Goodwin v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Abdul K Kallon on 8/18/2014. (PSM)
2014 Aug-18 PM 12:19
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
TERRY LEE GOODWIN,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security, )
CIVIL ACTION NO.
Plaintiff Terry Lee Goodwin (“Goodwin”) brings this action pursuant to Section
205(g) of the Social Security Act (“the Act”), 42 U.S.C. § 405(g), seeking review of the
final adverse decision of the Commissioner of the Social Security Administration
(“SSA”). This court finds that the Administrative Law Judge’s (“ALJ”) decision - which
has become the decision of the Commissioner - is supported by substantial evidence.
Therefore, for the reasons elaborated herein, the court will affirm the decision denying
I. Procedural History
Goodwin, whose past relevant experience includes work as a construction worker,
filed an application for Title II disability insurance benefits and Title XVI Supplemental
Security Income on May 17, 2010, alleging a disability onset date of July 31, 2007, due
to back pain and mental problems. (R. 20, 219). After the SSA denied Goodwin’s
claim, he requested a hearing before an ALJ. (R. 117). The ALJ subsequently denied
Goodwin’s claim, (R. 17-32), which became the final decision of the Commissioner
when the Appeals Council refused to grant review. (R. 1-6). Goodwin then filed this
action for judicial review pursuant to § 205(g) of the Act, 42 U.S.C. § 405(g). Doc. 1.
II. Standard of Review
The only issues before this court are whether the record contains substantial
evidence to sustain the ALJ’s decision, see 42 U.S.C. § 405(g); Walden v. Schweiker,
672 F.2d 835, 838 (11th Cir. 1982), and whether the ALJ applied the correct legal
standards. See Lamb v. Bowen, 847 F.2d 698, 701 (11th Cir. 1988); Chester v. Bowen,
792 F.2d 129, 131 (11th Cir. 1986). Title 42 U.S.C. § 405(g) mandates that the
Commissioner’s “factual findings are conclusive if supported by ‘substantial evidence.’”
Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). The district court may not
reconsider the facts, reevaluate the evidence, or substitute its judgment for that of the
Commissioner; instead, it must review the final decision as a whole and determine if the
decision is “reasonable and supported by substantial evidence.” See id. (citing
Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)). Substantial evidence
falls somewhere between a scintilla and a preponderance of evidence; “[i]t is such
relevant evidence as a reasonable person would accept as adequate to support a
conclusion.” Martin, 849 F.2d at 1529 (quoting Bloodsworth, 703 F.2d at 1239) (other
citations omitted). If supported by substantial evidence, the court must affirm the
Commissioner’s factual findings even if the preponderance of the evidence is against the
Commissioner’s findings. See Martin, 894 F.2d at 1529. While the court acknowledges
that judicial review of the ALJ’s findings is limited in scope, it notes that the review
“does not yield automatic affirmance.” Lamb, 847 F.2d at 701.
III. Statutory and Regulatory Framework
To qualify for disability benefits, a claimant must show “the inability to engage in
any substantial gainful activity by reason of any medically determinable physical or
mental impairments which can be expected to result in death or which has lasted or can
be expected to last for a continuous period of not less than twelve months.” 42 U.S.C.
§ 423(d)(1)(A); 42 U.S.C. § 416(i). A physical or mental impairment is “an impairment
that results from anatomical, physiological, or psychological abnormalities which are
demonstrated by medically acceptable clinical and laboratory diagnostic techniques.” 42
U.S.C. § 423(d)(3).
Determination of disability under the Act requires a five step analysis. 20 C.F.R.
§§ 404.1520(a)-(g), 416.920(a)-(g). Specifically, the Commissioner must determine in
whether the claimant is currently unemployed;
whether the claimant has a severe impairment;
whether the impairment meets or equals one listed by the Secretary;
whether the claimant is unable to perform his or her past work; and
whether the claimant is unable to perform any work in the national
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). “An affirmative answer to
any of the above questions leads either to the next question, or, on steps three and five, to
a finding of disability. A negative answer to any question, other than step three, leads to
a determination of ‘not disabled.’” Id. at 1030 (citing 20 C.F.R. § 416.920(a)-(f)). “Once
a finding is made that a claimant cannot return to prior work the burden shifts to the
Secretary to show other work the claimant can do.” Foote v. Chater, 67 F.3d 1553, 1559
(11th Cir. 1995) (citation omitted).
