Case Title: Hannah v. Naughton, M.D., et al.

Citation: 

Docket Number: 

State: alabama

Court: Alabama Supreme Court

Date: 2020-09-25T00:00:00Z

Document:
Rel: September 25, 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
____________________
1190216
____________________
Regina D. Hannah
v.
Michael J. Naughton, M.D., Michael J. Naughton, M.D., Ph.D.,
LLC, Terisa A. Thomas, M.D., and Terisa A. Thomas, M.D.,
P.C.
Appeal from Etowah Circuit Court
(CV-07-900185)
BOLIN, Justice.
Regina D. Hannah appeals from a summary judgment entered
by the Etowah Circuit Court in favor of Michael J. Naughton,
M.D.; Michael J. Naughton, M.D., Ph.D., LLC; Terisa A. Thomas,
1190216
M.D.; and Terisa A. Thomas, M.D., P.C. (hereinafter
collectively referred to as "the defendants"), on Hannah's
claims alleging medical malpractice.
Facts and Procedural History
On August 1, 2005, Hannah was seen by Dr. Terisa A.
Thomas, a board-certified general surgeon, for a female
health-care examination. Hannah was 32 years old at the time
she was first seen by Dr. Thomas and was complaining of
fatigue, weight gain, heavy menstrual cycles, cramping, and
painful sexual relations. Hannah also reported a significant
family medical history of cervical cancer and stated that she
was fearful of getting cancer. Hannah stated that her mother,
grandmother, and sister had suffered from cervical cancer. 
Dr. Thomas ordered a number of tests, including a pelvic
ultrasound and a Pap smear. Hannah returned to Dr. Thomas on
August 10, 2005. Dr. Thomas informed Hannah at that time that
the pelvic ultrasound was normal and that the results of the
Pap smear were still pending.
Dr. Thomas received the results of Hannah's Pap smear on
August 12, 2005.  The Pap-smear report indicated that it was
"abnormal" with a diagnosis of "Epithelial Cell Abnormality. 
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Atypical Squamous Cells Cannot Exclude High Grade Squamous
Intraepithelial Lesion (HSIL)."  Dr. Thomas stated that this
was not a diagnosis of cancer but, rather, that she considered
it an abnormal finding indicative of an "increased risk" of
cancer.  After receiving the Pap-smear report, Dr. Thomas's
office contacted Hannah to schedule a follow-up appointment
for August 15. Dr. Thomas's office also faxed a copy of the
Pap-smear 
report 
to 
Dr. 
John 
Morgan, 
an
obstetrician/gynecologist, and scheduled an appointment for
Hannah with Dr. Morgan for August 16. Dr. Thomas explained
that she went ahead and scheduled the appointment for Hannah
with Dr. Morgan before actually seeing Hannah because she
anticipated the need for follow-up care and testing and
because she did not want Hannah to have to wait  for follow-up
care in light of her extreme fear of cancer and her family
history of cancer. 
Hannah testified that a nurse from Dr. Thomas's office
contacted her while she was at work to schedule the follow-up
appointment for August 15.  Hannah testified that the nurse
told her that the results of the Pap smear  indicated the
presence of atypical squamous cells. Hannah stated that she
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asked the nurse what atypical squamous cells were and that the
nurse responded that they were cervical cancer. Hannah
testified that when the nurse told her on the telephone that
she had cervical cancer she became very upset and started
crying.  Hannah stated that at that point Dr. Thomas got on
the telephone to ask her to come into the office and that they
would discuss the results of the Pap smear further.  Hannah
testified that her coworkers were present and witnessed her
conversation with Dr. Thomas's office. Dr. Thomas stated that
her staff would not discuss the results of the Pap smear with
Hannah over the telephone and that she "would just be told
that she needed to come back in to discuss her results." Dr.
Thomas further stated that she did not remember talking to
Hannah on the telephone. 
Hannah was seen by Dr. Thomas on August 15 for the
follow-up appointment regarding the results of the Pap smear. 
Dr. Thomas testified that she discussed the results of the Pap
smear with Hannah, telling her that the Pap smear showed the
presence of "abnormal squamous cells" and that "it could not
exclude high grade squamous intraepithelial lesion." Dr.
Thomas stated that she told Hannah the Pap smear was abnormal
4
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but that it "certainly was not cancer." Dr. Thomas said she
further informed Hannah that the presence of abnormal cells
put her at an increased risk for cervical cancer and that she
would need to be closely monitored. 
Dr. Thomas explained to Hannah that her normal practice
with patients who have an abnormal Pap smear is to refer them
to an obstetrician/gynecologist for a second opinion and that
they had already scheduled an appointment for her with Dr.
Morgan.  Dr. Thomas testified that Hannah continued to be
extremely anxious and repeatedly stated that she had a
significant family history of cervical cancer and that  she
was fearful of getting cancer. Dr. Thomas testified that
Hannah told her that "she wanted to have it all [taken] out"
and wanted to discuss surgical options.  Dr. Thomas stated
that she proceeded to discuss a total abdominal hysterectomy
with Hannah, which may or may not involve the removal of her
ovaries.  Dr. Thomas stated that she told Hannah that if she
had her ovaries removed she would require hormone-replacement
therapy.    Dr. Thomas documented her conversation with Hannah
in her records, noting that the "[patient] wishes to proceed
5
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[with] hysterectomy due to abnormal Pap and strong [family
history of cancer]."  
Hannah testified that, when she arrived at Dr. Thomas's
office on August 15, she signed in and was taken to Dr.
Thomas's private office.  Hannah testified that Dr. Thomas
told her that she had cervical cancer and that she recommended
Hannah have a hysterectomy, including the removal of her
ovaries. Hannah stated that no options were given other than
a hysterectomy.  Hannah denied making the statement to Dr.
Thomas that she "wanted it all out."  Hannah testified that
she was  upset and that Dr. Thomas was "very consoling." 
Hannah's  appointment with Dr. Morgan was canceled. 
Because Dr. Thomas does not perform hysterectomies, Hannah was
given the names of several surgeons to whom Dr. Thomas
referred patients for hysterectomies. Hannah selected Dr.
Naughton, a board-certified general surgeon.  Dr. Thomas
contacted Dr. Naughton while Hannah was still in her office.
Dr. Thomas related to Dr. Naughton that she had a patient she
wanted to refer to him for a second opinion following an
abnormal Pap smear.  Dr. Thomas told Dr. Naughton that Hannah
was 32 years old and was extremely fearful of contracting
6
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cervical cancer because of her significant family history of
cervical cancer.  Dr. Thomas informed Dr. Naughton that Hannah
insisted on having a complete  hysterectomy.  Dr. Naughton
asked Dr. Thomas if Hannah had children because she was young
to have a hysterectomy. Dr. Thomas responded that Hannah had
had a previous tubal ligation and did not want to have more
children. Dr. Naughton agreed to see Hannah that day. 
Hannah was first seen by Dr. Naughton on August 15, for
an evaluation for a hysterectomy.   Hannah related a history
to Dr. Naughton of two vaginal births, heavy bleeding during
menstrual cycles, painful sexual intercourse, a tubal
ligation, and a significant family history of breast cancer
and cervical cancer.   Dr. Naughton stated that Hannah told
him that she was "very fearful of having cancer." Dr. Naughton
performed a pelvic exam on Hannah and noted that she
experienced pain upon any movement of her cervix or uterus. 
