DECLARATION OF DAVID M.J. HOFFMAN, M.D., FACP
I, David M.J. Hoffman, M.D., FACP, declare and state as follows:
1. 1am a physician licensed to practice medicine in the State of California, have been boardcertified in Medical Oncology and Hematology since 2000 and 2002, respectively (recertified 2010
and 2012), and was previously board certified in Internal Medicine. This declaration is based upon
my own personal knowledge, and I can competently testify thereto if called to do so.
2. | obtained my medical degree from Finch University of Health Sciences/Chicago Medical
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School
in 1994.
I completed
my
internship
in Internal
Medicine
at Cedars
Sinai
Medical
Center/University of California, Los Angeles, in 1995. I then completed my residency in Internal
Medicine at Cedars Sinai Medical Center/University of California, Los Angeles, in 1997. I also
completed my fellowship in Hematology/Oncology at the University of California, Los Angeles
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Medical Center in 2000. I was an assistant clinical professor of medicine in the department of
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medicine at the University of California, Los Angeles, from 2003 through 2012. I have been an
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associate clinical professor of medicine
in the department
of medicine
at the University
of
California, Los Angeles, since 2012. I have also been a clinical associate professor of medicine at
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Cedars Sinai since 2013. Since 2000, I have been in practice as a medical oncology and hematology
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physician with Tower Hematology Oncology Medical Group. I have been the medical director of
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Tower Hematology Oncology at Cedars Sinai Medical Center since 2018. I am familiar with the
treatment and prognosis of anal cancer patients in Southern California at all times pertinent to the
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care provided to Plaintiff Michelle Rush. A true and correct copy of my curriculum vitae, which
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provides a more complete listing of my qualifications, is attached hereto as Exhibit BB.
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3. I was retained by the law firm of Dr. Bruce G. Fagel & Associates for the purpose of
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rendering my opinion as to whether the acts and/or omissions of Defendants Kaiser Foundation
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
Hospital (“KFH”), Southern California Permanente Medical Group (“SCPMG”), as well as their
physician and non-physician staff, including Pamela Staiger, M.D. and gastrointestinal specialist
Anuradha Pappu, M.D., caused or substantially contributed to Ms. Rush’s injuries and damages.
4, Based on my education, training, and experience, I am familiar with the presentation,
evaluation, treatment, and prognosis of anal cancer patients like Ms. Rush. As a board-certified
medical oncologist with education, training and experience caring for anal cancer patients who
present with rectal bleeding, I am familiar with the causes and results of late-stage anal cancer in
patients like Ms. Rush. In reaching the opinion that Ms. Rush’s injuries and damages were caused
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their negligent acts and omissions substantially contributed to her injuries and damages, I have read
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the Declaration of Defendants’ family medicine expert, Richard A. Johnson, M.D., the deposition
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by the negligent acts and omissions on behalf of KFH, SCPMG, Dr. Staiger, and Dr. Pappu, or that
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transcript of Dr. Staiger, attached hereto in its entirety as Exhibit Y, as well as portions of Ms.
Rush’s medical records from Kaiser and Defendant Tabassum Chowdhury, M.D., attached hereto
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as Exhibits A-X. As the depositions of percipient witnesses have not been completed, neither is my
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review. Thus, the opinions stated within this declaration are preliminary relative to the primary care
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and treatment of Ms. Rush.
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5, My review of the aforementioned documents reflects the following pertinent facts relating
to the care and treatment of Plaintiff Michelle Rush:
a. On April 19, 2018, Ms. Rush saw Dr. Samir Abdelshehid, a primary care physician
who practiced with Dr. Staiger at Kaiser for a chief complaint of diarrhea. She reported waking up
every five minutes to have a bowel movement accompanied by nausea. She also reported vaginal
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bleeding. Physical exam revealed tenderness in the left abdomen.
Despite her gastrointestinal
complaints, no rectal exam was documented as having been performed. C-Reactive Protein and
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
Erythrocyte Sedimentation Rate, non-specific markers for inflammatory conditions, which include
inflammatory bowel disease, were normal. Ms. Rush was diagnosed with diarrhea as her primary
diagnosis as well as gastroenteritis, given information about irritable bowel syndrome, and advised
to return to clinic if symptoms progressed, worsened, or did not improve as anticipated. She was
prescribed Zofran as needed for nausea or vomiting. A copy of Dr. Abdelshehid’s note is attached
hereto as Exhibit A.
b. On April 23, 2018, Ms. Rush had a telephone visit with Dr. Staiger for a chief
complaint of worsening diarrhea, up to thirteen times per day, with incontinence. Despite her
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conduct a physical exam. Dr. Staiger diagnosed gastroenteritis, gave Ms. Rush information on the
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BRAT diet and advised her to use over the counter Imodium to alleviate the diarrhea. A copy of Dr.
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worsening gastrointestinal complaints, she was not advised to come to clinic for Dr. Staiger to
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Staiger’s April 23, 2018 telephone note is attached hereto as Exhibit B.
c. On July 13, 2018, at 6:45 PM, Ms. Rush called Kaiser’s on-call nurse with a chief
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complain of blood in stool/red blood per rectum and a recent history of diarrhea. She also reported
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feeling “unusually tired” and red blood per rectum. No doctor was called. Instead, “rectal bleed
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emergent instructions” were emailed to the patient. Ms. Rush informed the advice line nurse that
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she presented to Bakersfield Memorial Hospital Emergency Department for emergent care. A copy
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of the July 13, 2018 advice line telephone note is attached hereto as Exhibit C.
d. On
July
13, 2018,
at 7:43
PM,
Ms.
Rush
was
seen by Dr. Viet Vuong,
an
emergency physician at Bakersfield Memorial Hospital for a chief complaint of blood in stool. She
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reported bright red rectal bleeding with bowel movements, which began the prior morning, preceded
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by two 2-week episodes of non-bloody diarrhea, as well as mild left pelvic pain, which she first
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noticed the prior morning. Review of systems was significant for diarrhea and rectal bleeding. Dr.
