“Substantially Uninterrupted” Means Mostly Continuous: Reasonableness Limits Virginia’s Continuing Treatment Exception

1. Introduction

Cothran v. Jauregui addresses the boundary of Virginia’s “continuing treatment rule”—an exception that can delay accrual of a medical malpractice claim when alleged negligence occurs during a continuous and substantially uninterrupted course of care for a particular condition.

The plaintiff, Renee Jauregui, alleged she repeatedly reported a breast lump during pregnancy-related visits with her OB/GYN, Shannon J. Cothran, M.D., in 2018, was reassured, and later returned in August 2019—after noticing changes—when testing revealed metastatic breast cancer. The parties agreed the two-year limitations period would bar claims tied to visits before August 2019 unless the continuing treatment rule extended the limitations period to cover the 2018 encounters.

The case turned on a fact-intensive question: whether the 2018 visits and the 2019 follow-up formed a single “continuous and substantially uninterrupted” course of examination and/or treatment for the same malady (the breast lump), or whether the 10-month gap reflected a “substantial interruption” that ended the course and triggered limitations.

2. Summary of the Opinion

The Court reaffirmed that actual “treatment” is not a prerequisite to the continuing treatment exception; a continuous course of improper examination alone can suffice. But it emphasized that “substantially uninterrupted” adds a reasonableness-based limitation: the relationship must be “mostly” continuous, and a gap can become “substantial” when the parties proceed as though the course has ended.

3. Analysis

3.1 Precedents Cited

Farley v. Goode, 219 Va. 969 (1979)

Farley is the cornerstone of Virginia’s continuing treatment doctrine, quoted repeatedly for the proposition that when malpractice occurs during a “continuous and substantially uninterrupted course of examination and treatment” for a particular condition, accrual begins when the improper course terminates.

• No-treatment scenarios qualify: The Court used Farley to reject the notion that the exception requires affirmative “treatment.” In Farley, malpractice included a failure to diagnose and lack of treatment over years; thus, “treatment” is not a threshold requirement.
• Key limitation: Farley “presupposes” a course that is continuous and “substantially uninterrupted,” proved as a matter of fact; it does not apply to isolated acts.
• Critical move in this case: The Court clarified that Farley did not define “substantially uninterrupted,” and that the Court of Appeals mistakenly imported language defining “continuous treatment” (as more than a general physician-patient relationship and as concerning “the same or related illnesses or injuries”) to define “substantially uninterrupted.” That conflation, the Court held, creates redundancy and misstates the test.

Borgia v. City of New York, 187 N.E.2d 777 (N.Y. 1962)

Borgia is cited indirectly through Farley for the distinction between a general physician-patient relationship and treatment/diagnosis for the same or related condition. In Cothran, the Supreme Court treated Borgia as informing what “continuous treatment” means—but not what “substantially uninterrupted” means—thereby narrowing the Court of Appeals’ reliance on Borgia-derived language.

Grubbs v. Rawls, 235 Va. 607 (1988)

Grubbs is used to emphasize an “essential limitation” on the continuing treatment exception: the physician-patient relationship must exist with respect to the specific malady at issue. The Supreme Court invoked this principle to explain why, if the trial court had rejected Jauregui’s testimony about discussing the lump in 2018, the continuing treatment doctrine would fail at the threshold (no relevant continuous relationship to extend).

Chalifoux v. Radiology Assocs. of Richmond, Inc., 281 Va. 690 (2011)

Chalifoux supplies the baseline limitations framework: in Virginia, the statute begins to run when the plaintiff is injured, not when the injury is discovered. The continuing treatment exception is therefore significant because it can delay accrual despite Virginia’s general rejection of a discovery rule for personal injury claims.

Mulford v. Walnut Hill Farm Grp., LLC, 282 Va. 98 (2011), and Westgate at Williamsburg Condo. Ass'n v. Philip Richardson Co., 270 Va. 566 (2005)

These cases reinforce the ore tenus standard: factual findings after live testimony are treated like a jury verdict and will not be disturbed unless “plainly wrong or without evidence to support them.” In Cothran, this deference is outcome-determinative because the Supreme Court treated “substantial interruption” as a factual issue and concluded the record could support the trial court’s finding.

Jauregui v. Cothran, Record No. 1133-23-4, 2024 Va. App. LEXIS 652 (Nov. 12, 2024)

Although unpublished, the Court of Appeals’ reasoning framed the error corrected by the Supreme Court: it focused on whether Jauregui returned “pursuant to Dr. Cothran’s instructions” for the same condition and treated that as dispositive of “substantially uninterrupted.” The Supreme Court rejected that interpretive move and reinstated the circuit court’s factfinding.

3.2 Legal Reasoning

(A) Statutory backdrop and the exception’s structure

• Limitations period: Code § 8.01-243(A) requires medical malpractice actions within two years after accrual.
• Accrual rule: Code § 8.01-230 provides that accrual begins when the injury is sustained (not discovered), as reinforced by Chalifoux.
• Exception: The continuing treatment doctrine delays accrual until the improper course of examination and/or treatment for the particular malady ends (Farley).

(B) “Treatment” is not required—but continuity still must be proved

A central clarification is doctrinal housekeeping: calling it a “continuing treatment rule” is “a bit of a misnomer” because (i) it is an exception, not a freestanding rule, and (ii) it can be triggered by a continuous course of improper examination alone. The Court anchored this in Farley, where the malpractice involved failure to diagnose and lack of treatment.

