0J© 0Tó 0^G 0h¥ 0r  0| 0†û 0 1u 0d† Bê Æ 0DÍ 0@ 0DQ D/• BÄ D3á U> B)R DC{ AM¾ U* ^5“¢Uv~÷vÓu˜HP LaserJet 4SiHPPCL5MS,ü,,,,,ü0nLHÎ(ÈhH  Z 6Times New Roman RegularX(;cW$¡¡Ò°ÒÒ„°ÒÔ€XaBXXXÔ-šBu Z‹$Arrus BT Roman 1D23E45U6î78Ó€DGn~<$Ô3|xG(W(3Ï\$¤¤Ý ƒcW!ÝÒ°ÒÒ„°ÒÔ€X5XXXÔÝ  Ýà ` àòòÚ  Ú0Ú  Úóó !"%Cþÿ<< Cÿÿ($$””ò òÚ  Ú1Ú  Úó ó2 ÿÿ0Indent1Ô2ÔÔ3  Ô2" ÿÿ0Indent2à0 àÔ2ÔÔ3  Ô2, ÿÿ0Indent3à0 àà0 àÔ2ÔÔ3  Ô26 ÿÿ0Indent4à0 àà0 àà0 àÔ2ÔÔ3  Ô2@ ÿÿ0Indent5à0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2J ÿÿ0Indent6à0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2T ÿÿ0Indent7à0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô2^ ÿÿ0Indent8à0 àà0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô ÿÿ?AGMSYaioIndent0I.A.1.a.(1)(a)i)a)P ÿÿ8Mac DefaultMac DefaultÓ ` °šXÓ dƒLevel 1Level 2Level 3Level 4Level 5(3¯$¢¢Ý ƒ!ÝÝ  Ý("ÿÿ$££Ò  ÒÒ  Ò(#Ã$òòÚ  Ú0Ú  Úóó'''÷ÿ dxdüÿP Pd'ÿÿdxd< Œ 9p`(&Times New Roman% Line 7 d----7Border 1dd ".Cþÿ << Gÿÿ< Œ 9p`(Arial TÝ ƒ!ÝÑ  ÑÑ#€d#ÑÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÝ ƒ!"ÝÝ  ÝÔ€0ÔÔ€0ÔÓ  ÓÔ YYY ÔFILEDÔ€0XÔÌÌò òJulyÏ16,Ï1998ÌÌCecilÏCrowson,ÏJr.ÌÔ€0ôÔAppellateÏCourtÏClerkó ó ¸Ý ƒ!ÝÑ#€d#ÑÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÝ ƒ $Ýà àòòÚ  ÚÚ  ÚóóÝ  Ý€€At€trial,€Dr.€Pridham€testified€as€follows:Ìà8 àà8 àQ.€€€€€Can€you€in€any€way€reconcile€this€pathologyÏreport€with€Dr.€Souderððs€operative€report€and€whatÏshe€described€in€that€report?Ìà8 àà8 àA.€€€€€No,€that€really€does€not€make€a€lot€of€sense€toÏme.€€If€youððre€doing€a€Pomeroy€and€youððre€taking€aÏknuckle€of€tube€youððre€not€taking€the€fimbria.€€If€youÏdid€a€fimbriectomy,€which€is€a€different€procedure,Ïthen€you€would€have€the€fimbria.€€Those€donððt€makeÏsense.€€Ì ˜Ý ƒ!ÝÑ#€d#ÑÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÝ ƒ $Ýà àòòÚ  ÚÚ  ÚóóÝ  Ý€€Specifically,€Cole€mentions€Dr.€Wareððs€testimony€regarding€theÏappropriate€location€for€the€placement€of€the€fallope€ring,€the€use€of€methyleneÏblue€dye€as€a€test,€the€absence€of€scarring€in€Dr.€Souderððs€report,€the€alleged€lackÏof€evidence€of€alternative€explanations€for€the€failure€of€the€sterilization,€theÏUniversity€studies€that€Cole€attempted€to€introduce€into€evidence,€and€theÏalleged€lack€of€evidence€demonstrating€that€Dr.€Buxton€supervised€the€results.€ÌPtPtHHÚ(ÿáÿâùFG(üHHÚ(d'hStyl{WP}01•ÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃà Ãà Ãà Ãà Ãà ÃÃÃÃÃÃÃÃÃÃÃÐ ÐÐHHÐÐ  ÐÐ2ÐÐÿÿ¸æ$ÿÐÐHHÐÐÐÐÐÐÐÐ  ÐÐ ÐÐ ÐÑÑÑGenevaÑÑ ÑÑ € ÑÑ<Px–ÈÑÒÒÒ443!#4ÒÒ$ *$ÒÒ$*$ÒÒ ÿKK ÒÒ  Geneva ÒÒ  Geneva ÒÓ.,ÓÓÓÓ6ÓÓ ÓßßßßßßßßßßßßßßßßßßÑGenevaÑÑ ÑÒ  h HD: Geneva ÒÒ  h HD: Geneva ÒÝ ƒ!ÝÔ . ÔÔ€,ÔÒ  ÒÒ „ ÒÔ€ÔÝ  ÝÑ\R AØ'\ÑÑ7€¬—XXdðdÈ7ÑÑ  ÑÓ  ÓÞ ÞÌà@ àIN€THE€COURT€OF€APPEALS€OF€TENNESSEEÌà@ àAT€JACKSONÌà àà à€€€€______________________________________________ÌÌÙ€ Ùò òßR€/1.A1-j||u` à. `€€@ÿRßEARNESTINE€COLE,€ó óÌÌà àPlaintiff„Appellant,Ìà àà àà àà àà àà àà àClaims€Commission€No.€97487ÌVs.à àà àà àà àà àà àà àC.A.€No.€02A01„9801„BC„00004ÌÌò òSTATE€OF€TENNESSEE,€ó óÌÌà àDefendant„Appellee.Ì____________________________________________________________________________ÌÌà@ àFROM€THE€TENNESSEE€CLAIMS€COMMISSIONÌà@ àTHE€HONORABLE€MARTHA€BRASFIELD,€COMMISSIONERÌÌÌÌÌÌà@ àWilliam€B.€Raiford,€III;€Merkel€&€Cocke,€P.A.Ìà@ àof€Clarksdale,€MississippiÌà@ àFor€AppellantÌÌà@ àBeauchamp€E.€Brogan,€General€CounselÌà@ àJoAnn€C.€Cutting,€Assistant€General€CounselÌà@ àFor€AppelleeÌÌÌÌÌÌÌÌà@ àò òòòAFFIRMEDó óóóÌÌà@ àOpinion€filed:€€ÌÌÌÌÌà àÌà àà àà àà àà àà àà àà àò òW.€FRANK€CRAWFORD,Ìà àà àà àà àà àà àà àà àPRESIDING€JUDGE,€W.S.ÌÌÌÌCONCUR:ÌÌALAN€E.€HIGHERS,€JUDGEÌÌDAVID€R.€FARMER,€JUDGEó óÌÌÌÓÓ›à àThis€is€a€medical€malpractice€case€tried€by€the€Tennessee€ClaimsÏCommission.€€Claimant/Appellant€Earnestine€Cole€(Cole)€appeals€from€theÏjudgment€of€the€Claims€Commission€for€Defendant/Appellee€State€of€Tennessee.€ÏCole€filed€this€complaint€alleging€that€she€had€a€tubal€ligation€and€sterilizationÏperformed€while€a€patient€at€the€Regional€Medical€Center€in€Memphis,ÏTennessee.€€She€avers€that€she€was€under€the€care€and€treatment€of€Dr.€LynnÏWare,€a€medical€resident€employee€of€the€State€of€Tennessee€at€the€UniversityÏof€Tennessee€School€of€Medicine,€who€was€under€the€supervision€of€Dr.€BertramÏBuxton,€a€professor€at€the€university.€€Cole€essentially€alleges€that€the€defendant,ÏState€of€Tennessee,€through€its€employees,€breached€the€recognized€standard€ofÍacceptable€professional€practice€in€its€medical€treatment,€thus€resulting€in€herÏbecoming€pregnant€after€the€operation€was€performed.Ìà àAfter€an€evidentiary€hearing,€Commissioner€Martha€Brasfield€filed€aÏthorough€and€comprehensible€order€which€we€adopt€as€a€part€of€this€œOpinion:›Ìà8 àà8 àà àThe€claimant,€Ms.€Ernestine€Cole,€filed€a€claimÏfor€damages€against€the€defendant,€the€State€ofÏTennessee,€alleging€that€professional€malpractice€wasÏcommitted€upon€her€by€employees€of€the€UniversityÏof€Tennessee.