Richard E. MORRISON, Appellant,
v.
Tom MACNAMARA, et Al.,Appellees
District of Columbia Court of Appeals
407 A.2d 555; (1979)

Newman, C.J. Appellant Morrison, a plaintiff in a medical malpractice action in the trial court, challenges a judgment in favor of appellees, a nationally certified medical laboratory and a medical technician. He contends that the trial court erred in denying his requested jury instruction that the standard of care to which appellees should be held is a national standard as opposed to a local one. ***. We agree with [ the] appellant *** and reverse. ***

The facts at trial were basically undisputed. They indicated that upon orders of his personal physician, appellant went to appellee Oscar B. Hunter Memorial Laboratories, Inc., a nationally certified clinical medical laboratory located in the District of Columbia, for the performance of a urethral smear test. The test was administered by appellee Tom MacNamara, a clinical technician, who at that time had been employed by appellee Hunter Laboratories for approximately seven months. According to the technician, he administered the test by inserting a cotton swab about a quarter-inch into the penis with appellant in a standing position. Following the completion of the first test, appellant complained of feeling faint. The technician instructed appellant to sit down and rest, and to place his head between his legs. ***

Approximately two to three minutes later, the technician asked appellant "if it was okay to go ahead" with a second test and appellant replied "yes." The technician then proceeded to perform the test a second time, again with appellant in a standing position. While the test was being administered a second time, appellant fainted, striking his head on a metal blood pressure stand and on the tile covered floor. Subsequently, he was taken to George Washington University Hospital where he was admitted as a neurosurgery patient. As a result of this incident, appellant sustained a number of injuries including a permanent loss of his sense of smell and a partial loss of his sense of taste. Appellant brought an action against appellees charging them with professional malpractice in the manner in which they conducted the test ***

At trial the principal issue in dispute concerned the appropriate standard of care to be applied to appellees. Appellant maintained that since the laboratory was nationally certified and held itself out to the public as such, appellees should be held to a national standard of care. In this connection, appellant presented as an expert witness, Dr. George Shargel, a board certified urologist and a member of the American College of Surgeons, who practiced in the state of Michigan. Dr. Shargel stated that although appearing simple, the urethral smear test involved a highly invasive procedure causing severe pain, particularly if there is disease or inflammation present. He testified that the insertion of a swab into the male organ produces a vassal vagal reflex in a patient which causes the blood to rush from the brain to the area being traumatized, thereby causing the patient to feel faint. For this reason, Dr. Shargel explained, the nationally accepted medical standard of care requires the test to be administered with the patient in a prone or sitting position.

Appellees presented several expert witnesses who testified on the applicable professional standard of care -- all of whom were from the Washington, D.C. metropolitan area. Dr. Oscar B. Hunter, the principle owner of the appellee laboratory, testified that the laboratory was nationally certified by the College of American Pathologists and that the laboratory holds itself out to the public as such. According to Dr. Hunter, it is not a deviation from accepted medical standards in the Washington, D.C. metropolitan area or anywhere in the country for the urethral smear test to be administered with a male patient in a standing position. ***

Dr. Richard E. Palmer, a pathologist with a clinical laboratory in Alexandria, Virginia, also testified as an expert witness for the appellees. Dr. Palmer stated that he was not aware of any national standards for conducting the urethral smear test, but that in the Washington metropolitan area the accepted procedure is that the test is administered with a male patient in a standing position. ***

Appellees' final expert witness was Dr. William Dolan, a pathologist and director of the pathology laboratory at Arlington Hospital in Virginia. Dr. Dolan stated that he was not aware of any national standards for conducting the urethral smear test, but that for the past thirty years he has always administered the test with the patient in a standing position. ***

At the close of all the evidence, appellant submitted several jury instructions which were based on the national standard of care. Appellant maintained that in view of the national certification of the laboratory, the laboratory was under a duty to adhere to nationally accepted standards for administering the urethral smear test, and that the jury should be so instructed. Appellees argued that the laboratory owed only the duty to adhere to that standard of medical care recognized in the Washington, D.C. metropolitan area. The trial court agreed with appellees and instructed the jury as follows:

