Gardner v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Magistrate Judge T Michael Putnam on 7/24/15. (MRR)
2015 Jul-24 PM 12:44
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
RENEA N. GARDNER,
CAROLYN W. COLVIN,
Commissioner of Social Security,
Case No. 2:14-cv-1430-TMP
The plaintiff, Renea N. Gardner, appeals from the decision of the
Commissioner of the Social Security Administration (ACommissioner@) denying her
application for a period of disability and Disability Insurance Benefits (ADIB@).
Ms. Gardner timely pursued and exhausted her administrative remedies, and the
decision of the Commissioner is ripe for review pursuant to 42 U.S.C. '' 405(g),
1383(c)(3). The parties have consented to the jurisdiction of the undersigned
magistrate judge pursuant to 28 U.S.C. ' 626(c).
Ms. Gardner was 50 years old at the time of the Administrative Law Judge=s
(AALJ=s@) decision, and she has a high school education. (Tr. at 22). 1 Her past work
experiences are as a customer service manager, a delivery driver and auto parts
clerk, a floral designer, and a leasing consultant. (Id.) Ms. Gardner claims that she
became disabled on October 1, 2010, due to inflammatory arthritis; osteoarthritis of
the lumbar spine and bilateral knees; major depressive disorder; generalized anxiety
disorder; panic disorder; obesity; and chronic and severe pain. (Tr. at 16).
When evaluating the disability of individuals over the age of eighteen, the
regulations prescribe a five-step sequential evaluation process. See 20 C.F.R.
'' 404.1520, 416.920; see also Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir.
2001). The first step requires a determination of whether the claimant is Adoing
substantial gainful activity.@ 20 C.F.R. '' 404.1520(a)(4)(i), 416.920(a)(4)(i). If
she is, the claimant is not disabled and the evaluation stops. Id. If she is not, the
Commissioner next considers the effect of all of the physical and mental
impairments combined. 20 C.F.R. '' 404.1520(a)(4)(ii), 416.920(a)(4)(ii). These
impairments must be severe and must meet the durational requirements before a
claimant will be found to be disabled. Id. The decision depends upon the medical
Claimant was 47 years old at her alleged onset date, 49 when the hearing was held
before the ALJ, and she turned 50 two days before the ALJ=s decision was entered.
evidence in the record. See Hart v. Finch, 440 F.2d 1340, 1341 (5th Cir. 1971). If
the claimant=s impairments are not severe, the analysis stops.
'' 404.1520(a)(4)(ii), 416.920(a)(4)(ii). Otherwise, the analysis continues to step
three, which is a determination of whether the claimant=s impairments meet or equal
the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. 20
C.F.R. '' 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the claimant=s impairments fall
within this category, she will be found disabled without further consideration. Id.
If she does not, a determination of the claimant=s residual functional capacity
(ARFC@) will be made and the analysis proceeds to the fourth step. 20 C.F.R.
'' 404.1520(e), 416.920(e). Residual functional capacity is an assessment based
on all relevant evidence of a claimant=s remaining ability to do work despite her
impairments. 20 C.F.R. ' 404.1545(a).
The fourth step requires a determination of whether the claimant=s
impairments prevent him or her from returning to past relevant work. 20 C.F.R. ''
404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant can still do his or her past
relevant work, the claimant is not disabled and the evaluation stops. Id. If the
claimant cannot do past relevant work, then the analysis proceeds to the fifth step.
Id. Step five requires the court to consider the claimant=s RFC, as well as the
claimant=s age, education, and past work experience, in order to determine if he or
she can do other work. 20 C.F.R. '' 404.1520(a)(4)(v), 416.920(a)(4)(v). If the
claimant can do other work, the claimant is not disabled. Id. The burden of
demonstrating that other jobs exist which the claimant can perform is on the
Commissioner; and, once that burden is met, the claimant must prove his or her
inability to perform those jobs in order to be found to be disabled. Jones v. Apfel,
190 F.3d 1224, 1228 (11th Cir. 1999).
Applying the sequential evaluation process, the ALJ found that Ms. Gardner
has not been under a disability within the meaning of the Social Security Act from
the date of onset through the date of his decision. (Tr. at 23-24). He determined
that Ms. Gardner has not engaged in substantial gainful activity since the alleged
onset of her disability. (Tr. at 16).
