1 1 IN THE COURT OF COMMON PLEAS 2 PORTAGE COUNTY, OHIO 3 LISA GRUBB, et al., 4 Plaintiffs, 5 JUDGE ENLOW -vs- CASE NO. 99 CV 00774 6 7 ALAN L. ROSENWASSER, M.D., et al., 8 Defendants. 9 10 - - - - 11 Deposition of MICHAEL P. HOPKINS, M.D., taken as 12 if upon cross-examination before Laura L. Ware, a 13 Notary Public within and for the State of Ohio, at 14 the offices of Reminger & Reminger, 113 St. Clair 15 Building, Cleveland, Ohio, at 4:15 p.m. on Tuesday, 16 September 19, 2000, pursuant to notice and/or 17 stipulations of counsel, on behalf of the Plaintiffs 18 in this cause. 19 20 - - - - 21 WARE REPORTING SERVICE 22 21860 CROSSBEAM LANE ROCKY RIVER, OH 44116 23 (216) 533-7606 FAX (440) 333-0745 24 25 2 1 APPEARANCES: 2 Ellen Hobbs Hirshman, Esq. Linton & Hirshman 3 Hoyt Block Building - Suite 300 700 West St. Clair Avenue 4 Cleveland, Ohio 44113 (216) 781-2811, 5 - and - 6 Calvin F. Hurd, Jr., Esq. 7 3392 Ormond Road Cleveland Heights, Ohio 44118 8 (216) 932-7331, 9 On behalf of the Plaintiffs; 10 Stephen S. Crandall, Esq. Reminger & Reminger 11 113 St. Clair Building Cleveland, Ohio 44114 12 (216) 687-1311, 13 On behalf of the Defendants. 14 15 16 E X H I B I T I N D E X 17 PAGE 18 Plaintiffs' Hopkins Exhibit 1 3 19 Plaintiffs' Hopkins Exhibit 2 9 Plaintiffs' Hopkins Exhibit 3 15 20 21 22 23 24 25 3 1 - - - - 2 (Thereupon, Plaintiffs' Hopkins Exhibit 3 1 was mark'd for purposes of identification.) 4 - - - - 5 MICHAEL P. HOPKINS, M.D., of lawful age, 6 called by the Plaintiffs for the purpose of 7 cross-examination, as provided by the Rules of Civil 8 Procedure, being by me first duly sworn, as 9 hereinafter certified, deposed and said as follows: 10 CROSS-EXAMINATION OF MICHAEL P. HOPKINS, M.D. 11 BY MS. HIRSHMAN: 12 Q. Hi, Dr. Hopkins. I'm Ellen Hirshman and along with 13 Cal Hurd we represent the Grubb family, as you 14 know. I just marked a two-page letter dated January 15 19th as Plaintiffs' Exhibit 1. Would you just 16 verify for us whether or not that's the cover letter 17 from Mr. Crandall which accompanied the packet of 18 materials that were initially sent to you in this 19 case? 20 A. I think this was the first letter I received. 21 Q. My understanding is that you've seen Lisa Grubb on 22 five occasions at office visits in your office, 23 correct? 24 A. I'd have to check how many times I saw her. 25 Q. Do you have a copy of your office chart with you? 4 1 A. I don't with me. 2 Q. I didn't bring one with me. Okay. Well, you know 3 what, I'll represent to you I did look through the 4 chart. It looks like January 17th, January 28th, 5 March 24th, May 5th and June 27th, not holding you 6 to an exact account of the dates, you saw her -- 7 A. I know I saw her a few times. 8 Q. And you don't have your original office chart with 9 you today? 10 A. I don't, no. 11 Q. When you first saw Lisa Grubb, which I believe was 12 January 17th, can you recall how it was she came to 13 come to your office to be evaluated or examined by 14 you? 15 A. If I recollect, I believe you called me and asked me 16 if I could see her. 17 Q. You're looking at -- for the record, you're looking 18 at Mr. Crandall? 19 MR. CRANDALL: I feel like I'm getting 20 accused of something. 21 A. Steve Klein had given Mr. Crandall my name. I 22 believe that's how she came to my office. 23 Q. Dr. Steve Klein? 24 A. Yes. 25 Q. Can you tell me the extent of the information you 5 1 had about Lisa prior to actually seeing her for the 2 first time in your office? 3 A. When I first saw her I did not have any medical 4 record. I just went by her history. 5 Q. But even before she came into your office, before 6 you even elicited a medical history from her, did 7 you have any information whatsoever with respect to 8 any problems she may be having or the reason why she 9 was coming to be seen by you? 10 A. Well, the reason she was coming. 11 Q. Yes, and what was that? 12 A. As I recall, it was, Mr. Crandall described the 13 situation to me, that the working diagnosis was a 14 vaginal stenosis. 15 Q. So you understood that she had had some dyspareunial 16 problems with her and her husband having intercourse 17 for some period of time and that was the problem she 18 had that brought her to be seen by you? 19 A. Or vaginal stenosis. I had not talked to her about 20 dyspareunia. 21 Q. So really vaginal stenosis is probably the word you 22 heard from Mr. Crandall? 23 A. Yes. 24 Q. And as you said, you hadn't looked at any medical 25 records or depositions prior to the first time you 6 1 saw her? 2 A. No. 3 Q. Prior to your actually seeing her, given the nature 4 of some of your own writings and the literature, did 5 you have a suspicion or an interest in determining 6 whether or not she had vulvar vestibulitis? 7 A. Before I saw her? 8 Q. No. 9 A. Okay. 10 Q. Was that something you considered looking for? 11 A. Not when I talked to her. 12 Q. Not when you talked to her? 13 A. When I talked to her I did. 14 Q. What is it about what you discussed with her that 15 aroused your curiosity or concern as to whether she 16 had vulvar vestibulitis? 17 A. Her main symptom is what we call entry dyspareunia. 18 Q. And entry, you mean at the introitus? 19 A. Yes, or at the beginning of intercourse. 20 Q. Based upon the history she gave you, what is your 21 understanding as to her ability or inability to have 22 intercourse with her husband? 