IV. The ALJ’s Decision
In performing the five step analysis, the ALJ found that Goodwin had not engaged
in substantial gainful activity since July 31, 2007, and, therefore, met Step One. (R. 22).
Next, the ALJ found that Goodwin satisfied Step Two because he suffered from the
severe impairments of “hypertension; mild degenerative joint disease of the right knee;
obesity; and lumbar degenerative disc disease.” Id. The ALJ then proceeded to the next
step and found that Goodwin failed to satisfy Step Three because he “does not have an
impairment or combination of impairments that meets or medically equals one of the
listed impairments.” (R. 25). Although the ALJ answered Step Three in the negative,
consistent with the law, see McDaniel, 800 F.2d at 1030, the ALJ proceeded to Step Four
where she determined that Goodwin has the residual functional capacity (RFC) to
light work as defined in 20 CFR 404.1567(b) and 416.967(b) except for the
additional limitations described below. [Goodwin] requires a sit/stand
option permitting him to change position as needed. He is unable to use his
right foot to operate foot controls. He is unable to climb stairs, ladders,
ropes, or scaffolds. He can occasionally stoop but cannot kneel, crawl, or
crouch. He should avoid exposure to excessive vibrations, and he should
avoid workplace hazards, such as unprotected heights and hazardous
machinery. He should avoid concentrated exposure to extreme heat and
cold, humidity, chemicals, and pulmonary irritants such as fumes, odors,
dust, gases, and poorly ventilated areas. [He] is limited to unskilled work.
(R. 25-26). In light of his RFC, the ALJ held that Goodwin “is unable to perform any
past relevant work.” (R. 30). Lastly, in Step Five, the ALJ considered Goodwin’s age,
education, work experience,1 and RFC, and determined “there are jobs that exist in
significant numbers in the national economy [Goodwin] can perform.” (R. 31).
Therefore, the ALJ found that Goodwin “has not been under a disability, as defined in
the Social Security Act, from July 31, 2007, through the date of this decision.” Id.
The court now turns to Goodwin’s contentions that the ALJ erred by failing to (1)
give proper weight to the opinion of his treating physician; (2) recontact his treating
physician; and (3) include all of his limitations when assessing his RFC. See doc. 9 at 410. The court addresses each contention in turn.
The ALJ properly considered the opinions of Goodwin’s treating physician.
Goodwin contends the ALJ did not give proper weight to the opinions of Dr.
Carey Goodman, one of his treating physicians. The record shows Dr. Goodman treated
As of the date of the ALJ’s decision, Goodwin was 53 years old, had a limited
education, and past relevant very heavy unskilled work as a construction worker. (R.
Goodwin regularly for knee and back pain from November 5, 2007, through August 3,
2011. (R. 269-98, 320-31, 335-38). Dr. Goodman also completed a physical capacities
evaluation (PCE) on December 13, 2010, in which because of Goodwin’s “chronic pain
syndrome,” and his “[d]iagnos[is] with fibromyalgia,” Dr. Goodman limited Goodwin to,
among other things, a total of 30 minutes sitting, and 1 hour standing/walking in an
eight-hour day. (R. 317). Dr. Goodman also indicated on a Clinical Assessment of Pain
form that Goodwin’s pain was “distracting to adequate performance of daily activities or
work.” (R. 318).
Goodwin contends that Dr. Goodman’s opinion establishes that he is disabled and,
consequently, argues the ALJ erred in giving little weight to Dr. Goodman’s opinions.
