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COMMONWEALTH OF MASSACHUSETTS
DUKES, ss. SUPERIOR COURT
DOCKET NO. 2174CV00027
PATRICIA MARK,
Plaintiff,
ILED
SUPERIOR COURT
¥, COUNTY OF DUKES COUNTY
MARK LISKA, M.D. AND DERMATOLOGY SEP 14 2021
OF CAPE COD, P.C.
REC'D
_— CLERK
Defendants
PLAINTIFF’S OFFER OF PROOF AS TO
DEFENDANT, MARK LISKA, M.D. !
This Offer of Proof is made pursuant to Massachusetts General Laws, Chapter 231, §60B and
Massachusetts Superior Court Rule 73. Attached to this Offer of Proof and made part hereof are the
following exhibits:
Exhibit A - Expert Report of Mare Serota, M.D., FAAD, FAAAI, FACAAT;
Exhibit B - Curriculum Vitae of Marc Serota, M.D., FAAD, FAAAI, FACAAI;
Exhibit C - Medical Records from Mark Liska, M.D. and Dermatology of Cape Cod, P.C.;
Exhibit D - Medical Records from Theodore Calianos, M.D./Cape Cod Healthcare;
Exhibit E - Medical Records from Steve Garrett Practice;
Exhibit F - Medical Records from Mark Amster, M.D.; and
Exhibit G - Affidavit of Patricia Mark;
' The Plaintiff, in her Complaint and Demand for Jury Trial, has also brought counts against
Defendant, Dermatology of Cape Cod, P.C., respectively for respondeat superior. However, counts
alleging derivative liability are not appropriate for tribunal consideration. See Bing v. Drexler, 69
Mass. App. Ct. 186, 190-91, 866 N.E.2d 996, 1000 (2007). Therefore, the liability of Dermatology of
Cape Cod is not addressed in this Offer of Proof.
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STATEMENT OF THE CASE
A. STATEMENT OF FACTS
This is a medical malpractice action based on the alleged negligent management of the care and
treatment of Plaintiff, Patricia Mark. The Defendants, Mark Liska, M.D. and Dermatology of Cape Cod,
P.C., individually and by and through their doctors, nurses, administrators, and staff employees, failed to
meet the accepted standards of care, skill, and diligence, including but not limited to the following: their
failure to order more specific testing to rule out skin cancer in January 2015, April 2015, February 2016,
February 2017, and February 2018. Defendants were negligent in other respects, as well; with regard to
their failure to listen to and acknowledge the concerns of the patient.
On or about January 9, 2015, Patricia Mark presented to Defendant, Dermatology of Cape Cod for
a full skin exam and was seen by Sarah Orciuch P.A. Patricia Mark complained of a new lesion on her
nose, See Exhibit G - Affidavit of Patricia Mark, 96. Patricia Mark was reassured that there was no need
for treatment and to return in one year for her annual skin exam. See Exhibit C - Medical Records from
Mark Liska, M.D. and Dermatology of Cape Cod, P.C.
On or about April 2, 2015, Patricia Mark returned to Defendant, Dermatology of Cape Cod,
complaining of the same lesion on her right paranasal fold. See Exhibit G, 7. Sarah Orciuch P.A. and
Nancy Barnett M.D. noted the lesion as telangiectasia and noted the same on the mid tip of her nose, left
malar area, and right malar area. Mark was referred to plastic surgeon, Dr. Calianos for laser treatment.
See Exhibit C.
Patricia Mark presented to Defendant, Dr. Liska, for a full skin exam on or about February 12,
2016, She complained again of the lesion on her right paranasal fold. See Exhibit G, 8. Defendant, Dr.
Liska, noted the lesion as telangiectasia and referred her to the same plastic surgeon, Dr. Calianos. See
Exhibit C.
Patricia Mark presented to Defendant, Dermatology of Cape Cod, for a full skin exam on or about
February 17, 2017. Patricia Mark complained yet again of the lesion on her right paranasal fold. See
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Exhibit G, §9. Defendant, Dr. Liska, noted the lesion as telangectasia and again referred her to a plastic
surgeon for laser treatment. See Exhibit C.
On or about February 16, 2018, Patricia Mark again presented to Defendant, Dermatology of Cape
Cod for a full skin exam and again Defendant, Dr. Liska noted the lesion as telangiectasia. Defendant
noted that "patient feels this is a moderate to severe concern". See Exhibit C. In fact, Patricia Mark had
been complaining about the lesion since 2015. See Exhibit G, 45.
Patricia Mark presented to Dr. Calianos of Dermatology of Cape Cod for laser treatment of the
aforementioned area on or about April 19, 2018. Dr. Calianos declined treatment and recommended that
Mark have the lesion on her right paranasal fold biopsied by Dr. Liska. See Exhibit D - Medical Records
from Theodore Calianos, M.D./Cape Cod Healthcare and Exhibit G, 911.
Patricia Mark presented to Dr. Liska for a biopsy of the lesion on her right paranasal fold on or
about May 30, 2018. See Exhibit C and Exhibit G, 912.
On or about June 11, 2018, the biopsy report confirmed the lesion to be basal cell carcinoma and
further stated that it extended to the peripheral tissue edge. This was the first time Patricia Mark learned
that she had skin cancer. See Exhibit G, 14.
Based on the clinical notes of Dr. Liska and Cape Cod Dermatology and confirmed by Patricia
Mark, a dermatoscopic exam was never performed on any of Patricia Mark's lesions. See Exhibit A -
Expert Report of Marc Serota, M.D., FAAD, FAAAI, FACAAI. A dermatoscope is a tool used by many
dermatologists to aid in magnifying and enhancing suspicious legions. See Exhibit A.
From January 9, 2015 to the diagnoses of telangiectasia on the right paranasal fold to September
28, 2018 Mohs surgery, the lesion grew to 8mm when biopsied and required a 1.3cm x 1.3cm post-
operative wound that extended into the underlying subcutaneous tissue. See Exhibit A and Exhibit G, 716.
As a result of Dr. Liska’s delay and failure to properly diagnose and treat basal cell carcinoma skin
cancer, the lesion grew. Patricia Mark has suffered from a deformed left ear from the donor site for the
skin graft, hair loss that took one year to grow back, deformed and still elevated Mohs site as well as pain
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and suffering, and severe emotional distress. See Exhibit E, Exhibit F, and Exhibit G, 417.
B. STATEMENT OF LAW
To prevail before this Tribunal, Plaintiff's Offer of Proof must establish:
qd) The existence of a physician/patient relationship between Dr. Liska and Patricia Mark;
Q) Dr. Liska’s respective failure to conform to good medical practice while caring for Patricia
Mark; and
(3) The injuries to Patricia Mark were caused by Dr. Liska’s failure to conform to good
medical practice.
See Keppler v. Tufts, 38 Mass. App. Ct. 587, 589, 649 N.E.2d 1139, 1140 (1995); Perez v. Bay
State Ambulance & Hospital Rental Service, Inc., 413 Mass. 670, 676, 602 N.E. 2d 570, 573 (1992);
Blake v. Avedikian, 412 Mass. 481, 482, 590 N.E. 2d 183, 184 (1992).
a PHYSICIAN/PATIENT RELATIONSHIP
Dr, Liska’s and Dermatology of Cape Cod’s medical records definitively establish a
physician/patient relationship between Dr. Liska and Patricia Mark. Between at least January 9, 2015
through May 30, 2018, Patricia Mark was seen by Dr. Liska and his staff at Dermatology of Cape Cod for
treatment of the lesion on her nose. See Exhibit C and Exhibit G 6-14. It is clear that during these visits,
a physician/patient relationship existed between Dr. Liska and Patricia Mark.
(2) STANDARD OF CARE AND BREACH
The proper standard in evaluating the conduct of a physician is whether the physician used the
“reasonable degree of care such as ordinarily possessed by others providing medical care and treatment,
having regard to the current state of care and treatment to patients . . . -” Schwartz v. Goldstein, 400
Mass. 152, 155, 508 N.E.2d 97, 99 (1987).
Plaintiff has shown through the expert opinion of Marc Serota, M.D., FAAD, FAAAI, FACAAL
(Dr. Serota”), that Dr. Liska has indeed failed to exercise the reasonable degree of care as ordinarily
possessed by others while holding himself out as a physician with expertise in dermatology, skilled in
skin cancer treatment and prevention, and, in particular, represented to Patricia Mark as knowledgeable,
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competent, and qualified to diagnosis dermatology concerns. See Medical Expert Report of Dr. Serota,
attached as Exhibit A.
As noted by the Supreme Judicial Court in Letch v. Daniels, 401 Mass. 65, 514 N.E.2d 675
(1987):
“A medical expert need not be a specialist in the area concerned nor be
practicing in the same field as the defendant. ‘It is well established that
the professional specialty of a medical practitioner offered as a witness need
not be precisely and narrowly related to the medical issues of the case. Thus,
it has been held that a judge, in his discretion, properly admitted the opinions
of a general practitioner in a case which related to specialized medical issues.’
Kapp v. Ballantine, 380 Mass. 186, 192-193 n. 7, 402 N.E.2d 463 (1980).
Accord Commonwealth v. Boyd, 367 Mass. 169, 182-183, 326 N.E.2d 320 (1975)
(expert need not be a specialist in the field); Gill v. North Shore Radiological
Assocs., 10 Mass.App.Ct. 885, 886, 409 N.E.2d 248 (1980) (deeming it
unnecessary ‘for the plaintiff's medical expert to be a specialist in the area
concerned’); Samii v. Baystate Medical Center. Inc., 8 Mass.App.Ct. 911, 911-912,
395 N.E.2d 455 (1979) (approving expert testimony on standard of care in
obstetrics from a specialist in internal medicine familiar with subject matter). The
crucial issue is whether the witness has sufficient ‘education, training, experience
and familiarity’ with the subject matter of the testimony. Gill, supra. Samii, supra.”
L etch v. Daniels, 401 Mass. at 68, 514 N.E.2d at 677.
Dr. Serota is eminently qualified to give an expert opinion in the present suit regarding the
standard of care for those knowledgeable, competent, and qualified to diagnosis dermatology concerns,
any breach thereof, and any injuries caused by the same, due to the fact that he is a physician who is board
certified in dermatology.
Dr. Serota received an undergraduate liberal arts degree and medical degree in 2007 through a six-
year combined B.A./M.D. program at the University of Missouri Kansas City School of Medicine. He is
licensed to practice medicine in twenty-five (25) states, including Massachusetts. His professional training
includes a dermatology residency at the University of Colorado Denver from July 2012 through June
2015. He is currently the supervising physician in dermatology at the University of Colorado and
attending/supervising physician at the Veteran’s Affair’s Hospital Denver. His previous work history
includes practicing as a physician in general and medical dermatology at Colorado Dermatology
Specialists and Peak Dermatology. See the Curriculum Vitae of Dr. Serota, attached hereto as Exhibit B.
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“The standard for admission of expert testimony before a medical malpractice tribunal is
‘extremely lenient.’” Blake v. Avedikian, 412 Mass. 481, 482-83, 590 N.E. 2d 183, 184 (1992). “[T]he
tribunal should give consideration to the proffered opinion of an expert if the offer of proof is sufficient to
show that a trial judge in his discretion might properly rule that the qualifications of the witness are
sufficient.” Kapp v. Ballantine, 380 Mass. 186, 192, 402 N.E.2d 463 (1980) (emphasis added). “[T]he
opinions of an expert are to be received even if the tribunal (or its presiding judge) might decide that if the
exercise of discretion were in its province, it would not accept the expert as qualified.” Id. Dr. Serta’s
qualifications compel the conclusion that a trial judge would reasonably and properly rule that Dr. Serta
would be a competent witness to testify at a trial on this matter. Simmons v. Yurchak, 28 Mass. App. Ct.