Dr. Naughton also noted that he did not observe any lesions or
abnormal tissue during the examination.  Dr. Naughton
testified that he told Hannah "at least three times" that she
did not have cancer and that the majority of abnormal Pap
smears revert to normal. 
7
1190216
Dr. Naughton testified that he told Hannah there were
"multiple options" available to her and that his initial
recommendation to her was to repeat the Pap smear in six
months.   Dr. Naughton informed her that if the second Pap
smear came back abnormal they could discuss the option of
having a directed biopsy performed.  Dr. Naughton also
discussed more aggressive treatment options, including the
removal of the uterus and cervix with the preservation of the
ovaries or the removal of the uterus, cervix, and the ovaries. 
Dr. Naughton testified that Hannah chose the most aggressive
option, specifically stating that she wanted "it all out,"
including her ovaries.  Dr. Naughton agreed that Hannah's 
choice to remove her ovaries was indicated, given her fear of
developing ovarian cancer as well as the fact that an
abnormality on the ovaries could be the cause of her painful
intercourse. Dr. Naughton informed Hannah that if her ovaries
were removed she would require hormone-replacement therapy.  
Dr. Naughton had Hannah execute a "surgical-awareness"
form indicating that she  accepted full responsibility for her
decision to have the surgery.  Dr. Naughton stated that he
made the following notes on the form in Hannah's presence:
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"told Pap smear not cancer and high chance would change back
to normal -– discussed conversion. Options for treatment of
cervix given. Ovarian preservation discussed."  Both Dr.
Naughton and Hannah signed the "surgical-awareness" form.  The
form 
containing Dr. 
Naughton's 
handwritten 
notations 
was 
faxed
by Dr. Naughton's office to the Riverview Medical Center
before surgery and was received by that facility at 6:34 A.M.
on August 18, 2005.1   
Hannah testified that when she first saw Dr. Naughton he
reviewed her test results, took a medical history,  and
performed a pelvic exam.  Hannah stated that Dr. Naughton then
told her that he "agreed with Dr. Thomas ... that I had
cervical cancer, and he told me [that] his staff could set the
surgery."  Hannah stated that she asked Dr. Naughton about
preserving her ovaries and that he stated that there was a
chance the cancer would come back in the ovaries so he
recommended removing the ovaries.  Hannah stated that Dr.
Naughton never informed her that cancer could not be diagnosed
from an abnormal Pap smear.  Hannah further testified that Dr.
1Hannah has asserted that Dr. Naughton's handwritten
notations were added after her  surgery. 
9
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Naughton did not mention any treatment options other than a
full hysterectomy.  Hannah testified that she did sign the 
"surgical-awareness" form but denies that the form contained
any handwritten notes by Dr. Naughton stating that she did not
have cancer or that he discussed with her preserving her
ovaries. 
Hannah's surgery was performed on August 18, 2005.  Dr.
Naughton noted in the records an admitting diagnosis of
dyspareunia (painful intercourse), pelvic pain, and an
abnormal Pap smear.  There was no indication of any diagnosis
of cervical cancer mentioned in the surgical record.  Dr.
Naughton noted in the surgical record Hannah's family history
of cervical cancer and her own "great fear" of cancer.  Dr.
Naughton further noted that it was explained to Hannah that
the abnormal Pap smear was not an indication for the
hysterectomy and that she was given conservative treatment
options.  Dr. Naughton noted that Hannah elected to have a
full hysterectomy, including the removal of her ovaries. 
Hannah's surgery was completed without complication.  
Dr. Naughton testified that he saw Hannah in the hospital
on the day after surgery and that she complained of continued
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pain and problems "voiding."  Dr. Naughton examined Hannah at
this time and decided to keep her in the hospital one more
night because he did not want to send her home when she was
feeling uncomfortable.  Hannah's mother, Darlene Templeton,
states that she spoke with Dr. Naughton during this visit and
asked him if he got all the cancer and that he responded
"yes." 
Hannah returned to see Dr. Naughton on August 24 for a
follow-up appointment.  Dr. Naughton noted at that time that
the wound was healthy and that he removed her surgical
staples.  Dr. Naughton also had received at this time a copy
of the pathology report, which indicated that Hannah did not
have cancer. Dr. Naughton testified that he reviewed this
report with Hannah and told her there was no cancer present. 
Dr. Naughton testified that he did not discuss chemotherapy
treatments with Hannah because she did not have cancer. Dr.
Naughton stated that Hannah asked him if he "got everything." 
Dr. Naughton testified that, because he had already told
Hannah she did not have cancer, he assumed she meant
anatomically, and he responded "yes." Dr. Naughton testified
that Hannah was to follow up with Dr. Thomas. Following the
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surgery, Hannah sent Dr. Naughton a note thanking him for his
care and informing him that she was "recovering well and
feeling great."
Hannah testified that Dr. Naughton told her at the August
24  visit that he did not have the pathology report back but
that he "felt comfortable that ... he had gotten all the
cancer."  Hannah also stated that she asked Dr. Naughton about
chemotherapy treatments and that he stated that he "felt that
all the cancer had been taken, gotten out, and he felt good
about the surgery."  Hannah was not seen by Dr. Naughton after
August 24. 
Although Hannah denies any further visits with Dr.
Thomas, the medical records indicate that she was also seen by
Dr. Thomas on August 24.  Dr. Thomas stated that Hannah was
happy that everything had gone well with her surgery and was
relieved that she did not have cancer.  Dr. Thomas noted that
Hannah had had her surgical staples removed earlier that day
and that she was doing well following the surgery.  Dr. Thomas
testified that she had a copy of the pathology report, which
indicated that Hannah did not have cancer, and that she
discussed the results of the report with Hannah.  Dr. Thomas
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stated that she did not discuss chemotherapy options with
Hannah because she did not have cancer.  Dr. Thomas did not
see Hannah again after this visit.
Hannah testified that she attempted to follow up with Dr.
Naughton regarding her pathology report on several occasions
but states that her telephone calls were not returned.  Hannah
testified that she became aggravated with the lack of response
from Dr. Naughton's office so she saw a physician in Gadsden
who referred her to Dr. Max Austin, a gynecologic oncologist. 
Dr. Austin obtained a copy of Hannah's pathology report and,
according to Hannah, told her that she "never had nor did
[she] have cervical cancer."        
On July 31, 2007, Hannah sued the defendants under § 6-5-
480 et seq. and § 6-5-541 et seq., Ala. Code 1975, the Alabama
Medical Liability Act ("the AMLA"), alleging that the
defendants had "negligently or wantonly provided health care
services and/or medical care to [Hannah], including surgical
services, post surgical follow up care, [and] diagnostic
care."  Specifically, Hannah alleged, among other things, 
that the defendants breached their standard of care by falsely
informing her that she had cervical cancer based on an
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abnormal Pap-smear result; by advising her that she should
undergo an immediate hysterectomy, including the removal of
her ovaries; by performing a complete hysterectomy on Hannah
without first performing necessary tests/procedures to
properly diagnose the cause of Hannah's symptoms; by failing
to fully and properly advise Hannah of options other than
surgery; by failing to inform Hannah that she never had cancer
and/or 
falsely 
representing 
to 
her 
that 
cancerous
organs/tissue had been removed during surgery; and by failing
to inform her of the results of the pathology report. 