According to the ALJ, Ms. Gardner=s
inflammatory arthritis, osteoarthritis of the lumbar spine and bilateral knees, obesity,
major depressive disorder, generalized anxiety disorder, and panic disorder are
considered Asevere@ based on the requirements set forth in the regulations. (Tr. at
16-17). He further determined that these impairments neither meet nor medically
equal any of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1.
(Tr. at 17). The ALJ found Ms. Gardner=s testimony at the hearing and statements
in the record to be Aless than entirely credible@ with respect to the debilitating effects
of these conditions. (Tr. at 21). He determined that the plaintiff has the residual
functional capacity to perform light work with the following limitations: that she
can never climb ladders, ropes, or scaffolds, and should only occasionally stoop,
kneel, crouch, crawl, balance, and climb ramps or stairs.
He determined, in
addition, that she should avoid concentrated exposure to extreme temperatures,
operational control of moving machinery, and unprotected heights. He further
limited her work to the performance of simple, routine, and repetitive tasks, in a
work environment where changes occur on only an occasional basis, and where
there is no greater than occasional, brief, and superficial interaction with coworkers,
supervisors, or the public.
(Tr. at 18).
According to the ALJ, Ms. Gardner is unable to perform any of her past
relevant work, she was a Ayounger individual@ at the date of alleged onset but had
since aged into the category known as Aclosely approaching advanced age.@ (Tr. at
22). The ALJ further noted that Ms. Gardner has a high school education and is
able to communicate in English, as those terms are defined by the regulations. (Tr.
He determined that Atransferability of skills is not material to the
determination of disability@ in this case.
(Tr. at 22-23).
The ALJ found that Ms.
Gardner has the residual functional capacity to perform a significant range of light
work. (Tr. at 23). Even though Plaintiff cannot perform the full range of light
work, the ALJ found that there are a significant number of jobs in the national
economy that she is capable of performing, such as sorter, mail sorter, and machine
tender (plastics). (Tr. at 23). The ALJ concluded his findings by stating that
Plaintiff is Anot disabled@ under the Social Security Act. (Tr. at 23-24).
II. Standard of Review
This court=s role in reviewing claims brought under the Social Security Act is
a narrow one. The scope of its review is limited to determining (1) whether there is
substantial evidence in the record as a whole to support the findings of the
Commissioner, and (2) whether the correct legal standards were applied. See
Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Wilson v. Barnhart, 284 F.3d
1219, 1221 (11th Cir. 2002). The court approaches the factual findings of the
Commissioner with deference, but applies close scrutiny to the legal conclusions.
See Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996). The court may not decide
facts, weigh evidence, or substitute its judgment for that of the Commissioner. Id.
AThe substantial evidence standard permits administrative decision makers to act
with considerable latitude, and >the possibility of drawing two inconsistent
conclusions from the evidence does not prevent an administrative agency=s finding
from being supported by substantial evidence.=@ Parker v. Bowen, 793 F.2d 1177,
1181 (11th Cir. 1986) (Gibson, J., dissenting) (quoting Consolo v. Fed. Mar.
Comm=n, 383 U.S. 607, 620 (1966)). Indeed, even if this Court finds that the
evidence preponderates against the Commissioner=s decision, the court must affirm
if the decision is supported by substantial evidence. Miles, 84 F.3d at 1400.
