Bainbridge v. Social Security Administration

Filing 13

ORDER the final decision of the Commissioner is reversed and the case is remanded for further review. Signed by Magistrate Judge J. Thomas Ray on 6/25/18. (tjb)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF ARKANSAS
NORTHERN DIVISION
CATHY BAINBRIDGE
V.

PLAINTIFF
NO. 1:17CV00089-JTR

NANCY A. BERRYHILL,
Deputy Commissioner for Operations,
performing the duties and functions not reserved
to the Commissioner of Social Security

DEFENDANT

ORDER
I.

Introduction:
Plaintiff, Cathy Bainbridge, applied for disability benefits on April 20, 2015,

alleging a disability onset date of May 20, 2014. (Tr. at 35). After conducting a
hearing, the Administrative Law Judge (AALJ@) denied Bainbridge’s application.
(Tr. at 45). The Appeals Council denied her request for review. (Tr. at 1). Thus, the
ALJ=s decision now stands as the final decision of the Commissioner.
For the reasons stated below, the Court 1 reverses the ALJ’s decision and
remands for further review.
II.

The Commissioner’s Decision:
The ALJ found that Bainbridge had not engaged in substantial gainful activity

since the alleged onset date of May 20, 2014. (Tr. at 37). At Step Two, the ALJ found

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The parties have consented in writing to the jurisdiction of a United States Magistrate Judge.

that Bainbridge has the following severe impairments: bilateral foot pain and mood
disorder. Id.
After finding that Bainbridge’s impairments did not meet or equal a listed
impairment (Tr. at 38), the ALJ determined that Bainbridge had the residual
functional capacity (“RFC”) to perform medium work, except that: (1) she can
perform work where interpersonal contact is routine but superficial, the complexity
of tasks is learned by experience, involves several variables, uses judgment within
limits, and the supervision required is little for routine, but detailed for non-routine
tasks. (Tr. at 39).
The ALJ found that, based on Bainbridge’s RFC, she was able to perform past
relevant work as home health aide and certified nurse’s aide. (Tr. at 43). The ALJ
also relied upon the testimony of the Vocational Expert (“VE”), to find that, based
on Bainbridge’s age, education, work experience and RFC, jobs existed in
significant numbers in the national economy that she could perform, including
positions as medication tech and storeroom food checker. (Tr. at 44). Thus, the ALJ
concluded that Bainbridge was not disabled. Id.
III.

Discussion:
A.

Standard of Review

The Court’s function on review is to determine whether the Commissioner=s
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decision is supported by substantial evidence on the record as a whole and whether
it is based on legal error. Miller v. Colvin, 784 F.3d 472, 477 (8th Cir. 2015); see
also 42 U.S.C. ' 405(g). While Asubstantial evidence@ is that which a reasonable
mind might accept as adequate to support a conclusion, Asubstantial evidence on the
record as a whole@ requires a court to engage in a more scrutinizing analysis:
A[O]ur review is more than an examination of the record for the
existence of substantial evidence in support of the Commissioner=s
decision; we also take into account whatever in the record fairly
detracts from that decision.@ Reversal is not warranted, however,
Amerely because substantial evidence would have supported an
opposite decision.@
Reed v. Barnhart, 399 F.3d 917, 920 (8th Cir. 2005) (citations omitted).
B.

Bainbridge=s Arguments on Appeal

Bainbridge contends that substantial evidence does not support the ALJ=s
decision to deny benefits. She argues that: (1) the RFC for medium work exceeded
her functional abilities; and (2) more weight should have been given to the opinion
of her treating physician. For the reasons explained below, the Court agrees with
Bainbridge.
Bainbridge’s arguments address only limitations arising from her foot
conditions, so the Court will limit its discussion thereto.
Bainbridge testified that she has pain in her foot that keeps her from being
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able to sit, stand, and walk comfortably. (Tr. at 59, 75). Her doctors have
recommended that she use a cane, and she showed up with a cane at various doctor’s
appointments. (Tr. at 65). She also had a cane at the hearing, which the ALJ noted,
observing that “it’s been used for a while.” (Tr. at 64). The ALJ also noted that
Bainbridge had to stand during the hearing, because sitting for too long led to back
pain. (Tr. at 68). Bainbridge said that she elevates her foot throughout the day and
would need a job providing that opportunity. (Tr. at 66).
Bainbridge first presented to Mary Shields-Anderson (“Shields-Anderson”),2
M.D., on September 11, 2014, with complaints of foot pain aggravated by walking
and standing. (Tr. at 359-360). Physical exam showed abnormal right foot bunion
with deviated toes laterally and a mild contracture callus at the base of the toes. Id.
Dr. Shields-Anderson diagnosed bunion and foot pain. Id. She prescribed Ibuprofen
800 mg three times a day. Id.
Bainbridge saw Jeffrey Angel, M.D., an orthopedic doctor, on May 20, 2015
for foot pain. (Tr. at 372-374). He found a large callus on three toes, the presence of
hallux valgus, and hammertoes on four toes. Id. He diagnosed foot pain and bunion.
Id.

