Smith v. Zama: Conflicting Expert Proof on Discharge Anticoagulation/Beta-Blocker Decisions Creates Triable Issues and Defeats Summary Judgment

1. Introduction

Case: Smith v Zama, 2025 NY Slip Op 07357 (App Div, 3d Dept Dec. 31, 2025).
Parties: Plaintiffs Lucas Smith and spouse (derivative claim) vs. cardiothoracic surgeon Nche Zama, physician assistant Idriys A. McField, and institutional defendants including Arnot Ogden Medical Center (AOMC) and related entities.
Posture: Plaintiffs appealed from an order granting defendants summary judgment dismissing a medical malpractice complaint.

The dispute centers on post–cardiac surgery discharge planning after repair of a massive ascending aortic aneurysm. Plaintiffs contend that defendants negligently (i) failed to determine the cause of preoperative atrial fibrillation, (ii) failed to prescribe beta blockers and anticoagulants at discharge, and (iii) failed to appreciate that Smith was not properly anticoagulated—leading to a clot-related embolic event causing ischemic bowel and extensive resection.

The key appellate issue was procedural but outcome-determinative: whether the parties’ competing expert affirmations created material triable issues of fact (thus precluding summary judgment) regarding standard of care and causation, including what constituted “adequate anticoagulation” (with emphasis on INR and medication choices) and whether McField could obtain summary judgment on the theory that he exercised no independent medical judgment due to supervision.

2. Summary of the Opinion

The Third Department reversed Supreme Court’s order, denied defendants’ motions for summary judgment, and reinstated the complaint. Although defendants satisfied their prima facie burden through records, depositions, and a defense expert affirmation (Grossi), plaintiffs met their responsive burden with a detailed expert affirmation that directly rebutted the defense positions on rhythm management, beta-blocker use, anticoagulation strategy (including the significance of INR), and causation.

The court held that plaintiffs’ expert proof was not speculative or conclusory and that disputes—especially over the adequacy of anticoagulation and the interpretation of INR—presented credibility questions for a jury. Additionally, as to McField’s separate supervision-based defense, the court noted that the defense expert failed to address whether McField properly carried out Zama’s orders and acted at all times under Zama’s supervision, defeating summary judgment on that separate ground.

3. Analysis

A. Precedents Cited

The opinion is anchored in well-established Third Department summary judgment doctrine in medical malpractice cases and uses multiple precedents to define (i) the moving burden, (ii) the opposing burden, and (iii) the limited role of courts on summary judgment.

1) Moving defendant’s prima facie burden

• Henderson v Takemoto, 223 AD3d 996 (3d Dept 2024): Cited for the rule that defendants must rebut malpractice claims with competent proof—typically affidavits/affirmations, deposition testimony, and medical records—showing compliance with accepted standards or lack of causation. In Smith, defendants met this threshold via an expert surgeon’s affirmation and supporting record materials.

2) Plaintiff’s responsive burden and quality of expert opposition

• Scott v Santiago, 230 AD3d 933 (3d Dept 2024): Cited both for the burden-shifting framework and later for the proposition that conflicting expert opinions (here, adequacy of anticoagulation/INR) generate credibility questions for the factfinder. The court relied on Scott to characterize the INR dispute as a jury issue rather than a summary-judgment issue.
• Lubrano-Birken v Ellis Hosp., 229 AD3d 873 (3d Dept 2024): Cited for the requirement that plaintiff’s expert must address specific assertions made by defendants’ experts, with record support and explained reasoning—not speculation or conclusory claims. The court applied this standard and held plaintiffs satisfied it.
• Matney v Boyle, 237 AD3d 1382 (3d Dept 2025): Used to reinforce that an opposing expert affirmation that engages the record and directly rebuts the defense expert is sufficient to defeat summary judgment.

3) Court’s role on summary judgment (no factfinding/credibility determinations)

• McCarthy v Town of Massena, N.Y. [Massena Mem. Hosp.], 218 AD3d 1082 (3d Dept 2023): Cited for the principle that courts do not decide credibility or make factual findings on summary judgment; they identify whether triable issues exist. This directly undercut Supreme Court’s criticism of plaintiffs’ opposition as “conclusory” where, in fact, it created factual disputes.