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
Vuong documented the following for her rectal exam, “Normal external rectum. DRE with brown
stool that was guaiac positive,” confirming the report of bloody stools. While the external rectum
was normal, Dr. Vuong’s note does not contain any information about the internal rectum. It does
not appear an anoscope was used to examine
Ms. Rush. The differential diagnosis included,
“anemia, diverticular disease, IBD, hemorrhoids, and malignancy” as potential etiologies for her
symptoms. The final diagnosis was listed as rectal bleeding. Dr. Vuong’s note indicates that Ms.
Rush’s primary care doctor was not on staff and that she would require a GI referral from Kaiser as
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was advised to follow-up with her primary care doctor in 5 to 7 days. While Dr. Vuong’s note was
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apparently
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Chowdhury’s chart, it does not appear Kaiser requested and/or received a copy of Dr. Vuong’s note
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they could not directly refer Ms. Rush. She was not prescribed medication at discharge, rather, she
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requested
by
Defendant
Dr.
Chowdhury’s
office
and
thus
is contained
in Dr.
for Dr. Staiger’s review. A copy of Dr. Vuong’s note is attached hereto as Exhibit D.
e. On July 16, 2018, Ms. Rush saw Dr. Staiger, as instructed, for emergency room
follow-up to address her persistent rectal bleeding, chronic diarrhea, and left lower quadrant pain.
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She informed Dr. Staiger that she went to the ER after having four episodes of hematochezia with
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blood-streaked stools and that she had had three more episodes of bloody stools since. She also
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reported having 2 two-week episodes of diarrhea, feeling fatigued and nauseated. Weigh-ins from
her last three encounters showed an unintentional weight loss of 2 pounds since June 13, 2018. Dr.
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Staiger documented Ms. Rush, “[s]tates anoscopic exam was not revealing, but stool was [guaiac
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positive],” and that the ER doctor told her she needs an urgent colonoscopy. Dr. Staiger’s note also
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indicates that Ms. Rush showed her photos of stools with streaks of red blood and reported 6/10
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abdominal pain with defecations associated with instant nausea, as well as urgency with accidents.
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When asked at her deposition what she thought about Ms. Rush’s report of pain with defecation, Dr.
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
Staiger responded, “Well, it is more localizing to the rectal area.” (Exhibit Y, page 65, line 2).
Despite Dr. Staiger’s assessment of rectal bleeding, chronic diarrhea, left lower quadrant abdominal
and rectal pain, when asked if she had performed a physical exam during that visit, Dr. Staiger
responded, “No. I didn’t repeat an anal exam because it had just been done.” (Exhibit Y, page 60,
lines 3-4). No physical exam whatsoever is documented as having been performed. And despite
documenting that an anoscope exam performed in the ER was not revealing, based on the ER
physician’s note, it does not appear an anoscope exam was, in fact, performed (see Exhibit D). Dr.
Staiger diagnosed rectal bleeding as her primary diagnosis, chronic diarrhea, left lower quadrant
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pain, and screening for lipid disorder. Her plan included a lipid panel and referral to GI for
colonoscopy. A copy of Dr. Staiger’s July 16, 2018 note is attached hereto as Exhibit E.
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f. On July 16, 2018, Dr. Staiger completed a referral for Ms. Rush to consult with
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gastroenterologist, Defendant Dr. Chowdhury to be seen on July 19, 2018 for “hematochezia [fresh
blood from the anus] with left lower quadrant pain and chronic diarrhea and weight loss.” Under
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reason for referral, the form states, “Colonoscopy, Symptomatic, Any Risk Level (Abd pain, LGI
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[lower gastrointestinal] bleeding, etc.).” A copy of Dr. Staiger’s July 16, 2018 referral is attached
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hereto as Exhibit F.
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g. On July 19, 2017, Ms. Rush saw Dr. Chowdhury for a chief complaint of bright
red blood per rectum and chronic diarrhea, indicating that she had had seventeen loose stools, though
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she had no bleeding that day. She reported experiencing diarrhea, nausea, and some vomiting
starting in April, which had subsequently improved, but that her symptoms had returned 2 weeks
prior prompting her visit to the hospital where the stools were found to be guaiac positive, meaning
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they contained blood. Dr. Chowdhury did not perform or document a rectal exam. Dr. Chowdhury
indicated her nausea, vomiting, and diarrhea was most likely attributed to a viral gastroenteritis, but
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
since she could not rule out IBD, and especially given her rectal bleeding, Ms. Rush would be
scheduled for a colonoscopy/endoscopy. She was instructed to take Imodium AD since the stool
cultures, including ova, parasite, and Clostridioides difficile toxin were negative. Dr. Chowdhury’s
July 19, 2018 note was sent to Dr. Staiger and is attached along with her handwritten office note
hereto as Exhibit G.
h. Later that day, Ms. Rush saw Dr. Staiger for a chief complaint of vomiting and
diarrhea. She reported vomiting 8 times and 16 episodes of diarrhea since the night before. She
reportedly had not noticed blood but complained of generalized abdominal pain with the diarrhea.
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to be 130 pounds, representing a total unintentional loss of six pounds since June 13, 2018 when she
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was measured to weigh 136 pounds. Despite her recent worsening gastrointestinal symptoms, Dr.
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17). When asked if she performed a rectal exam at this visit, Dr. Staiger responded, “No. And I -- I
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would not have put her through it the way she was feeling either.” (Exhibit Y, page 69, lines 5-6).
Dr. Staiger further stated, “She was not doing well. She was dehydrated. And, in my opinion, she did
have acute gastroenteritis. I mean, she had the fever. She had the diarrhea. She was throwing up.
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And so I did what was expedient. I tried to hydrate her and get her to feeling better... And -- And I
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wouldn’t normally do a rectal exam anyhow on a patient who was having vomiting and diarrhea.
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That’s just not part of what I would do for what I would think would be a gastroenteritis.” (Exhibit
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abdominal exam, Dr. Staiger noted, “J might have. I noted in the history that she had -- was having
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And again, no rectal exam was performed. When asked at her deposition if she performed an
generalized pain, which would be non- -- nonfocal, not localizing.” (Exhibit Y, page 68, lines 15-
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Staiger’s assessment of diarrhea, vomiting and gastroenteritis, no abdominal exam was documented.
