Cainglit v. Barnhart ( 2003 )

F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
DEC 17 2003
FOR THE TENTH CIRCUIT
PATRICK FISHER
Clerk
DEBORAH CAINGLIT,
Plaintiff-Appellant,
v. No. 03-7004
(D.C. No. 01-CV-506-S)
JO ANNE B. BARNHART, (E.D. Okla.)
Commissioner of Social Security,
Defendant-Appellee.
ORDER AND JUDGMENT *
Before HARTZ , BALDOCK , and McCONNELL , Circuit Judges.
After examining the briefs and appellate record, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
ordered submitted without oral argument.
*
This order and judgment is not binding precedent, except under the
doctrines of law of the case, res judicata, and collateral estoppel. The court
generally disfavors the citation of orders and judgments; nevertheless, an order
and judgment may be cited under the terms and conditions of 10th Cir. R. 36.3.
Claimant Deborah Cainglit appeals the district court’s order affirming
the decision of the Commissioner of Social Security to deny her application
for disability and supplemental security income benefits. Because the
Commissioner’s decision is supported by substantial evidence and no legal
errors occurred, we affirm.
Ms. Cainglit applied for benefits in 1998, alleging an inability to work
since August 4, 1997, due to breathing problems, back and leg pain, and other
impairments that she characterized as “female problems.” Aplt. App. at 74.
Following a hearing before an administrative law judge (ALJ), the ALJ
determined that Ms. Cainglit was not disabled at step four of the five-step
sequential evaluation process, see Williams v. Bowen , 844 F.2d 748, 750-52
(10th Cir. 1988), because she had the residual functional capacity (RFC) to return
to her past relevant work as a “house (residence) supervisor.” Aplt. App. at 33.
The ALJ also determined, in the alternative at step five, that she had the RFC to
perform other work of a sedentary nature. Id.We review the Commissioner’s decision to determine only whether it is
supported by substantial evidence and whether legal errors occurred. See
Castellano v. Sec’y of Health & Human Servs. , 26 F.3d 1027, 1028 (10th Cir.
1994). “Substantial evidence is such relevant evidence as a reasonable mind
might accept as adequate to support a conclusion.” Id. (internal quotation marks
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omitted). This court may “neither reweigh the evidence nor substitute our
judgment for that of the agency.” Casias v. Sec’y of Health & Human Servs. ,
933 F.2d 799, 800 (10th Cir. 1991).
I. Step Two Analysis of Depression .
On appeal Ms. Cainglit first contends that the ALJ failed in his step two
analysis when he concluded that her depression was not a “severe” impairment.
At step two the ALJ must determine whether the claimant has a medically severe
impairment or combination of impairments. 20 C.F.R. §§ 404.1520(c),
416.920(c). An impairment is considered “not severe” if it does not significantly
limit a claimant’s physical and mental ability to do basic work activities.
20 C.F.R. §§ 404.1521(a), 416.921(a). Basic work activities are “abilities and
aptitudes necessary to do most jobs,” and include the ability to understand,
remember, and carry out simple instructions; to use judgment; to respond
appropriately to supervisors, co-workers, and usual work situations; and to deal
with changes in a routine work setting. 20 C.F.R. §§ 404.1521(b)(3)-(6),
416.921(b)(3)-(6).
Ms. Cainglit contends that the ALJ ignored her testimony that she felt she
was disabled in part due to her depression and ignored medical records indicating
that she has been diagnosed with major depression. The determination at step two
is based on medical factors alone. Williams , 844 F.2d at 750. Claimants “must
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show more than the mere presence of a condition or ailment.” Hinkle v. Apfel ,
132 F.3d 1349, 1352 (10th Cir. 1997).
The claimant bears the burden at step two to present evidence that she has
a medically severe impairment or combination of impairments, and, to meet that
burden, must furnish medical and other evidence in support of her claim. See
Bowen v. Yuckert , 482 U.S. 137, 146 & n.5 (1987). The ALJ discussed at length
the evidence in the record relating to Ms. Cainglit’s depression, and ultimately
concluded that the evidence did not establish that her depression had a significant
effect on her ability to work. Aplt. App. at 28-29. The ALJ’s finding is
supported by substantial evidence.