On March 8, 2012, the defendants moved the trial court
for a summary judgment.  The summary-judgment motion was
supported by affidavits from Dr. Thomas and Dr. Naughton
stating that they both met the applicable standard of care for
board-certified general surgeons in their care and treatment
of Hannah.  The defendants further  argued  that Hannah had
failed to support her claims with the required testimony from
a similarly situated medical expert.  
On March 13, 2012, the trial court ordered Hannah to
respond to the defendants' summary-judgment motion within 30
days.  On April 9, 2012, Hannah moved the trial court for
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additional 
time 
to 
respond 
to 
the 
defendants' 
summary-judgment
motion, stating, among other things, that she was required to
support her claims with expert medical testimony  and that she
needed additional time to obtain a medical expert.  On April
11, 2012, the trial court entered an order granting Hannah
additional time to respond.
On October 22, 2012, Hannah filed her response in
opposition to the defendants' summary-judgment motion. 
Hannah's opposition was supported by the testimony of Dr. Fred
Duboe, 
a board-certified 
physician 
of 
obstetrics 
and
gynecology, who testified that Dr. Thomas and Dr. Naughton
breached the applicable standard of care in several regards. 
On March 6, 2013, the defendants moved the trial court to
preclude his testimony and strike Dr. Duboe's affidavit,
arguing that Dr. Duboe was not  a "similarly situated" health-
care provider because Dr. Duboe was board certified in
obstetrics and gynecology and was not board certified in
general surgery as were Dr. Thomas and Dr. Naughton.
Accordingly, the defendants argued that Dr. Duboe was not
qualified to testify as to the standard of care applicable to
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Dr. Thomas and Dr. Naughton as board-certified general
surgeons in their treatment of Hannah. 
On June 14, 2013, Hannah responded to the defendants'
motion to preclude Dr. Duboe's testimony and strike his
affidavit, arguing that, although the "standard of care
allegedly 
breached 
virtually 
requires 
no 
expert 
testimony, 
the
plaintiff's expert witness Dr. Fred Duboe, who is board
certified in Obstetrics and Gynecology but not General
Surgery, is nevertheless similarly situated to the defendant
board certified general surgeons." Hannah also argued that the
deposition testimony of Dr. Thomas supports the position that
the standard of care to which Dr. Thomas and Dr. Naughton are
to be held and allegedly breached is undisputed and requires
no expert testimony because Dr. Thomas "readily agreed in her
deposition that if she [or Dr. Naughton] did tell Ms. Hannah
that she had cancer based on her Pap smear results that would
be below the standard of care."  Hannah also notes that Dr.
Thomas testified that it would be below the standard of care
for either her or Dr. Naughton to fail to tell Hannah that the
pathology report in her case showed no cancer.  Hannah further
argued that Dr. Duboe's testimony was  not precluded because
16
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Dr. Thomas's and Dr. Naughton's alleged misrepresentations
regarding the Pap-smear results and alleged cancer were not
within their specialty of general surgery.  Finally, Hannah
requested additional time to support her response in
opposition to the summary-judgment motion with a new expert
should the trial court grant the defendants' motion to
preclude Dr. Duboe's testimony and strike his affidavit. 
 On September 20, 2013, the trial court entered an order
precluding any standard-of-care testimony from Dr. Duboe and
striking his affidavit. The trial court granted Hannah
additional time to find and depose a substitute standard-of-
care medical expert. 
On December 10, 2013, Hannah filed a notice identifying
Dr. Lawrence Brickman, a general surgeon, as her standard-of-
care medical expert.  Dr. Brickman was deposed on June 5,
2014.  Dr. Brickman testified during his deposition that,
although he was board certified in general surgery at the time
of Hannah's surgery in 2005, he was no longer board certified
in general surgery at the time of his testimony. 
Subsequently, the trial court entered an order setting
the case for trial on May 6, 2019, and ordered Hannah to
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disclose any additional experts 90 days before trial, i.e., by
February 6, 2019.  The trial court also specified in its order
that 
no 
continuances 
would 
be 
granted 
except 
for
"extraordinary reasons."2 
On March 6, 2019, the defendants moved the trial court to
preclude the testimony of Dr. Brickman, arguing that, because
Dr. Brickman was not currently board certified in general
surgery as were Dr. Thomas and Dr. Naughton, he was not a 
"similarly situated health care provider" as defined by § 6-5-
548(c)(3), Ala. Code 1975, which provides that a similarly
situated health-care provider is one that "[i]s certified by
an appropriate American board in the same specialty."  The
defendants renewed their motion for a summary judgment,
arguing that Hannah had failed to support her claims with
expert testimony from a similarly situated health-care
provider as required by the AMLA and that, with or without Dr.
Brickman's testimony, Hannah had failed to establish by
substantial evidence that Dr. Thomas and Dr. Naughton had
breached the standard of care and that that breach probably
caused Hannah's injury. 
2The trial of this case did not take place on May 6, 2019.
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On August 16, 2019, Hannah filed another response in
opposition to the motion for a summary judgment, arguing that
she had presented substantial evidence creating a genuine
issue of material fact as to whether she was falsely told by
Dr. Thomas and Dr. Naughton that she had cervical cancer and
whether those false statements convinced her that she had no
option but to undergo a complete hysterectomy.  
Hannah further noted that Dr. Brickman had become a 
board-certified general surgeon in 1978 and that he was board
certified in general surgery at the time Dr. Thomas and Dr.
Naughton treated Hannah.  Relying upon Chapman v. Smith, 893
So. 2d 293 (Ala. 2004), Hannah argued that  § 6-5-548(c)(3)
did not contain any requirements as to the period that a
proffered medical expert must be board certified before that
medical expert can testify as 
a similarly situated health-care
provider. Thus, Hannah argued that Dr. Brickman's testimony
could not be precluded.   Further, Hannah contended that her
claims alleging that she was falsely told by Dr. Thomas and
Dr. Naughton that she had cervical cancer, which false
statements, she said, convinced her to have a hysterectomy,
are the type of claims that do not require the presentation of
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expert medical testimony because, she says, they are not
"beyond the ken of the average layman." Lively v. Kilgore, 51
So. 3d 1045, 1050 (Ala. Civ. App. 2010). In addition to the
response in opposition to the motion for a summary judgment,
Hannah also sought, pursuant to Rule 56(f), Ala. R. Civ. P.,
an opportunity and a reasonable period within which to find a
substitute expert to respond to the defendants' summary-
judgment motion should Dr. Brickman's testimony be precluded. 
On September 17, 2019, the trial court entered a summary
judgment finding that the defendants had made "a prima facie
showing of non-liability and 
[Hannah] ha[d] failed to overcome
this prima facie showing by failing to present substantial
evidence through a similarly situated health care provider
that the alleged negligence on the part of the defendants
probably caused the alleged injury to [Hannah]."  The trial
court also determined that Hannah's request for additional
time to obtain a medical expert was moot.   Hannah's
postjudgment motion to alter, amend, or vacate the summary
judgment was denied, and she appealed.
