Paige v. Colvin
Filing
29
MEMORANDUM OPINION AND ORDER entered that the decision of the Commissioner of Social Security denying Plaintiff benefits be AFFIRMED. Signed by Magistrate Judge P. Bradley Murray on 6/27/2017. (eec)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
NORTHERN DIVISION
MICHAEL PAIGE,
Plaintiff,
v.
NANCY A. BERRYHILL,
Acting Commissioner of Social
Security,
Defendant.
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CIVIL ACTION NO. 16-0383-MU
MEMORANDUM OPINION AND ORDER
Plaintiff Michael Paige brings this action, pursuant to 42 U.S.C. §§ 405(g) and
1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social
Security (“the Commissioner”) denying his claim for Supplemental Security Income
(“SSI”), based on disability. The parties have consented to the exercise of jurisdiction by
the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court.
(Doc. 26 (“In accordance with the provisions of 28 U.S.C. 636(c) and Fed. R. Civ. P. 73,
the parties in this case consent to have a United States Magistrate Judge conduct any
and all proceedings in this case, . . . order the entry of a final judgment, and conduct all
post-judgment proceedings.”)). Upon consideration of the administrative record, Paige’s
brief, the Commissioner’s brief, and the arguments of counsel at the May 10, 2017,
hearing before this Court, it is determined that the Commissioner’s decision denying
benefits should be affirmed.1
I. PROCEDURAL HISTORY
Paige applied for SSI, based on disability, under Title XVI of the Social Security
Act (“the Act”), 42 U.S.C. §§ 1381-1383d, on December 11, 2012, alleging disability
beginning on December 1, 2012. (Tr. 118). His application was denied at the initial level
of administrative review on May 2, 2013. (Tr. 64-69). On June 12, 2013, Paige
requested a hearing by an Administrative Law Judge (ALJ). (Tr. 72-74). After a hearing
on July 30, 2014, the ALJ issued an unfavorable decision finding that Paige was not
under a disability from the date the application was filed through the date of the
decision, December 11, 2014. (Tr. 17-28). Paige appealed the ALJ’s decision to the
Appeals Council, which denied his request for review of the ALJ’s decision on June 1,
2016. (Tr. 1-6).
After exhausting his administrative remedies, Paige sought judicial review in this
Court, pursuant to 42 U.S.C. §§ 405(g) and 1383(c). (Doc. 1). The Commissioner filed
an answer and the social security transcript on October 17, 2016. (Docs. 11, 12). After
both parties filed briefs setting forth their respective positions, the Court conducted a
hearing on this matter on May 10, 2017. (Docs. 14, 23). The case is now ripe for
decision.
1
Any appeal taken from this Order and Judgment shall be made to the Eleventh
Circuit Court of Appeals. See Doc. 26. (“An appeal from a judgment entered by a
Magistrate Judge shall be taken directly to the United States Court of Appeals for
the judicial circuit in the same manner as an appeal from any other judgment of
this district court.”).
2
II. CLAIM ON APPEAL
The sole claim on appeal is whether the ALJ erred in rejecting the medical
opinions of the consultative examiner, Dr. Judy Travis, and the psychological examiner,
Dr. John Goff, thereby rendering his residual functional capacity (“RFC”) assessment
unsupported by substantial evidence. (Doc. 14 at p. 1).
III. BACKGROUND FACTS
Paige was born on October 5, 1965, and was 47 years old at the time he filed his
claim for benefits. (Tr. 27). Paige alleged disability due to pain in his legs, pain in his left
hip, pain in his right shoulder, and problems sleeping due to pain. (Tr. 555). Paige
graduated from high school in 1984 in regular classes. (Tr. 139). He has worked as a
furniture mover, lubrication technician, log handler, car detailer, and delivery driver. (Tr.
61). He engages in normal daily activities; such as, personal care, cooking meals,
washing dishes, mowing the yard, taking walks, shopping, watching television, and
socializing. (Tr. 58).
After conducting a hearing, the ALJ found that Paige had the following severe
impairments: arthritis, degenerative joint disease, and schizoid personality disorder. (Tr.
19). He further determined that none of these impairments met or equaled a listing. (Tr.
19). The ALJ assessed Paige’s RFC and found that he could perform light work, with
additional exertional, postural, environmental, and mental limitations, and that
considering these limitations, his age, education, and work experience, Paige could
perform other work existing in the national economy. (Tr. 21-27). Accordingly, the ALJ
concluded that Paige was not entitled to benefits. (Tr. 28).
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IV. ALJ’S DECISION
The portion of the ALJ’s Decision that is relevant to the issue presented is as
follows:
4. After careful consideration of the entire record,
the undersigned finds that the claimant has the
residual functional capacity to perform light work as
defined in 20 CFR 416.967(b) except the claimant
occasionally can push or pull with upper left and
lower extremities. He can never climb ladders, ropes,
scaffolds but he can occasionally climb ramps and
stairs. He occasionally can balance, kneel, crouch,
crawl, and stoop. He occasionally can reach
overhead and otherwise frequently reach with his
upper left extremity. He should avoid concentrated
exposure to extreme temperatures and vibration.