371, 376, 551 N.E. 2d 539, 544 (1990); Jasper v. Tomaiolo, 20 Mass. App. Ct. 201, 203, 479 N.E. 2d 705,
707 (1985); Elwood v. Goodman, 21 Mass. App. Ct. 925, 485 N.E.2d 197, 198 (1985).
According to the Medical Expert Report of Dr. Serta, to a reasonable degree of medical certainty,
the standard of care applicable to the average health care provider caring for and treating a patient with
Patricia Mark’s condition, would result in a biopsy being ordered in the event of any lesion suspected of
being basal cell carcinoma. See Exhibit A.
Dr. Serta further states in his Medical Expert Report that to a reasonable degree of medical
certainty, Dr. Liska substantially deviated from good and accepted medical practice and committed
negligence by failing to order a biopsy of the lesion suspected of being basal cell carcinoma until 2018.
Dr. Sertoa notes that the medical documentation he reviewed did not describe basal cell carcinoma until it
was biopsied on May 30, 2018. However, he noted that Patricia Mark alleges that the lesion was present
in 2015 and grew over time to increase in size to a visible size of 8mm, creating a Mohs defect 1.3 x 1.3
cm. ‘There was mention in the dermatology reports from Dermatology of Cape Cod on several visits of
telangiectasia on the face. See Exhibit A.
Dr. Serota noted that telangiectasias are a typical feature of a basal cell carcinoma and it is
possible that telangiectasia on the right cheek was in fact describing this basal cell carcinoma. Further, Dr.
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Serota noted that he did not see a dermatoscopic exam performed on any lesions based on clinical notes.
Dr. Serota stated that diagnostic accuracy is improved by approximately 10% when using a dermatoscope.
In addition, telangiectasias take on an “arborizing vessel” pattern along with other typical features of a
basal cell. See Exhibit A.
Dr. Serta noted that were a basal cell carcinoma left undiagnosed for three years, to a reasonable
degree of medical certainty, some growth of the tumor would be expected. See Exhibit A.
Through Dr. Serota’s Medical Expert Report, Plaintiff has shown that Dr. Liska substantially
deviated from good and accepted medical practice and committed negligence, and therefore breached the
applicable standard of care.
Plaintiff need only present evidence in the Offer of Proof of Dr. Liska’s negligence that caused
harm to Patricia Mark. The Tribunal does not require evidence of what Dr. Liska should have done.
Mataitis v. St. Goar, 416 Mass. 325, 327, 621 NE2d 1176, 1178 (1993). Notwithstanding, in this action,
Plaintiff has far exceeded her burden of proof under M.G.L. c. 231, §60.
(3) CAUSATION
Evidence presented by the Offer of Proof must be reviewed by the Tribunal by a standard
comparable to a motion for a directed verdict; namely, in a light most favorable to the plaintiff. Blake v.
A vedikian, 590 N.E. 2d at 185; DiNozzi v. Lovejoy, 20 Mass. App. Ct. 973, 974, 482 N.E. 2d 338, 339,
rev. denied 396 Mass. 1103, 485 N.E. 2d 188 (1985). An Offer of Proof is sufficient if anywhere in the
evidence, from whatever source derived, any combination of circumstances could be found from which a
reasonable inference could be drawn in favor of the plaintiff. Lucas v. Collins, 51 Mass. App. Ct. 30, 33-
34, 743 N.E.2d 847, 849-850 (2001); Haywood v. Rachen, 45 Mass. App. Ct. 185, 189, 696 N.E.2d 549,
552. (1998).
It is not the function of the Tribunal to examine the weight and credibility of the evidence
presented in the Offer of Proof. Perez v. Bay State Ambulance & Hospital Rental Service. Inc., 413
Mass. at 676, 602 N.E. 2d at 573; DiNozzi v. Lovejoy, 20 Mass. App. Ct. at 974, 482 N.E. 2d at 339.
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Furthermore, “[w]here the relation of cause and effect between two facts has to be proved, the testimony
of (a medical) expert that such relation exists or probably exists is sufficient... .” Delicata v.
Boi urlesses, 9 Mass.App.Ct. 713, 720, 404 N.E.2d 667, 671 (1980), citing Berardi v. Menicks,340 Mass
396, 402, 164 N.E.2d 544, 545 (1960).
Dr. Liska’s failure to conform to good medical practice caused Patricia Mark’s aforementioned
injuries is proven by Dr. Serota’s Expert Opinion, where he states:
“If Ms. Mark did exhibit typical features of a basal cel] carcinoma on her right paranasal skin/check
area and this was not biopsied for three years that would be a deviation from the standard of care,
to a reasonable degree of medical certainty. I can state that were a basal cell carcinoma to be left
undiagnosed for three years that, to a reasonable degree of medical certainty, at least some growth
of the tumor would be expected.”
See Exhibit A.
Dr. Serota’s Medical Expert Report is sufficient to satisfy the Plaintiffs burden of proof in regard
to causation.
Cc. CONCLUSION
Clearly, the medical records provided by Dr. Liska and Dermatology of Cape Cod do not contain
the repeated expressions of concerns made by Patricia Mark.
Further, the expert report of Dr. Serota, the Statement of Facts, and the Statement of Law combine
to establish that the Plaintiff, Patricia Mark, is entitled to a finding from the Court pursuant to M.G.L. c.
231, §60B and Massachusetts Superior Court Rule 73 that will enable her to proceed against the
Defendant, Dr. Liska.
Therefore, the Plaintiff requests that the Court issue a finding that the evidence, if properly
substantiated, is sufficient to raise a legitimate question of liability appropriate for judicial inquiry, as
required by M.G.L. c. 231, § 60B, concerning the Defendant, Dr. Liska.
Respectfully submitted,
Patricia Mark
Plaintiff,
By her attorneys,
Dated: September 10, 2021
Thans, O# 042630
Terrence. J. Hurrie BO#689157
w Offices of Brtice Bierhans, LLC
540 Main Street, Suite 17
Hyannis, MA 02601
(508) 775-4500 (phone)
(508) 775-4511 (fax)
bruce@bierlaw.com
tjhurrie@bierlaw.com
CERTIFICATE OF SERVICE
I, Bruce A. Bierhans, hereby certify that a true copy of the within OFFER AS TO DEFENDANT. >
Mark Liska, M.D. , was served upon all Defendants’ respective counsel of record and Clerk of Courts via
first class mail at the below listed address and via e-mail on September 10, 2021:
Chad P. Brouillard, Esq.
Kelly K. Smith, Esq.
Foster & Eldridge, LLP
300 Trade Center, Suite 2610
Woburn, MA 01801
cbrouillard@fosteld.com
ksmith@fosteld.com
T. George Davis, Clerk of Courts
Dukes Superior Court
81 Main St.
P.O. Box 1267
Edgartown, MA 02539
Bierh
EXHIBIT A
v
Marc Serota M.D., FAAD, FAAAI, FACAAL
Board Certified: Dermatology, Allergy/Immunology, Pediatrics
9071 E. Mississippi Ave, Unit 6C
Denver CO, 80247
mj.serota@gmail.com
January 17, 2020
EDICAL EXPERT REPOR'
Marc Serota, M,D., FAAAI, FACAAI, FAAD
Re: Patricia Mark,
Background on expert:
1, Marc Serota M.D., am a practicing dermatologist. I am triple board certified in
dermatology, allergy /immunology and pediatrics. My CV is attached to this report. As partofmy
daily routine practice I perform full skin exams and J personally diagnose and treat patients for basal
cell carcinoma skin cancer.
Summary of Case/Medical Records:
Ihave reviewed all of the medical records provided to me in this case as follows:
Records Reviewed:
1. Dermatology of Cape Cod medical records.
2. Cape Cod Healthcare Theodore Calianos M.D. Plastic & Reconstructive Surgery medical records.
3. Steve Garrett, M.D, medical records.
4, Mark Amster, M.D. medical records.
Summary of case records:
Ms. Patricia Mark is a now 61 year old female (date of birth 4/25/59). Below is a summary
reflecting her clinical course regarding a basal cell skin cancer on her right paranasal skin. This
summary is not intended to be all-inclusive and the reader should refer back to the primary medical
records for complete details.
1/24/13 (Dermatology of Cape Cod, Suzy Amor PA-C, Mark Liska M.D.): Chief complaint of lesion on
her right shoulder and an area on herleft side of her cheek. A complete skin exam was performed.
Noted lentigo on the left cheek, Irritated seborrheic keratosis on the right anterior shoulder.
Performed cryotherapy to seborrheic keratosis.
1/17/14 (Dermatology of Cape Cod, Sarah Orciuch PA-C, Nancy Barnett, M.D,): Full skin exam. Noted
lentigo on the left malar area and a hemangioma on the left forehead.
6/6/14: (Dermatology of Cape Cod, Sarah Orciuch PA-C, Nancy Barnett, M.D.): Problem focused exam.
Chief complaint of a raised mole on her center back and posterior shoulder.. Biopsy performed on left
upper back which showed inflamed seborrheic keratosis. Diagnosed with actinic keratoses,
sebaceous cyst and seborrheic keratoses.
1/9/15: (Dermatology of Cape Cad, Sarah Orciuch PA-C, Nancy Barnett, M.D.): Chief complaint is full
skin exam. Notes itching and flaking on the right and left canthus. Treating with Eucerin. Notes red
hemangiomas on the left forehead and tip of her nose. Diagnoses were lentigo on the left malar
cheek. Dermatitis on the left upper eyelid. Seborrheic dermatitis on the right frontal scalp, left
frontal scalp. Nevus on the left lower back, Exam notes a spider hemangioma on the tip of the nose
“red to purple dome shaped papule” with a plan of reassurance and observation for changes.
04/02/15 (Dermatology of Cape Cod, Sarah Orciuch PA-C, Nancy Barnett MD) Chief Complaint,
Telangectasia on right paranasal fold, mid tip of nose, left malar area, right malar area. It has been
present for month(s), year(s). Referred to plastic surgeon Dr. Calianos for laser.
2/12/16 (Dermatology of Cape Cod, Mark Liska M.D.): Chief complaint is full skin exam. Notes
pigmented lesion on the left superior central cheek. Notes lentigines on the left superior central
cheek, right inferior central malar cheek. Notes AK on the right mid central malar, left superior
central malar cheeks. Hemangioma on the let superior central forehead, left inferior medial lower
chest, left medial lower abdomen. Notes telangiectasia on the right mid central malar, left‘superior
central malar cheeks present for years. Plan was to refer to plastic surgeon if PDT (photodynamic
therapy) didn’t help.
2/17/17 (Mark Liska M.D): Chief complaint: Full skin check. History states: onsidering laser with
Dr. Calianos ofa lesion on her left cheek. He would like confirmation that it isn’t cancerous.”