2

She goes by Dr. Shields, Dr. Anderson, and Dr. Shields-Anderson in the medical records, but will be
referred to throughout this Order as Dr. Shields-Anderson.

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On April 27, 2015, Bainbridge returned to Dr. Shields-Anderson with foot
pain. (Tr. at 356-357). She had fallen and was using a cane. Id. She complained of
pain at night and trouble sleeping. Id. Her foot knuckles were raised and bent, with
calluses. Id. Dr. Shields-Anderson prescribed Neurontin and Naproxen. Id.
In May 2015, Bainbridge was fitted for custom foot orthotics, prescribed by
Dr. Angel. (Tr. at 377). In June 2015, Bainbridge reported more foot pain to Dr.
Angel, although nerve testing was negative. (Tr. at 382-384). He found tender
calluses on her feet and diagnosed right foot pain, plantar fasciitis, and metatarsalgia.
Id. He told her to wear arch supports. Id.
On July 17, 2015, Dr. Shields-Anderson referred Bainbridge to a foot
specialist. She saw Jason Smith, D.P.M, on August 10, 2015 for bilateral foot pain
requiring the use of a cane. (Tr. at 397-398). She again said she could not stand or
walk for very long. Id. Dr. Smith found hyperkeratotic lesions on Bainbridge’s right
foot, with decreased range of motion. Id. He also diagnosed hallux valgus bilaterally
and polyneuropathy. Id. Dr. Smith noted that Bainbridge exhibited a “slow,
deliberate gait assisted with a cane.” Id. He doubled her dose of Gabapentin. Id.
When Bainbridge saw Dr. Smith again two weeks later, she said she
experienced little relief from increased Gabapentin. (Tr. at 399-400). Dr. Smith
added Amitriptyline to her medications. Id. When Bainbridge told Dr. Smith later
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that Amitriptyline helped some, he doubled the dosage. (Tr. at 401-402).
In April 2016, Bainbridge told Dr. Shields-Anderson that she could not be on
her feet more than 10 minutes at a time. (Tr. at 94-96). Dr. Shields-Anderson
prescribed Naproxen. Id. Also in April 2016, Dr. Smith debrided painful right foot
calluses for Bainbridge. (Tr. at 407-408). On April 27, 2016, x-rays of Bainbridge’s
right foot showed mild hallux valgus deformity at the first metatarsophalangeal joint.
(Tr. at 368-369). X-rays of the left foot showed mild nonspecific soft tissue swelling.
Id. On June 20, 2016, Dr. Smith debrided calluses again. (Tr. at 404-405).
On July 25, 2016, Dr. Shields-Anderson completed a medical source
statement. (Tr. at 414-415). She said Bainbridge could not stand or walk more than
2 hours in a workday. Id. She said Bainbridge would need to change positions
frequently, have frequent rest periods, take longer than normal breaks, and shift
positions at will. Id. She said that Bainbridge would miss more than 4 days of work
per month. Id.
Two state-agency reviewing physicians considered the medical records and
found that Bainbridge could perform medium work (opinions dated August 21, 2015
and September 30, 2015)(Tr. at 144, 172). The ALJ gave little weight to Dr. ShieldsAnderson’s opinion and uncritically accepted the opinions of the non-examining
reviewing physicians, each of whom arrived at conclusions that were clearly
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contrary to the overwhelming weight of the medical evidence, and the opinion of
Brainbridge’s long-time treating physician.
It is the ALJ’s function to review all of the medical evidence and resolve
conflicts among the various treating and examining physicians. Wagner v. Astrue,
499 F.3d 842, 848 (8th Cir. 2007); Pearsall v. Massanari, 274 F.3d 1211, 1219 (8th
Cir. 2001). A treating physician’s opinion must be discussed by the ALJ and, if
rejected, reasons are necessary. Ingram v. Charter, 107 F. 3d 598, 602 (8th Cir.
1997); Prince v. Bowen, 894 F.2d 283 (8th Cir. 1990). A treating physician’s opinion
accompanied by medically acceptable clinical or diagnostic data is entitled to
controlling weight. Baker v. Apfel, 159 F. 3d 1140, 1145-46 (8th Cir. 1998).
Bainbridge argues that the ALJ should have given more weight to Dr. ShieldsAnderson’s opinion, and the Court agrees. Dr. Shields-Anderson treated Bainbridge
starting in 2014, and she made multiple diagnoses relating to foot pain. She observed
Bainbridge in person, and listened to subjective complaints. She prescribed pain
medication and referred Bainbridge to specialists. And Bainbridge testified that Dr.
Shields-Anderson filled out her medical source statement while Bainbridge was in
the clinic room, having Bainbridge answer questions during the session. So the