23 A. From her history to me, she's not able to. 24 Q. And she's been unable to have intercourse with her 25 husband since the time of the delivery of her last 7 1 child, which was September of '94? 2 A. I would have to look at the record. I believe 3 that's what she told me. 4 Q. Do you have, based on anything you've since read in 5 the depositions or records or whatever, do you have 6 any reason to doubt that that, in fact, is true? 7 A. I wouldn't doubt her, no. 8 Q. Do you have a copy of your two reports that you've 9 written in this case? 10 MS. HIRSHMAN: Do you have a copy, 11 Steve, that he can follow along with me? 12 MR. CRANDALL: I don't know. I'd have 13 to go look for it, but if you want -- can you 14 mark them as exhibits and I'll just make a 15 copy, or do you want me to make a copy now? 16 MS. HIRSHMAN: Sure, why don't we do 17 that, that way he can follow along and it will 18 make it easier. 19 - - - - 20 (Off the record.) 21 - - - - 22 Q. I can ask you some questions while we wait for 23 that. When you saw Lisa in your office, actually 24 every time you saw her, you probably saw her along 25 with her husband, Don, or do you have a recollection 8 1 one way or the other? 2 A. I believe he was there for all the visits. 3 Q. As we sit here today, do you have an actual 4 recollection of any one or more of those office 5 visits with her -- 6 A. In -- 7 Q. -- at any time? I think you had five visits with 8 her. Do you actually remember any of those five 9 visits? 10 A. I remember checking her, yes. 11 Q. What is it about checking her that you remember? 12 A. That it confirmed my opinion as to what she had 13 wrong with her. 14 Q. Essentially doing the Q-tip testing? 15 A. Yes. 16 Q. And when you did the Q-tip testing, and I believe 17 we'll look at your report when we get it back in the 18 room, you noticed that she had exquisite tenderness 19 and pain and you identified a 4:00 and 8:00 20 position? 21 A. Yes. 22 MS. HIRSHMAN: I'm going to mark this 23 as Exhibit 2. 24 25 - - - - 9 1 (Thereupon, Plaintiffs' Hopkins Exhibit 2 2 was mark'd for purposes of identification.) 3 - - - - 4 Q. What we've marked is a diagram of the vulva 5 identifying the clitoris, urethra and vagina, its 6 general anatomy. It's not Lisa, no patient in 7 particular, but I'm going to hand that to you. 8 Looking at this Exhibit 2, would you be able to 9 mark in red circles the area of 4:00 and 8:00 where 10 you found this exquisite tenderness and pain? 11 A. I can give you a general area. 12 Q. Okay. 13 A. Because this is the anatomy of a woman who has never 14 had intercourse. 15 Q. Okay. 16 A. Because the hymenal ring looks intact and it's 17 certainly not someone who's had a vaginal delivery 18 or a baby. 19 Q. Okay. 20 A. So it's usually in this area here. 21 Q. Can you put an X or circle with the red pen. 22 A. (Complies.) 23 Q. Okay. Then could you draw an arrow to the 4:00 and 24 8:00 and mark it so that it's clear to all of us 25 what that is? 10 1 A. (Complies.) And this is an approximate area. 2 Q. Thank you. You noted in your report of January 17th 3 that the vagina easily admitted a speculum. Was it 4 a narrow speculum, was it a special speculum; would 5 you be able to tell me? 6 A. I can't remember whether I used -- 7 Q. Well, it says the narrow speculum a couple lines 8 down, if you see that. 9 A. Yes. 10 Q. Is that equivalent to two fingers? 11 A. The narrow speculum would be the equivalent of one 12 to one and a half fingers. 13 Q. Okay. Would you -- strike that. 14 Would you, and I'm doing this just so we're all 15 clear about these terms and anatomically where these 16 areas are, would you circle for me with this blue 17 marker on Exhibit 2 the area that is known as the 18 introitus? 19 A. (Complies.) 20 Q. And could you draw a line and write that down for 21 me, just so we're clear what that is? 22 A. (Complies.) 23 Q. Again, I'm looking at your report of January 17th 24 which you have in front of you, and the last 25 paragraph on the first page also says there was no 11 1 vaginal, is that, synechia? 2 A. Synechia. 3 Q. What is that, Doctor? 4 A. It would be scar tissue in the vagina. 5 Q. Nor did you find any adhesions in the vagina? 6 A. No. 7 Q. And your impression was that although you got a 8 history of narrowing or stenosis you did not 9 personally find any evidence of vaginal narrowing? 10 A. No. 11 Q. At the time of examining her the very first office 12 visit, did you come to a conclusion as to what was 13 the cause of her pain or her problems with her 14 inability to have intercourse? 15 A. When I saw her, I thought it was vestibulitis. 16 Q. Okay. And that's the same as vulvar vestibulitis? 17 A. Vulvar vestibulitis, yes. 18 Q. And can you tell me the basis as to why you 19 concluded that she had vulvar vestibulitis? 20 A. Entry dyspareunia, her description of the pain and 21 the testing that I did. 22 Q. With the Q-tip? 23 A. Eliciting really extreme pain at the -- right in 24 that area, mostly at the 4:00 and 8:00 position. 25 Q. At the first office visit when you came to the 12 1 conclusion that she had vulvar vestibulitis, did you 2 also arrive at an opinion or an impression as to 3 when she first developed this problem? 