Standard of Review
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This Court's standard of review relative to a summary
judgment is as follows:
"'"'This Court's review of a
summary judgment is de novo.
Williams v. State Farm Mut. Auto.
Ins. Co., 886 So. 2d 72, 74 (Ala.
2003). We apply the same standard
of review as the trial court
applied. Specifically, we must
determine whether the movant has
made a prima facie showing that
no genuine issue of material fact
exists and that the movant is
entitled to a judgment as a
matter of law. Rule 56(c), Ala.
R. Civ. P.; Blue Cross & Blue
Shield of Alabama v. Hodurski,
899 So. 2d 949, 952–53 (Ala.
2004). 
In 
making 
such 
a
determination, we must review the
evidence 
in 
the 
light 
most
favorable 
to 
the 
nonmovant.
Wilson v. Brown, 496 So. 2d 756,
758 (Ala. 1986). Once the movant
makes a prima facie showing that
there is no genuine issue of
material fact, the burden then
shifts 
to 
the 
nonmovant 
to
produce "substantial evidence" as
to the existence of a genuine
issue of material fact. Bass v.
SouthTrust 
Bank 
of 
Baldwin
County, 538 So. 2d 794, 797–98
(Ala. 1989);  Ala. Code 1975, §
12–21–12. 
"[S]ubstantial 
evidence
is evidence of such weight and
quality that fair-minded persons
in the exercise of impartial
judgment can reasonably infer the
existence of the fact sought to
21
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be proved." West v. Founders Life
Assur. Co. of Fla., 547 So. 2d
870, 871 (Ala. 1989).'"
"'Prince v. Poole, 935 So. 2d 431, 442
(Ala. 2006) (quoting 
Dow v. Alabama
Democratic Party, 897 So. 2d 1035, 1038–39
(Ala. 2004)).'
"Brown v. W.P. Media, Inc., 17 So. 3d 1167, 1169
(Ala. 2009).
"'"In order to overcome a defendant's
properly 
supported 
summary-judgment 
motion,
the 
plaintiff 
bears 
the 
burden 
of
presenting substantial evidence as to each
disputed element of [its] claim." Ex parte
Harold L. Martin Distrib. Co., 769 So. 2d
313, 314 (Ala. 2000).'
"White Sands Grp., L.L.C. v. PRS II, LLC, 32 So. 3d
5, 11 (Ala. 2009)."
Laurel v. Prince, 154 So. 3d 95, 97-98 (Ala. 2014).
This Court has further stated, in the context of a
medical-malpractice claim: 
"'Substantial evidence is defined in
the medical-malpractice context as "that
character of admissible evidence which
would convince an unprejudiced thinking
mind of the truth of the fact to which the
evidence is directed." § 6–5–542(5)[, Ala.
Code 1975]. Rule 56, Ala. R. Civ. P.,
governing motions for summary judgment,
must be read in conjunction with that
definition of substantial evidence. Golden
v. Stein, 670 So. 2d 904, 907 (Ala. 1995).
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1190216
"'This Court's review of a summary
judgment in a medical-malpractice case, as
in 
other 
cases, 
is 
guided 
by 
the
proposition that "this Court must review
the record in a light most favorable to the
nonmovant and must resolve all reasonable
doubts against the movant." Hobson v.
American Cast Iron Pipe Co., 690 So. 2d
341, 344  (Ala. 1997), quoted in Hauseman
v. University of Alabama Health Servs.
Found., 793 So. 2d 730, 734 (Ala. 2000).
"'If 
the 
movant 
in 
a
medical-malpractice case makes a prima
facie showing that there is no genuine
issue of material fact, then, as in other
civil cases, the burden shifts to the
nonmovant to present substantial evidence
creating such an issue. Ex parte Elba Gen.
Hosp. & Nursing Home, Inc., 828 So. 2d 308,
311 (Ala. 2001).
"'"...."
"'....
"'"[A] 
medical 
malpractice
plaintiff 
must 
produce
substantial evidence that 'the
alleged 
negligence 
"probably
caused 
the 
[complained 
of]
injury,"' in order to survive a
summary judgment motion, if the
defendant has made a prima facie
showing that no genuine issue of
material fact exists as to the
issue of causation."
"'Golden, 670 So. 2d at 907.
"'"'To present a jury question,
t h e  
pl a i n tiff 
[in 
a
23
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medical-malpractice action] must
adduce some evidence indicating
that the alleged negligence (the
breach 
of 
the 
appropriate
standard of care) probably caused
the injury. A mere possibility is
insufficient. 
The 
evidence
produced by the plaintiff must
have "selective application" to
one theory of causation.'"
"'Rivard v. University of Alabama Health
Servs. Found., P.C., 835 So. 2d 987, 988
(Ala. 2002).'
"Cain v. Howorth, 877 So. 2d 566, 575–76 (Ala.
2003)."
Boyles v. Dougherty, 143 So. 3d  682, 685  (Ala.  2013).
  Discussion
Hannah argues that the trial court erred in determining
that Dr. Brickman was not a similarly situated health-care
provider under § 6-5-548(c)(3) because he was not board
certified in general surgery at the time he gave his testimony
regarding the applicable standard of care in this case. 
Section 6-5-548, Ala. Code 1975, provides, in part:
"(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
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general line of practice ordinarily have and
exercise in a like case.
"....
"(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
alleged breach of the standard of care
occurred.
"....
"(e) ... It is the intent of the Legislature
that in the event that the defendant health care
provider is certified by an appropriate American
board or in a particular specialty and is practicing
that specialty at the time of the alleged breach of
the standard of care, a health care provider may
testify as an expert witness with respect to an
alleged breach of the standard of care ... against
another health care provider only if he or she is
25
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certified by the same American board in the same
specialty."
Section 6-5-542(2), Ala. Code 1975, defines the 
term "standard
of care" as 
"that level of 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 like cases. A breach
of the standard of care is the failure by a health
care provider to comply with the standard of care,
which failure proximately causes personal injury or
wrongful death whether in contract or tort and
whether based on intentional or unintentional
conduct."
A plaintiff in a medical-malpractice action 
"ordinarily must present expert testimony from a
'similarly situated health-care provider' as to (1)
'the appropriate  standard of  care,' (2) a
'deviation from that standard [of care],' and (3) 'a
proximate 
causal 
connection 
between 
the
[defendant's] act or omission constituting the
breach and the injury sustained by the plaintiff.'
Pruitt v. Zeiger, 590 So. 2d 236, 238 (Ala. 1991)
(quoting Bradford v. McGee, 534 so. 2d 1076, 1079
(Ala. 1988)).  The reason for the rule that
proximate causation must be established through
expert testimony is that the issue of causation in
a medical-malpractice case is ordinarily 'beyond
"the ken of the average layman."' Golden v. Stein,
670 So. 2d 904, 907 (Ala. 1995), quoting Charles W.
Gamble, McElroy's Alabama Evidence § 127.01(5)(c),
p. 333 (4th ed. 1991). The plaintiff must prove
through 
expert 
testimony 
'that 
the 
alleged
negligence "probably caused the injury."' McAfee v.