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Dr. Staiger noted that her stool studies and Celiac panel were negative. Her weight was measured
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Y, page 69, lines 9-19). Dr. Staiger ordered an electrolyte panel and a CBC which were both normal,
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
administered two bags of IV saline and Tylenol, and diagnosed diarrhea, tachycardia, dehydration,
vomiting, and gastroenteritis. Ms. Rush was not given any medications nor recommendations to
address her “ongoing diarrhea.” A copy of Dr. Staiger’s July 19, 2018 note is attached hereto as
Exhibit H.
i. On July 27, 2018, Dr. Chowdhury performed a colonoscopy on Ms. Rush. The
report sent to Dr. Staiger stated, “46-year-old female who has some nausea, vomiting, diarrhea in
April. The diarrhea has improved, but still has intermittent loose stools. She has to take Imodium
p.r.n. Colonoscopy is being performed to rule out colitis.” The report made no mention of the chief
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rectum. Dr. Chowdhury did not document having performed a digital rectal exam on that day. The
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report stated the terminal ileum appeared normal, colonic mucosa was unremarkable throughout,
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complaint, which prompted her urgent referral for colonoscopy, namely her bright red blood per
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and when the scope was advanced in the rectum, it showed “inflamed internal hemorrhoids.”
Random biopsies were taken of the right and left colon to check for microscopic colitis. Dr.
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Chowdhury recommended, “Metamucil 2 capsules daily, may increase to twice a day, may also take
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Imodium p.r.n., Anusol-HC suppositories.” When asked at her deposition if she had ever spoken
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with Dr. Chowdhury about Ms. Rush, she answered, “Well, not on this case...” (Exhibit Y, page
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62, line 8). When asked at deposition if she concluded after reading the report that Ms. Rush’s rectal
bleeding was being caused by internal hemorrhoids, Dr. Staiger answered, “J did.” (Exhibit Y, page
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Anusol-HC
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medication. While Anusol is available over the counter, Anusol-HC requires a prescription. A copy
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of Dr. Chowdhury’s colonoscopy report is attached hereto as Exhibit I.
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81, line 5). However, despite the fact both Dr. Staiger and Dr. Chowdhury recommended using
suppositories to treat her supposed hemorrhoids, apparently, neither prescribed the
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
j. On July 30, 2018, pathologist, Teresa Limjoco, M.D., interpreted the biopsies of
the duodenum, antrum portion of the stomach, and random samples of the colon. She noted a
preoperative diagnosis of “[d]iarrhea, nausea, vomiting, pain” and a postoperative diagnosis of,
“hiatal hernia, gastritis, colon: hemorrhoids.” The pathology report made no mention of her rectal
bleeding. And while the pathologist noted a postoperative diagnosis of hemorrhoids, no biopsy of
the rectum was performed. At deposition, Dr. Staiger testified that after learning of Ms. Rush’s
diagnosis of anal cancer in August of 2019, she went back and looked at the colonoscopy report,
and when asked, “/A/t that time, did you think that a biopsy should have been taken of the anus,”
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(Exhibit Y, page 168, lines 23-24), Dr. Staiger responded, “‘So it’s -- it’s always so different when
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you're retrospecting -- I mean what they call it, the -- the quarterback that looks at the replays. So
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I could say now that that would have been a great. But -- in that period of time -- Yes. I don’t know
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in that period of time if I ever said, ‘Wow. Why didn’t so and so do this?’” (Exhibit Y, page 169,
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lines 10-19) A copy of Dr. Limjoco’s pathology report is attached hereto as Exhibit J.
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k. On August 1, 2018, Dr. Staiger emailed Ms. Rush that she had no signs of cancer
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and her prognosis was good, writing, “Just wanted to let you know that your biopsies came out
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pretty good. You have chronic gastritis but it was reported to be inactive at the time of the biopsy.
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You had no signs of colitis or cancer or inflammatory bowel problems. Your Helicobacter test was
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also negative. So maybe you had some sort of nasty virus, or flair in IBS? Anyways, the prognosis
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is good.” Dr. Staiger’s message made no mention of hemorrhoids and as such no treatment or
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recommendations were given to address her ongoing complaints of diarrhea with rectal bleeding. A
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copy of Dr. Staiger’s August 1, 2018 email is attached hereto as Exhibit K.
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1. On August 30, 2018, Ms. Rush saw Dr. Staiger for a chief complaint of blood in
stool. She reported that the bloody stools had returned 6-7 days prior with the first one estimated to
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
contain “about 1/8 cup, dark blood and clots mixed with the stool, ‘like blood from menses.’ She
also reported blood with wiping and having “another episode 4 days later, about the same in quality
and quantity, both with no diarrhea or constipation. She further stated over the previous 2 days, “she
has had bleeding with every bowel movement - total of 5 times.” She was also very fatigued. Dr.
Staiger copied the pathological findings from the colonoscopy/endoscopy into her note but not the
portion which
contained the postoperative
diagnosis
of hemorrhoids.
Ms.
Rush
showed
her,
“[p]hotos of 3 stools in toilet (same time) coated in red blood; also blood on tp [toilet paper].” When
asked at her deposition if she thought the complaint at this visit was related to her previous
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rectum...” (Exhibit Y, page 89, lines 23-25). When asked more specifically if she thought her chief
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complaint at that visit of bloody stools was due to hemorrhoids, Dr. Staiger responded, “So at this
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complaints, Dr. Staiger responded, “J just assumed it was still rectal bleeding, blood from the
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point the patient had had two colonoscopies, and I had no better explanation, so I thought it was
still coming from the rectum from -- I mean from hemorrhoids.” (Exhibit Y, page 91, lines 7-10).
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And when asked if the amount of rectal bleeding was significant to her, Dr. Staiger responded,
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“[I]t’s become more problematic.” (Exhibit Y, page 92, line 12). For her physical exam, Dr. Staiger
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only examined the abdomen, noting it was soft without distension, tenderness, rebound, or guarding.
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However,
bowel
sounds
were, “hypoactive
(not heard within about
1 % minutes).” Again, Dr.
Staiger did not conduct any rectal exam. At her deposition the following exchange occurred:
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Q. And I take it when you do perform rectal exams, you always document those?
