0001
 1              IN THE COURT OF COMMON PLEAS
                  OF CUYAHOGA COUNTY, OHIO
 2                       - - - - -
 3   CAESAR C. DAILEY,
     Individually and as
 4   Administrator of the
     Estate of Lillian Dailey,
 5   deceased,
 6         Plaintiff,
 7         vs              Case No. CV-07-629950
 8   OHIO PERMANENTE
     MEDICAL GROUP, INC.,
 9   et al.,
10         Defendants.
11   
12                       - - - - -
13         DEPOSITION OF PATRICIA GRAYSON, M.D.
14                WEDNESDAY, MAY 7, 2008
15                       - - - - -
16        Deposition of PATRICIA GRAYSON, M.D., a
17   Witness herein, called by counsel on behalf of
18   the Plaintiff for examination under the statute,
19   taken before me, Vivian L. Gordon, a Registered
20   Diplomate Reporter and Notary Public in and for
21   the State of Ohio, pursuant to agreement of
22   counsel, at the offices of Buckingham, Doolittle
23   & Burroughs, One Cleveland Center, Cleveland,
24   Ohio, commencing at 1:30 o'clock p.m. on the day
25   and date above set forth.
0002
 1   APPEARANCES:
 2   On behalf of the Plaintiff
 3         Becker & Mishkind Co., LPA, by
 4         HOWARD D. MISHKIND, ESQ.
 5         Skylight Office Tower
 6         1660 West Second Street Suite 660
 7         Cleveland, Ohio 44113
 8         216-241-2600
 9   
10   
11   On behalf of the Defendants
12         Buckingham, Doolittle & Burroughs, LLP, by
13         DIRK E. RIEMENSCHNEIDER, ESQ.
14         1375 East Ninth Street
15         One Cleveland Center Suite 1700
16         Cleveland, Ohio 44115
17         216-621-5300
18   
19   
20                       - - - - -
21   
22   
23   
24   
25   
0003
 1         PATRICIA GRAYSON, M.D., a witness herein,
 2   called for examination, as provided by the Ohio
 3   Rules of Civil Procedure, affirming, as
 4   hereinafter certified, was deposed and said as
 5   follows:
 6         EXAMINATION OF PATRICIA GRAYSON, M.D.
 7   BY MR. MISHKIND:
 8         Q.    Good afternoon.
 9         A.    Good afternoon.
10         Q.    Would you please state your name.
11         A.    Patricia Susan Grayson.
12         Q.    It's my understanding that you are a
13   physician; is that correct?
14         A.    Yes.
15         Q.    Internal medicine?
16         A.    Yes.
17         Q.    Are you board certified in internal
18   medicine?
19         A.    No.
20         Q.    Dr. Grayson, have you had your
21   deposition taken at any time in the past?
22         A.    Yes.
23         Q.    When is the last time that your
24   deposition was taken?
25         A.    Several years ago.
0004
 1         Q.    Even though you have had your
 2   deposition taken before, I want to give you a
 3   couple ground rules.  I am also going to tell
 4   you a little bit about what I anticipate asking
 5   you so that you have an idea so that there
 6   aren't any surprises as we go through the
 7   deposition.
 8               When you answer my questions, even
 9   though you have had your deposition taken
10   before, make sure that you answer verbally
11   rather than nodding your head or answering
12   uh-huh or uh-ugh, so that Vivian's job isn't any
13   more difficult than it already is.
14               Will you do that for me?
15         A.    Yes.
16         Q.    If you don't understand my question,
17   will you tell me, Mr. Mishkind, I don't have a
18   clue what you are asking me, and I'll try to
19   rephrase the question?
20         A.    Yes.
21         Q.    If you answer the question, is it
22   reasonable for me to conclude that you
23   understood the question?
24         A.    Yes.
25         Q.    I anticipate asking you some
0005
 1   questions about your background and your
 2   training and your employment and then I want to
 3   go through and talk about Lillian Dailey and
 4   your involvement in Lillian's care.  I'm not
 5   going to go through each and every visit that
 6   you had with her, but I want to get a sense of
 7   Lillian as a patient and matters leading up to
 8   the time of her death and your knowledge as it
 9   relates to her surgery and the clearance for
10   surgery and her ultimate demise.  I'm going to
11   try to go in a chronological order.  Does that
12   make sense?
13         A.    Yes.
14         Q.    So the first thing I want to do is
15   talk to you a little bit about your background
16   in terms of your education.
17               Tell me, first, where did you go to
18   medical school?
19         A.    The Ohio State University.
20         Q.    And you graduated from Ohio State in
21   what year, ma'am?
22         A.    1974.
23         Q.    Where are you originally from?
24         A.    Do you mean where I was born?
25         Q.    Yes, ma'am.
0006
 1         A.    I was born in Washington, D.C.
 2         Q.    Okay.  You have a southern accent.
 3   I thought you were perhaps further down south
 4   than Washington, although that's south of
 5   Cleveland.
 6         A.    I graduated from Fisk University in
 7   Nashville, Tennessee.
 8         Q.    Okay.  I knew there was some
 9   southern component there.
10               After graduating from Ohio State in
11   '74, did you do a residency?
12         A.    Yes.
13         Q.    Where was your residency?
14         A.    In Columbus, Ohio.
15         Q.    What hospital or hospitals?
16         A.    Mt. Carmel Medical Center.
17         Q.    Was your residency in internal
18   medicine?
19         A.    Yes.
20         Q.    How many years was the residency?
21         A.    One year internship and two years
22   residency; three total.
23         Q.    After finishing your residency, did
24   you become board eligible?
25         A.    Yes.
0007
 1         Q.    Did you ever sit to take the boards?
 2         A.    Yes.
 3         Q.    And on how many occasions have you?
 4         A.    One.
 5         Q.    One time?
 6         A.    Yes.
 7         Q.    About what year was that?
 8         A.    1977.
 9         Q.    Have you attempted to satisfactorily
10   become board certified since 1977?
11         A.    No.
12         Q.    Is there a reason that you didn't
13   take the boards again?
14               MR. RIEMENSCHNEIDER:  Objection.  Go
15   ahead.
16               MR. MISHKIND:  The objection
17   Mr. Riemenschneider made is only for the record
18   unless he tells you not to answer the question.
19               MR. RIEMENSCHNEIDER:  You can answer
20   the question.
21         A.    Would you repeat the question?
22         Q.    You indicated to me before that you
23   are not board certified, so I presume that you
24   were not successful in your first attempt to
25   become board certified; true?
0008
 1         A.    Yes.
 2         Q.    Was that the oral or the written
 3   that you were unsuccessful in?
 4         A.    At that time it was only written.
 5         Q.    In order to take the boards again,
 6   did you have to pursue any additional classes or
 7   additional training?
 8         A.    No.
 9         Q.    Tell me why you didn't pursue board
10   certification.
11         A.    It was not a requirement.
12         Q.    After 1977, did you continue to
13   practice down in the Columbus area or did you
14   practice elsewhere?
15         A.    After 1977 I was hired by the Ohio
16   Permanente Medical Group.
17         Q.    Have you been an employee of OPMG
18   since 1977?
19         A.    Yes.
20         Q.    Have you worked for any other
21   medical group or corporation since 1977?
22         A.    No.
23         Q.    Do you work full time, ma'am?
24         A.    Yes.
25         Q.    Over the past 31 years, have you
0009
 1   worked for any other professional groups other
 2   than OPMG?
 3         A.    No.
 4         Q.    Has your practice been exclusively
 5   up in the northeast Ohio area or have you worked
 6   throughout other areas in the state with OPMG?
 7         A.    OPMG is not in other areas of the
 8   state.
 9         Q.    There is Cleveland, there is also
10   Akron, Fairlawn.  I'm just wondering whether
11   your practice has been just up in the Cleveland
12   area?
13         A.    Yes, the Cleveland area.
14         Q.    You have not worked down in
15   Fairlawn?
16         A.    No.
17         Q.    Okay.  When you saw Lillian, did you
18   see her just at the Cleveland Heights facility
19   or did you see her at other facilities?
20         A.    Only Cleveland Heights.
21         Q.    Doctor, do you have hospital
22   privileges?
23         A.    At this time, no.
24         Q.    When is the last time you had
25   hospital privileges?
0010
 1         A.    In the 1990s.  The organization now
 2   has physicians who only go to the hospital.
 3   They are called hospitalists.  And that's their
 4   job to only take care of hospital patients.
 5         Q.    About when did that status change
 6   that the company or the OPMG had hospitalists?
 7         A.    I would say in the 1990s.
 8         Q.    Are you able to give me a better
 9   sense?  Was that early 1990s?
10         A.    Mid, toward the end.
11         Q.    Prior to that, did you have hospital
12   privileges?
13         A.    Yes.
14         Q.    Where were they at?
15         A.    With the Kaiser Foundation, with
16   St. Luke's Hospital, and with The Cleveland
17   Clinic.
18         Q.    Since the 1990s, mid to whenever
19   that changed, have you had courtesy or admitting
20   privileges to any hospital?
21         A.    Since it changed, no.
22         Q.    Have you ever applied for privileges
23   to a hospital and been denied?
24         A.    No.
25         Q.    Have you ever been the subject of
0011
 1   any disciplinary action before any State Medical
 2   Board?
 3         A.    No.
 4         Q.    Have you published anything in any
 5   peer reviewed journals or books?
 6         A.    No.
 7         Q.    Have you written anything in any
 8   non-peer reviewed journals that's been
 9   published, a throw-away or anything?
10         A.    No.
11         Q.    Within the area of internal
12   medicine, do you have an area of subspecialty?
13         A.    No.
14         Q.    So you would consider yourself to be
15   general internal medicine?
16         A.    Yes.
17         Q.    You have been licensed to practice
18   medicine since 1974?
19         A.    Yes.
20         Q.    And has your license remained
21   current and continuous since 1974?
22         A.    Yes.
23         Q.    In the department of internal
24   medicine at Kaiser, help me understand, at the
25   Cleveland Heights facility, how many doctors of
0012
 1   internal medicine -- let's talk about back in
 2   the 2005-2006 period -- how many internal
 3   medicine doctors worked at the Cleveland Heights
 4   location?
 5         A.    I don't know the exact number.
 6         Q.    Can you give me an estimate of how
 7   many of the physicians there were besides
 8   yourself?
 9         A.    Twelve.
10         Q.    I started out the deposition by
11   asking you whether you've had your deposition
12   taken before and you told me you have.  Have you
13   ever been the party to any litigation where you
14   have been named as a defendant in any medical
15   negligence cases?
16               MR. RIEMENSCHNEIDER:  Objection.
17   Continuing objection.
18               MR. MISHKIND:  That's fine.
19               MR. RIEMENSCHNEIDER:  You can answer
20   that question, doctor.
21         A.    Not that I know of.
22         Q.    The circumstances that led you to
23   giving a deposition in the past, did it have to
24   do with one of your patients?
25         A.    Yes.
0013
 1         Q.    Were you testifying as a treating
 2   doctor on behalf of a patient?