To determine how much weight, if any, to give Dr. Goodman’s opinions, the ALJ had to
consider several factors, including whether Dr. Goodman (1) had examined Goodwin;
(2) had a treating relationship with Goodwin; (3) presented medical evidence and
explanation supporting the opinion; (4) provided an opinion that is consistent with the
record as a whole; and (5) is a specialist. See 20 C.F.R. § 416.927(c). Because Dr.
Goodman is a treating physician, the ALJ must give “controlling weight” to his opinion if
it “is well-supported by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with the other substantial evidence.” 20 C.F.R. §
416.927(c)(2). Moreover, in this circuit “the testimony of a treating physician must be
given substantial or considerable weight unless ‘good cause’ is shown to the contrary.”
Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). “Good cause” exists when the
evidence does not bolster the treating physician’s opinion; a contrary finding is supported
by the evidence; or the opinion is conclusory or inconsistent with the treating physician’s
own medical records. Id. Finally, if the ALJ rejects a treating physician’s opinion, “[t]he
ALJ must clearly articulate the reasons for giving less weight to the opinion . . . and the
failure to do so is reversible error.” Id.
Contrary to Goodman’s contention, the ALJ correctly applied the law and
articulated multiple reasons for giving Dr. Goodman’s opinion “little weight.” (R. 29).
In a nutshell, the ALJ discounted Dr. Goodman’s opinions because they were
inconsistent with Dr. Goodman’s own treatment notes:
Dr. Goodman’s assessment merits little weight, as it is markedly
inconsistent with [Goodwin’s] medical treatment records, which do not
provide any indication that Dr. Goodman has ever diagnosed [Goodwin]
with chronic pain syndrome or fibromyalgia. It does not appear that Dr.
Goodman or any other physician has ever performed a trigger point
examination or other evaluation to investigate the possibility of
(R. 29). To support his finding, the ALJ pointed out that in August 2011 Dr. Goodman
found “there were no signs of acute joint inflammation and no positive pertinent findings
of a distinct disease process,” and that on the date Dr. Goodman completed the PCE, Dr.
Goodman’s physical examination showed “no indication of any significant examination
findings that would explain the severe restrictions in this medical source statement, and
at this office visit, Dr. Goodman again advised [Goodwin] to walk for exercise.” Id. In
light of this advice for Goodwin to exercise, to no surprise, the ALJ also found that Dr.
Goodman’s indication that Goodwin required “an assistive device . . . to ambulate even
minimally in a normal workday,” was entitled to no weight because “[t]here is no
indication in [Goodwin’s] medical treatment records that Dr. Goodman has ever
prescribed or advised the use of a cane, and the doctor has regularly advised [Goodwin]
to walk for exercise.” (R. 29-30). Based on the court’s review of the record, the court
finds that the substantial evidence supports the ALJ’s finding that Dr. Goodman’s
treatment records contradict the opinions he outlined in the PCE.
Likewise, the substantial evidence supports the ALJ’s finding that Dr. Goodman’s
opinion that Goodwin “could rarely reach” was inconsistent with the rest of the medical
evidence because “there is no record of any impairment affecting [Goodwin’s] cervical
spine or upper extremities that would account for such a severe restriction” Id. Goodwin
failed to direct the ALJ or the court to any evidence in the record that supports this
opinion by Dr. Goodman. The record also supports the ALJ’s finding that Dr. Goodman
based his opinion on Goodwin’s subjective complaints. As the ALJ noted, “[i]t appears
that Dr. Goodman based this assessment of [Goodwin’s] physical abilities and pain on
[Goodwin’s] own subjective report, as he noted at the bottom of the form that [Goodwin]
had said his chronic problems inhibited him from most physical activities.” Id. The
ALJ’s reliance on this factor was proper because an ALJ may reject a physician’s opinion
when it “appears to be based primarily on [a claimant’s] subjective complaints of pain.”
Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1159 (11th Cir. 2004).