ÌÌà8 àà8 àà àThe€Tennessee€Claims€Commission€hasÏjurisdiction€over€this€claim€pursuant€to€Tenn.€CodeÏAnn.€section€9„8„307€(a)(1)(D).€ÌÌà8 àà8 àà àThe€parties€stipulated€that€the€physiciansÏnamed€in€this€lawsuit,€Dr.€Lynn€Ware€and€Dr.ÏBertram€Buxton,€were€employees€of€the€State€ofÏTennessee€at€the€time€the€alleged€malpracticeÏoccurred.ÌÌà8 àà8 àà àOn€March€9,€1988,€the€claimant,€a€35„year„oldÏsingle€mother€of€three€children,€had€a€tubal€ligationÏand€sterilization€performed€at€the€Regional€MedicalÏCenter€in€Memphis,€Tennessee.€€Prior€to€the€surgery,Ïthe€claimant€signed€a€Consent€for€Operation€whichÏstated€a€failure€rate€of€1:300„400€for€the€type€ofÏsterilization€to€be€performed.€€The€surgery€wasÏperformed€by€Dr.€Lynn€Ware,€a€medical€resident€atÏthe€University€of€Tennessee,€under€the€supervision€ofÏDr.€Bertram€Buxton,€a€professor€at€the€University€ofÏTennessee.€€The€type€of€ligation€which€Dr.€WareÏperformed€is€known€as€a€silastic€band€tubalÏsterilization.€€In€this€type€of€procedure,€a€segment€ofÏeach€fallopian€tube€is€grasped€with€a€surgicalÏinstrument€and€doubled€(or€ð ðknuckledðð),€and€a€tinyÏsilicone€(silastic)€ring€is€slipped€over€the€ð ðknuckleðð€toÏachieve€occlusion€of€the€tube.ÌÌà8 àà8 àà àDr.€Ware€had€performed€approximately€50Ïtubal€ligations€prior€to€the€claimantððs€surgical€ligation.€ÏHer€operative€report,€dictated€less€than€an€hour€afterÏshe€performed€the€claimantððs€tubal€ligation,€statedÏthat€she€placed€a€silastic€ring€on€each€fallopian€tubeÏand€then€injected€methylene€blue€dye€through€theÏuterus€and€into€the€tubes€to€verify€occlusion.€€NoÏspillage€of€dye€was€observed€from€either€fallopian€tube.€ÏDr.€Wareððs€notes€indicate€that€Dr.€Buxton€was€inÏattendance€during€the€surgery.€€Dr.€Buxton€testifiedÏthat€he€was€ð ðquite€diligentðð€in€his€role€as€an€attendingÏsurgeon,€and€that€it€was€his€practice€to€check€hisÏstudentsðð€surgical€work€before€the€surgical€incisionÏwas€closed.€€Although€he€did€not€specifically€recallÏattending€the€claimantððs€surgery,€he€testified€that€heÏbelieved€that€he€was€present€during€the€surgery€andÏthat€œhe›€inspected€Dr.€Wareððs€work€prior€to€the€closingÏof€the€surgical€wound.€€He€signed€the€operative€reportÏ(which€was€dictated€by€Dr.€Ware€approximatelyÍtwenty€to€thirty€minutes€after€the€surgery)€as€well€asÏthe€progress€notes.ÌÌà8 àà8 àà àIn€October€of€1988,€the€claimant€discoveredÏthat€she€was€pregnant€with€twins,€who€were€deliveredÏat€Baptist€Memorial€Hospital€by€Dr.€Marva€Souder€inÏFebruary€of€1989.€€Immediately€after€the€delivery€ofÏthe€twins,€a€second€tubal€ligation€procedure€wasÏperformed€by€Dr.€Souder.€€Dr.€Souderððs€operativeÏnotes€state:ÌÌà8 àà8 àà8 àFINDINGS:€Bilaterally€normal€appearingÏfallopian€tubes.€€There€was€no€ring€foundÏon€the€right€tube.€€On€the€left€tube,€theÏFallope€ring€was€on€the€mesosalpinx,€butÏthe€tube€did€not€appear€to€be€occluded.ÌÌà8 àà8 àà8 àTECHNIQUE:€.€.€.€The€right€fallopianÏtube€was€grasped€.€.€.€and€brought€to€theÍsurface€in€its€entire€length€with€theÏfindings€as€noted€above.€€The€tube€wasÏgrasped€in€an€avascular€area€to€form€aÏknuckle€of€tube.€€A€free„tie€of€.€.€.€plainÏcatgut€was€placed€at€the€base€of€theÏknuckle.€€A€second€free„tie€was€placedÏadjacent€to€the€first€tie.€€The€knuckle€ofÏtube€was€then€excised€and€the€resultingÏpedicle€was€inspected€for€hemostasis.€€ItÏwas€then€released€to€the€abdomen.€€TheÏsame€procedure€was€performed€on€theÏleft€tube€with€findings€as€noted€above€.€.€.Ï.€ÌÌà8 àà8 àà àThe€excised€portions€of€the€tubes€were€sent€to€aÏpathology€laboratory€for€routine€analysis.€€AccordingÏto€Dr.€Thomas€Chesney,€the€pathologist€whoÏexamined€the€specimens,€the€purpose€of€the€analysisÏwas€to€determine€whether€the€fallopian€tubes€hadÍbeen€entirely€transected€by€the€second€tubal€ligationÏprocedure.€€Following€his€examination€of€theÏspecimen,€Dr.€Chesney€issued€the€following€report:ÌÌà8 àà8 àà8 àA.€€PORTION€OF€LEFT€FALLOPIANÏTUBE:€Received€is€a€2.4€cm€long€x€0.4€xÏ0.5€cm,€white„tan,€tubular€structureÏenveloped€in€a€thin,€pink„tan,€fibrousÏmembrane.€€The€tissue€is€consistent€withÏa€portion€of€fallopian€tube.€€TheÏfimbriated€end€is€identified.€€A€fallopeÏring€is€present€at€the€proximal€end€of€theÏspecimen€.€.€.€.€ÌÌà8 àà8 àà8 àB.€€PORTION€OF€RIGHT€FALLOPIANÏTUBE:€Received€in€fixative€is€a€2.2€cm€inÏlength€x€0.8€x€0.6€cm€diameter,€white„tan,Ïtubular€portion€of€tissue€enveloped€in€aÏthin,€purple„tan,€fibrous€membrane.€€TheÍtissue€is€consistent€with€a€portion€ofÏfallopian€tube€and€the€fimbriated€[sic]Ïend€is€identified€.€.€.€.ÌÌà8 àà8 àThe€report€concluded€that€the€specimens€were€twoÏð ðcompletely€transected€negative€segment[s]€ofÏoviduct.[ðð]ÌÌà8 àà8 àà àIn€approximately€May€of€1990,€at€the€claimantððsÏrequest,€Dr.€Chesney€re„examined€the€fallopian€tubeÏspecimens€(which€had€been€preserved€in€paraffin€afterÏthe€initial€laboratory€analysis).