Assessment includes “hemangioma - capillary - red to purple dome shaped papules” with plan: refer
to Plastic Surgeon for laser. “Telangectasia on the left malar (infraorbital) area, right malar
(infraorbital area) present for year(s), increasing in number”,
2/16/18 (Dermatology of Cape Cod, Mark Liska M.D.): Chief complaint: Full skin check. Notes
telangiectasia on the left malar (infraorbital) area; mid dorsum (bridge) of nose, mid tip of nose, right
malar (infraorbital) area. “It has been present for year(s).” Notes that patient feels this is a
“moderate to severe concern”,
4/19/18 (Theodore Calianos, M.D.): Diagnosed with facial telangiectasia and truncal hemangioma.
Treated with V-beam laser. ~
5/30/18: {Dermatology of Cape Cod, Mark Liska M.D.): Black and white photo showing a dotted
circular area on the R nasal sidewall. Chief complaint: “Referred by Dr. Calianos for a bx ofa non
healing lesion on her nose. ” Assessment is “basal cell carcinoma on the right paranasal fold, Ithas
been present for month(s). leeds intermittently. She states the problem is a firm, pale pink, ill
defined plaque. She feels this is a mild concern.” Assessed as basal cell carcinoma most likely. “Ill
defined so will need Mohs most likely.” Describes a “pale pearly lesion with telangectasias”. Notes
size is 8 mm. A 3 mm punch biopsy was performed. At the time of the biopsy, it was confirmed the
lesion measured 8mm as per Liska's notes and photo. At the 2-month prior office visit with Dr. Liska
in February 2018, and according to the “slow” growth of Basil Carcinomas, the lesion was obviously
present and at 8mm, visible with the naked eye.
Biopsy repart 5/30/18: Basal cell carcinoma, superficial and nodular types; extending to the
peripheral tissue edge.
6/7/18: Suture removal visit. “No problems with the surgical site”,
7/19/18 (Steve Garrett M.D,): Mohs surgery performed with full thickness skin graft repair. Final
post operative wound measured 1.3 x 1.3 cm and extended into the underlying subcutaneous tissue.
af 4/19 (Mark Amster, M.D.): Seen for bump near surgical site. Biopsy showed scar tissue without
recurrence,
Ms, Mark Timeline
Ms. Mark has outlined the following history to me regarding her basal cell carcinoma thatis at
issue in this case. She states: “From April 2, 2015 diagnoses of Telangiectasia on Right Paranasal Fold
to September 28, 2018 Mohs surgery, the lesion grew to 8mm when biopsied and required a 1.3cm x
1,.3cm post-operative wound that extended into the underlying subcutaneous tissue.
. The donor site for the skin graft was behind the upper left ear, The graft has left my ear
deformed as.the ear is permanently closer to my head. In addition, significant amount of hair
was temoved from the site and took almost year to graw back. Uncomfortable wearing a
mask, -
After surgery I was not able to sleep on my left side for several months as it was very painful.
The Mohs site is still elevated and deformed.
Basal Carcinoma would have continued to grow for another year if Dr. Theodore Calianos C
laser doctor) did not recommend I return to Dr. Liska for biopsy of right paranasal lesion.
All through the years, I believed the lesion on my right paranasal fold was an irritation from
the nose pad on my reading glasses. :
Dr. Liska and or Dr. Barnett signed as the Provider for the examinations/reports for Suzi
Armor, PA-C and Sarah Orcuich, PA-C.
Itis noted in the various reports that I am categorized as Fitzgerald Type 2, higher risk for
skin cancer.”
Basal cell carcinoma background:
Per Uptodate online medical reference:
“Basal cell carcinoma (BCC) is a common skin cancer arising from the basal layer of epidermis and its
appendages. These tumors have been referred to as "epitheliomas" because of their low metastatic
potential. However, the term carcinoma is appropriate since they are locally invasive, aggressive, and
destructive of skin and the surrounding structures, including bone.
Approximately 70 percent of BCCs occur on the face, consistent with the etiologic role of solar
radiation, and 15 percent present on the trunk. Only rarely is BCC diagnosed on areas like thepenis,
vulva, or perianal skin, The clinical presentation of BCC can be divided into three groups, based upon
Jesion histopathology: nodular, superficial, and morpheaform,
Nodular — Nodular BCCs, which represent approximately 80 percent of cases, typically present on
the face asa pink or flesh-colored papule. The lesion usually has a pearly or translucent quality, and
a telangiectatic vessel is frequently seen within the papule. The papule may often be described as
having a “rolled” border, where the periphery is more raised than the middle. Ulceration isfrequent,
and the term “rodent ulcer" refers to these ulcerated nodular BCCs,
Superficial — Approximately 15 percent of BCCs are superficial BCCs. For unclear reasons, men
have a higher incidence of superficial BCC than do women.
Superficial BCCs most commanly occur on the trunk and typically present as slightly scaly, non-firm
macules, patches, or thin plaques light red to pink in color, The center of the lesion sometimes
exhibits an atrophic appearance and the periphery may be rimmed with fine translucent papules. A
shiny quality may be evident when a superficial BCC is illuminated. Occasionally, spotty brown or
black pigment is present, which may contribute to confusion with melanoma.
Superficial BCCs tend to grow slowly, and can vary in size from macules measuring just a few
millimeters in diameter to lesions several centimeters in diameter or more if left untreated.
Superficial BCCs are usually asymptomatic.
Morpheaform/ infiltrative — Morpheaform or sclerosing BCCs constitute 5 to 10 percent of
BCCs. These lesions are typically smooth, flesh-colored, or very light pink papules or plaques that are
frequently atrophic; they usually have a firm or indurated quality with ill-defined borders.
Infiltrative and micronodular subtypes are less common than the morpheaform BCC.
Other subtypes — Several other BCC subtypes have been described. Basosquamous cell carcinoma
is a rare tumor that behaves aggressively. Both nodular and superficial BCCs can produce pigment.
These lesions are referred to as pigmented BCCs.
Natural history — Most BCCs remain localized, and the growth rate is variable. However, afew
become locally aggressive or metastatic, and the acquisition of cytogenetic aberrations may be
associated with aggressive biologic behavior. In one series, for example, trisomy 6 was identified in
none of 22 nonaggressive, two of four locally aggressive, and all four metastatic BCCs.
Clinical and dermoscopic examination — Clinicians who are familiar with the clinical
manifestations of BCC are often able to make the diagnosis based upon clinical examination,
Examination of the lesion with a dermatoscope may assist in the clinical diagnosis of BCC.
Dermoscopic features of BCC include the lack of a pigmented network (which is typically associated
with melanocytic lesions) and the presence of one or more findings that are characteristic of BCC,
such as arborizing vessels, blue-gray ovoid nests, and ulceration. A meta-analysis of 13 studies found
that the pooled sensitivity and specificity of dermoscopy for the diagnosis of BCC were 91 and 95
percent, respectively; in a subgroup of five studies comparing the accuracy of naked eye examination
followed by dermoscopy with naked eye examination alone, the sensitivity and specificity were 85
percent and 98 percent, respectively, However, a skin biopsy is usually performed to provide
pathologic confirmation of the diagnosis and determine the histologic subtype.”
Discussion
Ms. Mark alleges that she has been harmed due to a basal cell carcinoma that went
undiagnosed for a period of at least 4 years. As a result, she alleges, that her tumor was left togrow
in its location on the right paranasal skin for this time period resulting in a lesion that was larger
than it would have otherwise been had it been diagnosed upon its initial presentation. The medical
evidence supporting when her basal cell carcinoma first presented is lacking. When the basal cell
carcinoma first presented is a factual element of the case. Ms. Mark alleges the lesion was present
beginning in 2015 and grew over that time to increase in size to a visible size of 8mm and creating a
Mohs defect 1.3 x 1.3 cm. The medical documentation provided to me does not describe a lesion
concerning for a basal cell carcinoma until it was biopsied on 5/30/18. There was mention in the
dermatology records from Dermatology of Cape Cod on several visits of telangiectasias on the face.
Telangiettaslas are a typical feature of a basal cell carcinoma and itis possible the telangiectasia on
the right cheek area was in fact describing this basal cell carcinoma, as Ms. Mark asserts. I did not see
that a dermatoscopic exam was performed on any lesions based on the clinical notes and Ms. Mark
informs me that her providers at Dermatology of Cape Cod never used one during her exam. A
dermatoscope is a tool used by many dermatologists to aid in magnifying and enhancing suspicious
lesions. I would not go as far as to say that its use is the standard of care, but | would say that in
practicing modern dermatology it is thought of as good practice. Per Uptodate (above article)
diagnostic accuracy is improved by approximately 10% when using a dermatoscope. In addition
telangiectasias take on an “arborizing vessel" pattern along with other typical features of a basal cell
described above. It is my clinical experience that by using a dermatoscope one can identify basal cell
carcinomas that otherwise would have likely been overlooked. In my practice I perform all full skin
checks with a dermatoscope in hand and will use it on any lesion that is clinically, or by patient
history, suspicious.
Itis consistent that a basal cell carcinoma would grow over time. While these tumors are
thought of as slow growing they are variable from tumor to tumor on how much they may enlarge
over a four year period of time, In addition some of the growth would be beneath the skin surface,
which would make it impossible to calculate a true measurement of how large the tumor was when it
started versus the final defect measured at 1.3 x 1.3 cm by the treating Mohs surgeon. Itis possible
this defect size could have represented the lesion size during this 4 year period, but it is much more
likely to a reasonable degree of medical certainty that there was at least some growth in the
intervening years, assuming this lesion was indeed present for that long. Ms. Mark also alleges that
were her tumor diagnosed initially that she would have been spared a full thickness skin graft repair
and would have endured.a smaller procedure and resultant scar. While it is reasonable to assume a
basal cell carcinoma would have enlarged over a period of 3 years, 1am unable to speculate as to the
size of the tumor that was present below the skin surface at that time or the choice of repair the
Mohs surgeon would have used to close the wound. These are complex clinical choices involving not
just the size of the tumor but its depth, histopathologic features, anatomic location, other patient
specific factors/comorbidities and perhaps mostly the clinical judgment of the surgeon.
Conclusion
In conclusion I can make several statements about this case. I can state, to a reasonable
degree of medical certainty, that it is the standard of care for any lesion suspected of being a basal
cell carcinoma to be biopsied. If Ms. Mark did exhibit typical features of a basal cell carcinoma on her
right paranasal skin/cheek area and this was not biopsied for three years that would be a deviation
from the standard of care, to a reasonable degree of medical certainty. I can state that were a basal
cell carcinoma to be left undiagnosed for three years that, to a reasonable degree of medical
certainty, at least some growth of the tumor would be expected. Beyond the clinical notes describing
“Some telangectasias on the face and Ms. Mark's recounting of the history of the lesion to me, I have no
objective evidence of the presence or absence of the tumor in question prior to it being biopsied on
5/30/18. Further cosmetic surgical and non-surgical treatments are options to improve the cosmetic
appearance of the raised scarring at the surgical graft site.
I, Marc Serota M.D., affirm that I have prepared and have read the above report and hereby certify
and affirm my findings and conclusions. | affirm that the fees paid to me in no way influenced my
conclusions reached or my opinion rendered. I have not been involved with this specific episode of
care prior to referral of this case for my review.
I certify and affirm thatI have no material, professional, or financial conflict of interest with any of
the parties discussed herein.
Ireserve the right to amend this report should new scientific, medical or factual information
regarding this case become available.