 3         A.    No.
 4         Q.    Was there an issue that this was a
 5   claim of medical negligence against Kaiser?
 6         A.    As far as I know.  I don't know the
 7   legal terminology.
 8         Q.    How many times have you been
 9   deposed?
10         A.    I would say two to three.
11         Q.    In any of those depositions, was
12   your care the subject of controversy?  And by
13   that I mean, was someone questioning whether or
14   not you had provided reasonable and safe care to
15   a patient?
16               MR. RIEMENSCHNEIDER:  Objection.
17   You can answer.
18         A.    No.
19         Q.    So this would be the third or fourth
20   time that your deposition has been taken?
21         A.    Yes.
22         Q.    Have you ever served as an expert
23   witness in any medical negligence cases?
24         A.    No.
25         Q.    Do you hold a title within the
0014
 1   department of internal medicine at Kaiser?
 2         A.    No.
 3         Q.    Have you ever held a title, either
 4   chair or chief of internal medicine or anything
 5   of that nature?
 6         A.    Not chair/chief.  I was the employee
 7   physician at one point in time.
 8         Q.    Employee physician?
 9         A.    When new employees come to apply for
10   the job, they have a history and physical done
11   and the records are reviewed and the labs are
12   reviewed.
13         Q.    Tell me about your current practice.
14         A.    I practice internal medicine.
15   Internal medicine is with adults age 18 and up.
16   My oldest patients are 99 years of age. I have
17   patients that I've seen for 30 years.
18               Internal medicine deals with adult
19   problems, such as hypertension, diabetes, heart
20   conditions, colds, backaches.
21         Q.    Do you provide well woman care?
22         A.    I do not know what you mean by the
23   term well woman care.
24         Q.    As an internist, you never heard of
25   the term well woman care?
0015
 1         A.    I have heard the term well woman,
 2   but the term may mean different things to
 3   different people in different organizations.
 4         Q.    Tell me what you understand the term
 5   well woman care to encompass.
 6         A.    To encompass care of women, women
 7   alone, as opposed to males and general
 8   evaluations.
 9         Q.    Do you do breast exams?
10         A.    Yes.
11         Q.    Do you provide screening for breast
12   cancer?
13         A.    Yes.
14         Q.    Do you do PAP smears?
15         A.    No.
16         Q.    There are certain internal medicine
17   doctors that provide a full array of care, well
18   woman care, which would include screening for
19   breast cancer as well as such things as PAP
20   smears and things of that nature.
21               So if there is a gynecological
22   issue, do you refer the patient out for
23   gynecological care, normal or abnormal?
24         A.    I refer to the Kaiser GYN
25   department.
0016
 1         Q.    You do order mammograms, though?
 2         A.    Yes.
 3         Q.    Within the area of screening for
 4   female patients, what areas do you exclude from
 5   your practice?  Gynecological issues, such as
 6   PAP smears, so anything relating to cervical,
 7   vaginal, uterine issues, you defer to a
 8   gynecologist for screening modalities?
 9         A.    Yes.
10         Q.    Do you review with your patients the
11   screening protocols, your female patients, the
12   screening protocols in terms of how often a
13   female within a certain age range should be seen
14   for routine mammograms or routine gynecological
15   evaluations?
16         A.    Yes.
17               MR. RIEMENSCHNEIDER:  Note my
18   objection as to the two questions.  I think she
19   only follows mammograms.  I want to make sure
20   the answer is clear.
21               MR. MISHKIND:  I'll be happy to
22   rephrase it.  It's probably the first time I've
23   ever given you credit.
24               MR. RIEMENSCHNEIDER:  It makes my
25   day.
0017
 1               MR. MISHKIND:  Every once in a
 2   while.
 3         Q.    In terms of the clinical guidelines
 4   for breast cancer surveillance, do you follow
 5   the American Cancer Association guidelines in
 6   terms of the frequency for mammography, clinical
 7   breast exams, and self breast exams, or do you
 8   follow a different guideline?
 9         A.    I follow the American guidelines.
10         Q.    American Cancer?
11         A.    Yes.
12         Q.    So do you for your adult female
13   patients recommend yearly clinical breast exams?
14         A.    Yearly clinical breast exams?
15         Q.    Yes.
16         A.    You mean by a clinician, not self
17   breast exams?
18         Q.    Correct.
19         A.    The recommendation is for
20   mammography.
21         Q.    And how often is it your
22   understanding that the American Cancer Society
23   recommends mammography for patients above -- is
24   it 40 and above that the recommendations apply?
25         A.    Yes, 40.
0018
 1         Q.    Is that yearly or every other year?
 2         A.    It depends.  There has been
 3   recommendations for every year and some of the
 4   other recommendations are every other year.
 5         Q.    Which ones do you follow?
 6         A.    With my patients I recommend yearly.
 7         Q.    And in terms of the clinical breast
 8   exam by the clinician as opposed to self breast
 9   exams, what do you recommend to your patients?
10         A.    Yearly.
11         Q.    In terms of self breast exams, what
12   do you recommend to your patients?
13         A.    At least monthly.
14         Q.    In terms of screening for
15   gynecological issues, you have told me a moment
16   ago that you don't do PAP smears and you don't
17   do other screening modalities yourself; true?
18         A.    Yes.
19         Q.    You would refer a patient to a
20   gynecologist for the routine GYN screening;
21   true?
22         A.    Yes.
23         Q.    How often do you recommend to your
24   female patients and at what age do you recommend
25   to your female patients that they have screening
0019
 1   for various GYN issues?
 2         A.    Any female 18 and over who is
 3   sexually active should be seen by a
 4   gynecologist.  Any female who is having any
 5   question of a gynecological issue should be seen
 6   in the GYN department regardless of their age.
 7               The recommendation is if a lady has
 8   had a negative PAP smear and she has not had any
 9   issue, the PAP does not have to be done but
10   every two to three years.
11         Q.    As an internist, do you routinely
12   review with your female patients the recommended
13   guidelines for regular follow up on GYN issues?
14               MR. RIEMENSCHNEIDER:  Objection.  Go
15   ahead.
16         A.    Yes.
17         Q.    And then you tell them that you
18   won't be providing that GYN screening, but that
19   they should be seen by someone, if they are a
20   Kaiser member, within the Kaiser Permanente
21   System; is that a fair statement?
22         A.    Yes.
23         Q.    To prepare yourself for today,
24   doctor, did you review Lillian's records?  Not
25   necessarily today, but in the recent past, did
0020
 1   you review her records?
 2         A.    I reviewed what was given to me by
 3   Mr. Riemenschneider.
 4         Q.    What was given to you?  Did it
 5   include your office notes?
 6         A.    My office notes, yes.
 7         Q.    I know that you were responsible for
 8   ordering certain tests for Lillian.  For
 9   example, you were the one that I believe ordered
10   one or perhaps more of the ultrasounds that were
11   done on Lillian in 2005; is that correct?
12         A.    No.
13         Q.    Did you ever order any ultrasounds?
14         A.    I ordered an ultrasound of the leg.
15         Q.    That was after she had her
16   hysterectomy?
17         A.    Yes.
18         Q.    Tell me -- and certainly please
19   refer to the records as necessary.  This is not
20   a memory contest -- but tell me when it was that
21   you first met Lillian.
22         A.    April 17th, 1979.
23         Q.    1979?
24         A.    1979.
25         Q.    How old was she at that time?
0021
 1         A.    Twenty-nine.
 2         Q.    Tell me what history you obtained
 3   from her at that time.
 4         A.    She came in for a physical and she
 5   was basically in good health.  Her concern was
 6   over weight gain and she hadn't been on a diet.
 7         Q.    Did you see Lillian periodically
 8   after 1979?
 9         A.    Yes.
10         Q.    How often did you see her -- and
11   remember I told you at the very beginning of the
12   deposition I wasn't going to go through each and
13   every visit -- but tell me how often you would
14   see her from 1979 up until the 1990s?
15         A.    I don't know without looking at the
16   record.
17         Q.    Remember a moment ago I said it's
18   not a memory contest.  Go ahead and look at the
19   record and give me an idea of how frequently you
20   saw her.
21               (Discussion off the record.)
22         Q.    Doctor, you are missing the point.
23   I'm not asking you to count it up.
24               After 1979, when did you next see
25   her?
0022
 1               MR. RIEMENSCHNEIDER:  This is my
 2   copy.  I think we sent you your records, give or
 3   take a few.  I'm not sure if there are some
 4   missing, but I think these go back.  Do the best
 5   you can.  Obviously we are spanning a long time
 6   period.
 7         A.    The first time I saw Mrs. Dailey was
 8   November 15 of 1977, not 1979.  The first paper
 9   in the copies of the record is listed as 1979,
10   that's why I said 1979.
11         Q.    But in actuality you saw her in
12   1977?
13         A.    Now that I have had a chance to
14   actually look at the record, the first time I
15   saw Mrs. Dailey was November 15th, 1977.
16         Q.    And what was the reason for that
17   visit, according to the record?
18         A.    Complaint of lump, right breast.
19         Q.    What did you do by way of exam or
20   testing on that date?
21         A.    I referred her to our dermatologist.
22         Q.    What was the outcome of the
23   referral?
24         A.    She was seen by the dermatologist in
25   fact on the same day and there was a cyst under
0023
 1   the right breast.  No treatment was needed.
 2         Q.    Was this a benign condition?
 3         A.    I do not know.  I'm only reading
 4   what is on the record.
 5         Q.    Did you know her in the '70s or the
 6   '80s or '90s to have any type of malignancy in
 7   the breast?
 8         A.    No.
 9         Q.    Is it fair to conclude that this
10   cyst that you referred her to the dermatologist
11   for was, in fact, a benign cyst?
12         A.    The record states here it was a
13   scarred acne formed cyst.  I'm trying to read
14   the writing here.  Scarred acne form cyst under
15   the right breast, not in the breast.
16         Q.    No ongoing treatment required for
17   that condition?
18         A.    The dermatologist wrote no treatment
19   needed.
20         Q.    Fair enough.  So then from '77, do
21   we then go to 1979 as being the next time that
22   you would have seen her?
23         A.    By the record, July 17, 1980.
24         Q.    So this April 17, '79 reference that
25   you had made earlier, was that in error?
0024
 1         A.    No, that was a physical.
 2         Q.    So you did a complete physical on
 3   her at that time?
 4         A.    Yes.
 5         Q.    Were there any abnormal findings
 6   based upon your physical examination?
 7         A.    Obesity and vaginitis monilia.
 8         Q.    Did you treat the vaginitis?
 9         A.    Yes.
10         Q.    What did you prescribe for her?
11         A.    Monistat 7.
12         Q.    Now, jumping ahead, doctor -- you
13   don't have to go to a record -- jumping ahead to
14   current day, if a female patient has vaginitis,
15   do you treat vaginitis or do you refer your
16   female patients to a GYN for the treatment of
17   vaginitis?
18         A.    I refer.
19         Q.    So back in the 1970s, you were
20   treating that within the scope of your internal
21   medicine practice?
22         A.    Yes.
23         Q.    Okay.  Do you know about when that
24   changed, approximately?