However, the Court simultaneously reinforced that the exception does not attach to a single, isolated incident and requires proof—“as a matter of fact”—of a continuous course that is “substantially uninterrupted.”

(C) The key interpretive move: separating “continuous treatment” from “substantially uninterrupted”

The Court of Appeals treated “substantially uninterrupted” as satisfied if later visits concerned the same condition and were pursued according to physician instructions. The Supreme Court rejected that because Farley uses “continuous treatment” to describe the “same or related illnesses or injuries” concept; if “substantially uninterrupted” meant the same thing, the phrase would be redundant.

This matters because it transforms the analysis from a categorical test (“same condition + return as instructed = uninterrupted”) into a context-sensitive inquiry: did the course remain mostly continuous in a reasonable sense, or did it end and later restart?

(D) Deference to trial-court factfinding drives the outcome

The Supreme Court accepted—for purposes of reviewing the alternative holding—Jauregui’s account that she reported the lump and was told to monitor and return upon changes. Even with that assumption, the Court held the trial court could reasonably find a “substantial interruption” based on how the parties proceeded after October 2018:

• There was an undisputed interruption in visits and active involvement after October 2018.
• Both parties “proceeded as though the physician/patient relationship had ended.”
• At least one party “had reasonably concluded” the course had reached its “logical conclusion,” with no forecasted need for further exam or treatment.
• The longer the gap, the more “substantial” the interruption can become; here, the gap was approximately ten months.

Applying ore tenus deference (Mulford; Westgate; Code § 8.01-680), the Supreme Court held it could not say the trial court’s “substantial interruption” finding was plainly wrong or without evidentiary support—so the plea in bar stood.

(E) A carefully bounded holding (and an important footnote)

The Court explicitly avoided a bright-line time rule. It noted that ten months may not be substantial under different facts, and a shorter time could be substantial in other circumstances. Likewise, the Court cautioned against reading the opinion to exclude “wait and see” approaches categorically. The lesson is not “gaps defeat the doctrine,” but rather “gaps are evaluated for reasonableness and continuity in context, and trial courts have substantial discretion as factfinders.”

3.3 Impact

(A) Doctrinal impact: a definitional correction with practical consequences

The opinion’s most significant contribution is the clarification that “continuous treatment” (same or related condition) and “substantially uninterrupted” (mostly continuous, with a reasonableness overlay) are distinct components. Future litigants should expect courts to:

• First confirm the relationship concerns the same malady (the Grubbs limitation); and
• Then separately assess whether the course was “mostly continuous” in a reasonable, fact-specific way.

(B) Litigation impact: heightened importance of factual development and ore tenus posture

Because “substantially uninterrupted” is treated as a question of fact and reviewed deferentially, the venue of decisionmaking matters. A party seeking to apply (or defeat) the continuing treatment exception should anticipate that:

• Evidence about the parties’ reasonable expectations at the end of a visit, planned follow-up, and how care was administratively and clinically “closed” can be decisive.
• “Return if symptoms change” instructions do not automatically preserve continuity; they may be framed as ending the course absent a scheduled or clinically anticipated follow-up.
• Appellate courts are less likely to reweigh those facts once a trial court has made an ore tenus finding.

(C) Clinical and risk-management impact

Although the Court did not impose documentation requirements, its reasoning incentivizes clearer “end-of-course” signaling:

• When a clinician believes an issue is resolved or no ongoing evaluation is anticipated, charting and discharge/follow-up instructions may become relevant to later “substantial interruption” disputes.
• Conversely, when ongoing monitoring is clinically intended, documenting a definite plan (including timing) may support continuity arguments.

4. Complex Concepts Simplified

• Plea in bar: A procedural device used to stop a case early because a legal bar (here, the statute of limitations) defeats the claim even if the complaint’s allegations are assumed true.
• Accrual (Code § 8.01-230): The moment a cause of action legally “begins,” starting the limitations clock—generally when the injury is sustained, not when discovered.
• Continuing treatment rule (exception): If malpractice happens during a continuous and substantially uninterrupted course of care (examination and/or treatment) for a particular condition, the clock may not start until that course ends.
• “Continuous treatment” vs. “substantially uninterrupted”:
  • Continuous treatment: care relating to the same or related illness/injury, not just a general doctor-patient relationship.
  • Substantially uninterrupted: mostly continuous in a reasonable sense; gaps can be permitted, but a “considerable” break can terminate the course.
• Ore tenus: The trial judge heard live testimony; resulting factual findings receive strong appellate deference and are reversed only if plainly wrong or unsupported by evidence.

5. Conclusion

Cothran v. Jauregui tightens and clarifies Virginia’s continuing treatment exception in two important ways. First, it confirms that a continuous course of improper examination—even without affirmative treatment—can qualify, consistent with Farley v. Goode. Second, and more significantly, it separates “continuous treatment” (same-condition relationship) from “substantially uninterrupted” (a distinct, reasonableness-infused continuity requirement) and rejects the Court of Appeals’ conflation of those concepts.

The practical message is that continuity disputes will often be decided on granular facts—how the course of care reasonably appeared to end, what follow-up was clinically anticipated, and how long the gap persisted—and trial-court findings on “substantial interruption” will be difficult to overturn on appeal.