4 A. No. 5 Q. Since you first saw her in January of this year, 6 have you arrived at an opinion to a reasonable 7 medical probability as to when she first developed 8 this problem of vulvar vestibulitis, as you found 9 it? 10 A. No, I haven't. 11 Q. So you have no opinion on that? 12 A. No. 13 Q. According to Exhibit No. 1, which is Mr. Crandall's 14 letter of January 19th, 2000, we know that you did 15 receive numerous office charts and prior records of 16 treatment for Lisa Grubb, along with some 17 depositions. Can you tell me at what point in time 18 you actually sat down and reviewed those materials, 19 if at all? 20 A. Probably sometime in February or March. I remember 21 looking, glancing through the records. 22 Q. And just so we're clear, do you understand Dr. 23 Rosenwasser treated Lisa in the postnatal period and 24 he did arrive at a diagnosis of tight introitus for 25 this patient, or do you have no knowledge of that 13 1 one way or the other? 2 A. I believe I remember seeing that in his records. I 3 had forgotten that. 4 Q. You're not questioning or doubting that diagnosis by 5 him when it was made? 6 A. I would have no way of knowing. 7 Q. Because you didn't see her at that time? 8 A. I never saw her. 9 Q. We also know she saw Dr. Sandra Bellin. Do you know 10 Dr. Bellin? 11 A. Yes. 12 Q. Do you know her personally and/or professionally? 13 A. I've done surgeries with her. 14 Q. Would that have been in your training or still 15 currently? 16 A. No, no, currently. 17 Q. And what type of surgeries have you done with her? 18 A. She would get me involved if she has a difficult 19 surgery or a problem. 20 Q. An oncologic procedure? 21 A. Or benign that's going to be difficult. 22 Q. In any event, did you see where she also found that 23 Lisa had adhesions and recommended surgery or a 24 secondary repair at the time of the next delivery? 25 A. I don't think I remember that. I'd have to look at 14 1 the record. 2 Q. So you don't remember seeing her office chart 3 offhand? 4 A. I don't remember seeing that. 5 Q. In any event, you probably, since you know her 6 professionally, wouldn't second guess such a finding 7 by her back in 1996? 8 A. Not necessarily, no. 9 Q. Did you notice the diagnosis of Dr. Grossman, when 10 he saw Lisa in January of 1997, of scar tissue? 11 A. You know, I had forgotten that, but he just showed 12 me, or Mr. Crandall just showed me, the picture that 13 he had sent over. 14 Q. Okay. 15 A. So I remember that he did see her. 16 MS. HIRSHMAN: And why don't we just 17 mark this then as Exhibit 3. 18 MR. CRANDALL: By the way, your 19 correspondence to me said that this was a 20 drawing that Dr. Grossman did. 21 MS. HIRSHMAN: Yeah. 22 MR. CRANDALL: Was this done at the 23 time that he saw her? 24 MS. HIRSHMAN: At the time Lisa went in 25 to see him he drew this and she took it, she 15 1 brought it with her. 2 MR. CRANDALL: Oh. 3 MS. HIRSHMAN: It's not in his office 4 chart. 5 MR. CRANDALL: No wonder. 6 MS. HIRSHMAN: Right. And in fact, I 7 will show you the original, if you want to see 8 it. It's on a paper towel. 9 MR. CRANDALL: It's on a paper towel? 10 MS. HIRSHMAN: Yeah. So I can show you 11 the original, if you want. 12 MR. CRANDALL: But this is Dr. 13 Grossman's drawing? 14 MS. HIRSHMAN: Yes. It's not in the 15 office chart. I looked. 16 MR. CRANDALL: No, I didn't think so. 17 MS. HIRSHMAN: Let's take a moment so 18 you can mark Exhibit 3. 19 - - - - 20 (Thereupon, Plaintiffs' Hopkins Exhibit 21 3 was mark'd for purposes of identification.) 22 - - - - 23 Q. Doctor, I'm going to hand you what's been marked as 24 Plaintiffs' Exhibit 3, and I will represent to you 25 that this is a drawing made by Dr. Grossman at the 16 1 time he saw Lisa back in January of '97. First of 2 all, you don't recall reviewing his office chart or 3 what his findings were when he saw her in January of 4 '97? 5 A. I would have to look back at the record. I don't 6 recall anything from that. 7 Q. In any event, if I represent to you that he did see 8 a band of scarring somewhere between the 2:00 or 9 3:00 position down to the 5:00 or 6:00 position, did 10 you find evidence of any such scaring when you saw 11 Lisa at any of the five office visits with her. 12 A. I did not see any significant scarring beyond what I 13 would expect from the surgery she's had. 14 Q. And you're able to see on Exhibit 3 the area that 15 I'm talking about, the 3:00 to 5:00 area? 16 A. Yes. 17 Q. Okay. You didn't -- is that actually in the 18 vaginal -- along the, as we look at it, the right, 19 but actually the left vaginal wall? 20 A. You'd have to ask him. I can't tell from that 21 picture. 22 Q. In any event, you have no reason to doubt his 23 findings at that point in time or question them? 24 A. No. I didn't examine her or anything at that time. 25 Q. You have reviewed the records of the Cleveland 17 1 Clinic and the records of visits to Dr. Ballard over 2 the years that Lisa has had? 3 A. Yes. 4 Q. And you reviewed the -- strike that. 5 You're aware that she has been treated -- it 6 was suggested to her to use dilators and she has 7 used dilators over the years at the suggestion of 8 several doctors; you're aware of that? 9 A. Yes. 10 Q. You don't question that plan of treatment or those 11 recommendations made to Lisa over the years? 12 A. Again, I never examined her, so I would have no way 13 of knowing. 14 Q. Would that be a reasonable way of treating vaginal 15 stenosis? 16 A. Yes. 17 Q. Having -- strike that. 18 Have you reviewed Dr. Ballard's actual 19 operative note for the surgical procedure he 20 performed in May of '98? 21 A. Yes. 22 Q. Do you have any criticisms or question his 23 recommending and/or performing that surgery on her? 24 A. No. 25 Q. That was an appropriate surgical procedure to pursue 18 1 for this patient? 