Case Title: Spencer v. Remillard

Citation: 

Docket Number: 

State: alabama

Court: Alabama Supreme Court

Date: 2020-09-04T00:00:00Z

Document:
REL:  September 4, 2020
Notice: This opinion is subject to formal revision before publication in the advance
sheets of Southern Reporter.  Readers are requested to notify the Reporter of Decisions,
Alabama Appellate Courts, 300 Dexter Avenue, Montgomery, Alabama 36104-3741 ((334) 229-
0649), of any typographical or other errors, in order that corrections may be made before
the opinion is printed in Southern Reporter.
SUPREME COURT OF ALABAMA
SPECIAL TERM, 2020
____________________
1180650
____________________
Kimberlee Spencer, as personal representative
of the Estate of James Scott Spencer, deceased
v.
Michael A. Remillard, M.D.,
and Helena Family Medicine, LLC
Appeal from Shelby Circuit Court
(CV-11-900701)
MENDHEIM, Justice.
Kimberlee 
Spencer 
("Kimberlee"), 
as 
personal
representative of 
the estate of James Scott Spencer ("Scott"),
her deceased husband, appeals from a judgment as a matter of
1180650
law entered by the Shelby Circuit Court ("the trial court") at
the close of Kimberlee's medical-malpractice case against
Michael A. Remillard, M.D., and Helena Family Medicine, LLC,
the entity through which Dr. Remillard operates his family-
medicine clinic ("the clinic").  We reverse and remand.
I.  Facts
A. Dr. Remillard's Patient Care of Scott
In 2001, Scott began seeing Dr. Remillard as his family
doctor at the clinic.  Dr. Remillard is board certified in the
specialty of family-medicine practice and has been practicing
medicine since 1997.  On a visit in 2006 for a physical, Scott
informed Dr. Remillard that his father had been diagnosed with
early-stage prostate cancer.  Scott had blood work and lab
tests done during the 2006 visit, including a PSA test, which
is a blood test used to assess a man's risk for developing
prostate cancer.  At that time, Scott's PSA level was 1.9,
which was within the normal range for a man his age, 46 years
old. 
 
On 
September 
28, 
2009, 
Scott 
again 
visited
Dr. Remillard.  Scott told Dr. Remillard that he had seen some
blood in his stool, and Dr. Remillard performed a rectal
examination on Scott.  Dr. Remillard concluded from that exam
2
1180650
that Scott's prostate was firm and normal, so he recommended
that Scott get a colonoscopy to determine if there was a
problem with his colon.  Scott also had blood work done during
the 2009 visit.  At that time, Scott's PSA level was 14.3,
which Dr. Remillard and Kimberlee's medical experts agreed is
an elevated PSA level for a 49-year-old.
A pivotal factual dispute in this case centers on when
Dr. Remillard and Helena Family Medicine first informed Scott
of the 2009 elevated PSA level.  Dr. Remillard testified at
trial that the standard practice at the clinic was to have
patients who have lab tests taken during a visit fill out a
postcard with the patient's mailing address.  The patient is
told that, if lab-test results come back as normal, the
patient will receive the postcard in the mail approximately a
week to 10 days later and that, if the lab-test results are in
any way abnormal, the patient will receive a telephone call
from the clinic.  Dr. Remillard further testified that he
evaluated Scott's 2009 lab-test results soon after he 
received
them and that he wrote on the lab report that Scott's
cholesterol level was normal but that his PSA level was
elevated and that he needed to be evaluated by a urologist. 
3
1180650
The 2009 lab report contains an undated handwritten note to
that effect.  Dr. Remillard's certified medical assistant
("CMA"), 
Joan 
Ehlman, 
testified 
that 
she 
received
Dr. Remillard's lab-report note and that on October 1, 2009,
she telephoned Scott and left a message on his cell-phone
voicemail informing him that he had an abnormal lab-test
result that he needed to discuss either with her or in a
follow-up appointment with Dr. Remillard.1  A notation written
on Scott's lab report by Ehlman states:  "10/1/09 - L.M. [left
message] to call."  Ehlman further testified that the next day
she heard a voicemail message left by Scott sometime after
5:00 p.m. on October 1, 2009 -- after close of business at the
clinic -- in which he stated that he would make a follow-up
appointment with Dr. Remillard.2  Ehlman made another notation
1Ehlman testified that she did not provide Scott's PSA
lab-test result in the voicemail because it would violate
regulations promulgated pursuant to the Health Insurance
Portability and Accountability Act based on concerns as to who
may have access to voicemail accounts.
2Scott's AT&T cell-phone call log for that period was
introduced into evidence.  Dr. Remillard and Helena Family
Medicine contend that the phone records support Ehlman's
testimony about her phone call and Scott's return call. 
Kimberlee contends that the call log demonstrates that Scott
actually talked to a person when he called the clinic.
4
1180650
on Scott's lab report documenting that voicemail:  "10-1-09 -
pt. [patient] left message - he will RTO [return to office]." 
In contrast, Scott testified by video deposition that he
called the clinic on October 1, 2009, to inquire about his
cholesterol level and that he spoke with an individual who
"told [me] that my cholesterol was within acceptable levels
and my triglycerides were a little out of whack.  But,
otherwise, no other information was provided to me.  There was
no mention of PSA levels."  Scott stated that he therefore did
not make a follow-up appointment with Dr. Remillard in 2009. 
Scott testified that his father passed away in April 2010 and
that his mother became ill that same year, and so he failed to
visit Dr. Remillard in 2010.
Scott next visited Dr. Remillard on April 7, 2011.  Scott
testified that he made the appointment because he was
experiencing discomfort around his bladder area and 
was 
having
some trouble urinating.  During that visit, Dr. Remillard did
not tell Scott about his 2009 elevated PSA level, but he did
perform a rectal examination, and he determined that Scott's
prostate was enlarged.  Dr. Remillard diagnosed Scott with
benign prostatic hyperplasia, and he prescribed Scott some
5
1180650
medication for the condition.  Blood work was also performed
on Scott at the April 7, 2011, visit.
Shortly after the April 7, 2011, visit, Scott called the
clinic to relate that he was experiencing swelling in his
right leg.  The clinic scheduled a sonogram for Scott's right
leg to determine whether he had a blood clot.  On April 21,
2011, Scott returned to the clinic for the sonogram and saw
Dr. Remillard.  Dr. Remillard told Scott that the sonogram was
negative, but he also informed Scott that he had an elevated
PSA level and that he was referring Scott to a urologist for
an immediate consultation.3  Scott testified that it was at
the April 21, 2011, clinic visit that he first learned that he
had had an elevated PSA in 2009.
Scott visited a urologist the following day and was
diagnosed with stage IV metastatic prostate cancer: scans
showed that the cancer had spread to his lymph nodes and his
bones.  Scott underwent a variety of treatments over the
course of a few years, but he died as a result of the cancer
on March 6, 2014.
3Scott's PSA level from the blood work done on April 7,
2011, was 131, a dangerously high level.
6
1180650
B. Litigation in the Trial Court
On July 29, 2011, Scott and Kimberlee commenced an action
under the Alabama Medical Liability Act, § 6–5–480 et seq. and
§ 6–5–540 et seq., Ala. Code 1975 ("the AMLA"), against
Dr. 
Remillard 
and 
Helena 
Family 
Medicine 
(hereinafter referred
to collectively as "the defendants").  They alleged that the
defendants failed to inform the Spencers about Scott's 2009
elevated PSA level in a timely fashion and that, if Scott had
been timely informed, he could have received treatment for his
prostate cancer beginning in 2009.  They further alleged that,
in 2009, Scott's prostate cancer had not metastasized -- i.e.,
had not spread beyond his prostate to his bones and lymph
nodes -- and thus that, if he had received treatment at that
time, his prognosis for a cure of the cancer would have been
very good.  After Scott's death, Kimberlee amended the
complaint to assert claims of wrongful death against the
defendants based on the same alleged facts.
The case was initially set to be tried on December 11,
2017. The parties submitted several pretrial motions,
including motions in limine.  One motion in limine relevant to
this appeal is the defendants' motion in limine #24
7
1180650
("MIL #24"), which sought to preclude Kimberlee from "offering
any argument, evidence, or testimony regarding any alleged
breach of the standard of care relative to Mr. Spencer's
April 7, 2011 office visit to" the clinic.  The defendants
argued that Kimberlee had never alleged that a breach of the
standard of care had occurred on April 7, 2011, and thus, they
asserted, Kimberlee should not be permitted to insinuate that
Dr. Remillard did anything wrong by not informing Scott of his
2009 elevated PSA level during the April 7, 2011, clinic
visit.  The trial court granted MIL #24, ruling that Kimberlee
could elicit testimony from Dr. Remillard as to what did occur
during the April 7, 2011, clinic visit but that she could not
ask any questions pertaining to what did not happen on that
visit -- e.g., that Scott was not told about the elevated 2009
PSA level.
In another motion in limine ("MIL #26"), the defendants
sought to prohibit any witness "from offering testimony
regarding 
'safer' 
or 
'better' 
approaches or 
otherwise equating
or suggesting that safety defines the standard of care"
because, they asserted, the actual standard of care under the
AMLA is that a physician must provide "reasonable care."  The
8
1180650
trial court granted MIL #26, concluding that the AMLA
precluded any use of the term "patient safety."
The defendants filed three motions in limine that
collectively sought to preclude Kimberlee's expert, Jennifer
Wood, a CMA, from offering testimony concerning the standard
of care for a CMA when notifying patients about abnormal lab-
test results based on instructions from a supervising
physician.  The defendants contended that, under the AMLA,
Wood was not a "similarly situated health care provider" to
Ehlman because, in the year preceding the care at issue
(2008-09), Wood had worked as a CMA at a cardiovascular clinic
rather than at a family-medicine clinic and, as such, had not
communicated an abnormal PSA lab-test result to a patient
during that period.  The trial court precluded Wood from
testifying.  
In the trial that began on December 12, 2017, Kimberlee's
counsel gave an opening statement in which counsel purportedly
violated the trial court's ruling pertaining to MIL #24 by
referencing the fact that Dr. Remillard did not tell Scott
about the elevated 2009 PSA level during the April 7, 2011,
clinic visit.  Upon a motion from the defendants, the trial
9
1180650
court granted a mistrial based on the purported violation. 
The second trial was set for April 8, 2019.  At a pretrial
hearing for the second trial, the trial court adopted its
previous rulings concerning the parties' motions in limine
after hearing some additional arguments regarding MIL #24 and
the motions respecting CMA Wood.  
During the second trial, Kimberlee presented video-
deposition testimony from Scott, deposition testimony from
AT&T phone analyst Marti Shuper, live testimony from CMA
Ehlman, live testimony from Dr. Remillard, live testimony from
Kimberlee's medical experts, Dr. Joe Haines and Dr. Joph
Steckel, and live testimony from Kimberlee.  We will recount
the testimony that is pertinent to this appeal.
