PRESENT: Lemons, C.J., Goodwyn, McClanahan, Powell, Kelsey, and McCullough, JJ., and
Millette, S.J.

ALEXIA SUMMERS
                                                              OPINION BY
v. Record No. 160377                                JUSTICE STEPHEN R. McCULLOUGH
                                                               July 20, 2017
J. MICHAEL SYPTAK, ET AL.


                 FROM THE CIRCUIT COURT OF ROCKINGHAM COUNTY
                             Thomas J. Wilson, IV, Judge

       Alexia Summers appeals from the dismissal with prejudice of her medical malpractice

action. In her complaint, she alleged that Dr. J. Michael Syptak, a physician with Harrisonburg

Family Practice Associates, P.C., knew or should have known about certain conditions afflicting

her. These conditions are described in the medical records of her earlier treatment by that

practice. She alleged that, while treating her, Dr. Syptak made “unsolicited, unwanted,

inappropriate, and highly offensive sexual comments, ‘jokes,’ and sexual innuendo” and that

these statements caused her preexisting conditions to worsen. On this appeal she focuses her

arguments on the contention that the circuit court erred in holding on summary judgment that a

plaintiff must proffer an expert who can testify concerning what medical records a physician is

required to consult under the standard of care and what statements a physician can make to a

patient. Although Dr. Syptak contests the plaintiff’s arguments on these points, he offers an

alternative ground for affirmance: that the plaintiff’s failure to designate an expert to testify

concerning proximate causation of her injuries is fatal to her case. We agree with this alternative

ground, and we accordingly affirm the judgment of the trial court on that basis.

                                         BACKGROUND

       According to the allegations in the complaint, Summers was a patient at the Harrisonburg

Family Practice. Beginning in September 2010, she received treatment from Dr. Deborah A. Nio
at this practice group for the psychological, emotional, and physical symptoms Summers was

experiencing as a result of being the victim of “past and present sexual abuse and harassment,”

including at her workplace. In November 2010, Dr. Nio wrote that Summers may suffer from

Post-Traumatic Stress Disorder, or PTSD. Summers experienced suicidal and homicidal

thoughts. During this time, Dr. Nio prescribed various medications for her conditions, including

anti-depressant, anti-anxiety, and sleep aid medications. Her treatment there continued through

August 2011.

       More than two years later, in March 2014, Summers returned to Harrisonburg Family

Practice because of high blood pressure. Dr. Nio was unavailable, so she was seen by Dr.

Syptak, another physician at the practice. Dr. Syptak happens to be Dr. Nio’s husband.

Summers alleged that, while treating her for high blood pressure over the course of several visits,

Dr. Syptak “engage[d] in conduct involving unsolicited and unwanted sexual comments and

innuendo to [p]laintiff, including the following:”

               a. Telling Plaintiff that if she lost weight she would feel and look
               sexy;

               b. Using the terms “Love,” “Sweetpea,” and “Sweets” in
               conversation with Plaintiff when referring to her;

               c. Describing his sex life with his wife including telling Plaintiff
               that although he had slowed down with age he was still like a “jack
               rabbit” and maybe that’s why they’ve had a number of children;

               d. Telling Plaintiff a “joke” about a boy who did not want his
               mother to wash his white tube socks because he had masturbated
               and ejaculated into them;

               e. Inquiring about Plaintiff and her husband’s sex life, wondering
               whether it was the same as his – “on and off;”

               f. Telling Plaintiff that around Harrisonburg the term “fiancée” is
               like “redneck layaway” - and how you can try them out before you
               buy the merchandise;



                                                 2
               g. Giving Plaintiff a sample of a nasal spray and then “jokingly”
               telling her “it’s for your nostrils - no other holes;”

               h. Telling Plaintiff a story about a man who, when his wife left
               him, shot himself in the shoulder and how if his wife left him,
               while he might be upset at the outset, he would get over it as he
               would be able to see other women, including “the nanny,” and
               have some fun; and

               i. Describing to Plaintiff how he and his wife have sex in their king
               size bed; telling Plaintiff that for people their size it’s like five beds
               and that “having sex is like boarding a pirate ship . . . it’s true, I
               don’t know if you ever had a big bed like that, but the wife wanted
               one and I was fine with it.”

Summers surreptitiously recorded some, but not all, of these remarks. Dr. Syptak made some of

these comments while Summers was accompanied by her husband and at least one of the

comments was directed toward him.

