G.R. No.

171127; 171217; 171228 March 11, 2015

NOEL CASUMPANG, RUBY SANGA-MIRANDA and SAN JUAN DEDIOS HOSPITAL, vs.
NELSON CORTEJO

BRION, J.:

Edmer Cortejo was brought by, his mother, Mrs. Jesusa Cortejo, San Juan de Dios Hospital
due to difficulty in breathing, chest pain, stomach pain, and fever. At the Emergency Room, Dr.
Ramoncito Livelo physically examined him, took his medical history, and did an x-ray test on his
chest. The diagnosis was "bronchopneumonia” and Edmer was confined in the hospital.

Using their HMO, the mother and child were referred to Dr. Noel Casumpang, an accredited
pediatrician. The doctor confirmed the initial diagnosis through the use of stethoscope alone. Mrs.
Cortejo informed the doctor about the high fever of Edmer and other symptoms but Dr. Casumpang
reassured her of the diagnosis. The next day, Mrs. Cortejo informe Dr. Casumpang of Edmer’s fever,
throat irritation, chest and stomach pains, and the traces of blood in coughed up by Edmer. Again,
the doctor just reassured the mother of the said illnesss.

After some hours, Edmer vomited with blood again prompting his Father to request for a
doctor. Dr. Ruby Sanga-Miranda attended them but she failed to examine the phlegm since the
father had washed it out already. She physically examined the kid and raised some doubts in her
findings whether or not the kid has dengue fever.

In the afternoon, Edmer vomited blood again and this time, Dr. Miranda was shown his
sputum and other irritations. She managed to examine it and suspected the kid was suffering from
dengue so she performed some medical procedures for Edmer, a tourniquet test, monitoring of
blood pressure, and blood tests.

The female doctor then called Dr. Casumpang informing him about the several procedures
done to Edmer. When the blood test results came out she arrived at a diagnosis and informed the
spouses that Edmer was already suffering from “Dengue Hemorrhagic Fever”. Afterwards, Dr.
Casumpang recommended to transfer Edmer to the ICU but it was full of patients; instead, the male
doctor suggested the spouses to hire a private nurse but the latter wanted to transfer Edmer to
Makati Medical Center; therefore, Dr. Casumpang had them sign a waiver, and checked upon
Edmer for the last time, noting Edmer’s condition as comfortable. Mr. Cortejo requested for an
ambulance but there was no driver, so he hired a private ambulance.

When they arrived at Makati Med, Dr. Casumpang gave the attending physician Edmer’s
medical records. The attending physician diagnosed Edmer was unfortunately suffering from
Dengue Fever at an irreversible stage already. Sadly, it caused the death of Edmer. It prompted Mr.
Cortejo to file an action for damages against SJDH and the two physicians on the ground of medical
negligence.

The RTC ruled in favor of the pinning the defendant’s negligence on the heavy reliance of
the doctors on the initial symptoms and chest x-ray results leading to their failure to reasonably
foresee the actual illness to which the doctors failed to prove otherwise; and, finding SJDH solidarily
liable due to its legal relationship with the accused physicians.

On appeal, the CA wholly affirmed the ruling of the RTC finding the defendants’ failure to
exercise minimum medical care, attention, and treatment expected of an ordinary doctor under like
circumstances due to failure to read the most basic signs of a dengue fever expected of an ordinary
doctor as medical negligence, giving credence with the expert testimony of Dr. Rodolfo Jaudian, a
specialist in pathology, to which the respondents failed to contradict. Regarding SJDH’s liability, the
CA based it on Art. 2180 of the Civil Code regarding vicarious liability of employer’s over their
employee, to which they failed to contradict, and opined that the employment relationship of the
hospital is based on its exercise of control over its consultants and power to hire and terminate their
services.

ISSUE:

The Petitions

I. Dr. Casumpang’s Position (G.R. No. 171127)

Dr. Casumpang contends that he gave his patient medical treatment and care to the best of his
abilities, and within the proper standard of care required from physicians under similar
circumstances. He claims that his initial diagnosis of bronchopneumonia was supported by the chest
x-ray result.

Dr. Casumpang also contends that dengue fever occurs only after several days of confinement. He
alleged that when he had suspected that Edmer might be suffering from dengue fever, he
immediately attended and treated him.

Dr. Casumpang likewise raised serious doubts on Dr. Jaudian’s credibility, arguing that the CA erred
in appreciating his testimony as an expert witness since he lacked the necessary training, skills, and
experience as a specialist in dengue fever cases.