The claimant should avoid all exposure to
dangerous machinery, unprotected heights and any
work requiring walking on uneven terrain. During a
regularly scheduled workday, or the equivalent
thereof, the claimant can understand and remember
short and simple instructions, but is unable to do so
with detailed or complex instructions. He can
perform simple, routine, repetitive tasks, but is
unable to do so with detailed or complex tasks. He
can deal with changes in the workplace, if introduced
occasionally and gradually, and are well-explained.
After careful consideration of the evidence, the undersigned
finds that the claimant's medically determinable impairments
could reasonably be expected to cause the alleged
symptoms; however, the claimant's statements concerning
the intensity, persistence and limiting effects of these
symptoms are not entirely credible for the reasons explained
in this decision.
While receiving emergent care for abdominal and chest
pain on February 16, 2011 that was ultimately diagnosed
as constipation, an x-ray also revealed arthritic changes in
the claimant's hips. However, he denied any
musculoskeletal problems during the review of systems
(Exhibit 2F, pgs. 3-17).
4
The objective record is decidedly sparse for evidence
documenting any treatment for the claimant's alleged
disabling conditions. Indeed, the bulk of objective evidence
in this case concerns the claimant's history of substance
and alcohol abuse (Exhibit 4F). On October 8, 2012, the
claimant initiated treatment at West Alabama Mental Health
Center ("WAMHC") for alcohol and marijuana abuse. He
denied any legal problems because of his use, but admitted
that his consumption of alcohol had increased and that
withdrawal symptoms of anxiety and feelings of sadness,
tenseness, and anger hindered his ability to maintain
employment. Indeed, the treating provider noted that
the claimant's work history was “ sporadic;”
nevertheless, the claimant admitted that he was
currently working part-time cutting grass and
washing cars, despite his allegation of chronic left
hip pain.
The mental status examination was largely unremarkable
but for the claimant displaying a sad facial expression and
mildly impaired recent and remote memories. Alcohol abuse
and cannabis abuse were diagnosed and a Global
Assessment of Functioning (“GAF”) score of 55 was
assigned, which indicates only moderate symptoms (e.g.,
flat affect and circumstantial speech, occasional panic
attacks) OR moderate difficulty in social, occupational, or
school functioning (e.g., few friends, conflicts with peers or
co-workers) according to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (“DSM-IV”) (Id.
at pgs. 4-25) (emphasis added).
The recent abandonment of GAF scores and the inherent
subjectivity used to determine them precludes their use as
dispositive evidence in a disability decision or indicative of
the severity threshold for mental impairments. Accordingly,
the claimant's GAF score received weight only to the extent
that it is supported by the objective record.
The claimant consistently attended monthly appointments
at WAMHC and eventually achieved sobriety. Throughout
his near monthly appointments, he rarely reported any
problems and no psychological abnormalities were
detected. On December 3, 2012, he reported that he
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continued to work part-time performing “odd jobs”
to “stay productively busy” (Id. at pg. 47) (emphasis
added). Although primary insomnia was diagnosed, this
condition was well- managed with medication, from which
the claimant denied any side effects (Id. at pg. 51)
(emphasis added).
It should be noted that the objective record reveals no
evidence documenting ongoing marijuana or alcohol use or
limitations from it; therefore, the undersigned finds it
immaterial in this decision.
The claimant submitted a disability application on
December 13, 2012 (Exhibit 2E). He alleged that sleep
disturbance and pain in his legs, left, hip, and right shoulder
limited his ability to work. Notably, the claimant
admitted that he stopped working on August 30,
2004 because “ no work available” - not because of
his alleged disabling conditions (Id. at pgs. 2)
(emphasis added).
In a function report, the claimant asserted that his
conditions affected his ability to lift, bend, stand, sit, and
kneel. He alleged the ability to walk only one-half block
before needing a 20-minute rest period. He attributed sleep
disturbance to hip pain and cramps and generally alleged, “I
can’t do much now.”
Despite his alleged limitations, the claimant managed to
complete various activities. He admitted handling his own
personal care, preparing meals, washing dishes, and cutting
grass. Further, he reported shopping in stores for groceries
and clothing while managing his own finances. He socialized
with others via telephone and in person while also regularly
attending church. He admitted maintaining attention and
following written and verbal instructions well. Additionally ,
he denied any problems handling stress or changes in
routine and denied being fired from a job for failing to get
along with others (Exhibit 3E, pgs. 1-8).
The claimant also completed a pain questionnaire. He
reported the onset of nearly constant pain in his right
shoulder, left hip, knees, and legs in January 2006 and
6
alleged that it was exacerbated by “bad weather, moving
the wrong way, and trying to kneel down.” Notably, he
admitted that Aleve, an over-the-counter medication,
was effective in relieving his pain symptoms without
any side effects (Exhibit 5E) (emphasis added).
The undersigned carefully considered the claimant's
reports. Despite his allegations, the responses do not
support extensive limitation. Accordingly, his reports
warranted some, but not great, weight.