€€The€purpose€of€thisÏexamination€was€to€determine€whether€the€segmentÏremoved€by€Dr.€Souder€showed€evidence€of€tubalÏocclusion.€€Dr.€Chesney€re„sectioned€and€re„examinedÏthe€fallopian€tube€specimens€and€issued€the€followingÏreport:ÌÌà8 àà8 àà8 àNOTE:€The€remaining€available€tissueÍfrom€the€fallopian€tube€segments€.€.€.€wasÏsubmitted€for€sectioning€on€May€15,Ï1990€.€.€.€The€cross€sections€do€not€revealÏtubal€obstruction,€òònor€would€they€beÏexpected€toóó€since€the€pathologicalÏanalysis€of€these€tubes€was€directed€toÏascertainment€of€the€completeness€of€theÏtubal€interruption€procedure€of€FebruaryÏ25,€1989.€€The€portions€of€left€tube€.€.€.Ïpresent€on€the€slides€may€not€representÏthe€part€immediately€adjacent€to€theÏgrossly€identified€fallope€ring,€nor€was€itÏintended€that€the€portions€of€the€rightÏtube€.€.€.€represent€the€previously€ligatedÏarea.€€The€latter€may€indeed€still€remainÏin€the€patient.€€These€recut€slides€.€.€.Ïfirst€as€the€original€slides€.€.€.€reflectÏportions€of€the€tubes€apparentlyÏuninvolved€by€the€original€tubal€ligationÍprocedure€of€1988,€thus€no€opinion€canÏbe€rendered€as€to€the€completeness€ofÏthat€procedure€on€the€basis€of€thisÏmicroscopic€material.ÌÌà8 àà8 àà àThe€claimant€maintains€that€the€tubal€ligationÏperformed€by€Dr.€Ware€in€March€of€1988€wasÏnegligently€done.€€The€claimant€further€avers€that€Dr.ÏBuxton€failed€to€properly€supervise€the€procedureÏperformed€by€Dr.€Ware.€€As€a€result€of€this€allegedÏmalpractice,€the€claimant€maintains€that€she€hasÏsuffered€physical,€mental€and€monetary€damages.€€SheÏsues€the€defendant€for€the€recovery€of€the€costsÏassociated€with€the€pregnancy€and€birth€of€the€twins,Ïfor€the€costs€of€the€second€tubal€ligation,€for€pain€andÏsuffering,€and€for€mental€anguish.ÌÌà8 àà8 àà àThe€defendant€denies€malpractice€in€the€tubalÏligation€procedure,€and€maintains€that€the€claimantÍhas€failed€to€prove€that€Dr.€Ware€violated€theÏrecognized€standard€of€acceptable€professionalÏpractice€in€the€medical€profession.€€The€defendantÏholds€that€tubal€ligations€sometimes€fail€because€theÏfallopian€tubes€ð ðrecanalize,ðð€or€because€occludingÏdevices€(in€this€case,€silastic€rings)€can€ð ðmigrate,ððÏbreak,€or€slip€post„operatively,€either€of€whichÏcircumstances€could€arise€absent€a€physicianððsÏmalpractice.€€The€defendant€points€out€that€theÏclaimant€signed€a€consent€for€operation€form€whichÏspecifically€stated€that€tubal€ligation€procedures€fail€atÏa€rate€of€1:300„400.ÌÌà8 àà8 àà àThe€claimantððs€burden€of€proof€in€this€claim€isÏset€out€in€Tenn.€Code€Ann.€Section€29„26„115(a):€ð ðInÏa€malpractice€action,€the€claimant€shall€have€theÏburden€of€proving€by€evidence€as€provided€byÏsubsection€(b)€€(1)€The€recognized€standard€ofÏacceptable€professional€practice€in€the€profession€andÍthe€specialty€thereof,€if€any,€that€the€defendantÏpractices€in€the€community€in€which€he€practices€orÏin€a€similar€community€at€the€time€the€alleged€injuryÏor€wrongful€action€occurred;€(2)€That€the€defendantÏacted€with€less€than€or€failed€to€act€with€ordinary€andÏreasonable€care€in€accordance€with€such€standards;€(3)ÏAs€a€proximate€result€of€the€defendantððs€negligent€actÏor€omission,€the€plaintiff€suffered€injuries€which€wouldÏnot€otherwise€have€occurred.ðð€€Negligence€may€not€beÏpresumed€from€the€fact€that€the€treatment€wasÏunsuccessful.€€(òòSeeóó,€òòJohnson€v.€Lawrenceóó,€720€S.W.2dÏ430€(Tenn.€Ct.€App.€1986)€and€òòWatkins€v.€UnitedÏStates,óó€482€F.€Supp.€1006€(M.D.€Tenn.€1980).ÌÌà8 àà8 àà àœThe›€parties€essentially€agreed€that€œthe›€tubalÏligation€procedures€described€by€Dr.€Ware€in€herÏoperative€report€met€the€recognized€standard€ofÏacceptable€professional€practice€for€tubal€ligations€òòifÏthose€procedures€were€performed€as€Dr.€WareÍdescribedóó.€€The€claimant€alleges€that€the€standardÏprocedures€were€òònotóó€performed€by€Dr.€Ware€asÏdescribed€in€her€operative€notes,€that€Dr.€Ware€failedÏto€act€with€ordinary€and€reasonable€care€inÏperforming€those€procedures,€and€that€Dr.€BuxtonÏfailed€to€act€with€ordinary€and€reasonable€care€inÏsupervising€and€inspecting€Dr.€Wareððs€work.€€InÏsupport€of€her€allegations,€the€claimant€points€out€theÏfollowing:ÌÌà8 àà8 à(1)€During€the€second€sterilization€procedure,€Dr.ÏSouder€found€no€silastic€ring€on€the€right€fallopianÏtube;ÌÌà8 àà8 à(2)€Dr.€Souder€observed€no€scarring€on€eitherÏfallopian€tube;ÌÌà8 àà8 à(3)€Dr.€Souder€observed€that€the€left€silastic€ring€wasÏon€the€mesosalpinx€instead€of€on€the€fallopian€tube;ÌÌà8 àà8 à(4)€In€her€initial€deposition,€Dr.€Ware€described€anÏincorrect€location€for€placement€of€the€silastic€rings;€ÌÌà8 àà8 à(5)€There€was€no€evidence€or€opinion€that€the€leftÏsilastic€ring€had€ð ðmigratedðð€from€another€location;ÌÌà8 àà8 à(6)€There€was€no€evidence€that€the€silastic€rings€usedÏby€Dr.