ÿWPC@7 I#  %n­ 0 4ÌUBUNBn­w@=4}‘ 0‚  0Ä"æ AQî 0J? Y>‰ 0TÇ Æ 0Dá 0^% 0hƒ 0rë 0|] 0†Ù B_ 0| 0D  0@P 1u D/ 0d4 B˜ D3µU 6èU.U *LB)vDCŸ AMâý/U">,»j`%Æ…ØKg #nŠ'÷ø,v~ï/vÓm1˜HP LaserJet 4SiHPPCL5MS,ü,,,,,ü0nLhÎX«<þ6X9`(*Courier 12pt10cpiXXxþ6X@ÉJQX@( ¤T$¡¡Ó  Ó<þ6X9`(*Courier 12pt10cpi(ÈhH  Z ‹6Times New Roman Regular«<þ6X9`(*Courier 12pt10cpiXXxþ6X@ÉJQX@ tEuvEw[xyUzU{U|Ó€†ê‚_#3|xˆ(AÎi$Ô€X†èXXXÔÔ€X†èXX X†èÔòòÚ  Ú0Ú  Úóó(t(2&”$¤¤Ý ƒ¤T!ÝÓ  ÓÝ  ÝÒ€°ÒÔ€XQMXXXÔÔ€XQMXXXQMÔà Ø àòòÚ  Ú0Ú  Úóó"#&Cþÿ<< Cÿÿ2 ÿÿ0Indent1Ô2ÔÔ3  ÔG:\IB011S16\RULE11\R11-MLD.FRM2" ÿÿ0Indent2à0 àÔ2ÔÔ3  ÔƒLevel 1Level 2Level 3Level 4Level 5($$””ò òÚ  Ú1Ú  Úó ó2, 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  Ô d2^ ÿÿ0Indent8à0 àà0 àà0 àà0 àà0 àà0 àà0 àÔ2ÔÔ3  Ô(3¯$¢¢Ý ƒ!ÝÝ  Ý("ÿÿ$££Ò  ÒÒ  Ò! ÿÿ?AGMSYaioIndent0I.A.1.a.(1)(a)i)a)(('÷ÿ dxdP ÿÿ8Mac DefaultMac DefaultÓ ` °šXÓüÿP Pd 'ÿÿdxd< Œ 9p`(Courier New< Œ 9p`(Courier< Œ 9p`(Arial% Line 7 d66667Border 1dd#7Cþÿ << Gÿÿ óÝ ƒ!ÝÔ€2ÔÝ  ÝÝ ƒ""ÝÝ  ÝÔ€4ÔÔ€4ÔÓ  Óò òÔ YYY ÔFILEDÔ€4XÔÌÌFebruary€17,€1998ÌÌCecil€W.€CrowsonÌAppellate€Court€ClerkÔ  Ôó ó< Œ 9p`(&Times New Roman ±Ý ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔTenn.€Code€Ann.€ðð€29„26„116€provides€for€a€one„year€statute€of€limitations€inÏmalpractice€actions,€but€ð ð[i]n€the€event€the€alleged€injury€is€not€discovered€within€said€one€(1)Ïyear€period,€the€period€of€limitation€shall€be€one€(1)€year€from€the€date€of€such€discovery.€€In€noÏevent€shall€any€action€be€brought€more€than€three€(3)€years€after€the€date€on€which€theÏnegligent€act€or€omission€occurred€except€where€there€is€fraudulent€concealment€on€the€part€ofÏthe€defendant€in€which€case€the€action€shall€be€commenced€within€one€(1)€year€after€discoveryÏthat€the€cause€of€action€exists.ðð€€Tenn.€Code€Ann.€ðð€29„26„116(a)(1),€(2)€and€(3).€€Ô€;ÔÔ€;XÔÌ VÝ ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔThe€ð ðpedicleðð€is€part€of€the€vertebra.€€Ô€;ÔÔ€;XÔÌ ¼Ý ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔThe€letter€from€Dr.€Coker€to€Shadrickððs€attorney€states€in€pertinent€part:€ð ðI€think€toÏsimplify€what€has€happened,€it€might€be€reasonable€to€say€that€[Shadrickððs]€emotions€haveÏbecome€imprinted€with€the€pain€that€he€initially€experienced€and€his€emotions€have€not€let€go€ofÏthat€pain€even€though€his€disk€and€nerve€appear€to€have€let€go€of€it.€€This€type€of€fixation€is€notÏunheard€of€but€it€certainly€is€a€difficult€situation€to€resolve.€€Obviously,€[Shadrick]€has€had€severalÏsurgical€procedures,€none€of€which€have€made€him€any€better.€€The€differential€spinal€test€plusÏthe€psychological€tests€indicated€that€he€has€a€fixation€on€the€pain€which€is€not€supported€by€hisÏphysical€findings.€€This€does€not€imply€in€any€way€that€[Shadrick]€is€mentally€deranged,€it€onlyÏindicates€that€he€has€unconsciously€grasped€the€concept€of€having€chronic€pain€and€will€notÏconsciously€dismiss€that€from€his€mind.ðð€€Ô€;ÔÔ€;XÔÌ ÎÝ ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔThe€Shadricks€voluntarily€dismissed€their€appeal€against€Centennial€Medical€CenterÏafter€this€Court€granted€review.€€Thus,€the€only€defendant€before€us€is€Dr.€Coker.€Ô€4XÔÔ€;ÔÌ ] Ý ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔAccording€to€Dr.€Frederick,€Shadrick€should€have€been€informed€of€the€following:€thatÏthe€pedicle€screws€were€not€approved€by€the€FDA;€that€the€screws€were€€experimental;€that€theÏscrews€might€cause€a€fracture€of€bony€structures€in€the€spine;€that€the€screws€might€causeÏbursitis€to€develop€over€the€implants;€that€the€screws€might€break€or€loosen;€that€the€screwsÏmight€cause€delayed€nerve€root€irritation€or€injury€due€to€displaced€or€broken€implantÏcomponents;€that€the€patient€might€experience€bone€resorption€around€the€implants€resulting€inÏloosening€or€displacement€of€the€device;€that€the€implants€might€cause€an€allergic€reaction€to€aÏforeign€body€due€to€metal€sensitivity;€that€the€patient€might€suffer€pain,€discomfort€or€abnormalÏsensations€caused€by€the€presence€of€the€implants;€that€additional€surgery€might€be€requiredÏafter€normal€healing€has€occurred€to€remove€the€implants;€that€the€implants€might€cause€irritationÏor€discomfort;€that€the€screws€might€cause€prolonged€illness,€a€draining€wound,€the€need€forÏblood€transfusions,€the€need€for€further€major€surgery€and/or€permanent€pain,€deformity€andÏinconvenience;€that€the€screws€might€fail€to€achieve€their€objective€and€that€the€implants€might€inÏfact€cause€the€patientððs€pain€level€and€disability€to€become€worse;€that€the€patient€might€sufferÏpossible€local€or€systemic€adverse€reactions€from€any€potential€degradation€products;€that€aÏmechanical€grinding€action€could€possibly€occur€that€might€generate€wear€debris;€that€the€wearÏdebris€that€might€occur€could€cause€local€bone€loss€in€articulating€joints;€that€excessive€orÏrepeated€stresses€on€the€implants€might€cause€them€to€break€or€loosen€and€cause€the€failure€ofÏthe€surgical€procedure;€that€the€patient€was€participating€in€a€clinical€investigation€study;€that€theÏscrews€might€cause€dural€leaks;€that€the€implants€might€cause€paralysis;€that€the€screws€mightÏcause€sensory€loss;€that€the€screws€might€cause€loss€of€bowel€or€bladder€control;€that€theÏimplants€might€cause€retrograde€ejaculations€or€impotence;€and€that€the€screws€might€causeÏscarring€of€nerve€roots.ÌÔ€;ÔÔ€;XÔ dÝ ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔThe€burden€of€proof€on€the€standard€of€care€element€is€controlled€by€Tenn.€Code€Ann.