2 A. Again, I didn't examine her at the time. 3 Q. Well, based upon what you can glean from the records 4 for what he said he was treating her for, this 5 vaginal stenosis, would that be reasonable surgery, 6 the surgery that he performed? 7 A. Yes. 8 Q. Postoperatively, did you note in the Cleveland 9 Clinic records that she continued to have difficulty 10 and inability to have sex with her husband? 11 A. I believe she did, yes. 12 Q. And again, she was sent for physical therapy with 13 dilators at the Cleveland Clinic. Do you have any 14 reason to criticize that treatment? 15 A. No. 16 Q. That's reasonable, given her situation at the time? 17 A. I believe so. 18 Q. At one time she actually went up to Michigan and saw 19 Dr. DeLancey. Did she tell you about that? 20 A. Yes. 21 Q. Do you know Dr. DeLancey? 22 A. Yes, we're personal friends. 23 Q. Oh, okay. And he's known to have some expertise or 24 interest in this area of vulvar pain syndromes? 25 A. Okay. 19 1 Q. I'm asking you, is he, is he known to have some 2 expertise or interest in vulvar pain syndromes? 3 A. I don't know. 4 Q. In any event, he did see her on one occasion, I 5 believe it was in May of 1998. Did you see his 6 office notes too? 7 A. I believe I did. I have to look back at those. I 8 don't recall what -- 9 Q. What his findings are? 10 MR. CRANDALL: Why don't we look at 11 them. 12 A. I believe she saw him before her surgery. 13 Q. Basically for a second opinion, right. 14 A. Okay. He did see her. 15 Q. Essentially, Dr. DeLancey, as a second opinion, 16 agrees that an attempt to release the stricture 17 would be appropriate? 18 A. Yes. 19 Q. At no time up until that point in time in anybody's 20 records does anybody come to a conclusion that she 21 has vulvar vestibulitis, do they? 22 A. Not that I found in the chart anywhere. 23 Q. Do you have an understanding one way or the other or 24 an opinion one way or the other whether or not she 25 had vulvar vestibulitis at any point in time prior 20 1 to her seeing you? 2 A. I would have no way of knowing. 3 Q. Looking at the records and based upon what the 4 records say, do you have an opinion one way or the 5 other? 6 A. No. 7 Q. Do you know, since you happen to be a friend of Dr. 8 DeLancey's, one way or another whether or not he's 9 familiar with vulvar vestibulitis and the Q-tip 10 testing that can be performed on a patient to 11 determine whether or not they may have this 12 condition? 13 A. I don't know if he is. 14 Q. Do you have an understanding as to whether or not 15 most doctors or a certain percentage of 16 gynecologists do have an understanding about this 17 syndrome, vulvar vestibulitis, and the Q-tip testing 18 that can be performed to elicit -- 19 A. I have an opinion. 20 Q. What's your impression? 21 A. I don't have any data, but I have an opinion. 22 Q. Just from your own -- 23 A. Many don't recognize it. 24 Q. Okay. But you have no way of knowing whether or not 25 any of these doctors that saw her before you ever 21 1 tested for it or whether or not they have an 2 understanding of the condition? 3 A. No. 4 Q. Did you notice -- strike that. 5 Do you know who Dr. Walters is at the Cleveland 6 Clinic? 7 A. Yes. 8 Q. Is he the chief of gynecology there? 9 A. I think he is now. 10 Q. Did you note in the records that in August of '99 he 11 actually noted in his chart that he saw no signs of 12 vestibulitis? 13 A. No, I don't recall seeing that. 14 Q. Well, if we assume that in fact the records say 15 that, you would have no reason to dispute he saw no 16 signs of vestibulitis at the time he saw her in 17 August of '99? 18 A. No. 19 Q. In fact, it looks like in August of '99 Dr. Walters' 20 diagnoses or impression is that Lisa suffers from 21 vaginismus, he also uses the word vulvodynia. Was 22 that your recollection of what you saw from the 23 records? 24 A. I'd have to look back at it. 25 Q. Do you remember whether or not he made any 22 1 recommendations back in August of '99 for Lisa in 2 terms of treatment? 3 A. I can't remember. I'd have to look. 4 Q. I'll represent to you that he recommended she go see 5 Dr. Grazier in New York City for biofeedback and to 6 take Elavil and maybe get some psychological 7 counseling or testing to assist in her treatment. 8 Do you have any criticism or comment on those 9 recommendations to her in terms of a mode of 10 treatment for her condition? 11 A. I wouldn't have a comment. For vaginismus, that's 12 one of the treatments. 13 Q. Lisa and Don never went to New York for biofeedback, 14 nor did they ever use the Elavil. Lisa never used 15 the Elavil. Is that very uncommon, that a woman may 16 be apprehensive about going into biofeedback for a 17 condition like this? 18 A. I guess I really couldn't answer that question. 19 Q. Okay. So you don't know? 20 A. I presume anyone would be apprehensive. 21 Q. You wouldn't be critical of Lisa for being 22 apprehensive about going and following a doctor's 23 recommendation to go to New York City for 24 biofeedback and to take antidepressive medicine? 25 A. I wouldn't be critical of her for being 23 1 apprehensive, no. 2 Q. Do you have an opinion as to whether or not that 3 type of treatment, biofeedback and Elavil, and 4 psychological counseling, would be of any benefit to 5 her based upon your physical examination? 