1.  Testimony from Kimberlee's Standard-of-Care
Expert
Kimberlee's standard-of-care expert, Dr. Joe Haines,
testified that he had practiced in family medicine for
38 years and that he had been board certified in family-
medicine practice for the past 30 years.  Dr. Haines's
deposition testimony and his curriculum vitae revealed that
during most of his career he had been in private family-
medicine practice, including founding and owning his own
10
1180650
family-medicine practice from 1982 to 1997, and 
that afterward
he had worked in other family-medicine clinics.  However,
Dr. Haines testified at trial that, in 2005, he was
commissioned as a lieutenant commander in the United States
Navy Medical Corps and stayed in the service for 11 years.  As
part of that service, starting in 2007, he entered an
aerospace residency program to earn his wings as a flight
surgeon.  During 2007-08, Dr. Haines did classroom work as
part of the aerospace residency program to earn a master's
degree in public health, and he did not treat patients during
that period.  Between 2008 and 2010, Dr. Haines practiced as
a resident in the aerospace residency program at the Naval Air
Station in Pensacola, Florida.  Concerning that period,
Dr. Haines testified on cross-examination as follows:
"Q. And as you said in another deposition, that did
not involve family medicine.  You have testified to
that?
"A. No, that did involve seeing patients, family
medicine patients, aerospace medicine patients, you
know, anything within my privileges that I had with
the Navy."
Also on cross-examination, Dr. Haines further testified that,
during his aerospace residency, he "moonlighted" at private
clinics outside the Naval station.
11
1180650
"Q. Moonlighting in emergency rooms and things of
that sort?
"A. Urgent care centers primarily.
"Q. Urgent care?
"A. Yes.
"Q. Okay.  Not a community-based family practice
program.  You may have brought some of those skills
to bear at the urgent care, I'm not arguing that,
but as you told me under oath, not in a private
community-based family practice clinic, correct,
sir?
"A. No.  Some of these were hybrids, they were
family practice/urgent care.  The one in New Bern,
North Carolina, for example, you did both family
practice and urgent care simultaneously.
"Q. Did you testify in this case that you were not
functioning in a private family practice clinic
capacity during the time that you were in the
aerospace program even though you did moonlight in
these urgent care centers?
"A. Well, if I did, the statement -- [what] I meant
was I was not operating a private practice on my
own.
"....
"Q. So you wouldn't be -- during that period of time
that you were in that residency program, you would
not have been in the position of being the one to
oversee or manage any system of notification of
patients on a daily basis, would you?
"A. Correct.
12
1180650
"Q. All right.  And that would be true for the time
that you were in the aerospace residency program
from '08 to '10 until you finished and went back
into private practice?
"A. Yeah, but I had done it my whole career.
"Q. I understand that.  And you did it for years, I
think, prior to going into the Navy?  I'm not --
"Q. Twenty-four years."
(Emphasis added.)  Dr. Haines also stated that "I have always
practiced family medicine in some capacity" and that,
following his service in the military, he returned to private
family-medicine practice and continues to practice family
medicine.
With respect to the applicable standard of care in this
case, Dr. Haines testified on direct examination that, in his
opinion, Dr. Remillard had breached the standard of care in
two respects.
"Q. And what breaches did you identify?
"A. Well, very -- very simply, in 2009, a failure to
provide Mr. Spencer with the abnormal PSA result of
14.3.  And secondly, a failure to refer him to a
urologist for further evaluation, diagnosis and
treatment of prostate cancer.
"Q. So what -- what did the standard of care require
in this case?
13
1180650
"A. Well, the standard of care required some means
of providing the patient with the information, that
he had an elevated PSA and, in fact, it was seven
times the elevation of what his previous PSA was,
which was 1.9. And to be the advocate for that
patient, and have him understand that this was a
serious problem that could well be cancer, that
could shorten his life.
"Q. So why is that the standard of care?
"A. Well, the standard of care is because, you know,
as a physician, I have the -- other physicians, we
have the knowledge, we understand what an elevated
PSA means.  And a layman may not.  He may not
understand what that means.  And so standard of care
says you -- we have -- we have a duty and
responsibility to provide that information to the
patient so they can make an informed decision, so
they can, you know, realize in their mind, hey, this
is important; I need to go, you know, follow through
and get the right treatment and find out what the
options are."
Dr. Haines expanded on this opinion as follows:
"Q. ...  If Mr. Spencer did, in fact, call the
office, Helena Family Medicine, on October 1st,
2009, and leave a voicemail saying that he will
return to the office, would the duty to inform Mr.
Spencer about that abnormal PSA and the duty to
refer him to a urologist, would it end at that
point?
"A. No, it would not.
"Q. Why not?
"A. Because the duty doesn't end until the physician
knows that the patient has been turned over to the
care of the urologist. So -- because if we don't
know, then it may require additional phone calls, a
14
1180650
letter, some sort of proof that he has, in fact,
made that appointment and been seen.
"Q. So when does the duty to inform end?
"A. Once the urologist assumes care of the patient."
Concerning the clinic's patient-notification system,
Dr. 
Haines 
testified 
that 
it 
was 
Dr. 
Remillard's
responsibility to set up that system and to maintain its
suitability for informing patients about lab-test results.  
"Q. ...  Were there any other family physicians at
Helena Family Medicine, based on your review, in
2008 and 2009 that would have had the responsibility
of setting up the communication system for abnormal
lab values?
A. No, sir, not that I know of.
Q. So is it -- who would have been responsible for
putting that system in place?
A. It was Dr. Remillard's practice, so he would be.
"Q. So would it have been his responsibility to set
that system up?
"A. Yes, sir.
"Q. And would it have been his responsibility to
maintain that system?
"A. Yes, sir.
"Q. And if any changes needed to be made for that
system, whose responsibility would it have been?
"A. It would have been his."
15
1180650
On cross-examination, Dr. Haines was asked more questions
about Dr. Remillard's responsibility to inform patients about
abnormal lab-test results.
"Q. Now, you also have said in this case that the
opinion that you have expressed in response, for
example, to [Kimberlee's counsel's] questions is
that you were holding Dr. Remillard to a standard of
ensuring or guaranteeing that the communication with
the patient about the lab results and the referral
to the urologist occurred, right?
"A. Yes, sir.
"Q. All right.  The basis of your opinion is that
you say that the -- Dr. Remillard fell below the
standard of care by not informing the patient of his
PSA results and ensuring that he saw a urologist in
a timely fashion?
"A. Correct.
"....
"Q. So if it was a -- and I got what you said in
response to my questions a few minutes ago.  Even if
the physician has a reasonable and appropriate
method for following up with his patients, a system,
that is designed and that would be considered to be
a reasonable approach for contacting and notifying
patients about abnormalities, it is your position
that even if such a reasonable system exists, the
doctor is required to guarantee that the patient
does get the information?
"A. 
Yes, 
he's 
-- 
that's 
his 
duty, 
his
responsibility.  And the problem I had with this
system is there was no red flag –- ....
"....
16
1180650
"Q. Okay. Now, I understand that the position that
you take in this case is that even with a reasonable
system in place, you're critical of a physician and
his practice if that system does not produce the
guaranteed 
result 
of 
patient 
notification 
of
elevated PSA and referral to a urologist, correct?
"A. You're correct.
"Q. That's the standard you're applying, right?
"A. Yes.
"Q. All right.
"A. Absolutely.
"Q. And I'll just put it to you this way, as we did
in your deposition. And, you know, I'm really not
suggesting that your opinion is any different than
what you have said that it is. But if the standard
of care, in fact, required something different of
Dr. Remillard than what you say, for example, if the
standard of care simply requires that a physician
such as Dr. Remillard and his practice take
reasonable steps in an effort to communicate the
abnormal lab results, but if the standard of care
does not require the physician to continuously
pursue the patient after the patient has agreed to
return to the office, then you told me under oath it
is true that Dr. Remillard met the standard of care.
And if those facts are so, we're still in agreement,
aren't we?
"A. Right. And I don't agree with those facts."
(Emphasis added.)
17
1180650
On 
redirect 
examination, 
Kimberlee's 
counsel 
had
Dr. Haines reiterate his explanation of the standard of care
applicable in this case.
"Q. Doctor, I believe you gave us your definition of
the standard of care earlier?
"A. Right.
"Q. Could you restate that, please?
"A. Well, yes, in a nutshell, it's what a reasonable
physician would do in treating the same or similar
patient in the same or similar circumstances.
"Q. Is that a standard of perfection?
"A. No.
"Q. Is that a standard of guaranteeing outcomes?
"A. No.
"Q. As you sit here today, are you using the
standard as you defined it and not as a standard of
guaranteeing an outcome of the service?
"A. Right. It's not a guarantee of anything.
"....
"Q. ...  What did the standard of care require of
Dr. Remillard?
"A. It required that he notify the patient of the
elevated PSA and help him to understand the
significance of that elevated PSA, and that it could
shorten his life, that it could cause prostate
cancer -- I mean it could be prostate cancer.  Then
his obligation under the standard of care was for
18
1180650
him to refer that patient to the urologist. And then
finally to follow up to be sure that that
appointment with the urologist was made.
"It's very simple. There's nothing complicated
here at all.
"....
"Q. The criticisms that you have expressed here
today in regard to the standard of care and the
opinions that you have expressed, are those based on
a reasonable standard?
"A. Yes, sir."
2. Testimony from Kimberlee's Causation Expert
Kimberlee's causation expert, 
Dr. 
Joph 
Steckel, testified
that he is a board-certified urologist with a subspecialty in
oncology and that he has been in practice for 24 years. 
Dr. Steckel testified on direct examination that "close to
sixty percent of all oncology patients that I see are prostate
cancer patients."  Specifically concerning Scott, Dr. Steckel
testified that, "more probably than not," he had cancer in his
prostate in 2009 because "[t]his is a man who is forty-nine
years old whose PSA should be under two and a half and it is
14.3 with a family history of prostate cancer."  Dr. Steckel
then explained how urologists evaluate the range of PSA test
scores.
19
1180650
"Q. Now, in regard to the PSA as a risk assessment
tool, are there any ranges of score where a
urological oncologist would have more concern about
the character and potential spread of the cancer?
"A. Yes, absolutely.
"Q. Can you talk to the Ladies and Gentlemen of the
Jury about that?
"A, We tend -- in PSAs less than 10, the chance of
having metastatic spread with any type of prostate
cancer is very, very low, almost to the point that
we are -- we don't do bone scans or CAT scans in men
who are diagnosed with prostate cancer provided
their PSA level is less than 10.
"Now, greater than 20, there's a chance that
there's metastatic spread, in which case you
definitely would do an evaluation to make sure that
the bones or the lymph nodes are not involved.
Between 10 and 20 is sort of the gray zone where
there's a real but not a very high chance of
probability that the prostate cancer has spread
either to the bones or lymph nodes.
"Under 10 it is unnecessary to do any scans
because statistically we know that the chance of
metastatic spread of that number is incredibly low."
(Emphasis added.)
Dr. Steckel then provided his medical opinion as to
whether, in 2009, Scott's prostate cancer had spread beyond
his prostate to his bones or his lymph nodes.  This portion of
Dr. Steckel's testimony is replete with objections from
20
1180650
counsel for the defendants, most of which were sustained by
the trial court, but some which were not.
"Q. Now, in regard specifically to your evaluation
of whether or not Mr. Spencer had bone metastasis in
October of 2009, is your review of the medical
record, all the information about the cancer that
was later diagnosed and based on your experience and
training and knowledge of the literature, did you
form an opinion as to the probability as to whether
or not in October of 2009 Mr. Spencer's cancer had
already metastasized to the bone?
