Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_14-cv-01145/USCOURTS-caed-2_14-cv-01145-1/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:1383 Review of HHS Decision

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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

JAMES HERBERT LOCKHART, JR., No. 2:14-CV-1145-JAM-CMK

Plaintiff, 

vs. FINDINGS AND RECOMMENDATIONS

COMMISSIONER OF SOCIAL

SECURITY,

Defendant.

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Plaintiff, who is proceeding with retained counsel, brings this action under 

42 U.S.C. § 405(g) for judicial review of a final decision of the Commissioner of Social Security. 

Pending before the court are plaintiff’s motion for summary judgment (Doc. 13) and defendant’s

cross-motion for summary judgment (Doc. 14). 

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I. PROCEDURAL HISTORY

Plaintiff applied for social security benefits on August 31, 2010. In the

application, plaintiff claims that disability began on August 22, 2005. Plaintiff’s claim was

initially denied. Following denial of reconsideration, plaintiff requested an administrative

hearing, which was held on September 11, 2012, before Administrative Law Judge (“ALJ”)

Trevor Skarda. In a January 10, 2013, decision, the ALJ concluded that plaintiff is not disabled

based on the following relevant findings:

1. The claimant has the following severe impairment(s): degenerative disc

disease, borderline intellectual functioning, and anxiety disorder.

2. The claimant does not have an impairment or combination of impairments

that meets or medically equals an impairment listed in the regulations.

3. The claimant has the following residual functional capacity: the claimant

can perform light work except: he can never climb ropes, ladders, or

scaffolds; he can occasionally balance with a hand-held assistive device;

he can occasionally stoop, kneel, crouch, and crawl; he can occasionally

climb ramps and stairs; he is limited to jobs that can be performed while

using a hand-held assistive device for uneven terrain, prolonged

ambulation, and at all times while standing and walking; he must avoid

concentrated exposure excessive vibration, operational control of

dangerous moving machinery, and unprotected heights; he is limited to

simple, routine, and repetitive tasks; he is limited to work in a low-stress

job, which is defined as requiring only occasional decision-making and

only occasional changes in the work setting. 

4. Considering the claimant’s age, education, work experience, residual

functional capacity, and vocational expert testimony, there are jobs that

exist in significant numbers in the national economy that the claimant can

perform.

After the Appeals Council declined review on March 20, 2014, this appeal followed.

II. STANDARD OF REVIEW

The court reviews the Commissioner’s final decision to determine whether it is: 

(1) based on proper legal standards; and (2) supported by substantial evidence in the record as a

whole. See Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999). “Substantial evidence” is

more than a mere scintilla, but less than a preponderance. See Saelee v. Chater, 94 F.3d 520, 521

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(9th Cir. 1996). It is “. . . such evidence as a reasonable mind might accept as adequate to

support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971). The record as a whole,

including both the evidence that supports and detracts from the Commissioner’s conclusion, must

be considered and weighed. See Howard v. Heckler, 782 F.2d 1484, 1487 (9th Cir. 1986); Jones

v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). The court may not affirm the Commissioner’s

decision simply by isolating a specific quantum of supporting evidence. See Hammock v.

Bowen, 879 F.2d 498, 501 (9th Cir. 1989). If substantial evidence supports the administrative

findings, or if there is conflicting evidence supporting a particular finding, the finding of the

Commissioner is conclusive. See Sprague v. Bowen, 812 F.2d 1226, 1229-30 (9th Cir. 1987). 

Therefore, where the evidence is susceptible to more than one rational interpretation, one of

which supports the Commissioner’s decision, the decision must be affirmed, see Thomas v.

Barnhart, 278 F.3d 947, 954 (9th Cir. 2002), and may be set aside only if an improper legal

standard was applied in weighing the evidence, see Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th

Cir. 1988). 

III. DISCUSSION

In his motion for summary judgment, plaintiff argues that the ALJ failed to

provide sufficient reasons for rejecting the opinions of Drs. Baron, Van Kirk, Wakefield, and

Chellsen. The weight given to medical opinions depends in part on whether they are proffered by

treating, examining, or non-examining professionals. See Lester v. Chater, 81 F.3d 821, 830-31

(9th Cir. 1995). Ordinarily, more weight is given to the opinion of a treating professional, who

has a greater opportunity to know and observe the patient as an individual, than the opinion of a

non-treating professional. See id.; Smolen v. Chater, 80 F.3d 1273, 1285 (9th Cir. 1996);

Winans v. Bowen, 853 F.2d 643, 647 (9th Cir. 1987). The least weight is given to the opinion of

a non-examining professional. See Pitzer v. Sullivan, 908 F.2d 502, 506 & n.4 (9th Cir. 1990).