25         A.    Fifteen years.
0025
 1         Q.    So you treated her for the vaginitis
 2   and I presume at some reasonable period of time
 3   the vaginitis cleared up?
 4         A.    I don't see another visit for that
 5   condition on the record.
 6         Q.    Is it fair for me to conclude that
 7   the condition resolved?
 8         A.    Your conclusion.
 9         Q.    Tell me if my conclusion is
10   ill-founded.
11         A.    You can't say whether a condition
12   resolved or not.  I mean, if there was not a
13   follow-up, perhaps it did, but you are not the
14   patient, so you don't know.
15         Q.    Let me ask this then, and it might
16   help a little bit about making this process a
17   little bit easier for you.
18               Tell me, since we are talking a span
19   of almost 30 years that Lillian was your
20   patient, can you tell me whether you found
21   Lillian, in general -- and I emphasize in
22   general -- to be a compliant patient.
23         A.    Yes.
24         Q.    She was obese and had been obese
25   from the time that she first became a patient of
0026
 1   yours; true?
 2         A.    Yes.
 3         Q.    You also treated her for some other
 4   medical problems.  I believe she at one point in
 5   time was diagnosed as a diabetic?
 6         A.    Yes.
 7         Q.    Was she insulin or noninsulin
 8   dependent?
 9         A.    Noninsulin dependent.
10         Q.    Was she prescribed medication for
11   her diabetes?
12         A.    Not that I recall.
13         Q.    Diet controlled?
14         A.    Diet controlled.
15         Q.    Did she appear, in terms of the
16   blood work that you did on her to check her
17   glucose and hemoglobin, A1C, to be compliant
18   with the diet regimen?
19         A.    Yes.
20         Q.    Did she have any significant
21   sequelae as a consequence of the diabetes?
22         A.    No.
23         Q.    In addition to the diabetes and her
24   obesity, was she also treated at one point in
25   time for hyperlipidemia?
0027
 1         A.    Not that I recall.
 2         Q.    What about hypertension?
 3         A.    Not that I recall.
 4         Q.    What medical conditions or ailments
 5   did you treat her for on a chronic or long-term
 6   basis other than managing her diabetes and the
 7   issues that may arise with her diabetes, were
 8   there any other conditions that she saw you for
 9   and that you managed over the course of time
10   before we get into her perimenopausal or her,
11   let's say, her late 40s, early 50s?
12               THE WITNESS: Am I allowed to look at
13   the record?
14               MR. RIEMENSCHNEIDER:  Yes.
15         Q.    Doctor, you can use the record as
16   much as you need.  Again, I'm not trying to make
17   this a memory contest, but certainly you have a
18   long history with this patient, more than
19   probably any other doctor that treated her, so
20   that's why I want to get a sense of what
21   conditions you treated her for.
22         A.    Knee pain, hypertension.
23         Q.    When did you first note
24   hypertension?
25         A.    October 26th, 2001.
0028
 1         Q.    Did you prescribe medication for her
 2   hypertension?
 3         A.    Yes. Hydrochlorothiazide 25
 4   milligrams.
 5         Q.    Continue, please.
 6         A.    She had been seen for colds
 7   periodically, sore throat and cold.
 8         Q.    As you look through that to sort of
 9   summarize what you told us about thus far in
10   terms of chronic medical conditions, she had
11   hypertension that she was treated with
12   medication; diabetes, which she was on diet
13   control; and her obesity, was it just a weight
14   management program that you had to have her
15   follow?
16         A.    Yes.
17         Q.    And did she follow the diet
18   recommendations that you made?  I know sometimes
19   it's difficult to lose weight, but did she
20   appear to be interested in improving her health?
21         A.    Yes.
22         Q.    Besides the hypertension, the
23   diabetes, the obesity, what other -- and
24   obviously colds and knee problems, were there
25   any other issues other than general physicals
0029
 1   that you did on her over the course of the years
 2   before we start getting into the 2000s and start
 3   talking about some of the issues that are
 4   germane to her perimenopausal or irregular
 5   uterine bleeding?
 6         A.    No.
 7         Q.    Okay.  Let me ask you a couple
 8   questions about Lillian.  You obviously remember
 9   Lillian?
10         A.    Yes.
11         Q.    Did you have occasion to meet any of
12   Lillian's family prior to Lillian's demise?
13         A.    No.
14         Q.    After Lillian died, did you have any
15   communication with any of the family?
16         A.    Not that I recall.
17         Q.    You knew that she had a daughter?
18         A.    Yes.
19         Q.    But you never had occasion to meet
20   her, either in the lobby or --
21         A.    No.  I never met her daughter nor
22   her husband.
23         Q.    What about her sister or any other
24   family members?
25         A.    No.
0030
 1         Q.    How would you describe the
 2   communication that you and Lillian had?  Did you
 3   have a good physician/patient relationship?
 4         A.    Yes.
 5         Q.    Did she seem to confide in you?  In
 6   other words, if she had a physical problem,
 7   would she describe it?
 8         A.    Yes.
 9         Q.    And I think you told me before that
10   she seemed to be interested in doing the right
11   thing to maintain her state of health?
12         A.    Yes.
13         Q.    Did she have any mental health
14   issues?  Any issues of anxiety or depression
15   that you either observed or treated her for
16   during the course in time?
17         A.    No.
18         Q.    What was her occupation?
19         A.    As I recall, she was employed by
20   Community College and her background was in
21   English from Northwestern University.
22         Q.    Was Lillian, in terms of her
23   demeanor -- even though you can have a good
24   relationship with a patient, sometimes the
25   patient can be a difficult person, even though
0031
 1   you have a good relationship.  Was she friendly
 2   and cordial in your physician/patient
 3   relationship encounters?
 4         A.    Yes.
 5         Q.    Can you think of a situation where
 6   Lillian got upset with you or was mad at you for
 7   not being responsive to something or making a
 8   recommendation that she took issue with?
 9         A.    No.
10         Q.    Congratulations.  I know that you
11   can't say that about every patient.
12               As an internist, even though you
13   don't treat GYN issues, I presume that you are
14   familiar with the risk factors for a woman
15   developing uterine cancer?
16         A.    No.
17         Q.    You are not?
18         A.    No.
19         Q.    Were you aware of the risk factors
20   for a woman developing uterine sarcoma?
21         A.    No.
22         Q.    In terms of your keeping current
23   with regard to matters of internal medicine --
24   and I think you told me your internal medicine
25   practice took you from, was it from adolescence?
0032
 1         A.    No.  Eighteen.
 2         Q.    Eighteen to grave?
 3         A.    Eighteen continuously.  Live
 4   patients.
 5         Q.    To immediately before the grave.
 6   But as far as being familiar with the risk
 7   factors for a middle age woman in terms of
 8   whether a middle age woman was more or less at
 9   risk of having uterine cancer or uterine
10   sarcoma, you were not then nor are you now
11   familiar with what the risk factors are --
12               MR. RIEMENSCHNEIDER:  Objection.
13   Asked and answered.
14         Q.    -- is that a fair statement?
15               MR. RIEMENSCHNEIDER:  Objection.
16   Asked and answered.  You can answer it one more
17   time.  Go ahead.
18         A.    Can you repeat the question?
19         Q.    Sure.  My question to you was -- and
20   I just want to make sure I understand.  You are
21   telling me that even though you don't treat GYN
22   issues, you were not then, back in 2004, 2005,
23   nor are you now familiar with what the risk
24   factors are that increase the likelihood of a
25   patient having uterine cancer?
0033
 1         A.    Yes, I am not familiar.
 2         Q.    Okay.  And the same thing for
 3   uterine sarcoma, you weren't then nor are you
 4   now familiar with what the risk factors are for
 5   the development of uterine sarcoma?
 6         A.    Yes, I am not familiar.
 7         Q.    In terms of keeping current with
 8   evidence based medicine as it relates to
 9   internal medicine, what journals do you
10   regularly read?
11         A.    The AMA, the Family Practice
12   Journal, Internal Medicine News, and The
13   Cleveland Clinic Journal.
14         Q.    The Cleveland Clinic Journal, does
15   it have a particular name?
16         A.    I don't recall if it has a name
17   beyond The Cleveland Clinic Journal.
18         Q.    Do you do web based research to keep
19   current on areas of internal medicine as well?
20         A.    No.
21         Q.    So you would receive publications or
22   the journals that you just mentioned?
23         A.    Yes.
24         Q.    And are those peer reviewed
25   journals?
0034
 1         A.    I don't know if they are peer
 2   reviewed.  These are journals that are
 3   established, you know, throughout not only the
 4   United States, throughout the world, people read
 5   them.
 6         Q.    Fair enough.  And do you read those
 7   journals on a regular basis to keep current and
 8   up to date on evidence based medicine in the
 9   area of medicine?
10         A.    Yes.
11         Q.    Do you refer to those journals as
12   opposed to referring to treatises, such as
13   Harrison's or textbooks on internal medicine or
14   do you also refer to Harrison's and perhaps some
15   of the other internal medicine journals to keep
16   current in the areas of evidence based medicine
17   in internal medicine?
18         A.    Textbook and journals.
19         Q.    Is Harrison's, in your opinion, a
20   reasonably reliable and authoritative text in
21   the area of internal medicine?
22         A.    Yes.
23         Q.    What other textbooks do you consider
24   to be reasonably reliable and authoritative in
25   the area of internal medicine?
0035
 1         A.    Cecil.
 2         Q.    Do you refer to Cecil and Harrison
 3   from time to time to keep current?
 4         A.    Yes.
 5         Q.    Any other textbooks that you refer
 6   to from time to time and consider to be
 7   reasonably reliable and authoritative beyond
 8   Cecil's and Harrison's?
 9         A.    No.
10         Q.    To prepare yourself for today, other
11   than meeting with this fine gentleman seated to
12   your right, did you review any medical
13   literature?
14         A.    No.
15         Q.    Have you at any time seen the
16   autopsy on Lillian?
17         A.    Seen the report?
18         Q.    The actual autopsy.
19         A.    No.
20         Q.    Did you know that Lillian died of
21   pulmonary sarcoma embolism and thromboembolism
22   and pulmonary metastasis due to the sarcoma of
23   her uterus?
24         A.    No.
25         Q.    So when I just read that to you,
0036
 1   that was the first time you were aware of that?
 2         A.    I heard the terminology pulmonary
 3   sarcoma, but the other, no, I have never seen
 4   the report.
 5         Q.    Have you ever, in your knowledge,
 6   training and experience, ever known of a patient
 7   that from a pathophysiological standpoint had
 8   uterine sarcoma and then died of a pulmonary
 9   sarcoma embolism?
10         A.    No.
11         Q.    Did you ever talk with the doctor
12   from The Cleveland Clinic or any of the doctors
13   from The Cleveland Clinic that treated Lillian
14   for the hysterectomy or any of the initial
15   workup before her hysterectomy?
16         A.    No.
17         Q.    Have you ever had occasion to refer
18   any of your patients, doctor, to Dr. Michener at
19   The Cleveland Clinic?
20         A.    No.
21         Q.    Do you know what kind of doctor
22   Dr. Michener is?
23         A.    No.
24         Q.    Do you know what a uterine leiomyoma
25   is?