"MR. WRIGHT: We object to the question as calling
for speculation and lack of foundation.
"THE COURT: Overruled. You can go ahead.
"Q. ...  You can answer.
"A. Yes, I have an opinion.
"Q. And what is that opinion?
"MR. WRIGHT: Same objection, same grounds.
"THE COURT: Overruled.
"A. My opinion is that most likely to a greater
degree of certainty that the cancer was localized to
his prostate given his PSA of 14 and his normal
digital exam by the doctor's assessment. 
"....
"Q. ...  What is your understanding, Doctor, in a
general sense as to what the rate of bony metastasis
is in patients regarding their PSA levels?
"....
21
1180650
"A. As I said before, the rate of bony metastasis in
men with PSAs less than 10 is essentially zero,
which is why we do not do bone scans once men are
diagnosed with prostate cancers and their PSAs are
below 10.  We know that the rate of metastasis in
patients -- bony metastasis patients with PSAs
greater than 20 can be up to about twenty or thirty
percent.
"So somewhere between twenty and thirty percent
and zero is where we fall in with this case because
his PSA was 14.3. So if I were to ask -- if I were
to give you a number, the probability of his having
bony metastasis with a PSA --" 
(Emphasis added.)  At this point, counsel for the defendants
interrupted and objected to Dr. Steckel's attempting to give
a percentage, and the trial court sustained the objection. 
Kimberlee's counsel then continued with questioning about
whether Scott's cancer was localized to his prostate in 2009.
"Q. In regard to your evaluation of this case and in
regard to the knowledge that you have formed over
the years in taking care of these patients and
looking at all of the information that was available
to you, is it your opinion that Mr. Spencer had a
treatable prostate cancer in 2009?
"MR. WRIGHT: Same objection. Lack of foundation.
"THE COURT: I am going to let him answer that one.
"A. I can answer?
"THE COURT: Yes.
"A. Yes, I think he had a treatable prostate cancer
when his PSA was 14.3, absolutely.
22
1180650
"Q. ...  And can you describe for the Ladies and
Gentlemen of the Jury what a urological surgeon
would have done, what the standard of care required
a urological surgeon to have done in assessing and
treating [Scott] if he had been evaluated in October
of 2009?
"....
"A. Absolutely.  So a forty-nine-year-old man with
a family history of prostate cancer with a PSA of
14.3 absolutely would have required a transrectal
ultrasound guided by a --
"....
"A. A transrectal ultrasound-guided biopsy of the
prostate.  In other words, he needed his prostate
biopsied to rule out a malignancy.
"....
"Q. ...  And if indeed his biopsy was positive, what
would the standard of care require the urological
surgeon to do at that point?
"A. Well, with a positive biopsy, then you have to
ask yourself is the cancer outside the prostate or
contained. So he would have had a bone scan and a
CAT scan, which gets us back to what we discussed
before.  In the absence of any metastatic disease in
a patient like this, he would have been offered and
should have certainly opted for definitive care and
treatment for his prostate cancer.
"Q. When you say 'definitive care,' what options did
that include?
"A. Either surgery, which would be complete removal
of the prostate and the lymph nodes, or radiation
therapy, which would be having him see a radiation
23
1180650
oncologist.  And they would use their devices to
radiate the prostate and the surrounding tissue.
"....
"Q. Dr. Steckel, in regard to [Scott], in October of
2009, based on the factual knowledge that included
that his PSA was 14.3, correct?
"A. Uh-huh, correct.
"Q. And he had a Gleason score of 4-5, which was
aggressive, correct?[4]
"A. Correct.
"Q. The fact that he had a normal prostate exam, the
fact that he had a father with prostate cancer, the
fact that he had no symptoms from his prostate at
that time, the fact that his prior PSA in 2006 had
been 1.9, taking all that information into account,
you've described to us that a urologist would then
perform a biopsy, and it was your opinion that the
biopsy at this time would more likely than not show
a cancer of the prostate, correct?
"A. Correct.
"Q. Taking all that into account, if a bone scan had
been done, hypothetically, at that time in October
of 2009 and a CT scan had been done to look for
lymph nodes, and if those two tests were both
negative, do you have an opinion in regard to his
4Earlier in his testimony, Dr. Steckel had explained that
"Gleason scoring is a scoring system, based on the histologic,
meaning for all purposes pathologic, features of the cancer
cells from a biopsy."  The first Gleason number rates the most
prominent cell configuration and the second Gleason number
rates the less prominent cells biopsied.  The combined score
indicates the type of cancer cells in the patient's body,
i.e., the aggressiveness of the cancer.
24
1180650
prognosis, if he had undergone either a radical
prostatectomy 
or 
radiation 
treatment 
of 
his
prostate, do you have an opinion regarding his
prognosis?
"....
A. I think it is more likely than not his prostate
cancer would have been confined to his prostate and
he had a good chance of cure.
"[Trial Court again sustains an objection with
respect to Dr. Steckel's giving a percentage on
Scott's chances of a cure if treatment had been
provided in 2009].
"Q. Is it your opinion that the -- that you just
shared with us in regard that the cancer would more
likely than not be limited to the prostate and you
say he had a good prognosis, is that opinion
consistent with your opinion more probable than not
he would have been cured of the prostate cancer?
"A. Correct.
"MR. WRIGHT: Same objection.
"THE COURT: More probably than not but not the
percentage.
"A. More probably than not."
(Emphasis added.)
On cross-examination, counsel for the defendants probed
Dr. Steckel's testimony that, in his opinion, Scott's cancer
was localized in his prostate in 2009.  In doing so, for
25
1180650
certain 
questions, 
counsel 
quoted 
from 
Dr. 
Steckel's
deposition.
"Q. ...  Now, what you told me when I took your
deposition was you could not rule out the presence
of bone metastasis for Mr. Spencer in 2009 with a
PSA of 14 and what we know to be a Gleason 9, 4 plus
5 Gleason 9 score.  Do you remember telling me that?
"A. You can't rely -- without a bone scan, you can't
rule out the presence of bony metastasis. I agree.
"....
"Q. Is what I just asked you, that it is just as
likely that he did have metastatic bone cancer as he
didn't in 2009?
"A. In 2009 when his PSA was 14.3, if he were to
have metastatic disease, it is likely that he could
have had it to his bones, to his lymph nodes.  And
it is just as likely his disease could have been
totally localized to his prostate, totally localized
to the prostate without any spread.
"And the only way you are going to know that is
by doing your tests to determine.  The fact that
tests were not done, you are only guessing as to
where the tumor possibly could be.
"....
"Q. ...  My question is, 'You, Dr. Steckel, cannot
on the basis of any evidence that we have' -- did I
read that part right so far?
"A. So far.
"Q. -- 'any evidence that we have rules out the
possibility that Mr. Spencer had bony metastasis' --
meaning spread to the bone, right?
26
1180650
"A. Correct.
"Q. -- 'with a PSA of 14 and what we know was a
Gleason 4-5 tumor in 2009, and that is a true
statement.'  And his answer -- your answer, I'm
sorry, 'That is true because we don't have the bone
scan or CAT scan at that point.'  And that is part
of what you just said, isn't it?
"A. Correct.  If you don't have the tests, you don't
know what the results are.
"Q. Let's read on, 'It would be speculation to say
that he didn't, and you would tell me that it would
be speculation to say that he did.  It would be
equal.  Am I right?'  And you said, 'Well, equal is
saying it is a coin toss whether he had it.'
"And I said, question: 'The point is, we don't
have any evidence that gives us anything but a coin
toss.'  And what was your answer?
"A. I said 'right.'
"....
"Q. And you have testified that with earlier
diagnosis, there were some approaches to Mr.
Spencer's 
workup 
that, 
in 
your 
opinion, 
if
evaluation and potential treatment had occurred
then, those approaches to his treatment could have
made a difference in his outcome.  You have
testified to that, haven't you?
"A. I agree.
"Q. And then your testimony was it could have made
a difference in the outcome and equally it could not
have made any difference in the outcome.  That is
what you said under oath, isn't it?
"A. Yes.
27
1180650
"Q. All right. And you stand by that testimony,
don't you?
"A. Right.
"Q. You have said also on this business of what you
mentioned after -- right before lunch when I had
asked you about metastatic cancer being uncurable,
you said well, it is incurable but it might be
controlled with treatment, right?
"A. Controlled, correct.
"Q. Controlled.  And so I asked you in your
deposition and I am now asking you to acknowledge
this because you have stated and you do not know and
you cannot say that Mr. Spencer would have been in
a group of patients who might have been controlled
by earlier therapy or one that might have been
unaffected by the treatment.  That is what you said
when I took your deposition, isn't it?
"A. Correct.
"Q. As you told me, that would be speculation on
your part to say that he would have been controlled.
"A. All we can say is in populations what would be
the chances that he'd be more likely controlled or
not likely controlled.  But for the individual
patient, you are right, that would be speculation.
"Q. 
Right. 
In 
Mr. 
Spencer's 
case, 
that 
is
speculation?
A. In the individual patient, it is speculation.
"....
"Q. All right.  For example, you said that with a
known Gleason 9 and a PSA of 14, you have made the
28
1180650
comment, indulging speculation, as you admitted,
that you felt the tumor was confined to the
prostate. That is what you said?
"A. Correct.
Q. All right. And you also told me, when I asked you
about that in your deposition, there's no scientific
study or research that you could point to to support
that statement.
"A. Correct.
"Q. All right.  No studies that you can point to
that would suggest that the -- that high grade
aggressive tumors in a young man of his age are
confined to the prostate with just a normal digital
examination and the PSA of 14?
"A. Other than studies that have shown that men who
have PSAs of 14, there's a twenty percent chance
that 
they 
will 
require 
adjunctive 
treatment
afterwards with an eighty percent chance of cure."
(Emphasis added.)
3. Disposition by the Trial Court
At the close of Kimberlee's case, the defendants moved
for a judgment as a matter of law ("JML"). Kimberlee filed a
response in opposition to the motion.  The trial court held a
hearing on the motion following the conclusion of Kimberlee's
presentation of her case on April 11, 2019.  The trial court
then orally announced that it was granting the defendants'
motion for a JML.  The trial court explained, in part:
29
1180650
"I will tell you that it is somewhat troubling
to me, some of the testimony given by the experts,
when it came to speculation and coin tosses and that
kind of thing.  And in viewing this case in the
light most favorable to the plaintiff, as [counsel
for Kimberlee] has stated, in reaching my decision,
that is what I am going to do, is in light of the
most favorable to the plaintiff.
"However, 
after 
careful 
consideration 
of 
the 
law
and applying the testimony to the law, it is my
opinion that the defendants in this matter are
entitled to a judgment as a matter of law in this
case."
On April 12, 2019, the trial court entered a written order
granting the defendants' motion for a JML.  On April 30, 2019,
the trial court entered a "Memorandum Opinion and Order"
explaining its decision.  In the April 30, 2019, order, the
trial court noted the arguments of the defendants pertaining
both to Dr. Haines and to Dr. Steckel, and it quoted some
opinions of this Court addressing the issue of causation in an
AMLA action.  The trial court then concluded:
"After 
closely 
reviewing 
the 
applicable 
case 
law
and trial testimony of Dr. Haines and Dr. Steckel,
and upon careful consideration of the oral arguments
and extensive briefing submitted by both sides, the
Court finds that the Motion for Judgment as a Matter
of Law filed by the defendants is well taken and due
to be granted."