Ïðð€29„26„118,€which€requires€that€in€a€lack€of€informed€consent€action€the€plaintiff€prove,€byÏexpert€testimony,€ð ðthat€the€defendant€did€not€supply€appropriate€information€to€the€patient€inÏobtaining€his€informed€consent€to€the€procedure€out€of€which€plaintiffððs€claim€allegedly€arose€inÏaccordance€with€the€recognized€standard€of€acceptable€professional€practice€in€the€professionÏand€in€the€speciality,€if€any,€that€the€defendant€practices€in€the€community€in€which€he€practicesÏor€in€similar€communities.ðð€€òòSeeóó€òòalsoóó€òòGerman€v.€Nichopoulosóó,€577€S.W.2d€197,€204€(Tenn.€App.Ï1978)€(ð ð[I]n€matters€of€informed€consent€the€plaintiff€has€the€burden€of€proving€by€expertÏmedical€evidence,€(a)€what€a€reasonable€medical€practitioner€of€the€same€or€similar€communitiesÏunder€the€same€or€similar€circumstances€would€have€disclosed€to€the€patient€about€theÏattendant€risks€incident€to€a€proposed€diagnosis€or€treatment€and€(b)€that€the€defendantÏdeparted€from€the€norm.ðð).€€Ô€;ÔÔ€;XÔÌ íÝ ƒ!ÝÑ#€d#ÑÔ€2ÔÝ  ÝÝ ƒ $ÝÒ € ÒÒ ° ÒÔ€;ÔÔ€;XÔà àòòÚ  ÚÚ  ÚóóÝ  ÝÔ€;ôÔÔ€4ÔThe€creation€of€the€discovery€rule€was€necessary€to€ð ðalleviate€the€intolerable€result€ofÏbarring€a€cause€of€action€by€holding€that€it€ððaccruedðð€before€the€discovery€of€the€injury€or€theÏwrong.ðð€€òòFosteróó,€633€S.W.2d€at€305.€€Otherwise,€a€plaintiff€would€be€required€to€sue€to€vindicateÏa€wrong€at€a€time€when€the€injury€was€ð ðunknown€or€unknowable.ðð€€òòStanbury€v.€Bacardióó,€òò€€€€€óóÏS.W.2d€€òò€€€€€€€óó,€____€(Tenn.1997).€€Ô€;ÔÔ€;XÔÌPtPtHHÚ(ÿáÿáùEG(üHHØ(d'`Styl{WP}01•ÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃÃà Ãà Ãà Ãà Ãà ÃÃÃÃÃÃÃÃÃÃÃÐ ÐÐHHÐÐ  ÐÐ2ÐÐÿÿ¸æ$ÿÐÐHHÐÐÐÐÐÐÐÐ  ÐÐ ÐÐ ÐÑÑÑGenevaÑÑ ÑÑ € ÑÑ<Px–ÈÑÒÒÒ443!#4ÒÒ$ *$ÒÒ$*$ÒÒ ÿKK ÒÒ  Geneva ÒÒ  Geneva ÒÓ.,ÓÓÓÓ6ÓÓ ÓßßßßßßßßßßßßßßßßßßÑGenevaÑÑ ÑÒ  ion-F Geneva ÒÒ  ion-F Geneva ÒÝ ƒ!ÝÔ . ÔÔ€2ÔÝ  ÝÒ € ÒÒ ° ÒØ ØÓ&€33X°d&ÓÑ  ÑÓ  ÓÑ  ÑÑ\R AØ'\ÑÔ€4Ô›Þ ÞÌà@ àIN€THE€SUPREME€COURT€OF€TENNESSEEÌà@ àAT€NASHVILLE€œò òòòÌÌ›ÌÌÌÓ&` ܆X»Q2€%ŽX&Óó óóóDONALD€R.€SHADRICK€and€wife,òòò òà àóóó ó)€à àòòò òFOR€PUBLICATIONóóó óÌVALERIE€SHADRICK€,à àà à€€€€€€€€€€€€)€€€€à àœ›à àà àà àà àà àà à)€à àò òFiled:€€€February€17,€1998ó óÌà àPlaintiffs/Appellees,à àà à)à àà àà àà àà àà àà àà à)€à àÌv.à àà àà àà àà àà à)€à àDavidson€CircuitÌà àà àà àà àà àà à)à àà àHon.€Walter€C.€KurtzÌ€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€à à)Ì€€€€€€à àà àà àà àà à€€€€€€€€€€€€)€à àNo.€01S01„9705„CV„00100ÌÙ€ÙœßR€8:7A1-j|!Ì` Ä `€€@ÿRß›€à àà àà àà àà àà à)ÌWESLEY€L.€COKER,€M.D.,à àà à)Ìà àà àà àà àà àà à)Ìà àDefendant/Appellant.à àà à)ÌÌÓ&` ܆X»Q-€%ŽX&ÓòòÌÌà@ àÌÌÓ)` ܆X»Q -€%ŽX)ÓFor€Plaintiffs„Appelleesóó:à àà àòòà àà àFor€Defendant„Appellantóó:ò òÌÌó óG.€Thomas€Nebelà àà àà àà àà àRobert€T.€TrenthamÌJohn€B.€Carlsonà àà àà àà àà àG.€Brian€JacksonÌWilliams/Nebel€&€Associates,€P.C.à àà àTrabue,€Sturdivant€&€DewittÌNashvilleà àà àà àà àà àà àNashvilleÌÌà àÌÌòòFor€Amici€Curiae,€American€MedicalÌAssociation€and€Tennessee€MedicalÌAssociation:óóÌÌSam€B.€Blair,€Jr.ÌBaker,€Donelson,€Bearman€&€CaldwellÌMemphisÌÌœÌÌÌ›ÌòòÌà@ àOPINIONóóÌÌÌÌœÌÌÌJUDGMENT›€OF€COURT€OF€APPEALSà€ àDROWOTA,€J.ÌœAFFIRMED.›ÇÑ ° ÑÓÓÑ7€ÖAXXdÈXXdÈ7Ñà àà àIn€this€lack€of€informed€consent€medical€malpractice€action,€theÏdefendant,€Wesley€L.€Coker,€M.D.,€appeals€from€the€Court€of€Appealsðð€reversalÏof€summary€judgment€entered€by€the€trial€court€in€his€favor€based€on€theÏexpiration€of€the€applicable€statute€of€limitations€and€statute€of€repose.€€TheÏissue€for€our€determination€is€whether€the€claims€of€the€plaintiffs,€DonaldÏShadrick€and€Valerie€Shadrick,€are€barred€by€the€one„year€statute€ofÏlimitations€or€the€three„year€statute€of€repose€for€medical€malpractice€actions.€ÏòòSeeóó€Tenn.€Code€Ann.€ðð€29„26„116.× ƒ< ××  ×€€After€carefully€examining€the€recordÏbefore€us€and€considering€the€relevant€authorities,€we€conclude€that€disputedÏissues€of€material€fact€exist€regarding€(1)€when€the€statute€of€limitations€beganÏto€run€and,€(2)€€whether€the€fraudulent€concealment€exception€to€the€statute€ofÏrepose€applies.€€Accordingly,€for€the€reasons€explained€hereafter,€we€affirmÏthe€decision€of€the€Court€of€Appeals€to€reverse€the€trial€courtððs€grant€ofÏsummary€judgment€to€the€defendant.€€ÌÌà@ àòòò òBACKGROUNDó óóóÌÌà àà àThe€plaintiff,€Donald€Shadrick,€injured€his€back€at€work€inÏDecember€1988.€€He€was€treated€for€this€injury€by€the€defendant,€Wesley€L.ÍCoker,€M.D.,€an€orthopedic€surgeon€practicing€in€Nashville.€€On€March€12,Ï1990,€after€three€previous€surgeries€performed€by€Dr.€Coker€failed€to€alleviateÏShadrickððs€back€pain,€Dr.€Coker€performed€a€laminectomy€and€disc€excision.€ÏThis€surgery€was€done€at€West€Side€Hospital€in€Nashville,€which€is€nowÏCentennial€Medical€Center.€€€During€the€March€12€surgery,€Dr.€Coker€insertedÏð ðpedicle€screwsðð× ƒ= ××  ×€and€related€hardware€into€Shadrickððs€spine€to€provideÏstability€and€help€the€vertebrae€fuse€together.€€According€to€ShadrickððsÏtestimony,€which€must€be€assumed€to€be€true€for€purposes€of€summaryÏjudgment€analysis,€ð ðno€one€told€[him]€before€the€operation€that€screws€wouldÏbe€implantedðð€in€his€back€and€€ð ðnobody€ever€told€[him]€about€any€risk€of€injuryÏor€any€problems€that€could€be€caused€by€the€screws.ðð€€When€Shadrick€wokeÏup€after€the€surgery,€he€was€told€by€Dr.€Coker€that€the€screws€had€been€put€inÏhis€back€and€that€the€screws€were€ð ðroutine€treatmentðð€for€the€type€of€surgery€heÏhad€undergone.€€€€ÌÌà àà àFollowing€the€March€12€surgery,€Shadrickððs€€pain€worsened.€€HeÏwould€fall€on€his€buttocks€when€his€ð ðleg€went€outðð€due€to€pain.€€Dr.€CokerÏthought€that€Shadrick€was€merely€ð ðworking€through€an€inflammatory€problem.ðð€ÏHowever,€an€x„ray€taken€in€September€1990€revealed€that€one€of€the€screwsÏin€Shadrickððs€back€had€broken€on€the€same€side€he€was€having€pain.ÏShadrick€underwent€surgery€that€same€month€to€repair€the€broken€screw.