II. Dr. Sanga’s Position (G.R. No. 171217)

In her petition, Dr. Sanga faults the CA for holding her responsible for Edmer’s wrong diagnosis,
stressing that the function of making the diagnosis and undertaking the medical treatment devolved
upon Dr. Casumpang, the doctor assigned to Edmer, and who confirmed "bronchopneumonia."

Dr. Sanga also alleged that she exercised prudence in performing her duties as a physician,
underscoring that it was her professional intervention that led to the correct diagnosis of "Dengue
Hemorrhagic Fever." Furthermore, Edmer’s Complete Blood Count (CBC) showed leukopenia and
an increase in balance as shown by the differential count, demonstrating that Edmer’s infection,
more or less, is of bacterial and not viral in nature.

Dr. Sanga as well argued that there is no causal relation between the alleged erroneous diagnosis
and medication for "Bronchopneumonia," and Edmer’s death due to "Dengue Hemorrhagic Fever."

Lastly, she claimed that Dr. Jaudianis not a qualified expert witness since he never presented any
evidence of formal residency training and fellowship status in Pediatrics.

III. SJDH’s Position (G.R. No. 171228)

SJDH, on the other hand, disclaims liability by asserting that Dr. Casumpang and Dr. Sanga are
mere independent contractors and "consultants" (not employees) of the hospital. SJDH alleges that
since it did not exercise control or supervision over the consultants’ exercise of medical profession,
there is no employer-employee relationship between them, and consequently, Article 2180 of the
Civil Code does not apply.

SJDH likewise anchored the absence of employer-employee relationship on the following

circumstances: (1) SJDH does not hire consultants; it only grants them privileges to admit patients in
the hospital through accreditation; (2) SJDH does not pay the consultants wages similar to an
ordinary employee; (3) the consultants earn their own professional fees directly from their patients;
SJDH does not fire or terminate their services; and (4) SJDH does not control or interfere with the
manner and the means the consultants use in the treatment of their patients. It merely provides them
with adequate space in exchange for rental payment.

Furthermore, SJDH claims that the CA erroneously applied the control test when it treated the
hospital’s practice of accrediting consultants as an exercise of control. It explained that the control
contemplated by law is that which the employer exercises over the: (i) end result; and the (ii) manner
and means to be used to reach this end, and not any kind of control, however significant, in
accrediting the consultants.

SJDH moreover contends that even if the petitioning doctors are considered employees and not
merely consultants of the hospital, SJDH cannot still be held solidarily liable under Article 2180 of the
Civil Code because it observed the diligence of a good father of a family in their selection and
supervision as shown by the following: (1) the adequate measures that the hospital undertakes to
ascertain the petitioning doctors’ qualifications and medical competence; and (2) the documentary
evidence that the petitioning doctors presented to prove their competence in the field of pediatrics.27

SJDH likewise faults the CA for ruling that the petitioning doctors are its agents, claiming that this
theory, aside from being inconsistent with the CA’s finding of employment relationship, is unfounded
because: first, the petitioning doctors are independent contractors, not agents of SJDH; and second,
as a medical institution, SJDH cannot practice medicine, much more, extend its personality to
physicians to practice medicine on its behalf.

Lastly, SJDH maintains that the petitioning doctors arrived at an intelligently deduced and correct
diagnosis. It claimed that based on Edmer's signs and symptoms at the time of admission (i.e., one
day fever,28 bacterial infection,29 and lack of hemorrhagic manifestations30), there was no reasonable
indication yet that he was suffering from dengue fever, and accordingly, their failure to diagnose
dengue fever, does not constitute negligence on their part.

The Case for the Respondent

In his comment, the respondent submits that the issues the petitioners raised are mainly factual in
nature, which a petition for review on certiorari under Rule 45 of the Rules of Courts does not allow.

In any case, he contends that the petitioning doctors were negligent in conducting their medical
examination and diagnosis based on the following: (1) the petitioning doctors failed to timely
diagnose Edmer’s correct illness due to their non-observance of the proper and acceptable standard
of medical examination; (2) the petitioning doctors’ medical examination was not comprehensive, as
they were always in a rush; and (3) the petitioning doctors employed a guessing game in diagnosing
bronchopneumonia.
The respondent also alleges that there is a causal connection between the petitioning doctors’
negligence and Edmer’s untimely death, warranting the claim for damages.