€Ware€were€defective€or€broken;ÌÌà8 àà8 à(7)€Although€the€methylene€dye€test€revealed€noÏspillage€of€dye€from€the€fallopian€tubes,€the€test€is€notÏa€reliable€test€of€tubal€occlusion.ÌÌà8 àà8 àà àWith€regard€to€the€surgical€procedure,€itself,Ïand€the€malpractice€allegedly€committed€by€Dr.€Ware,Ïthe€claimantððs€expert€witness,€Dr.€Albert€Alexander,€aÏretired€obstetrician€and€gynecologist,€testified€thatÏDr.€Ware€inappropriately€placed€the€left€silastic€ringÍon€the€mesosalpinx€near€the€fimbriated€end€of€the€leftÏfallopian€tube,€and€had€placed€no€ring€at€all€on€theÏright€fallopian€tube.€€He€based€his€findings€on€Dr.ÏSouderððs€operative€notes.€€He€opined€the€claimantððsÏfallopian€tubes€should€have€evidenced€scarring€had€theÏsilastic€rings€been€appropriately€placed€and€remainedÏin€place€for€as€little€as€12„24€hours.€€Dr.€AlexanderÏfurther€testified€that€a€recanalization€of€the€fallopianÏtubes€should€have€left€visible€œsigns›€which€Dr.€SouderÏshould€have€been€able€to€have€seen€during€the€secondÏsterilization€procedure.€€Dr.€Alexander€also€discountedÏthe€defendantððs€theory€that€the€silastic€rings€may€haveÏbroken,€migrated€or€slipped.€€He€stated€that€a€brokenÏor€defective€ring€should€have€evidenced€its€defectÏduring€the€surgery.€€With€regard€to€the€methylene€dyeÏtest,€Dr.€Alexander€testified€that€although€the€spillageÏof€dye€from€the€fallopian€tubes€is€a€certain€indicatorÏthat€an€attempted€occlusion€was€òònotóó€successful,€theÏtest€is€ð ðvery€unreliableðð€for€proving€successful€tubalÍocclusion;€therefore,€the€dye€test€performed€by€Dr.ÏWare€did€not€prove€conclusively€that€the€silastic€ringsÏhad€been€properly€placed.ÌÌà8 àà8 àà àThe€defendantððs€expert€witness,€Dr.€DwightÏPridham,€a€professor€at€the€University€of€LouisvilleÏmedical€school€specializing€in€obstetrics€andÏgynecology€and€in€reproductive€endocrinology,€opinedÏthat€Dr.€Souderððs€findings€with€regard€to€the€silasticÏrings€did€not€prove€that€the€rings€had€been€improperlyÏplaced€during€the€first€tubal€ligation€procedure.€€Dr.ÏPridham€testified€that€necrosis€(death€of€tissue)€oftenÏoccurs€in€the€ð ðknucklesðð€of€the€tube€formed€by€theÏligation€process,€and€that€these€knuckles€may€ð ðdropÏoffðð€following€successful€occlusion€of€fallopian€tubes,Ïleaving€the€silastic€rings€ð ðattached€to€what€was€leftÏafter€the€necrosis€had€occurred,€which€is€often€theÏmesosalpinx€below€the€fallopian€tube.ðð€€He€testifiedÏthat€the€rings€may€also€become€ð ðepithelizedðð€(coveredÍwith€tissue)€and€thus€may€not€be€visible€to€the€nakedÏeye.€€Dr.€Chesney,€the€pathologist€who€examined€theÏfallopian€tube€segments€excised€by€Dr.€Souder,€alsoÏtestified€that€the€tiny€silastic€rings€sometimes€becomeÏencapsulated€with€tissue€and€may€be€invisible€to€theÏnaked€eye.€€With€regard€to€the€lack€of€scarring,€Dr.ÏPridham€testified€that€ð ð[m]ost€of€the€time€you€canÏidentify€a€scarred€area,€an€area€that€is€absent€ofÏapparent€tubal€lumen,€but€that€is€not€always€the€case€.Ï.€.€there€have€been€a€number€of€occasions€when€I€haveÏbeen€looking€at€a€uterus,€often€at€the€time€ofÏhysterectomy€and€occasionally€at€the€time€of€re„anastomosis€(reversal€of€a€tubal€ligation)where€itððsÏbeen€difficult€to€tell€where€the€tube€has€beenÏobstructed.ððÌÌà8 àà8 àà àAll€of€the€physicians€testified€that€tubalÏligations€can€fail€due€to€the€ð ðrecanalizationðð€of€theÏfallopian€tubes.€€According€to€Dr.€Pridham,€thisÍrecanalization€is€not€always€evident€to€the€naked€eye.ÌÌà8 àà8 àà àFurther,€all€physicians€testified€and€all€proofÏindicated€that€the€methylene€blue€dye€test€is€not€aÏperfect€indicator€of€tubal€occlusion.€€œSpillage›€of€blueÏdye€from€the€fimbriated€end€of€the€tube€indicates€thatÏthe€tube€is€not€occluded;€the€fact€that€blue€dye€doesÏòònotóó€spill€from€the€fimbriated€end€is€òònotóó€proof€that€theÏtube€òòisóó€occluded.€€(The€proof€showed€that€the€dye€mayÏnot€spill€from€the€fimbriated€ends€of€a€patent€(non„occluded)€tube€for€several€reasons:€(1)€The€dye€is€notÏproperly€injected€into€the€uterus,€which€wouldÏconstitute€negligence€on€the€part€of€a€medicalÏprofessional;€(2)€The€fallopian€tube€can€spasm,Ïshutting€off€the€flow€of€the€dye;€(3)€Another€occlusionÏor€obstruction€in€the€tube€can€prevent€the€flow€of€theÏdye.€€Items€2€and€3€would€not€constitute€negligenceÏon€the€part€of€a€medical€professional.)€€Nevertheless,Ïthe€blue€dye€test€was€the€only€available€test€whichÍcould€be€performed€after€tubal€ligations€which€gave€anÏindication€of€occlusion,€and€administering€this€testÏwas€the€standard€of€care€in€this€operation.ÌÌà8 àà8 àà àIt€must€be€found€that€Dr.€Pridhamððs€credentialsÏmore€thoroughly€qualify€him€to€opine€in€the€field€ofÏtubal€ligations€and,€specifically,€in€the€area€of€re„anastomosis€of€fallopian€tubes.€€As€was€previouslyÏstated,€Dr.