0037
 1         A.    Yes.
 2         Q.    What is it?
 3         A.    Fibroid.
 4         Q.    Is a uterine leiomyoma a benign or
 5   nonbenign condition or can it be either?
 6         A.    That I don't know.
 7         Q.    What I'm going to do now, doctor,
 8   just so you can focus in now, is I'm going to
 9   concentrate on asking you some questions
10   relative to the period of 2004 and 2005.  It is
11   unlikely that I'm going to go back in time
12   before 2004.  If I do, I will let you know so
13   that I don't make it any more difficult for you,
14   okay?
15         A.    Yes.
16         Q.    In 2004, we know from the records
17   that Lillian was seen in the department of
18   obstetrics and gynecology by a nurse
19   practitioner specifically on October 8th, at
20   which point in time she had an appointment for a
21   well woman exam, but had an enlarged uterus and
22   there were some issues with regard to her GYN
23   status.
24               The reason I mention that sort of as
25   a prelude to the next question is that you saw
0038
 1   her on November 5, 2004 after she was seen for a
 2   well woman exam.
 3               Were you aware that she had been
 4   seen in the department of GYN when you saw her
 5   on November 5, 2004?
 6         A.    I don't recall.
 7         Q.    Do you have your November 5, 2004
 8   note in front of you?
 9         A.    Yes.
10         Q.    Do you see the reason for the visit
11   was referral to GI?
12         A.    Yes.
13         Q.    And do me a favor, if you would,
14   read to me under where it says right below other
15   current medical medications, list below, can you
16   read me what is written?
17         A.    VS stable.
18         Q.    That's vital signs stable?
19         A.    Yes.  BP stable.  Chest clear.
20   Cardiac normal S1S2.  Lab, CBC, lytes, BUN,
21   creatinine, glucose, lipid, liver, thyroid, uric
22   acid, calcium, screening colonoscopy.  RTC seven
23   months.  Then my signature and the nurse's
24   signature.
25         Q.    Now, tell me, you have a number of
0039
 1   different medical terms that are listed after
 2   the chest and then what you have just read.
 3   What are you describing?
 4         A.    That's lab and it's a dash and then
 5   all of those words that I used.
 6         Q.    So in other words, you wanted labs
 7   done to evaluate certain things?
 8         A.    Yes.
 9         Q.    And what were you looking for and
10   why were you ordering those labs on November 5,
11   2004?
12         A.    Because the patient had hypertension
13   and these are basic screening labs.
14         Q.    Now, where it says referral to GI,
15   GI stands for?
16         A.    Gastroenterology department --
17   gastrointestinal department.
18         Q.    And you were referring her for, was
19   it a colonoscopy?
20         A.    Screening colonoscopy.
21         Q.    At this point in time, she was --
22   let's see, how old was she?
23         A.    Fifty-five years and two months.
24         Q.    Would this be her first, to your
25   knowledge, her first screening colonoscopy?
0040
 1         A.    I don't know.
 2               MR. RIEMENSCHNEIDER:  Howard, I need
 3   to take a break.
 4               (Recess had.)
 5         Q.    Now, doctor, when you order a test
 6   on a patient in internal medicine, do you
 7   routinely receive a copy of the test results?
 8         A.    Yes.
 9         Q.    For example, if you order blood
10   work, the results of the blood work will come
11   back to you?
12         A.    Yes.
13         Q.    And is it your duty and
14   responsibility to then check the blood work to
15   determine whether or not there are any
16   abnormalities?
17         A.    Yes.
18         Q.    And if there are any abnormalities,
19   to determine whether or not it's something that
20   you within your practice can treat or whether it
21   needs to be referred to someone else?
22         A.    Yes.
23         Q.    If you order an x-ray or any other
24   diagnostic studies, not blood work, but if you
25   order a particular study, is it the routine and
0041
 1   practice and custom for the results of an x-ray
 2   or diagnostic study to come back to you?
 3         A.    Yes.
 4         Q.    And then do you have a duty and
 5   responsibility to review the report to determine
 6   whether or not it is something within your area
 7   of expertise or whether it needs to be referred
 8   to a specialist?
 9         A.    Yes.
10         Q.    Going back to the November 5, 2004
11   office visit, is it fair to say that when
12   Lillian came to see you that she was coming
13   because she needed to be referred by you to a GI
14   doctor?
15         A.    Yes.
16         Q.    And it looks like that was
17   essentially the only reason for her visit?
18         A.    Yes.
19         Q.    Now, when you saw her on that date,
20   on the problem list, the left-hand side,
21   hypertension benign is circled.  Did you circle
22   that?
23         A.    Yes.
24         Q.    Tell me why you circled that.
25         A.    The protocol at the time was to list
0042
 1   under problems on that list the diagnosis for
 2   the patient at that point in time.  Hypertension
 3   benign was typed on, so you did not have to
 4   rewrite what was typed on.  So that was the
 5   reason for the visit.  Blood pressure was
 6   checked and evaluated and hypertension benign
 7   was circled.
 8         Q.    Did you have the kind of
 9   relationship with your patients where you would
10   review general state of health with the patient
11   even though they may only be present for a
12   specific reason on a particular visit?
13         A.    I would ask them in general how they
14   were.  I would not review, say, a review of
15   systems.
16         Q.    So, for example, on this visit, even
17   though she was seeing you for a referral for GI,
18   you would have talked with her about the status
19   of her hypertension and the need for some blood
20   work to be done?
21         A.    I would have told her at the end of
22   the visit what I would like to have done.  I
23   would've told her her blood pressure result and
24   that I wanted to have her to have lab done and
25   it had been ordered.
0043
 1         Q.    Okay.  And you would have known on
 2   November 5, 2004 that she had been seen about
 3   less than a month earlier and had a vaginal
 4   infection; correct?
 5         A.    No.
 6         Q.    What is Diflucan?
 7         A.    Diflucan is a medication that is
 8   given for a yeast infection.
 9         Q.    Under the current medications, you
10   would have known had you looked at the record
11   that she was seen on October 8th by Evelyn James
12   and was taking Diflucan 150 milligrams one time
13   a day; correct?
14         A.    If I read that.
15         Q.    Well, would there be any reason why
16   you wouldn't have read that record?
17               MR. RIEMENSCHNEIDER:  You are
18   talking about her record here or Evelyn James'
19   record?
20               MR. MISHKIND:  Her record.
21         Q.    It says less than a month earlier --
22         A.    You are saying is there a reason why
23   I would not have read it?
24         Q.    Let me make it easier for you.  She
25   comes to you for a referral for GI.  You do
0044
 1   vital signs with her.  I presume being a
 2   reasonable and prudent physician that you would
 3   have looked and seen just less than a month ago
 4   she was put on medication for a yeast infection.
 5   Correct me if I am wrong.
 6               Maybe I'm entirely wrong, but I
 7   would presume that you would have asked her how
 8   she was doing, given the fact that it was just
 9   less than a month earlier and she was taking
10   Diflucan for a yeast infection.  Maybe I'm
11   wrong.
12         A.    No.
13         Q.    You wouldn't have even mentioned it?
14   You would have skimmed right past that?
15         A.    I would not use that terminology.
16         Q.    Would you have discussed with her
17   her current medications and how she was doing
18   relative to that particular condition?
19         A.    I would have discussed internal
20   medicine medications.
21         Q.    Okay.  And at that particular point,
22   because Diflucan was something that you were
23   deferring to GYN, would you have left that out
24   of your discussion with her entirely?
25         A.    Yes.
0045
 1         Q.    Now, if she had mentioned something
 2   to you about the status of her GYN visit, would
 3   you have -- what would you have done under those
 4   circumstances?
 5         A.    It would depend on what Mrs. Dailey
 6   would have said.
 7         Q.    Okay.  On the left-hand side it says
 8   female climacteric state.  Do you know what that
 9   means?
10         A.    No.
11         Q.    And obviously uterine leiomyoma,
12   NOS.  We have already talked about that being a
13   fibroid growth or fibroid tumor in the uterus.
14   The NOS I think you told me you didn't know what
15   that stood for?
16         A.    I don't know, but you did not ask me
17   before, that I recall.
18         Q.    I might have been confusing you with
19   maybe a previous witness.
20         A.    You did not ask me about NOS.
21         Q.    What does NOS stand for?
22         A.    I do not know.
23               (Discussion off the record.)
24         Q.    Have you ever heard of NOS being
25   referred to as not otherwise specified?
0046
 1         A.    No.
 2         Q.    Now, your recommendation was that
 3   she have a screening colonoscopy and return in
 4   how many months was that?
 5         A.    Seven months.
 6         Q.    Did she have the colonoscopy done?
 7         A.    I do not know without reviewing a
 8   record.
 9         Q.    Go ahead.  Again, I would like to
10   know whether you see --
11         A.    The record I have is only --
12               MR. RIEMENSCHNEIDER:  I only sent
13   her her records.
14         A.    -- this is only my information, my
15   signature.
16               MR. RIEMENSCHNEIDER:  If you have a
17   copy of it, it will go quicker.
18         Q.    Here is a copy of a page from, it
19   looks to be -- I'll identify it on the record
20   and then I'll hand it to you so you can look at
21   it.
22               But it's a document from the
23   department of gastroenterology and it looks like
24   it's titled internal referral and it's got your
25   name across the top, Patricia Grayson.  I'm
0047
 1   going to hand this to you.  You do have a copy
 2   of that?
 3         A.    That's what I wrote.  This is what I
 4   wrote.
 5         Q.    Got it.  So this would have been the
 6   referral form that you would have filled out to
 7   initiate the colonoscopy; is that a fair
 8   statement?
 9         A.    Yes.
10         Q.    And if there was a colonoscopy that
11   was performed, you would have expected that you
12   would have received back a copy of the
13   colonoscopy, correct, or the interpretation of
14   the colonoscopy?
15         A.    Yes.
16         Q.    Okay.  Now, on November 5, did you
17   order any other tests to be performed other than
18   the blood work and the colonoscopy for Lillian?
19         A.    No.
20         Q.    Again, had you ordered any other
21   tests on November 5, the standard practice would
22   be for the results of those test to come back to
23   you; correct?
24         A.    Yes.
25         Q.    And then for you to be aware of the
0048
 1   results and either to act upon them as the
 2   physician or to refer the patient as necessary
 3   for further evaluation; true?
 4         A.    Yes.
 5         Q.    That would be the standard of care;
 6   true?
 7         A.    Yes.
 8         Q.    I'm going to show you a copy of an
 9   ultrasound that was ordered on November 5, 2004.
10   Do you see the name of the ordering physician on
11   that form?
12         A.    Yes.
13         Q.    And whose name is that?
14         A.    My name.
15         Q.    In order for Lillian to have had an
16   ultrasound, you needed to order that ultrasound;
17   correct?
18         A.    No.
19         Q.    Can you explain to me why your name
20   is on that form as the ordering physician?
21         A.    I don't know why my name is on this
22   form.