The respondent, too, asserted that SJDH is also negligent because it was not equipped with proper
paging system, has no bronchoscope, and its doctors are not proportionate to the number of its
patients. He also pointed out that out of the seven resident physicians in the hospital, only two
resident physicians were doing rounds at the time of his son’s confinement.

The Issues

The case presents to us the following issues:

1. Whether or not the petitioning doctors had committed "inexcusable lack of precaution" in
diagnosing and in treating the patient;

2. Whether or not the petitioner hospital is solidarily liable with the petitioning doctors;

3. Whether or not there is a causal connection between the petitioners’ negligent

act/omission and the patient’s resulting death; and

4. Whether or not the lower courts erred in considering Dr. Rodolfo Tabangcora Jaudian as
an expert witness.

Our Ruling

We find the petition partly meritorious.

A Petition for Review on Certiorari

under Rule 45 of the Rules of Court
is Limited to Questions of Law.

The settled rule is that the Court’s jurisdiction in a petition for review on certiorari under Rule 45 of
the Rules of Court is limited only to the review of pure questions of law. It is not the Court’s function
to inquire on the veracity of the appellate court’s factual findings and conclusions; this Court is not a
trier of facts.31

A question of law arises when there is doubt as to what the law is on a certain state of facts, while
there is a question of fact when the doubt arises as to the truth or falsity of the alleged facts.32

These consolidated petitions before us involve mixed questions of fact and law. As a rule, we do not
resolve questions of fact. However, in determining the legal question of whether the respondent is
entitled to claim damages under Article 2176 of the Civil Code for the petitioners’ alleged medical
malpractice, the determination of the factual issues – i.e., whether the petitioning doctors were
grossly negligent in diagnosing the patient’s illness, whether there is causal relation between the
petitioners’ act/omission and the patient’s resulting death, and whether Dr. Jaudian is qualified as an
expert witness– must necessarily be resolved. We resolve these factual questions solely for the
purpose of determining the legal issues raised.

Medical Malpractice Suit as a

Specialized Area of Tort Law
The claim for damages is based on the petitioning doctors’ negligence in diagnosing and treating the
deceased Edmer, the child of the respondent. It is a medical malpractice suit, an action available to
victims to redress a wrong committed by medical professionals who caused bodily harm to, or the
death of, a patient.33 As the term is used, the suit is brought whenever a medical practitioner or
health care provider fails to meet the standards demanded by his profession, or deviates from this
standard, and causes injury to the patient.

HELD:

Dr. Casumpang is guilty of medical malpractice on the grounds that he is negligent in the
performance of his duty while Dr. Miranda? Is not..

To successfully pursue a medical malpractice suite, the plaintiff has the burden to prove that
the doctor either failed to do what a reasonably prudent doctor would have done, or did what
a reasonably prudent doctor would not have done; and the act or omission had caused injury
to the patient.

The Elements of a Medical Malpractice Suit or medical negligence are: (1) duty; (2) breach; (3)
injury; and (4) proximate causation.

Duty refers to the standard of behavior that imposes restrictions on one's conduct. In medical
malpractice suit, there must be a physician-patient relationship. It is created when a patient
engages the services of a physician, and the latter accepts or agrees to provide care to the
patient. This professional relationship is created by mere consent and may be implied. The
important factor considering a physician’s consent is his action to diagnose or treat a
patient, or at least participated in such diagnosis.

Once a physician-patient relationship is established, the legal duty of care follows. The
doctor accordingly becomes duty-bound to use at least the same standard of care that a
reasonably competent/prudent doctor would use to treat a medical condition under similar
circumstances.

In the present case, the physician-patient relationship between Dr. Casumpang and Edmer was
created when the latter’s parents sought the medical services of the former who in turn impliedly
consents when he examined, diagnosed, and treated Edmer.

With respect to Dr. Sanga, her professional relationship with Edmer arose when she assumed the
obligation to provide resident supervision over the latter. Dr. Sanga is deemed to have agreed to the
creation of physician-patient relationship with the hospital’s patients when she participated in the
diagnosis and prescribed a course of treatment for Edmer.

Breach of duty occurs when the doctor fails to comply with, or improperly performs his
duties under professional standards. This determination is both factual and legal, and is
specific to each individual case with the requirement of presentation by expert witnesses to
provide guidance to the court on matters falling within the domain of medical science, and
legal, insofar as the Court, after evaluating expert testimonies, and guided by medical
literature, learned treatises, and its fund of common knowledge, ultimately determines
whether breach of duty took place.