€Pridhamððs€area€of€specialization€is€inÏreproductive€endocrinology,€and€as€a€part€of€his€workÏhe€has€personally€viewed€the€fallopian€œtubes›€ofÏapproximately€200€women€who€had€undergone€tubalÏligations.€€(Dr.€Pridhamððs€field€of€specializationÏinvolves€reversals€of€tubal€ligations.)€€His€credentialsÏevidence€a€special€knowledge€in€the€field€ofÏsterilization€by€tubal€ligation.ÌÌà8 àà8 àà àDr.€Alexanderððs€testimony€cannot€be€given€asÏmuch€credence€as€Dr.€Pridhamððs€for€several€factualÍreasons:€(1)€Dr.€Alexander€had€never€performed€aÏtubal€ligation€using€silastic€rings;€(2)€He€hadÏpersonally€seen€the€internal€anatomy€of€only€oneÏpatient€who€had€previously€undergone€an€unsuccessfulÏtubal€ligation€procedure;€and€(3)€Dr.€AlexanderððsÏtestimony€evidenced€some€confusion€with€regard€toÏthe€usage€of€the€words€ð ðproximalðð€and€ð ðdistalðð€inÏrelation€to€the€two€ends€of€a€fallopian€tube.€€ThisÏconfusion€resulted€in€a€misinterpretation€of€theÏpathology€laboratoryððs€findings€concerning€theÏlocation€of€the€silastic€ring€found€by€Dr.€Souder.ÌÌà8 àà8 àà àDr.€Pridhamððs€testimony€effectively€and€crediblyÏrefutes€the€claimantððs€assertion€that€Dr.€Souder€s€[sic]Ïfindings€prove€that€malpractice€was€committed€by€Dr.ÏWare.€€Dr.€Pridham€gave€convincing€testimony€thatÏsilastic€bands€can€become€displaced€even€whenÏproperly€placed.€€He€also€gave€convincing€testimonyÏconcerning€a€fallopian€tubeððs€ability€to€show€noÍimmediately„visible€signs€of€scarring€and/or€occlusionÏfollowing€successful€ligation.€€Therefore,€it€wouldÏappear€that€even€though€Dr.€Souder€may€not€haveÏfound€silastic€rings€where€Dr.€Ware€should€haveÏplaced€them,€this€is€not€absolute€proof€that€Dr.€WareÏincorrectly€placed€the€rings.ÌÌà8 àà8 àà àFurther,€it€must€be€noted€that€the€accuracy€ofÏDr.€Souderððs€operative€notes€appears€questionableÏwhen€compared€with€Dr.€Chesneyððs€(the€pathologistððs)Ïfindings.€€First,€Dr.€Chesney€described€receiving€theÏfimbriated€ends€of€the€left€and€right€fallopian€tubes.€ÏDr.€Souderððs€operative€notes€indicate€that€she€excisedÏtwo€ð ðknuckle[s]€of€tube.ðð€€Dr.€Chesney€testified,€ð ð[i]tÏsounds€like€sheððs€taking€out€a€segment€of€the€midÏportion€of€the€fallopian€tube,€but€not€taking€out€theÏdistal€[fimbriated]€end€of€the€tube€.€.€.€I€would€sayÏthat€this€sounds€like€sheððs€done€a€different€operationÏthan€the€operation€you€would€do€to€get€the€specimenÍthat€we€got.ðð€€Secondly,€Dr.€Souder€described€havingÏobserved€the€left€silastic€ring€on€the€mesosalpinx,Ïwhile€Dr.€Chesneyððs€observation€was€that€the€ð ðfallopeÏring€[was]€present€at€the€proximal€end€of€theÏspecimen.ðð€€According€to€Dr.€Chesney,€the€ð ðproximalÏendðð€was€the€cut€end€of€the€specimen€„„€the€end€closerÏto€the€uterus.€€Except€for€certain€testimony€of€Dr.ÏAlexander€in€interpreting€Dr.€Chesneyððs€pathologyÏreport,€all€the€physicians€who€discussed€the€termsÏð ðproximalðð€and€ð ðdistalðð€as€it€pertained€to€a€fallopianÏtube€testified€that,€in€medical€terminology,€theÏproximal€end€of€the€fallopian€tube€was€that€partÏnearer€to€the€uterus,€and€the€distal€end€was€that€partÏnearer€to€the€fimbriated€end.€€During€specificÏquestioning€regarding€the€location€of€the€silastic€ringÏon€the€specimen€received€by€the€pathology€lab,€Dr.ÏChesney€testified€that€he€believed€that€the€ring€ð ðwasÏon€the€tube€rather€than€on€the€mesosalpinx.ðð€€Dr.ÏChesney€studied€the€specimen€in€the€laboratory€and,Ítherefore,€his€pathological€analysis€of€the€tissueÏsamples€would€have€been€more€thorough€than€Dr.ÏSouderððs€clinical€observations.€€Thus,€it€would€appearÏthat€at€least€two€of€Dr.€Souderððs€observations€„„€(1)Ïthe€portions€of€tube€she€excised€and€(2)€the€locationÏof€the€left€silastic€band€„„€were€incorrect.ÌÌà8 àà8 àà àIn€must€further€be€noted€that€Dr.€SouderððsÏclaim€that€the€fallopian€tubes€were€ð ðbrought€to€theÏsurface€in€[their]€entiretyðð€was€found€by€Dr.€PridhamÏto€be€unusual€or€unlikely.€€Dr.€Pridham€explained€that,Ïwhile€the€fimbriated€ends€of€fallopian€tubes€(theÏð ðdistalðð€ends)€are€ð ðsomewhat€loose,ðð€they€are€held€inÏplace€near€the€ovaries€by€ligaments.€€Dr.€Souder€didÏnot€use€a€laparoscope€during€the€tubal€ligationÏprocedure.€€Access€to€the€fallopian€tubes€was€gainedÏthrough€a€small€incision€(typically€ðððð€to€1",Ïaccording€to€Dr.€Pridham)€made€below€the€umbilicus.€ÏDr.€Pridham€testified€that€ð ð[w]ith€postpartumÍsterilizations€the€exposure€and€visualization€that€youÏhave€is€adequate€to€do€a€sterilization,€but€you€do€notÏhave€a€very€good€overall€visualization€of€the€entireÏpelvis€.€.€.€You€can€see€a€portion€of€things€at€a€timeÏwell€enough€to€identify€the€tube€and€to€pull€it€up€andÏto€remove€a€portion,€but€not€an€overall€visualizationÏas€you€would€have€in€a€more€routine€laparotomy,€aÏlarger€incision€.€.€.€[Y]ou€would€not€usually€be€able€toÏeasily€bring€the€entire€tube€through€the€incision€atÏone€time.€€You€can€pick€up€a€portion€and€work€yourÏway€down€the€tube€to€see€the€fimbriated€end€.€.€.