Sincerely,
WW. Sus
Marc Serota, M.D., FAAAAI, FACAAI, FAAD.
Board certified: Dermatology, Allergy /Asthma/Immunology, and Pediatrics.
EXHIBIT B
—
Marc Serota M.D., FAAD, FAAAI, FACAAI
Board Certified: Dermatology,
Alergy /Immunology, Pediatrics
9071 E. Mississippi Ave. Unit 6C
Denver CO, 80247
mj.serota@gmail.com
E-mail:
Phone (cell):
816-679-2211
Medical Education:
University of Missouri Kansas City School of Medicine, Kansas City, Missouri
08/2001 - 05/2007
B.A/M.D., 05/2007
Education:
Graduate - University of Missouri Kansas City, Kansas City, Missouri
Liberal Arts/Medicine - Six Year Combined BA/MD Program
08/2001 - 05/2007
B.A./M.D., 05/2007
Professional training:
Pediatrics Residency (July 2007- June 2010)
Cohen's Children's Hospital
New Hyde Park, NY
Board Certified in Pediatrics.
Altergy/Immunclogy Fellowship (July 2010- June 2012)
Children’s Mercy Hospital
Kansas City, MO
Board Certified in Allergy/Immunology.
Dermatology Residency (July 2012-June 2015)
University of Colorado Denver
Denver, CO
Board Certified in Dermatology.
Work experience following training:
Peak Dermatology
Position: Physician (General/medical dermatology and allergy/asthma/immunology)
Colorado Dermatology Specialists (August 2015 — December 201 7)
Position: Physician (Generalmedical dermatology and allergy/asthma/immunology)
Veteran's Affairs Hospital Denver (August 2016 — current)
Position: Physician and Attending/Supervising physician.
Position: Reading and generating reports for the Denver VA teledermatology program covering
CO, OKand MT. Attending dermatologist supervising outpatient and inpatient consults at the VA
hospital in Denver Colorado.
University of Colorado (August 2016 — current)
Position: Supervising physician in Dermatology.
www. Healthtap.com (August 2014 — current}
Position: Founding doctor and dermatologist/allergist practicing telemedicine for dermatology and
general medicine patients.
www.americanwell.com (2017 — current)
Position: Physician dermatology, allergy/asthma/immunology practicing telemedicine.
Membership and Honorary/Professional Societies:
Golden Key !nternational Academic Honor Society, American Medical Student Association
(AMSA), American Medical Association (AMA), American Academy of Pediatrics (AAP), Fellow,
ACAAI, Fellow AAAAI, Fellow FAAD
Honors / Awards:
Academic All American; Verizon Academic All-Midwest; Member of Galden Key International
Academic Honor Society; Snake Award Winner given annually to the highest achieving medical
student group at UMKC; Student Representative at Chancellor's Symposium On Future Planning
For Statewide University of Missouri System; Elected fellow representative for Children’s Mercy
Hospital residency council.
FIT Travel grant for 2011 AAAAI National meeting
FIT Travel grant for 2012 ACAAI National meeting
FIT Travel grant for 2012 AAAAI National meeting
Resident Travel grant for 2013 AAD National meeting
Certification/Licensure:
ACLS
PALS
NALS
Colorado Medical License
New York Medical License
Florida Medical License
Missouri Medical License
Montana Medical License
New Hampshire Medical License
Mississippi Medical License
Alabama Medical License
Hawaii Medical License
Nebraska Medical License
Kansas Medica! License
South Dakota Medical License
Texas Medical License
Wyoming Medical License
Utah Medical License
Nevada Medical License
Arizona Medical License
Washington Medical License
West Virginia Medical License
lowa Medical License
Idaho Medica! License
Louisiana Medical License
Wisconsin Medical License
Illinois Medical License
California Medical License
North Carolina Medical License
South Carolina Medical License
Maryland Medical License
North Dakota Medical License
Michigan Medical License
Pennsylvania Medical License
Connecticut Medical License
New Mexico Medical License
Board Certified in Pediatrics
Board Certified in Allergy/immunology
Board Certified in Dermatology
Examinations:
Dermatology Board Certification Exam Passed 10/15
Allergy/Immunology Board Certification Exam Passed 12/12
Pediatric Board Certification Exam Passed 10/10
USMLE Step 3 Passed 2/2008
USMLE Step2 CS (Clinical Skills) Passed 10/2006
USMLE Step2 CK (Clinical Knowledge) Passed 12/2008
USMLE Step 1 Passed 06/2005
Publications:
Peer Reviewed Journal Articles/Abstracts
Meth M.J., Serota M., Rosenthal D.W., Santiago M.T, Cavuoto M.A.. High Frequency of CF
Transmembrance Conductance Regulator (CFTR) Mutations in a Population with Persistent
Asthma and Chronic Rhinosinusitis. AAAAI Annual Meeting 2009 abstract/ poster presentation.
Serota M, Barnes C, Meng J. The Relationship Of Sensitization And Specific IgE With Age In A
Pediatric Population With Asthma. AAAAI Annual Meeting 2011 abstract/poster presentation:
Serota M, Portnoy J. Accelerated Immunotherapy Schedules for Aeroallergens. Up to date
online medical reference,
Serota M. Portnoy J. Accelerated Immunotherapy Schedules for Venom Immunotherapy. Up to
date online medical reference.
Serota M. Portnoy J. Clinical utility of pseudopod development on skin prick testing (under
review)
Textbook chapter: The Autoimmune diseases. Non-bullous skin disease: Alopecia, Vitiligo,
Psoriasis and Urticaria. Noel R. Rose and lan R. Mackay. iSBN-13: 978-0-12-595961-2 ISBN-
10: 0-12-595967-3
Textbook chapter: Fitzpatrick: Dermatology Secrets Plus, 5th Edition. Chapter 33 Urticaria and
Angioedema.
Serota M, Fathi R, Brown M. Identifying and Managing Local Anesthetic Allergy in Dermatologic
Surgery. Dermatol Surg. 2016 Feb;42(2):147-56
Textbook chapter: Fitzpatrick: Dermatology Secrets Plus, 6th Edition. Chapter 23 Urticaria and
Angiaedema.
Odhav A, Ciaccio C, Serota M, Dowling P. Barriers to Treatment with Epinephrine for
Anaphylaxis By School Nurses. J Allergy Clin Immunol Vol 135 Num 2, Abstract AB211
_
Lectures/Presentations/Teaching Experiences:
National lecture: Children's Mercy Hospital Conferences Online Allergy 8/16/10: Chronic cough
National lecture: Children’s Mercy Hospital Conferences Online Allergy 10/4/10: Patient
Management Conference. “Interesting cases in allergy.”
Children’s Mercy Hospital Conferences Online Allergy 11/22/10: Journal club
National lecture: Children's Mercy Hospital Conferences Online Allergy CME 12/3/10: Reflective
practice and Seadership: “Medical Poker: How we speak without talking.”
National lecture: Children’s Mercy Hospital Conferences Online Allergy: 1/7/11: “Mucus and
mucociliary clearance.”
Catholic Charities of Northeast Kansas 4/1/11 - Keynote speaker discussing atopic dermatitis,
allergies and asthma.
National lecture: Children's Mercy Hospital Conferences Online Allergy: 5/13/11: “Stinging insect
allergy.”
Children's Mercy Hospital Conferences Online Allergy: 10/3/11; Patient Mangement Conference.
“Interesting Cases In Allergy.”
National lecture: Children's Mercy Hospital Conferences Online Allergy: 11/16/11; Journal Club.
National lecture: Children’s Mercy Hospital Conferences Online Allergy: 1/6/12: “Allergic Disease
and the Elderly.”
National lecture: Children’s Mercy Hospital Conferences Online Allergy: 2/6/12: Patient
Management Conference.
National lecture: Children's Mercy Hospital Conferences Online Allergy: 3/9/12: Journal Club.
Colorado Dermatologic Society Annual meeting: 9/13: Resident case presentation.
Society Meeting/Keynote speaker: Colorado Allergy Society: “Dermatology for the Allergist’:
10/15.
Keynote speaker American College of Allergy, Asthma and Immunology 3/16. “Atopic
Dermatitis.”
National lecture for the American College of Allergy Asthma and Immunology: “Dermatology For
The Allergist” 2/14, 2/15, 3/16.
National lecture for the American College of Allergy Asthma and Immunology “Local! Anesthetic
Allergy’ 4/16.
Keynote speaker: Aspen Allergy Conference keynote speaker 7/16. “Biologics In Dermatology.”
National lecture: AAAAI National Meeting 3/19. “Dermatology For the Allergist": AAAAI.
Society Meeting/Keynote speaker: Colorado Allergy and Asthma Society: “Dermatology for the
Allergist": 12/18.
os.
Society Meeting/Keynote speaker: Colorado Allergy and Asthma Society: “Dermatology for the
Allergist’: 12/19.
Society Meeting/Keynote speaker: Southeaster Allergy Asthma and Immunology Society:
“Dermatology for the Allergist”: 9/19.
Society Meeting/Keynote speaker: Southeastern Allergy Asthma and Immunology Society:
“Allergic disease of the skin": 9/19.
National Meeting/Keynote speaker: American Osteopathic College of Dermatolgy: “Allergy for the
Dermatologist”. 9/19.
National Meeting/Keynote speaker: American Osteopathic College of Dermatolgy: “Telehealth for
the Dermatologist”. 9/19.
Society Meeting/Keynote speaker: Greater Kansas City Allergy Society: “Dermatology for the
Allergist.” 1/25/20.
Meetings attended/lectured:
March 2009 AAAAI National Meeting ~ Poster presentation
November 2009 ACAAI National Meeting
October 2010 Sixth Annual Healthy Indoor Environments Conference (Overland Park KS)
March 2011 AAAAI National Meeting — Poster presentation
November 2011 ACAA! National Meeting — Oral presentation
March 2012 AAAA| National Meeting — Poster presentation
March 2013 AAD National Meeting
March 2014 AAD National Meeting
March 2015 AAD National Meeting
March 2016 AAD National Meeting.
March 2018 AAAA! National Meeting.
October 2018 Fall Clinical Meeting.
February 2019 AAAAI National Meeting.
March 2019 AAD National Meeting.
Volunteer Experience:
09/ 2004 - 07/2005
UMKC School of Medicine Council on Selection, Missouri
Council On Selection Student Member, Alan Salkind M.D.
[was 1 of 2 elected student representatives to serve on the council on selection. My
responsibilities included interviewing and evaluating applicants to the School of Medicine and
making recommendations for acceptance for incoming classes
Q4/ 2001 - 04/2006
Kansas City Parks and Recreation Department, Missouri
Volunteer soccer coach for underprivileged youth
This volunteer based organization was designed to promote health and wellness as well as a safe
environment for underprivileged youth of Kansas City. Once a week | very much enjoyed
teaching these children not only how to play soccer but also how athletics can build good decision
making, team building and how athletics helped shape my future in medicine.
04/2011
Keynote speaker discussing allergies and asthma at Catholic Charities of Northeast Kansas.
“s
Background, Hobbies & Interests:
| grew up in Long Island New York and attended the 6 year combined BA/MD program at the
University of Missouri-Kansas City. Throughout callege and medical school | played division I
soccer with a full athletic scholarship. | continue to enjoy soccer and most other sports. lam a
professional magician and specialize in close up card magic.