Whether or not Dr. Casumpang and Dr. Sanga committed a breach of duty is to be measured
by the yardstick of professional standards observed by the other members of the medical
profession in good standing under similar circumstances.

It is in this aspect of medical malpractice that expert testimony is essential to establish not
only the professional standards observed in the medical community, but also that the
physician’s conduct in the treatment of care falls below such standard.

In the present case, expert testimony is crucial in determining first, the standard medical
examinations, tests, and procedures that the attending physicians should have undertaken in
the diagnosis and treatment of dengue fever; and second, the dengue fever signs and
symptoms that the attending physicians should have noticed and considered.

Both the RTC and the CA relied largely on Dr. Jaudian’s expert testimony on dengue
diagnosis and management to support their finding that the petitioning doctors were guilty of
breach of duty of care.

Dr. Jaudian testified that Edmer’s rapid breathing, chest and stomach pain, fever, and the
presence of blood in his saliva are classic symptoms of dengue fever. According to him, if
the patient was admitted for chest pain, abdominal pain, and difficulty in breathing coupled
with fever, dengue fever should definitely be considered; if the patient spits coffee ground
with the presence of blood, and the patient’s platelet count drops to 47,000, it becomes a
clear case of dengue fever, and bronchopneumonia can be reasonably ruled out.

Furthermore, the standard of care according to Dr. Jaudian is to administer oxygen

inhalation, analgesic, and fluid infusion or dextrose. If the patient had twice vomited fresh
blood and thrombocytopenia has already occurred, the doctor should order blood
transfusion, monitoring of the patient every 30 minutes, hemostatic to stop bleeding, and
oxygen if there is difficulty in breathing.

We find that Dr. Casumpang, as Edmer’s attending physician, did not act according to these
standards and, hence, was guilty of breach of duty.

The Negligence of Dr. Casumpang is founded on the diagnosis he performed and the
treatment that follows. During Dr. Casumpang’s attention to Edmer, he already had
knowledge of the latter’s laboratory results, medical history, and symptoms but said
information did not lead the former to the possibility that Edmer could be suffering from
dengue fever, or dengue hemorrhagic fever as he clung to his diagnosis of
bronchopneumonia. Given the symptoms exhibited, Dr. Casumpang already ruled out the
possibility of other diseases like dengue.

In other words, it was lost on Dr. Casumpang that the characteristic symptoms of dengue (as
Dr. Jaudian testified) are: patient’s rapid breathing; chest and stomach pain; fever; and the
presence of blood in his saliva. All these manifestations were present and known to Dr.
Casumpang at the time of his first and second visits to Edmer. While he noted some of these
symptoms in confirming bronchopneumonia, he did not seem to have considered the
patient’s other manifestations in ruling out dengue fever or dengue hemorrhagic fever.

Dr. Casumpang selectively appreciated some, and not all of the symptoms; worse, he
casually ignored the pieces of information given by Mrs. Cortejo that could have been
material in detecting dengue fever.

Dr. Jaudian opined that Dr. Casumpang’s medical examination was not comprehensive
enough to reasonably lead to a correct diagnosis. Dr. Casumpang only used a stethoscope in
coming up with the diagnosis that Edmer was suffering from bronchopneumonia; he never
confirmed this finding with the use of a bronchoscope. Furthermore, Dr. Casumpang based
his diagnosis largely on the chest x-ray result that is generally inconclusive.

Significantly, it was only at around 5:00 in the afternoon of April 23, 1988 (after Edmer’s third
episode of bleeding) that Dr. Casumpang ordered the conduct of hematocrit, hemoglobin,
blood typing, blood transfusion and tourniquet tests. These tests came too late, as proven
by: (1) the blood test results that came at about 6:00 in the evening, confirming that Edmer’s
illness had developed to "Dengue Hemorrhagic Fever;" and (2) Dr. Jaudian’s testimony that
"dengue fever could have been detected earlier than 7:30 in the evening of April 23, 1988
because the symptoms were already evident."

Even assuming that Edmer’s symptoms completely coincided with the diagnosis of
bronchopneumonia (so that this diagnosis could not be considered "wrong"), we still find Dr.
Casumpang guilty of negligence.

First, we emphasize that we do not decide the correctness of a doctor’s diagnosis, or the
accuracy of the medical findings and treatment. Our duty in medical malpractice cases is to
decide – based on the evidence adduced and expert opinion presented– whether a breach of
duty took place.