II.  Standards of Review
30
1180650
This Court's standard of review for a ruling on a motion
for a JML is de novo:
"'"When reviewing a ruling
on a motion for a [judgment as a
matter of law], this Court uses
the same standard the trial court
used 
initially 
in 
deciding
whether to grant or deny the
motion for a [judgment as a
matter of law].  Palm Harbor
Homes, Inc. v. Crawford, 689 So.
2d 3 (Ala. 1997).  Regarding
questions of fact, the ultimate
question is whether the nonmovant
has presented sufficient evidence
to allow the case to be submitted
to 
the 
jury 
for 
a 
factual
resolution.  Carter v. Henderson,
598 So. 2d 1350 (Ala. 1992).  The
nonmovant must have presented
substantial evidence in order to
withstand 
a 
motion 
for 
a
[judgment as a matter of law].
See § 12–21–12, Ala. Code 1975;
West v. Founders Life Assurance
Co. of Florida, 547 So. 2d 870,
871 (Ala. 1989).  A reviewing
court must determine whether the
party who bears the burden of
proof has produced substantial
evidence 
creating 
a 
factual
dispute requiring resolution by
the jury.  Carter, 598 So. 2d at
1353.  In reviewing a ruling on a
motion for a [judgment as a
matter of law], this Court views
the evidence in the light most
favorable to the nonmovant and
entertains 
such 
reasonable
31
1180650
inferences as the jury would have
been free to draw.  Id."'"
Thompson v. Patton, 6 So. 3d 1129, 1133 (Ala. 2008) (quoting
Leiser v. Raymond R. Fletcher, M.D., P.C., 978 So. 2d 700,
705–06 (Ala. 2007), quoting in turn Waddell & Reed, Inc. v.
United Investors Life Ins. Co., 875 So. 2d 1143, 1152 (Ala.
2003)).
"In reviewing a ruling on the admissibility of
evidence, including expert testimony, the standard
is whether the trial court exceeded its discretion
in excluding the evidence.  In Bowers v. Wal–Mart
Stores, Inc., 827 So. 2d 63, 71 (Ala. 2001), this
Court stated: 'When evidentiary rulings of the trial
court are reviewed on appeal, "rulings on the
admissibility of evidence are within the sound
discretion of the trial judge and will not be
disturbed on appeal absent an abuse of that
discretion."'  (Quoting Bama's Best Party Sales,
Inc. v. Tupperware, U.S., Inc., 723 So. 2d 29, 32
(Ala. 1998).)"
Swanstrom v. Teledyne Cont'l Motors, Inc., 43 So. 3d 564, 574
(Ala. 2009).
III.  Analysis
Kimberlee raises several issues in this appeal, but the
two most pressing issues concern the qualifications of her
standard-of-care expert and the admissibility of testimony
presented by her experts on the standard of care and causation
because those are indispensable elements of an action under
32
1180650
the AMLA.  See, e.g., Kraselsky v. Calderwood, 166 So. 3d 115,
118 (Ala. 2014) ("To prevail in a medical-malpractice action
under the [AMLA], a plaintiff must establish 1) the
appropriate standard of care, 2) that the defendant
health-care provider breached that standard of care, and 3) a
proximate 
causal 
connection 
between 
the 
health-care 
provider's
alleged breach and the identified injury.").  Thus, we will
first address the arguments concerning those two experts.
Although our conclusions as to those issues require reversal
of the trial court's judgment, for the sake of judicial
economy we will also analyze the trial court's rulings with
respect to the defendants' motions in limine that Kimberlee
challenges in this appeal.  See, e.g., Ex parte Johnson, 620
So. 2d 709, 712 (Ala. 1993) (explaining that, "[a]lthough we
reverse for the reasons stated above, for the sake of judicial
economy we address two other issues raised by Johnson, which
are almost certain to come up again on remand for a new
trial").
A. Issues Concerning Dr. Haines's Testimony
1. Dr. Haines's Qualifications as an Expert Witness
Section 6-5-548(a), Ala. Code 1975, provides:
33
1180650
"(a) In any action for injury or damages or
wrongful death, whether in contract or in tort,
against a health care provider for breach of the
standard of care, the plaintiff shall have the
burden of proving by substantial evidence that the
health care provider failed to exercise such
reasonable care, skill, and diligence as other
similarly situated health care providers in the same
general line of practice ordinarily have and
exercise in a like case."
(Emphasis added.)  Because Dr. Remillard is board certified in
a medical specialty, family-medicine practice, the standard
for what constitutes a "similarly situated health care
provider" is further defined by § 6-5-548(c):
"(c) Notwithstanding any provision of the
Alabama Rules of Evidence to the contrary, if the
health care provider whose breach of the standard of
care is claimed to have created the cause of action
is certified by an appropriate American board as a
specialist, is trained and experienced in a medical
specialty, and holds himself or herself out as a
specialist, a 'similarly situated health care
provider' is one who meets all of the following
requirements:
"(1) Is licensed by the appropriate
regulatory board or agency of this or some
other state.
"(2) Is trained and experienced in the
same specialty.
"(3) Is certified by an appropriate
American board in the same specialty.
"(4) Has practiced in this specialty
during the year preceding the date that the
34
1180650
alleged breach of the standard of care
occurred."
(Emphasis added.)  Section 6-5-548(e) adds that "[a] health
care provider may testify as an expert witness in any action
for injury or damages against another health care provider
based on a breach of the standard of care only if he or she is
a 'similarly situated health care provider' as defined above."
As is recounted in the rendition of the facts,
Kimberlee's 
standard-of-care 
expert, 
Dr. 
Haines, 
like
Dr. 
Remillard, is 
board 
certified 
in 
family-medicine practice. 
He had his own private family-medicine practice for 14 years
and practiced in other similar clinics for a few years after
that.  However, Dr. Haines testified that, in the year
preceding the alleged breach, he was in the Navy's aerospace
residency program at the Naval Air Station in Pensacola,
Florida.  Dr. Haines explained that, as part of the aerospace
residency program, he saw as patients the pilots in the
program and their family members.  He also testified that he
"moonlighted" at urgent-care clinics and at some hybrid
urgent-care/family-medicine establishments in his off-duty
hours during the period when he was in the residency program. 
Dr. Haines admitted that during this period he did not oversee
35
1180650
a patient-notification system, but, he said, he had done so
for much of his career.
As they did in the trial court, the defendants argue that
Dr. Haines "was not qualified to define the standard of care
applicable to Dr. Remillard ... because he did not practice as
a board-certified family practice physician in a family
practice clinic overseeing and managing patient notification
systems in the year preceding the alleged breach."  The
defendants' brief, pp. 53-54.
Kimberlee contends that this is "a hyper-technical
analysis of the similarly-situated rule.  ...  The requirement
under § 6-5-548 is that Dr. Haines had to practice family
medicine during the year preceding alleged breach of the
standard of care.  There is no requirement that his private
practice must be identical to Dr. Remillard's in each and
every aspect." Kimberlee's brief, pp. 36-37.
In sum, the crux of the parties' dispute is whether
Dr. Haines was unqualified to testify about the applicable
standard of care because of two facts:  (1) Dr. Haines was not
rendering patient care in medical practice identical to that
of Dr. Remillard between 2008 and 2009 because Dr. Haines was
36
1180650
practicing at the Naval Air Station in Pensacola and not at a
private-practice clinic and (2) Dr. Haines did not oversee a
patient-notification system during that year.  In the trial
court and on appeal, the defendants have emphasized two cases
in support of this position:  Carraway v. Kurtts, 987 So. 2d
512 (Ala. 2007) ("Carraway"), and Holcomb v. Carraway, 945
So. 2d 1009, 1020–21 (Ala. 2006) ("Holcomb").
In Carraway, the Court concluded that the plaintiff's
proffered medical expert, Dr. Toni Cutson, was not qualified
under § 6-5-548(c) because the admissible evidence before the
trial court did not establish that Dr. Cutson was board
certified in the same specialty as the defendant or that she
had practiced in that specialty during the year preceding the
alleged breach of the standard of care.  See Carraway, 987
So. 2d at 518 ("The affidavit does not state whether
Dr. Cutson is a board-certified family practitioner; neither
does it state whether Dr. Cutson had practiced in the same
specialty as Dr. Kurtts during the year preceding the alleged
breach.").  The Carraway Court went on to discuss whether, if
inadmissible evidence was considered, Dr. Cutson would be
qualified under § 6-5-548(c).  The Court noted that the
37
1180650
curriculum vitae of Dr. Cutson indicated that, like the
defendant, she was a board-certified family practitioner.
"[H]owever, none of the professional appointments
listed on Dr. Cutson's curriculum vitae indicate
that she practiced in the same general area of
practice at the time of the hearing or during the
year preceding the alleged breach, as is required of
similarly situated physicians. § 6–5–548(c)(4), Ala.
Code 1975.  Only those positions Dr. Cutson held for
the year preceding May through November 2003 are
relevant to whether Dr. Cutson qualifies as a
similarly situated physician. See § 6–5–548(c)(4),
Ala. Code 1975.  Dr. Cutson's curriculum vitae
states that during the relevant period she served as
an 'Assistant Medical Director,' a 'Staff Physician,
Geriatric Research, Education and Clinical Center,'
a 'Staff Physician, Spinal Cord Injury & Dysfunction
Team,' a 'Medical Director of the Palliative Care
Consult Team,' and a 'Physician member of VISN 6 VHA
Palliative Care Team.'  Dr. Kurtts is not accused of
breaching the standard of care applicable to a
medical director, a researcher in geriatrics, a
spinal-cord 
specialist, 
or 
a 
palliative-care
specialist, 
nor 
do 
any 
of 
these 
positions
affirmatively indicate that Dr. Cutson was involved
in the specialty of family practice during the
relevant period.  To conclude that she was would
require us to speculate as to what she might have
been doing as a medical director or researcher or in
her other specialties, something that she could
easily have made clear in her affidavit if she had
in fact been actively engaged in family-practice
medicine at the relevant time.  Therefore, even if
we were to consider the curriculum vitae, it is not
apparent from the curriculum vitae that the
positions 
listed 
are 
sufficient 
to 
qualify
Dr. Cutson as a similarly situated physician."
38
1180650
Carraway, 987 So. 2d at 519 (footnote omitted; emphasis
added).  Although the defendants do not expressly say so,
presumably they believe there is a parallel between the
Carraway Court's conclusion that Dr. Cutson had not been
"actively engaged in family-practice medicine at the relevant
time," id., and Dr. Haines's position in the military in 2008-
09.
However, there are several ways in which Carraway is
distinguishable from this case.  First, the Carraway Court's
primary conclusion was that no admissible evidence indicated
that Dr. Cutson was board certified in family medicine.  No
such impediment exists here, because the defendants readily
concede that Dr. Haines is board certified in family-medicine
practice.  Second, the Carraway Court went on to discuss -- as
dictum -- the fact that "none of the professional appointments
listed on Dr. Cutson's curriculum vitae indicate that she
practiced in the same general area of practice at the time of
the hearing or during the year preceding the alleged breach,
as 
is 
required 
of 
similarly 
situated 
physicians.