Substantial evidence is more than a scintilla, but less than a preponderance. No
decision is automatic, however, for Adespite this deferential standard [for review of
claims] it is imperative that the Court scrutinize the record in its entirety to
determine the reasonableness of the decision reached.@ Bridges v. Bowen, 815 F.2d
622, 624 (11th Cir. 1987). Moreover, failure to apply the correct legal standards is
grounds for reversal. See Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
Ms. Gardner alleges that the ALJ=s decision should be reversed and remanded
because, she argues, the ALJ failed to give proper weight to the opinions of her
treating physicians. (Doc. 9, p. 8). Plaintiff contends that the ALJ failed to
properly weigh the opinion of Dr. Eudy, the claimant=s treating rheumatologist, who
opined that Ms. Gardner would be unable to work an 8-hour day, would be in
significant pain that would make her unable to stay on task, and therefore was not
Counsel further asserts that the opinion of Dr. Jones, the
claimant=s treating psychiatrist, that Ms. Gardner had several Amarked@ and
Aextreme@ impairments performing in a work environment that render her unable to
sustain employment. (Doc. 9, p. 10).
The Commissioner has responded that the
opinions of Drs. Eudy and Jones were properly assessed as being inconsistent with
other evidence in the record, including their own treatment records. (Doc. 10, pp.
Under prevailing law, a treating physician=s testimony is entitled to
Asubstantial or considerable weight unless >good cause= is shown to the contrary.@
Crawford v. Commissioner of Social Security, 363 F.3d 1155, 1159 (11th Cir. 1997)
(internal quotations omitted).
The weight to be afforded a medical opinion
regarding the nature and severity of a claimant=s impairments depends, among other
things, upon the examining and treating relationship the medical source had with the
claimant, the evidence the medical source presents to support the opinion, how
consistent the opinion is with the record as a whole, and the specialty of the medical
source. See 20 C.F.R. '' 404.1527(d), 416.927(d). AGood cause@ exists for an
ALJ not to give a treating physician=s opinion substantial weight when the
A(1) treating physician=s opinion was not bolstered by the evidence; (2) evidence
supported a contrary finding; or (3) . . . was conclusory or inconsistent with the
doctor=s own medical records.@ Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir.
2004) citing Lewis, 125 F.3d at 1440; see also Edwards v. Sullivan, 937 F.2d 580,
583-84 (11th Cir. 1991) (holding that Agood cause@ exists where the opinion was
contradicted by other notations in the physician=s own record).
Opinions such as whether a claimant is disabled, the claimant=s residual
functional capacity, and the application of vocational factors Aare not medical
opinions, . . . but are, instead, opinions on issues reserved to the Commissioner;@
thus the court Amay not decide facts anew, reweigh the evidence, or substitute [its]
judgment for that of the Commissioner.@ Dyer v. Barnhart, 395 F.3d 1206, 1210
(11th Cir. 2005).
The court instead looks to the doctors= evaluations of the
claimant=s condition and the medical consequences thereof, not their opinions of the
legal consequences of his [or her] condition.@ Lewis, 125 F.3d at 1440. See also
20 C.F.R. ' 404.1527(d)(1) (AA statement by a medical source that you are >disabled=
or >unable to work= does not mean that we will determine that you are disabled.@).
Such statements by a physician are relevant to the ALJ=s findings, but they are not
determinative, because it is the ALJ who bears the responsibility of assessing a
claimant=s residual functional capacity. See, e.g., 20 C.F.R. ' 404.1546(c).
The court reviews the ALJ=s consideration of the opinions of the treating
physicians in turn. Dr. Eudy is a rheumatologist who began treating Ms. Gardner as
early as May of 2007, and through the time after she applied for DIB benefits. Dr.
Eudy diagnosed Ms. Gardner with osteoarthritis of the lumbar spine and both knees,
as well as inflammatory arthritis.
In the Physical Capacities Evaluation he
completed on September 9, 2011, he determined that Ms. Gardner was able to sit no
more than 5 hours during an 8-hour work day, and could stand no more than 2 hours
of a workday. (Tr. at 316). Thus, by his calculation, she was incapable of working
an entire 8-hour day. He further opined that her pain level was Aintractable and
virtually incapacitating.@ (Tr. at 317). His treatment notes, which were virtually
ignored by the ALJ, frequently assess her pain as Apersistent@ and Aongoing@ with
Aintermittent@ swelling. (See, e.g., Tr. at 322, 330). While the ALJ stated that Dr.