There is evidence in the record that Ms. Cainglit has a history of depression
and anxiety, for which she received treatment at Mental Health Services of
Southern Oklahoma (MHSSO). Aplt. App. at 169, 176, 211, 212-26, 231. As the
ALJ concluded, however, this evidence does not demonstrate that this impairment
significantly limits Ms. Cainglit’s physical or mental ability to do basic work
activities. The counselors at MHSSO reported that her depression did not impair
her intellectual functioning, noting specifically no impairment of her level of
consciousness, attention span, abstract thinking, calculation ability, or
intelligence. Id. at 213-15. The counselors noted either no impairment or only
slight or occasional impairment of Ms. Cainglit’s ability to manage her daily
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living activities or to make reasonable life decisions. Id. The counselors noted
no impairment of her memory or her stream of thought, and reported that she did
not suffer from any phobias, depersonalizations, homicidal ideation, delusions, or
ideas of reference or of influence, and suffered from only slight or occasional
compulsions, obsessions or suicidal ideations, except that one of these reports
stated that her obsessions were marked or repeated. Id. She was not markedly or
repeatedly domineering, submissive, provocative, suspicious, overly compliant, or
uncooperative with her counselors. Id. The counselors described her
predominant affect or mood as slight or marked fear or anxiety and slight or
marked depression. Id. There were some reports of marked or repeated problems
with posture, facial expression, bodily movements, and loud speech, and one of
these reports noted she was markedly or repeatedly unkempt. But in
Ms. Cainglit’s MHSSO’s case management plan, it was reported that she had a
good work history and was able to live independently. Id. at 218. The
counselors’ evaluations thus are consistent with the ALJ’s determination that
Ms. Cainglit’s depression did not interfere with her ability to understand,
remember, and carry out simple instructions; to use judgment; to respond
appropriately to supervisors, co-workers, and usual work situations; and to deal
with changes in a routine work setting.
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There is one unsigned document in the MHSSO records stating, in relevant
part, that Ms. Cainglit is in a depressed mood all the time, has no motivation or
energy, struggles with suicidal thoughts, has impaired judgment, places herself in
dangerous situations, and has very poor coping skills. Aplt. App. at 221. Unlike
the other more detailed MHSSO examination reports, this document does not
indicate the severity of these symptoms, or the degree of restriction caused by
these symptoms. This document also states that Ms. Cainglit has demonstrated
the ability to work and meet role expectations in the past. We conclude,
therefore, that this document, standing alone, is insufficient evidence to require a
conclusion that Ms. Cainglit’s depression significantly interferes with her ability
to perform basic work activities.
A state agency medical consultant, Dr. Stephen Miller, characterized
Ms. Cainglit’s mental impairments of affective disorder (depression) and
substance addiction as “[n]ot [s]evere.” Id. at 199. Dr. Miller found that
Ms. Cainglit did have depression characterized by appetite disturbance, sleep
disturbance, and decreased energy, but that her depression caused only slight
restrictions in her daily living activities or social functioning and seldom caused
difficulties in her concentration, persistence, or pace, and that she only once or
twice had episodes of deterioration or decompensation in work or work-like
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settings. Id. at 202, 206. All these findings indicate that a mental impairment is
not severe. See 20 C.F.R. §§ 404.1520a(d)(1), 416.920a(d)(1).
The ALJ ordered a consultative mental examination, which was performed
by Dr. Gerald Ball. Aplt. App. at 195-97. He also diagnosed Ms. Cainglit with
major depression of moderate severity and amphetamine withdrawal, id. at 197,
and noted that she cried during the examination, id. at 196. He also reported,
however, that she was oriented as to time, place, and person, that there was no
evidence of any thought disorder, id. at 195, that her short-term memory and
mental control were intact and her long-term memory was adequate, that she
could read and follow written directions, that she could fill out job applications,
and that she would be able to manage any benefits without assistance, id. at 197.
This evidence is consistent with the ALJ’s determination that Ms. Cainglit’s
depression would not significantly interfere with her ability to do basic work
activities.
Ms. Cainglit notes that Dr. Ball reported claimant’s Global Assessment of
Functioning (GAF) score as 45, id. at 197, and that the counselors at MHSSO
reported her GAF score as 39, id. at 217, and argues that these scores demonstrate
that her depression is a severe impairment. The GAF scale is used by clinicians
to report an individual’s overall level of functioning. See American Psychiatric
Assoc., Diagnostic and Statistical Manual of Mental Disorders 32 (Text Revision
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4th ed. 2000). A GAF score of 41-50 indicates “[s]erious symptoms . . . OR
any serious impairment in social, occupational, or school functioning,” while
a GAF score of 31-40 indicates “[s]ome impairment in reality testing or
communication . . . OR major impairment in several areas, such as work, school,
family relations, judgment, thinking or mood.” Id. at 34. A GAF score of 39-45
thus may indicate problems that do not necessarily relate to one’s ability to work.