After the claimant's application initially was denied, he
submitted an appeal report on June 13, 2013 alleging
worsening pain in his hip, leg, and lower back. He denied
the onset of any new conditions (Exhibit 9E, pg. 1).
The claimant underwent a physical consultative examination
on April 9, 2013 in conjunction with his disability application.
Here, he reported pain in his legs, knees, left hip, and right
shoulder. The claimant attributed minimal medical treatment
of his symptoms to a lack of financial resources but the
examining physician, Judy Travis, M.D., noted that the
claimant had a daily smoking habit for the previous three
years. Upon examination, she found tenderness to
palpation and percussion in the claimant's back and some
difficulty squatting but no other remarkable findings.
Indeed, the claimant enjoyed normal range of motion
in his back, hips, and knees; normal gait without
assistance; normal grip strength and dexterity in
his upper extremities; and no neurological deficits.
Ultimately, Dr. Travis diagnosed joint pain and traumatic
arthropathy of the shoulder (Exhibit 1 F, pgs. 1-5)
(emphasis added).
Therefore, while Dr. Travis did not opine as to the
claimant's ability to engage in work here, the undersigned
finds that the dearth of findings indicating any significant
physical abnormalities is quite compelling and substantiates
the ultimate decision in this case. Accordingly, this
assessment received substantial weight.
During an appointment at WAMHC on April 11, 2013, the
claimant displayed a euthymic mood and reported sobriety
as well as his intention to stop smoking cigars. He
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reported being in good spirits because of seasonally
warmer weather, in that “he is able to work outdoors
and do other activities outdoors, which he enjoys
doing” (Exhibit 4F, pgs. 39-40) (emphasis added).
On July 3, 2013, the claimant returned to Dr. Travis to
establish care. Contrary to his allegations of pain in multiple
areas during the consultative examination three months
earlier, here, he only sought treatment for left hip pain. The
results of the corresponding physical examination were
unchanged, including the finding of normal range of motion
in his hips and knees without atrophy. Dr. Travis assessed
joint pain, a hip injury, and hip deformity but administered
conservative treatment with only one prescription
medication (Exhibit 3F, pgs. 2-4).
The claimant expressed the desire to work on
November 4, 2013 during a psychiatric appointment
at WAMHC, where he reported “ doing fine” with
good sleep and appetite. Consequently, he was referred
to supported employment by the treating psychiatrist, Swati
Poddar, M.D. (Exhibit 4F, pg. 71). Quite contradictorily, the
claimant's therapist, James Ward, opined less than one
month later, “due to physical and cognitive impairment,
client [the claimant] will likely not be able to work in the
future,” citing the claimant's complaints of finger numbness
in cold weather, back pain, and avoidance of heavy lifting.
Mr. Ward further opined that the claimant's “primary
problem at this point in time seems to be his
physical/medical conditions” (Id. at pgs. 66-67) (emphasis
added).
Per SSR 06-03p, the undersigned must consider several
factors in evaluating a medical source statement ("MSS"),
such as how long the source has known and how frequently
the source has seen the individual; how consistent the
opinion is with other evidence; the degree to which the
source presents relevant evidence to support an opinion;
how well the source explains the opinion; and whether the
source has a specialty or area of expertise related to the
individual's impairment(s). While the record clearly
demonstrates that Mr. Ward has been the claimant's
therapist, absolutely nothing in the longitudinal objective
record substantiates his MSS regarding the claimant's
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conditions, particularly since his opinion concerns an area
of expertise for which he is not qualified to opine. Therefore,
the undersigned justifiably afforded his MSS little weight.
Indeed, as further evidence of Mr. Ward's incongruent
findings regarding the claimant's conditions, he noted on
May 14, 2014, “client [the claimant] is in good health”
excepting “an upset stomach” that the claimant treated with
over-the-counter antacids (Exhibit S F, pg. 4).
During an appointment at WAMHC on June 11, 2014, the
claimant reported good sleep and denied any substance
use although he admitted “occasional” consumption of a
wine cooler. He indicated that his girlfriend provided a good
support system and provided transportation because his
driver's license had been revoked following a charge for
driving under the influence in 1991. He reported that he had
not attempted to have it reinstated; however, here, he
suggested that he had considered doing so, but for the costprohibitive fee (Id. at pg. 2).
The claimant underwent a psychological examination at the
behest of his representative on June 30, 2014 (Exhibit 6F).
Here, he reported that he stopped working in 2004 because
of problems with his hip, which is inconsistent with his
admission in his disability application that he only stopped
working because of difficulty finding employment. Further,
he stated that he no longer drove because of problems with
his back and had poor sleep due to pain, which is
inconsistent with his discussion of reinstatement of his
driver's license earlier in the month to a different treating
source and the longitudinal records from WAMHC wherein
the claimant consistently reported good sleep with
medication. Rather contradictorily, the examining
psychologist, John Goff, Ph.D., opined, “ he is a
straightforward person,” despite finding “some subtle
suggestions that he [the claimant] attempted to
portray himself in a somewhat negative light.” The
claimant discussed his educational background, reporting
that he graduated from high school with a regular diploma.