6 A. Based on what I found, I don't -- the Elavil might 7 be of some help, but I don't think biofeedback would 8 help. 9 Q. And Elavil might be helpful in what way? 10 A. It will sometimes block the pain sensation to the 11 brain, so that it does help for vulvodynia and 12 generalized pain of the vulva. 13 Q. I noted in your second report, which is in front of 14 you dated June 1st of 2000, that you say you 15 classified her pain as being both significant and 16 severe, and at times, I think the first report, you 17 called it exquisite. Based on your own personal 18 observation on a scale of one to ten, with ten being 19 the worst, is this ten type pain, based on your 20 observations? 21 A. That is a term that I use to describe it when I test 22 with the Q-tip, and I would -- hers was eight to 23 nine. It was quite significant when I tested her. 24 Q. You also say in this June report the vaginal caliber 25 is normal. What does that refer to, Doctor? 24 1 A. The width of the vagina. 2 Q. So that's laterally, horizontally, or just 3 circumferentially? 4 A. Diameter. 5 Q. And palpation of the vaginal side walls disclose no 6 significant pain or narrowing. That was your 7 findings? 8 A. That was my finding when I examined her then, yes. 9 Q. Did you perform this kind of an examination every 10 time you saw her in your office? 11 A. I would have to look at the records. I don't 12 believe I did the full exam because she was tender 13 with the introitus, and just introducing the 14 examining finger caused some pain, so I would see 15 her back and test her with the Q-tip to see if we 16 were getting some response. 17 Q. We can pull out -- 18 MS. HIRSHMAN: Do you have a copy of 19 his office chart here, Steve? 20 MR. CRANDALL: I didn't know you sent 21 me one, but I'm sure you might have. 22 Q. In any event, in your office chart there's only a 23 note on one office visit actually depicting a little 24 diagram and showing the 4:00 and 8:00 tenderness. 25 Would that be what you would mark if, in fact, you 25 1 performed that Q-tip testing? 2 A. That's how I do it in my office chart, yes. 3 Q. If there's an absence of such a notation at the time 4 of an office visit, would that necessarily mean you 5 didn't perform that type of examination on her? 6 A. Not necessarily. 7 Q. I know when you wrote your first letter on January 8 17th you did note that you did not tell Lisa and Don 9 about your impressions about her diagnosis. Can you 10 tell us the reason for that at that time? 11 A. I guess I had never done this before and I was asked 12 to provide an independent medical opinion, and I 13 had -- I didn't know if I was allowed to tell her. 14 Q. Right. 15 A. So I didn't. 16 Q. And at that time you called Mr. Crandall so that he 17 could know what your diagnosis was and you also 18 suggested to him at that time that you'd like to 19 talk to her about trying the topical steroidal 20 treatment? 21 A. No. 22 Q. You didn't talk -- 23 A. I told him what it was, and I left it open if she 24 wanted to come back she could. 25 Q. Okay. And then she did come back? 26 1 A. Yes. 2 Q. Somehow it was communicated to her that you thought 3 you could help her, you'd like for her to come back 4 if she's willing to treat with you, but no lawyers 5 involved, you didn't want any lawyers in your 6 office, right? 7 A. As I recall, that was our discussion, yes. 8 Q. And she and Don did come back then to meet with 9 you? 10 A. Yes. 11 Q. Your recommendation was the Topicort? 12 A. Yes. 13 Q. Why did you recommend that she use the Topicort? 14 A. That's a steroid ointment, and it's one of the only 15 ones I've found that works because it does not have 16 an alcohol base so it doesn't burn when it's put on, 17 and vestibulitis is an inflammation of the glands, 18 so the steroid cream works for the inflammation. 19 Q. When you actually examined Lisa, do you remember if 20 you were able to physically see with your eyes, 21 actually visualize any discoloration or tenderness, 22 I should say redness, erythema, whatever? 23 A. As I recall, she had some erythema and some red 24 areas in the 4:00 and 8:00 position. 25 Q. When you recommended the Topicort, was there some 27 1 hesitancy or concerns that Lisa and Don had about 2 this type of treatment? 3 A. Hesitancy that they had? 4 Q. Yeah. 5 A. Not that I recall. 6 Q. And she did go ahead and try the Topicort, didn't 7 she? 8 A. She told me she did, yes. 9 Q. So based upon your discussions with Lisa and Don at 10 every subsequent office visit, she represented to 11 you that she was trying the Topicort and using it 12 over the months she treated with you? 13 A. Yes. 14 Q. Do you have any reason to disbelieve her? 15 A. No. 16 Q. Did you talk with the Grubbs about success rates 17 you've had with treating patients with vulvar 18 vestibulitis when treating them with the Topicort? 19 A. I believe I might have mentioned numbers to them. 20 Q. Okay. What type of numbers would those have been? 21 A. Roughly in the range of 75 percent. 22 Q. And that's been your own personal experience? 23 A. Yes. 24 Q. So that I'm clear, 75 percent of the time that 25 you've treated patients with vulvar vestibulitis 28 1 they've been successfully treated when they used the 2 Topicort? 3 A. Yes. 4 Q. And generally how long, can you give me a range of 5 how long it takes for the Topicort treatment to be 6 successful or alleviate their problem? 7 A. Roughly it's one to three months. 