ÏThatððs€because€the€tube€is€obviously€attached€toÏsomething€in€the€pelvis€.€.€.€I€really€canððt€say€itððsÏimpossible€to€do€it,€just€that€it€would€be€atypical€inÏthis€type€of€procedure€to€bring€the€entire€tube€in€theÏincision.ðð€€Dr.€Pridhamððs€testimony€evoked€additionalÏdoubt€concerning€the€accuracy€of€the€findings€asÏreported€by€Dr.€Souderððs€operative€notes.ÌÌà8 àà8 àà àDr.€Souderððs€observations€were€the€claimantððsÏonly€evidence€that€Dr.€Ware€incorrectly€placed€(orÏfailed€to€place)€the€silastic€rings€during€the€first€tubalÏligation€procedure,€but€the€discrepancies€and€odditiesÏin€her€report€rob€it€œof€much€of€its›€credibility.€€NeitherÏDr.€Pridham€nor€Dr.€Chesney€could€reconcile€Dr.ÏSouderððs€report€with€the€specimens€received€by€theÏpathology€laboratory.€€Dr.€Souder€did€not€testify€inÏthis€claim,€and€thus€these€discrepancies€remainÏunreconciled.ÌÌà8 àà8 àà àRule€of€Civil€Procedure€56.05€provides€in€partÏthat€ð ð[e]xpert€opinion€affidavits€shall€be€governed€byÏTennessee€Rule€of€Evidence€703"€which€states€asÏfollows:ÌÌà8 àà8 àà8 àThe€facts€or€data€in€the€particular€caseÏupon€which€an€expert€bases€an€opinion€orÏinference€may€be€those€perceived€by€orÍmade€known€to€the€expert€at€or€beforeÏthe€hearing.€€If€of€a€type€reasonably€reliedÏupon€by€experts€in€the€particular€field€inÏforming€opinions€or€inferences€upon€theÏsubject,€the€facts€or€data€need€not€beÏadmissible€in€evidence.€€òòThe€court€shallÏdisallow€testimony€in€the€form€of€anÏopinion€or€inference€if€the€underlyingÏfacts€or€data€indicate€lack€ofÏtrustworthinessóó.€[Emphasis€added]ÌÌà8 àà8 àà àIn€this€claim,€the€ð ðunderlying€facts€or€dataðð€onÏwhich€the€claimantððs€expert€based€his€opinion€„„€theÏoperative€report€of€Dr.€Souder€„„€lacksÏtrustworthiness.€€The€procedure€described€in€herÏoperative€notes€(i.e.,€lifting€the€entire€fallopian€tubeÏthrough€the€incision)€was,€according€to€theÏdefendantððs€expert€witness,€unlikely€or€unusual.€€MoreÏimportantly,€Dr.€Souderððs€description€of€the€portionsÍof€tube€which€she€excised€during€the€second€tubalÏligation€procedure€does€not€describe€the€portions€ofÏtube€received€by€the€pathological€laboratory.ÌÌà8 àà8 àà àIn€òòFreda€G.€Moon€v.€St.€Thomas€Hospitalóó,ÏCourt€of€Appeals,€Middle€Section,€April€25,€1997,€theÏcourt€stated,€ð ð[i]f€opinion€testimony€must€beÏdisallowed€when€the€underlying€facts€indicate€a€lack€ofÏtrustworthiness,€it€certainly€must€be€disallowed€whenÏthe€underlying€facts€are€inaccurate.ðð€€As€the€claimantððsÏexpert€witness,€Dr.€Alexander,€based€his€opinions€onÏDr.€Souderððs€operative€report,€and€as€this€operativeÏreport€appears€to€be€an€inaccurate€and€unreliableÏsource€of€information,€Dr.€Alexanderðð€testimony€andÏexpert€opinions,€which€are€based€upon€Dr.€SouderððsÏoperative€report,€should€be€disallowed€pursuant€toÏTennessee€Rule€of€Evidence€703.ÌÌà8 àà8 àà àNothing€in€Dr.€Chesneyððs€second€laboratoryÍanalysis€confirms€the€claimantððs€theory€that€the€tubalÏrings€were€mis„placed€by€Dr.€Ware.€€By€the€time€ofÏthe€second€analysis,€the€fallope€ring€had€becomeÏseparated€from€the€remainder€of€the€specimen,€andÏDr.€Chesney€could€not€locate€it.€€Dr.€Chesney€re„sectioned€the€remaining€fallopian€tube€specimens€andÏdid€not€find€evidence€of€tubal€occlusion;€however,€asÏDr.€Chesney€stated,€the€portions€of€tube€removedÏduring€the€second€sterilization€were€apparentlyÏuninvolved€in€the€first€sterilization€procedure.€€If€Dr.ÏWare€placed€the€silastic€rings€in€an€appropriate€areaÏ(which,€according€to€the€expert€witnesses,€is€theÏmiddle€third€of€the€tube,€slightly€toward€the€uterus),Ïone€would€not€expect€the€fimbriated€ends€of€the€tubesÏto€evidence€occlusion:€the€occluded€area€of€the€tubeÏwould€remain€inside€the€claimantððs€body.€€Thus,€theÏabsence€of€occlusion€in€the€specimens€sent€to€theÏpathology€laboratory€does€not€prove€that€theÏclaimantððs€fallopian€tubes€were€never€occluded€by€theÍfirst€tubal€ligation.ÌÌà8 àà8 àà àThe€claimant€points€out€that€Dr.€Ware,€in€herÏfirst€deposition,€incorrectly€described€the€properÏlocation€for€the€placement€of€silastic€bands.€€In€thatÏdeposition,€Dr.€Ware€stated€that€the€rings€should€beÏplaced€roughly€in€about€the€middle€of€the€tube,€outÏtowards€the€fimbriated€ends€rather€than€up€close€toÏ[the]€uterus.€€This€is€an€incorrect€location,€accordingÏto€the€physician€witnesses.€€In€her€second€deposition,ÏDr.€Ware,€herself,€stated€that€the€rings€should€beÏplaced€just€a€little€past€[the]€first€third€of€the€tube,€orÏcloser€to€the€uterus€than€to€the€fimbriated€ends.€€TheÏfact€that€Dr.€Ware€initially€described€an€incorrectÏlocation,€coupled€with€the€fact€that€Dr.€Chesney€foundÏthe€left€fallope€ring€at€the€cut€end€of€a€sample€whichÏwas€2.4€cm.€long€(and€testified€that€he€believed€theÏring€to€have€been€initially€placed€in€that€location),Ïtends€to€lend€weight€to€the€claimantððs€position€thatÍDr.