Upon examination, Dr. Goff found that “he did not appear to
be particularly apprehensive or anxious” and noted
“ generally logical and coherent discourse.” The claimant
walked “very slowly” with a limp and Dr. Goff noted, “he did
9
appear to be somewhat uncomfortable;” however, the
claimant admitted that his left hip pain was “not as
bad as it used to be.” The Wechsler Adult Intelligence
Scale, Fourth Edition (“WAIS-IV”) was administered, where
after the claimant earned a full-scale IQ score of 80, verbal
comprehension score of 80, perceptual reasoning score of
76, working memory score of 97, and processing speed
score of 89, which Dr. Goff determined placed him in the
borderline to low average range of intellectual functioning.
Ultimately, Dr. Goff diagnosed pain disorder with
psychological features with a general medical condition and
schizoid personality disorder. While he found that the
claimant could understand, carry out, and follow
moderately complex instructions, he also opined that the
claimant could not interact very well with others and that his
personality disorder and left hip pain would be “significant
impediment[s] to vocational activity.” Indeed, he completed
a MSS indicating that the claimant had marked limitation in
maintaining concentration, persistence, and pace as well
as constriction of interests (Id. at pgs. 1-8).
Dr. Goff has grossly exaggerated the extent of the
claimant's conditions, as the lack of any supportive
objective evidence and the claimant's own subjective reports
belie his findings. Therefore, although the undersigned
acknowledged Dr. Goff’s diagnoses, his opinions were
generally inconsistent with the record and received minimal
weight.
Dr. Travis completed an MSS on August 12, 2014 finding
that the claimant could lift and carry up to 50 pounds, sit up
to 8 hours, and stand/walk less than one hour in normal
workday. Additionally, she assessed some postural and
manipulative limitations while also opining that the claimant
would have more than three absences per month. Notably,
she admitted that the left hip pain was not objectively
confirmed and that it did not prevent the claimant from
maintaining concentration, persistence, and pace of at least
two-hour periods (Exhibit 7F, pgs. 1-2). The undersigned
afforded Dr. Travis's opinion some weight, as the medical
record is devoid of any objective evidence reflecting
significant physical abnormalities; however, her finding that
the claimant would be expected to have more than three
absences per month lacks sufficient support.
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Against this backdrop, the claimant appeared and testified
at length. He testified that he lived with a friend and
received food stamps. Interestingly , the claimant stated that
he never had a valid driver's license and relied on a friend
to bring him to the hearing. He admitted that he left his last
job because the business closed and supported himself
thereafter with odd jobs, such as cutting grass and painting.
The claimant's representative elicited testimony regarding
the claimant's left hip and specifically directed him regarding
difficulty walking because of it, which the representative
described thusly: “you were all bent over walking down that
long hall,” to which the claimant agreed. Indeed, the
claimant's representative directed him to provide a
demonstration of his gait and station, wherein the claimant
walked very slowly in apparent pain; however, the
undersigned observed the claimant walked into the hearing
room quickly. The claimant went on to testify that he could
sit no longer than 15 minutes before needing to alternate
positioning, stand only 10 minutes, and walk half the length
of a football field only slightly faster than a snail's pace.
Further, he testified that he laid down approximately 2 hours
per day because of pain symptoms.
In describing his daily activities, the claimant testified
that he performed personal hygiene, prepared food,
feed his pet, swept the floor, and walked approximately
100 yards for leisure, which is rather contradictory to his
testimony regarding difficulty walking. The claimant also
testified that he experienced left shoulder pain, which he rated
as a 6 or 7 on a pain scale from 1 to 10. Additionally, he testified
that pain disrupted his sleep.
The undersigned carefully considered the claimant's testimony
along with the medical, objective, and subjective evidence
discussed above. To the extent that his testimony was consistent
with that evidence, it is reflected in the residual functional
capacity. Beyond that extent, the claimant's testimony simply
was not consistent with or supported by the medical or objective
evidence of record.
In short, neither the objective medical evidence, nor the
claimant's objectively unsupported documentary and testimonial
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statements establishes that his ability to function has been so
severely eroded as to preclude all work activity. However, the
undersigned assessed a residual functional capacity which gives
the claimant every benefit of the doubt possible under the
applicable laws, rulings and regulations and which, at the same
time, can be found to be at least somewhat consistent with the
objective medical records. In doing so, and despite the minimal
nature of the objective evidence and apparent exaggerations and
inconsistencies to be found in the claimant's testimonial and
documentary statements, the undersigned finds that the claimant
is capable of work at a light exertional level with the additional
limitations referred to above.
The undersigned finds that the cumulative weight of the credible
evidence in favor of a finding that the claimant's ability to function
has not been so severely eroded as to preclude all work activity
far exceeds the cumulative weight of the credible evidence
supporting a finding of total disability.
(Tr. 21-26).