Eudy saw Ano signs or symptoms to suggest active lupus or autoimmune disease@ (tr.
at 18), his notes indicate that she had positive ANA results that suggest Sjogren=s
Syndrome, which is an autoimmune disease. (Tr. at 330). The positive ANA and
probably Sjogren=s Syndrome was also noted by Dr. Reddy, the claimant=s treating
internist. (Tr. at 339). Dr. Eudy=s physical examinations consistently showed that
she had tenderness in her fingers, toes, knees, hips, and elbows. (Tr. at 323, 331,
346, 475). Dr. Eudy=s treatment notes are generally consistent with those of Dr.
Reddy, with the objective medical records, and with the claimant=s own testimony.
The ALJ found Dr. Eudy=s assessment of the plaintiff was Anot credible,@ and
stated that it was Ainconsistent with the claimant=s treatment records,@ and that
Aconservative treatment generally appeared to control her symptoms when she was
(Tr. at 19).
He thus found that Ms. Gardner=s condition was
Agenerally stable@ and gave Dr. Eudy=s opinion Alittle weight.@
The court is unable
to reconcile the ALJ=s assessment with Dr. Eudy=s records and the records of her
He consistently found that the plaintiff had pain and tenderness
associated with osteoarthritis, and that she got only partial relief from her
medications. The only medication she was Anoncompliant@ with was a Vitamin D
supplement, and no evidence in the record suggests that the vitamin would have
alleviated her pain. While she reported that she did not start the Plaquenil as soon
as it was prescribed in 2009, she clearly began taking it thereafter, and she was
apparently continued taking it, although she Aran out@ in 2010, and told Dr. Reddy
that she needed to see Dr. Eudy about getting more. (Tr. at 229, 369). The ALJ=s
description of the plaintiff=s treatment as Aconservative@ seems to be the ALJ=s own
medical opinion, as nowhere in the record does any medical authority suggest that
there are more aggressive treatments that would or could be employed to treat Ms.
Gardner=s impairments. 2 There is no question that she has been diagnosed as
positive for anti-nuclear antibodies (ANA+), a clear sign of rheumatic autoimmune
diseases, 3 and probably with Sjogren’s syndrome. 4 (Tr. at 346). Although Dr.
Eudy sometimes described her osteoarthritis as Astable,@ (tr. at 226), he also
sometimes noted that her spine and knees were Aworse@ (tr. at 228), or that, while
stable, the pain was Achronic.@
(Tr. at 230).
Standard treatment options for
The plaintiff was taking NSAIDs and narcotic pain medications to treat the
osteoarthritis. She was prescribed Plaquenil to slow or prevent joint damage due to rheumatic
diseases, see http://www.drugs.com/plaquenil.html (July 24, 2015), and Colcrys to treat painful
gout. http://www.drugs.com/colcrys.html (July 24, 2015).
Rheumatic disease is also known as connective tissue disease. See generally
http://rheumatology.oxfordjournals.org/content/39/6/581.full (July 24, 2015). “ANAs occur in
patients with a variety of autoimmune diseases, both systemic and organ-specific. They are
particularly common in the systemic rheumatic diseases, which include lupus erythematosus (LE),
discoid LE, drug-induced LE, mixed connective tissue disease, Sjogren syndrome, scleroderma
(systemic sclerosis), CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility,
sclerodactyly, telangiectasia) syndrome, polymyositis/dermatomyositis, and rheumatoid arthritis.”
http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/9026 (July 24,
Sjogren’s syndrome is an autoimmune disease in which a person’s white blood cells
attack the moisture-producing glands of the body. It is a debilitating disease often accompanied
by other auto-immune disorders, such as rheumatoid arthritis, lupus, and scleroderma. See
http://www.sjogrens.org/home/about-sjogrens-syndrome (July 24, 2015).
rheumatoid arthritis include physical therapy and medications, such as Plaquenil,5
to slow or prevent joint damage, which was prescribed for plaintiff by Dr. Eudy.