€€€€Dr.ÍCoker€believed€that€the€broken€screw€was€caused€by€Shadrickððs€repeated€fallsÏon€his€buttocks.€€ÌÌà àà àIn€November€1990,€Shadrick€again€had€surgery€on€his€back.€ÏOne€of€the€purposes€of€this€surgery€was€to€remove€the€screws.€€ShadrickÏcontinued€to€have€pain€after€this€surgery.€€Dr.€Coker€discussed€with€ShadrickÏthe€possibility€that€his€pain€was€due€to€scarring,€about€which€little€could€beÏdone.€€ÌÌà àà àShadrick€continued€to€complain€of€pain€in€his€back€following€theÏremoval€of€the€screws.€€In€March€1991,€Dr.€Coker€and€Shadrick€discussed€Dr.ÏCokerððs€belief€that€Shadrick€ð ðappears€.€.€.€not€[to]€tolerate€pain€well€and€thereÏprobably€is€significant€evidence€he€has€an€emotional€component€to€this€[pain]Ïproblem.ðð€€Dr.€Coker€subsequently€referred€Shadrick€to€a€psychologist.€€InÏSeptember€1991,€Dr.€Coker€wrote€a€letter€to€Shadrickððs€attorney€whichÏreflected€Dr.€Cokerððs€view€that€Shadrickððs€pain€was€psychosomatic€becauseÏð ðhe€has€unconsciously€grasped€the€concept€of€having€chronic€pain€and€will€notÏconsciously€dismiss€that€from€his€mind.ðð× ƒ> ××  ×ÌÌà àà àFor€over€three€years€following€the€removal€of€the€screws,ÏShadrick€continued€to€have€pain€in€his€back.€Shadrick€continued€to€seeÏDr.Coker€for€treatment.€€At€no€time€did€Dr.€Coker€attribute€ShadrickððsÏcontinued€pain€to€the€installation€of€the€pedicle€screws.€€Due€to€the€severity€ofÏhis€back€pain,€Shadrick€has€been€unable€to€work.€€ÌÌà àà àOn€December€17,€1993,€Shadrick€saw€a€television€programÏ(ABCððs€ð ð20/20")€in€which€a€story€was€done€on€pedicle€screws.€€It€was€from€thisÏprogram€that€Shadrick€first€learned€that€pedicle€screws€were€experimental,Ïthat€they€had€not€been€approved€by€the€Food€and€Drug€Administration€for€useÏin€the€spine,€and€that€such€screws€had€been€found€to€cause€a€number€ofÏproblems€in€patients.€€Until€seeing€the€television€program€on€December€17,Ï1993,€Shadrick€had€been€ð ðled€to€believe€that€[he]€had€undergone€a€routineÏprocedure€and€that€everything€would€be€all€right.ðð€€Shadrick€testified€that€hadÏhe€been€informed€about€the€true€nature€of€pedicle€implants€he€never€wouldÏhave€elected€to€have€surgery€involving€their€use.ÌÌà àà àOn€December€16,€1994€„„€approximately€four€years€and€nineÏmonths€after€the€pedicle€screws€were€implanted€in€his€back€„„€Shadrick€filedÏthis€lawsuit€against€Dr.€Coker€and€Centennial€Medical€Center.× ƒ? ××  ×€€The€complaintÍalleged€medical€malpractice,€lack€of€informed€consent€and€battery.€€TheÏcomplaint€also€alleged€that€Dr.€Coker€fraudulently€concealed€the€ð ðtrue€factsÏconcerning€[his]€actions€and€the€true€nature€of€the€pedicle€or€back€screws€andÏrelated€hardware.ðð€€Shadrick€claimed€that€prior€to€his€surgery€on€March€12,Ï1990,€he€was€not€informed€that€pedicle€screws€would€be€placed€in€his€spine.€ÏHe€stated€in€an€affidavit€that€after€the€operation€Dr.€Coker€informed€him€thatÏscrews€had€been€used€in€the€surgery,€but€that€he€was€never€led€to€believe€thatÏthe€screws€were€anything€other€than€ð ðroutine€treatment.ðð€€According€toÏShadrick,€Dr.€Coker€never€told€him€that€pedicle€screws€were€experimental,€thatÏthe€screws€had€not€been€approved€by€the€Food€and€Drug€Administration€forÏuse€in€spinal€surgery,€or€that€there€were€risks€associated€with€their€use€in€theÏspine.€Ms.€Shadrick€sued€for€loss€of€consortium.à àà àÌà0 àà0 àà àÌà àà àIn€response€to€the€plaintiffsðð€complaint,€Dr.€Coker€filed€a€motionÏfor€summary€judgment.€€He€asserted€in€the€motion€that€the€suit€was€barred€byÏthe€three„year€statute€of€repose€and€the€one„year€statute€of€limitations€found€inÏTenn.€Code€Ann.€ðð€29„26„116.€€ÌÌà àà àThe€plaintiffs,€in€turn,€filed€the€affidavit€of€Raymond€O.€Frederick,ÏM.D.,€who€is€a€surgeon€and€an€expert€in€back€problems.€€According€to€Dr.ÏFrederick,€pedicle€screws€in€1990€were€experimental€in€nature€and€had€notÏbeen€approved€by€the€Food€and€Drug€Administration€for€use€in€spinal€surgery.€ÏMoreover,€according€to€Dr.€Frederick,€the€standard€of€care€in€1990€required€Dr.ÍCoker€to€ensure€that€patients€who€were€to€receive€pedicle€screw€implantsÏwere€fully€advised€that€those€implants€were€not€approved€for€use€in€the€spineÏand€to€ensure€that€patients€fully€understood€the€risks.€€Dr.€Frederick€listedÏseveral€specific€items€that€should€have€been€part€of€the€informed€consentÏobtained€by€Dr.€Coker€from€Shadrick,€such€as€informing€him€that€pedicleÏscrews€were€experimental€as€well€as€informing€him€of€a€list€of€possibleÏcomplications€and€risks€associated€with€their€use.× ƒA ××  ×€€Because€Dr.€Coker€did€notÏprovide€Shadrick€with€the€information€identified€by€Dr.Frederick€as€beingÏrequired€for€informed€consent,€Dr.€Frederick€concluded€that€ð ðto€a€reasonableÏdegree€of€medical€certainty,€Dr.Coker€.€.€.€€violated€the€applicable€standard€ofÏcare€with€respect€to€informed€consent.ððÌÌà àà àDr.€Coker€did€not€file€an€affidavit€nor€did€he€file€any€affidavits€ofÏexperts€in€response€to€Dr.€Frederickððs€affidavit€submitted€by€Shadrick.€€Instead,ÏDr.€Coker€relied€upon€Shadrickððs€answers€to€discovery€requests€in€arguingÏthat€Shadrick€knew€or€reasonably€should€have€known€of€his€cause€of€action€inÏ1990€because€Shadrick€was€told€soon€after€the€March€12,1990€operation€thatÏthe€pedicle€screws€had€been€implanted€in€his€back.€Alternatively,€Dr.CokerÏargued€that€Shadrickððs€cause€of€action€was€barred€by€the€three„year€statute€ofÏrepose.ÌÌà àà àThe€trial€court€granted€Dr.€Cokerððs€motion€for€summary€judgment.€ÏThe€court€found€that€Shadrickððs€suit€was€not€saved€by€the€discovery€ruleÏbecause€he€was€told€by€Dr.€Coker€right€after€the€surgery€on€March€12,€1990Ïthat€the€screws€had€been€implanted€in€his€back,€which€was€somethingÏShadrick€knew€he€had€not€authorized€before€the€surgery.