       Summers filed this action against both Dr. Syptak and Harrisonburg Family Practice,

pleading theories of intentional infliction of emotional distress and negligence. She alleged that

his “unsolicited, unwanted, inappropriate, and highly offensive sexual comments, ‘jokes,’ and

sexual innuendo” caused the plaintiff’s preexisting mental and physical health to “drastically”

deteriorate. In response to interrogatories, Summers stated that, among other things, her PTSD,

depression, and fibromyalgia worsened as a consequence of Dr. Syptak’s statements.

       Dr. Syptak filed a request for an expert witness certification under Code § 8.01-20.1,

contending that the plaintiff was required to obtain an expert who could testify that the defendant

had “deviated from the applicable standard of care and the deviation was a proximate cause of

the injuries claimed.” The plaintiff responded that no expert certification was required because

whether Dr. Syptak was negligent and whether the statements he made proximately caused the

plaintiff’s injuries were matters that fell “within the range of the jury’s common knowledge and




                                                   3
experience.” Dr. Syptak then moved for summary judgment, arguing that the plaintiff’s failure

to designate an expert required dismissal. He asserted that the plaintiff was required to designate

an expert who could testify concerning “[t]he existence–and extent–of a physician’s duty to

review a patient’s chart before treating her for hypertension,” and that it “is not something that

‘clearly’ falls within the ‘jury’s common knowledge and experience.’” In addition, he noted that

the plaintiff alleged that she had a preexisting history of mental distress and that “[u]nraveling

whether [p]laintiff’s psychiatric condition was caused by her visit[s] to Dr. Syptak, as opposed to

those earlier traumas, is not something that is within the ‘jury’s common knowledge and

experience.’” Dr. Syptak submitted an expert designation to address the extent to which a

reasonably prudent family practice physician had a duty to review a patients’ prior chart, and to

what extent Dr. Syptak’s statements to his patient deviated from the standard of care.

       Summers later submitted an expert designation, designating Mercy Souder, a licensed

professional counselor, as a prospective expert witness. In a report Summers attached to her

designation, Souder detailed Summers’ difficult childhood, her history of sexual abuse from a

young age, and sexual harassment she experienced at work. Souder stated that Summers has

been diagnosed with Bipolar Disorder and Post-Traumatic Stress Disorder, and that “her

symptoms have worsened after the incident with her doctor in which he made vulgar and

inappropriate comments.” Souder, however, did not purport to offer any opinion expressing a

conclusion that Dr. Syptak’s comments were a proximate cause of the worsening of Summers’

preexisting conditions. Dr. Syptak submitted a reply in support of his motion for summary

judgment, arguing, among other things, that the plaintiff “needs – and does not have – a

causation expert.” Summers responded that whether Dr. Syptak’s actions violated the standard

of care was within the common knowledge of the jury and that the allegations that the plaintiff’s




                                                  4
condition worsened after her visits to Dr. Syptak were sufficient to create a jury issue even

without expert testimony.

       The trial court granted summary judgment to Dr. Syptak on the basis that the plaintiff

was required “to designate a qualifying expert to testify on the standard of care and causation.”

In its memorandum opinion, the trial court did not address the causation point in detail.

                                            ANALYSIS

       Summers assigns error to the trial court’s holding that expert testimony was required. At

trial, the parties and the court focused on two issues: (1) whether expert testimony was required

to establish a physician’s duty under the standard of care to familiarize himself with a patient’s

medical records and (2) whether a plaintiff needed to designate an expert who could offer an

opinion on whether Dr. Syptak violated the standard of care in his communications with his

patient. Dr. Syptak, however, also argued that the plaintiff was required to designate an expert

who could offer testimony that Dr. Syptak’s statements were a proximate cause of Summers’

injuries. Although the trial court appears to have accepted this argument, it did not develop the

issue in any detail. Nevertheless, we are “not limited to the grounds offered by the trial court in

support of its decision, and [we are] ‘entitled to affirm the court’s judgment on alternate grounds,

if such grounds are apparent from the record.’” Perry v. Commonwealth, 280 Va. 572, 582, 701

S.E.2d 431, 437 (2010) (quoting MM v. Sch. Dist. of Greenville Cnty., 303 F.3d 523, 536 (4th

Cir. 2002)). See also Miller & Rhoads Bldg., L.L.C. v. City of Richmond, 292 Va. 537, 542, 790

S.E.2d 484, 487 (2016) (‘“This Court may uphold a judgment even when the correct reasoning is

not mentioned by a party in trial argument or by the trial court in its decision, as long as the

record contains sufficient information to support the proper reason.”’) (quoting Haynes v.