V. DISCUSSION
A claimant is entitled to an award of SSI benefits if the claimant is unable to
engage in substantial gainful activity by reason of any medically determinable physical
or mental impairment which can be expected to result in death or last for a continuous
period of not less than 12 months. See 20 C.F.R. § 416.905(a). The impairment must be
severe, making the claimant unable to do the claimant’s previous work or any other
substantial gainful activity that exists in the national economy. 42 U.S.C. § 423(d)(2); 20
C.F.R. §§ 404.1505-11. “Substantial gainful activity means work that … [i]nvolves
doing significant and productive physical or mental duties [that] [i]s done (or intended)
for pay or profit.” 20 C.F.R. § 404.1510.
In all Social Security cases, an ALJ utilizes a five-step sequential evaluation in
determining whether the claimant is disabled:
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(1) whether the claimant is engaged in substantial gainful activity; (2) if not,
whether the claimant has a severe impairment; (3) if so, whether the severe
impairment meets or equals an impairment in the Listing of Impairment in the
regulations; (4) if not, whether the claimant has the RFC to perform her past
relevant work; and (5) if not, whether, in light of the claimant’s RFC, age,
education and work experience, there are other jobs the claimant can perform.
Watkins v. Comm’r of Soc. Sec., 457 F. App’x 868, 870 (11th Cir. 2012) (per curiam)
(citing 20 C.F.R. §§ 404.1520(a)(4), (c)-(f), 416.920(a)(4), (c)-(f); Phillips v. Barnhart,
357 F.3d 1232, 1237 (11th Cir. 2004)) (footnote omitted). The claimant bears the burden
of proving the first four steps, and if the claimant does so, the burden shifts to the
Commissioner to prove the fifth step. Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir.
1999).
The reviewing court must determine whether the Commissioner’s decision to
deny benefits was “supported by substantial evidence and based on proper legal
standards.” Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011)
(citations omitted); see 42 U.S.C. § 405(g). “Substantial evidence is more than a scintilla
and is such relevant evidence as a reasonable person would accept as adequate to
support a conclusion.” Winschel, 631 F.3d at 1178 (citations omitted). “In determining
whether substantial evidence exists, [the reviewing court] must view the record as a
whole, taking into account evidence favorable as well as unfavorable to the
[Commissioner’s] decision.” Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). The
reviewing court, however, “may not decide the facts anew, reweigh the evidence, or
substitute [its] judgment for that of the [Commissioner].” Id. When a decision is
supported by substantial evidence, the reviewing court must affirm “[e]ven if [the court]
find[s] that the evidence preponderates against the Secretary’s decision.” MacGregor v.
Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). “A clearly articulated credibility finding
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with substantial supporting evidence in the record will not be disturbed by a reviewing
court.” Foote v. Chater, 67 F.3d 1553, 1562 (11th Cir. 1995).
In this case, Paige asserts that the ALJ erred in rejecting the medical opinions of
Dr. Travis and Dr. Goff. Paige also argues that the ALJ’s residual functional capacity
(FRC) assessment is not supported by substantial evidence because Dr. Travis and Dr.
Goff rendered the only medical opinions. The Commissioner asserts that the ALJ
provided valid reasons for the weight accorded the doctors’ opinions, that those findings
are supported by substantial evidence, and that the ALJ’s evaluation of their opinions is
entitled to deference.
“In assessing whether a claimant is disabled, an ALJ must consider the medical
opinions in a case record together with the rest of the relevant evidence received.”
Chambers v. Comm’r of Soc. Sec., 662 F. App’x 869, 870 (11th Cir. 2016) (citing 20
C.F.R. § 404.1527(b)) (emphasis added). The relevant social security regulations
provide that medical opinions are weighed by considering the following factors: 1)
whether the source of the opinion examined the claimant; 2) whether the source treated
the claimant and, if so, a) the length of the treatment relationship and the frequency of
examination and b) the nature and extent of the treatment relationship; 3) the
supportability of the opinion with relevant evidence and by explanations from the
source; 4) the consistency of the opinion with the record as a whole; 5) whether the
opinion was offered by a specialist about a medical issue related to his or her area of
specialty; and 6) any other factors which tend to support or contradict the opinion. 20
C.F.R. § 404.1527(c)(1)-(6); see also Nichols v. Comm’r, Soc. Sec. Admin., No. 1611334, 2017 WL 526038, at * 5 (11th Cir. Feb. 8, 2017) (citing 20 C.F.R. §§ 404.1527(c),
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416.927(c)) (“In determining how much weight to give a medical opinion, the ALJ
considers such factors as the examining or treating relationship, whether the opinion is
well-supported, whether the opinion is consistent with the record, and the doctor’s
specialization.”).
“[T]he more consistent an opinion is with the record as a whole, the more
weight the ALJ will give to that opinion.” Chambers, 662 F. App’x at 871 (citing 20
C.F.R. 404.1527(c)(4)) (emphasis added). The ALJ is to consider the claimant’s daily
activities when evaluating the symptoms and severity of an impairment. Id. (citing 20
C.F.R. § 404.1529(c)(3)(i)). The ALJ does not have to give a treating physician’s opinion
considerable weight if the claimant’s own testimony about daily activities contradicts that
opinion. Id. (citing Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004)). If the
claimant’s own testimony regarding the claimant’s daily activities contradicts the
consulting physician’s opinion, the ALJ’s decision not to give the physician’s
opinion considerable weight is not in error. See id. at 872 (emphasis added). “[A]n
ALJ may reject any medical opinion if the evidence supports a contrary finding.” Nichols,
2017 WL 526038, at *5 (citing Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir. 1985));
see also Harris v. Comm’r Soc. Sec., 330 F. App’x 813, 816 (11th Cir. 2009) (holding
that the ALJ did not err by rejecting the consultative psychologist’s finding of severe
impairment because the record evidence as a whole established that Plaintiff did not
have deficits in adaptive functioning to meet Listing 12.05(D)).