€Ware€simply€did€not€know€the€correct€locationÏfor€placement€of€the€bands€and€put€them€in€the€wrongÏplace.€€However,€there€has€been€no€testimonyÏconcerning€the€over„all€length€of€the€claimantððsÏfallopian€tubes.€€The€physicians€testified€that€theÏlength€of€womenððs€fallopian€tubes€varies€from€six€toÏeight€centimeters.€€If€the€claimantððs€fallopian€tubesÏwere€at€the€shorter€end€of€this€estimate,€by€the€time€aÏknuckle€of€tube€was€formed€and€the€knuckle€necrosed,Ïthe€ring€might€well€have€been€properly€placed€on€theÏmiddle€third€of€the€tube€and€still€have€been€found€2.4Ïcm.€from€the€fimbriated€end.ÌÌà8 àà8 àà àIn€further€support€of€her€allegation€that€Dr.ÏWare€did€not€properly€place€the€rings€on€the€fallopianÏtubes,€the€claimant€submitted€for€introduction€fourÏstudies€performed€by€senior€medical€students€at€UT.€ÏTwo€studies€were€introduced€as€exhibits:€(1)€ð ðMethodÏFailures€of€Laparoscopic€Tubal€Sterilization€in€aÍResidency€Training€Programðð€[Exhibit€1a]€and€(2)Ïð ðChromopertubation€at€Laparoscopic€TubalÏOcclusionðð€[Exhibit€16].€€The€remaining€two€studies,Ï(3)€ð ðA€Model€for€Resident€Surgical€Training€inÏLaparoscopic€Sterilizationðð€and€(4)€ð ðGross€andÏHistologic€Examination€of€Tubal€Ligation€Failures€in€aÏResidency€Training€Program,ðð€were€introduced€asÏexhibits€Y€and€Z€for€identification€purposes€only,€withÏa€ruling€to€be€made€on€their€admissibility€in€the€finalÏorder.ÌÌà8 àà8 àà àThe€first€of€these€studies€[Exhibit€1A]€wasÏconducted€by€G.€€Michael€Henry€and€was€presented€toÏthe€UT€faculty€and€residents€by€Dr.€Henry€as€hisÏð ðsenior€paperðð€in€approximately€May€of€1988.€€ThisÏpaper€indicated€a€greater„than„average€failure€rate€forÏtubal€ligations€performed€by€UT€residents.ÌÌà8 àà8 àà àThe€second€study€evaluated€the€effectiveness€ofÍthe€methylene€blue€dye€testÏœ(chromopertubation)following›€tubal€ligations€toÏdetermine€if€the€tubes€were€occluded.ÌÌà8 àà8 àà àThe€third€study€sought€to€identify€possibleÏanatomical€reasons€for€the€high€failure€rate€of€tubalÏligations.€€This€study,€published€in€September€of€1990,Ïconcluded€that€it€was€the€residentsðð€lack€of€expertiseÏand€the€attending€surgeonsðð€failure€to€properlyÏsupervise€the€procedures€that€were€responsible€for€theÏhigh€failure€rate.ÌÌà8 àà8 àà àThe€fourth€study,€published€in€March€of€1994,Ïsuggested€training€techniques€and€for€residents€[sic]Ïwhich€were€expected€to€lower€the€failure€rate€forÏfuture€procedures.ÌÌà8 àà8 àà àThe€defendant€objected€to€the€entering€theseÏstudies€into€evidence€[sic].ÌÌà8 àà8 àà àThe€claimant€suggests€that€these€studiesÏindicate€that,€more€likely€than€not,€Dr.€Ware€wasÏnegligent€in€performing€the€claimantððs€tubal€ligation.€ÏThe€claimant€acknowledges€that€she€did€notÏparticipate€in€any€of€these€studies.€€There€is€no€proofÏthat€Dr.€Ware€performed€any€of€the€ligations€whichÏwere€included€in€the€studies€or€that€she€wasÏinterviewed€in€these€studies.€€These€studies€are€notÏrelevant€to€the€issue€as€to€whether€or€not€Dr.€WareÏwas€negligent€in€performing€the€claimantððs€tubalÏligation.€€Studies€3€and€4€will€not€be€admitted€intoÏevidence€œand€will€not›€be€considered€in€this€opinion.ÌÌà8 àà8 àà àWith€regard€to€Dr.€Buxtonððs€supervision€of€theÏprocedure€performed€upon€the€claimant€by€Dr.€Ware,Ïthe€operative€notes€reflect€that€Dr.€Buxton€wasÏpresent€in€the€operative€suite.€€Dr.€Buxton€testified€toÏan€honest€diligence€to€his€role€as€attending€physician.€ÍDr.€Buxton€did€not€have€any€specific€recollectionÏabout€the€claimantððs€surgery,€but€testified€very€firmlyÏthat€he€routinely€and€normally€checked€behind€theÏresidents,€and€that€he€would€have€left€the€operatingÏroom€when€he€ð ðhad€indeed€seen€that€the€rings€wereÏplaced€on€what€[he]€agreed€were€the€tubes,€numberÏone,€and€number€two,€waited€to€see€whether€anyÏretrograde€administration€of€methylene€blue€cameÏthrough€the€cannula€placed€in€the€uterus€and€out€theÏtubes€and€then€[he]€would€have€left€.€.€.€.ðð€€TheÏclaimant€presented€no€evidence€that€Dr.€Buxton€wasÏnot€in€the€operating€suite€or€did€not€inspect€Dr.ÏWareððs€work€before€the€closing€of€the€surgical€wound.€ÏThus,€it€must€be€found€that€the€claimant€has€failed€toÏprove€her€claim€that€Dr.€Buxton€was€negligent€in€hisÏsupervision€of€the€surgery€performed€upon€her€by€Dr.ÏWare.ÌÌà8 àà8 àà àIt€is€found€that€the€claimant€has€failed€to€carryÍher€burden€of€proving€negligence€on€the€part€of€Dr.ÏWare€and/or€Dr.€Buxton.€€Thus,€this€claim€must€beÏdismissed.€ÌÌà8 àà8 àà àIT€IS,€THEREFORE,€ORDERED,€ADJUDGEDÏAND€DECREED€that€this€claim€should€be,€and€isÏhereby,€dismissed.ÌÌà àThis€is€a€direct€appeal€from€the€Tennessee€Claims€Commission€and€isÏgoverned€by€œthe€Tennessee›€Rules€of€Appellate€œProcedure€and€T.C.A.›€ðð€œ9„8„403(a)(1)›€(Supp.€1997).€€Since€this€is€a€nonjury€case,€it€is€reviewed€ò òòòde€novoó óóóÏupon€the€record€with€a€presumption€of€correctness€of€the€CommissionerððsÏfindings€of€fact.