Haggerty, 291 Va. 301, 305, 784 S.E.2d 293, 294 (2016)). We hold that the plaintiff was




                                                  5
required to designate an expert who could offer testimony that Dr. Syptak’s words were a

proximate cause of the aggravation of the plaintiff’s preexisting conditions.

       The general rule in medical malpractice cases is that an expert is required to establish that

the defendant “deviated from the applicable standard of care and the deviation was a proximate

cause of the injuries claimed.” Code § 8.01-20.1. As we have noted, “[i]ssues involving medical

malpractice often fall beyond the realm of common knowledge and experience of a lay jury.”

Beverly Enterprises-Virginia, Inc. v. Nichols, 247 Va. 264, 267, 441 S.E.2d 1, 3 (1994).

       There is an exception to this rule, although its application is “rare.” Id.; Raines v. Lutz,

231 Va. 110, 113, n.2, 341 S.E.2d 194, 196 n.2 (1986). Under this exception, “expert testimony

is unnecessary [when] the alleged act of negligence clearly lies within the range of the jury’s

common knowledge and experience.” Beverly Enterprises-Virginia, 247 Va. at 267, 269, 441

S.E.2d at 3, 4 (no expert required to establish the standard of care because “whether a reasonably

prudent nursing home would permit its employees to leave a tray of food with an unattended

patient who had a history of choking and who was unable to eat without assistance is certainly

within the common knowledge and experience of a jury”); Webb v. Smith, 276 Va. 305, 308, 661

S.E.2d 457, 459 (2008) (doctor agreed to perform two distinct operations at the same time but

only performed one, requiring the plaintiff to undergo a second surgery; the issue of causation in

that instance “was within the common knowledge of laymen”).

       Summers suffered from a number of debilitating preexisting conditions, including PTSD,

fibromyalgia, depression, and radiculopathy. She alleged that Dr. Syptak’s statements caused

these conditions to worsen. This Court has not previously addressed the question presented here:

whether a plaintiff suffering from preexisting mental, emotional, or physical conditions such as




                                                 6
those at issue here must designate an expert who can testify that a physician’s statements were a

proximate cause of the aggravation of such preexisting conditions.

       Although the facts are not exactly parallel with the present case, courts in other states

have addressed analogous situations. See Singh v. Lyday, 889 N.E.2d 342 (Ind. Ct. App. 2008);

Hare v. Wendler, 949 P.2d 1141 (Kan. 1997); Carmichael v. Carmichael, 597 A.2d 1326 (D.C.

1991). In each of these cases, a psychologist or a psychiatrist engaged in sexual relations with a

patient who suffered from preexisting conditions. The plaintiff claimed there was no need for

expert testimony. In addressing the issue, our sister courts have recognized that the existence of

preexisting conditions complicates the question of whether the injuries were attributable to the

misconduct. Singh, 889 N.E.2d at 358; Hare, 949 P.2d at 1148; Carmichael, 597 A.2d at 1331.

In each instance, those courts rejected the plaintiff’s argument that a jury was qualified to

determine causation unaided by expert testimony. Singh, 889 N.E.2d at 359; Hare, 949 P.2d at

1148; Carmichael, 597 A.2d at 1331.

       We find the reasoning of these cases persuasive. Ordinarily, when there are preexisting

conditions, “discerning the causal connection between [the alleged malpractice] and [the

patient’s] resulting injuries is a complicated medical question that is not within the understanding

of a lay person.” Singh, 889 N.E.2d at 358 (alternations in original) (quotations and citations

omitted). A lay jury is not equipped from common experience with the knowledge of what can

cause the aggravation of complex preexisting medical problems like PTSD, fibromyalgia,

depression, and radiculopathy. Consequently, expert testimony is required. The plaintiff did not

produce such an expert. Therefore, the trial court correctly dismissed the action. 1




       1
         The circuit court ruled that the plaintiff’s intentional infliction of emotional distress
claim survived summary judgment, but the plaintiff later nonsuited that claim.


                                                  7
       Summers points us to several tort cases outside of the medical malpractice context for the

proposition that lay testimony is admissible on the question of causation. See Bussey v. E.S.C.