€€Further,€ShadrickÏknew€by€November€1990€that€one€of€the€screws€had€broken€and€had€to€beÏreplaced.€€Thus,€he€was€placed€on€notice€there€was€a€problem€with€theÏscrews.€€The€trial€court€also€rejected€Shadrickððs€contention€that€the€fraudulentÏconcealment€exception€to€the€statute€of€repose€applied€because€Dr.€CokerÏmade€no€affirmative€concealment€of€the€fact€that€the€screws€had€beenÏimplanted€in€Shadrickððs€back.€€The€trial€judge€opined€that€ð ð[h]ere€there€was€noÏaffirmative€concealment€and€the€facts€were€such€that€[Shadrick]€knew€or€wasÏon€notice€of€inquiry€that€the€implantation€of€the€screws€had€been€unsuccessfulÏand€possibly€harmful.€€Even€if€the€doctor.€.€.€.€should€have€told€[Shadrick]€moreÍabout€the€screws,€such€information€does€not€change€the€fact€that€[Shadrick]Ïknew€or€should€have€known€in€1990€that€there€was€a€problem€with€theÏscrews.ððÌÌà àà àShadrick€appealed€to€the€Court€of€Appeals.€€The€Court€ofÏAppeals€disagreed€with€the€trial€courtððs€grant€of€summary€judgment€andÏreversed.€€The€court€found€that€there€were€disputed€issues€of€material€fact€asÏto€when€Shadrick€should€have€discovered€his€cause€of€action€and€whetherÏthere€was€fraudulent€concealment€on€the€part€of€€Dr.€Coker.€€The€Court€ofÏAppeals€reasoned€that€because€there€was€a€confidential€relationship€betweenÏDr.€Coker€and€Shadrick€(i.e.,€doctor/patient),€there€was€an€issue€of€fact€as€toÏwhether€Dr.€Cokerððs€silence€amounted€to€fraudulent€concealment€since€Dr.ÏCoker€had€a€duty€to€inform€Shadrick€of€the€experimental€status€of€the€pedicleÏscrews.€ÌÌà àà àThereafter,€we€granted€review€to€determine€whether€the€one„yearÏstatute€of€limitations€or€the€three„year€statute€of€repose€for€medical€malpracticeÏactions€in€Tenn.€Code€Ann.€ðð€29„26„116€bar€the€Shadricksðð€suit€against€Dr.ÏCoker.€€For€the€reasons€that€follow,€we€agree€with€the€Court€of€Appeals€thatÏthere€are€disputed€issues€of€material€fact€as€to€when€the€statute€of€limitationsÏbegan€to€run€and€whether€the€fraudulent€concealment€exception€to€the€statuteÏof€repose€applies.€ÌÌà@ àòòò òANALYSISóóÌà@ àI.ó óÌà àà àThe€standards€governing€an€appellate€courtððs€review€of€a€€motionÏfor€summary€judgment€are€well€settled.€€Summary€judgment€is€appropriateÏonly€if€there€are€no€genuine€issues€of€material€fact€and€the€moving€party€isÏentitled€to€judgment€as€a€matter€of€law.€€Tenn.€R.€Civ.€P.€56.03.€€Dr.€Coker,€asÏthe€party€moving€for€summary€judgment,€has€the€burden€of€demonstrating€thatÏno€genuine€issue€of€material€fact€exists.€€òòByrd€v.€Hallóó,€847€S.W.2d€208,€210Ï(Tenn.€1993).€€We€are€to€review€the€record€before€us€without€attaching€anyÏpresumption€of€correctness€to€the€trial€courtððs€judgment€to€determine€whetherÏthe€absence€of€genuine€issues€of€material€fact€entitle€Dr.€Coker€to€judgment€asÏa€matter€of€law.€€òòRobinson€v.€Omeróó,€952€S.W.2d€423,€426€(Tenn.€1997);€€òòBainÏv.€Wellsóó,€936€S.W.2d€618,€622€(Tenn.€1997).€€Further,€we€are€required€to€viewÏthe€evidence€in€the€light€most€favorable€to€the€nonmoving€party,€Shadrick,Ïdraw€all€reasonable€inferences€in€his€favor,€and€discard€all€countervailingÏevidence.€€òòByrdóó,€847€S.W.2d€at€210„11.€€If€both€the€facts€and€conclusions€to€beÏdrawn€from€the€facts€permit€a€reasonable€person€to€reach€only€one€conclusion,Ïsummary€judgment€should€be€granted.€€òòRobinsonóó,€952€S.W.2d€at€426;€òòBainóó,Ï936€S.W.2d€at€622;€òòMcClung€v.€Delta€Square€Ltd.€Partnershipóó,€937€S.W.2dÏ891,€894€(Tenn.€1996)ÌÌ.€à@ àò òII.ó óÌÌà àà àShadrickððs€suit€is€based€on€the€theory€of€lack€of€informedÏconsent.€€He€contends€that€Dr.€Coker€did€not€inform€him€prior€to€the€surgery€inÏMarch€1990€that€the€screws€were€going€to€be€implanted€in€his€back,€much€lessÏthat€the€screws€were€experimental€in€nature€or€that€there€were€specific€andÏmaterial€risks€associated€with€their€use.€€Therefore,€Shadrick€maintains€heÏnever€consented€to€their€use.€€ÌÌà àà àA€cause€of€action€based€on€the€lack€of€informed€consent€stemsÏfrom€the€premise€that€a€competent€patient€should€be€allowed€to€formulate€anÏintelligent,€informed€decision€about€surgical€or€other€treatment€procedures€theÏpatient€undertakes.€€òòHoush€v.€Morrisóó,€818€S.W.2d€39,€41€(Tenn.€App.€1991).€ÏThe€basic€policy€consideration€which€supports€the€recognition€of€the€cause€ofÏaction€for€lack€of€informed€consent€has€been€explained€as€follows:ÌÌÓÓà8 àThe€root€premise€is€the€concept€fundamental€in€AmericanÏjurisprudence€that€ððevery€human€being€of€adult€years€and€soundÏmind€has€a€right€to€determine€what€shall€be€done€with€his€ownÏbody€.€.€.€.ðð€€True€consent€to€what€happens€to€oneððs€self€is€theÏinformed€exercise€of€a€choice,€and€that€entails€an€opportunity€toÏevaluate€knowledgeably€the€options€available€and€the€risksÏdependant€upon€each.€€The€average€patient€has€little€or€noÏunderstanding€of€the€medical€arts,€and€ordinarily€has€only€hisÏphysician€to€whom€he€can€look€for€enlightenment€with€which€toÏreach€an€intelligent€decision.€€From€these€almost€axiomaticÏconsiderations€springs€the€need,€and€in€turn€the€requirement,€ofÏa€reasonable€divulgence€by€[the]€physician€to€[the]€patient€toÏmake€such€a€decision€possible.à àà àà à€ÌÌÌòòCanterbury€v.€Spenceóó,€464€F.2d€774,€780€(D.C.€Cir.€1972).ÓÓÌÌà àà àAccordingly,€the€law€recognizes€that€a€health€care€provider,€suchÏas€a€physician€or€surgeon,€who€proposes€a€treatment€or€surgical€procedureÏhas€a€duty€to€provide€the€patient€with€enough€information€about€the€nature€ofÏthe€treatment€or€procedure€involved€to€enable€the€patient€to€make€anÏintelligent€decision€and€thereby€give€an€ò òinformedó ó€consent€to€the€treatment€orÏprocedure.€€òòSeeóó€òòCardwell€v.€Bechtolóó,€724€S.W.2d€739,€750€(Tenn.