Baptist Med. Ctr., 641 So. 2d 265, 267 (Ala. 1994)."
26
1190216
Lyons v. Walker Reg'l Med. Ctr., 791 So. 2d 937, 942 (Ala.
2000).   See also Youngblood v. Martin, [Ms. 1171037, January
10, 2020] __ So. 3d __ (Ala. 2020).
Dr. Brickman is a graduate of the medical school at the
University of Brussels in Belgium.   He completed his surgical
residency in 1976 and became a board-certified surgeon in
1978.  Dr. Brickman was recertified in 1988 and again in 1996.
Dr. Brickman has worked as a clinical associate professor at
New York Medical College and State University of New York at
Stonybrook. Dr. Brickman served as the chief of general
surgery at Huntington Hospital.  At the time Dr. Brickman gave
his deposition testimony in this case, he was the clinical
associate 
professor 
of 
surgery 
at 
Florida 
Atlantic 
University,
Charles E. Schmidt College of Medicine. Dr. Brickman also
served as the director of the clinical-surgical clerkship and
director of clinical education and surgery at the medical
school. Dr. Brickman was performing general surgery in 2005,
the year the defendants treated Hannah.  Although Dr. Brickman
continued to maintain his fellowship in the American College
of Surgeons, he was no longer performing any primary surgery
at the time he gave his deposition.  Dr. Brickman testified
27
1190216
that he last performed a hysterectomy in 1974. It is
undisputed that he was not board certified in general surgery
at the time of the deposition.  
Hannah argues that the decision in Chapman v. Smith, 893
So. 2d 293 (Ala. 2004), does not require disqualifying Dr.
Brickman as an expert in this case on the basis that he was
not board certified in general surgery at the time he
testified in his deposition.   In Chapman, the plaintiffs sued
Dr. Chapman alleging medical malpractice based on Dr.
Chapman's alleged negligent administration of a cervical
epidural injection. The plaintiffs sought to present the
testimony of their two experts, Dr. Pawan Grover and Dr.
William Kendall.  Dr. Chapman objected to their testimony on
the basis that neither Dr. Grover nor Dr. Kendall was
qualified to testify at trial. The trial court granted the
objection as to Dr. Grover, stating that he was not "qualified
to testify as an expert in this case because he was not
board-certified in anesthesiology in the year preceding the
event which gives rise to the cause of action in this case." 
893 So. 2d at 294.  The trial court granted the objection as
to Dr. Kendall because Dr. Kendall had "not established the
28
1190216
standard of care as to the use of fluoroscopy in cervical
epidural injections."  893 So. 2d at 295. Subsequently, the
trial court entered a judgment as a matter of law in favor of
Dr. Chapman. 
The plaintiffs moved the trial court to alter, amend, or
vacate the trial court's judgment.   The trial court entered
an order granting the postjudgment motion, stating that Dr.
Grover met the criteria of § 6–5–548(c) and that, therefore,
he was a similarly situated health-care provider competent to
give expert testimony.   The trial court ordered that its
prior order striking the testimony of Dr. Grover and Dr.
Kendall be vacated. 
Dr. Chapman argued on appeal that Dr. Grover was not  a
board-certified specialist during the year preceding Dr.
Chapman's alleged breach of the standard of care, that he was
not similarly situated to Dr. Chapman, who was board certified
in anesthesiology and in pain management, and thus that he
could not testify concerning the appropriate standard of care
Dr. Chapman should have exercised in administering the
cervical epidural injection. The plaintiffs argued that Dr.
Chapman  misconstrued the meaning of § 6–5–548(c), because
29
1190216
that section did not require that Dr. Grover be board
certified during the 
year preceding the alleged malpractice to
testify as an expert in a medical-malpractice action.
Dr. Chapman argued that Dr. Grover was not similarly
situated to Dr. Chapman because Dr. Grover was not board
certified in anesthesiology or in pain management during the
year preceding Dr. Chapman's alleged breach of the standard of
care in this case.  According to Dr. Chapman,  although §
6–5–548(c)(3) does not explicitly require that a proffered
expert witness be board certified in a specialty during the
year preceding the alleged breach in a case, a doctor cannot
practice in a specialty as required by § 6-5-548(c)(4), Ala.
Code 1975, unless he or she is certified by an appropriate
American board as a specialist as required in subsection (3).
Thus, Dr. Chapman contended that this Court should construe §
6–5–548(c)(3) to require that a proffered expert witness be
certified by an appropriate American board in the same
specialty as the defendant during the year preceding the date
on which the alleged breach of the standard of care occurred.
The plaintiffs asserted that the plain language of §
6–5–548(c) did not require that, before he could qualify as a
30
1190216
similarly situated health-care provider, Dr. Grover be board
certified in anesthesiology and in pain management during the
year preceding Dr. Chapman's alleged breach of the standard of
care. Thus, the plaintiffs argued that this Court should not
construe § 6-5-548(c)(3) to require that a proffered expert be
board certified during the year preceding the alleged breach. 
Construing  § 6–5–548(c) according to its plain language
to ascertain and give effect to the legislature's intent in
enacting the statute, this Court stated, with regard to Dr.
Grover's status as a similarly situated health-care provider:
"The controlling statute in this case, §
6–5–548(c), states in subsection (3) that a
proffered expert witness must be 'certified by an
appropriate American board in the same specialty' as
the specialist charged with medical malpractice in
order to testify against a specialist concerning the
applicable 
standard 
of 
care. 
There 
are 
no
qualifications in subsection (3) as to the period of
time the proffered expert must be board-certified
before he or she can testify against a specialist.
Section 6–5–548(c) further mandates in subsection
(4) that the proffered expert must only have
practiced in the specialty 'during the year
preceding the date that the alleged breach of the
standard of care occurred.' According to the plain
language of § 6–5–548(c), the only qualifications as
to length of time the Legislature has placed on a
proffered expert witness is that the witness have
practiced the necessary specialty during the year
preceding the alleged breach. Construing the plain
language of § 6–5–548(c), we must conclude that the
Legislature chose not to require that a proffered
31
1190216
expert witness testifying against a specialist be
board-certified in the same specialty during the
year preceding the alleged breach of the standard of
care.  Thus, the appellants' argument that Dr.
Grover is not qualified to testify concerning the
applicable standard of care in this case because he
was not board-certified in anesthesiology or in pain
management during the year preceding the alleged
breach in this case must fail."
Chapman, 893 So. 2d at 297-98.  Accordingly, this Court
concluded that Dr. Grover was qualified to testify against Dr.
Chapman.
As for Dr. Kendall, Dr. Chapman argued on appeal that Dr.
Kendall was not a similarly situated health-care provider
because Dr. Kendall had never been board certified as a pain-
management specialist.  This Court noted that  § 6–5–548(c)(3)
and (e) required that any proffered expert witness testifying
against Dr. Chapman must be certified by an appropriate
American board in the same speciality and that Dr. Kendall had
never been board certified in pain management as indicated by
his deposition testimony.  Accordingly, this Court concluded
that Dr. Kendall was not qualified to testify against Dr.
Chapman. 