23         Q.    Can we agree that if that
24   ultrasound, which reflects that you were the
25   ordering physician, that under normal practice
0049
 1   at Kaiser that a copy of that, the results of
 2   that ultrasound would be sent to you as the
 3   ordering physician?
 4         A.    I don't know.
 5         Q.    Didn't you tell me a moment ago that
 6   if you order a test, whether it be lab work or a
 7   diagnostic study, that the report comes back to
 8   you and either you need to act upon it or to
 9   take a look at it and to refer the patient for
10   evaluation if it's outside your area of
11   expertise?
12         A.    If you were the one ordering the
13   tests.  I did not order this test.
14         Q.    So what you are telling me is that
15   where it says ordering physician on that form,
16   that is an error?
17         A.    Yes.
18         Q.    Can you tell me if you didn't order
19   it who ordered it?
20         A.    I do not know.
21         Q.    Do you know whether a nurse
22   practitioner can order an ultrasound without a
23   physician filling out the requisition?
24         A.    That I do not know.
25         Q.    Okay.  So your testimony is that
0050
 1   while that document that I just handed to you
 2   has your name as the ordering physician, you
 3   have no knowledge of ordering that?
 4         A.    I did not order this test.
 5         Q.    Okay.  And as to who ordered it, you
 6   don't know?
 7         A.    I do not know.
 8         Q.    Can we agree that whoever ordered
 9   that test result, it should have been sent to
10   that person?
11         A.    It depends on who ordered it.  I do
12   not know who ordered it.
13         Q.    Okay.  But listen to my question
14   again.  Whoever ordered that test result, if
15   it's within the Kaiser System, can we agree that
16   whoever that person was that ordered it should
17   have been sent a copy of the result?
18         A.    Yes.
19         Q.    And the reason that it should have
20   been sent to the person that ordered it is that
21   it's important for the person that ordered the
22   test result to have the information to take
23   whatever action may be necessary; is that a fair
24   statement?
25         A.    Could you repeat the question?
0051
 1               (Record read.)
 2         A.    Yes.
 3         Q.    And can we agree that this report
 4   has across the top of it abnormal?
 5         A.    Yes.
 6         Q.    And do you have any knowledge as to
 7   why that report is referenced to be abnormal?
 8         A.    Because the radiologist who
 9   interpreted this report stated that this is what
10   he wanted to have typed on the report.
11         Q.    Are you able to tell me as an
12   internal medicine doctor -- are you able to tell
13   me what is abnormal as it relates to the
14   findings on that radiology report?
15         A.    As stated on the impression, this is
16   what the radiologist stated as being abnormal.
17         Q.    What part of it is abnormal?
18         A.    Enlarged bulky uterus is noticed,
19   measuring -- and gives the measurement. A large
20   fibroid is noticed upon the posterior
21   myometrium -- gives the measurement.
22   Endometrium deviated anteriorly by large
23   fibroid.  Endometrium is prominent, and then it
24   gives the measurements.
25         Q.    Did you have a question about that?
0052
 1         A.    I want to know if I can ask my
 2   counselor something.
 3               MR. RIEMENSCHNEIDER:  We can take a
 4   break.
 5               THE WITNESS: Can I take this?
 6               MR. MISHKIND:  Sure, you can.
 7               (Discussion off the record.)
 8         Q.    All set?
 9         A.    Yes.
10         Q.    Doctor, we took a break so that you
11   could talk to counsel.  Was there anything that
12   you wanted to clarify relative to this report?
13               Because I want to be entirely fair
14   to you so when we look back at this deposition
15   when this matter goes to trial, there is no
16   question that I've been anything other than fair
17   to you.
18         A.    Fair.
19         Q.    So going back to the report again,
20   it's your testimony that you didn't order the
21   test; correct?
22         A.    I did not order the test.
23         Q.    You don't know who ordered the test?
24         A.    I do not know who ordered the test.
25         Q.    And whoever it is that ordered the
0053
 1   test should have received the results of the
 2   test; correct?
 3         A.    Yes.
 4         Q.    Where it indicates that the
 5   endometrium is deviating anteriorly, do you know
 6   the significance, if any, to that statement?
 7         A.    No.
 8         Q.    In terms of the endometrium being
 9   prominent and measuring .9 centimeters, do you
10   know the significance of that, if any?
11         A.    No.
12         Q.    Is there a system or was there a
13   system in effect at Kaiser back in 2004 for you
14   as the primary care physician for this patient
15   to be made aware of tests that had been ordered
16   by you that for whatever reason were not
17   performed on a patient?
18         A.    For some, handwritten papers would
19   possibly have come back.  As a no show, the
20   patient cancelled, yes.  Some.
21         Q.    Because I know that looking through
22   the encounter notes in terms of telephone calls
23   and things of that nature, there is a lot of
24   tracking through the Kaiser System, both with
25   regard to scheduling of appointments and then
0054
 1   also communication by a member to Kaiser, to a
 2   help line or to a nurse or to try to reach a
 3   physician in between appointments, there is a
 4   real good system on encounter notes.
 5               And specifically, what I'm getting
 6   at is, with regard to the colonoscopy, if, in
 7   fact, the colonoscopy was not performed on the
 8   patient, what mechanism would be in place for
 9   you as the ordering physician to be notified
10   that your patient who had a requisition filled
11   out to have a colonoscopy did not in fact have
12   the colonoscopy?
13         A.    It's likely that the requisition
14   would have been returned, written as a no show,
15   patient cancelled.
16         Q.    That would be the standard and
17   customary practice?
18         A.    I would not say standard.
19         Q.    Would that be the usual practice?
20         A.    I would say that likely it was the
21   usual practice.  I have received handwritten
22   requisitions returned to me saying the patient
23   cancelled or no showed.
24         Q.    In this particular case, as you look
25   at the documents that you have available, do you
0055
 1   have any explanation for whether the patient had
 2   a colonoscopy or not?
 3         A.    From the documents I have, I don't
 4   know whether a colonoscopy was done.
 5         Q.    Is there any indication that there
 6   was any communication back to you as the primary
 7   care physician indicating that the patient was a
 8   no show or it was cancelled or anything that
 9   would give you an ability to tell me what
10   ultimately happened with that colonoscopy?
11         A.    It may be in the entire record, but
12   I don't have the entire record.
13         Q.    Okay.  Based upon the information
14   you have there, there is just no way for you to
15   tell me whether she had it -- you can't tell me
16   whether she had the colonoscopy; true?
17         A.    I can't tell from the records that I
18   have here.  These are only partial of the chart.
19         Q.    We know you ultimately saw the
20   patient again?
21         A.    Yes.
22         Q.    Now, when you saw the patient again,
23   would that have been in July of '05?
24         A.    Yes.
25         Q.    And in between that period of
0056
 1   time -- strike that.  Would that appointment in
 2   July have been -- strike that again.
 3               When you had seen her last on
 4   November 5, 2004 and said to return in seven
 5   months, would she have walked out and scheduled
 6   an appointment with a medical assistant or a
 7   secretary at that point?
 8         A.    No.
 9         Q.    Tell me how the scheduling process
10   would take place when you would put down an RTC,
11   seven months?
12         A.    A reminder would be put in the
13   computer for an informational letter, paper to
14   be sent to the patient stating that, please call
15   for an appointment with doctor, whoever it may
16   be, at such-and-such a time.
17         Q.    So if the system was working -- I
18   see you counting using your fingers -- if the
19   system was working back in 2004 at Kaiser, a
20   letter would have been generated to Lillian
21   sometime in, would it be May?
22         A.    I would say two months ahead, maybe,
23   at least two months ahead, because the scheduled
24   books are usually two months in advance.
25         Q.    But the anticipated appointment
0057
 1   would be for some time at or around the early
 2   part of May to come back, because of it being
 3   November '04?
 4         A.    No.  It said seven months, so if you
 5   count up seven months, December, January,
 6   February, March, April, May, June.
 7         Q.    Okay.  So I guess I should have used
 8   my fingers.
 9         A.    That's why I was using my fingers.
10         Q.    Okay.  That's why I became a lawyer
11   rather than a mathematician.
12               So sometime in June, before June,
13   she would have received notification to schedule
14   an appointment for sometime --
15         A.    It would have been two months
16   before.
17         Q.    So is it fair to say in April or
18   thereabouts, she would have received a
19   notification about scheduling an appointment for
20   June?
21         A.    Not necessarily so, because I have
22   written seven months, but I am not positive
23   about the computer, whether it would send out
24   letters at seven months as opposed to even
25   numbers:  Two months, four months, six months,
0058
 1   eight months, 12 months.
 2               And the patient would be verbally
 3   told.  I would tell the patient I would like to
 4   see you back within this time frame and it
 5   depends on when the patient would call.  If the
 6   book was open, you may miss it by -- you may
 7   want June and the book is open in July.  You
 8   could've missed it by one day and the next
 9   month's book is opened up.
10         Q.    Do you find it reasonable for her in
11   terms of returning to you, the department of
12   internal medicine, that she came to see you on
13   July 13, 2005?
14         A.    Do I find it reasonable?
15         Q.    Was that reasonable in relationship
16   to the seven month return?
17         A.    That was right almost exact.
18         Q.    Okay.  Now, your follow-up, was it
19   to check on the status of her hypertension?
20         A.    Yes.
21         Q.    Was the return to check on anything
22   else besides the hypertension?
23         A.    No.
24         Q.    Now, when you saw her in July, you
25   would have had the problem list along the
0059
 1   left-hand side that had more items on it than
 2   the last time you saw her; correct?
 3         A.    If I had gone back to my previous
 4   note and noted that there were some additions,
 5   but by looking at it, the way it was, you would
 6   not know that new additions had been put on
 7   unless you could have something to compare it
 8   with.
 9         Q.    Sure.  If there are times where you
10   want to have information to make sure that the
11   patient has good coordination of her health
12   care, being that she is being seen in the GYN
13   department, you know that you had referred her
14   for a colonoscopy to the GI department, you
15   would have access, would you not, to information
16   on the computer?
17         A.    I don't recall what actually would
18   have been on the computer at the time.  We were
19   handwriting notes at that time.
20         Q.    Okay.  So that if that is the case,
21   then on July 13, 2005, the physical chart for
22   the patient would have been available to you,
23   would it not?
24         A.    Could have been, but sometimes not.
25         Q.    Okay.  In this case, can you say to
0060
 1   me that when you saw her on July 13, 2005, that
 2   her physical chart that would have contained
 3   information from your last visit back in
 4   November and any additional test results or
 5   office visits, that they would not have been
 6   included in the chart?
 7         A.    No, I'm not saying they would not
 8   have been included.  What I'm saying is I cannot
 9   say that I physically had the entire -- had the
10   chart.  When I say entire, the chart.  As
11   opposed to the chart, if it could have been in
12   another department or another building.
13   Everything is included in the chart, but I may
14   not have had the chart.