Professional interests
During my Allergy/Immunclogy fellowship | developed an interest in Dermatology and the overlap
that exists within the specialties. | decided to continue my education and pursue a second
residency in Dermatology at the University of Colorado Denver. | am now in private practice in
Denver Colorado where | practice both Dermatology and Allergy/Immunology. My colleagues in
both Dermatology and Allergy/Asthma/Immunclogy consider me an expert in numerous
dermatologic conditions such as acne, atopic dermatitis, chronic urticaria, psoriasis, allergic
contact dermatitis and immunology/immunologic mediated disease/skin disease. | lecture both
locally and nationally on various topics in dermatology and allergy/asthma. .
Cases retained as a medical expert:
1. Wang v. Blue Moon Asian Grill: CO, April 2017: Medical expert witness
Preview
4 COMMONWEALTH OF MASSACHUSETTS DUKES, ss. SUPERIOR COURT DOCKET NO. 2174CV00027 PATRICIA MARK, Plaintiff, ILED SUPERIOR COURT ¥, COUNTY OF DUKES COUNTY MARK LISKA, M.D. AND DERMATOLOGY SEP 14 2021 OF CAPE COD, P.C. REC'D _— CLERK Defendants PLAINTIFF’S OFFER OF PROOF AS TO DEFENDANT, MARK LISKA, M.D. ! This Offer of Proof is made pursuant to Massachusetts General Laws, Chapter 231, §60B and Massachusetts Superior Court Rule 73. Attached to this Offer of Proof and made part hereof are the following exhibits: Exhibit A - Expert Report of Mare Serota, M.D., FAAD, FAAAI, FACAAT; Exhibit B - Curriculum Vitae of Marc Serota, M.D., FAAD, FAAAI, FACAAI; Exhibit C - Medical Records from Mark Liska, M.D. and Dermatology of Cape Cod, P.C.; Exhibit D - Medical Records from Theodore Calianos, M.D./Cape Cod Healthcare; Exhibit E - Medical Records from Steve Garrett Practice; Exhibit F - Medical Records from Mark Amster, M.D.; and Exhibit G - Affidavit of Patricia Mark; ' The Plaintiff, in her Complaint and Demand for Jury Trial, has also brought counts against Defendant, Dermatology of Cape Cod, P.C., respectively for respondeat superior. However, counts alleging derivative liability are not appropriate for tribunal consideration. See Bing v. Drexler, 69 Mass. App. Ct. 186, 190-91, 866 N.E.2d 996, 1000 (2007). Therefore, the liability of Dermatology of Cape Cod is not addressed in this Offer of Proof. 1 STATEMENT OF THE CASE A. STATEMENT OF FACTS This is a medical malpractice action based on the alleged negligent management of the care and treatment of Plaintiff, Patricia Mark. The Defendants, Mark Liska, M.D. and Dermatology of Cape Cod, P.C., individually and by and through their doctors, nurses, administrators, and staff employees, failed to meet the accepted standards of care, skill, and diligence, including but not limited to the following: their failure to order more specific testing to rule out skin cancer in January 2015, April 2015, February 2016, February 2017, and February 2018. Defendants were negligent in other respects, as well; with regard to their failure to listen to and acknowledge the concerns of the patient. On or about January 9, 2015, Patricia Mark presented to Defendant, Dermatology of Cape Cod for a full skin exam and was seen by Sarah Orciuch P.A. Patricia Mark complained of a new lesion on her nose, See Exhibit G - Affidavit of Patricia Mark, 96. Patricia Mark was reassured that there was no need for treatment and to return in one year for her annual skin exam. See Exhibit C - Medical Records from Mark Liska, M.D. and Dermatology of Cape Cod, P.C. On or about April 2, 2015, Patricia Mark returned to Defendant, Dermatology of Cape Cod, complaining of the same lesion on her right paranasal fold. See Exhibit G, 7. Sarah Orciuch P.A. and Nancy Barnett M.D. noted the lesion as telangiectasia and noted the same on the mid tip of her nose, left malar area, and right malar area. Mark was referred to plastic surgeon, Dr. Calianos for laser treatment. See Exhibit C. Patricia Mark presented to Defendant, Dr. Liska, for a full skin exam on or about February 12, 2016, She complained again of the lesion on her right paranasal fold. See Exhibit G, 8. Defendant, Dr. Liska, noted the lesion as telangiectasia and referred her to the same plastic surgeon, Dr. Calianos. See Exhibit C. Patricia Mark presented to Defendant, Dermatology of Cape Cod, for a full skin exam on or about February 17, 2017. Patricia Mark complained yet again of the lesion on her right paranasal fold. See 2 Exhibit G, §9. Defendant, Dr. Liska, noted the lesion as telangectasia and again referred her to a plastic surgeon for laser treatment. See Exhibit C. On or about February 16, 2018, Patricia Mark again presented to Defendant, Dermatology of Cape Cod for a full skin exam and again Defendant, Dr. Liska noted the lesion as telangiectasia. Defendant noted that "patient feels this is a moderate to severe concern". See Exhibit C. In fact, Patricia Mark had been complaining about the lesion since 2015. See Exhibit G, 45. Patricia Mark presented to Dr. Calianos of Dermatology of Cape Cod for laser treatment of the aforementioned area on or about April 19, 2018. Dr. Calianos declined treatment and recommended that Mark have the lesion on her right paranasal fold biopsied by Dr. Liska. See Exhibit D - Medical Records from Theodore Calianos, M.D./Cape Cod Healthcare and Exhibit G, 911. Patricia Mark presented to Dr. Liska for a biopsy of the lesion on her right paranasal fold on or about May 30, 2018. See Exhibit C and Exhibit G, 912. On or about June 11, 2018, the biopsy report confirmed the lesion to be basal cell carcinoma and further stated that it extended to the peripheral tissue edge. This was the first time Patricia Mark learned that she had skin cancer. See Exhibit G, 14. Based on the clinical notes of Dr. Liska and Cape Cod Dermatology and confirmed by Patricia Mark, a dermatoscopic exam was never performed on any of Patricia Mark's lesions. See Exhibit A - Expert Report of Marc Serota, M.D., FAAD, FAAAI, FACAAI. A dermatoscope is a tool used by many dermatologists to aid in magnifying and enhancing suspicious legions. See Exhibit A. From January 9, 2015 to the diagnoses of telangiectasia on the right paranasal fold to September 28, 2018 Mohs surgery, the lesion grew to 8mm when biopsied and required a 1.3cm x 1.3cm post- operative wound that extended into the underlying subcutaneous tissue. See Exhibit A and Exhibit G, 716. As a result of Dr. Liska’s delay and failure to properly diagnose and treat basal cell carcinoma skin cancer, the lesion grew. Patricia Mark has suffered from a deformed left ear from the donor site for the skin graft, hair loss that took one year to grow back, deformed and still elevated Mohs site as well as pain 3 and suffering, and severe emotional distress. See Exhibit E, Exhibit F, and Exhibit G, 417. B. STATEMENT OF LAW To prevail before this Tribunal, Plaintiff's Offer of Proof must establish: qd) The existence of a physician/patient relationship between Dr. Liska and Patricia Mark; Q) Dr. Liska’s respective failure to conform to good medical practice while caring for Patricia Mark; and (3) The injuries to Patricia Mark were caused by Dr. Liska’s failure to conform to good medical practice. See Keppler v. Tufts, 38 Mass. App. Ct. 587, 589, 649 N.E.2d 1139, 1140 (1995); Perez v. Bay State Ambulance & Hospital Rental Service, Inc., 413 Mass. 670, 676, 602 N.E. 2d 570, 573 (1992); Blake v. Avedikian, 412 Mass. 481, 482, 590 N.E. 2d 183, 184 (1992). a PHYSICIAN/PATIENT RELATIONSHIP Dr, Liska’s and Dermatology of Cape Cod’s medical records definitively establish a physician/patient relationship between Dr. Liska and Patricia Mark. Between at least January 9, 2015 through May 30, 2018, Patricia Mark was seen by Dr. Liska and his staff at Dermatology of Cape Cod for treatment of the lesion on her nose. See Exhibit C and Exhibit G 6-14. It is clear that during these visits, a physician/patient relationship existed between Dr. Liska and Patricia Mark. (2) STANDARD OF CARE AND BREACH The proper standard in evaluating the conduct of a physician is whether the physician used the “reasonable degree of care such as ordinarily possessed by others providing medical care and treatment, having regard to the current state of care and treatment to patients . . . -” Schwartz v. Goldstein, 400 Mass. 152, 155, 508 N.E.2d 97, 99 (1987). Plaintiff has shown through the expert opinion of Marc Serota, M.D., FAAD, FAAAI, FACAAL (Dr. Serota”), that Dr. Liska has indeed failed to exercise the reasonable degree of care as ordinarily possessed by others while holding himself out as a physician with expertise in dermatology, skilled in skin cancer treatment and prevention, and, in particular, represented to Patricia Mark as knowledgeable, 4 competent, and qualified to diagnosis dermatology concerns. See Medical Expert Report of Dr. Serota, attached as Exhibit A. As noted by the Supreme Judicial Court in Letch v. Daniels, 401 Mass. 65, 514 N.E.2d 675 (1987): “A medical expert need not be a specialist in the area concerned nor be practicing in the same field as the defendant. ‘It is well established that the professional specialty of a medical practitioner offered as a witness need not be precisely and narrowly related to the medical issues of the case. Thus, it has been held that a judge, in his discretion, properly admitted the opinions of a general practitioner in a case which related to specialized medical issues.’ Kapp v. Ballantine, 380 Mass. 186, 192-193 n. 7, 402 N.E.2d 463 (1980). Accord Commonwealth v. Boyd, 367 Mass. 169, 182-183, 326 N.E.2d 320 (1975) (expert need not be a specialist in the field); Gill v. North Shore Radiological Assocs., 10 Mass.App.Ct. 885, 886, 409 N.E.2d 248 (1980) (deeming it unnecessary ‘for the plaintiff's medical expert to be a specialist in the area concerned’); Samii v. Baystate Medical Center. Inc., 8 Mass.App.Ct. 911, 911-912, 395 N.E.2d 455 (1979) (approving expert testimony on standard of care in obstetrics from a specialist in internal medicine familiar with subject matter). The crucial issue is whether the witness has sufficient ‘education, training, experience and familiarity’ with the subject matter of the testimony. Gill, supra. Samii, supra.” L etch v. Daniels, 401 Mass. at 68, 514 N.E.2d at 677. Dr. Serota is eminently qualified to give an expert opinion in the present suit regarding the standard of care for those knowledgeable, competent, and qualified to diagnosis dermatology concerns, any breach thereof, and any injuries caused by the same, due to the fact that he is a physician who is board certified in dermatology. Dr. Serota received an undergraduate liberal arts degree and medical degree in 2007 through a six- year combined B.A./M.D. program at the University of Missouri Kansas City School of Medicine. He is licensed to practice medicine in twenty-five (25) states, including Massachusetts. His professional training includes a dermatology residency at the University of Colorado Denver from July 2012 through June 2015. He is currently the supervising physician in dermatology at the University of Colorado and attending/supervising physician at the Veteran’s Affair’s Hospital Denver. His previous work history includes practicing as a physician in general and medical dermatology at Colorado Dermatology Specialists and Peak Dermatology. See the Curriculum Vitae of Dr. Serota, attached hereto as Exhibit B. 5 “The standard for admission of expert testimony before a medical malpractice tribunal is ‘extremely lenient.’” Blake v. Avedikian, 412 Mass. 481, 482-83, 590 N.E. 2d 183, 184 (1992). “[T]he tribunal should give consideration to the proffered opinion of an expert if the offer of proof is sufficient to show that a trial judge in his discretion might properly rule that the