€1987).€ÏDepending€on€the€usual€and€customary€advice€given€to€patients€to€procureÏconsent€in€similar€situations,€the€health€care€provider€must€typically€inform€theÏpatient€of€the€diagnosis€or€nature€of€the€patientððs€ailment,€the€nature€of€and€theÏreasons€for€the€proposed€treatment€or€procedure,€the€risks€or€dangersÏinvolved,€and€the€prospects€for€success.€€òòSeeóó€€70€C.J.S.€òòPhysicians€andÏSurgeonsóó€ðð€93€(1987).€€The€patient€must€also€be€informed€of€alternativeÏmethods€of€treatment,€the€risks€and€benefits€of€such€treatment€and,€ifÏapplicable,€that€the€proposed€treatment€or€procedure€is€experimental.€€òòIdóó.€ÏWhether€the€information€given€to€the€patient€is€sufficient€ð ðdepends€on€theÏnature€of€the€treatment,€the€extent€of€the€risks€involved,€and€the€standard€ofÏcare€[applicable€to€the€defendant€health€care€provider].ðð€òòCardwellóó,€724€S.W.2dÍat€749.× ƒB ××  ×ÌÌà àà àWhen€the€health€care€provider€performs€the€treatment€orÏprocedure€without€the€requisite€informed€consent€of€the€patient,€liabilityÏattaches€for€the€resulting€injuries€regardless€of€whether€those€injuries€resultedÏfrom€negligence.€€òòHoushóó,€818€S.W.2d€at€42;€òòGermanóó,€577€S.W.2d€at€202;€€òòRayÏv.€Scheibertóó,€484€S.W.2d€63,€71€(Tenn.€App.€1972).€€This€is€because€theÏdoctrine€of€lack€of€informed€consent€is€based€upon€the€tort€of€battery,€notÏnegligence,€since€the€treatment€or€procedure€was€performed€without€havingÏfirst€obtained€the€patientððs€informed€consent.€€òòCardwellóó,€724€S.W.2d€at€751;ÏòòCary€v.€Arrowsmithóó,€777€S.W.2d€8,€21€(Tenn.€App.€1989).€€We€have€explainedÏthe€relationship€between€lack€of€informed€consent€and€battery€as€follows:ÌÌÓÓà8 àà à[T]he€failure€to€give€such€information€[needed€to€obtain€anÏinformed€consent]€is€not€the€type€of€omission€that€results€inÏnegligence,€but€rather€it€negates€consent€for€the€treatment.€ÏWithout€consent,€the€treatment€constitutes€a€battery.€€ÌÌà8 àà à[T]he€correct€analysis€in€our€opinion€is€that€if€the€evidenceÏshows€that€the€person€had€the€capacity€to€consent,€then€theÍquestion€becomes€whether€the€consent€given€was€effectiveÏbecause€it€was€based€upon€adequate€information€on€which€toÏmake€the€decision€to€submit€to€treatment;€if€not,€then€a€batteryÏresults,€but€if€so,€then€the€question€becomes€whether€theÏdefendant€subsequently€did€anything€negligent€in€theÏadministration€of€the€treatment€for€which€consent€was€obtained.€.Ï.€.ÌÌà8 àà àThese€theories,€battery€and€malpractice,€are€not€ordinarilyÏinconsistent,€and€no€election€of€remedies€is€generally€required;€ifÏa€battery€exists,€then€malpractice€may€not€necessarily€beÏreached,€but€if€no€battery€can€be€shown,€then€the€issue€clearlyÏemerges€as€one€of€malpractice.€€This€distinction€between€batteryÏand€malpractice€(as€a€form€of€negligence)€is€consistentlyÏrecognized€in€the€case€law.€€ÌÌà8 àà àà àÌÓÓòòCardwellóó,€724€S.W.2d€at€751.€€ÌÌà àà àThis€is€not€to€suggest,€however,€that€a€health€care€provider€isÏrequired€to€enumerate€in€detail€every€aspect€of€the€proposed€treatment€orÏprocedure€or€discuss€every€possible€thing€that€might€go€wrong€in€an€effort€toÏobtain€the€patientððs€informed€consent.€€€ð ðIn€the€first€place,€to€do€so€is€humanlyÏimpossible.€€In€the€second€place,€if€all€the€gory€details€of€a€proposed€surgeryÏwere€graphically€explained€to€every€patient€and€all€possible€medical€maladiesÏthat€might€result€were€enumerated€we€doubt€that€a€lay€person€would€have€theÏstomach€to€listen€to€it€all;€and€if€the€patient€did,€would€probably€be€in€such€aÏfearful€state€that€no€rational€decision€could€be€made.ðð€€òòLongmire€v.€Hoeyóó,€512ÏS.W.2d€307,€310€(Tenn.€App.€1974).€€Accordingly,€health€care€providers€areÏgenerally€not€required€to€disclose€risks€that€are€not€material,€such€as€those€thatÏare€extremely€unlikely€to€occur€or€one€that€a€reasonable€patient€would€not€careÍto€know€due€to€its€insignificance;€risks€that€are€obvious€or€already€known€byÏthe€patient;€risks€that€are€unforeseeable€or€unknowable;€or€where€the€patientððsÏmedical€condition€renders€discussion€of€the€risks€and€benefits€of€the€treatmentÏor€procedure€impossible€or€medically€inadvisable,€such€as€in€an€emergencyÏwhere€the€patient€is€unconscious€or€otherwise€incapable€of€consenting,€orÏwhere€full€disclosure€would€be€detrimental€to€the€patientððs€total€care,€i.e.,€theÏpatient€is€unduly€alarmed€or€apprehensive€to€start€with€and€additionalÏinformation€would€overload€the€patient€and€jeopardize€his€or€her€physical€orÏemotional€well„being.€€òòSeeóó€òòHoushóó,€818€S.W.2d€at€42;€òòLongmireóó,€512€S.W.2dÏat€310;€òòRayóó,€484€S.W.2d€at€71;€òòBall€v.€Mallinkrodt€Chem.€Worksóó,€381€S.W.2dÏ563,€567€(Tenn.€App.€1964);€70€C.J.S.€òòPhysicians€and€Surgeonsóó€ðð€94€(1987);ÏFrantz,€Annotation,€òòModern€Status€of€Views€as€to€General€Measure€ofÏPhysicianððs€Duty€to€Inform€Patient€of€Risks€of€Proposed€Treatmentóó,€88€A.L.R.3dÏ1008€(1978).€€€€ÌÌà àà àCauses€of€action€based€on€lack€of€informed€consent,€likeÏtraditional€medical€malpractice€cases€involving€negligence,€are€subject€to€theÏone„year€statute€of€limitations€and€three„year€statute€of€repose€provided€for€inÏTenn.€Code€Ann.€ðð€29„26„116.€€The€so„called€discovery€rule,€which€was€firstÏadopted€in€òòTeeters€v.€Curreyóó,€518€S.W.2d€512€(Tenn.€1974),× ƒD ××  ×€was€codified€inÍ1975€as€part€of€Tenn.€Code€Ann.€ðð€29„26„116(a)(2).€€That€statute€provides€thatÏð ð[i]n€the€event€the€alleged€injury€is€not€discovered€within€the€said€one€(1)€yearÏperiod,€the€period€of€limitation€shall€be€one€(1)€year€from€the€date€of€suchÏdiscovery.ðð€€This€Court€has€interpreted€Tenn.€Code€Ann.