Hannah points to this Court's language in Chapman that
"there are no qualifications in subsection (3) as to the
32
1190216
period of time the proffered expert must be board-certified
before he or she can testify against a specialist," 893 So. 2d
at 298, to argue that there is no requirement that a proffered
expert be board certified at the time he or she gives
testimony against a specialist. This  argument completely
misconstrues this Court's holding in Chapman.  In Chapman, Dr.
Chapman raised the specific argument that § 6–5–548(c)(3)
should be construed as requiring a proffered expert witness be
board certified during the year preceding the date on which
the alleged breach of the standard of care occurred. 
Considering the plain and unambiguous nature of the language
in § 6–5–548(c)(3), this Court simply held that there were no
qualifications in that section as to the period a proffered
expert must be board certified before he or she can testify
against a specialist. Nothing in this Court's holding in 
Chapman can reasonably be construed as holding that a
proffered expert need not be board certified at the time the
proffered expert gives his or her testimony. 
Hannah also points to this Court's language in Chapman in
which it held that Dr. Kendall was not qualified to testify as
a similarly situated health-care provider against Dr. Chapman
33
1190216
under § 6-5-548(c) because he has "never been 
board-certified"
in pain management. Chapman, 893 So. 2d at 298.   Hannah
contends that this language supports the finding that, if a
proffered expert has ever been board certified in a specialty,
the proffered expert would qualify as a similarly situated
health-care provider in that specialty under § 6-5-548(c).  
Thus, Hannah contends that, because Dr. Brickman had
previously been board  certified in general surgery, he
qualifies as a similarly situated health-care provider under
§ 6-5-548(c).  
Again, Hannah's argument misconstrues the clear
holding in Chapman on this point.  This Court stated simply
that, because Dr. Kendall had never been board certified in
pain management, he was not qualified as a similarly situated
health-care provider under § 6-5-548(c)(3),  which expressly
states that a similarly situated health-care provider is one
that  "[i]s certified by an appropriate American board in the
same specialty."  This Court's holding in Chapman that Dr.
Kendall was not a qualified expert because he had "never been
board-certified" in pain management is completely consistent
with the requirement in § 6-5-548(c)(3) that a similarly
situated 
health-care 
provider 
"[i]s 
certified 
by 
an
34
1190216
appropriate American board in the same specialty."  Again,
nothing can be reasonably extrapolated from this Court's
holding in Chapman, based on this contention of Hannah's, that
does not require that a proffered expert be currently board
certified at the time he or she  gives his or her testimony. 
This Court has stated:
"'"'The fundamental rule of statutory
construction is to ascertain and give
effect to the intent of the legislature in
enacting the statute. Words used in a
statute must be given their natural, plain,
ordinary, and commonly understood meaning,
and where plain language is used a court is
bound to interpret that language to mean
exactly what it says. If the language of
the statute is unambiguous, then there is
no room for judicial construction and the
clearly 
expressed 
intent 
of 
the 
legislature
must be given effect.'"'
"Ex parte Alabama Dep't of Mental Health & Mental
Retardation, 840 So. 2d 863,  867 (Ala. 2002)
(quoting Ex parte Master Boat Builders, Inc., 779
So. 2d 192, 196 (Ala. 2000), quoting in turn IMED
Corp. v. Systems Eng'g Assocs. Corp., 602 So. 2d
344,  346 (Ala. 1992))."
Douglas v. King, 889 So. 2d 534, 538 (Ala. 2004).
Section 6-5-548(c)(3) expressly states that a similarly
situated health-care provider is one who "[i]s certified by an
appropriate American board in the same specialty."  Section 6-
5-548(e) expressly states that  a proffered expert may testify
35
1190216
against a defendant health-care provider  "only if he or she
is certified by the same American board in the same
specialty." Subsections 6-5-548(c)(3) and (e) are plain and
unambiguous, and under no reasonable reading could those
subsections be interpreted to allow testimony from a 
proffered expert who "was" once board certified in the same
specialty as the defendant health-care provider but who was no
longer so certified at the time the proffered expert provided
his or her testimony.  Subsections 6-5-548(c)(3) and (e)
clearly require a similarly situated health-care provider who
is proffered as an expert to be board certified in the same
specialty as the defendant heath-care provider at the time the
proffered expert testifies.  Had the legislature intended to
require the proffered expert to simply be board certified at
any time in the past it could have easily so provided in the
statute.  Section 6-5-548(c)(4) requires that a similarly
situated health-care provider proffered as an expert be one
who "[h]as practiced in this specialty during the year
preceding the date that the alleged breach of the standard of
care occurred."  The fact that the legislature chose to tie,
in subsection (c)(4), the action to a specific point in time
36
1190216
and chose to so qualify § 6-5-548(c)(3) and (e) evidences its
intention that a proffered expert may not testify as a
similarly situated health-care provider against a defendant
health-care provider unless the proffered expert is board
certified in the same specialty as the defendant  health-care
provider  at the time the proffered expert gives his or her
testimony.
Accordingly, because Dr. Brickman was not board certified
in general surgery at the time he offered his testimony in
this case, he was not a similarly situated health-care
provider under § 6-5-548(c)(3) and (e), and the trial court
properly refused to consider his testimony.
  Hannah next argues that expert medical testimony is not
required in this case because, she says, her claims that Dr.
Thomas and Dr. Naughton falsely told her that she had cervical
cancer and that she had no option but to have a full
hysterectomy are not beyond the understanding of the average
layperson.   
 As mentioned above, the plaintiff in a medical-
malpractice case generally must present expert medical
testimony to establish (1)  the applicable standard of  care, 
37
1190216
(2) a breach of  that standard of care, and (3) a proximate
causal connection between the defendant's breach of the
standard of care and the injury sustained by the plaintiff.
Lyons, supra.  However, it is well settled that there is an
exception to the rule requiring expert testimony "'in a case
where want of skill or lack of care is so apparent ... as to
be understood by a layman, and requires only common knowledge
and experience to understand it.'"  Tuscaloosa Orthopedic
Appliance Co. v. Wyatt, 460 So. 2d 156, 161 (Ala. 
1984)(quoting Dimoff v. Maitre, 432 So. 2d 1225, 1226–27 (Ala.
1983)); see also Anderson v. Alabama Reference Labs., 778 So.
2d 806  (Ala.  2000).   The following situations have been
recognized as exceptions to the general rule that the
plaintiff in a medical-malpractice action must proffer
independent expert medical testimony:
"'(1) where a foreign instrumentality is found in
the plaintiff's body following surgery; 2) where the
injury complained of is in no way connected to the
condition for which the plaintiff sought treatment;
3) where the plaintiff employs a recognized standard
or authoritative medical text or treatise to prove
what is or is not proper practice; and 4) where the
plaintiff is himself or herself a medical expert
qualified 
to 
evaluate 
the 
doctor's 
allegedly
negligent conduct.'"
38
1190216
Allred v. Shirley, 598 So. 2d 1347, 1350 (Ala. 1992)(quoting
Holt v. Godsil, 447 So. 2d 191, 192–93 (Ala. 1984)(citations
omitted in Allred)); see also Anderson v. Alabama Reference
Labs., supra.
In Ex parte HealthSouth Corp., 851 So. 2d 33 (Ala. 