qualifications of the witness are sufficient.” Kapp v. Ballantine, 380 Mass. 186, 192, 402 N.E.2d 463 (1980) (emphasis added). “[T]he opinions of an expert are to be received even if the tribunal (or its presiding judge) might decide that if the exercise of discretion were in its province, it would not accept the expert as qualified.” Id. Dr. Serta’s qualifications compel the conclusion that a trial judge would reasonably and properly rule that Dr. Serta would be a competent witness to testify at a trial on this matter. Simmons v. Yurchak, 28 Mass. App. Ct. 371, 376, 551 N.E. 2d 539, 544 (1990); Jasper v. Tomaiolo, 20 Mass. App. Ct. 201, 203, 479 N.E. 2d 705, 707 (1985); Elwood v. Goodman, 21 Mass. App. Ct. 925, 485 N.E.2d 197, 198 (1985). According to the Medical Expert Report of Dr. Serta, to a reasonable degree of medical certainty, the standard of care applicable to the average health care provider caring for and treating a patient with Patricia Mark’s condition, would result in a biopsy being ordered in the event of any lesion suspected of being basal cell carcinoma. See Exhibit A. Dr. Serta further states in his Medical Expert Report that to a reasonable degree of medical certainty, Dr. Liska substantially deviated from good and accepted medical practice and committed negligence by failing to order a biopsy of the lesion suspected of being basal cell carcinoma until 2018. Dr. Sertoa notes that the medical documentation he reviewed did not describe basal cell carcinoma until it was biopsied on May 30, 2018. However, he noted that Patricia Mark alleges that the lesion was present in 2015 and grew over time to increase in size to a visible size of 8mm, creating a Mohs defect 1.3 x 1.3 cm. ‘There was mention in the dermatology reports from Dermatology of Cape Cod on several visits of telangiectasia on the face. See Exhibit A. Dr. Serota noted that telangiectasias are a typical feature of a basal cell carcinoma and it is possible that telangiectasia on the right cheek was in fact describing this basal cell carcinoma. Further, Dr. 6 Serota noted that he did not see a dermatoscopic exam performed on any lesions based on clinical notes. Dr. Serota stated that diagnostic accuracy is improved by approximately 10% when using a dermatoscope. In addition, telangiectasias take on an “arborizing vessel” pattern along with other typical features of a basal cell. See Exhibit A. Dr. Serta noted that were a basal cell carcinoma left undiagnosed for three years, to a reasonable degree of medical certainty, some growth of the tumor would be expected. See Exhibit A. Through Dr. Serota’s Medical Expert Report, Plaintiff has shown that Dr. Liska substantially deviated from good and accepted medical practice and committed negligence, and therefore breached the applicable standard of care. Plaintiff need only present evidence in the Offer of Proof of Dr. Liska’s negligence that caused harm to Patricia Mark. The Tribunal does not require evidence of what Dr. Liska should have done. Mataitis v. St. Goar, 416 Mass. 325, 327, 621 NE2d 1176, 1178 (1993). Notwithstanding, in this action, Plaintiff has far exceeded her burden of proof under M.G.L. c. 231, §60. (3) CAUSATION Evidence presented by the Offer of Proof must be reviewed by the Tribunal by a standard comparable to a motion for a directed verdict; namely, in a light most favorable to the plaintiff. Blake v. A vedikian, 590 N.E. 2d at 185; DiNozzi v. Lovejoy, 20 Mass. App. Ct. 973, 974, 482 N.E. 2d 338, 339, rev. denied 396 Mass. 1103, 485 N.E. 2d 188 (1985). An Offer of Proof is sufficient if anywhere in the evidence, from whatever source derived, any combination of circumstances could be found from which a reasonable inference could be drawn in favor of the plaintiff. Lucas v. Collins, 51 Mass. App. Ct. 30, 33- 34, 743 N.E.2d 847, 849-850 (2001); Haywood v. Rachen, 45 Mass. App. Ct. 185, 189, 696 N.E.2d 549, 552. (1998). It is not the function of the Tribunal to examine the weight and credibility of the evidence presented in the Offer of Proof. Perez v. Bay State Ambulance & Hospital Rental Service. Inc., 413 Mass. at 676, 602 N.E. 2d at 573; DiNozzi v. Lovejoy, 20 Mass. App. Ct. at 974, 482 N.E. 2d at 339. 7 Furthermore, “[w]here the relation of cause and effect between two facts has to be proved, the testimony of (a medical) expert that such relation exists or probably exists is sufficient... .” Delicata v. Boi urlesses, 9 Mass.App.Ct. 713, 720, 404 N.E.2d 667, 671 (1980), citing Berardi v. Menicks,340 Mass 396, 402, 164 N.E.2d 544, 545 (1960). Dr. Liska’s failure to conform to good medical practice caused Patricia Mark’s aforementioned injuries is proven by Dr. Serota’s Expert Opinion, where he states: “If Ms. Mark did exhibit typical features of a basal cel] carcinoma on her right paranasal skin/check area and this was not biopsied for three years that would be a deviation from the standard of care, to a reasonable degree of medical certainty. I can state that were a basal cell carcinoma to be left undiagnosed for three years that, to a reasonable degree of medical certainty, at least some growth of the tumor would be expected.” See Exhibit A. Dr. Serota’s Medical Expert Report is sufficient to satisfy the Plaintiffs burden of proof in regard to causation. Cc. CONCLUSION Clearly, the medical records provided by Dr. Liska and Dermatology of Cape Cod do not contain the repeated expressions of concerns made by Patricia Mark. Further, the expert report of Dr. Serota, the Statement of Facts, and the Statement of Law combine to establish that the Plaintiff, Patricia Mark, is entitled to a finding from the Court pursuant to M.G.L. c. 231, §60B and Massachusetts Superior Court Rule 73 that will enable her to proceed against the Defendant, Dr. Liska. Therefore, the Plaintiff requests that the Court issue a finding that the evidence, if properly substantiated, is sufficient to raise a legitimate question of liability appropriate for judicial inquiry, as required by M.G.L. c. 231, § 60B, concerning the Defendant, Dr. Liska. Respectfully submitted, Patricia Mark Plaintiff, By her attorneys, Dated: September 10, 2021 Thans, O# 042630 Terrence. J. Hurrie BO#689157 w Offices of Brtice Bierhans, LLC 540 Main Street, Suite 17 Hyannis, MA 02601 (508) 775-4500 (phone) (508) 775-4511 (fax) bruce@bierlaw.com tjhurrie@bierlaw.com CERTIFICATE OF SERVICE I, Bruce A. Bierhans, hereby certify that a true copy of the within OFFER AS TO DEFENDANT. > Mark Liska, M.D. , was served upon all Defendants’ respective counsel of record and Clerk of Courts via first class mail at the below listed address and via e-mail on September 10, 2021: Chad P. Brouillard, Esq. Kelly K. Smith, Esq. Foster & Eldridge, LLP 300 Trade Center, Suite 2610 Woburn, MA 01801 cbrouillard@fosteld.com ksmith@fosteld.com T. George Davis, Clerk of Courts Dukes Superior Court 81 Main St. P.O. Box 1267 Edgartown, MA 02539 Bierh EXHIBIT A v Marc Serota M.D., FAAD, FAAAI, FACAAL Board Certified: Dermatology, Allergy/Immunology, Pediatrics 9071 E. Mississippi Ave, Unit 6C Denver CO, 80247 mj.serota@gmail.com January 17, 2020 EDICAL EXPERT REPOR' Marc Serota, M,D., FAAAI, FACAAI, FAAD Re: Patricia Mark, Background on expert: 1, Marc Serota M.D., am a practicing dermatologist. I am triple board certified in dermatology, allergy /immunology and pediatrics. My CV is attached to this report. As partofmy daily routine practice I perform full skin exams and J personally diagnose and treat patients for basal cell carcinoma skin cancer. Summary of Case/Medical Records: Ihave reviewed all of the medical records provided to me in this case as follows: Records Reviewed: 1. Dermatology of Cape Cod medical records. 2. Cape Cod Healthcare Theodore Calianos M.D. Plastic & Reconstructive Surgery medical records. 3. Steve Garrett, M.D, medical records. 4, Mark Amster, M.D. medical records. Summary of case records: Ms. Patricia Mark is a now 61 year old female (date of birth 4/25/59). Below is a summary reflecting her clinical course regarding a basal cell skin cancer on her right paranasal skin. This summary is not intended to be all-inclusive and the reader should refer back to the primary medical records for complete details. 1/24/13 (Dermatology of Cape Cod, Suzy Amor PA-C, Mark Liska M.D.): Chief complaint of lesion on her right shoulder and an area on herleft side of her cheek. A complete skin exam was performed. Noted lentigo on the left cheek, Irritated seborrheic keratosis on the right anterior shoulder. Performed cryotherapy to seborrheic keratosis. 1/17/14 (Dermatology of Cape Cod, Sarah Orciuch PA-C, Nancy Barnett, M.D,): Full skin exam. Noted lentigo on the left malar area and a hemangioma on the left forehead. 6/6/14: (Dermatology of Cape Cod, Sarah Orciuch PA-C, Nancy Barnett, M.D.): Problem focused exam. Chief complaint of a raised mole on her center back and posterior shoulder.. Biopsy performed on left upper back which showed inflamed seborrheic keratosis. Diagnosed with actinic keratoses, sebaceous cyst and seborrheic keratoses. 1/9/15: (Dermatology of Cape Cad, Sarah Orciuch PA-C, Nancy Barnett, M.D.): Chief complaint is full skin exam. Notes itching and flaking on the right and left canthus. Treating with Eucerin. Notes red hemangiomas on the left forehead and tip of her nose. Diagnoses were lentigo on the left malar cheek. Dermatitis on the left upper eyelid. Seborrheic dermatitis on the right frontal scalp, left frontal scalp. Nevus on the left lower back, Exam notes a spider hemangioma on the tip of the nose “red to purple dome shaped papule” with a plan of reassurance and observation for changes. 04/02/15 (Dermatology of Cape Cod, Sarah Orciuch PA-C, Nancy Barnett MD) Chief Complaint, Telangectasia on right paranasal fold, mid tip of nose, left malar area, right malar area. It has been present for month(s), year(s). Referred to plastic surgeon Dr. Calianos for laser. 2/12/16 (Dermatology of Cape Cod, Mark Liska M.D.): Chief complaint is full skin exam. Notes pigmented lesion on the left superior central cheek. Notes lentigines on the left superior central cheek, right inferior central malar cheek. Notes AK on the right mid central malar, left superior central malar cheeks. Hemangioma on the let superior central forehead, left inferior medial lower chest, left medial lower abdomen. Notes telangiectasia on the right mid central malar, left‘superior central malar cheeks present for years. Plan was to refer to plastic surgeon if PDT (photodynamic therapy) didn’t help. 2/17/17 (Mark Liska M.D): Chief complaint: Full skin check. History states: onsidering laser with Dr. Calianos ofa lesion on her left cheek. He would like confirmation that it isn’t cancerous.” Assessment includes “hemangioma - capillary - red to purple dome shaped papules” with plan: refer to Plastic Surgeon for laser. “Telangectasia on the left malar (infraorbital) area, right malar (infraorbital area) present for year(s), increasing in number”, 2/16/18 (Dermatology of Cape Cod, Mark Liska M.D.): Chief complaint: Full skin check. Notes telangiectasia on the left malar (infraorbital) area; mid dorsum (bridge) of nose, mid tip of nose, right malar (infraorbital) area. “It has been present for year(s).” Notes that patient feels this is a “moderate to severe concern”, 4/19/18 (Theodore Calianos, M.D.): Diagnosed with facial telangiectasia and truncal hemangioma. Treated with V-beam laser. ~ 5/30/18: {Dermatology of Cape Cod, Mark Liska M.D.): Black and white photo showing a dotted circular area on the R nasal sidewall. Chief complaint: “Referred by Dr. Calianos for a bx ofa non healing lesion on her nose. ” Assessment is “basal cell carcinoma on the right paranasal fold, Ithas been present for