€€T.R.A.P.€13(d),€ò òòòSanders€v.€Stateó óóó,€783€S.W.2d€948,€951€(Tenn.ÏApp.€1989).Ìà àThe€sole€issue€on€appeal€is€whether€the€evidence€preponderates€againstÏthe€Claims€Commissionerððs€finding€that€the€claimant€failed€to€show€that€theÏState€employees€did€not€conform€to€the€standard€of€care.€€Ìà àÓÔÓThe€plaintiffððs€burden€of€proof€as€set€out€in€Ó©ÓT.C.A.€ðð€œ29„26„115(a)›€(1980)Ïis€included€in€the€Commissionerððs€order.€€ÓÓCole€first€contends€that€theÍœCommissioner›€misapplied€the€plaintiffððs€burden€of€proof€by€requiring€her€toÏprove€the€physiciansðð€negligence€by€more€than€a€preponderance€of€evidence.€ÏCole€cites€the€following€portion€of€the€Commissionerððs€order€in€support€of€thisÏcontention:ÌÓÓà8 àà8 àà àDr.€Pridhamððs€testimony€effectively€and€crediblyÏrefutes€the€claimantððs€assertion€that€Dr.€Souder€s€[sic]Ïfindings€prove€that€malpractice€was€committed€by€Dr.ÏWare.€€Dr.€Pridham€gave€convincing€testimony€thatÏsilastic€bands€can€become€displaced€even€whenÏproperly€placed.€€He€also€gave€convincing€testimonyÏconcerning€a€fallopian€tubeððs€ability€to€show€noÏimmediately„visible€signs€of€scarring€and/or€occlusionÏfollowing€successful€ligation.€€Therefore,€it€wouldÏappear€that€even€though€Dr.€Souder€may€not€haveÏfound€silastic€rings€where€Dr.€Ware€should€haveÏplaced€them,€this€is€not€òòò òabsolute€proof€ó óóóthat€Dr.€WareÏincorrectly€placed€the€rings.ÌÌÓÓ(Emphasis€added).€€This€argument€is€without€merit.€€When€this€finding€isÏplaced€in€context€with€the€entirety€of€the€œCommissionerððs›€order,€it€is€clear€thatÏthe€œCommissioner›€issued€œher€ruling›€based€on€a€preponderance€of€the€evidenceÏstandard.€€€œ›à àCole€next€asserts€that€even€if€the€trial€court€employed€the€properÏburden€of€proof,€the€preponderance€of€the€evidence€does€not€support€its€ruling.€ÏThe€thrust€of€Coleððs€suit€is€based€on€the€testimony€of€her€expert,€Dr.€Alexander,Ïwho,€in€turn,€based€his€opinion€primarily€on€Dr.€Souderððs€operative€report€ofÏthe€second€sterilization€procedure.€€The€preponderance€of€the€evidence€does€notÍweigh€against€the€œCommissionerððs›€decision€to€discount€Dr.€AlexanderððsÏtestimony,€since€it€justifiably€found€that€Dr.€Souderððs€report€was€inaccurate€andÏunreliable.Ìà àAs€elucidated€in€the€œCommissionerððs›€Order,€several€unresolvedÏdiscrepancies€exist€between€Dr.€Souderððs€report€and€Dr.€Chesneyððs€pathologyÏreport.€€Namely,€there€were€discrepancies€concerning€the€segment€of€the€tubeÏthat€was€excised€by€Dr.€Souder€and€delivered€to€Dr.€Chesney× ƒ2 ××  ×€and€discrepanciesÏconcerning€the€location€of€the€silastic€band€in€relation€to€the€left€fallopian€tube.€ÏBased€on€the€testimony€of€both€Dr.€Chesney€and€Dr.€Pridham,€Dr.€SouderððsÏreport€is€inconsistent€with€the€procedure€performed.€€Furthermore,€Dr.ÏPridham€noted€that€Dr.€Souderððs€report€may€be€unreliable€due€to€the€size€of€theÏincision,€the€presence€of€inadequate€lighting,€and€the€unlikelihood€of€pulling€theÏfallopian€tubes€in€their€entirety€to€the€surface€of€the€skin€as€described€by€Dr.ÏSouderððs€report.€€Although€Coleððs€expert,€Dr.€Alexander,€attempted€to€reconcileÍthe€reports,€the€preponderance€of€the€evidence€supports€the€œCommissionerððs›Ïfinding€that€Dr.€Pridham€is€a€more€qualified€expert€for€the€reasons€set€forth€inÏthe€œCommissionerððs›€Order.€€ò òòòSee€State€v.€Ballardó óóó,€855€S.W.2d€557,€562€(ð ðInÏTennessee€the€qualifications,€admissibility,€relevancy€and€competency€of€expertÏtestimony€are€matters€which€largely€rest€within€the€discretion€of€the€trialÏcourt.ðð)€€€€In€light€of€the€unreliability€of€Dr.€Souderððs€report,€the€œCommissioner›Ïwas€justified€in€discounting€Dr.€Alexanderððs€testimony.€€ò òòòSee€ó óóóTenn.€R.€Evid.€703Ï(ð ðThe€court€shall€disallow€testimony€in€the€form€of€an€opinion€or€inference€ifÏthe€underlying€facts€or€data€indicate€lack€of€trustworthiness.ðð).Ìà àIn€her€brief,€Cole€raises€several€arguments,€each€of€which€were€discussedÏin€detail€in€the€œCommissionerððs›€Order.× ƒ3 ××  ×€€After€an€extensive€review€of€the€record,Ïwe€find€that€the€œCommissionerððs›€findings€with€regard€to€these€arguments€areÏsupported€by€the€preponderance€of€the€evidence€and€the€law.€€Although€ColeÏdid€an€exemplary€job€in€demonstrating€the€ò òòòpossibilityóóó ó€that€the€sterilizationÏprocedure€was€negligently€performed,€we€are€unable€to€hold€that€theÏpreponderance€of€the€evidence€indicates€that€the€œCommissionerððs›€findings€areÍerroneous.Ìà àThe€judgment€of€the€œCommissioner›€is€affirmed.€€Costs€on€appeal€areÏassessed€against€the€Appellant.€€ÌÓÓà àà àà àà àà àà àà à_________________________________Ìà àà àà àà àà àà àà àò òW.€FRANK€CRAWFORD,€Ìà àà àà àà àà àà àà àPRESIDING€JUDGE,€W.S.ó óÌò òœCONCUR:›ÌÌœ____________________________________›ÌALAN€E.€HIGHERS,€JUDGEó óÌÌ____________________________________Ìò òDAVID€R.€FARMER,€JUDGEó óœÔ€Ô