15         Q.    If things are operating in the usual
16   and normal course of things when a patient such
17   as Lillian Dailey sees you on July 13, 2005,
18   unless her chart was unavailable or in a
19   different department, you would have had her
20   chart that would have included notes for any
21   visits in June of '05, May of '05, perhaps April
22   of '05 or whatever visits had preceded this July
23   13th visit since you last saw her back in
24   November; is that a fair statement?
25         A.    Yes.
0061
 1         Q.    Okay.  And so that if there was
 2   reason for you as a reasonable and prudent
 3   physician to check and see what the results were
 4   of the gastroenterology, the colonoscopy, or any
 5   other test results and you needed to see that
 6   information, if the full chart was there, it
 7   would have been physically there for you to
 8   review; true?
 9         A.    Yes.
10         Q.    Okay.  Tell me about that visit in
11   terms of what you marked down.  I can see it
12   says vital signs stable.  This is now July 13,
13   2005.
14         A.    Vital signs stable.  BP stable.
15   Strong family history of diabetes.  Chest clear.
16   Cardiac, normal S1S2.  Lab to our GTT,
17   hemoglobin A1C, lytes, calcium.  RTC after
18   testing.  My name, and the diagnosis, HTN.
19         Q.    Now, so you wanted to have some
20   additional blood work done?
21         A.    Yes.  It was ordered.
22         Q.    You must have been concerned for
23   your patient on that office visit given the fact
24   that there is some reference to a possible
25   malignant neoplasm from a mammogram; is that a
0062
 1   fair statement?
 2         A.    No.
 3         Q.    Certainly had you looked on the left
 4   side of the page, you would have been aware that
 5   there was some screening being done for a
 6   possible malignant neoplasm; correct?
 7         A.    It's just the wording there.  Other
 8   screening.  In fact, it's written three times.
 9   Wait a minute.  Wait a minute; one, two, three,
10   four.
11               Other screening mammogram for
12   malignant neoplasm.  That may be just the
13   standard information that is for a screening
14   mammogram.
15         Q.    What about menstrual disorder not
16   otherwise specified or excessive menstruation,
17   those were notes that would have been new since
18   you saw her back in November of 2004.  Would you
19   likely have had some discussion with the patient
20   about the status of these conditions?
21         A.    No.
22         Q.    And is that because you're assuming
23   that those issues are being taken care of by
24   others in the Kaiser System?
25         A.    I did not list it as a diagnosis.
0063
 1         Q.    If you had the entire chart and took
 2   some time to look back at your last office
 3   visit, you would have very quickly been aware of
 4   the fact that the patient was continuing to have
 5   abnormal uterine bleeding since you had last
 6   seen her back in November of 2004; correct?
 7         A.    Are you speaking of my last office
 8   visit?
 9         Q.    Right.  Between November of 2004 and
10   July 13, 2005.
11         A.    Can you repeat that?
12               (Record read.)
13         A.    No.
14         Q.    Why do you say that?
15         A.    You say if I looked back at my last
16   office visit.
17         Q.    Your last office visit would have
18   been in November of 2004; correct?
19         A.    Correct.
20         Q.    And then in between that she had had
21   an office visit in May of 2005 where she was
22   seen with a history of uterine bleeding and then
23   she was seen in June of 2005 with uterine
24   bleeding, and then you saw her in July of 2005.
25         A.    If I had seen those, if I had seen
0064
 1   that particular paperwork.
 2         Q.    Okay.  And if the chart was
 3   organized and everything was together as it
 4   customarily is, that information would have been
 5   available to you if you had looked back a page
 6   or two before your July 13th note; correct?
 7         A.    Yes.
 8         Q.    Is it fair to say that you didn't
 9   look back at the notes for June and May?
10               MR. RIEMENSCHNEIDER:  Objection.  Go
11   ahead.
12         A.    Yes.
13         Q.    Because had you looked back at those
14   notes for June or May, you would have had some
15   discussion with the patient as to what was going
16   on with her abnormal uterine bleeding; true?
17         A.    No.
18         Q.    What would you have done had you
19   been aware of the fact that this patient who is
20   55 years old is having abnormal uterine bleeding
21   on a daily basis?
22         A.    I would not have discussed it with
23   the patient.  If I had seen the notes, and as
24   you are saying she had two visits to GYN, then I
25   would have known that she had been evaluated and
0065
 1   had been seen in the gynecological department.
 2         Q.    And you would have assumed that
 3   everything was being taken care of
 4   appropriately; is that a fair statement?  You
 5   can't look to Dirk to answer questions.
 6         A.    Can I ask him a question?
 7               MR. RIEMENSCHNEIDER:  You can ask me
 8   a question.
 9         A.    My question is about assume.  Are
10   you allowed legally to use that terminology,
11   assume?
12         Q.    Doctor, if you don't understand my
13   question --
14               MR. RIEMENSCHNEIDER:  If you don't
15   understand the question, just say you don't know
16   and that you can't assume anything.
17         A.    I can't assume anything.
18         Q.    Doctor, in May of 2005, there was
19   another ultrasound done, and I presume that it's
20   your testimony that you had nothing to do with
21   ordering that ultrasound?
22         A.    I did not order the ultrasound.
23         Q.    And would you expect that when you
24   saw Lillian in July of 2005 that the chart would
25   have had a copy of the November 2004 ultrasound?
0066
 1         A.    Yes.
 2         Q.    And would have also had a copy of
 3   the May 20, 2005 ultrasound, as well?
 4         A.    Yes.
 5         Q.    Okay.  And the May 20 -- I'm reading
 6   it upside down -- the May 20, 2005 ultrasound
 7   was ordered by Dr. Verghese.  Do you see that?
 8         A.    I see that it is typed ordered by.
 9   I don't know who ordered it.
10         Q.    All right.  When a radiologist does
11   an ultrasound on a patient, isn't the standard
12   practice to designate who it is that had ordered
13   the test?
14               MR. RIEMENSCHNEIDER:  Objection.
15   That's way outside of her --
16         A.    I don't know what the standard of
17   practice is for a radiologist.  I'm not a
18   radiologist.
19         Q.    When you order tests -- and you have
20   been ordering tests throughout your career,
21   x-rays.  You talked about treating patients for
22   back pain -- you know that you as the ordering
23   physician get a copy of that result; correct?
24         A.    Yes.
25         Q.    And you also know that reports have
0067
 1   certain information on them in terms of
 2   pertinent clinical data; correct?
 3         A.    Yes.
 4         Q.    And you also know, do you not, that
 5   the reports reflect who ordered the test,
 6   whether it be an x-ray, an ultrasound; that
 7   there is an ordering physician's name that's
 8   designated on radiology reports?
 9         A.    There is an ordering name typed on
10   the report.
11         Q.    And do you know why it's important
12   to have the name of the physician that ordered
13   the test on that report?
14         A.    So the physician ordering the report
15   can get the report delivered to them.
16         Q.    Good.  So on July 13, 2005, other
17   than lab work, did you order any other test to
18   be performed?
19         A.    No.
20         Q.    It looks like you saw Lillian next
21   on September 30, 2005.
22         A.    Yes.
23         Q.    And tell me about that visit.  What
24   was the reason for that?
25         A.    A follow-up, DM, diabetes mellitis.
0068
 1         Q.    RBS stands for what?
 2         A.    Random blood sugar.
 3         Q.    That says opposed to a fasting?
 4         A.    Fasting.
 5         Q.    Okay.  Was her random blood sugar of
 6   177 of any significant concern to you given her
 7   prior blood sugars?
 8         A.    No.
 9         Q.    And shoes and socks off, were you
10   looking to see if there were any diabetic
11   peripheral issues?
12         A.    Yes.
13         Q.    And do your notes indicate whether
14   or not there was any skin breakdown or any
15   problems?
16         A.    No.
17         Q.    They don't indicate one way or
18   another?
19         A.    No.
20         Q.    Her body mass index was 38.6, her
21   BMI?
22         A.    Yes, 38.6.
23         Q.    Of what concern did you have as it
24   related to her physical well-being on that date
25   in light of the status of her blood sugar and
0069
 1   her body weight?
 2         A.    She was overweight.
 3         Q.    Was her body mass index getting
 4   higher, lower, staying the same?
 5         A.    I would have to compare with the
 6   past, the past records.
 7         Q.    On this particular visit, doctor,
 8   you talked about a 1800 calorie per day diet.
 9   I'm not sure, and you may have, but I don't
10   recall you indicating a particular caloric diet
11   before.
12               Did you have a heightened degree of
13   concern about the status of her weight on that
14   visit?
15         A.    No.
16         Q.    Do you remember anything about this
17   office visit outside of the record?
18         A.    No.
19         Q.    Now, I think on this visit -- and if
20   the records reflect otherwise, I certainly
21   apologize -- but it looks like this visit is the
22   first time that you reference morbid obesity.
23   And morbid obesity is a medical term, is it not?
24         A.    I did not reference morbid obesity.
25         Q.    Who would have put that in there?
0070
 1         A.    I don't know.
 2         Q.    That shouldn't be put in there
 3   unless it's accurate, should it?
 4         A.    Nothing should be put in unless it
 5   is accurate, ideally.
 6         Q.    Is that inaccurate as to her being
 7   morbidly obese?
 8         A.    By definition at 38, yes, this would
 9   put, to my recollection -- I'm not positive
10   whether this would be in the category of morbid
11   obesity as opposed to obesity.
12         Q.    Is morbid obesity of more clinical
13   concern to you as an internist in a patient such
14   as Lillian than obesity that is not morbid?
15         A.    Morbid obesity would be a concern to
16   any patient.
17         Q.    May I assume on the September 30th,
18   2005 date that you did not have any discussion
19   with Lillian relative to the issues of her
20   ongoing abnormal uterine bleeding?
21         A.    I did not have any discussion.
22         Q.    And whether you looked back to see
23   what was going on with treatment by others, it's
24   impossible for you to say whether you did or
25   didn't based upon this note; correct?
0071
 1         A.    Yes.
 2         Q.    Nothing preventing you if the chart
 3   was there and been complete for you to have
 4   looked back to see what was going on; true?
 5         A.    No.
 6         Q.    That's an accurate statement?
 7         A.    No.  You say there was nothing
 8   preventing me?
 9         Q.    Correct.
10         A.    Yes.  There could have been
11   something preventing me.
12         Q.    Such as?
13         A.    Such as involvement with the issues
14   at hand, which were her diabetes, and discussion
15   and time constraints.
16         Q.    Are you limited in terms of how much
17   time you can spend with a patient on any given
18   visit?
19         A.    We have appointments scheduled, but
20   no one says that if a patient needs to have more
21   time that you cannot take the time with the
22   patient.
23         Q.    Do you recall the September visit,
24   the July visit, the November the previous year
25   visit, whether or not Lillian was accompanied by
0072
 1   anyone during --
 2         A.    I never saw anyone accompany her.
 3         Q.    Are you telling me, therefore, that
 4   there was no one in the examining room or --
 5         A.    There was no one in the examining --
 6   you mean accompanying into the room or
 7   accompanying into Kaiser?
 8         Q.    Into the examining room.
 9         A.    I'm sorry, when someone says
10   accompany, we have people who drive -- you know,
11   I'm thinking medically.  You know, we have
12   people on the bus, people who have the cab
13   waiting for them, the RTA.