§ 6–5–548(c)(4), Ala. Code 1975."  Carraway, 987 So. 2d at 519
(emphasis added).  The same cannot be said of Dr. Haines. 
39
1180650
Dr. Haines plainly testified that he was actively engaged in
family-medicine practice in 2008-09, both on the Naval base
and during his moonlighting while off-duty.  Carraway offers
no support for the proposition that the specialty of family-
medicine practice means being engaged in a family-medicine
practice identical to that of the defendant; the positions
held by Dr. Cutson in Carraway were, on their face, clearly
different from the role of a family-medicine practitioner. 
In Holcomb, the plaintiff commenced an action against
multiple doctors for a failure to diagnose her with breast
cancer in a timely fashion.  Three of the defendants were
radiologists who, the plaintiff alleged, negligently misread
her mammograms.  The plaintiff's proffered expert, like those
defendants, was board certified in radiology, and those
defendants conceded that the plaintiff's expert "meets the
technical requirements of § 6-5-548(c) ...."  945 So. 2d at
1015.  However, the defendant radiologists argued that the
trial court had properly excluded the plaintiff's expert from
testifying as a "similarly situated health care provider"
because he had not performed or interpreted mammograms during
40
1180650
the relevant period.5  Thus, the defendant radiologists
contended that the plaintiff's expert "could not have been
familiar with the standard of care applicable to a radiologist
performing mammograms during the 12-month period preceding
their alleged breaches," 945 So. 2d at 1016, and therefore,
they asserted, the trial court had discretion under Rule 702,
Ala. R. Evid., to exclude testimony from the plaintiff's
expert.  The Holcomb Court engaged in an extensive analysis of
the language used in § 6-5-548 and concluded that the statute
did not inhibit the discretion a trial court otherwise
possessed under the Rules of Evidence to exclude evidence if
the trial court believed it would not "assist the trier of
fact."  Rule 702(a), Ala. R. Evid.  The Holcomb Court
therefore concluded that the trial court did not exceed its
discretion in excluding the testimony of the plaintiff's
expert.
The defendants contend that, as in Holcomb, "the trial
court was well within its discretion to determine testimony
from Dr. Haines regarding Dr. Remillard's care would not have
5The plaintiff's expert testified that "the earliest
breach by any of the defendant radiologists occurred in June
1997."  Holcomb, 945 So. 2d at 1015.  Thus, the relevant
period was June 1996 to June 1997.
41
1180650
assisted the trier of fact because Dr. Haines was not
qualified to define or testify as to any alleged deviation
from the standard of care."  The defendants' brief, p. 61. 
Again, the defendants argue that Dr. Haines was unqualified
because in 2008-09 he was not engaged in a private family-
medicine practice and was not overseeing a patient-
notification system.  
But, as in Carraway, Holcomb presented a situation in
which the plaintiff's proffered expert had not engaged at all
in the practices at issue, i.e., performing and reading
mammograms, for at least three or four years up to the
relevant period.  In fact, the plaintiff's expert admitted
that he had "consider[ed] himself 'semi-retired to his office
since 1996 or '97.'"  Holcomb, 945 So. 2d at 1016 n.6.  In
contrast, Dr. Haines testified that he has "always practiced
family medicine in some capacity" and that he continued to do
so up to the time of trial.  Thus, Holcomb, like Carraway,
does not illuminate the specific issue here of what
constitutes "practic[ing] in this specialty [of family-
medicine practice] during the year preceding the date that the
42
1180650
alleged 
breach 
of 
the 
standard 
of 
care 
occurred." 
 
§ 
6-5-548(c)(4).
There is no dispute that Dr. Haines was "trained and
experienced in the same specialty" as Dr. Remillard and that
he was "certified by an appropriate American board in the same
specialty" as Dr. Remillard.  § 6-5-548(c)(2) & (3).  That
"same speciality" was family-medicine practice. Given that
context, we conclude that the requirement in  § 6-5-548(c)(4)
that an expert must have "practiced in this specialty" in the
year preceding the alleged breach of the standard of care
refers to the actual practice of the specialty at issue rather
than the exact setting in which the defendant doctor practices
the speciality.  Cf. Medlin v. Crosby, 583 So. 2d 1290, 1296
(Ala. 1991) (noting that § 6-5-548 "does not specify the
amount of time spent practicing or the nature and quality of
the practice").  Even though Dr. Haines's family-medicine-
practice experience in 2008-09 was not "in a community based
family practice clinic," the defendants' brief, p. 31,
Dr. Haines testified that he was still practicing family
medicine in 2008-09.  Therefore, we believe that Dr. Haines
could assist the jury with the standard of care applicable to
43
1180650
a family-medicine practitioner who receives a patient's
abnormal PSA lab-test result.
Moreover, the defendants repeatedly conflate whether
Dr. Haines was overseeing a patient-notification system in
2008-09 with whether he was "practic[ing] in th[e] specialty
[of family-medicine practice] during the year preceding the
date that the alleged breach of the standard of care
occurred."  § 6-5-548(c).  According to Medlin, identifying
the breach of the standard of care at issue is necessary in
order to "decid[e] whether a proffered expert witness
qualifies as a 'similarly situated health care provider'
within the meaning of the statute."  583 So. 2d at 1293. 
Dr. Haines identified the standard of care as follows:
"[A] failure to provide Mr. Spencer with the
abnormal PSA result of 14.3.  And secondly, a
failure to refer him to a urologist for further
evaluation, diagnosis and treatment of prostate
cancer."
An expert is required to assist the jury in answering those
questions 
because 
a 
family-medicine practitioner would 
need 
to
inform the jury as to whether a physician with such a
specialty would comprehend the meaning of a PSA lab-test
result of 14.3, i.e., whether that result was abnormal,
44
1180650
whether the result needed to be communicated to the patient,
and whether such a result necessitated referral of the patient
to a urologist.  The defendants fail to provide any
authorities establishing that identifying and maintaining an
acceptable method for notifying patients of abnormal lab-test
results is unique to the specialty of family medicine and
that, therefore, evidence on that subject would require expert
testimony from a family-medicine practitioner.  Indeed, given
that lab-test results are used by doctors in many different
fields of practice, there is no reason to assume that
communicating the results from such lab tests belongs to any
particular medical specialty.  Even if evaluating the
effectiveness of a patient notification did require medical-
expert testimony, there is no dispute that Dr. Haines has
extensive 
experience 
overseeing 
a 
patient-notification 
system;
he just did not do so in the year before Dr. Remillard's
alleged breach of the standard of care.  Thus, we conclude
that Dr. Haines cannot be deemed unqualified to testify
regarding the applicable standard of care on the basis of the
fact that he did not oversee a patient-notification system in
2008-09. 
45
1180650
2. The Admissibility of Dr. Haines's Testimony
At trial and again on appeal, the defendants have also
objected to Dr. Haines's testimony on the ground that
allegedly "he sought to hold Dr. Remillard and his clinic to
a heightened standard of insuring or guaranteeing outcome
(that certain communication with the patient and follow up
with a specialist occurred), which is contrary to Alabama
law."  The defendants' brief, p. 58.  They argue that "[a]
physician's duty to a patient is to exercise 'reasonable
care,' not to 'insur[e] ... the successful issue of treatment
or service.'  Ala. Code § 6-5-484," but that "Dr. Haines'
criticisms were premised on the flawed position that the
defendants had a duty beyond having a reasonable system in
place and instead had a duty to guarantee outcome."  Id.,
pp. 59 & 60 (emphasis in original).  In support of this
argument, the defendants cite answers Dr. Haines provided on
cross-examination in which he appeared to state that the
defendants had a duty to guarantee that Scott received the
result of his 2009 PSA lab test.
Kimberlee responds that "Dr. Haines made clear that his
opinion was based on a reasonable standard -- not some
46
1180650
standard of perfection."  Kimberlee's brief, pp. 37-38.  In
support, Kimberlee cites portions of Dr. Haines's testimony on
direct examination, as well as this Court's opinion in Downey
v. Mobile Infirmary Medical Center, 662 So. 2d 1152 (Ala.
1995).  In Downey, the Court reversed a trial court's
exclusion of standard-of-care testimony from the plaintiff's
proffered nursing expert, concluding that the trial court had
failed to evaluate the expert's testimony as a whole.
"After reviewing Nurse Read's testimony as a
whole, we conclude that the trial court erred in
determining that her testimony was insufficient on
the basis that she did not accurately state the
standard of care required by law.  The trial court
focused on only one of her answers, ignoring the
rest of Nurse Read's 196–page deposition and
ignoring 
her 
affidavit. 
 
When 
asked 
her
understanding as to the standard of care that is to
be exercised by nurses in Alabama, Nurse Read
responded: 'To ensure the safety and the welfare of
patients.'  The trial court read the use of the word
'ensure' as violating § 6–5–484(b), which provides
that a health care provider is not considered 'an
insurer of the successful issue of treatment or
service.'  The statement that a nurse should ensure
the safety and welfare of patients is not a
statement that the nurse should '[insure] the
successful issue of treatment or service' and
guarantee 
the 
treatment 
or 
service. 
 
This
interpretation of Nurse Read's testimony ignores the
rest of her deposition and her affidavit, in both of
which she clearly demonstrates her knowledge of the
standard of care.
47
1180650
"This Court has consistently held that the
testimony of an expert witness in a medical
malpractice case must be viewed as a whole, and that
a portion of it should not be viewed abstractly,
independently, or separately from the balance of the
expert's testimony.  Hines v. Armbrester, 477 So. 2d
302 (Ala. 1985); Malone v. Daugherty, 453 So. 2d 721
(Ala. 1984).  Here the trial court erred in striking
Nurse Read's affidavit, which was presented to the
trial court in response to the trial judge's
statement to the lawyers that they should 'go back
and brief this and give me something to go on why I
shouldn't grant it [the summary judgment motion].'
Rather than presenting a 'new opinion,' as the trial
court said the affidavit did, the affidavit
presented an explanation that further clarified
Nurse Read's knowledge of the standard of care.
Nurse Read stated in that affidavit:
"'I was asked during my deposition
what was the standard of care for nurses in
Alabama.  I responded to ensure patient
safety.  By using the word ensure I was not
indicating that a nurse was an insurer of
the successful issue of treatment or
service.  By using the word ensure, it was
not my meaning, nor do I contend that the
nurse was responsible to guarantee the
safety of the patient.  I used the word
only in the context that it was a nurse's
duty to make reasonable provision and/or
take reasonable and necessary measures to
provide for a patient's safety and I
further testified as to the proper measures
which should have been taken with regard to
Mr. Downey.'"
Downey, 662 So. 2d at 1154 (emphasis added).
It is true that Dr. Haines's testimony could be
understood as setting up a standard of guaranteed care for a
48
1180650
patient; however, it is also true that his testimony could be
understood 
as 
simply 
opining 
that, 
in 
his 
opinion,
Dr. Remillard did not follow the protocols that a reasonable
family-medicine 
practitioner 
would 
have 
followed 
upon
receiving the abnormal PSA lab-test result from Scott's
September 28, 2009, clinic visit. This Court has "cautioned
against the practice of relying on isolated excerpts from ...
testimony to argue in favor of a proposition the testimony as
a whole does not support."  Kraselsky, 166 So. 3d at 121. 