4) Additional Third Department citations reinforcing denial where expert conflicts exist

• Sovocool v Cortland Regional Med. Ctr., 218 AD3d 947 (3d Dept 2023): Cited as supporting authority for denying summary judgment where the nonmovant’s expert proof creates triable issues.
• Schwenzfeier v St. Peter's Health Partners, 213 AD3d 1077 (3d Dept 2023): Similarly cited to confirm the impropriety of summary judgment where record-based expert disagreement exists.

5) Supervision/no-independent-judgment defense (physician assistant context)

In Footnote 2, the court contrasted the record with Second Department cases addressing when a subordinate clinician may obtain summary judgment based on lack of independent judgment:

• Molina v Goldberg, 231 AD3d 46 (2d Dept 2024)
• Motto v Beirouti, 90 AD3d 723 (2d Dept 2011)
• Vaccaro v St. Vincent's Med. Ctr., 71 AD3d 1000 (2d Dept 2010)

The Third Department’s point was not to adopt a new substantive supervision test, but to emphasize an evidentiary requirement on summary judgment: if a defendant (here, McField) seeks dismissal on “no independent medical judgment” grounds, the moving papers—particularly expert proof—must actually address whether the defendant acted under direction, control, and supervision and properly carried out orders. Grossi’s affirmation did not do that work; therefore, summary judgment on that separate theory was unavailable.

B. Legal Reasoning

1) Defendants met the prima facie showing—but that only shifted the burden

Defendants’ expert (a board-certified general and cardiothoracic surgeon) framed the case as appropriate post-operative management:

• The aneurysm repair “converted” Smith to normal sinus rhythm and telemetry/testing supported stability through discharge.
• Beta blockers were contraindicated because Smith was hypotensive postoperatively and even required interventions to raise blood pressure.
• Anticoagulation was avoided because of bleeding risks after major cardiothoracic surgery, and Smith was “low risk for clots”; an INR of 1.6 was described as “adequately anticoagulated,” with Aspirin 81 mg deemed appropriate.

This was sufficient for prima facie purposes. Critically, the appellate decision underscores that meeting prima facie burden does not entitle defendants to judgment if plaintiffs can raise a genuine, record-based dispute on standard of care and causation.

2) Plaintiffs’ expert directly rebutted key defense assertions with record anchors

Plaintiffs’ expert (also board-certified in general and cardiothoracic surgery) did what Lubrano-Birken requires: address specific defense assertions with explanation and citations to record-consistent facts:

• Etiology of atrial fibrillation: The expert criticized the assumption that aneurysm repair would resolve the arrhythmia, emphasizing multiple possible causes and the known increased risk of postoperative atrial fibrillation in cardiac surgery patients—consistent with deposition testimony, including Zama’s acknowledgment that postoperative atrial fibrillation is common.
• Beta blockers as standard rhythm/rate/blood pressure management (“anti-impulse therapy”): The expert opined that beta blockers reduce postoperative atrial fibrillation incidence and should have been used, particularly given Smith’s later readmission showing atrial flutter/irregular rhythm and hypertension—conditions the expert stated are managed by beta blockers.
• Anticoagulation versus aspirin: The expert distinguished antiplatelet therapy (aspirin) from anticoagulation and opined aspirin was insufficient to reduce embolic risk in this context.
• INR dispute as a core factual conflict: The expert disagreed that INR 1.6 was “adequate,” asserting that an INR target of 2–3 was needed given unknown atrial fibrillation etiology and elevated postoperative risk, and linked inadequate anticoagulation to the clot-related embolic event causing bowel ischemia.

3) The court treated the INR/anticoagulation disagreement as a jury question

The court emphasized that the bowel injury was undisputedly clot-related, making anticoagulation decisions central to causation. With two qualified experts disagreeing over whether INR 1.6 and aspirin were adequate at discharge and whether anticoagulants/beta blockers should have been prescribed, the appellate court held that Supreme Court improperly resolved what was, in substance, a credibility/fact dispute. Under McCarthy and Scott, that dispute must be resolved by a jury.