14               So when you said accompany, I
15   thought you meant accompanying her physically
16   into just the office building not into the
17   examination room.
18               No, no one was in the examination
19   room.
20         Q.    Whether she was accompanied with
21   someone to the lobby, she may or may not have,
22   you just don't know one way or another?
23         A.    That I do not know.  There was no
24   one in the examination room.
25         Q.    Okay.  Let's move forward.  The next
0073
 1   office visit that you had with her would have
 2   been in -- tell me, was that December?
 3         A.    I have 10-25-05.
 4         Q.    What was the reason for that visit?
 5         A.    Abdominal pain.
 6         Q.    That's interesting.  This note has,
 7   it says Cleveland Heights "A" care team,
 8   internal medicine.  The other notes have your
 9   name on it.
10         A.    Yes.
11         Q.    Can you tell me why it says
12   Cleveland Heights "A" care team, internal
13   medicine?
14         A.    At that point in time the department
15   of internal medicine Cleveland Heights had two
16   care teams; care team A and care team B.  The
17   section of the building that I'm in was
18   designated as care team A.  The next section
19   down was designated as care team B.  The care
20   team is a group of providers who take call-in
21   patients on that day.
22               The patient will call in requesting
23   an appointment and if their physician, their PCP
24   is not available, they are offered an
25   appointment on, quote, what is called the care
0074
 1   team.  We all have to take turns working on the
 2   care team.  On that particular day I was on the
 3   care team A, my section.
 4         Q.    So this was not a regularly
 5   scheduled appointment?
 6         A.    No.
 7         Q.    But she was fortunate enough that
 8   her primary care physician, you, happened to be
 9   available to see her?  Fair statement?
10         A.    Thank you for the terminology,
11   fortunate, yes.
12         Q.    Tell me, just so I don't miss what
13   you have written there, can you tell me what
14   your findings were or what you described, other
15   than vital signs?
16         A.    Do you want me to read the note?
17         Q.    Please.
18         A.    Patient with diffuse lower abdominal
19   pain had back pain four days ago.  Had been on
20   antibiotic for UTI.  No nausea or vomiting but
21   feels constipation.  Had --
22         Q.    Maybe hard?
23         A.    No, no.  I think that's had BM and
24   pain persists.  No discharge, no blood noted in
25   stool.  Took Pepto Bismol.  Over.  Then it's the
0075
 1   clinical.
 2         Q.    Continue, please.
 3         A.    Continue.  T, 99.5.  Chest clear.
 4   Cardiac normal S1S2.  Abdomen soft.  Sounds
 5   present.  The insignia means without.  It's like
 6   an O with a line across the top.  Without
 7   palpable masses.  Diffuse tenderness.  Rectal,
 8   stool dark.  Guaiac negative.  Parenthesis, took
 9   Pepto Bismol.  To ER for additional evaluation
10   and treatment.  Husband will drive her.  Report
11   called.  Diagnosis, abdominal pain.  My
12   signature and then the nurse's signature after
13   that.
14         Q.    Okay.  On that particular date, what
15   was within your differential as to the cause or
16   potential causes for her abdominal pain?
17         A.    I was not sure why she was having
18   it, that's why I referred her immediately to the
19   ER for additional evaluation.
20         Q.    Did you have a differential as to
21   potential causes for the abdominal pain?  Even
22   though you were referring her for testing, did
23   you have a differential in mind?
24         A.    Possible diverticulitis.
25         Q.    What else would have been within
0076
 1   your differential?
 2         A.    At that time or are you asking me
 3   what would be in a differential now?
 4         Q.    No.  At that time, looking at it
 5   with all of the information that you would have
 6   had at hand and available to you on October 25,
 7   2005, what would have been within your
 8   differential?
 9         A.    At that point in time, I would say
10   diverticulitis.
11         Q.    Nothing else in the differential?
12         A.    No, not at that point in time.
13         Q.    So you referred her to the ER for --
14   what testing was it that you wanted?
15         A.    No, just additional.  No, I just say
16   additional.
17         Q.    Evaluation?
18         A.    Additional evaluation and treatment.
19         Q.    You didn't specify what that
20   additional evaluation would include, did you?
21         A.    No, because I cannot tell another
22   physician what to do.
23         Q.    Would you have had any communication
24   with -- the doctor's name is escaping me --
25   Dr. Celestina?
0077
 1         A.    I don't recall who I spoke to.
 2   However, I did speak with someone, because as I
 3   noted, I called the report.
 4         Q.    You called the report to the
 5   emergency room?
 6         A.    I called the report to the emergency
 7   room; however, it is customary that the report
 8   is given from physician to physician.
 9         Q.    Okay.  And then it would be
10   customary that whatever results were obtained
11   from the emergency room would then be
12   communicated back to you; correct?
13         A.    No.
14         Q.    Why not?
15         A.    Do you mean verbally communicated
16   back to me?
17         Q.    Either one.  Verbally and/or a
18   written report.
19         A.    A general written report would be in
20   the chart.
21         Q.    Okay.  Now, the patient had a CAT
22   scan of her pelvis with contrast; correct?
23         A.    I don't know.
24         Q.    If there were abnormal findings on
25   the CAT scan that was done in the emergency room
0078
 1   by Dr. Celestina in the usual and ordinary
 2   course of business, should those results be
 3   reported back to you or to another physician?
 4         A.    It depends on what name was on the
 5   report.
 6         Q.    Well, weren't you the one that was
 7   the requesting --
 8         A.    I requested the patient to be seen
 9   in the emergency room.  My request was for the
10   patient to be seen there.  I do not know unless
11   I actually saw the report whose name is on the
12   report.
13         Q.    Okay.  Well, on that particular day,
14   being the A team, you would expect that the
15   report would come back to either you, because
16   she was fortunate enough to see you, or to the A
17   team?
18         A.    No.
19         Q.    Well --
20         A.    The A team is not a person.
21         Q.    The department that had got the
22   evaluation, according to the record that I have,
23   was internal medicine and the emergency room
24   doctor -- you know Dr. Celestina, don't you?
25         A.    I don't know him personally.  I have
0079
 1   never seen him.
 2         Q.    Really?
 3         A.    That's the truth.
 4         Q.    I believe you.
 5         A.    I have never seen him.  If I have
 6   seen him, I don't know the name with the face.
 7         Q.    Here is what I'm getting at.  I'm
 8   sorry, in the CAT scan of the pelvis that was
 9   done on October 25, 2005, based upon your
10   telling Lillian to go to the emergency room, the
11   CAT scan of the pelvis reflected in terms of the
12   impression a primary endometrial neoplasm or
13   sarcoma is in the differential.  There were also
14   other things in terms of severely enlarged and
15   dissented uterus with multiple regions of low
16   attenuation, but there is a reference in this CT
17   of endometrial neoplasm/sarcoma being within the
18   differential.
19               Was that information communicated to
20   you at any time after she went to the emergency
21   room?
22         A.    Not that I recall.
23         Q.    Would you expect that under normal
24   circumstances that kind of information should be
25   reported back to you as the physician that had
0080
 1   requested the emergency room evaluation?
 2               MR. RIEMENSCHNEIDER:  Objection.
 3         A.    No.
 4         Q.    Why?
 5         A.    Because I don't know whose name was
 6   on the report.  If it was ordered by one
 7   physician, without seeing the report, I don't
 8   know.  As we went through before where it says
 9   ordered by, I don't know if the patient went to
10   the ER, what typed name was on the report.  If
11   it was ordered by an emergency room physician, I
12   don't know if that name is typed on there, my
13   name as having sent her, I don't know, unless I
14   can see the report.
15         Q.    I'm not holding it back from you,
16   believe me.  I'll be more than happy to show it
17   to you.  I just want to be clear in terms of the
18   chronology that the patient was directed to go
19   to the emergency room by you; correct?
20         A.    Yes.
21         Q.    After October 25, it looks like you
22   saw -- well, tell me when did you see her after
23   October 25?
24         A.    December 30, '05.
25         Q.    And that was for a pre-op
0081
 1   evaluation?
 2         A.    No.  Diabetes checkup before
 3   surgery.
 4         Q.    So between October 25 and over the
 5   next basically two months, you didn't see the
 6   patient; correct?
 7         A.    No.
 8         Q.    Tell me about that December 30, 2005
 9   visit, please.
10         A.    The reason for the visit was
11   diabetes checkup before surgery.  Glucose was
12   101, her blood pressure 120 over 70.  Vital
13   signs were stable.  Diabetes stable on diet
14   alone.  Patient scheduled for hysterectomy next
15   week.  Fibroids and still painful.  Chest clear,
16   cardiac normal S1S2.  Abdomen soft, tender and
17   continued ADA diet and fluids.  And diagnosis
18   for diabetes and hypertension.  Follow up after
19   surgery.
20         Q.    Did you know the reason that she was
21   undergoing a hysterectomy?
22         A.    No.  Outside of fibroids.  Fibroids,
23   that is the reason.  Because in my note I have
24   patient scheduled for hysterectomy next week and
25   I have fibroids written down.
0082
 1         Q.    Do you know how long as of December
 2   of 2005 the records reflect that she had had
 3   abnormal uterine bleeding?
 4         A.    No.
 5         Q.    After her surgery it looks like
 6   there was a telephone call that she had a hard
 7   stool, huge hard stool.
 8               MR. RIEMENSCHNEIDER:  What date are
 9   you looking at?
10               MR. MISHKIND:  January 23.
11         Q.    I'm not sure whether that call was
12   directed to you or not.
13               MR. MISHKIND:  Do you have that,
14   Dirk?
15         Q.    The reason I reference it, it has
16   your name on it.  I don't know whether that call
17   was directed to you for action or not.
18               As you are looking at it, I will
19   correct myself.  I think Celestina was the
20   emergency room doctor on the 25th of January.  I
21   think it was a different doctor from the
22   emergency room on the previous date.
23               (Discussion off the record.)
24         Q.    You are reading over the telephone
25   encounters
0083
 1         A.    No.  Do you want me to look at the
 2   first one?
 3         Q.    I guess I'm trying to figure out --
 4   I know sometimes it's difficult to put the
 5   telephone encounters together, but were you the
 6   one that had handled the call?
 7               I know she had hard stool and I know
 8   that you saw her in the office, it looks like,
 9   on January 24, 2006, it looks like the next day
10   for follow-up after her surgery.  I'm just
11   trying to figure out whether or not that
12   telephone call concerning the hard stool was
13   directed to you or not.
14         A.    Okay.  Can you read to me the part
15   where -- okay.  The first one.  It says up there
16   message sender.  Where it says 2:15 in the
17   morning?
18         Q.    Yes.
19         A.    That was entered to the chart.
20   Because on the next page it has specifically
21   route to and my name.  The next page, 1:38 p.m.
22   on the 11th.  But that was an earlier.  That was
23   1-11-06.
24         Q.    I think you might be confusing
25   yourself.
0084
 1         A.    Wait a minute.  You are asking me
 2   about this one?