Moreover, as we noted in the standards-of-review section of
this opinion, on a motion for a JML the trial court is
supposed to view the evidence in the light most favorable to
the nonmovant and to entertain such reasonable inferences as
the jury would have been free to draw.  See, e.g., Thompson,
6 So. 3d at 1133.  When Dr. Haines's testimony is viewed in
its totality and in a light most favorable to Kimberlee, it
cannot be concluded that his testimony should be excluded for
attempting to hold Dr. Remillard to a heightened standard of
ensuring or guaranteeing an outcome in patient care.
49
1180650
3. Dr. Remillard's Standard-of-Care Testimony
Finally, with respect to the standard of care, we also
observe that Kimberlee has argued -- correctly in our view --
that Dr. Remillard himself provided the applicable standard of
care in this case in light of a key factual dispute between
the parties.  Specifically, Dr. Remillard testified under
questioning from Kimberlee's counsel as follows:
"Q.  Now, once you were aware of this elevated PSA
in a general sense, did you have a duty under the
standard of care to try to notify your patient of
both the elevated PSA and the need for a urology
specialist referral?
"A.  Yeah.  We had a duty to make a reasonable
attempt to notify Mr. Spencer of the abnormal lab.
"....
"Q.  Now, if Mr. Spencer, once you had this result,
if he had direct communication with you October 1st,
September 30th, October 2nd of 2009, right around
this time when you found out about this PSA test --
if he had direct communication with you by phone or
by coming to the clinic to see you personally, would
the standard of care have required you to tell him
about his elevated PSA, and would it have required
you to refer him to a urologist?
"A.  Yes, sir."
Based on the foregoing testimony, if the jury chose to
believe that Scott's version of the events of October 1, 2009,
is what unfolded -- i.e., that he talked to someone at the
50
1180650
clinic but that person did not tell him about his elevated PSA
level -- then Dr. Remillard himself established the 
applicable
standard of care and admitted to a breach of that standard. 
In other words, given that what transpired on October 1, 2009,
with respect to the clinic's communication to Scott about his
lab-test results is clearly an issue of fact to be resolved by
a jury, then, by Dr. Remillard's own testimony, a scenario
exists in which a jury could find that he breached the
standard of care.  Therefore, even apart from the facts that
Dr. Haines was qualified as an expert in family-medicine
practice and that his testimony should have been viewed as a
whole more favorably toward Kimberlee, the trial court erred
to the extent it entered a JML in favor of the defendants on
the basis of an alleged failure by Kimberlee to present
competent testimony regarding the standard of care.
B. Causation Testimony from Dr. Steckel
"With regard to proximate causation in an AMLA case, this
Court has stated that 'the plaintiff must prove, through
expert 
medical 
testimony, 
that 
the 
alleged 
negligence probably
caused, rather than only possibly caused, the plaintiff's
injury.'"  Kraselsky, 166 So. 3d at 119 (quoting University of
51
1180650
Alabama Health Servs. Found. v. Bush, 638 So. 2d 794, 802
(Ala. 1994)) (emphasis added in Kraselsky).  By the same
token, 
"[t]he 
standard 
for 
proving 
causation 
in 
a
medical-malpractice action 
is 
not 
proof 
that 
the 
complained-of
act or omission was the certain cause of the plaintiff's
injury.  Instead, as this Court has frequently reiterated, the
standard is one of the 'probable' cause ...."  Hill v.
Fairfield Nursing & Rehab. Ctr., LLC, 134 So. 3d 396, 406
(Ala. 2013).
At trial and again on appeal, the defendants have
contended that Kimberlee did not present competent causation
testimony because, they assert, her causation expert's
opinions were based on speculation.  They concede that
Kimberlee's causation expert, Dr. Steckel, was an eminently
qualified urologist who had 24 years of experience treating
cancer patients and who estimated that approximately 60% of
his practice was composed of prostate-cancer patients.
However, the defendants insist that Dr. Steckel's opinion that
Scott would have had a much better prognosis in 2009 than in
2011
"required an assumption that Mr. Spencer probably
did not have bone metastasis in 2009.  Ultimately,
52
1180650
on cross-examination, Dr. Steckel admitted it would
be speculation to say Mr. Spencer's disease was
probably not metastatic in 2009, and consequently it
would be speculative to say that the outcome could
have been different with earlier treatment.  Such
testimony simply amounts to a personal opinion based
on no fact or science, which he admitted would
require the indulgence of speculation that Mr.
Spencer lost a possible chance at survival based on
the alleged delay in diagnosis.  This testimony
cannot rise to satisfy the Plaintiff's burden of
proof under Alabama law."
The defendants' brief, pp. 41-42.  In support of this
argument, the defendants cite testimony from Dr. Steckel on
cross-examination in which he stated that, "without a bone
scan, you can't rule out the presence of bony metastasis" and
that, absent such a scan, it would be "speculation" to say
whether Scott did or did not have "bony metastasis."  The
defendants emphasize that this Court has explained that
"'[t]he opinions of an expert may not rest on "mere
speculation and conjecture."  Townsend v. General
Motors Corp., 642 So. 2d 411, 423 (Ala. 1994).'
Dixon v. Board of Water & Sewer Comm'rs of Mobile,
865 So. 2d 1161, 1166 (Ala. 2003).  '[A]s a theory
of causation, a conjecture is simply an explanation
consistent with known facts or conditions, but not
deducible from them as a reasonable inference.  See,
e.g., Griffin Lumber Co. v. Harper, 247 Ala. 616, 25
So. 2d 505 (1946).'  Alabama Power Co. v. Robinson,
447 So. 2d 148, 153–54 (Ala. 1983).  An expert
witness's opinion that is conclusory, speculative,
and without a proper evidentiary foundation cannot
create a genuine issue of material fact. Becton v.
53
1180650
Rhone–Poulenc, Inc., 706 So. 2d 1134, 1141–42 (Ala.
1997)."
Bradley v. Miller, 878 So. 2d 262, 266 (Ala. 2003).
The defendants further argue that, because of the nature
of Dr. Steckel's testimony, this is not a case in which the
plaintiff 
presented 
"sufficient 
evidence 
that 
prompt 
diagnosis
and treatment would have placed the patient in a better
position than [he] was in as a result of the inferior medical
care."  Hrynkiw v. Trammell, 96 So. 3d 794, 806 (Ala. 2012). 
Instead, they insist, because Dr. Steckel's theory that
Scott's prostate cancer was curable in 2009 is based on
speculation about how far the disease had spread at that time,
Kimberlee's claims amounted to seeking "recovery for the loss
of any chance of 
recovery resulting from medical malpractice,"
which is not permitted in Alabama.  Id.  In other words, they
contend that Kimberlee's claims are based on a mere
possibility, rather than a probability, that Scott's cancer
was treatable in 2009.  The trial court apparently agreed with
the 
defendants' 
contentions 
concerning 
Dr. 
Steckel's 
causation
testimony.
In contrast, Kimberlee argues that Dr. Steckel 
54
1180650
"provided substantial evidence on direct examination
that is sufficient for a reasonable juror to find
that the alleged dilatory diagnosis and treatment
severely worsened Scott's prognosis and proximately
caused his death.  He testified that Mr. Spencer
probably did not have metastatic disease in October
2009, and thus, he probably would have had a good
prognosis if he had been promptly informed of his
elevated PSA and treated by urology."
Kimberlee's brief, p. 27.  For support, Kimberlee points to
testimony on direct examination in which Dr. Steckel stated
that "[m]y opinion is that most likely to a greater degree of
certainty that the cancer was localized to [Scott's] prostate
given his PSA of 14 and his normal digital exam by the
doctor's assessment" and that Scott "absolutely ... had a
treatable prostate cancer when his PSA was 14.3."
Kimberlee also cites Hrynkiw, supra, in which this Court
discussed at length the necessity of viewing a witness's
testimony as a whole and that the jury must be permitted to
determine the weight and credibility of witness testimony.
"At the outset, we note that the jury determines
the credibility of the expert witnesses and
determines the weight to give to their opinions.
Kilcrease v. John Deere Indus. Equip. Co., 663
So. 2d 900 (Ala. 1995).  Here, it was for the jury
to determine whether it believed Dr. Hash's
explanation of his earlier testimony given during
his deposition.  In Graves v. Brookwood Health
Services, Inc., 43 So. 3d 1218 (Ala. 2009), the
plaintiff's expert testified in a deposition that
55
1180650
the intravenous infiltration probably caused the
injury to the plaintiff's right hand.  Then, in a
subsequent deposition, the same expert told defense
counsel that it was merely 'possible' that the
infiltration caused plaintiff's injury and that he
could not say that it was the 'probable' cause. This
Court reversed the summary judgment for Brookwood
Health Services and held that any contradictions or
unclarity in the expert's testimony created jury
questions of weight and credibility. This Court
said:
"'Our cases make it abundantly clear,
however, that a portion of the testimony of
the plaintiff's expert cannot be viewed
"abstractly, independently, and separately
from the balance of his testimony."  Hines
v. Armbrester, 477 So. 2d 302, 304 (Ala.
1985). 
See, 
e.g., 
Downey 
v. 
Mobile
Infirmary Med. Ctr., 662 So. 2d 1152, 1154
(Ala. 1995)(noting that "[t]his Court has
consistently held that the testimony of an
expert witness in a medical malpractice
case must be viewed as a whole, and that a
portion of it should not be viewed
abstractly, independently, or separately
from 
the 
balance 
of 
the 
expert's
testimony").
"'....
"'"'We are to view the [expert]
testimony as a whole, and, so viewing it,
determine if the testimony is sufficient to
create a reasonable inference of the fact
the plaintiff seeks to prove.'" Giles v.
Brookwood Health Servs., Inc., 5 So. 3d
533, 550 (Ala. 2008) (quoting Hines, 477
So. 2d at 304–05).  Viewing Dr. Buckley's
testimony as a whole and viewing the
evidence in the light most favorable to
Graves, 
we 
conclude 
that 
Graves
56
1180650
demonstrated the existence of a genuine
issue as to medical causation and that the
trial court's summary judgment against her
on this basis therefore was in error.'
"43 So. 3d at 1228."
Hrynkiw, 96 So. 3d at 800-01.  Based on Hrynkiw, Kimberlee
argues that the jury should have been permitted to sort
through 
any 
perceived 
discrepancies in 
Dr. 
Steckel's 
testimony
about the likelihood that Scott's cancer had already
metastasized in 2009.
Kimberlee also contends that Dr. Steckel's opinion that
Scott's prostate cancer had not metastasized in 2009 was not
based on speculation because Dr. Steckel plainly testified
that his assessment was based upon Scott's 2006 PSA level of
1.6, his 2009 PSA level of 14.3, the fact that bone scans are
not ordinarily mandated unless a patient has a PSA level of 20
or above,6 the fact that Dr. Remillard's rectal scan of Scott
in 2009 found no abnormalities in Scott's prostate, and
Dr. Steckel's extensive experience in working with prostate-
cancer patients.  Thus, Kimberlee argues, Dr. Steckel's
conclusion is a reasonable inference deducible from the facts
6Dr. Steckel testified that PSA levels between 10 and 20
are in a "gray zone" in which ordering a scan is based on the
individual characteristics of a patient.