Dr. Travis first examined Paige on April 9, 2013, at the request of the SSA. (Tr.
190). Paige reported pain in his legs, knees, left hip, and right shoulder. (Id.). Dr.
Travis’s physical examination revealed normal range of motion in his hips and knees
15
and no muscular atrophy. (Tr. 191). The only abnormal finding was difficulty squatting.
(Tr. 190-91). Her assessment was pain in multiple joint sites and traumatic arthropathy
shoulder. (Tr. 192). She did not provide a functional assessment. (Tr. 190-92). Paige
returned to see Dr. Travis on July 3, 2013, complaining of chronic left hip pain. (Tr. 213).
Again, all assessments, except for difficulty in squatting, were normal. (Tr. 213-15).
On August 12, 2014, more than one year after she had last seen Paige and at his
attorney’s request, Dr. Travis completed a one-page, check-the-box form titled “Medical
Source Statement (Physical)” on which she indicated that Paige could sit for eight hours
in an eight hour workday, but could stand or walk for less than one hour in an eight hour
workday; that he could occasionally lift or carry fifty pounds and frequently lift and carry
25 pounds; that he did not require an assistive device to walk; that he was not required
to avoid environmental irritants; that he could frequently use his hands for gross and
fine manipulation, bend or stoop, and reach; that he could occasionally operate motor
vehicles; and that he could rarely push or pull, climb, or balance, or work with or around
hazardous machinery. She also opined that he would be absent more than three times
per month. (Tr. 310). Dr. Travis wrote that the limitations she assessed were limitations
normally expected from Paige’s diagnoses, but also noted that the diagnoses in this
case were not confirmed by objective medical findings. (Id.). She recommended an xray of his left hip.2 (Id.). Dr. Travis also completed a form titled “Clinical Assessment of
2
Dr.
Travis indicated that Paige needed an x-ray of his left hip, and Paige criticizes the
SSA for not ordering one. However, the record includes a report from x-rays of the
abdomen and pelvis taken on February 16, 2011 that showed severe arthritic changes
in the left hip. (Tr. 208). Although Paige contends that the ALJ “failed to acknowledge”
the 2011 x-ray of his abdomen and pelvis, this contention is incorrect because the ALJ
explicitly discussed that x-ray in his Decision and observed that it showed arthritic
changes in Paige’s hip. (Tr. 21-22).
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Pain” at Paige’s attorney’s request, in which she stated that Paige has pain, but it “does
not prevent functioning in everyday activities or work.” (Tr. 311). She indicated that
physical activity would increase his pain “to such a degree as to cause distraction from
task or total abandonment of task,” but she also stated that his pain would not prevent
him “from maintaining attention, concentration or pace for periods of at least two hours.”
(Id.).
Based on his review of Dr. Travis’s records and reports, as well as the other
evidence in the record, the ALJ gave Dr. Travis’s findings of April 9, 2013 “substantial
weight.” (Tr. 23). The ALJ gave the opinions set forth by Dr. Travis in the Medical
Source Report on August 12, 2014 “some weight, as the medical record is devoid of
any objective evidence reflecting significant physical abnormalities; however, her finding
that the claimant would be expected to have more than three absences per month lacks
sufficient support.” (Tr. 25). Thus, contrary to Paige’s contention that the ALJ rejected
Dr. Travis’s opinion, he actually did give a portion of it “substantial weight” and another
portion “some weight.” The Court notes that the ALJ concluded in his Decision that
Paige’s statements were not entirely credible, a finding that he has not challenged. (Tr.
25-26). Accordingly, the Court agrees that Dr. Travis’s reliance on Paige’s subjective
complaints as the basis for her 2014 opinions detracts from the weight those opinions
were due. See Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1159-60 (11th Cir.
2004) (holding that the ALJ’s decision to discount the opinion of the plaintiff’s treating
physician because it was “inconsistent with his own treatment notes, unsupported by
the medical evidence, and appear[ed] to be based primarily on [the plaintiff’s] subjective
17
complaints of pain” was supported by substantial evidence).
Paige also argues that the ALJ improperly rejected Dr. Goff’s diagnosis of
schizoid personality disorder. The ALJ found that “Dr. Goff has grossly exaggerated the
extent of the claimant’s conditions, as the lack of any supportive objective evidence and
the claimant’s own subjective reports belie his findings.” (Tr. 25). Dr. Goff conducted a
psychological evaluation of Paige at the request of his attorney on June 30, 2014. (Tr.
303). Dr. Goff diagnosed Paige with pain disorder and schizoid personality disorder. (Tr.