4) Timing and subsequent events strengthened plaintiffs’ causation narrative

The court highlighted that within two days of discharge, Smith returned with atrial flutter/irregular heart rate and hypertension and was then given an anticoagulant despite the bleeding-risk rationale previously invoked. While not dispositive as a matter of law, this chronology supported plaintiffs’ expert’s claim that the discharge regimen was inadequate and that earlier anticoagulation could have prevented the embolic event.

5) McField’s “no independent judgment” theory failed for lack of targeted proof

Footnote 2 is a practical summary-judgment lesson: a defendant cannot prevail on a narrow, role-based defense unless the moving proof squarely addresses the elements of that defense. Grossi opined generally that communication between McField and Zama was appropriate, but did not analyze whether McField acted “at all times” under direction, control, and supervision or whether he properly carried out orders. That omission prevented dismissal on that separate ground.

C. Impact

1) Reinforcement (and sharpening) of what counts as “nonconclusory” expert opposition

Smith v Zama reinforces that an opposing expert affirmation is sufficient when it (i) directly answers the defense expert’s precise claims, (ii) explains the “why” (medical reasoning), and (iii) ties those opinions to record evidence (tests, medications, readmission findings, deposition admissions). Trial courts are cautioned against labeling such submissions “conclusory” where they are, in effect, classic battles of experts.

2) Discharge-medication decisions in cardiac surgery cases are fertile ground for triable issues

The decision signals that summary judgment is particularly difficult where the alleged malpractice is not an intraoperative error but a discharge planning/pharmacologic management decision involving risk-benefit judgments (bleeding risk vs. embolic risk; hypotension vs. arrhythmia/hypertension control). When each side presents plausible expert reasoning, courts are likely to find triable issues.

3) Role-based defenses (supervision/no independent judgment) require tailored expert proof

The footnote discussion is likely to influence litigation strategy in cases involving physician assistants and other supervised clinicians: to obtain summary judgment on “no independent medical judgment” grounds, defendants should present specific testimony/affidavits/affirmations addressing supervision, delegation, and execution of orders—not merely general statements about communication.

4. Complex Concepts Simplified

• Summary judgment: A pretrial request to dismiss a case because there are no genuine disputes of material fact requiring a trial. If experts disagree on key medical issues, summary judgment is often denied.
• Prima facie burden (medical malpractice): The moving defendant must first show, with competent proof, either no deviation from accepted practice or no causation. Only then must the plaintiff respond with contrary proof.
• Triable issue of fact: A real, material disagreement about facts or expert conclusions that a jury must decide.
• Atrial fibrillation / atrial flutter: Abnormal heart rhythms that can be intermittent. They can promote clot formation, which can travel (“embolize”) and block blood vessels elsewhere.
• Anticoagulant vs. antiplatelet (aspirin): Both reduce clotting risk but work differently. Anticoagulants (e.g., heparin/warfarin-type agents) more directly reduce formation of fibrin clots; antiplatelets (aspirin) reduce platelet clumping. Plaintiffs’ expert emphasized this difference to argue aspirin alone was insufficient.
• INR (International Normalized Ratio): A lab measure commonly used to reflect how long blood takes to clot. In some anticoagulation contexts, higher INR targets (often around 2–3) are used to reduce clot risk; too low may mean inadequate anticoagulation, while too high increases bleeding risk. Here, experts disputed whether INR 1.6 was “adequate.”
• Beta blockers: Medications that can slow heart rate and reduce blood pressure; they may also reduce certain arrhythmias. Defendants emphasized hypotension risk; plaintiffs emphasized arrhythmia/hypertension control and postoperative atrial fibrillation prevention.
• Proximate cause: The requirement that the alleged deviation be a substantial factor in producing the injury. Plaintiffs linked discharge medication choices to embolic bowel ischemia.

5. Conclusion

Smith v Zama stands as a strong Third Department reminder that where qualified experts offer record-based, competing explanations for discharge medication decisions—especially involving anticoagulation adequacy (including INR interpretation) and beta-blocker use—courts must not resolve the dispute on summary judgment. The decision also underscores that role-based defenses like “no independent medical judgment” demand focused evidentiary support addressing supervision and execution of orders. In the broader medical malpractice landscape, the opinion reinforces that discharge planning and post-operative pharmacologic strategy are fact-intensive arenas in which expert conflicts will typically be for the jury.