57
1180650
rather than just a conjecture.  See Bradley, 878 So. 2d at
266.  Kimberlee insists that Dr. Steckel's statements on
cross-examination referred to the fact that it could not be
known for certain that Scott's cancer was localized to his
prostate in 2009 because no scan by a urologist was performed
at that time, but he clearly believed it was probable that the
cancer had not spread at that time.  In Kimberlee's view,
categorizing Dr. Steckel's testimony as purely speculative
conflates "the inability to rule out the possibility of
metastatic disease in 2009 with Scott's likely prognosis in
2009 had he been promptly diagnosed and treated."  Kimberlee's
reply brief, p. 17. 
The evaluation required with respect to Dr. Steckel's
causation testimony is similar to what is required in
examining the defendants' objection that Dr. Haines's
standard-of-care testimony sought to impose a heightened
standard of care.  That is, Dr. Steckel's testimony could be
understood as positing a "probability of a possibility" that
Scott's cancer had not metastasized in 2009, as the defendants
put it.  The defendants' brief, p. I.  However, Dr. Steckel's
testimony also could be understood as stating that, in all
58
1180650
probability, Scott's cancer had not metastasized in 2009, and
probability, not certainty, is what is required to present
substantial evidence of causation under the AMLA.  As we
concluded with respect to the testimony of Dr. Haines, when
Dr. Steckel's testimony is viewed in its totality and in a
light most favorable to Kimberlee, his testimony should not
have been excluded for a failure to provide substantial
evidence of causation.  It should have been left to a jury to
decide if Dr. Steckel established that the 
defendants' alleged
breach of the standard of care probably caused Scott not to be
in a better position than he otherwise would have been if he
had been informed of the PSA lab-test result in 2009.
In fact, the defendants' argument seems to ignore the
premise of the "better-position" principle that "'the issue of
causation in a malpractice case may properly be submitted to
the jury where there is evidence that prompt diagnosis and
treatment would have placed the patient in a better position
than [he] was in as a result of inferior medical care.'" 
Hamilton v. Scott, 278 So. 3d 1180, 1186 (Ala. 2018) (quoting
Parker v. Collins, 605 So. 2d 824, 827 (Ala. 1992)) (emphasis
59
1180650
altered).  As Kimberlee's counsel observed during the hearing
on the motion for a JML:
"Judge, under the circumstances where a patient was
not diagnosed, and there's no imaging test to
completely rule in or rule out bony metastasis or no
CT scan test that was done to rule out lymph node
metastasis, the plaintiff is left in the position of
looking at all of the data points that we have
present in this case, applying that to what is the
general knowledge in the field of urological
surgery, knowledge that was admitted by both experts
in this case, that a PSA level of 14 relates to a
risk of metastasis of less than thirty percent.  And
based on that exercise, that it is more probable
than not that you would not -- that he did not have
metastatic disease."
  In other words, the defendants complain that Kimberlee
cannot prove that the cancer was localized in Scott's prostate
in 2009 because no scan was performed at that time even though
the whole premise of Kimberlee's action is that no diagnosis
was made and no referral for urological testing was done in
2009.  It is inherent in a failure-to-diagnose-and-treat case
that a medical judgment assessing a patient's prognosis if
earlier treatment had occurred is necessarily based on less
evidence than would be available if that earlier treatment
actually had occurred.  The key issue is whether the expert
medical judgment is, in fact, based on evidence rather than
just a baldly stated opinion.  Dr. Steckel clearly did testify
60
1180650
that facts supported his medical opinion, namely Scott's 2006
PSA level of 1.6, his 2009 PSA level of 14.3, the fact that
bone scans are not ordinarily mandated unless a patient has a
PSA level of 20 or above, the findings of Dr. Remillard's 2009
rectal scan of Scott's prostate, and Dr. Steckel's extensive
experience with similar cancer patients.  Accordingly, Dr.
Steckel's testimony provided sufficient evidence of causation
for the issue to be submitted to a jury.
C. Testimony from CMA Wood
Kimberlee takes issue with the trial court's rulings on
three motions in limine filed by the defendants that prevented
CMA Wood from testifying about the standard of care applicable
to a CMA's informing patients of abnormal lab-test results
based on instructions from a supervising physician.  
Kimberlee
sought this witness testimony ostensibly to counter testimony
from CMA Ehlman who worked for Dr. Remillard at the clinic.
For someone who is not a specialist, an expert witness
will be considered a "similarly situated health care provider"
if the person meets the three criteria stated in § 6-5-548(b),
Ala. Code 1975:
"(1) Is licensed by the appropriate regulatory
board or agency of this or some other state.
61
1180650
"(2) Is trained and experienced in the same
discipline or school of practice.
"(3) Has practiced in the same discipline or
school of practice during the year preceding the
date that the alleged breach of the standard of care
occurred."
(Emphasis added.)  The trial court excluded Wood's testimony
on the basis of § 6-5-548(b)(3) because Wood had worked in a
cardiovascular clinic during the year immediately preceding
the alleged breach of the standard of care, whereas Ehlman had
been working in Dr. Remillard's family-medicine practice.
Kimberlee contends that the trial court's reasoning is
erroneous:
"The relevant inquiry under 
§ 
6-5-548 
is 
whether
Joanne Ehlman and Jennifer Wood both practiced in
the same discipline or school of practice during the
year preceding October 1, 2009. Both Jennifer Wood
and Joanne Ehlman are certified medical assistants
with experience communicating abnormal lab values in
the year preceding the alleged breach.  CMAs are not
specialists, and both Jennifer Wood and Joanne
Ehlman have worked in multiple different types of
medical offices.
"There 
is 
no 
distinction 
between 
the
certification for a CMA who works in a family
practice 
clinic 
and 
a 
CMA 
who 
works 
in 
a
cardiovascular setting.  And the communication of an
abnormal lab value is general and not specific.
Jennifer Wood is therefore similarly situated to
Joanne 
Ehlman 
and 
qualified 
to 
proffer
standard-of-care testimony."
62
1180650
Kimberlee's brief, p. 46.
The defendants agree with the trial court's finding that
Wood had not "practiced the same discipline or school of
practice" as Ehlman during the year preceding the alleged
breach of the standard of care.  For support, they cite
Anderson v. Alabama Reference Laboratories, 778 So. 2d 806
(Ala. 2000).  In Anderson, the plaintiffs alleged that a
medical-lab testing company, Alabama Reference Laboratories
("ARL"), had
"failed to properly perform tuberculosis testing on
Mr. Anderson's sputum specimen, by allowing it be
contaminated with the specimen of another donor, so
that it gave an inaccurate test result.  Thus, the
standard of care to be applied to this case is that
of a 'health care provider' practicing tuberculosis
testing."
778 So. 2d at 812.  The erroneous testing had caused
Mr. Anderson to be diagnosed with tuberculosis even though he,
in fact, had not contracted the disease.  ARL filed a summary-
judgment motion that it supported with an affidavit from "a
medical technologist certified by the American Society of
Clinical Pathologists ('ASCP') and 
[who] was the supervisor of
microbiology at ARL when it tested Mr. Anderson's sputum
specimen."  Id. at 810.  In opposition to motion, the
63
1180650
Andersons countered with deposition testimony from their
expert, Dr. Linda Pifer.  The trial court concluded that
Dr. Pifer was not qualified to testify against ARL as to the
applicable standard of care and its alleged breach under
§ 6-5-548(b)(3).  This Court agreed with the trial court's
conclusion:
"Dr. Pifer does not ... meet the requirement of
(b)(3).  Although Dr. Pifer has training and
experience in the general field of microbiology, she
does not have recent training or experience in the
specific field of tuberculosis testing.  In her
deposition testimony, Dr. Pifer admits that she has
never worked in a reference or clinical laboratory
or a mycobacteriology department; that prior to the
time of the testing that is the basis of this case,
she never supervised, or participated in, the
performance of tuberculosis testing and never did
any of the kinds of tuberculosis testing that were
performed by ARL on Anderson's sputum specimen; that
she has no practical experience in the field of
mycobacteria or tuberculosis testing; that she has
no personal knowledge of quality-assurance programs
at clinical or reference laboratories that conduct
tuberculosis testing; that she is not familiar with
the tuberculosis-testing guidelines recommended by
the 
primary 
certifying 
agency 
for 
clinical
laboratories; that she is not familiar with the
Centers for Disease Control guidelines relating to
mycobacteriology and tuberculosis testing; that she
has not written any article relating to tuberculosis
testing; and that she has no teaching experience in
the area of tuberculosis testing.  Finally, in her
deposition testimony, Dr. Pifer admits that she does
not practice in the same specialty as Decker or
Green. ... Because Dr. Pifer's own testimony shows
that she did not practice in the specialty of
64
1180650
tuberculosis testing in the year preceding the
testing of Anderson's sputum specimen, she does not
qualify as a 'similarly situated health care
provider' and, thus, is not competent to give expert
testimony concerning ARL's alleged breach of the
applicable standard of care."
Anderson, 778 So. 2d at 812-13.  
The defendants contend that Anderson is analogous
because, like Dr. Pifer in that case, Wood did not practice in
the same discipline or school of practice as Ehlman during the
year preceding the date of the alleged breach of the standard
of care.  However, Anderson is factually distinguishable from
this case because Dr. Pifer admitted she had never performed
the types of tuberculosis testing at issue in that case,
whereas Wood testified in her deposition that she had worked
as a CMA for a family-medicine practitioner between 1989 and
1994.  Moreover, Anderson does not illuminate the issue of
what is the applicable standard of care with respect to
CMA Ehlman?  Does the standard of care entail notifying
patients about abnormal PSA lab-test results -- which Wood
admitted she had not notified patients about in the relevant
year because she worked in a cardiovascular clinic -- or did
it entail notifying patients about abnormal lab-test results
in general -- which Wood testified was one of her regular
65
1180650
responsibilities?  In short, does "the same discipline or
school of practice" in § 6-5-548(b)(3) mean that which is
identical to the defendant, including the type of lab test to
be reported to a patient?
The question of what constitutes "the same discipline or
school of practice" for purposes of the applicable standard of
care of a CMA is similar to the issue we addressed earlier
with regard to whether Dr. Haines was qualified to offer an
opinion as to the standard of care for a family-medicine
practitioner because he was not working in a private,
community-based family-medicine practice during the year
preceding the breach of the standard of care.  On that issue,
we concluded that "this speciality" in § 6-5-548(c)(4) refers
to the board-certified specialty practiced by the defendant
doctor rather than the exact setting in which the defendant
doctor practiced that speciality.  Likewise, a CMA who carries
out a task that is very similar, though not identical, to the
task of the defendant CMA7 is still "practic[ing] in the same
discipline or school of practice."  § 6-5-548(b)(3).  The
defendants have not identified anything about notifying a
7We recognize that CMA Ehlman is a "defendant" only in the
sense that she is an employee of the defendants in this case.