Based on the record before this court, it is evident that the ALJ considered the
factors set forth in the regulations and, consistent with the law of this circuit, articulated
good cause for giving Dr. Goodman’s opinions little weight: i.e., that Dr. Goodman’s
opinions were inconsistent with his own treatment notes and the other medical evidence,
and were based on Goodwin’s subjective complaints. Therefore, the ALJ had good cause
for rejecting Dr. Goodman’s opinions, and committed no reversible error. See Lewis, 125
F.3d at 1440 (“good cause” exists when physician’s opinion is inconsistent with own
records, a contrary finding is supported by the evidence, and the evidence does not bolster
physician’s opinion); 20 C.F.R. § 416.927(c)(2) (opinion must be “well-supported by
medically acceptable clinical and laboratory diagnostic techniques” to receive controlling
The ALJ was not required to recontact Dr. Goodman.
The court is not persuaded by Goodwin’s second contention that the ALJ should
have contacted Dr. Goodman for clarification. Doc. 9 at 8. Under the relevant regulation
in effect at the time,2 the ALJ only had a duty to contact Dr. Goodman if the medical
evidence was insufficient for the ALJ to determine whether Goodwin was disabled:
When the evidence we receive from your treating physician or psychologist
or other medical source is inadequate for us to determine whether you are
disabled, we will need additional information to reach a determination or a
decision. To obtain the information, we will take the following actions.
New regulations regarding recontacting of medical sources went into effect on
March 26, 2012. 77 Fed. Reg. 10651-01 (February 23, 2012). Under the new
regulations, recontacting a medical source is within the discretion of the ALJ. See 20
C.F.R. § 404.1520b(c)(1) (“We may recontact your treating physician . . . .”) (emphasis
(1) We will first recontact your treating physician or psychologist or
other medical source to determine whether the additional information
we need is readily available.
20 C.F.R. § 404.912(e)(2010) (emphasis added). Unfortunately for Goodwin, the medical
evidence included numerous treatment notes and a consultative examination that showed
the extent of his impairments. Consequently, the ALJ had no obligation to recontact Dr.
Alternatively, Goodwin’s contention fails because he has not shown the requisite
prejudice. Before remanding for further development of the record, a reviewing court
must consider “whether the record reveals evidentiary gaps which result in unfairness or
‘clear prejudice.’” Smith v. Schweiker, 677 F.2d 826, 830 (11th Cir.1982) (quoting Ware
v. Schweiker, 651 F.2d 408, 413 (5th Cir. Unit A July 1981). Goodwin has not
established the requisite prejudice because there are no evidentiary gaps in the record that
prevented the ALJ from making a conclusive determination regarding his disability.
Therefore, remand for development of the record is not required.
The ALJ properly assessed Goodwin’s RFC.
Goodwin’s final contention is that the ALJ erred because she did not include all of
the restrictions contained in the report of Dr. Morton Rickless, the consultative orthopedic
examiner. Doc. 9 at 9-10. Goodwin’s contention is based on his assumption that the
ALJ’s RFC finding must be based on an RFC evaluation from a physician. See id. at 10
(“[T]he ALJ’s RFC is not consistent with any RFC evaluations provided by treating or
examining physicians.”). Unfortunately, Goodwin overlooks that the regulations and the
law of this circuit do not impose such a requirement. Rather, the pertinent regulation
provides that opinions on issues reserved to the Commissioner are not medical opinions:
Opinions on some issues, such as the examples that follow, are not medical
opinions, . . . but are, instead, opinions on issues reserved to the
Commissioner because they are administrative findings that are dispositive
of a case; i.e., that would direct the determination or decision of disability.
20 C.F.R. § 404.1527(d). One of the specifically reserved examples is a claimant’s RFC:
“Although we consider opinions from medical sources on issues such as . . . your residual
functional capacity . . . the final responsibility for deciding these issues is reserved to the
Commissioner.” 20 C.F.R. § 404.1527(d)(2). Consequently, the Eleventh Circuit has
recognized that “the task of determining a claimant’s residual functional capacity and
ability to work is within the province of the ALJ, not of doctors.” Robinson v. Astrue,
365 F. App’x 993, 999 (11th Cir. 2010). Moreover, an ALJ’s RFC finding can be
supported by substantial evidence even without a medical source statement in the record.