Second, we clarify that a wrong diagnosis is not by itself medical malpractice.6 Physicians are
generally not liable for damages resulting from a bona fide error of judgment. Nonetheless,
when the physician’s erroneous diagnosis was the result of negligent conduct (e.g., neglect
of medical history, failure to order the appropriate tests, failure to recognize symptoms), it
becomes an evidence of medical malpractice.

Third, we also note that medicine is not an exact science; and doctors, or even specialists,
are not expected to give a 100% accurate diagnosis in treating patients who come to their
clinic for consultations. Error is possible as the exercise of judgment is called for in
considering and reading the exhibited symptoms, the results of tests, and in arriving at
definitive conclusions. But in doing all these, the doctor must have acted according to
acceptable medical practice standards.

In the present case, evidence on record established that in confirming the diagnosis of
bronchopneumonia, Dr. Casumpang selectively appreciated some and not all of the
symptoms presented, and failed to promptly conduct the appropriate tests to confirm his
findings. In sum, Dr. Casumpang failed to timely detect dengue fever, which failure,
especially when reasonable prudence would have shown that indications of dengue were
evident and/or foreseeable, constitutes negligence.

Apart from failing to promptly detect dengue fever, Dr. Casumpang also failed to promptly
undertake the proper medical management needed for this disease.

As Dr. Jaudian opined, the standard medical procedure once the patient had exhibited the
classic symptoms of dengue fever should have been: oxygen inhalation, use of analgesic,
and infusion of fluids or dextrose; and once the patient had twice vomited fresh blood, the
doctor should have ordered: blood transfusion, monitoring of the patient every 30 minutes,
hemostatic to stop bleeding, and oxygen if there is difficulty in breathing.

Dr. Casumpang failed to measure up to these standards. The evidence strongly suggests that
he ordered a transfusion of platelet concentrate instead of blood transfusion. The tourniquet
test was only conducted after Edmer’s second episode of bleeding, and the medical
management (as reflected in the records) did not include antibiotic therapy and complete
physical examination.

Although Dr. Casumpang presented the testimonies of Dr. Rodolfo Jagonap and Dr.
Ellewelyn Pasion (Dr. Pasion), Personnel Officer and Medical Director of SJDH, respectively
as well as the testimonies of Dr. Livelo and Dr. Reyes (the radiologist who read Edmer’s chest
x-ray result), these witnesses failed to dispute the standard of action that Dr. Jaudian
established in his expert opinion. We cannot consider them expert witnesses either for the
sole reason that they did not testify on the standard of care in dengue cases.

On the other hand, Dr. Sanga is Not Liable for Negligence. There is a distinction between the
responsibilities of Dr. Casumpang, as the attending physician, and Dr. Sanga, as a resident
physician.

In his testimony, Dr. Pasion declared that resident applicants are generally doctors of
medicine licensed to practice in the Philippines and who would like to pursue a particular
specialty. They are usually the front line doctors responsible for the first contact with the
patient. During the scope of the residency program, resident physicians (or
"residents") function under the supervision of attending physicians or of the hospital’s
teaching staff. Under this arrangement, residents operate merely as subordinates who
usually defer to the attending physician on the decision to be made and on the action to be
taken.

The attending physician, on the other hand, is primarily responsible for managing the
resident’s exercise of duties. While attending and resident physicians share the collective
responsibility to deliver safe and appropriate care to the patients, it is the attending physician
who assumes the principal responsibility of patient care. Because he/she exercises a
supervisory role over the resident, and is ultimately responsible for the diagnosis and
treatment of the patient, the standards applicable to and the liability of the resident for
medical malpractice is theoretically less than that of the attending physician.

These relative burdens and distinctions, however, do not translate to immunity from the legal
duty of care for residents, or from the responsibility arising from their own negligent act.
We find that Dr. Sanga was not independently negligent. Although she had greater patient
exposure, and was subject to the same standard of care applicable to attending physicians,
we believe that a finding of negligence should also depend on several competing factors,
among them, her authority to make her own diagnosis, the degree of supervision of the
attending physician over her, and the shared responsibility between her and the attending
physicians.

In this case, before Dr. Sanga attended to Edmer, both Dr. Livelo and Dr. Casumpang had
diagnosed Edmer with bronchopneumonia. In her testimony, Dr. Sanga admitted that she had
been briefed about Edmer’s condition, his medical history, and initial diagnosis; and based
on these pieces of information, she confirmed the finding of bronchopneumonia.