66
1180650
patient of an abnormal PSA lab-test result based on
instructions 
from 
a 
supervising 
physician 
that 
is
significantly different from notifying a patient about an
abnormal lab-test result concerning a heart condition.
Accordingly, with respect to a CMA, the relevant question in
this case is what are the proper measures for notifying a
patient of an abnormal lab-test result based on instructions
from a supervising physician, not what are the proper measures
for notifying a patient regarding a specific kind of lab-test
result.  Given that standard, we conclude that CMA Wood should
have been permitted to testify regarding the standard
applicable to a CMA in this case.
D. Trial Court's Ruling on Scott's April 7, 2011, Clinic Visit
By granting MIL #24, the trial court prohibited
Kimberlee's counsel from asking Dr. Remillard about his not
telling Scott about the 2009 abnormal PSA lab-test result
during Scott's April 7, 2011, clinic visit.  The trial court
based that prohibition on § 6-5-551, Ala. Code 1975, which
requires the plaintiff in an AMLA action to "include in the
complaint filed in the action a detailed specification and
factual description of each act and omission alleged by
67
1180650
plaintiff to render the health care provider liable to
plaintiff ...."  The trial court concluded that, because
Kimberlee had not alleged that Dr. Remillard had breached the
standard of care on April 7, 2011, questioning Dr. Remillard
about his "failure" to notify Scott about the 2009 abnormal
PSA lab-test result on that visit would amount to adding an
act or omission that Kimberlee had not pleaded in the
complaint.
Kimberlee argues that the trial court's ruling on MIL #24
was erroneous because the complaint did include an allegation
that Dr. Remillard did not inform Scott about the 2009
abnormal PSA lab-test result during the April 7, 2011, clinic
visit. Kimberlee contends that the failure to inform Scott of
the test result was "an integral part of the theory of
liability" because 
"[Kimberlee's] main theory of liability is that
[Dr.] Remillard failed to timely inform Scott about
the 2009 PSA results.  Given that [Dr.] Remillard
did not inform Scott about his prior 2009 elevated
PSA test when Scott presented just eighteen months
later complaining of prostate issues, the jury could
reasonably infer that Dr. Remillard missed the
elevated PSA in 2009 and didn't know about it until
later.  In other words, a jury can reasonably infer
that Dr. Remillard didn't tell Scott about the prior
2009 elevated PSA on April 7th because he didn't
know it was elevated.  ...  A juror should be able
68
1180650
to consider why Dr. Remillard, if he had truly known
that Scott had an elevated PSA test from just
eighteen months earlier, would diagnose Scott with
a benign condition and not inform him about the
prior elevated PSA and serious concern for prostate
cancer.  The exclusion of this evidence was highly
prejudicial 
and 
substantially 
affected 
[Kimberlee's]
rights and ability to try the case."
Kimberlee's brief, pp. 19-21.
The defendants contend that Kimberlee's argument should
be "rejected out of hand" because Kimberlee's counsel stated
numerous times that Kimberlee was not accusing Dr. Remillard
of a breach of the standard of care during the April 7, 2011,
clinic visit.  The defendants's brief, p. 62.  For example,
during one argument concerning MIL #24, Kimberlee's counsel
stated:  "[W]hether it was finally diagnosed on April 7th or
April 21st, it makes no difference to the causation issue of
the case."  In the same argument, Kimberlee's counsel flatly
stated:  "We're not saying that they breached the standard of
care on April 7[, 2011].  I'm not saying that, Judge." 
Therefore, the defendants argue, the trial court was clearly
within its discretion to prohibit questioning about an
omission that had no bearing on the alleged injury to Scott. 
The defendants also observe that Kimberlee was permitted to
ask Dr. Remillard anything about what was said to Scott during
69
1180650
the April 7, 2011, clinic visit, so the jury was not being
deprived of details as to what occurred during the visit.
Kimberlee's argument with respect to MIL #24 at best
confuses the issue of what was the actual omission that was
alleged as a breach of the standard of care.  The consistent
allegation regarding a breach of the standard of care
concerned a failure to inform Scott in a timely manner about
the 2009 abnormal PSA lab-test result.  Yet, Kimberlee argues
that Dr. Remillard's failure to tell Scott about that result
during the April 7, 2011, clinic visit indicates that "Dr.
Remillard missed the elevated PSA in 2009 and didn't know
about it until later."  Kimberlee's brief, p. 21.  The timing
of Dr. Remillard's knowledge of the 2009 abnormal PSA lab-test
result is ultimately irrelevant to whether the 
defendants took
appropriate steps to inform Scott of the test result in a
timely manner.  It is true that if Dr. Remillard was unaware
of the 2009 PSA lab-test result until April 21, 2011, that
fact could lend credence to Scott's testimony that he was not
told about an abnormal test result in 2009.  On the other
hand, it is also true that specific questions to Dr. Remillard
about his failure to tell Scott about the 2009 abnormal PSA
70
1180650
lab-test result on April 7, 2011, could confuse a jury as to
the ultimate issue in the case.  See, e.g., Davis v. Hanson
Aggregates Southeast, Inc., 952 So. 2d 330, 338 (Ala. 2006)
(noting that "[a] trial court has discretion to exclude
otherwise admissible evidence in order to avoid misleading the
jury" (citing Rule 403, Ala. R. Evid.)).  Moreover, a review
of Dr. Remillard's testimony about the April 7, 2011, clinic
visit reveals that Kimberlee's counsel was able to ask
Dr. Remillard about everything that did occur during that
visit.  Further, Kimberlee's counsel was also permitted to ask
Dr. Remillard about informing Scott of his elevated PSA level
on April 21, 2011.  Thus, the jury was free to infer that
Dr. Remillard did not inform Scott about the 2009 abnormal PSA
lab-test result during the April 7, 2011, clinic visit. 
Kimberlee was just not permitted to draw an inference for the
jury as to what Dr. Remillard's failure to mention the 2009
PSA lab-test result on April 7, 2011, meant with respect to
the alleged breach of the standard of care. Given all of the
foregoing, we cannot conclude that the trial court erred in
its ruling on MIL #24.
71
1180650
E. The Trial Court's Ruling on Kimberlee's Use of the Term
"Patient Safety"
The trial court granted MIL #26, which sought to prohibit
any witness "from offering testimony regarding 'safer' or
'better' approaches or otherwise equating or suggesting that
safety defines the standard of care" because the actual
standard of care under the AMLA is that a physician must
provide "reasonable care."  Kimberlee contends that this was
error because 
"it does not run afoul of the AMLA, applicable case
law, ... or Ala. R. Evid. 402-403, to allow the
plaintiff to address, through qualified experts,
'better' or 'safer' approaches than the approach
used by the defendants, so long as the plaintiff's
expert addresses what the standard of care requires
and the approaches that fall within it."
Kimberlee's brief, p. 42.  
We decline to examine the substance of this argument
because -- as the defendants observe -- Kimberlee did not
preserve this error for appellate review.
"When there is no indication in the record that a
trial court's ruling on a motion in limine was
absolute or unconditional, the proponent of the
contested evidence must attempt to admit the
evidence at trial and obtain a specific adverse
ruling in order to preserve the issue for appellate
review."
72
1180650
Pensacola Motor Sales, Inc. v. Daphne Auto., LLC, 155 So. 3d
930, 936–37 (Ala. 2013).  There is no indication in the record
that the trial court's ruling on MIL #26 was absolute or
unconditional.  Therefore, it was incumbent upon Kimberlee to
proffer the testimony with respect to "patient safety" at
trial and to obtain an adverse ruling.  Kimberlee did not do
so, and Kimberlee did not address the defendants' response to
this argument in her reply brief.  Accordingly, this argument
has not been properly preserved for our review, and we uphold
the trial court's ruling on this issue.
IV.  Conclusion
Based on the foregoing, we conclude that Kimberlee
presented competent expert-witness testimony regarding the
standard of care and causation.  In the interest of judicial
economy, we also have addressed other rulings by the trial
court challenged by Kimberlee in this appeal.  Concerning
those rulings, Kimberlee's CMA nursing expert should have been
permitted to testify, but the trial court properly excluded
Kimberlee's counsel from directly questioning Dr. Remillard
about his failure to tell Scott about his 2009 abnormal PSA
lab-test result during his April 7, 2011, visit to the clinic. 
73
1180650
Moreover, Kimberlee's challenge to MIL #26 was not properly
preserved for appellate review.  The judgment of the trial
court is reversed, and the cause is remanded for a new trial.
REVERSED AND REMANDED.
Parker, C.J., and Wise, Bryan, Stewart, and Mitchell,
JJ., concur.
Sellers, J., concurs in part and dissents in part as to
the rationale and concurs in the result.
Shaw, J.,* concurs in the result.
*Although Justice Shaw did not sit for oral argument of
this case, he has reviewed a recording of that oral argument.
74
1180650
SELLERS, Justice (concurring in part and dissenting in part as
to the rationale and concurring in the result).  
I respectfully dissent from the holding that the trial
court erred in determining that plaintiff Kimberlee Spencer's
expert certified medical assistant ("CMA"), Jennifer Wood, is
not a similarly situated health-care provider with respect to
CMA Joan Ehlman.  I concur in the result as to the resolution
of the issue whether the plaintiff's expert physician, Dr. Joe
Haines, is a similarly situated health-care provider with
respect to defendant Dr. Michael A. Remillard.  I concur fully
in all other aspects of the opinion, and I agree that the
judgment as a matter of law in favor of the defendants should
be reversed and the cause remanded for a new trial.
CMA Wood was prepared to testify as to the standard of
care applicable to a CMA's responsibility to inform patients
of 
abnormal 
laboratory-test results 
based 
on 
instructions 
from
a supervising physician.  The trial court concluded that CMA
Wood had not "practiced in the same discipline or school of
practice during the year preceding the date" that CMA Ehlman
allegedly breached the standard of care.  § 6-5-548(b)(3),
Ala. Code 1975.  Thus, the trial court determined that CMA
75
1180650
Wood was not a similarly situated health-care provider under
§ 6-5-548(b)(3) and that her testimony could not establish
whether a breach of the standard of care occurred.  In
Anderson v. Alabama Reference Laboratories, 778 So. 2d 806
(Ala. 
2006), 
this 
Court 
held 
that 
an 
expert
microbiologist/medical-laboratory professional was not a
similarly situated health-care provider with respect to a
medical technologist who had tested the plaintiff for
tuberculosis, an infectious disease caused by bacteria. 
Although the expert had significant knowledge and experience
in microbiology, which includes "the laboratory analysis of
different types of bacteria and viruses," she had not
practiced in the specific area of tuberculosis testing in the
year preceding the alleged breach of the standard of care. 
778 So. 2d at 812.  In the present case, the alleged breach of
the standard of care was the failure to timely inform Scott
Spencer of his elevated PSA levels.  During the year preceding
the alleged breach of the standard of care, CMA Wood had
experience with receiving and reporting abnormal test results
with respect to some conditions, but not elevated PSA levels. 
As the appellant, Kimberlee Spencer bears the burden of
76
1180650
demonstrating that the trial court exceeded its discretion. 
I do not believe that she has demonstrated that there is no
significant difference between receiving and reporting
abnormal PSA test results and receiving and reporting other
abnormal test results.
77