A. Yes
Q. Okay. And there isn’t one document here. So you didn’t perform a rectal exam at
this visit; correct?
A. Correct.
Q. Okay. Did you consider performing a rectal?
A. I -- I don’t -- I don’t know the answer. I may have; I may not have.”
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
(Exhibit Y, page 93, line 25 through page 94, line 9). Dr. Staiger diagnosed rectal bleeding as her
primary diagnosis, commenting, “possibly an inflammatory bowel condition such as lymphocytic
duodenitis??” She also diagnosed chronic gastritis, noting it was found to be inactive on the July 27,
2018 endoscopy, and acute exacerbation of chronic bronchitis due to frequent upper respiratory
infections. Dr. Staiger prescribed 5 days of Prednisone. Given this is commonly prescribed to treat
acute bronchitis, it is unclear whether Prednisone was prescribed to treat suspected inflammatory
bowel disease or suspected acute bronchitis. Of note, Dr. Chowdhury believed the Prednisone was
for “respiratory systems” (see Exhibit M). Dr. Staiger indicated she would reach out to other
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that Dr. Staiger attributed her worsening rectal bleeding to hemorrhoids, she did not offer treatment
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or recommendations to address the chief complaint, which had persisted for more than 6 weeks. At
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specialties for advice including rheumatology, gastroenterology, and allergy. Nevertheless, given
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her deposition,
Dr.
Staiger testified that she had treated more
than a hundred patient with
hemorrhoids and when asked how she treats hemorrhoids, Dr. Staiger responded, “So there’s local
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treatment with things like Anusol with hydrocortisone suppositories. There’s Proctofoam. There’s
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various salves like you would use on an infant, like Desitin and A&D. And there’s something that’s
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actually called Butt Paste. So those are all things to -- to calm down an irritated musoca that is
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friable or irritable that -- that might burn and bleed... Then there’s the surgical arm, which would
involve banding, hemorrhoidectomy, things like that.’ (Exhibit Y, page 105, lines 4-22). When
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management?” (Exhibit Y, page 106, lines 1-3), Dr. Staiger responded, “J -- J -- I don’t know.”
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(Exhibit Y, page 106, line 7). A copy of Dr. Staiger’s August 30, 2018 note is attached hereto as
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Exhibit L.
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asked, “/w/Jas there a reason why you didn’t treat the hemorrhoids at that time, or is it [expectant]
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
m. On September 4, 2018, Ms. Rush saw Dr. Chowdhury for a chief complaint of
intermittent rectal bleeding and follow-up of her colonoscopy. Dr. Chowdhury’s assessment was
that the “bright red rectal bleeding [was] suspect[ed to be] from hemorrhoids,” however she would
schedule a capsule study to “rule out small bowel cause.” Dr. Chowdhury did not conduct a physical
exam, nor inspect her rectum, at this visit. Despite Dr. Chowdhury’s attributing her rectal bleeding
to hemorrhoids, she did not offer treatment or recommendations to address the chief complaint,
which had now persisted for nearly 2 months. A copy of Dr. Chowdhury’s September 4, 2018 note,
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which was sent to Dr. Staiger, is attached hereto as Exhibit M.
n. On September 21, 2018, Ms. Rush saw Dr. Anuradha Pappu for a chief complaint
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of, “unexplained rectal bleeding, malaise, and frequent URIs.” Ms. Rush had been advised by Kaiser
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personnel that rheumatology and allergy pointed to gastroenterology, thus was seeing Dr. Pappu for
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malaise/fatigue, and weight loss. Despite the fact Ms. Rush was told she had hemorrhoids, this
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diarrhea and up to 15 bowel movements in one day. As reported by the patient, this was attributed
to hemorrhoids
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Pappu noted had been “done for rectal bleeding.” Dr. Pappu noted Ms. Rush complained of bloody
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a “second opinion regarding possible GI autoimmune disorder” after the colonoscopy, which Dr.
and not colitis. Review
of systems
was
significant for blood
in stool, nausea,
diagnosis is not listed on the patient’s active problem list, which Dr. Pappu imported into her note.
Also, there are no medications used to treat hemorrhoids listed under the patient’s current outpatient
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prescriptions. Despite the fact Ms. Rush was seeing Dr. Pappu for a second opinion to address her
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ongoing rectal bleeding, she did not perform and/or document a rectal exam. Dr. Pappu diagnosed
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rectal bleeding, abdominal bloating, nausea; all attributed to viral “gastroenteritis with post infection
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irritable bowel syndrome.” Dr. Pappu repeated another round of tests for Celiac and H. Pylori, as
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
well as stool studies for ova and parasites, all of which had been found to be normal the month prior.
A copy of Dr. Pappu’s September 21, 2018 note is attached hereto as Exhibit N.
o. On January 22, 2019, Ms. Rush saw Dr. Staiger for a chief complaint of diarrhea
and vomiting. She reported, “diffuse cramping abdominal pain (immediately prior to diarrhea),
nausea and emesis x3, and low grade temp to about 99, and watery or loose diarrhea x9 with myalgia
or feeling like she was ran over by a truck.” Dr. Staiger noted she was unable to obtain relief with
the recommended “BRAT diet (bananas, apples, rice, toast).” Despite the patient’s chronic diarrhea
associated with pain on defecation, Dr. Staiger did not perform a rectal exam at this visit. She did
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and noted no halitosis. Dr. Staiger diagnosed gastroenteritis, prescribed Zofran for nausea or
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vomiting, and recommended the BRAT diet, oral hydration, and Imodium for diarrhea. When asked
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conduct an abdominal exam, noting it was soft without distention, tenderness, rebound, or guarding
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at her deposition, “Did you also have in your mind at that time that the malaise and frequent URIs
and rectal bleeding could also potentially be due to cancer?” (Exhibit Y, page 104, lines 10-12),
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Dr. Staiger responded, “So that -- that’s a complex question. And -- And I think I wanted to know
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for certain -- Again, there's -- there’s rectal bleeding. So I wanted to know,
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colonoscopy.’ I -- I just wanted to make sure that -- that -- that there wasn’t anything else going on,
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and so that’s why I was asking for help from another specialist. I -- I mean there
‘Okay. She’s had a
was
little more
that I could do, so I was asking for somebody else to look at the case. I was stumped.” (Exhibit Y,
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p. On March 21, 2019, Ms. Rush had a telephone visit with Dr. Staiger for follow up
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care, complaining of “continued rectal bleeding.” Dr. Staiger noted the patient was being followed
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page 104, lines 13-21). A copy of Dr. Staiger’s January 22, 2019 note is attached hereto as Exhibit
27
by Dr. Pappu, “who requested studies (gastric emptying, a blood test, and capsule endoscopy?)