2002), this Court explained that the list of exceptions in
Allred to the general rule requiring expert testimony was
illustrative only and not exclusive.   In HealthSouth, this
Court went on to reformulate the exceptions to the general
rule 
requiring 
expert 
medical 
testimony 
in 
medical-malpractice
actions 
"[t]o recognize first, a class of cases '"where want
of skill or lack of care is so apparent ... as to be
understood by a layman, and requires only common
knowledge 
and 
experience 
to 
understand 
it,"'
[Tuscaloosa Orthopedic Appliance Co. v.] Wyatt, 460
So. 2d [156] at 161 [(Ala. 1984)](quoting Dimoff v.
Maitre, 432 So. 2d 1225, 1226–27 (Ala. 1983)), such
as when a sponge is left in, where, for example, the
wrong leg is operated on, or, as here, where a call
for assistance is completely ignored for an
unreasonable period of time.  A second exception to
the rule requiring expert testimony applies when a
plaintiff relies on '"'a recognized standard or
authoritative medical text or treatise,'"'  Anderson
[v. Alabama Reference Labs., 778 So. 2d [806] at 811
[(Ala. 2000)], or is himself or herself a qualified
medical expert."
851 So. 2d at 39.   
39
1190216
In Collins v. Herring Chiropractic Center, LLC, 237 So. 
3d 867, 871 (Ala. 2017),  this Court explained the
reformulation of the exceptions as follows:
"The 
Court's 
reformulation 
of 
categories 
in
HealthSouth essentially clarifies the exceptions to
the general rule requiring expert testimony in
medical-malpractice actions by emphasizing in the
first exception as reformulated that there are
situations where the lack of skill is so apparent as
to be understood by a layperson, thereby requiring
only common knowledge and experience to understand
it, and that further the list of examples of such
situations was not exhaustive but merely set out
examples of possible situations. In the second
exception as reformulated, the Court simply combines
the use of an authoritative treatise and the
plaintiff's own testimony as a medical expert as the
second exception to the general rule."
As for the issue of causation in a medical-malpractice
action, this Court explained in Sorrell v. King, 946 So. 2d
854, 862-63 (Ala. 2006):
"A plaintiff in a medical-malpractice action
must also present expert testimony establishing a
causal connection between the defendant's act or
omission constituting the alleged breach and the
injury suffered by the plaintiff. Pruitt v. Zeiger,
590 So. 2d 236, 238 (Ala. 1991). See also Bradley v.
Miller, 878 So. 2d 262, 266 (Ala.  2003); University
of Alabama Health Servs. Found., P.C. v. Bush, 638
So. 2d 794, 802 (Ala. 1994); and Bradford v. McGee,
534 So. 2d 1076, 1079 (Ala. 1988). To prove
causation 
in 
a 
medical-malpractice 
case, 
the
plaintiff must demonstrate '"that the alleged
negligence 
probably 
caused, 
rather 
than 
only
possibly caused the plaintiff's injury."' Bradley,
40
1190216
878 So. 2d at 266 (quoting  University of Alabama
Health Servs., 638 So. 2d at 802). ... In Cain v.
Howorth, 877 So. 2d 566 (Ala. 2003), this Court
stated:
"'"'To present a jury question, 
the
plaintiff 
[in 
a 
medical-malpractice 
action]
must adduce some evidence indicating that
the alleged negligence (the breach of the
appropriate standard of care) probably
caused the injury. A mere possibility is
insufficient. The evidence produced by the
plaintiff 
must 
have 
"selective 
application"
to one theory of causation.'"'
"877 So. 2d at 576 (quoting Rivard v. University of
Alabama Health Servs. Found., P.C., 835 So. 2d 987,
988 (Ala. 2002)). However, the plaintiff in a
medical-malpractice case is not required to present
expert testimony to establish the element of
proximate causation in cases where 'the issue of
proximate cause is not ... "beyond the ken of the
average layman."' Golden v. Stein, 670 So. 2d 904,
908 (Ala. 1995). Therefore, '[u]nless  "the cause
and effect relationship between the breach of the
standard of care and the subsequent complication or
injury is so readily understood that a layperson can
reliably 
determine 
the 
issue 
of 
causation,"
causation in a medical-malpractice case must be
established 
through 
expert 
testimony.' 
DCH
Healthcare Auth., 883 So. 2d at 1217–18 (quoting
Cain, 877 So.2d at 576)."
Hannah claims that Dr. Thomas and Dr. Naughton falsely
told her that she had cervical cancer based on the results of
an abnormal Pap smear, claims that she had no other treatment
options but to have a complete hysterectomy based on that
diagnosis, and claims that the hysterectomy was performed
41
1190216
because Dr. Thomas and Dr. Naughton falsely represented to her
the presence of cancer as determined from the abnormal Pap
smear. 
Hannah relies upon Ex parte Sonnier, 707 So. 2d 635 (Ala.
1997), in support of her argument that the nature of her
claims does not 
require expert medical testimony to establish. 
In Ex parte Sonnier, the plaintiff claimed that she was
informed by the defendant physician in March 1991 that she had
cervical cancer and that a hysterectomy was necessary. On
April 1, 1991, the defendant doctor performed the recommended
hysterectomy.  Subsequently, a postoperative pathology report
indicated that the plaintiff did not have cancer.  The
plaintiff returned to the defendant doctor on at least three
occasions between April 1991 and October 1991, and on each
visit the defendant doctor represented to the plaintiff that
she had had cervical cancer. The plaintiff sued the defendant
doctor, alleging, among other things, that the doctor had
committed medical malpractice by continuing to falsely
misrepresent to her that she had had cervical cancer after the
pathology report confirmed that she did not. 
42
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The plaintiff offered the affidavit testimony of a board-
certified physician in support of her claims.  The defendant
doctor objected to the affidavit testimony, arguing that the
proffered expert was not board certified in obstetrics and
gynecology as was the defendant doctor and that, therefore,
the proffered expert was not a similarly situated health-care
expert.  In determining that the affidavit testimony was
admissible, the  Court stated:   
"The alleged malpractice here was the doctors'
continuing to tell [one of the plaintiffs] that she
had 
cancer, 
even 
after 
the 
results 
of 
the
hysterectomy showed that she did not have cancer.
From all that appears in the record, we conclude
that Dr. Bruck was qualified to testify as a
similarly situated health care provider as to this
alleged breach of the standard of care. In
opposition to the defendants' summary judgment
motion, the [plaintiffs] submitted substantial
evidence indicating that the alleged breach is not
relevant 
to 
the 
specialty 
of 
obstetrics 
or
gynecology. Instead, the [plaintiffs] allege a
breach that virtually requires no expert testimony:
after the issuance of a tissue report showing no
evidence of cancer, the defendant doctors continued
to tell [one of the plaintiffs] that she had had
cancer of the uterus. This is substantial evidence
that the defendant doctors made material false
representations to [one of the plaintiffs]  as their
patient. The circuit court's judgment should not be
affirmed based on any conclusion that, to give the
pertinent opinions in his affidavit, Dr. Bruck would
have to be certified in obstetrics and gynecology.
At least absent any countervailing evidence by the
43
1190216
defendants, Dr. Bruck's testimony is substantial
evidence of a breach of the standard of care."