8 Q. So she did try this for it looks like about four 9 months -- 10 A. Yes. 11 Q. -- or five months? 12 A. Yes. 13 Q. February, March, April, May, June? 14 A. Yes. 15 Q. And it was unsuccessful? 16 A. Correct. 17 Q. There was no improvement nor worsening of her 18 condition? 19 A. It seemed to stay the same. 20 Q. And when you say successful, do you follow up with 21 your patients for an extended period of time or a 22 certain period of time to determine whether or not 23 they remain pain free after using or treating them 24 with the Topicort? 25 A. Usually I'll see them back in three to six months, 29 1 but sometimes I leave it up to them to come back in 2 if they're having symptoms. 3 Q. And that's how you calculate your success rate? 4 A. Yes. 5 Q. Approximately how many patients would be included in 6 that patient population, the total patient 7 population of people you've treated with the 8 Topicort? 9 A. This would be an estimate, somewhere in the range of 10 60 to 70. 11 Q. Can you tell me what it is about Lisa which probably 12 put her in that category of patients who were 13 unsuccessful with the Topicort treatment? 14 A. I can't give you any reason. 15 Q. I know from your report of June of 2000 that you say 16 the etiology for vestibulitis is unknown, correct? 17 A. Yes. 18 Q. So essentially there's no one main known cause for 19 vulvar vestibulitis? 20 A. Correct. 21 Q. However, are there some suggestions, whether it be 22 in the literature or based upon your own knowledge, 23 some suggestions as to what may cause this condition 24 in women? 25 A. There are theories, but no one has shown what causes 30 1 it. 2 Q. Nobody has proven them, okay. Some people, some 3 doctors, have suggested that maybe candidal 4 infections or yeast infections may be a cause? 5 A. Yes. 6 Q. But it hasn't been proven? 7 A. Correct. 8 Q. It's also been suggested that the HPV virus -- 9 A. Correct. 10 Q. -- may be a cause? 11 A. Correct. 12 Q. But there's been no definitive proof? 13 A. No. 14 Q. Okay. That's lacking, isn't it? 15 A. Yes. 16 Q. It's also been suggested that maybe some 17 gynecological procedures or surgeries may cause it? 18 A. I've not seen that in the literature. 19 Q. Would you be -- 20 A. Surgery itself would cause it. 21 Q. So you would disagree that's a possible cause? 22 A. I wouldn't disagree that it's possible. 23 Q. It's been associated -- vulvar vestibulitis has been 24 associated with episiotomies? 25 A. That I've not seen either. 31 1 Q. How about vaginismus, that's been associated with 2 gynecologic procedures and surgeries possibly being 3 a cause? 4 A. Not classic vaginismus. 5 Q. How about scarring from tears following vaginal 6 deliveries, has that been a known cause, a possible 7 cause for vulvar vestibulitis? 8 A. I've seen one patient with that, but it's not been 9 associated with it, to my knowledge. 10 Q. That's a patient other than Lisa? 11 A. Yes. 12 Q. You also state in your report that you do not 13 believe the vestibulitis is related to her vaginal 14 delivery. Can you tell me why that is? 15 A. It's just not been able to be proven as to what 16 cause it is and this is so far after the delivery. 17 Q. And just so I'm clear, you don't have an opinion one 18 way or the other as to whether or not vaginal 19 scarring or stenosis that other doctors diagnosed 20 Lisa as having prior to Dr. Ballard's surgery, 21 whether or not those were related to the vaginal 22 delivery? 23 A. No, I couldn't have an opinion on that. 24 Q. In the records it is noted that Lisa has had yeast 25 infections over the years from time to time. Do you 32 1 have an opinion one way or the other as to whether 2 or not any of those yeast infections may be the 3 cause of her vulvar vestibulitis as you found it? 4 A. No. 5 Q. Any opinion as to whether or not the HPV virus in 6 this patient is the cause of her vulvar 7 vestibulitis? 8 A. No. 9 Q. And smoking, smoking really has no affect on the 10 outcome of how a patient might do if they have a 11 perineoplasty for a condition like vulvar 12 vestibulitis? 13 A. It shouldn't. 14 Q. You have suggested to Lisa and Don that they go to 15 see Dr. Babbish in Cincinnati; is that correct? 16 A. That's what I suggested to them, yes. 17 Q. Why did you suggest that? 18 A. He is the only one -- not the -- I take that back. 19 He's not the only one. He's written on the subject 20 and is interested in the topic, that's why I 21 suggested she go there. 22 Q. Have you performed perineoplasty? 23 A. Yes. 24 Q. On how many occasions? 25 A. Again, somewhere between 30 to 50. 33 1 Q. And that's over what span of years? 2 A. Fifteen years. 3 Q. And personally, what type of success rates have you 4 had in performing that procedure? 5 A. Short term with a year or so to follow up to two 6 years, somewhere in the range of 70 percent to 80 7 percent. 8 Q. And how about beyond the one or two years, how 9 often -- 10 A. I don't follow all the patients beyond that. 11 Q. So you're not sure -- 12 A. Again, I leave it to the patients if they're having 13 symptoms to come back and have me just look at it. 14 Q. Are there any controlled studies that you know of 15 that talk about success rates of perineoplasty as a 16 surgical intervention for patients with vulvar 17 vestibulitis? 18 A. There are -- I don't believe there are any 19 controlled studies. 20 Q. What is a controlled study? 21 A. Where you would take two different treatments and 22 compare them or compare treatment to no treatment. 