You are instructed that a medical laboratory and its personnel are required to exercise such care and skill as is exercised by other medical laboratories and their employees in good standing in the same community. That the degree of care and skill required is not the highest degree of care and skill known to the profession, but that which is exercised by ordinary and reasonably competent laboratory personnel in the treatment of patients under the same or similar circumstances. . .. ***

The elements which govern ordinary negligence actions are also applicable in actions for professional negligence. The plaintiff bears the burden of presenting evidence "which establishes the applicable standard of care, demonstrates that this standard has been violated, and develops a causal relationship between the violation and the harm complained of. *** In negligence actions the standard of care by which the defendant's conduct is measured is often stated as "that degree of care which a reasonably prudent person would have exercised under the same or similar circumstances. *** Accordingly, this standard of care, which evaluates a defendant's conduct against that conduct which is reasonable under the circumstances, is also applicable in the law of professional negligence. The law of negligence generally does not acknowledge differing standards or categories of care, but requires an adherence to a uniform standard of conduct: that of reasonable care under the circumstances.***

One of the factors which may be relevant to the determination of what is reasonable care under the circumstances is the special knowledge or skills which a defendant possesses. *** As Comment m to the RESTATEMENT OF TORTS explains:

If the actor has in fact more than the minimum of these qualities [i.e., attention, perception, memory, knowledge, intelligence, and judgment], he is required to exercise the superior qualities that he has in a manner reasonable under the circumstances. The standard becomes, in other words, that of a reasonable man with such attributes.

In sum, the duty of reasonable care requires that those with special training and experience adhere to a standard of conduct commensurate with such attributes. It is this notion of specialized knowledge and skill which animates the law of professional negligence. ***

In medical malpractice, a term referring to ordinary negligence concepts in the area of medical diagnosis, treatment, and the like, the duty of care is generally formulated as that degree of reasonable care and skill expected of members of the medical profession under the same or similar circumstances. ***

The locality rule states that the conduct of members of the medical profession is to be measured solely by the standard of conduct expected of other members of the medical profession in the same locality or the same community. *** This doctrine is indigenous to American jurisprudence and appears to have developed in the late nineteenth century. *** The rule was designed to protect doctors in rural areas who, because of inadequate training and experience, and the lack of effective means of transportation and communication, could not be expected to exhibit the skill and care of urban doctors. ***

In the smaller towns and country, those who practice medicine and surgery, though often possessing a thorough theoretical knowledge of the highest elements of the profession, do not enjoy so great opportunities of daily observation and practical operations, where the elementary studies are brought into every day use, as those have who reside in the metropolitan towns; and, though just as well informed in the elements and literature of their profession, they should not be expected to exercise that high degree of skill and practical knowledge possessed by those having greater facilities for performing and witnessing operations, and who are, or may be, constantly observing the various accidents and forms of disease. ***

In addition, it was argued that in view of the ability of urban areas to attract the most talented doctors, a rule which would hold rural doctors to urban standards of care would precipitate the departure of doctors from rural areas and thereby leave rural communities without sufficient medical care. *** In sum, the locality rule was premised on the notion that the disparity in education and access to advances in medical science between rural and urban doctors required that they be held to different standards of care.

The cases in this jurisdiction exhibit a lack of uniformity on the issue of the geographic area in which the conduct of members of the medical profession is to be measured. *** Since courts in this jurisdiction were never directly presented with this issue, the empirical validity of the assumptions behind the locality rule has not previously been examined.

Even a cursory analysis of the policy behind the locality doctrine reveals that whatever relevance it has to the practice of medicine in remote rural communities, it has no relevance to medical practice in the District of Columbia. Clearly the nation's capital is not a community isolated from recent advances in the quality of care and treatment of patients. Rather, it is one of the leading medical centers in quality health care. The medical schools in the nation's capital rate as some of the most outstanding schools in the nation. The hospitals in the District not only possess some of the most recent medical technology, but also attract some of the best medical talent from all over the country. Moreover, medical journals from all over the country are available to health care professionals in the District of Columbia, serving to keep practitioners abreast of developments in other communities. In short, the locality rule was designed to protect medical practitioners in rural communities, not practitioners in leading metropolitan centers such as the District of Columbia.