See Green v. Soc. Sec. Admin., 223 F. App’x 915, 922-23 (11th Cir. 2007) (rejected the
claimant’s argument “that without [the physician’s] opinion, there [was] nothing in the
record” to support the ALJ’s RFC assessment).
Here, the ALJ properly relied on the treatment records and Dr. Rickless’s medical
source statement to assess Goodwin’s RFC. In particular, the ALJ gave great weight to
Dr. Rickless’s opinions:
As for the opinion evidence, the undersigned gives great weight to Dr.
Morton Rickless, who completed a medical source statement based on the
findings of his December 2011 consultative orthopedic examination of
[Goodwin]. Dr. Rickless determined that [Goodwin] could lift and carry
up to 20 pounds frequently, and during the course of an eight-hour
workday, he could perform a total of six hours of sitting, five hours of
standing, and/or four hours of walking. Dr. Rickless specified that
[Goodwin] did not need a cane or other assistive device to help him walk.
He indicated that [Goodwin] could not operate foot controls with his right
lower extremity because he had arthritis in his right knee. These
conclusions merit great weight, as they are consistent with the examination
findings and other medical evidence of record. The undersigned gives no
weight, however, to Dr. Rickless’s indication that [Goodwin] could never
stoop. This restriction is inconsistent with the exam findings, which
included no more than minimal limitation in the range of motion of
[Goodwin]’s lumbar spine. It is also inconsistent with his conclusion that
[Goodwin] could use public transportation and perform basic activities of
daily living, such as cooking, shopping, and caring for personal hygiene.
Such activities would be impossible without some ability to stoop, which is
defined as bending the body downward and forward by bending the spine
at the waist (SSR 85-15).
(R. 28-29). Although the ALJ gave great weight to Dr. Rickless’s statement, she did not
include all of Dr. Rickless’s limitations in her RFC finding. In that regard, Goodwin
contends the ALJ should have included Dr. Rickless’s restriction that Goodwin could not
balance, could only occasionally operate controls with his left foot, and could only walk
for four hours and stand five hours in an eight-hour day. Doc. 9 at 9. Unfortunately for
Goodwin, the omission of a restriction on balancing is irrelevant because none of the jobs
identified by the ALJ require balancing. See DICOT 729.687-010, 1991 WL 679733;
DICOT 706.687-010, 1991 WL 679074; DICOT 726.687-010, 1991 WL 679633.
Moreover, the ALJ’s inclusion of a “sit/stand option permitting [Goodwin] to change
position as needed” is not inconsistent with Dr. Rickless’s limitations on standing and
walking because he indicated Goodwin can sit for up to six hours in an eight-hour day,
leaving only two hours of combined standing and walking. (R. 345). Finally, substantial
evidence supports the ALJ’s assessment that Goodwin had no limitation in his ability to
operate controls with his left foot because Dr. Rickless only identified “arthritis [of the]
right knee” to support this limitation, (R. 346), and Goodwin testified that he walked for
exercise and mowed his lawn with a push lawn mower. (R. 58, 68).
Put simply, the ALJ was not required to rely on an RFC from a physician, or to
accept all of Dr. Rickless’s opinions about Goodwin’s physical limitations. Moreover,
because, there was was sufficient medical evidence to allow the ALJ to assess Goodwin’s
RFC and determine whether he was disabled, the record was complete. See 20 C.F.R. §
404.1513(e). Consequently, no additional development was required, and the ALJ
committed no reversible error in assessing Goodwin’s RFC.
Based on the foregoing, the court concludes that the ALJ’s determination that
Goodwin is not disabled is supported by substantial evidence, and that the ALJ applied
proper legal standards in reaching this determination. Therefore, the Commissioner’s
final decision is AFFIRMED. A separate order in accordance with the memorandum of
decision will be entered.
Done this 18th day of August, 2014.
ABDUL K. KALLON
UNITED STATES DISTRICT JUDGE
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