month(s). leeds intermittently. She states the problem is a firm, pale pink, ill defined plaque. She feels this is a mild concern.” Assessed as basal cell carcinoma most likely. “Ill defined so will need Mohs most likely.” Describes a “pale pearly lesion with telangectasias”. Notes size is 8 mm. A 3 mm punch biopsy was performed. At the time of the biopsy, it was confirmed the lesion measured 8mm as per Liska's notes and photo. At the 2-month prior office visit with Dr. Liska in February 2018, and according to the “slow” growth of Basil Carcinomas, the lesion was obviously present and at 8mm, visible with the naked eye. Biopsy repart 5/30/18: Basal cell carcinoma, superficial and nodular types; extending to the peripheral tissue edge. 6/7/18: Suture removal visit. “No problems with the surgical site”, 7/19/18 (Steve Garrett M.D,): Mohs surgery performed with full thickness skin graft repair. Final post operative wound measured 1.3 x 1.3 cm and extended into the underlying subcutaneous tissue. af 4/19 (Mark Amster, M.D.): Seen for bump near surgical site. Biopsy showed scar tissue without recurrence, Ms, Mark Timeline Ms. Mark has outlined the following history to me regarding her basal cell carcinoma thatis at issue in this case. She states: “From April 2, 2015 diagnoses of Telangiectasia on Right Paranasal Fold to September 28, 2018 Mohs surgery, the lesion grew to 8mm when biopsied and required a 1.3cm x 1,.3cm post-operative wound that extended into the underlying subcutaneous tissue. . The donor site for the skin graft was behind the upper left ear, The graft has left my ear deformed as.the ear is permanently closer to my head. In addition, significant amount of hair was temoved from the site and took almost year to graw back. Uncomfortable wearing a mask, - After surgery I was not able to sleep on my left side for several months as it was very painful. The Mohs site is still elevated and deformed. Basal Carcinoma would have continued to grow for another year if Dr. Theodore Calianos C laser doctor) did not recommend I return to Dr. Liska for biopsy of right paranasal lesion. All through the years, I believed the lesion on my right paranasal fold was an irritation from the nose pad on my reading glasses. : Dr. Liska and or Dr. Barnett signed as the Provider for the examinations/reports for Suzi Armor, PA-C and Sarah Orcuich, PA-C. Itis noted in the various reports that I am categorized as Fitzgerald Type 2, higher risk for skin cancer.” Basal cell carcinoma background: Per Uptodate online medical reference: “Basal cell carcinoma (BCC) is a common skin cancer arising from the basal layer of epidermis and its appendages. These tumors have been referred to as "epitheliomas" because of their low metastatic potential. However, the term carcinoma is appropriate since they are locally invasive, aggressive, and destructive of skin and the surrounding structures, including bone. Approximately 70 percent of BCCs occur on the face, consistent with the etiologic role of solar radiation, and 15 percent present on the trunk. Only rarely is BCC diagnosed on areas like thepenis, vulva, or perianal skin, The clinical presentation of BCC can be divided into three groups, based upon Jesion histopathology: nodular, superficial, and morpheaform, Nodular — Nodular BCCs, which represent approximately 80 percent of cases, typically present on the face asa pink or flesh-colored papule. The lesion usually has a pearly or translucent quality, and a telangiectatic vessel is frequently seen within the papule. The papule may often be described as having a “rolled” border, where the periphery is more raised than the middle. Ulceration isfrequent, and the term “rodent ulcer" refers to these ulcerated nodular BCCs, Superficial — Approximately 15 percent of BCCs are superficial BCCs. For unclear reasons, men have a higher incidence of superficial BCC than do women. Superficial BCCs most commanly occur on the trunk and typically present as slightly scaly, non-firm macules, patches, or thin plaques light red to pink in color, The center of the lesion sometimes exhibits an atrophic appearance and the periphery may be rimmed with fine translucent papules. A shiny quality may be evident when a superficial BCC is illuminated. Occasionally, spotty brown or black pigment is present, which may contribute to confusion with melanoma. Superficial BCCs tend to grow slowly, and can vary in size from macules measuring just a few millimeters in diameter to lesions several centimeters in diameter or more if left untreated. Superficial BCCs are usually asymptomatic. Morpheaform/ infiltrative — Morpheaform or sclerosing BCCs constitute 5 to 10 percent of BCCs. These lesions are typically smooth, flesh-colored, or very light pink papules or plaques that are frequently atrophic; they usually have a firm or indurated quality with ill-defined borders. Infiltrative and micronodular subtypes are less common than the morpheaform BCC. Other subtypes — Several other BCC subtypes have been described. Basosquamous cell carcinoma is a rare tumor that behaves aggressively. Both nodular and superficial BCCs can produce pigment. These lesions are referred to as pigmented BCCs. Natural history — Most BCCs remain localized, and the growth rate is variable. However, afew become locally aggressive or metastatic, and the acquisition of cytogenetic aberrations may be associated with aggressive biologic behavior. In one series, for example, trisomy 6 was identified in none of 22 nonaggressive, two of four locally aggressive, and all four metastatic BCCs. Clinical and dermoscopic examination — Clinicians who are familiar with the clinical manifestations of BCC are often able to make the diagnosis based upon clinical examination, Examination of the lesion with a dermatoscope may assist in the clinical diagnosis of BCC. Dermoscopic features of BCC include the lack of a pigmented network (which is typically associated with melanocytic lesions) and the presence of one or more findings that are characteristic of BCC, such as arborizing vessels, blue-gray ovoid nests, and ulceration. A meta-analysis of 13 studies found that the pooled sensitivity and specificity of dermoscopy for the diagnosis of BCC were 91 and 95 percent, respectively; in a subgroup of five studies comparing the accuracy of naked eye examination followed by dermoscopy with naked eye examination alone, the sensitivity and specificity were 85 percent and 98 percent, respectively, However, a skin biopsy is usually performed to provide pathologic confirmation of the diagnosis and determine the histologic subtype.” Discussion Ms. Mark alleges that she has been harmed due to a basal cell carcinoma that went undiagnosed for a period of at least 4 years. As a result, she alleges, that her tumor was left togrow in its location on the right paranasal skin for this time period resulting in a lesion that was larger than it would have otherwise been had it been diagnosed upon its initial presentation. The medical evidence supporting when her basal cell carcinoma first presented is lacking. When the basal cell carcinoma first presented is a factual element of the case. Ms. Mark alleges the lesion was present beginning in 2015 and grew over that time to increase in size to a visible size of 8mm and creating a Mohs defect 1.3 x 1.3 cm. The medical documentation provided to me does not describe a lesion concerning for a basal cell carcinoma until it was biopsied on 5/30/18. There was mention in the dermatology records from Dermatology of Cape Cod on several visits of telangiectasias on the face. Telangiettaslas are a typical feature of a basal cell carcinoma and itis possible the telangiectasia on the right cheek area was in fact describing this basal cell carcinoma, as Ms. Mark asserts. I did not see that a dermatoscopic exam was performed on any lesions based on the clinical notes and Ms. Mark informs me that her providers at Dermatology of Cape Cod never used one during her exam. A dermatoscope is a tool used by many dermatologists to aid in magnifying and enhancing suspicious lesions. I would not go as far as to say that its use is the standard of care, but | would say that in practicing modern dermatology it is thought of as good practice. Per Uptodate (above article) diagnostic accuracy is improved by approximately 10% when using a dermatoscope. In addition telangiectasias take on an “arborizing vessel" pattern along with other typical features of a basal cell described above. It is my clinical experience that by using a dermatoscope one can identify basal cell carcinomas that otherwise would have likely been overlooked. In my practice I perform all full skin checks with a dermatoscope in hand and will use it on any lesion that is clinically, or by patient history, suspicious. Itis consistent that a basal cell carcinoma would grow over time. While these tumors are thought of as slow growing they are variable from tumor to tumor on how much they may enlarge over a four year period of time, In addition some of the growth would be beneath the skin surface, which would make it impossible to calculate a true measurement of how large the tumor was when it started versus the final defect measured at 1.3 x 1.3 cm by the treating Mohs surgeon. Itis possible this defect size could have represented the lesion size during this 4 year period, but it is much more likely to a reasonable degree of medical certainty that there was at least some growth in the intervening years, assuming this lesion was indeed present for that long. Ms. Mark also alleges that were her tumor diagnosed initially that she would have been spared a full thickness skin graft repair and would have endured.a smaller procedure and resultant scar. While it is reasonable to assume a basal cell carcinoma would have enlarged over a period of 3 years, 1am unable to speculate as to the size of the tumor that was present below the skin surface at that time or the choice of repair the Mohs surgeon would have used to close the wound. These are complex clinical choices involving not just the size of the tumor but its depth, histopathologic features, anatomic location, other patient specific factors/comorbidities and perhaps mostly the clinical judgment of the surgeon. Conclusion In conclusion I can make several statements about this case. I can state, to a reasonable degree of medical certainty, that it is the standard of care for any lesion suspected of being a basal cell carcinoma to be biopsied. If Ms. Mark did exhibit typical features of a basal cell carcinoma on her right paranasal skin/cheek area and this was not biopsied for three years that would be a deviation from the standard of care, to a reasonable degree of medical certainty. I can state that were a basal cell carcinoma to be left undiagnosed for three years that, to a reasonable degree of medical certainty, at least some growth of the tumor would be expected. Beyond the clinical notes describing “Some telangectasias on the face and Ms. Mark's recounting of the history of the lesion to me, I have no objective evidence of the presence or absence of the tumor in question prior to it being biopsied on 5/30/18. Further cosmetic surgical and non-surgical treatments are options to improve the cosmetic appearance of the raised scarring at the surgical graft site. I, Marc Serota M.D., affirm that I have prepared and have read the above report and hereby certify and affirm my findings and conclusions. | affirm that the fees paid to me in no way influenced my conclusions reached or my opinion rendered. I have not been involved with this specific episode of care prior to referral of this case for my review. I certify and affirm thatI have no