opinion was more than a conclusory check-box opinion, which are often given less
weight. It was grounded in a longitudinal relationship with Bainbridge, and based
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upon clinical testing and objective findings. While the ALJ said that Dr. ShieldsAnderson’s opinion was based upon subjective complaints alone, the fact that a
treating doctor relies, in part, on a claimant’s subjective complaints does not provide
a basis for discounting it. See Flanery v. Chater, 112 F.3d 346, 350 (8th Cir. 1997)(“a
patient’s report of complaints, or history, is an essential diagnostic tool”).
Furthermore, the state-agency physicians did not examine Bainbridge, and
their opinions issued before x-rays of Bainbridge’s feet were taken, and before Dr.
Shields-Anderson rendered her opinion. The “opinion of a non-treating, nonexamining physician” normally does not constitute substantial evidence to support
an RFC assessment, especially when treatment developed after the opinions issued.
Vossen v. Astrue, 612 F.3d 1011, 1016 (8th Cir. 2010). The ALJ erred in giving little
weight to the opinion of Dr. Shields-Anderson.
Finally, the ALJ’s conclusion that Bainbridge could perform medium work is
not supported by any credible medical evidence and it contrary to all the facts in the
record. Medium work requires walking or standing for approximately 6 hours of
the day. https://secure.ssa.gov/poms.nsf/lnx/0425001001; 20 C.F.R. § 404.1567. A
claimant’s RFC represents the most he can do despite the combined effects of all of
his credible limitations and must be based on all credible evidence. McCoy v. Astrue,
648 F.3d 605, 614 (8th Cir. 2011). In determining the claimant’s RFC, the ALJ has
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a duty to establish, by competent medical evidence, the physical and mental activity
that the claimant can perform in a work setting, after giving appropriate
consideration to all of his impairments. Ostronski v. Chater, 94 F.3d 413, 418 (8th
Cir. 1996). Adequate medical evidence must exist that addresses the claimant’s
ability to function in the workplace. See Lewis v. Barnhart, 353 F.3d 642, 646 (8th
Cir. 2003).
Bainbridge was diagnosed with several foot conditions; she sought out
consistent treatment from her PCP and two specialists; she took her medications as
prescribed including increased dosages; and she walked with a can and wore
orthotics and arch supports. All of this lent credibility to her complaints of moderate
to severe pain over a two-year period. Bainbridge said she could do a few activities
of daily living, but said she had to take breaks, use a chair in the shower, and could
not drive to doctors’ appointments. (Tr. at 65-68). The ability to do some activities
of daily living does not mean a claimant can perform full-time competitive work.
Hogg v. Shalala, 45 F.3d 276, 278 (8th Cir. 1995). Bainbridge’s only hobbies were
watching TV and visiting on the phone, neither of which required standing or
walking. Bainbridge’s complaints of pain were consistent with her daily activities
and borne out by the medical evidence. Bainbridge unquestionably has serious and
complicated foot problems, which calls into serious question how the ALJ could
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reach the startling conclusion that she was capable of standing and walking for 6
hours per day. Thus, the ALJ’s determination that Bainbridge has the RFC for
medium work is clearly error and not supported by substantial medical evidence.
IV.

Conclusion:
It is not the task of this Court to review the evidence and make an independent

decision. Neither is it to reverse the decision of the ALJ because there is evidence in
the record which contradicts his findings. The test is whether there is substantial
evidence in the record as a whole which supports the decision of the ALJ. Miller,
784 F.3d at 477). The Court has reviewed the entire record, including the briefs, the
ALJ’s decision, and the transcript of the hearing. The Court finds that the ALJ’s
decision is not supported by substantial evidence, because the ALJ did not give
proper weight to the opinion of Bainbridge’s treating physician, and the RFC
exceeded Bainbridge’s functional abilities.
IT IS THEREFORE ORDERED that the final decision of the Commissioner
is REVERSED and the case is REMANDED for further review.
DATED this 25th day of June, 2018.
___________________________________
UNITED STATES MAGISTRATE JUDGE

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