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
patient wants as many studies as possible to be done here [Bakersfield] for transportation issues.”
Dr. Staiger diagnosed rectal bleeding and gastroparesis and noted, “Await to here from Dr. Pappu
and will order as much of requested work-up as is possible for here.” As this was a telephone visit,
no physical exam was performed. Dr. Staiger did not instruct the patient to come to clinic for an
exam, nor placed any other orders for the encounter. At this point, Ms. Rush had presented or
consulted doctors more than 10 times over the previous year for diarrhea and/or rectal bleeding, and
yet no Kaiser physician had conducted a basic rectal exam. At her deposition, when questioned
10
11
12
13
14
(
15
16
Okay.
And
up
until this point, you
had
never
seen
the actual
hemorrhoid
or
examined for it rec- -- digitally; correct?
q. On April 9, 2019, Ms. Rush saw Dr. Staiger for a chief complaint of “blood in
stool.” Dr. Staiger noted, “Patient has had ongoing rectal bleeding since 3/21/19. She had bleeding
22
prior to her July colonoscopy and had inflammed [sic] hemorrhoids. She has only had a few days of
23
no bleeding--from photos, would estimate about a teaspoon on tp [toilet paper] -- has had some in
24
toilet. There is some rectal pain with or without bms [bowel movements], but not continually. Patient
goes back and forth between constipation and diarrhea, and both irritate her bottom.” At this visit,
26
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going on?
A. So I just said, ‘continued rectal bleeding.’ And there had been two colonoscopies at that
point that looked okay. So I was -- She was in process of further evaluation with Dr. Pappu
to see if there was anything else. So my working diagnosis would still be the hemorrhoids.
with investigation further.
A. ...1 don’t believe so. (Exhibit Y, page 118, line 25 through page 119, line 13).
25
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caused by the hemorrhoids, or did you start thinking that maybe something else was
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&
Q. [D]id you continue to believe that the rectal bleeding was caused -- was being
Q.
20
of
following exchange occurred:
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about Dr. Staiger’s March 21, 2019 telephone note, which is attached hereto as Exhibit P, the
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Dr. Staiger attempted for the first time to conduct a rectal exam. No external hemorrhoids were seen
and it does not appear that Dr. Staiger performed a digital exam to assess for internal hemorrhoids,
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
noting “[h]ad to abort attempt at anoscopy as patient experience too much rectal pain and was
intolerant.” When asked at her deposition about the purpose of a digital exam, Dr. Staiger concurred
that it is a tactile assessment to determine if there are any irregularities in the rectum, (Exhibit Y,
page 42, lines 16-19). And when asked if she performs a digital rectal exam to assess for anything
else besides hemorrhoids, Dr. Staiger responded, “Yes, of course, you could feel the tissue around,
but again, that can be a pretty limited exam. You only have one finger. You have limited space.”
(Exhibit Y, page 44, lines 2-4). Dr. Staiger never performed a digital rectal nor an anoscope exam
on Ms. Rush in order to feel and directly visualize the tissue. When asked at her deposition about
10
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That might have just even been touching the outside. She was very tender. So I’m -- I’m not sure if
13
it was -- if you would interpret that as a digital rectal exam or even just touching the rectum...”
14
(
15
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you just -- you don’t push it. Inever... force it.” (Exhibit Y, page 131, lines 6-14). When asked why
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-- just that they tense up so much that, you know, you can try to put the scope in, and -- and they
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&
Staiger responded, “... J don’t recall the point. Sometimes it will happen -- I mean with any patient
won't relax, and they’ll be uncomfortable, so you try again, and they tense up even more, and so
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(Exhibit Y, page 127, lines 21-25). When asked at what point she aborted the anoscope exam, Dr.
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the attempted rectal exam, Dr. Staiger stated, “... I’m not even sure I was able to do a digital exam.
she attempted to perform an anoscope exam, Dr. Staiger responded, “J wish I could tell you what
was going on in my mind at the time. But, I mean, I was just being thorough to try to look at the
source
of where
there the bleeding was
coming from...”
(Exhibit Y, page
132, lines 4-7).
24
Nevertheless, she continued to presume the patient’s persistent rectal bleeding was attributed to
25
hemorrhoids. On April 9, 2019, Dr. Staiger diagnosed internal hemorrhoids for the first time. This
6
visit was also the first time she offered treatment for hemorrhoids and recommendations to address
27
Ms. Rush’s anorectal pain and rectal bleeding, instructing her how to use A&D ointment following
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
each bowel movement, and prescribing Anusol suppositories for 10 days. When asked if she expects
to see a change in the hemorrhoid over the course of 10 days, Dr. Staiger responded, “7 would. That’s
the -- the length of time that’s I think generally acceptable, ten days to allow for healing, and then
you could do a reexam.”’ However, Dr. Staiger never re-examined the patient to assess whether Ms.
Rush’s presumed hemorrhoids showed a treatment response, instead instructing her to follow-up if
she was “still having problems.” A copy of Dr. Staiger’s April 9, 2019 note is attached hereto as
Exhibit Q.
r. On May 24, 2019, Ms. Rush saw Dr. Alex Lee, a primary care physician who
10
ll
12
Lee conducted a complete physical exam, noting there was no inguinal adenopathy present and
13
specifically, “No L groin mass. No erythema. No drainage. No warmth.” Nevertheless, she was
14
(
practiced with Dr. Staiger at Kaiser for a chief complaint of a lump in her left groin for 1 week. Dr.