material, professional, or financial conflict of interest with any of the parties discussed herein. Ireserve the right to amend this report should new scientific, medical or factual information regarding this case become available. Sincerely, WW. Sus Marc Serota, M.D., FAAAAI, FACAAI, FAAD. Board certified: Dermatology, Allergy /Asthma/Immunology, and Pediatrics. EXHIBIT B — Marc Serota M.D., FAAD, FAAAI, FACAAI Board Certified: Dermatology, Alergy /Immunology, Pediatrics 9071 E. Mississippi Ave. Unit 6C Denver CO, 80247 mj.serota@gmail.com E-mail: Phone (cell): 816-679-2211 Medical Education: University of Missouri Kansas City School of Medicine, Kansas City, Missouri 08/2001 - 05/2007 B.A/M.D., 05/2007 Education: Graduate - University of Missouri Kansas City, Kansas City, Missouri Liberal Arts/Medicine - Six Year Combined BA/MD Program 08/2001 - 05/2007 B.A./M.D., 05/2007 Professional training: Pediatrics Residency (July 2007- June 2010) Cohen's Children's Hospital New Hyde Park, NY Board Certified in Pediatrics. Altergy/Immunclogy Fellowship (July 2010- June 2012) Children’s Mercy Hospital Kansas City, MO Board Certified in Allergy/Immunology. Dermatology Residency (July 2012-June 2015) University of Colorado Denver Denver, CO Board Certified in Dermatology. Work experience following training: Peak Dermatology Position: Physician (General/medical dermatology and allergy/asthma/immunology) Colorado Dermatology Specialists (August 2015 — December 201 7) Position: Physician (Generalmedical dermatology and allergy/asthma/immunology) Veteran's Affairs Hospital Denver (August 2016 — current) Position: Physician and Attending/Supervising physician. Position: Reading and generating reports for the Denver VA teledermatology program covering CO, OKand MT. Attending dermatologist supervising outpatient and inpatient consults at the VA hospital in Denver Colorado. University of Colorado (August 2016 — current) Position: Supervising physician in Dermatology. www. Healthtap.com (August 2014 — current} Position: Founding doctor and dermatologist/allergist practicing telemedicine for dermatology and general medicine patients. www.americanwell.com (2017 — current) Position: Physician dermatology, allergy/asthma/immunology practicing telemedicine. Membership and Honorary/Professional Societies: Golden Key !nternational Academic Honor Society, American Medical Student Association (AMSA), American Medical Association (AMA), American Academy of Pediatrics (AAP), Fellow, ACAAI, Fellow AAAAI, Fellow FAAD Honors / Awards: Academic All American; Verizon Academic All-Midwest; Member of Galden Key International Academic Honor Society; Snake Award Winner given annually to the highest achieving medical student group at UMKC; Student Representative at Chancellor's Symposium On Future Planning For Statewide University of Missouri System; Elected fellow representative for Children’s Mercy Hospital residency council. FIT Travel grant for 2011 AAAAI National meeting FIT Travel grant for 2012 ACAAI National meeting FIT Travel grant for 2012 AAAAI National meeting Resident Travel grant for 2013 AAD National meeting Certification/Licensure: ACLS PALS NALS Colorado Medical License New York Medical License Florida Medical License Missouri Medical License Montana Medical License New Hampshire Medical License Mississippi Medical License Alabama Medical License Hawaii Medical License Nebraska Medical License Kansas Medica! License South Dakota Medical License Texas Medical License Wyoming Medical License Utah Medical License Nevada Medical License Arizona Medical License Washington Medical License West Virginia Medical License lowa Medical License Idaho Medica! License Louisiana Medical License Wisconsin Medical License Illinois Medical License California Medical License North Carolina Medical License South Carolina Medical License Maryland Medical License North Dakota Medical License Michigan Medical License Pennsylvania Medical License Connecticut Medical License New Mexico Medical License Board Certified in Pediatrics Board Certified in Allergy/immunology Board Certified in Dermatology Examinations: Dermatology Board Certification Exam Passed 10/15 Allergy/Immunology Board Certification Exam Passed 12/12 Pediatric Board Certification Exam Passed 10/10 USMLE Step 3 Passed 2/2008 USMLE Step2 CS (Clinical Skills) Passed 10/2006 USMLE Step2 CK (Clinical Knowledge) Passed 12/2008 USMLE Step 1 Passed 06/2005 Publications: Peer Reviewed Journal Articles/Abstracts Meth M.J., Serota M., Rosenthal D.W., Santiago M.T, Cavuoto M.A.. High Frequency of CF Transmembrance Conductance Regulator (CFTR) Mutations in a Population with Persistent Asthma and Chronic Rhinosinusitis. AAAAI Annual Meeting 2009 abstract/ poster presentation. Serota M, Barnes C, Meng J. The Relationship Of Sensitization And Specific IgE With Age In A Pediatric Population With Asthma. AAAAI Annual Meeting 2011 abstract/poster presentation: Serota M, Portnoy J. Accelerated Immunotherapy Schedules for Aeroallergens. Up to date online medical reference, Serota M. Portnoy J. Accelerated Immunotherapy Schedules for Venom Immunotherapy. Up to date online medical reference. Serota M. Portnoy J. Clinical utility of pseudopod development on skin prick testing (under review) Textbook chapter: The Autoimmune diseases. Non-bullous skin disease: Alopecia, Vitiligo, Psoriasis and Urticaria. Noel R. Rose and lan R. Mackay. iSBN-13: 978-0-12-595961-2 ISBN- 10: 0-12-595967-3 Textbook chapter: Fitzpatrick: Dermatology Secrets Plus, 5th Edition. Chapter 33 Urticaria and Angioedema. Serota M, Fathi R, Brown M. Identifying and Managing Local Anesthetic Allergy in Dermatologic Surgery. Dermatol Surg. 2016 Feb;42(2):147-56 Textbook chapter: Fitzpatrick: Dermatology Secrets Plus, 6th Edition. Chapter 23 Urticaria and Angiaedema. Odhav A, Ciaccio C, Serota M, Dowling P. Barriers to Treatment with Epinephrine for Anaphylaxis By School Nurses. J Allergy Clin Immunol Vol 135 Num 2, Abstract AB211 _ Lectures/Presentations/Teaching Experiences: National lecture: Children's Mercy Hospital Conferences Online Allergy 8/16/10: Chronic cough National lecture: Children’s Mercy Hospital Conferences Online Allergy 10/4/10: Patient Management Conference. “Interesting cases in allergy.” Children’s Mercy Hospital Conferences Online Allergy 11/22/10: Journal club National lecture: Children's Mercy Hospital Conferences Online Allergy CME 12/3/10: Reflective practice and Seadership: “Medical Poker: How we speak without talking.” National lecture: Children’s Mercy Hospital Conferences Online Allergy: 1/7/11: “Mucus and mucociliary clearance.” Catholic Charities of Northeast Kansas 4/1/11 - Keynote speaker discussing atopic dermatitis, allergies and asthma. National lecture: Children's Mercy Hospital Conferences Online Allergy: 5/13/11: “Stinging insect allergy.” Children's Mercy Hospital Conferences Online Allergy: 10/3/11; Patient Mangement Conference. “Interesting Cases In Allergy.” National lecture: Children's Mercy Hospital Conferences Online Allergy: 11/16/11; Journal Club. National lecture: Children’s Mercy Hospital Conferences Online Allergy: 1/6/12: “Allergic Disease and the Elderly.” National lecture: Children’s Mercy Hospital Conferences Online Allergy: 2/6/12: Patient Management Conference. National lecture: Children's Mercy Hospital Conferences Online Allergy: 3/9/12: Journal Club. Colorado Dermatologic Society Annual meeting: 9/13: Resident case presentation. Society Meeting/Keynote speaker: Colorado Allergy Society: “Dermatology for the Allergist’: 10/15. Keynote speaker American College of Allergy, Asthma and Immunology 3/16. “Atopic Dermatitis.” National lecture for the American College of Allergy Asthma and Immunology: “Dermatology For The Allergist” 2/14, 2/15, 3/16. National lecture for the American College of Allergy Asthma and Immunology “Local! Anesthetic Allergy’ 4/16. Keynote speaker: Aspen Allergy Conference keynote speaker 7/16. “Biologics In Dermatology.” National lecture: AAAAI National Meeting 3/19. “Dermatology For the Allergist": AAAAI. Society Meeting/Keynote speaker: Colorado Allergy and Asthma Society: “Dermatology for the Allergist": 12/18. os. Society Meeting/Keynote speaker: Colorado Allergy and Asthma Society: “Dermatology for the Allergist’: 12/19. Society Meeting/Keynote speaker: Southeaster Allergy Asthma and Immunology Society: “Dermatology for the Allergist”: 9/19. Society Meeting/Keynote speaker: Southeastern Allergy Asthma and Immunology Society: “Allergic disease of the skin": 9/19. National Meeting/Keynote speaker: American Osteopathic College of Dermatolgy: “Allergy for the Dermatologist”. 9/19. National Meeting/Keynote speaker: American Osteopathic College of Dermatolgy: “Telehealth for the Dermatologist”. 9/19. Society Meeting/Keynote speaker: Greater Kansas City Allergy Society: “Dermatology for the Allergist.” 1/25/20. Meetings attended/lectured: March 2009 AAAAI National Meeting ~ Poster presentation November 2009 ACAAI National Meeting October 2010 Sixth Annual Healthy Indoor Environments Conference (Overland Park KS) March 2011 AAAAI National Meeting — Poster presentation November 2011 ACAA! National Meeting — Oral presentation March 2012 AAAA| National Meeting — Poster presentation March 2013 AAD National Meeting March 2014 AAD National Meeting March 2015 AAD National Meeting March 2016 AAD National Meeting. March 2018 AAAA! National Meeting. October 2018 Fall Clinical Meeting. February 2019 AAAAI National Meeting. March 2019 AAD National Meeting. Volunteer Experience: 09/ 2004 - 07/2005 UMKC School of Medicine Council on Selection, Missouri Council On Selection Student Member, Alan Salkind M.D. [was 1 of 2 elected student representatives to serve on the council on selection. My responsibilities included interviewing and evaluating applicants to the School of Medicine and making recommendations for acceptance for incoming classes Q4/ 2001 - 04/2006 Kansas City Parks and Recreation Department, Missouri Volunteer soccer coach for underprivileged youth This volunteer based organization was designed to promote health and wellness as well as a safe environment for underprivileged youth of Kansas City. Once a week | very much enjoyed teaching these children not only how to play soccer but also how athletics can build good decision making, team building and how athletics helped shape my future in medicine. 04/2011 Keynote speaker discussing allergies and asthma at Catholic Charities of Northeast Kansas. “s Background, Hobbies & Interests: | grew up in Long Island New York and attended the 6 year combined BA/MD program at the University of Missouri-Kansas City. Throughout callege and medical school | played division I soccer with a full athletic scholarship. | continue to enjoy soccer and most other sports. lam a professional magician and specialize in close up card magic. Professional interests During my Allergy/Immunclogy fellowship | developed an interest in Dermatology and the overlap that exists within the specialties. | decided to continue my education and pursue a second residency in Dermatology at the University of Colorado Denver. | am now in private practice in Denver Colorado where | practice both Dermatology and Allergy/Immunology. My colleagues in both Dermatology and Allergy/Asthma/Immunclogy consider me an expert in numerous dermatologic conditions such as acne, atopic dermatitis, chronic urticaria, psoriasis, allergic contact dermatitis and immunology/immunologic mediated disease/skin disease. | lecture both locally and nationally on various topics in dermatology and allergy/asthma. . Cases retained as a medical expert: 1. Wang v. Blue Moon Asian Grill: CO, April 2017: Medical expert witness