Moreover, any purported disparity between the skills of practitioners in various urban centers has for the most part been eliminated. Unlike the diversified and often limited training that was available a hundred years ago, medical education has been standardized throughout the nation through a system of national accreditation. *** Moreover, the significant improvements in transportation and communication over the past hundred years cast further doubt on continued vitality of the doctrine. ***

In sum, the major underpinnings of the locality doctrine no longer obtain. The locality rule has been quite properly criticized as a relic of the nineteenth century which has no relevance to the realities of modern medical practice.***

Quite apart from the locality rule's irrelevance to contemporary medical practice, the doctrine is also objectionable because it tends to immunize doctors from communities where medical practice is generally below that which exists in other communities from malpractice liability. *** Rather than encouraging medical practitioners to elevate the quality of care and treatment of patients to that existing in other communities, the doctrine may serve to foster substandard care, by testing the conduct of medical professionals by the conduct of other medical professionals in the same community.

The locality rule is peculiar to medical malpractice. Architects are not held to a standard of conduct exercised by other architects in the District or a similar locality. *** Moreover, the conduct of lawyers is not measured solely by the conduct of other lawyers in the District or a similar community. ***

Despite these criticisms, the locality rule is still followed in severaleral jurisdictions. *** The majority of jurisdictions, however, have abandoned the locality rule.***

Courts which have abandoned the locality rule have taken different approaches in defining the geographical boundary within which the conduct of a medical practitioner is to be measured. For example, a number of courts have modified the locality rule by extending the geographical reference group of the standard of care to include that of "the same or similar localities. ***

This approach has been criticized because of the difficulty in determining whether two communities are similar. *** In addition, the similar locality formulation has been criticized for containing the same deficiencies as the traditional locality rule, i.e., if the standard of conduct in a similar community is substandard, the similar locality rule would immunize those medical professionals whose conduct conforms to the substandard medical practice in a similar community. ***

Other courts, noting that medical standards have been nationalized largely through a system of national board certification, have adopted a national standard of care, and accordingly have eliminated any reference to a geographically defined area in their formulation of the standard of care applicable to medical professionals. *** The import of these decisions is that health care professionals who are trained according to national standards and who hold themselves out to the public as such, should be held to a national standard of care.

We are in general agreement with those courts which have adopted a national standard of care. Varying geographical standards of care are no longer valid in view of the uniform standards of proficiency established by national board certification. Moreover, the tremendous resources available in the District for medical professionals keep them abreast of advances in the care and treatment of patients that occur in all parts of the country. More importantly, residents of the District desirous of medical treatment do not rely upon a medical professional's conforming to the standard of care practiced in the District or in a similar locality. Rather, they rely upon his training, certification, and proficiency. "Negligence cannot be excused on the ground that others in the same [or similar locality] practice the same kind of negligence." Pederson v. Dumanchel, supra at 78, 431 P.2d at 977. Substandard practice is substandard whether it is followed in the same or in a similar community.

Although we have found no cases which address the issue of the standard of care applicable to a clinical laboratory, the same reasons which justify the application of a national standard of care to physicians and hospitals appear to apply with equal validity to medical laboratories. Medical laboratories are often staffed and operated by doctors who undergo the same rigorous training as other physicians. The opportunities for keeping abreast of medical advances that are available to doctors are equally available to clinical laboratories. *** Moreover, clinical laboratories generally conduct many of the routine tests that would normally be performed by physicians and hospitals. Accordingly, they owe similar duties in their care and treatment of patients. ***

Thus we hold that at least as to board certified physicians, hospitals, medical laboratories, and other health care providers, the standard of care is to be measured by the national standard. It follows that an instruction which compares a nationally certified medical professional's conduct exclusively with the standard of care in the District or a similar community is erroneous.

In the present case, appellees concede that they are a nationally certified medical laboratory and that they hold themselves out to the public as such. Appellant's expert witness testified at trial that the proper procedure to be employed in conducting a urethral smear test, according to national standards, is with the patient in a sitting or prone position. Appellees' expert witnesses who were all from the Washington metropolitan area testified that they were not aware of any national standards for conducting the test and that they always conducted the test with the patient in a standing position. However, the trial court instructed the jury that the appellees' conduct is to be compared solely with the standard of care prevailing in Washington, D.C. Thus, in effect the jury was instructed to ignore the testimony of appellant's expert witness on the standard of care. This instruction was error. The conflict in expert testimony was for the jury to resolve. Accordingly, we vacate the judgment in favor of appellees and order a new trial. ***

Reversed.