€ðð€29„26„116(a)(2)€toÏmean€that€the€statute€of€limitations€commences€to€run€when€the€patientÏð ðdiscovers,€or€reasonably€should€have€discovered,€(1)€the€occasion,€theÏmanner,€and€the€means€by€which€a€breach€of€duty€occurred€that€produced€[theÏpatientððs]€injuries;€and€(2)€the€identity€of€the€defendant€who€breached€the€duty.ðð€ÏòòStanbury€v.€Bacardióó,€òò€€€€€€€€óó€S.W.2d€òò€€€€€€€€óó,€òò€€€€€€€€€óó€(Tenn.€1997)€(quoting€òòFoster€v.ÏHarrisóó,€633€S.W.2d€304,€305€(Tenn.€1982)).€ÌÌà àà àThe€plaintiff€may€not,€however,€delay€filing€suit€until€all€theÏinjurious€effects€and€consequences€of€the€alleged€wrong€are€actually€known€toÏthe€plaintiff.€€òòWyatt€v.€A„Best€Companyóó€910€S.W.2d€851,€855€(Tenn.€1995).€ÏSimilarly,€the€statute€of€limitations€is€not€tolled€until€the€plaintiff€actually€knowsÏthe€ð ðspecific€type€of€legal€claim€he€or€she€has,ðð€òòStanburyóó,€òò€€€€€€€óó€S.W.2d€at€òò€€€€€€€€€óó,Ïor€that€ð ðthe€injury€constitute[d]€a€breach€of€the€appropriate€legal€standard,ðð€ÏòòRoe€v.€Jeffersonóó,€875€S.W.2d€653,€657€(Tenn.€1994).€Rather,€as€we€haveÏrecently€emphasized,€the€statute€of€limitations€begins€to€run€when€the€plaintiffÏknows€or€in€the€exercise€of€reasonable€care€and€diligence€should€know€thatÏan€injury€has€been€sustained€as€a€result€of€wrongful€or€tortious€conduct€by€theÏdefendant.€€òòStanburyóó,€òò€€€€€€€óó€S.W.2d€at€òò€€€€€€€€€€óó;€òòseeóó€òòalsoóó€òòRoeóó,€875€S.W.2d€at€657Ï(ð ð[T]he€plaintiff€is€deemed€to€have€discovered€the€right€of€action€if€he€is€awareÍof€facts€sufficient€to€put€a€reasonable€person€on€notice€that€he€has€suffered€anÏinjury€as€a€result€of€wrongful€conduct.ðð).€€ð ðIt€is€knowledge€of€facts€sufficient€toÏput€a€plaintiff€on€notice€that€an€injury€has€been€sustained€which€is€crucial.ðð€ÏòòStanburyóó,€òò€€€€€óóS.W.2d€at€òò€€€€€€óó.€€Such€knowledge€€includes€not€only€an€awarenessÏof€the€injury,€but€also€the€tortious€origin€or€wrongful€nature€of€that€injury.€ÏòòHathaway€v.€Middle€Tennessee€Anesthesiology,€P.C.óó,€724€S.W.2d€355,€359Ï(Tenn.€App.€1986).€ÌÌà àà àApplying€these€principles€to€the€record€before€us,€we€cannotÏagree€with€Dr.€Cokerððs€insistence€that€the€statute€of€limitations€began€to€run€asÏa€matter€of€law€in€November€1990€(at€the€latest)€when€Shadrick€had€theÏsurgery€to€remove€the€screws€from€his€back.€€It€is€true,€as€pointed€out€by€Dr.ÏCoker,€that€Shadrick€was€told€upon€waking€up€from€the€surgery€on€March€12,Ï1990€that€the€screws€were€implanted€in€his€back.€This€was€somethingÏShadrick€knew€he€had€not€authorized€before€the€surgery.€€Also,€ShadrickÏknew€he€had€received€the€surgical€implants€without€being€informed€of€any€ofÏthe€potential€risks€or€complications€associated€with€their€use.€€Finally,€he€knewÏthat€one€of€the€screws€had€broken€„„€one€of€the€unmentioned€risks€of€theÏprocedure€„„€and€had€to€have€surgery€in€September€1990€to€repair€the€brokenÏscrew.€ÌÌà àà àHowever,€we€are€not€persuaded€that€these€facts€necessarilyÏcompel€a€reasonable€person€to€conclude€that€Shadrick€knew€or€reasonablyÍshould€have€known€that€his€problems€were€the€result€of€wrongful€or€tortiousÏconduct€on€the€part€of€Dr.€Coker.€€Although€Shadrick€was€told€by€Dr.€Coker€thatÏthe€screws€had€been€put€in€his€back€when€he€woke€up€from€the€March€12,Ï1990€surgery,€he€was€also€told€at€that€time€that€the€screws€were€ð ðroutineÏtreatmentðð€for€the€type€of€surgery€he€had€undergone.€€The€fact€that€ShadrickÏwas€informed€that€the€screws€had€been€put€in€his€back€after€the€surgery€ð ðdidÏnot€mean€anything€to€[him]€because€nobody€ever€told€[him]€about€any€risk€ofÏinjury€or€any€problems€that€could€be€caused€by€the€screws.€€At€the€time,€[he]Ïhad€no€idea€that€the€screws€were€experimental,€that€they€had€not€beenÏapproved€by€the€Food€and€Drug€Administration€for€use€in€the€spine,€or€thatÏthey€would€cause€[him]€any€problems.ðð€€Indeed,€it€was€not€until€December€17,Ï1993€while€watching€television€that€Shadrick€learned€that€pedicle€screws€wereÏexperimental,€that€they€had€not€been€approved€by€the€Food€and€DrugÏAdministration€for€use€in€the€spine,€and€that€such€screws€had€been€found€toÏcause€a€number€of€problems€in€patients.€€Until€seeing€the€television€programÏShadrick€had€been€ð ðled€to€believe€that€[he]€had€undergone€a€routineÏprocedure.€.€.€.ðð€€As€a€reasonable€lay€person,€Shadrick€could€have€believed€Dr.ÏCoker€when€he€informed€him€that€the€screws€were€routine€for€use€in€back„fusion€surgeries,€especially€since€Dr.€Coker€had€never€disclosed€any€risks€orÏpotential€complications€related€to€the€use€of€the€screws€or€even€theirÏexperimental€nature.€€€ÌÌà àà àFurthermore,€it€is€significant€that€Dr.€Coker€offered€a€number€ofÏexplanations€for€Shadrickððs€continuing€back€problems.€€Dr.€Coker€attributedÏthe€failure€of€the€screw€that€broke€to€Shadrickððs€repeated€falls€on€his€buttocks.ÏHe€attributed€Shadrickððs€continuing€pain€to€first€an€inflammatory€problem,€thenÏto€scarring€about€which€little€could€be€done,€and€then€finally€to€ShadrickððsÏpsychological€state.€€At€no€time€did€Dr.€Coker€attribute€Shadrickððs€continuingÏproblems€to€the€installation€of€the€pedicle€screws.€€It€was€not€until€DecemberÏ1993€that€Shadrick€realized€that€the€pedicle€screws€were€not€ð ðroutineÏtreatmentðð€and€that€there€were€specific,€material€risks€associated€with€theirÏuse.€€As€Shadrick€put€it,€ð ðI€did€not€know€or€suspect€until€December€17,€1993Ïthat€the€implants€placed€in€me€by€Dr.€Coker€.€.€.€were€the€cause€of€myÏproblems.ðð€€ÌÌà àà àViewing€this€evidence€in€the€light€most€favorable€to€Shadrick€andÏallowing€all€reasonable€inferences€in€his€favor,€we€conclude€that€there€isÏevidence€in€the€record€from€which€a€jury€could€reasonably€find€that€ShadrickÏwas€reasonably€unaware€of€the€wrongful€or€tortious€origin€of€his€injury€untilÏDecember€1993.€Dr.