15
diagnosed with lymphadenitis as her primary diagnosis for which he recommended over-the-counter
Tylenol, as needed, warm compresses, and to return to clinic if symptoms worsen. Of note, the
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copy of Dr. Lee’s May 24, 2019 note is attached hereto as Exhibit R.
s. On June 26, 2019, Ms. Rush saw Dr. Staiger for a chief complaint of a “painful
lesion in [the] groin area and buttocks.” Dr. Staiger wrote, “Patient thinks she has a thrombosed
hemorrhoid -- has painful knot around rectum for several weeks. Has been using sitz baths and stool
softeners. Level is 9-10/10. Last bowel movement was 3 days ago.” She also noted, Ms. Rush had
24
left groin lymphadenitis for which she saw Dr. Lee, and was told to follow-up if it did not improve.
25
Despite her primary complaints of left groin and severe rectal pain, Dr. Staiger did not perform a
26
physical exam. Rather, she discussed the patient’s mood, as Ms. Rush was experiencing anxiety
Bruce G. Fagel
Associates
Anusol suppositories were marked as discontinued under the list of her outpatient medications. A
27
from unrelated family issues. Despite the lack of any physical exam, Dr. Staiger diagnosed a
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
thrombosed external hemorrhoid, lymphadenitis, and constipation for which she prescribed a trial
of Proctofoam, and was advised to “use stool softener 3 per day and drink copious fluids,” and
follow-up, “if not better in 1 week.” A copy of Dr. Staiger’s June 26, 2019 note is attached hereto
as Exhibit S.
t. On July 29, 2019, Ms. Rush saw Dr. Staiger for a chief complaint of a persistent
tender lump in her left inguinal region and follow-up regarding her presumed hemorrhoid. Dr.
Staiger noted, “Patient stated proctofoam is burning. Still has discomfort from thrombosed external
hemorrhoid (6/26 visit) and it is causing rectal bleeding and painful defecation. She is using a stool
10
11
(
softener. It seems prolapsed, and lately she can’t seem to get it to go back up.” When asked at her
12
deposition if she visualized the prolapse, Dr. Staiger answered that it was just the patient’s report.
13
(Exhibit Y, page 152, lines 14-16). At this visit, Dr. Staiger attempted a second rectal exam, after
14
aborting the first in April, noting, “Rectal exam shows mass and tenderness... She has extreme rectal
15
tenderness and induration at about
12:00 -- can’t do anoscopic
exam.
Could be thrombosed
16
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hemorrhoid, or possibly a perirectal abscess, which would explain left inguinal lymph node.” Dr.
Staiger diagnosed a thrombosed external hemorrhoid, rectal bleeding, anorectal pain, and inguinal
19
lymphadenopathy for which she was instructed to use “Sitz baths, Tucks, and try anusol. Follow-up
20
as needed.” She did not prescribe Anusol at this visit so it is unclear if she intended Ms. Rush use
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and provided a referral to General Surgery. Under referral priority, she selected, “Routine.” A copy
of Dr. Staiger’s July 29, 2019 note is attached hereto as Exhibit T.
25
u. On July 31, 2019, Ms. Rush saw Dr. Mark Mishkind, a general surgeon at Kaiser
26
for a chief complaint of hemorrhoids. Dr. Mishkind documented the following: “Michelle A Rush
Bruce G. Fagel
Associates
the over-the-counter version. Instead, she prescribed Cephalexin 500 mg for the suspected abscess
27
is a 47 year old female who presents with anal pain and bleeding for one year. Pain is only during
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
bowel movement. Tried multiple hemorrhoid treatments with no relief. Had a colonoscopy one year
ago. Now also notes enlarged node in left groin.” Despite the patient’s supposed diagnoses of
internal hemorrhoid since April 2019 and a thrombosed hemorrhoid since earlier that week, neither
appears on the patient’s active problem list. In addition, despite Dr. Staiger’s recommendation that
the patient use Anusol at her last visit with Ms. Rush, no prescription medication used to treat
hemorrhoids is listed on her outpatient medication list. Dr. Mishkind performed a complete physical
exam,
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in the anterior anus and in the canal, rectal tenderness,
and inguinal
adenopathy. Based only on the history and physical exam findings, Dr. Mishkind diagnosed anal
cancer, writing, “patient appears to have an anal cancer with met to left groin. Needs exam under
12
anesthesia for tissue biopsy and then will also get MRI of pelvis and PET/CT. I explained to patient
13
that xrt [radiation] and chemo are the treatment of choice for anal cancer. Risk sphincter injury
14
(
indicating a mass
3
discussed.” A copy of Dr. Mishkind’s note is attached hereto as Exhibit U.
v. On August 5, 2019, Dr. Mishkind performed an anal biopsy under anesthesia,
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noting, “Finger palpation immediately identified a mass anterior anus on the left. Has mass extended
18
from the anal verge up into the rectum. There was a break in the anal canal mucosa at about 1 o’clock
19
or the mass was invading through the mucosa. It was also palpable from the vagina, and in the
20
subcutaneous tissue lateral to the sphincter muscle and on the perineum. Where the break in the
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mucosa was located, hard tissue was identified, consistent with tumor.” Treatment A copy of Dr.
Michkind’s August 5, 2019 operative report is attached hereto as Exhibit V.
24
w. On August 9, 2019, Ms. Rush saw Dr. Staiger for a chief complaint of “Personal
25
Problems.” Dr. Staiger noted she had a new diagnosis of anal cancer for which she was devastated.
6
27
Dr.
Staiger
carcinoma,”
copied
the
biopsy
findings
which
and noted Dr. Mishkind would
stated,
“invasive
keratinizing
refer the patient to Oncology
squamous
cell
and to Radiation
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
Oncology. She also wrote, “had colonoscopy/endoscopy on 7/27/18 - because of rectal bleeding.”
A copy of Dr. Staiger’s August 9, 2019 note is attached hereto as Exhibit W.
x. On December
10, 2019, Ms. Rush sought an external consult from AIS Cancer
Center at Adventist Health Bakersfield for a second opinion of her then stage IIIC cT4Nic anal
cancer. The consult note documents a strong family history of cancer in both her mother and father.