See id . In this case neither Dr. Ball nor the MHSSO counselors stated that
Ms. Cainglit’s depression would interfere with her ability to work. Aplt. App. at
196-97, 212-26. Rather, they noted problems with her family and social
relationships. Id. at 216. In the absence of any evidence indicating that Dr. Ball
or the MHSSO assigned these GAF scores because they perceived an impairment
in Ms. Cainglit’s ability to work, the scores, standing alone, do not establish an
impairment seriously interfering with Ms. Cainglit’s ability to perform basic work
activities. Cf. Howard v. Comm’r of Soc. Sec. , 276 F.3d 235, 241 (6th Cir. 2002).
In sum, the ALJ’s determination that Ms. Cainglit’s depression did not
significantly limit her physical and mental ability to do basic work activities,
and therefore that her depression was not a “severe” mental impairment at
step two, is supported by substantial evidence.
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II. Weight Given to Treating Physician; Development of the Record .
Ms. Cainglit’s next two arguments are related. First, she contends that the
ALJ failed to consider properly the report of her treating physician, Dr. Woods,
and, second, that in considering Dr. Woods’ records, the ALJ failed to develop
the record fully. Dr. Woods’ records consist of two pages of treatment notes from
March, April and May of 1999, Aplt. App. at 211, 230, a two-page analysis of
Ms. Cainglit’s RFC in September 1999, id. at 228-29, and a one-paragraph letter
dated May 21, 1999, from Dr. Woods, stating her opinion that Ms. Cainglit was
totally and permanently disabled, id. at 231.
An ALJ is required to give controlling weight to a treating physician’s
opinion only if “it is well supported by clinical and laboratory diagnostic
techniques and if it is not inconsistent with other substantial evidence in the
record.” Castellano , 26 F.3d at 1029; 20 C.F.R. §§ 404.1527(d)(2),
416.927(d)(2); 20 C.F.R. §§ 404.1527(e)(1), 416.927(e)(1). When an ALJ
decides that a treating source’s opinion is not entitled to controlling weight,
he must determine the weight it should be given after considering
(1) the length of the treatment relationship and the frequency of
examination; (2) the nature and extent of the treatment relationship,
including the treatment provided and the kind of examination or
testing performed; (3) the degree to which the physician’s opinion is
supported by relevant evidence; (4) consistency between the opinion
and the record as a whole; (5) whether or not the physician is a
specialist in the area upon which an opinion is rendered; and
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(6) other factors brought to the ALJ’s attention which tend to support
or contradict the opinion.
Drapeau v. Massanari, 255 F.3d 1211, 1213 (10th Cir. 2001).
Ms. Cainglit acknowledges that the ALJ did not explicitly reject
Dr. Woods’ opinion. Appellant’s Br. at 14. Rather, the ALJ properly set forth
specific, legitimate explanations for disregarding certain limited aspects of
Dr. Woods’ RFC assessment and correctly observed that Dr. Woods’ opinion that
Ms. Cainglit was disabled was not supported by clinical and laboratory diagnostic
techniques. Dr. Woods’ RFC assessment of Ms. Cainglit’s exertional abilities is
consistent with the ALJ’s assessment of her exertional abilities, and is not
inconsistent with the ALJ’s determination that Ms. Cainglit had the physical
strength to perform sedentary work. Compare Aplt. App. at 28, with id . at
228-29; see also 20 C.F.R. §§ 404.1567(a), 416.967(a) (describing exertional
requirements of sedentary work). There were only slight differences in the two
RFC assessments, for which the ALJ provided specific and legitimate
explanations that are supported by the record. For example, Dr. Woods found that
Ms. Cainglit had a non-exertional limitation of needing to avoid exposure to dust,
fumes, and humidity. Id. at 229. The ALJ differed from Dr. Woods merely in his
determination that Ms. Cainglit needed only to be restricted from excessive
exposure to these irritants, and supported this conclusion with the evidence that
Ms. Cainglit continued to smoke and that Dr. Woods’ treatment notes do not
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reflect any acute breathing difficulties and did not suggest further evaluation,
such as a pulmonary function study. Id. at 27-28.
In discussing Dr. Woods’ treatment of Ms. Cainglit, the ALJ noted that
Dr. Woods had prescribed a medication for her that would not likely be prescribed
for persons with a respiratory disease. Id. at 27. Ms. Cainglit asserts that the
ALJ was impermissibly substituting his lay opinion for medical opinion.