 3               MR. RIEMENSCHNEIDER:  He just wants
 4   to know, can you tell from here if you are the
 5   one they called in.
 6         A.    No, because it says route to NT END.
 7   That's not my name there.
 8         Q.    What Mr. Riemenschneider provided
 9   you were a number of telephone encounters which
10   may have caused you confusion.  I was just
11   referring to the one on January 23, '06 and that
12   was it.
13               MR. RIEMENSCHNEIDER:  It's stapled.
14   I only wanted you to look at January 23rd.  It's
15   hard to tell.  It was 1-11-06.
16         A.    But for me to answer the question, I
17   made additional -- you gave me the whole paper
18   so I looked at all of them.
19         Q.    I didn't.  The record should reflect
20   Mr. Riemenschneider did.
21               But what you did was, in order to
22   answer my question about the January 23rd, you
23   looked at the entries before January 23rd;
24   correct?
25         A.    I looked at -- yes, I thought you
0085
 1   wanted me to look through the whole pile here.
 2         Q.    Let's move on.
 3         A.    Okay.  Can she read back the
 4   question?  I don't know if I answered the
 5   question.
 6         Q.    You did sufficiently enough.
 7               MR. RIEMENSCHNEIDER:  Listen to his
 8   question.
 9               THE WITNESS:  I'm listening.
10         Q.    I want you to know we are on the
11   home stretch and coming to the finish line --
12   not to use the Kentucky derby phrase, but I want
13   to let you know.
14               Let's talk about the last visit you
15   had which was January 24, 2006.  You saw her,
16   according to the note, and the reason for that
17   visit was diabetes?
18         A.    Yes.
19         Q.    And if you would, please, her random
20   blood sugar was 227?
21         A.    227.
22         Q.    And you had shoes and socks off
23   again to look for whether or not there was any
24   skin breakdown or diabetic neuropathy or
25   diabetic ulcers?
0086
 1         A.    Yes.
 2         Q.    And tell me what your notes show
 3   under your physical exam, please.
 4         A.    Swelling right leg.  Do you want me
 5   to read the entire --
 6         Q.    Yes.
 7         A.    Because the other part is not
 8   physical, it's a statement.
 9         Q.    It says patient status post --
10         A.    You want me to start from there?
11         Q.    Yes, please.
12         A.    Same as before.  Vital signs stable.
13   Patient status postsurgery at CCF for GYN
14   malignancy.
15               MR. RIEMENSCHNEIDER:  Having less.
16         A.    Having less pain.  Home glucometer
17   checks in range.  Appetite not good.  Has lost
18   weight.  Swelling right leg.  Negative
19   ultrasound for DVT last week.  Stat ultrasound
20   today.  Again negative for DVT.  Over.
21               Leg warm, dry.  Gait stable.
22   Continued diuretic.  Lab, CBC, lytes, BUN,
23   creatinine, glucose, A1C, lipid, liver, thyroid.
24   Continue meds.  Diagnoses DM, diabetes mellitus,
25   hypertension.  Return one month.  My signature.
0087
 1         Q.    In light of the negative ultrasound,
 2   did you have an opinion then as to what most
 3   likely was causing the swelling in her leg?
 4         A.    Possible pressure from lymph nodes.
 5         Q.    Is this a manifestation of the
 6   metastatic disease?
 7         A.    I would not have known about the
 8   disease and what had occurred.
 9         Q.    Well, you knew she had a GYN
10   malignancy?
11         A.    Yes.
12         Q.    What would cause the swelling of the
13   lymph nodes in a patient such as this with a
14   negative ultrasound?
15         A.    Having a malignancy.
16         Q.    That's what I was getting at.
17   Doctor, is the 24th of January the last time you
18   saw her?
19         A.    Yes.
20         Q.    How did you learn of your patient's
21   death?
22         A.    I was called at home.
23         Q.    Who called you?
24         A.    I don't recall who made the call.
25         Q.    Was it a family member or someone
0088
 1   from Kaiser?
 2         A.    No, no.  I don't recall.  It was
 3   definitely not a family member because a family
 4   member wouldn't have access to home telephones.
 5         Q.    What were you told?
 6         A.    I was told that the patient had an
 7   episode at home, had a seizure, syncope, the
 8   rescue was called and she was taken to the
 9   emergency room.
10         Q.    And we know that that emergency room
11   was Dr. Celestina as opposed to the previous
12   one, and again, I stand corrected on that.
13               Do you remember talking to the
14   emergency room doctor relative to your patient?
15         A.    No.  I don't recall who I spoke to.
16         Q.    You mean this telephone call?
17         A.    Yes.
18         Q.    Okay.  You don't know whether this
19   was the emergency room calling to tell you that
20   your patient had or someone from the emergency
21   room calling to tell you that your patient had
22   collapsed, had an episode of syncope, or was
23   someone else from Kaiser calling you?
24         A.    I don't recall who gave me the
25   history and the information that Mrs. Dailey had
0089
 1   passed.
 2         Q.    After obtaining that information,
 3   whether it was from the emergency room or
 4   someone else from Kaiser, did you have any
 5   further communication with anyone from Kaiser
 6   about the events leading up to her death?
 7         A.    No.
 8         Q.    Did you ever talk to Dr. Green or
 9   Dr. Stuffer or anyone else that was involved in
10   the GYN care of Lillian after she passed to get
11   a better sense of what caused this to happen?
12         A.    No.
13         Q.    I take it you were shocked?
14         A.    Yes.  Yes, shocked and saddened.
15         Q.    Did you consider Lillian,
16   parenthetically, in light of how long she had
17   been your patient, to also be your friend?
18               MR. RIEMENSCHNEIDER:  Objection.  Go
19   ahead.
20         A.    What is your definition of a friend?
21         Q.    Well, that could take me a long time
22   and we haven't known each other long enough for
23   me to tell you my full definition, but kidding
24   aside, let me rephrase that, okay?
25               Did you have the kind of
0090
 1   relationship with Lillian that not only did you
 2   feel badly when you heard about this, but that
 3   you would want to extend your condolences to the
 4   family?
 5         A.    It is my policy to extend
 6   condolences to the family of one of my patients
 7   that has passed.  It was then and has remained
 8   my policy.
 9               What I try to do is to call to the
10   home number to see if I can speak with someone
11   who answers the phone and in many cases there is
12   an answering machine there and I do leave my
13   name and express my condolences in hopes that it
14   will be received when someone listens to the
15   answering machine.
16         Q.    Is there any indication in the chart
17   or any notes anywhere that you did that in
18   Lillian's case?
19         A.    From my notes, no.
20         Q.    Do you specifically and
21   independently recall making a telephone call to
22   the Dailey household after learning of her
23   demise?
24         A.    I cannot say that I definitely
25   recall; however, I will state again, it is my
0091
 1   policy back then and it remains my policy if I
 2   am able to. In many cases you cannot get ahold
 3   of the family.  People, there are many things
 4   going on, no answering machine, answering
 5   machine is full.
 6         Q.    Okay.  Assuming you did make a call
 7   to the family, you don't have a recollection of
 8   getting a return call or having any discussion
 9   with the family at any time thereafter about the
10   circumstances?
11         A.    No.  I have not heard anything from
12   the family, no.
13         Q.    MR. MISHKIND:  Okay, doctor, I said
14   we were coming to the end.  We are now at the
15   end.
16               I know there were some questions
17   raised about these ultrasounds, the one that has
18   your name on it and one that doesn't.  You have
19   explained to me that you do not remember and in
20   fact take the position that you didn't order the
21   first one.
22         A.    I did not order.
23         Q.    Okay.
24         A.    And I know that I didn't.
25         Q.    Okay.  And the reason you know that
0092
 1   you didn't is why?
 2         A.    Because of the terminology where it
 3   says pertinent clinical data, enlarged bulky
 4   uterus.  I never examined Mrs. Dailey.  I never
 5   did a pelvic or GYN procedure at that point in
 6   time.  No way could I have said enlarged bulky
 7   uterus, and it's not my policy to order
 8   ultrasounds on a GYN case.  This is why we have
 9   a very, you know, competent full GYN department
10   to see, examine patients and to order what needs
11   to be done.
12         Q.    Okay.  Even though we didn't go
13   through each and every visit, we pretty much
14   started with your initial relationship with her
15   and then we went up to 2004.
16               Have I given you an opportunity to
17   explain what you did and what your relationship
18   was like with Lillian throughout this
19   deposition?
20               MR. RIEMENSCHNEIDER:  Objection.  Go
21   ahead.
22         A.    Yes.
23         Q.    Have I been fair to you during the
24   course of this deposition?
25               MR. RIEMENSCHNEIDER:  Objection.  Go
0093
 1   ahead.
 2         A.    It depends on what your definition
 3   of fair is.
 4         Q.    Have I cut you off and not let you
 5   explain things?
 6         A.    No, no.
 7         Q.    Do you feel as if you have been able
 8   to fairly explain to me your relationship and
 9   what your involvement was with regard to the
10   care of Lillian Dailey?
11         A.    Yes.
12               MR. MISHKIND: Thank you very much.
13   No further questions.
14               MR. RIEMENSCHNEIDER:  We will
15   reserve signature.
16                      - - - - -
17          (Deposition concluded at 4:32 p.m.)
18               (Signature not waived.)
19                      - - - - -
20   
21   
22   
23   
24   
25   
0094
 1                       AFFIDAVIT
 2         I have read the foregoing transcript from
 3   page 1 through 93 and note the following
 4   corrections:
 5   PAGE  LINE     REQUESTED CHANGE
 6   
 7   
 8   
 9   
10   
11   
12   
13   
14   
15   
16   
17   
18   
19   
20                  PATRICIA GRAYSON, M.D.
21   
           Subscribed and sworn to before me this
22   day of          , 2008.
23                  Notary Public
     My commission expires            .
24   
25   
0095
 1                     CERTIFICATE
 2   State of Ohio,
                        SS:
 3   County of Cuyahoga.
 4   
           I, Vivian L. Gordon, a Notary Public
 5   within and for the State of Ohio, duly
     commissioned and qualified, do hereby certify
 6   that the within named PATRICIA GRAYSON, M.D. was
     by me first duly sworn to testify to the truth,
 7   the whole truth and nothing but the truth in the
     cause aforesaid; that the testimony as above set
 8   forth was by me reduced to stenotypy, afterwards
     transcribed, and that the foregoing is a true
 9   and correct transcription of the testimony.
10         I do further certify that this deposition
     was taken at the time and place specified and
11   was completed without adjournment; that I am not
     a relative or attorney for either party or
12   otherwise interested in the event of this
     action.  I am not, nor is the court reporting
13   firm with which I am affiliated, under a
     contract as defined in Civil Rule 28(D).
14   
           IN WITNESS WHEREOF, I have hereunto set my
15   hand and affixed my seal of office at Cleveland,
     Ohio, on this 14th day of May, 2008.
16   
17   
18   
19                   Vivian L. Gordon, Notary Public
                     Within and for the State of Ohio
20   
     My commission expires June 8, 2009.
21   
22   
23   
24   
25