Despite Ms. Rush having been a patient of Dr. Staiger since 2012, it does not appear that she ever
inquired about her history relating to cancer diagnoses in first-degree relatives. The note states Ms.
10
li
(
+s
Rush had first noticed the rectal mass at least 18 months prior and that an August 5, 2019 biopsy
confirmed invasive keratinizing squamous cell carcinoma, moderately differentiated. MRI of the
12
pelvis on August 19, 2019 showed a malignant lesion involving the left anal canal compatible with
13
a T4 lesion secondary to invasion of the posterior left aspect of the vagina. Given the presence of
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17
bilateral inguinal lymphadenopathy, findings were compatible with an Nic lesion. A suspicious T2
hyperintense lesion was also seen within the anterior right acetabulum concerning for osseous
metastasis. PET/CT on August 20, 2019 showed a metabolically active large left anal lesion, small
metabolically active lesion in the left perirectal fat corresponding to mesenteric implant and
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August 29, 2019 showed a minute fragment of lymphoid tissue with metastatic squamous cell
carcinoma. Ms. Rush complete 2 cycles of chemotherapy with Mitomycin and Fluorouracil on
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November 4, 2019. Her last radiation treatment to that date was performed on November 20, 2019.
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A copy of the AIS Cancer Center’s December 10, 2019 note is attached hereto as Exhibit X.
25
6. Based on my review of the aforementioned records, as well as my education, training, and
26
experience in medical oncology and the treatment of anal cancer patients, it is my opinion that Ms.
Bruce G. Fagel
Associates
metastatic left inguinal lymphadenopathy. Ultrasound guided biopsy of the left inguinal node on
27
Rush’s primary care physician, Dr. Staiger, gastrointestinal consultant, Dr. Pappu, KFH,
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
and
SCPMG,
caused or substantially contributed to Ms. Rush’s injuries and damages, namely her
probability, to a reasonable degree of medical certainty, of having a greater than 50% chance of
being disease-free at 5 years and thus cured of her anal cancer; by delaying her eventual diagnosis
until the cancer had advance to Stage IIIC (T4N1c). This opinion is based on the following:
a. Dr. Staiger testified when treating hemorrhoids, she expects to see improvement
within 10 days. If there is no improvement or the patient’s condition worsens, as was the case here,
according to her own standards as outlined in her deposition, she should have referred the patient to
10
11
b. To a reasonable degree of medical probability, in August and September of 2018,
12
Ms. Rush’s anal cancer was likely Stage 0 or carcinoma in-situ, meaning the dysplasia had not yet
13
broken through the basement membrane, presenting the potential for nodal spread. Stage 0 anal
14
(
Dr. Mishkind well before July 31, 2019.
s
16
17
cancers have a near 100% survival rate and can be ablated through minimally invasive procedures
such as infrared photocoagulation. They do not require chemotherapy, radiation, or resection.
c. To a reasonable degree of medical probability, throughout the Winter of 2018 and
18
into the early Spring of 2019, Ms. Rush’s anal cancer was still at a relatively early stage. While it
19
likely advanced to Stage I or Stage II, by definition, this meant that there was still no spread to her
20
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lymph nodes. This is supported by Ms. Rush’s clinical history as she first noticed the lump in her
groin, representing cancerous spread to her left inguinal node, on or around May 17, 2019, one week
before presenting to Dr. Lee (see Exhibit R). Stage I refers to patients who have a Tl tumor (<
24
2cm); Stage IIA refers to patients who have a T2 tumor (> 2cm but < 5cm); and Stage IIB refers to
25
patients who have a T3 (tumor > Scm) but are still NO (no regional lymph node metastasis). For
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Bruce G, Fagel
these anal cancer patients, their 5-year survival rate is greater than 80%. The major difference in
&
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overall survival and/or disease-free survival, occurs when the tumor invades adjacent organs, such
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
as the vagina, as is the case with Ms. Rush (based on imaging). And once there is regional lymph
node metastasis to either the inguinal, internal or external iliac nodes,
the prognosis diminishes
considerably. In this case, Ms. Rush was not diagnosed until her cancer had advanced to an Nic,
meaning it had spread to the external iliac and inguinal nodes. According to the RTOG 98-11 Phase
3 Trial!, for those who are node positive T4Nc, as is the case with Ms. Rush, 5-year disease-free
survival for those treated with radiation therapy plus Mitomycin and Fluorouracil, was 27%.
Compare that to those who are T2NO (Stage ITA) meaning tumors as large as 5 cm without invasion
into adjacent organs and no nodal involvement, where the 5-year disease-free survival rate on the
10
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into adjacent organs such as the vagina, but still have no nodal involvement, the 5-year disease-free
13
survival rate on the same regimen was 65%.
14
(
same regimen was 80%. Even those who are T4NO0 (Stage IIIB), meaning the tumor has invaded
15
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d. Dr. Staiger acknowledged at deposition that on July 31, 2019, Dr. Mishkin, the
general surgeon, was able to make the diagnosis of anal cancer, based on nothing more than history
and physical exam (Exhibit Y, page 161, lines 3-12). This diagnosis was confirmed on August 5,
18
2019. As a direct result of Dr. Staiger’s failure to adequately and timely examine, diagnose, and
19
treat Ms. Rush’s increasingly concerning symptoms, which included:
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1) diarrhea, nausea, left abdominal tenderness (first presenting April 19, 2018);
2) bowel incontinence (first presenting April 23, 2018);
3) bloody stools, bright red blood per rectum, fatigue (first presenting July 13, 2018);
4) left lower quadrant 6/10 pain on defecation, urgency (first presenting July 16, 2018);
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6
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' Int J Radiat Oncol Biol Phys. Anal Carcinoma: Impact of TN Category of Disease on Survival, Disease Relapse, and
Colostomy Failure in US Gastrointestinal Intergroup RTOG 98-11 Phase 3 Trial. 2013 November 15; 87(4): 638-645
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
5) chronic diarrhea, 6-pound unintentional weight loss (first presenting July 19, 2018);
6) excessive rectal bleeding measuring 1/8 of a cup (still complaining August 30, 2018);
7) unexplained rectal bleeding, malaise (still complaining September 21, 2018);
8) abdominal cramping with watery stools, myalgia (first presenting January 22, 2019);
9) persistent rectal bleeding (still complaining March 21, 2019);
10) alternating diarrhea/constipation, persistent rectal pain (first presenting April 9, 2019);
11) lump in her left groin (first presenting May 24, 2019);
12) persistent rectal “knot” causing 9-10/10 pain (first presenting June 26, 2019);
10
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12
Ms. Rush’s anal cancer grew beyond a precancerous in-situ carcinoma, beyond Stage I, beyond
13
Stage ILA, even beyond Stage IIB, and metastasized to her lymph nodes, substantially worsening
14
(
13) left inguinal tenderness, and prolapsed rectal mass (first presenting July 29, 2019);
15
her prognosis. As such, to a reasonable degree of medical probability, Dr. Staiger’s and Dr. Pappu’s
negligence caused or substantially contributed to Ms. Rush not being diagnosed until she was stage
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IIIC with invasion into the vagina (on imaging) and spread to inguinal/iliac nodes, carrying a much
poorer prognosis.