There simply is no evidence in the record to indicate that how Dr. Eudy treated
plaintiff is “conservative,” or that there are more aggressive treatments for pain were
available. Surgery becomes a treatment option only for severely damaged joints,
but debilitating pain in the joints long precedes the need for surgical repair. The
issue in this case is whether Dr. Eudy’s opinion that plaintiff’s pain prevented her
from working a full 8-hour day is inconsistent with his own medical treatment of her,
and that simply is not the case.
The assertion that plaintiff received only
“conservative” treatment is not an adequate reason for disregarding the treating
physician’s opinions about the degree of disability plaintiff suffered because there is
nothing inconsistent between type of treatment Dr. Eudy provided and the opinions
“There is no cure for rheumatoid arthritis. Medications can reduce inflammation in
your joints in order to relieve pain and prevent or slow joint damage. Occupational and physical
therapy can teach you how to protect your joints. If your joints are severely damaged by
68 (July 24, 2015).
Plaintiff next asserts that the ALJ erred in giving little weight to the opinion of
Dr. Rebecca Jones, a psychiatrist, who treated Ms. Gardner in 2011 and 2012.
Jones noted that Ms. Gardner had major depressive disorder, severe, with psychotic
features, and panic disorder. (Tr. at 276). Dr. Jones also noted that Ms. Gardner
complained of aggression and grief, and that even Ahigh dose SSRI therapy has not
helped@ quell the aggression plaintiff displayed toward others.6 (Tr. at 273). Dr.
Jones further noted that the claimant reported that her family told her she was
Acrazy,@ and that she has hallucinations of her brother and father, both of whom are
deceased. (Tr. at 276-77). The treatment notes of Dr. Jones further demonstrate
trouble sleeping, recurrent nightmares, feeling guilty, experiencing crying spells,
and having little energy.
(Tr. at 440-44).
Dr. Jones prescribed psychiatric
medications including Paxil, Wellbutrin, Abilify, Ambien, Trazodone, and Adderall.
Dr. Jones opined in August 2011 that the plaintiff had Amarked@ difficulty in
maintaining social functioning, Amarked@ deficiencies of concentration, persistence,
or pace resulting in frequent failure to complete tasks in a timely manner; Amarked@
impairment of ability to respond to customary work pressures, Amarked@ limitations
Plaintiff’s aggression was severe enough to cause her to be terminated from her last job.
Clearly, psychological problems leading to that level of aggression have a marked impact on her
ability “to respond to customary work pressures” or “to respond appropriately to supervision in a
work setting,” yet this was disregarded by the ALJ.
in understanding, carrying out, or remembering instructions in a work setting,
Aextreme@ impairment in the ability to respond appropriately to supervision in a
work setting, and Aextreme@ impairment in responding appropriately to coworkers,
along with Amarked@ impairment in performing simple tasks in a work setting and in
performing repetitive tasks in a work setting. (Tr. at 313-14). Dr. Jones=s notes are
internally consistent, consistent with the other medical records, and supported by the
claimant=s own testimony. The ALJ essentially discounts Dr. Jones=s assessment in
favor of that of a state agency psychologist, who never examined or treated the
plaintiff. (Tr. at 309-11).
The ALJ=s failure to give adequate reasons for virtually ignoring the opinions
of Dr. Eudy and Dr. Jones, two physicians who treated plaintiff over an extended
period, compels the conclusion that the matter is due to be remanded for further
consideration by the ALJ. There appears to be no “good cause” to give less than
substantial weight to their opinions. The combined debilitating effects of plaintiff’s
psychological problems, rheumatic diseases, osteoarthritis, obesity, and diabetes
appear to be grossly understated by the ALJ in a way that is not supported by
substantial evidence in the record, particularly when proper weight is accorded to the
opinions of the plaintiff’s treating physicians.
Upon review of the administrative record, and considering all of Ms.
Gardner=s arguments, the undersigned Magistrate Judge finds the Commissioner=s
decision is not supported by substantial evidence and is not in accord with the
applicable law; therefore, the Commissioner’s denial of benefits is VACATED and
this matter is REMANDED for further consideration in light of this Memorandum
DATED the 24th day of July, 2015.
T. MICHAEL PUTNAM
UNITED STATES MAGISTRATE JUDGE
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