307). The ALJ gave minimal weight to Dr. Goff’s opinion because it was based largely
on Paige’s unreliable subjective complaints and because it lacked support and was
inconsistent with other evidence. (Tr. 25). With regard to Dr. Goff’s opinion, the ALJ
stated:
The claimant underwent a psychological examination at the
behest of his representative on June 30, 2014 (Exhibit 6F).
Here, he reported that he stopped working in 2004 because
of problems with his hip, which is inconsistent with his
admission in his disability application that he only stopped
working because of difficulty finding employment. Further,
he stated that he no longer drove because of problems with
his back and had poor sleep due to pain, which is
inconsistent with his discussion of reinstatement of his
driver's license earlier in the month to a different treating
source and the longitudinal records from WAMHC wherein
the claimant consistently reported good sleep with
medication. Rather contradictorily, the examining
psychologist, John Goff, Ph.D., opined, “ he is a
straightforward person,” despite finding “some subtle
suggestions that he [the claimant] attempted to
portray himself in a somewhat negative light.” …
…The claimant walked “very slowly” with a limp and Dr.
Goff noted, “he did appear to be somewhat uncomfortable;”
however, the claimant admitted that his left hip pain
was “not as bad as it used to be.” … Ultimately, Dr. Goff
diagnosed pain disorder with psychological features with a
18
general medical condition and schizoid personality
disorder. While he found that the claimant could
understand, carry out, and follow moderately complex
instructions, he also opined that the claimant could not
interact very well with others and that his personality
disorder and left hip pain would be “significant
impediment[s] to vocational activity.” Indeed, he completed
a MSS indicating that the claimant had marked limitation in
maintaining concentration, persistence, and pace as well
as constriction of interests (Id. at pgs. 1-8).
Dr. Goff has grossly exaggerated the extent of the
claimant's conditions, as the lack of any supportive
objective evidence and the claimant's own subjective
reports belie his findings. Therefore, although the
undersigned acknowledged Dr. Goff’s diagnoses, his
opinions were generally inconsistent with the record and
received minimal weight.
(Tr. 24-25) (italicized emphasis added).
The Court finds that substantial evidence supports the ALJ’s finding that Dr.
Goff’s opinion was entitled to minimal weight because it was based largely on Paige’s
inconsistent and unreliable subjective complaints, as well as other inconsistencies in
the record. See, e.g., Crawford, 363 F.3d at 1159-60. As the ALJ noted, Paige told Dr.
Goff that he stopped working in 2004 because of “problems with his hip.” (Tr. 24; see
also Tr. 303). However, he admitted in his disability application that he stopped
working because he had difficulty finding employment. (Tr. 24; see also Tr. 138).
Although Paige objects to the ALJ’s statement that he has worked part-time since
2004, the record shows that Paige told his treating providers that he was “working parttime,” mowing lawns, washing cars, performing “odd jobs,” and staying “productively
busy,” (Tr. 222, 262). Paige apparently did not tell Dr. Goff about these activities.
19
Paige also told Dr. Goff that he no longer drove a car because of “problems with
his back.” (Tr. 24; see also Tr. 303). However, he earlier told a treating source that he
stopped driving because his license had been suspended after he was convicted of
driving under the influence (Tr. 24; see also Tr. 297).3 In addition, Paige told Dr. Goff
that he slept poorly due to pain. (Tr. 24; see also Tr. 304). Treatment notes from West
Alabama Mental Health Center (WAHMC), however, consistently show that he reported
sleeping well with medication. (Tr. 24; see also Tr. 219-295, 297-301).
While Dr. Goff opined that Paige had disabling mental limitations that prevented
him from working, the ALJ noted that Paige did not stop working because of any alleged
mental impairments. Rather, he stopped working because he had difficulty finding
employment. (Tr. 23; see also Tr. 138). Similarly, while Dr. Goff opined, based on his
examination, that Paige’s gait was abnormal, Dr. Travis, a medical doctor, found that he
had a normal gait and did not observe any gait-related problems. (Tr. 23; see also Tr.
191, 214). The ALJ also noted Paige’s report that over-the-counter medication, like
Aleve, relieved his pain without side effects. (Tr. 23; see also Tr. 154). In addition,
although Dr. Goff opined that Paige was unable to sustain attention or concentration for
two-hour periods, was socially withdrawn, and had other severe mental limitations, the
ALJ observed that treatment notes from WAMHC, where he was seen and treated on
multiple occasions, revealed normal mental findings, and did not indicate cognitive
problems. (Tr. 219- 295, 297-301). Indeed, treatment notes from WAHMC specifically
indicated that Paige had “No Problem” with attention span, concentration, social
3
He changed his story yet again at the hearing. When the ALJ asked Paige if
he had a driver’s license, he testified: “No sir, never had any driver’s license,
sir.” (Tr. 38).
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withdrawal, social activities with family, peers, or others, or in the ability to work. (Tr.
224). Dr. Travis also opined that his pain would not prevent him “from maintaining
attention, concentration or pace for periods of at least two hours.” (Tr. 311).