€Cokerððs€argument€that€Shadrick€was€aware€of€his€claim€inÏ1990€rings€hollow€given€that€Shadrick€was€never€informed€of€the€risksÏinvolved€in€the€installation€of€pedicle€screws€in€his€spine,€was€never€told€thatÏsuch€medical€devices€were€experimental,€was€told€that€the€screws€wereÏð ðroutine€treatment,ðð€and€was€led€to€believe€that€his€continuing€difficulties€wereÏdue€to€a€number€of€problems,€none€of€which€were€related€to€the€implantationÍof€the€screws.€€Given€these€circumstances,€a€jury€could€find€that€Shadrick€hadÏno€reason€to€suspect€that€he€had€sustained€an€injury€resulting€from€Dr.€CokerððsÏwrongful€or€tortious€conduct€until€December€1993.€€Dr.€Coker€has€not€met€hisÏburden€of€demonstrating€that€no€genuine€issue€of€material€fact€exists€as€toÏwhen€the€statute€of€limitations€began€to€run.€€€ÌÌà@ àò òIII.ó óÌÌà àà àHaving€decided€that€the€one„year€statute€of€limitations€does€notÏnecessarily€bar€Shadrickððs€claim,€we€turn€to€whether€there€are€disputed€issuesÏof€material€fact€regarding€fraudulent€concealment€on€the€part€of€Dr.Coker€soÏas€to€avoid€application€of€the€three„year€statute€of€repose.€ÌÌà àà àTenn.€Code€Ann.€ðð€29„26„116(a)(3)€provides€that€regardless€ofÏwhen€a€plaintiff€discovers€the€cause€of€action,€no€cause€of€action€may€beÏbrought€after€three€years€from€the€date€of€the€alleged€malpractice.€€Hence,€theÏthree„year€statute€of€repose€establishes€a€ceiling€on€the€time€in€which€aÏmalpractice€suit€may€be€brought.€€The€three„year€limit€is€unrelated€to€theÏaccrual€of€the€cause€of€action,€commencing€not€on€discovery€like€the€statute€ofÏlimitations,€but€on€the€date€of€the€alleged€wrongful€act.€€òòBraden€v.€Yoderóó,€592ÏS.W.2d€896,€897€(Tenn.€App.€1979).€€Nonetheless,€the€statute€of€repose€mayÏbe€tolled€where€there€is€ð ðfraudulent€concealment€on€the€part€of€the€defendant,ððÏin€which€case€the€cause€of€action€must€be€brought€within€one€year€afterÍdiscovering€that€the€cause€of€action€exists.€€Tenn.€Code€Ann.€ðð€29„26„116(a)(3).€€ÌÌà àà àTo€establish€fraudulent€concealment,€a€plaintiff€must€prove€(1)Ïthat€the€defendant€took€affirmative€action€to€conceal€the€cause€of€action€ò òoró óÏremained€silent€and€failed€to€disclose€material€facts€despite€a€duty€to€do€soÏand,€(2)€the€plaintiff€could€not€have€discovered€the€cause€of€action€despiteÏexercising€reasonable€care€and€diligence.€€òòStanburyóó,€òò€€€€óó€S.W.2d€at€òò€€€€óó,€n.€6;ÏòòBenton€v.€Snyderóó,€825€S.W.2d€409,€414€(Tenn.€1992).€€In€this€regard€it€hasÏbeen€observed€that€when€there€is€a€confidential€or€fiduciary€relationshipÏbetween€the€parties,€the€ð ðfailure€to€speak€where€there€is€a€duty€to€speak€is€theÏequivalent€of€some€positive€act€or€artifice€planned€to€prevent€inquiry€or€escapeÏinvestigation.ðð€€òòHall€v.€De€Saussureóó,€297€S.W.2d€81,€85€(Tenn.€App.€1956).€€€€InÏour€most€recent€case€addressing€the€subject,€we€recognized€thatÌÌÓÓà8 àthe€affirmative€action€on€the€part€of€the€defendant€must€beÏsomething€more€than€mere€silence€or€a€mere€failure€to€discloseÏthe€known€facts.€€There€must€be€some€trick€or€contrivanceÏintended€to€exclude€suspicion€and€prevent€inquiry,€ò òor€elseÏthere€must€be€a€duty€resting€on€the€party€knowing€suchÏfacts€to€disclose€them€.€.€.€.€€For€example,€such€a€dutyÏarises€where€a€confidential€relationship€exists,€asÏbetween€physician€and€patient.€€In€such€cases,€there€isÏa€duty€to€disclose,€and€that€duty€may€render€silence€orÏfailure€to€disclose€known€facts€fraudulent.ó ó€€This€is€the€ruleÏin€Tennessee€and€in€other€jurisdictions.€€ÌÌÌÓÓòòBentonóó,€825€S.W.2d€at€414€(emphasis€in€original)€(citations€omitted).ÌÌ€€€€€€€€€€€€€€€€€€€€€€The€third€essential€element€of€fraudulent€concealment€isÏknowledge€on€the€part€of€the€defendant€of€the€facts€giving€rise€to€the€cause€ofÏaction.€€€òòBentonóó,€825€S.W.2d€at€414.€€In€other€words,€the€defendant€must€beÏaware€of€the€wrong.€€òòSeeóó€òòHoushóó,€818€S.W.2d€at€43€(ð ðBasically,€fraudulentÏconcealment€will€be€shown€where€the€physician€had€knowledge€of€the€wrongÏdone€and€concealed€such€information€from€the€patient.ðð);€òòRayóó,€484€S.W.2d€atÏ72€(ð ðOur€Tennessee€cases€hold€that€knowledge€on€the€part€of€the€physician€ofÏthe€fact€of€a€wrong€done€is€an€essential€element€of€fraudulent€concealment.ðð).€ÌÌ€€€€€€€€€€€€€€€€€€€€€The€fourth€and€final€essential€element€of€fraudulent€concealment€isÏa€concealment€of€material€information€from€the€plaintiff.€€òòBentonóó,€825€S.W.2d€atÏ414.€€Concealment€ð ðmay€consist€of€withholding€information€or€making€use€ofÏsome€device€to€misleadðð€the€plaintiff€in€order€to€exclude€suspicion€or€preventÏinquiry.€€òòIdóó.€€€When€there€is€a€relationship€involving€trust€and€confidenceÏbetween€the€parties€which€would€impose€a€duty€to€make€a€full€disclosure€of€theÏmaterial€facts,€mere€silence€or€nondisclosure€may€constitute€concealment.€ÏòòSeeóó€54€C.J.S.€òòLimitations€of€Actionsóó€ðð€90€(1987).€€The€rationale€for€this€ruleÏhas€been€explained€as€follows:ÌÌÓÓà8 àFiduciary€relationship,€confidential€relationship,€constructiveÏfraud€and€fraudulent€concealment€are€all€parts€of€the€sameÏconcept.€[T]he€nature€of€the€relationship€which€creates€a€duty€toÏdisclose,€and€a€breach€of€[that]€duty€constitutes€constructive€fraudÏor€fraudulent€concealment,€springs€from€the€confidence€and€trustÍreposed€by€one€in€another,€who€by€reason€of€a€specific€skill,Ïknowledge,€training,€judgment€or€expertise,€is€in€a€superiorÏposition€to€advise€or€act€on€behalf€of€the€party€bestowing€trustÏand€confidence€in€him.€€Once€the€relationship€exists€ððthere€existsÏa€duty€to€speak€.€.€.€[and]€mere€silence€constitutes€fraudulentÏconcealment.ððÌÌà8 àIn€the€common€knowledge€of€man,€patients€submit€themselves€toÏthe€skills€and€arts,€proficiency€and€expertise,€of€hospitalÏpersonnel,€once€they€become€confined€to€the€hospital.