Rests, Inc., 270 Va. 531, 538, 620 S.E.2d 764, 768 (2005) (illness following restaurant meal);

Todt v. Shaw, 223 Va. 123, 126, 286 S.E.2d 211, 213 (1982) (motor vehicle accident); Sumner v.

Smith, 220 Va. 222, 226, 257 S.E.2d 825, 827 (1979) (same); Pepsi-Cola Bottling Co. v.

McCullers, 189 Va. 89, 97, 52 S.E.2d 257, 260 (1949) (mouse found in a soda bottle). That line

of authority is inapposite here. This case is a medical malpractice action, and the General

Assembly has imposed a presumptive requirement of expert testimony in such cases. See Code

§ 8.01-20.1.

       Summers also relies on Nichols v. Kaiser Found. Health Plan, 257 Va. 491, 514 S.E.2d

608 (1999). In Nichols, the plaintiff alleged that a pharmacist provided the wrong medication, a

steroid that was five times more potent than the medication she was supposed to receive, and that

she suffered adverse effects from the error. Id. at 493, 514 S.E.2d at 609. She did not present

what this Court characterized as “pure” expert testimony, that is, she did not offer a qualified

expert who responded to hypothetical questions. Id. at 499-500, 514 S.E.2d at 612-13. She did,

however, present “abundant opinion testimony from plaintiff’s treating physicians.” Id. at 499,

514 S.E.2d at 612. Her treating physician related the symptoms she experienced to the

erroneously dispensed steroid. Id. at 495-96, 514 S.E.2d at 610-11. The plaintiff also testified

about the adverse effects the medication had on her and her son testified about the change in her

condition after she began taking the erroneously provided medication. Id. at 496-97, 514 S.E.2d

at 611. We reasoned that

               the case reduces to whether there was sufficient evidence,
               comprised of medical opinion and lay testimony, to present a jury
               question on causation. We answer that query in the affirmative;
               testimony from a “pure” expert witness was unnecessary.



                                                 8
Id. at 499, 514 S.E.2d at 612. The “medical facts and medical opinion combined with lay

testimony, without the addition of ‘pure’ expert testimony,” was sufficient for that case to go to

the jury. Id. at 500, 514 S.E.2d at 613. In this case, however, there was no comparable linking

of medical opinion and lay testimony. All the plaintiff was able to tender, from her own

testimony and from her licensed professional counselor, was that her symptoms became worse

after Dr. Syptak made his comments. She did not, however, identify an expert witness who was

prepared to offer an opinion that Dr. Syptak’s comments were a proximate cause of her worsened

condition.

       Just because a plaintiff suffers a deterioration of several preexisting conditions after

seeing a physician does not mean that the doctor’s actions were a proximate cause of the

plaintiff’s worsened condition. Indeed, there is a name for the logical fallacy that assumes a

causal relationship from a merely sequential one: “post hoc ergo propter hoc,” which is Latin

for “after this, therefore because of this.” Black’s Law Dictionary 1285 (9th ed. 2009). To

illustrate, one might erroneously reason that since a rooster crows each day at sunrise, the rooster

causes the sun to rise. A more concrete historical example is the mistaken attribution of cholera

epidemics to “miasma” exposure, that is, exposure to polluted fumes and toxic aromas. In fact,

the disease is caused by bacterial contamination of water. See Steven Johnson, The Ghost Map

(2006) (discussing the pioneering scientific work of London physicians in identifying the source

of cholera epidemics). Whether the alleged acts of malpractice aggravated preexisting

conditions like radiculopathy, PTSD, and fibromyalgia or whether her symptoms stemmed from

some other cause presented a complex question beyond “the jury’s common knowledge and

experience.” Code § 8.01-20.1; see also Va. R. Evid. 2:701 (providing that “[o]pinion testimony

by a lay witness is admissible if it is reasonably based upon the personal experience or



                                                 9
observations of the witness”); Va. R. Evid. 601 (providing that “a witness may not testify to a

matter unless evidence is introduced sufficient to support a finding that the witness has personal

knowledge of the matter”). Without evidence proffered as required by Code § 8.01-20.1 that

even addresses the issue of causation, the trial court correctly entered summary judgment for the

defendant. 2

                                         CONCLUSION

       For these reasons, we will affirm the judgment of the trial court.

                                                                                          Affirmed.




       2
         Our resolution of the case on this ground obviates the need for us to address whether
and when a plaintiff must proffer an expert who can testify concerning what the standard of care
requires of a physician with respect to consulting past medical records.


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