Dr. Sanga likewise duly reported to Dr. Casumpang, who admitted receiving updates
regarding Edmer’s condition. There is also evidence supporting Dr. Sanga’s claim that she
extended diligent care to Edmer. In fact, when she suspected – during Edmer’s second
episode of bleeding– that Edmer could be suffering from dengue fever, she wasted no time in
conducting the necessary tests, and promptly notified Dr. Casumpang about the incident.
Indubitably, her medical assistance led to the finding of dengue fever.

We note however, that during Edmer’s second episode of bleeding, Dr. Sanga failed to
immediately examine and note the cause of the blood specimen. Like Dr. Casumpang, she
merely assumed that the blood in Edmer’s phlegm was caused by bronchopneumonia

Based on her statements, Dr. Sanga was not entirely faultless. Nevertheless, her failure to
discern the import of Edmer’s second bleeding does not necessarily amount to negligence as
the respondent himself admitted that Dr. Sanga failed to examine the blood specimen
because he washed it away. In addition, considering the diagnosis previously made by two
doctors, and the uncontroverted fact that the burden of final diagnosis pertains to the
attending physician (in this case, Dr. Casumpang), we believe that Dr. Sanga’s error was
merely an honest mistake of judgment influenced in no small measure by her status in the
hospital hierarchy; hence, she should not be held liable for medical negligence.

If the patient, as a result of the breach of duty, is injured in body or in health, actionable malpractice is committed, entitling
the patient to damages.

To successfully claim damages, the patient must lastly prove the causal relation between the negligence and the injury.
This connection must be direct, natural, and should be unbroken by any intervening efficient causes. In other words, the
negligence must be the proximate cause of the injury.

The injury or damage is proximately caused by the physician’s negligence when it appears, based on the evidence and the
expert testimony, that the negligence played an integral part in causing the injury or damage, and that the injury or
damage was either a direct result, or a reasonably probable consequence of the physician’s negligence.

Dr. Jaudian’s testimony strongly suggests that due to Dr. Casumpang’s failure to timely
diagnose Edmer with dengue, the latter was not immediately given the proper treatment. In
fact, even after Dr. Casumpang had discovered Edmer’s real illness, he still failed to promptly
perform the standard medical procedure.

Dengue fever, if left untreated, could be a life threatening disease. As in any fatal diseases, it
requires immediate medical attention. With the correct and timely diagnosis, coupled with the
proper medical management, dengue fever is not a life threatening disease and could easily
be cured.

Furthermore, as Dr. Jaudian testified, with adequate intensive care, the mortality rate of
dengue fever should fall to less than 2%. Hence, the survival of the patient is directly related
to early and proper management of the illness.

To reiterate, Dr. Casumpang failed to timely diagnose Edmer with dengue fever despite the
presence of its characteristic symptoms; and as a consequence of the delayed diagnosis, he
also failed to promptly manage Edmer’s illness. Had he immediately conducted confirmatory
tests, (i.e., tourniquet tests and series of blood tests)and promptly administered the proper
care and management needed for dengue fever, the risk of complications or even death,
could have been substantially reduced.

Furthermore, medical literature on dengue shows that early diagnosis and management of
dengue is critical in reducing the risk of complications and avoiding further spread of the
virus.96 That Edmer later died of "Hypovolemic Shock/hemorrhagic shock," "Dengue
Hemorrhagic Fever Stage IV," a severe and fatal form of dengue fever, established the causal
link between Dr. Casumpang’s negligence and the injury.

Based on these considerations, we rule that the respondent successfully proved the element
of causation.

Dr. Jaudian’s Professional Competence and Credibility

One of the critical issues the petitioners raised in the proceedings before the lower court and before this Court
was Dr. Jaudian’s competence and credibility as an expert witness. The petitioners tried to discredit his expert
testimony on the ground that he lacked the proper training and fellowship status in pediatrics.

● Criteria in Qualifying as an Expert Witness

The competence of an expert witness is a matter for the trial court to decide upon in the exercise of its
discretion. The test of qualification is necessarily a relative one, depending upon the subject matter of the
investigation, and the fitness of the expert witness. In our jurisdiction, the criterion remains to be the expert
witness’ special knowledge experience and practical training that qualify him/her to explain highly technical
medical matters to the Court.