€€Indeed,Ïmost€frequently,€they€have€no€real€choice€in€the€matter;€they€areÏphysically€and€intellectually€unable€to€do€much€more€than€submitÏand€rely€upon€the€medical€superiority€and€ethical€propriety€ofÏtheir€attendants.€ÌÌÌÓÓòòGarcia€v.€Presbyterian€Hospital€Ctr.óó,€593€P.2d€487,€489€„€90€(N.M.€App.Ï1979)(citations€omitted).€€òòSeeóó€òòalsoóó€òòLynch€v.€Watersóó,€349€S.E.2d€456€(Ga.Ï1986)(ð ðThe€physician„patient€relationship€is€a€confidential€one€and€silence€orÏfailure€to€disclose€what€should€be€said€or€disclosed€can€amount€to€fraud.€.€.€.ðð);ÏòòLeach€v.€Shapiroóó,€469€N.E.2d€1047€(Ohio€App.€1984)(ð ðWhen€the€physicianÏhas€knowledge€of€a€fact€concerning€the€patientððs€physical€condition€which€isÏmaterial€to€the€patient,€this€fiduciary€relationship€may€render€the€physicianððsÏsilence€fraudulent.ðð);€òòNixdorf€v.€Hickenóó,€612€P.2d€348€(Utah€1980)(ð ðWhere€aÏphysician€has€knowledge€of€a€fact€concerning€the€patientððs€physical€conditionÏwhich€is€material€to€that€patient€and€he€fails€to€disclose€it,€the€confidenceÏrelationship€between€them€creates€a€duty€to€disclose€which€may€render€hisÏsilence€fraudulent.ðð);€òòHardin€v.€Farrisóó,€530€P.2d€407€(N.M.€App.Ï1974)(ð ðNormally€some€positive€act€of€concealment€must€be€shown.€.€.€.€ÏHowever,€in€a€confidential€relationship€where€there€exists€a€duty€to€speak,Ísuch€as€in€a€doctor„patient€relationship,€mere€silence€constitutes€fraudulentÏconcealment.ðð).€€ÌÌà àà àTo€summarize,€a€plaintiff€in€a€lack€of€informed€consent€case€(orÏany€other€medical€malpractice€case)€attempting€to€toll€the€statute€of€reposeÏcontained€in€T.C.A.€€29„26„116(a)(3)€by€relying€upon€the€fraudulentÏconcealment€exception€to€the€statute€must€establish€that€(1)€the€health€careÏprovider€took€affirmative€action€to€conceal€the€wrongdoing€or€remained€silentÏand€failed€to€disclose€material€facts€despite€a€duty€to€do€so,€(2)€the€plaintiffÏcould€not€have€discovered€the€wrong€despite€exercising€reasonable€care€andÏdiligence,€(3)€the€health€care€provider€knew€of€the€facts€giving€rise€to€the€causeÏof€action€and,€(4)€a€concealment,€which€may€consist€of€the€defendantÏwithholding€material€information,€making€use€of€some€device€to€mislead€theÏplaintiff,€or€simply€remaining€silent€and€failing€to€disclose€material€facts€whenÏthere€was€a€duty€to€speak.ÌÌà à€€€€€€€€Our€review€of€the€record€before€us€demonstrates€that€there€isÏevidence€sufficient€to€create€a€jury€issue€on€all€the€key€elements€of€fraudulentÏconcealment.€€The€evidence€from€which€the€jury€could€infer€concealmentÏconsisted€of€Dr.€Cokerððs€silence€regarding€the€risks€and€complicationsÏassociated€with€the€use€of€pedicle€screws€in€the€spine€and€the€failure€toÏdisclose€their€experimental€nature.€€This€is€particularly€true€since€Dr.€CokerÏand€Shadrick€had€a€confidential€or€fiduciary€relationship€by€virtue€of€having€aÍdoctor„patient€relationship,€which€imposed€a€duty€upon€Dr.€Coker€to€discloseÏmaterial€information.€€Furthermore,€the€jury€could€infer€that€Dr.€CokerÏattempted€to€conceal€material€facts€(i.e.,€the€risks€and€potential€complicationsÏand€experimental€nature€of€the€procedure)€associated€with€the€wrong€byÏoffering€various€explanations€for€Shadrickððs€continuing€problems,€none€ofÏwhich€had€to€do€with€the€implantation€of€the€screws.€There€was€also€theÏassurance€by€Dr.€Coker€to€Shadrick€that€the€screws€were€ð ðroutine€treatmentððÏfor€the€type€of€surgery€Shadrick€had€undergone.€€A€jury€could€thus€find€thatÏthroughout€Dr.€Cokerððs€treatment€of€Shadrick€Dr.€Coker€allayed€any€possibleÏsuspicions€that€Shadrick€might€have€had€concerning€a€claim€against€him€byÏfirst€representing€that€the€screws€were€routine€treatment€and€then€laterÏattributing€the€complications€to€several€different€causes,€none€of€which€relatedÏto€the€screws.€Evidence€of€knowledge€could€also€be€inferred€from€this€proof,Ïparticularly€in€light€of€Dr.€Frederickððs€testimony€that€such€information€shouldÏhave€been€discussed€with€Shadrick€(but€wasnððt)€in€order€to€have€obtained€hisÏinformed€consent€and€comply€with€the€applicable€standard€of€care.ÌÌ€€€€€€€€€€€€€€€€€€€€Finally,€we€are€also€persuaded€that,€for€the€reasons€discussed€inÏthe€statute€of€limitations€portion€of€this€opinion,€there€is€a€question€of€factÏregarding€whether€Shadrick€could€have€discovered€the€wrong€(failing€toÏobtain€his€informed€consent)€through€the€exercise€of€reasonable€care€andÏdiligence.€€We€would€only€add€that€ð ð[w]hether€the€plaintiff€exercisedÍreasonable€care€and€diligence€in€discovering€the€injury€or€wrong€is€usually€aÏquestion€of€fact€for€the€jury€to€determine.ðð€€òòWyattóó,€910€S.W.2d€at€854.ÌÌ€€€€€€€€€€€€€€€€€€€€€€It€follows€that,€after€taking€the€strongest€legitimate€view€ofÏShadrickððs€evidence€and€allowing€all€reasonable€inferences€in€his€favor€andÏdiscarding€all€countervailing€evidence,€more€than€one€conclusion€could€beÏdrawn€from€the€evidence.€€Therefore,€this€is€not€an€appropriate€case€forÏsummary€judgment.€ÌÌÌòòà@ àò òCONCLUSIONó óà àà àóóÌÌà àà àIn€view€of€the€foregoing€discussion,€we€conclude€that€disputedÏissues€of€material€fact€exist€regarding€when€the€statute€of€limitations€began€toÏrun€and€whether€the€fraudulent€concealment€exception€to€the€statute€of€reposeÏapplies.€€Accordingly,€we€affirm€the€reversal€of€summary€judgment.€€€Costs€ofÏthis€appeal€are€taxed€to€the€defendant€„€appellant.€€ÌÌÌÓÓà àà àà àà àà àà à________________________________Ìœ›à àà àà àà àà àà àFRANK€F.€DROWOTA,€III,€€€€€€€€€€€€€€€€€€€€€Ïà àà àà àà àà àà àJUSTICE€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€ÌÌÌò òConcur:ó óÌÌAnderson,€C.J.,ÌReid,€Birch,€Holder,€J.J.Ì