Ex parte Sonnier, 707 So. 2d at 640. 
Ex parte Sonnier is distinguishable from the case
currently before the Court. In Ex parte Sonnier one of the
plaintiffs was told that she had cervical cancer before the
results of the pathology report was  known and continued to be
told by the defendant doctor that she had cervical cancer
after the pathology report indicated that she did not have
cancer. The basis of the plaintiffs' misrepresentation claim
was 
the 
defendant 
doctor's 
knowing 
and 
continued
misrepresentation to one of the plaintiffs that she had
cervical cancer even though the pathology report indicated
that she did not. The understanding that the defendant doctor
breached the standard of care by continuing to represent to
that plaintiff that she had had cervical cancer when the
pathology report indicated that she had not is within the
common knowledge and general understanding of a layperson
without regard to a particular medical specialty.  In other
words, a layperson is capable of understanding the inherent
wrong in a doctor's continuing to misrepresent a patient's
diagnosis without the testimony of a medical expert. 
44
1190216
However, in this case the basis of Hannah's claim is the
alleged false representation that she had cervical cancer made
to her by Dr. Thomas and Dr. Naughton based on their
interpretation of the abnormal Pap smear. The allegation here
is not as simple as an ongoing misrepresentation made to a
patient by a doctor in the face of medical evidence contrary
to the ongoing misrepresentation.  To the extent Dr. Thomas
and Dr. Naughton made an alleged false representation to
Hannah that she had cervical cancer, that representation was
made based on their interpretation of the abnormal Pap smear
and the treatment protocol dictated by that interpretation.
Dr. Thomas and Dr. Naughton's interpretation of the abnormal
Pap smear and resulting treatment recommendations based on
that 
interpretation require 
a 
knowledge 
and 
understanding that
is beyond the common knowledge, understanding, and experience
of a layperson, and this case is thus distinguishable from the
facts of Ex parte Sonnier.
Accordingly, we conclude that Hannah's claims do not fall
within the layperson exception to the rule that a plaintiff
must support his or her medical-malpractice claim with expert
45
1190216
testimony from a "similarly situated health-care provider" in
relation to the defendant medical professional. 
Hannah next argues that the trial court erred in ruling
that she failed to present substantial evidence through a
similarly situated health-care provider that the defendants' 
alleged negligence probably caused her alleged injury. 
As discussed above,  the plaintiff  in a medical-
malpractice case must generally prove by expert medical
testimony that the defendant's alleged negligence "probably
caused, rather than only possibly caused," the plaintiff's
injury in order to establish proximate causation in a medical-
malpractice case. Sorrell, 946 So. 2d at 862-63.  With this
Court having determined that Dr. Brickman's testimony was
properly excluded because he was not a "similarly situated
health-care provider" in relation to Dr. Thomas and Dr.
Naughton in this case and that Hannah's claim does not fall
within the recognized exception to the general rule that
requires a 
medical-malpractice claim to be supported by expert
medical testimony from a similarly situated health-care
provider, Hannah cannot prove any of the elements necessary to
establish a medical-malpractice claim.
46
1190216
Accordingly, we conclude that the trial court did not err
in determining that Hannah failed to present substantial
evidence to establish the element of proximate causation in
this case.
Finally, Hannah argues that the trial court erred in
failing to grant her Rule 56(f), Ala. R. Civ. P., motion
requesting the opportunity to procure an additional medical
expert to oppose the defendants' summary-judgment motion in
the event the trial court precluded Dr. Brickman's testimony,
which it did.  
Rule 56(f) provides: 
"Should it appear from the affidavits of a party
opposing the motion that the party cannot, for
reasons stated, present by affidavit facts essential
to justify the party's opposition, the court may
deny the motion for summary judgment or may order a
continuance to permit affidavits to be obtained or
depositions to be taken or discovery to be had or
may make such other order as is just."
This Court has stated:
"As we noted in Scrushy v. Tucker, 955 So. 2d 988,
1007 (Ala. 2006), '"[s]uch an affidavit should state
with specificity why the opposing evidence is not
presently 
available 
and 
should 
state, 
as
specifically as possible, what future actions are
contemplated to discover and present the opposing
evidence."' (Citing Committee Comments to August 1,
1992, Amendment to Rule 56(c) and Rule 56(f).) As
the rule indicates, whether to deny a motion for
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summary judgment or to grant a continuance to allow
discovery to proceed is discretionary with the trial
court."
Fogarty v. Southworth, 953 So. 2d 1225, 1129 (Ala. 2006). 
From the time the complaint in this case was filed in
July 2007 until the trial court  entered an order granting the
defendants' summary-judgment motion in September 2019,
approximately 12 years had elapsed.  During that time Hannah
proffered the expert testimony of Dr. Duboe, which the trial
court precluded.  However, the trial court granted Hannah a
continuance to procure and depose an additional expert. 
Hannah then filed a notice identifying Dr. Brickman as her
medical expert.  Thereafter, the trial court set the case for
trial on May 6, 2019, and ordered Hannah to disclose any
additional  experts 90 days before trial. The trial court
stated in that order that no continuances would be granted
except for "extraordinary reasons." 
On March 6, 2019, the defendants moved the trial court to
preclude the testimony of Dr. Brickman and  renewed their
motion for a summary judgment.   On  August 16, 2019, Hannah
filed her response in opposition to the motion for a summary
judgment.  In addition to the response in opposition to the
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motion for a summary judgment, Hannah also sought, pursuant to
Rule 56(f), an opportunity and reasonable period within which
to find a substitute expert to respond to the defendants'
summary-judgment motion should Dr. Brickman's testimony be
precluded.  On September 17, 2019, the trial court entered an
order granting the defendants' motion for a summary judgment,
finding that Hannah had 
failed to present substantial evidence
through a similarly situated health-care provider that the
alleged negligence on the part of the defendants probably
caused her alleged injury. Because the trial court entered a
summary judgment in favor of the defendants, it determined
that Hannah's request for additional time to obtain a medical
expert was moot.  
We note that the trial court initially did not preclude
and strike Dr. Brickman's affidavit testimony.  The trial
court simply found that Hannah failed to support her claims
with substantial evidence from a similarly situated health-
care provider, which thereby rendered her request pursuant to
Rule 56(f) moot. Further, we note that Hannah failed to file
the necessary affidavits required by Rule 56(f).  Although she
did not file the necessary affidavits, she did file a written
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request in which she asked for the opportunity to obtain an
additional medical expert because the motion filed by the
defendants 
to 
preclude 
Dr. 
Brickman's 
testimony 
was
"unexpected," was filed more than four years after his
deposition, and, if his testimony was precluded, would leave
her without an expert to oppose the defendants' motion for a
summary judgment.  The trial court had entered an order when
it set the trial date stating that there would be no
continuances except for "extraordinary reasons."  We cannot
say that the reasons given by Hannah were extraordinary.
Accordingly, we cannot say that the trial court exceeded its
discretion in failing to grant Hannah's Rule 56(f) motion. 
Conclusion
We affirm the summary judgment entered in favor of the
defendants.
AFFIRMED.
Parker, C.J., and Wise, Sellers, and Stewart, JJ.,
concur.
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