Jurisprudence states that the witnesses may be disqualified to testify as an expert based on their incapacity to
shed light on the standard of cares that must be observed by the defendant-physicians; that the expert
witnesses’ specialties do not match the physicians’ practice area only constituted, at most, one of the
considerations that should not be taken out of context. After all, the sole function of a medical expert witness,
regardless of his/her specialty, is to afford assistance to the courts on medical matters, and to explain the
medical facts in issue.

There must be reasonable indication that the expert witness possesses a sufficient familiarity with the standard
of care applicable to the accused-physician’s specialties

It is well established that "the testimony of a qualified medical doctor cannot be excluded simply because he is
not a specialist x x x." The matter of "x x x training and specialization of the witness goes to the weight rather
than admissibility x x x."
 It is the specialist’s knowledge of the requisite subject matter, rather than his/her specialty that determines
his/her qualification to testify.

To qualify a witness as a medical expert, it must be shown that the witness (1) has the required professional
knowledge, learning and skill of the subject under inquiry sufficient to qualify him to speak with authority on the
subject; and (2) is familiar with the standard required of a physician under similar circumstances; where a
witness has disclosed sufficient knowledge of the subject to entitle his opinion to go to the jury, the question of
the degree of his knowledge goes more to the weight of the evidence than to its admissibility.

Nor is it critical whether a medical expert is a general practitioner or a specialist so long as he exhibits
knowledge of the subject. Where a duly licensed and practicing physician has gained knowledge of the
standard of care applicable to a specialty in which he is not directly engaged but as to which he has an opinion
based on education, experience, observation, or association wit that specialty, his opinion is competent.

The witness’ familiarity, and not the classification by title or specialty, which should control issues regarding the
expert witness’ qualifications:

The general rule as to expert testimony in medical malpractice actions is that "a specialist in a particular branch
within a profession will not be required." Most courts allow a doctor to testify if they are satisfied of his familiarity
with the standards of a specialty, though he may not practice the specialty himself. One court explained that "it
is the scope of the witness’ knowledge and not the artificial classification by title that should govern the
threshold question of admissibility.

In this case, Dr. Jaudian is competent to testify on the standard of care in dengue fever cases.1avvphi1

Although he specializes in pathology, it was established during trial that he had attended not less than 30
seminars held by the Pediatric Society, had exposure in pediatrics, had been practicing medicine for 16 years,
and had handled not less than 50 dengue related cases.

As a licensed medical practitioner specializing in pathology, who had practical and relevant exposure in
pediatrics and dengue related cases, Dr. Jaudian demonstrated sufficient familiarity with the standard of care to
be applied in dengue fever cases. Furthermore, he possesses knowledge and experience sufficient to qualify
him to speak with authority on the subject.

Liability of SJDH

We now discuss the liability of the hospital.

The respondent submits that SJDH should not only be held vicariously liable for the petitioning
doctors’ negligence but also for its own negligence. He claims that SJDH fell short of its duty of
providing its patients with the necessary facilities and equipment
SJDH on the other hand disclaims liability by claiming that the petitioning doctors are not its
employees but are mere consultants and independent contractors.

The hospital’s liability not on the basis of Article 2180 of the Civil Code, but on the basis of the
doctrine of apparent authority or agency by estoppel.

There is No Employer-Employee Relationship Between SJDH and the Petitioning Doctors

In determining whether an employer-employee relationship exists between the parties, the following
elements must be present: (1) selection and engagement of services; (2) payment of wages; (3) the
power to hire and fire; and (4) the power to control not only the end to be achieved, but the means to
be used in reaching such an end.

Control, which is the most crucial among the elements, is not present in this case.

Based on the records, no evidence exists showing that SJDH exercised any degree of control over
the means, methods of procedure and manner by which the petitioning doctors conducted and
performed their medical profession. SJDH did not control their diagnosis and treatment. Likewise, no
evidence was presented to show that SJDH monitored, supervised, or directed the petitioning
doctors in the treatment and management of Edmer’s case. In these lights, the petitioning doctors
were not employees of SJDH, but were mere independent contractors.

Despite the absence of employer-employee relationship between SJDH and the petitioning doctors,
SJDH is not free from liability.

As a rule, hospitals are not liable for the negligence of its independent contractors. However, it may
be found liable if the physician or independent contractor acts as an ostensible agent of the hospital.
This exception is also known as the "doctrine of apparent authority."

Under the doctrine of apparent authority, hospitals could be found vicariously liable for the
negligence of an independent contractor:

Therefore, we hold that, under the doctrine of apparent authority, a hospital can be held vicariously
liable for the negligent acts of a physician providing care at the hospital, regardless of whether the
physician is an independent contractor, unless the patient knows, or should have known, that the
physician is an independent contractor.