23 Most of the series that have been published are just 24 individual series. 25 Q. And most of the published literature about the 34 1 procedure, perineoplasty, are with small populations 2 of patients? 3 A. Yes. 4 Q. In your patient population on the patients whom 5 you've performed perineoplasty, have you had to 6 perform any revisions with any frequency? 7 A. I've had two or three patients that we had to re-do 8 or do again, take out a small area that was still 9 sensitive. 10 Q. And this is all on an outpatient basis? 11 A. Yes. 12 Q. And how were those two or three patients after the 13 second procedure? 14 A. They were better. 15 Q. Their symptoms didn't totally resolve? 16 A. I have one or two patients where they didn't totally 17 resolve, but they were better. 18 Q. You gave a success rate about the perineoplasty. 19 Was it in the 70 to 80 percent range? 20 A. Yes. 21 Q. How about that 30 to 20 percent of patients on whom 22 the perineoplasty were not successful, how those 23 patients fared and what were the symptoms after the 24 perineoplasty? 25 A. Most of the patients have gotten somewhat better to 35 1 where they can function. 2 Q. When you say function, you're saying intercourse or 3 sexual relations? 4 A. Yes. 5 Q. But they still have some dyspareunia to some 6 extent? 7 A. Yes. 8 Q. How about Interferon treatment, is that something 9 that would offer any real chance of success for 10 Lisa? 11 A. I would have to look at the literature again. As I 12 recall, a few years ago a few papers came out that 13 it didn't work. 14 Q. How about laser vaporization, would that be a 15 reasonable option for her? 16 A. That has been -- some people do that as a 17 procedure. I have found that, at least in my 18 experience, it's better to just remove the entire 19 gland as opposed to the laser. 20 Q. How about reducing dietary oxalates? First of all, 21 what are dietary oxalates? 22 A. Oxalate comes in spinach, peanuts, cocoa, caffeine 23 and about ten years ago somebody thought that was 24 the answer. The oxalate gets in the urine and 25 irritates the vulvar tissues, and I've had one 36 1 patient where that works, actually. 2 Q. So that's not something that would be a reasonable 3 option for her? 4 A. I believe I might have talked to her about that with 5 her diet. I think I did. We didn't talk about it 6 before, but oxalate is something that it's just very 7 unusual that that's the cause. I have one patient 8 that it's very dramatic. It just works nicely with 9 her. I believe I did talk to Lisa about that. 10 Q. At this point you don't see dilators or the Topicort 11 as being a real option for her? 12 A. Neither one has seemed to work. 13 Q. And you would expect, I believe you said, to see 14 some result, if you're going to see any, in two to 15 three months? 16 A. We should have by now, yes. 17 Q. Did you actually tell her that she really doesn't 18 need to try the dilators anymore, that you didn't 19 see any benefit to that? 20 A. I can't recall if I told her that or not 21 specifically. She has a lot of pain when she uses 22 them. 23 Q. If it's her statement that you told her that she 24 doesn't need to do that anymore, that would not be 25 inconsistent of her impressions of how she should 37 1 proceed on that line? 2 A. Correct, yes. 3 Q. Just so we're clear, based on -- strike that. 4 Based on your physical findings when you 5 examined Lisa, this definitely isn't something 6 that's psychosomatic, is it, something that she's 7 created in her head, she has an actual physical 8 finding that you've pointed to that's the cause for 9 her inability to have intercourse? 10 A. That's my impression, yes. 11 Q. Getting back to Dr. Babbish, have you talked or 12 spoken with him or anyone from his office with 13 respect to this particular patient, Lisa Grubb? 14 A. No. 15 Q. Do you have an opinion as to what the likelihood of 16 success would be with this particular patient, 17 knowing what you know about her history and having 18 examined her, what the likelihood of success is if 19 she were to undergo perineoplasty? 20 A. I would hope she'd fall into the 70, 80 percent 21 category. 22 Q. Do you have any reason to believe whether or not she 23 would fall into those success rates? 24 A. Not any more than anyone else. 25 Q. You can't tell me why she didn't fall into that 70, 38 1 80 percent success category with the Topicort? 2 MR. CRANDALL: I think he said 75 3 percent. 4 MS. HIRSHMAN: Somewhere between 70 and 5 80, yeah. 6 A. No. 7 Q. If Lisa and Don are hesitant to go ahead with one 8 more procedure, this perineoplasty, would you find 9 that that's unusual, given the history that they've 10 been through and all the things that they've tried, 11 being a little hesitant about trying yet another 12 surgical procedure? 13 A. That wouldn't surprise me. 14 Q. You've probably had patients who have been through 15 less than she has and who are very hesitant to 16 undergo a surgical procedure like that; is that 17 true? 18 A. It's an individual thing in terms of surgery. 19 Q. Do you have an opinion one way or the other as to 20 whether or not Lisa would have vulvar vestibulitis, 21 as you have found her to have, in the year 2000, if 22 she had undergone a cesarean section? 