See Sisco v. United States Dep’t of Health & Human Servs. , 10 F.3d 739, 744
(10th Cir. 1993) (holding ALJ erred in rejecting unrebutted medical diagnosis of
chronic fatigue syndrome based on lack of conclusive laboratory tests when there
were no such “dipstick” tests available for chronic fatigue syndrome). We
disagree. The ALJ was evaluating Dr. Woods’ opinion based upon a variety of
factors, and was not rejecting or discounting Dr. Woods’ opinion based upon this
single observation. See Aplt. App. at 27-28.
The ALJ did disagree with Dr. Woods’ conclusion that Ms. Cainglit is
totally disabled. The ALJ did not err in doing so. An opinion by a treating
physician that a claimant is “disabled” or “unable to work” has no special
significance because it is not a medical opinion. 20 C.F.R. §§ 404.1527(e)(1);
416.927(e)(1). These determinations are legal conclusions that are “reserved to
the Commissioner.” Id. See also Castellano , 26 F.3d at 1029 (holding that
“responsibility for determining the ultimate issue of disability is reserved to the
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[Commissioner]”). As the ALJ noted, Dr. Woods’ disability opinion was not
supported by specific findings or any objective clinical or laboratory diagnostic
findings, and Dr. Woods’ treatment notes do not support the severity of
impairments she described in her disability opinion letter. See Aplt. App.
at 27-28.
In a related argument, Ms. Cainglit contends that the ALJ failed to develop
the record in two instances; first, when he noted the incongruity between
Dr. Woods’ statement that she had treated Ms. Cainglit since August 1998 and
the absence of any treatment notes from Dr. Woods prior to March 1999, and
second, when he noted that Dr. Woods had never ordered any pulmonary function
tests to assess the severity of Ms. Cainglit’s breathing problems. Ms. Cainglit
contends that the ALJ should have made an attempt to obtain either the missing
records or an explanation for their absence and should have ordered pulmonary
function tests.
As noted above, the burden to prove disability in a social security case is on
the claimant, and to meet this burden, the claimant must furnish medical and other
evidence of the existence of the disability. Yuckert , 482 U.S. at 146. A social
security disability hearing is nonadversarial, however, and the ALJ bears
responsibility for ensuring that “an adequate record is developed during the
disability hearing consistent with the issues raised.” Henrie v. United States
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Dep’t of Health & Human Servs. , 13 F.3d 359, 360-61 (10th Cir. 1993).
Generally, “[a]n ALJ has the duty to develop the record by obtaining pertinent,
available medical records which come to his attention during the course of the
hearing.” Carter v. Chater , 73 F.3d 1019, 1022 (10th Cir. 1996). Where the
medical evidence in the record is inconclusive, “a consultative examination is
often required for proper resolution of a disability claim.” Hawkins v. Chater ,
113 F.3d 1162, 1166 (10th Cir. 1997); see also 20 C.F.R. §§ 404.1512(f),
416.912(f).
Nevertheless, “[t]he ALJ should ordinarily be entitled to rely on the
claimant’s counsel to structure and present claimant’s case in a way that the
claimant’s claims are adequately explored” and “may ordinarily require counsel
to identify the issue or issues requiring further development.” Hawkins , 113 F.3d
at 1167. Ms. Cainglit’s counsel was familiar with the record submitted to the
ALJ. Counsel did not indicate or suggest to the ALJ that any medical records
from Dr. Woods were missing, nor ask for the ALJ’s assistance in obtaining any
such records. On appeal, counsel has failed to identify the evidence that she
claims the ALJ should have obtained. Given Ms. Cainglit’s failure to provide the
as-yet-unidentified records herself, to ask the Commissioner for assistance, or to
show the relevance of any records she claims the ALJ should have obtained,
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we conclude she has not demonstrated the ALJ violated his duty to develop
the record.
Nor was the ALJ required to order a pulmonary function test. The ALJ did
order two consulting examinations. Neither the treatment records nor the
consulting examination relating to Ms. Cainglit’s breathing problems indicate that
further examinations were needed. The consulting physician stated that although
Ms. Cainglit reported having asthma and breathing difficulties, he did not see that
demonstrated in his examination. Aplt. App. at 189. He reported that
Ms. Cainglit’s chest and lungs were clear, that he heard no wheezes and no chest
rales in her lungs whatsoever, that she had good breath sounds bilaterally, and
that after he put her through all the exams, she was not short of breath. Id.
at 188-89.
We conclude there was an adequate record by which the ALJ could decide
this case. He had before him not only Dr. Woods’ records but also the records of
Ms. Cainglit’s other physicians, as well as those of the consulting physicians.
Further, we conclude the ALJ gave proper weight to Dr. Woods’ opinions. See
Castellano, 26 F.3d at 1029.
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The judgment of the district court is AFFIRMED.
Entered for the Court
Harris L Hartz
Circuit Judge
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