The ALJ also considered Paige’s activities of daily living. (Tr. 23). Paige
reported that he was able to perform personal care activities independently (Tr. 143,
144-45); prepared meals, including grits, eggs, toast, and bacon, on a daily basis (Tr.
145); performed house and yard work independently, without encouragement (Tr.
145); washed dishes and mowed the lawn (Tr. 145); went outside every day to walk
(Tr. 146) and enjoyed taking walks of about 100 yards, the length of a football field, for
leisure (Tr. 44); shopped in stores, rather than by phone, mail, or computer, for food
and clothing (Tr. 146); was able to manage his own finances, including paying bills,
counting change, handling a savings account, and using a checkbook and money
orders (Tr. 146); watched television “everyday very well,” and he did not note any
difficulty paying attention to or concentrating on the programs he watched (Tr. 147);
socialized with others in person and on the phone and went to church on a regular
basis (Tr. 147); has no problems getting along with family, friends, neighbors, or others
(Tr. 148); could pay attention “well,” finished what he started (such as conversations,
chores, reading books, or watching movies), and followed written and spoken
instructions “well” (Tr. 148); and handled stress and changes in routine “OK” (Tr. 149).
Dr. Goff relied on Paige’s unreliable statements in assessing his functioning. (Tr.
303-04). The ALJ’s decision to discount Dr. Goff’s opinion because it was based on
Paige’s subjective complaints and inconsistent with other evidence, as outlined above,
was not in error.
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Lastly, Paige asserts that the ALJ was forced to make the RFC assessment by
interpreting the medical evidence himself and making his own conclusions about the
extent of Paige’s limitations because the ALJ “rejected” both Dr. Travis’s and Dr. Goff’s
assessments, which he claims were the only medical assessments in the record.
According to Paige, because the RFC assessment was not supported by the medical
evidence, it was not supported by substantial evidence, and the matter should be
remanded for further development. The Commissioner argues the RFC assessment
made by the ALJ was supported by substantial evidence.
First, contrary to Paige’s assertion, the record reflects that the ALJ did not
“reject” the opinions of Dr. Goff and Dr. Travis. As determined above, based on the
evidence of record, the ALJ properly acknowledged Dr. Goff’s findings, but accorded
little weight to Dr. Goff’s opinion regarding Paige’s employability and gave a portion of
Dr. Travis’s opinion “substantial weight” and another portion “some weight.” Secondly,
the RFC assessment is an administrative determination that the ALJ is responsible for
assessing based on all the evidence of record. See 20 C.F.R. §§ 416.945, 404.1546.
Here, the ALJ appropriately assessed Plaintiff’s RFC based on all the evidence of
record, including Dr. Travis’s examination findings and related opinion, Dr. Goff’s
diagnoses, mental health records from WAMHC, opinions from state agency
physicians and psychologists, Paige’s reports (e.g., that his pain was relieved by overthe-counter medications), and other evidence. In his Decision, the ALJ provided a
complete review of the medical evidence, as well as a review of Paige’s testimony and
the written details Paige gave concerning his daily activities and history. As discussed
above, the ALJ determined based on this review of the records and testimony to
22
acknowledge Dr. Goff’s diagnoses, but to give his opinions concerning employment
factors minimal weight because they were generally inconsistent with the record. He
also decided to give substantial weight to the objective assessment made by Dr. Travis, to
afford Dr. Travis's opinions set forth in her medical source statement only some
weight, as the medical record is devoid of any objective evidence reflecting significant
physical abnormalities, and to reject her finding that Paige would be expected to have
more than three absences per month because that opinion lacks sufficient support.
The majority of Dr. Goff’s opinions and some of Dr. Travis’s opinions were based on
the history given to them by Paige, which was not consistent with other evidence in the
record. The ALJ found that Paige’s testimony was not consistent and was not
supported by objective findings or his own observations. Paige did not challenge the
ALJ’s findings concerning his credibility. Paige’s credibility is important to the veracity
of the medical opinions because some of the opinions were based on subjective
complaints made by him that were not supported by objective findings. An ALJ is not
required to include findings in the RFC that have been properly rejected as
unsupported. See Crawford, 363 F.3d at 1161.
This Court finds that the ALJ properly considered all credible evidence
presented and made an assessment of Paige’s RFC based on the totality of the
evidence. Accordingly, the Court concludes that the RFC assessment made by the
ALJ is supported by substantial evidence and is not in error.
CONCLUSION
As noted above, it is not this Court’s place to reweigh the evidence or
substitute its judgment for that of the Commissioner. It is well-established that
23
this Court is limited to a determination of whether the ALJ’s decision is supported
by substantial evidence. The Court finds that the ALJ’s weighing of the medical
opinions of Dr. Travis and Dr. Goff is supported by substantial evidence. The
Court further finds that the RFC assessment made by the ALJ is supported by
substantial evidence. Accordingly, it is ORDERED that the decision of the
Commissioner of Social Security denying Plaintiff benefits be AFFIRMED.
DONE and ORDERED this the 27th day of June, 2017.
s/P. BRADLEY MURRAY
UNITED STATES MAGISTRATE JUDGE
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