23 A. I would have no way of knowing that. 24 Q. I have noted in the literature that early accurate 25 diagnosis of vulvar vestibulitis is essential to the 39 1 successful treatment of the condition; is that 2 true? 3 A. Again, no one knows what causes it and the 4 treatments have been variable. It seems to help if 5 you diagnose it early only because the patients 6 don't have as long a sequence of pain. 7 Q. Well, is early accurate diagnosis essential to 8 success? 9 A. I can't say that. From my experience, I've had 10 patients that have had it for a while that are 11 successfully treated and others just a short period 12 of time. 13 Q. What's the prevalence of dyspareunia in the general 14 population? Let's just talk in general, not about 15 your own practice. 16 A. I don't know offhand. I'd have to look at that. 17 It's probably in the range of five to ten percent. 18 Q. I know you're a gynecologic oncologist. What 19 percentage of your practice is devoted to your 20 gynecological practice -- I mean oncologic 21 practice? 22 A. To the cancer patients? 23 Q. Yes. 24 A. Two-thirds to 75 percent. 25 Q. What percentage of your practice is actually devoted 40 1 to patients who have vulvar pain syndromes or 2 difficulty in that regard? 3 A. I probably see two or three patients a month, new 4 patients. 5 Q. And how long have you been seeing patients at that 6 rate for the vulvar pain problems? 7 A. I probably first started at the University of 8 Michigan on the faculty, so '86. 9 Q. Did you meet Dr. DeLancey there? 10 A. We were junior faculty together. 11 Q. Do you know Dr. Edgell or Rosenwasser? 12 A. Yes. 13 Q. And how do you know them? 14 A. I work with them occasionally. 15 Q. And how long have you been working together with 16 them? 17 A. Probably for ten years. They'll refer me oncology 18 cases. 19 Q. Do you ever perform procedures with them or are you 20 called upon to perform procedures like you do with 21 Dr. Bellin occasionally? 22 A. I will occasionally at Robinson. 23 Q. When was the last time you did? 24 A. It's probably been at least six months. 25 Q. Have they ever talked to you personally about this 41 1 patient or this case? 2 A. No. 3 Q. On an annual basis, how frequently do you have 4 referrals of patients to you and/or contact with 5 Drs. Edgell and Rosenwasser? 6 A. Probably six, eight times a year. 7 Q. In addition to referrals to you, do they also refer 8 patients or have contact with your partners? 9 A. I believe they probably do. 10 Q. Have you consulted with the Reminger firm before? 11 A. I believe I have, but I would have to look. 12 MS. HIRSHMAN: I'll go off the record a 13 moment. 14 - - - - 15 (Thereupon, a discussion was had off 16 the record.) 17 - - - - 18 Q. Dr. Hopkins, do you have an opinion as to whether or 19 not the condition you diagnosed Lisa as having is a 20 permanent condition? 21 MR. CRANDALL: You mean without 22 treatment? 23 MS. HIRSHMAN: Well, whether or not 24 it's a permanent condition whether or not she 25 has treatment. 42 1 MR. CRANDALL: Well, he's already 2 indicated that if she had surgery more likely 3 than not it would have been successful. 4 MS. HIRSHMAN: Well, I think he said he 5 would hope she would fall into this category. 6 Q. Let me ask you this, do you have an opinion to a 7 reasonable medical probability whether or not if 8 Lisa were to undergo the perineoplasty whether or 9 not that treatment would be successful? 10 A. I would counsel her that she would have a 70 to 80 11 percent chance that the surgery would be successful 12 or be helpful. 13 Q. Can you tell me based upon your patient population 14 what it is about the patients that are successful 15 versus those that are unsuccessful? 16 MR. CRANDALL: Are you talking now 17 about the surgery? 18 MS. HIRSHMAN: Yes. 19 A. No, I can't tell you. 20 MS. HIRSHMAN: Okay. I don't have any 21 other questions. 22 MR. CRANDALL: Doctor, this is up to 23 you. You could either read this and perhaps 24 make any corrections, or you could waive that 25 right to read it and it would just -- the final 43 1 copy would be as what she typed today. What 2 would you like to do? We've got trial coming 3 up October 2nd, so you would have to do it 4 fairly quickly. This wasn't that long of a 5 deposition, so I'll leave it up to you. Do you 6 want to read or do you want to waive it? 7 THE WITNESS: I'll read it. 8 9 MICHAEL P. HOPKINS, M.D. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 44 1 2 C E R T I F I C A T E 3 The State of Ohio, ) SS: 4 County of Cuyahoga.) 5 6 I, Laura L. Ware, a Notary Public within and for the State of Ohio, do hereby certify that the 7 within named witness, MICHAEL P. HOPKINS, M.D., was by me first duly sworn to testify the truth, the 8 whole truth, and nothing but the truth in the cause aforesaid; that the testimony then given was reduced 9 by me to stenotypy in the presence of said witness, subsequently transcribed into typewriting under my 10 direction, and that the foregoing is a true and correct transcript of the testimony so given as 11 aforesaid. 12 I do further certify that this deposition was taken at the time and place as specified in the 13 foregoing caption, and that I am not a relative, counsel or attorney of either party or otherwise 14 interested in the outcome of this action. 15 IN WITNESS WHEREOF, I have hereunto set my hand and affixed my seal of office at Cleveland, 16 Ohio, this 25th day of September, 2000. 17 18 Laura L. Ware, Ware Reporting Service 19 21860 Crossbeam Lane, Rocky River, Ohio 44116 My commission expires May 17, 2003. 20 21 22 23 24 25