The elements of the action have been set out as follows:

For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that: (1) the
hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital; (2) where the
acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital
had knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of
the hospital or its agent, consistent with ordinary care and prudence.

The two factors in determining hospital liability as follows:

The first factor focuses on the hospital’s manifestations and is sometimes described as an inquiry
whether the hospital acted in a manner which would lead a reasonable person to conclude that the
individual who was alleged to be negligent was an employee or agent of the hospital. In this regard,
the hospital need not make express representations to the patient that the treating physician is an
employee of the hospital; rather a representation may be general and implied.

The second factor focuses on the patient's reliance. It is sometimes characterized as an inquiry on
whether the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with
ordinary care and prudence.

In sum, a hospital can be held vicariously liable for the negligent acts of a physician (or an
independent contractor) providing care at the hospital if the plaintiff can prove these two factors: first,
the hospital’s manifestations; and second, the patient’s reliance.

It involves an inquiry on whether the hospital acted in a manner that would lead a reasonable person
to conclude that the individual alleged to be negligent was an employee or agent of the hospital. As
pointed out in Nogales, the hospital need not make express representations to the patient that the
physician or independent contractor is an employee of the hospital; representation may be general
and implied.

the hospital, by providing emergency room care and by failing to advise patients that they were
being treated by the hospital’s agent and not its employee, has created the appearance of agency;
and;

patients entering the hospital through the emergency room, could properly assume that the treating
doctors and staff of the hospital were acting on its behalf.1âwphi1

In this case, the court considered the act of the hospital of holding itself out as provider of complete
medical care, and considered the hospital to have impliedly created the appearance of authority.

It involves an inquiry on whether the plaintiff acted in reliance on the conduct of the hospital or its
agent, consistent with ordinary care and prudence.

the important consideration in determining the patient’s reliance is: whether the plaintiff is seeking
care from the hospital itself or whether the plaintiff is looking to the hospital merely as a place for
his/her personal physician to provide medical care. Thus, this requirement is deemed satisfied if the
plaintiff can prove that he/she relied upon the hospital to provide care and treatment, rather than
upon a specific physician. In this case, we shall limit the determination of the hospital’s apparent
authority to Dr. Casumpang, in view of our finding that Dr. Sanga is not liable for negligence.

SJDH impliedly held out and clothed Dr. Casumpang with apparent authority leading the
respondent to believe that he is an employee or agent of the hospital.

Based on the records, the respondent relied on SJDH rather than upon Dr. Casumpang, to care and
treat his son Edmer. His testimony during trial showed that he and his wife did not know any doctors
at SJDH; they also did not know that Dr. Casumpang was an independent contractor. They brought
their son to SJDH for diagnosis because of their family doctor’s referral. The referral did not
specifically point to Dr. Casumpang or even to Dr. Sanga, but to SJDH. Significantly, the respondent
had relied on SJDH’s representation of Dr. Casumpang’s authority. To recall, when Mrs. Cortejo
presented her Fortune Care card, she was initially referred to the Fortune Care coordinator, who was
then out of town. She was thereafter referred to Dr. Casumpang, who is also accredited with Fortune
Care. In both instances, SJDH through its agent failed to advise Mrs. Cortejo that Dr. Casumpang is
an independent contractor.

Mrs. Cortejo accepted Dr. Casumpang’s services on the reasonable belief that such were being
provided by SJDH or its employees, agents, or servants. By referring Dr. Casumpang to care and
treat for Edmer, SJDH impliedly held out Dr. Casumpang, not only as an accredited member of
Fortune Care, but also as a member of its medical staff. SJDH cannot now disclaim liability since
there is no showing that Mrs. Cortejo or the respondent knew, or should have known, that Dr.
Casumpang is only an independent contractor of the hospital. In this case, estoppel has already set
in.

We also stress that Mrs. Cortejo’s use of health care plan (Fortune Care) did not affect SJDH’s
liability. The only effect of the availment of her Fortune Care card benefits is that her choice of
physician is limited only to physicians who are accredited with Fortune Care. Thus, her use of health
care plan in this case only limited the choice of doctors (or coverage of services, amount etc.) and
not the liability of doctors or the hospital.

WHEREFORE, Dr. Noel Casumpang and San Juan de Dios Hospital solidarily liable for negligent
medical practice.