7. To areasonable degree of medical certainty, if Dr. Staiger and/or Dr. Pappu had referred
Ms. Rush to Dr. Mishkin before her cancer had spread to her inguinal node, she would have had a
greater than 60% chance of being disease free. Given that Ms. Rush first noticed pain in her groin
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around mid-late May
when
she saw Dr. Lee, who mistakenly diagnosed lymphadenitis, to a
24
reasonable degree of medical certainty the cancer had not yet spread to her lymph node when Dr.
25
Staiger aborted her first attempted rectal exam on April 9, 2019. Therefore, the 4-month delay
6
between Dr. Staiger’s first aborted rectal exam and Dr. Mishkind’s rectal exam on August 5, 2019,
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
cost Ms. Rush her last opportunity of being treated in time to have a greater than 50% chance of
being disease-free and cured of her anal cancer.
8. It is my understanding upon reviewing the declaration of Defendants’ expert, Richard A.
Johnson,
M.D.,
hemorrhoids,
that
it was
he
asserts,
appropriate
“based
for
Dr.
on
the
Staiger
gastroenterologist’s
to
eliminate
any
diagnosis
of inflamed
suspicion
of potential
gastrointestinal malignancy [and] absent any complaints or findings of malignancy issues, as was
the case here, a referral to another specialist was not indicated at the time this patient was seen by
Dr. Staiger.” (see Dr. Johnson’s Declaration, page 10, lines 22-27). I disagree with this assertion as
10
it is unsupported by the medical records and Dr. Staiger’s testimony. As a medical oncologist, I am
i
12
familiar with complaints and findings indicating the potential for gastrointestinal malignancy, which
13
include, “pain, bleeding, weight loss, change in bowel [habits]” (Exhibit Y, page 26, lines 15-16),
14
(
15
and more specifically, pain on defecation, left lower quadrant abdominal pain unrelated to ingestion,
excessive
and
persistent
rectal
bleeding,
hematochezia,
unintentional
weight
loss,
bowel
16
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18
the time that Dr. Chowdhury diagnosed internal hemorrhoids (see Paragraph 6 (d) 1-7). In my
19
opinion, based on Ms. Rush’s presentation and persistent complaints, Dr. Steiger should not have
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incontinence/urgency, fatigue, and malaise, all of which Ms. Rush had complained of at or around
eliminated any suspicion of malignancy from her differential and by apparently doing so, caused or
substantially contributed to the delay in Ms. Rush’s eventual diagnosis of Stage IIIC anal cancer.
9. It is my further understanding upon reviewing Dr. Johnson’s declaration that he asserts,
24
“t]he examinations and referrals by Dr. Staiger based upon the patients’ presentation and the
25
opinions of other specialists was appropriate at all times [as] Dr. Staiger diligently ordered creams,
6
ointments, medications, referrals to various specialists, and repeated rescheduling to address the
27
patient’s concerns [and] no action or failure to act in a timely and appropriate fashion by Dr. Staiger
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.
to
at any time caused or contributed to an alleged delay in the diagnosis and treatment of the patient’s
anal cancer.” (see Dr. Johnson’s Declaration, page 11, lines 14-17). I disagree with this assertion,
as it too, is unsupported by the medical records and Dr. Staiger’s testimony. Dr. Stager did not
attempt to examine the patient’s chief complaint of rectal bleeding by performing a rectal until April
9, 2019. While she repeatedly rescheduled appointments to see Ms. Rush, these visits did not address
the patient’s chief complaint as Dr. Staiger did not diagnose nor include hemorrhoids on any of her
visit note assessments
until April 9, 2019. In addition, Dr. Staiger did not order any creams,
ointments, or medications to treat Ms. Rush’s rectal bleeding/presumed hemorrhoids until April 9,
10
2019. It is my expert opinion, to a reasonable degree of medical probability, in failing to examine,
11
12
diagnose, or treat Ms. Rush’s rectal bleeding until April 9, 2019, Dr. Staiger’s negligent acts and
omissions caused or substantially contributed to Ms. Rush’s injuries and damages. Furthermore, it
is my expert opinion, to a reasonable degree of medical probability, that by failing to refer Ms. Rush
to the general surgeon, Dr. Mishkind, at or around the time of her first attempted rectal exam and
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certainly once her attempted treatment of Ms. Rush’s worsening rectal pain, bleeding, and change
18
in bowel habits, failed to alleviate her symptoms in the early Spring of 2019, more than one month
19
before Ms. Rush first noticed the lump in her left inguinal region; these negligent acts and omissions
20
further contributed to Ms. Rush’s injuries and damages.
21
I declare, under penalty of perjury under the laws of the State of California, that the above is
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4
true and correct.
i
Executed on July
#2
1! 9921 at?
nn
re]
a
ever, fils, California.
mratanenverereenmenanytnaman
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_Dewia M.J. =~
Bruce G. Fagel
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~\
M.D., FACS
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DECLARATION OF DAVID M.J. HOFFMAN, M.D. IN SUPPORT OF OPPOTION TO
MOTION FOR SUMMARY JUDGMENT BY DEFENDANT PAMELA STAIGER, M.D.