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In addition to considering its source, to evaluate whether the Commissioner

properly rejected a medical opinion the court considers whether: (1) contradictory opinions are

in the record; and (2) clinical findings support the opinions. The Commissioner may reject an 

uncontradicted opinion of a treating or examining medical professional only for “clear and

convincing” reasons supported by substantial evidence in the record. See Lester, 81 F.3d at 831. 

While a treating professional’s opinion generally is accorded superior weight, if it is contradicted

by an examining professional’s opinion which is supported by different independent clinical

findings, the Commissioner may resolve the conflict. See Andrews v. Shalala, 53 F.3d 1035,

1041 (9th Cir. 1995). A contradicted opinion of a treating or examining professional may be

rejected only for “specific and legitimate” reasons supported by substantial evidence. See Lester,

81 F.3d at 830. This test is met if the Commissioner sets out a detailed and thorough summary of

the facts and conflicting clinical evidence, states her interpretation of the evidence, and makes a

finding. See Magallanes v. Bowen, 881 F.2d 747, 751-55 (9th Cir. 1989). Absent specific and

legitimate reasons, the Commissioner must defer to the opinion of a treating or examining

professional. See Lester, 81 F.3d at 830-31. The opinion of a non-examining professional,

without other evidence, is insufficient to reject the opinion of a treating or examining

professional. See id. at 831. In any event, the Commissioner need not give weight to any

conclusory opinion supported by minimal clinical findings. See Meanel v. Apfel, 172 F.3d 1111,

1113 (9th Cir. 1999) (rejecting treating physician’s conclusory, minimally supported opinion);

see also Magallanes, 881 F.2d at 751. 

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A. Dr. Baron

Plaintiff argues: “The ALJ failed to mention, let alone address or weigh, the

opinion of Dr. Baron (treating physician) and failed to weigh the physical evaluation findings.”

Specifically, plaintiff asserts that the ALJ failed to discuss Dr. Baron’s opinion contained in a

physical functional capacity evaluation at Exhibit 13F. Regarding this exhibit, the ALJ stated:

. . .He [plaintiff] had a painful, diminished range of motion in the back,

reduced muscle strength on the left side of his body, and an inability to

kneel during a physical therapy session held on April 4, 2012 (Exhibit

13F, 14). . . .

* * *

. . .Multiple diagnostic images showed a few positive findings throughout

the claimant’s spine, and relevant positive clinical signs were detected

during multiple physical examinations (Exhibits 3F, 8F, 12F, 13F, and

15F). . . .

According to plaintiff: “These references do not indicate that the ALJ realized that the report was

actually an opinion as opposed to a progress note.” Plaintiff concludes that a remand to the

agency is necessary so that the evidence contained in Exhibit 13F “can be ‘weighed’ the first

time.” 

Exhibit 13F consists of medical records from San Joaquin General Hospital

supplied by plaintiff’s counsel covering the period June 13, 2011, through May 15, 2012. These

records largely consist of Dr. Baron’s handwritten treatment and progress notes and reflect

plaintiff’s subjective complaints as well as the doctor’s objective observations. They also

contain physical therapy progress notes. 

The court has reviewed Exhibit 13F in detail and finds no indication of any nonconclusory opinions expressed by Dr. Baron (or the physical therapist for that matter), let alone

any opinions which are supported by reference to specific objective clinical findings. The parties

both refer to a largely unintelligible handwritten May 15, 2012, progress report in which the

doctor notes: “Spinal cord injury / scoliosis w/ spondylolisthesis / . . . pt. disabled unable to lift

& do any physically strenuous active or repetitive motion . . .of lumbar spine.” Contrary to

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plaintiff’s characterization, the court finds that this record reflects, at best, a minimally supported

conclusory opinion. In particular, Dr. Baron does not provide any detailed assessment of

plaintiff’s functional capacity, such as his ability to stand, walk, sit, etc. While it appears that Dr.

Baron opined that plaintiff cannot perform strenuous motions involving the lumbar spine, the

doctor does not indicate how, if at all, this limitation affects plaintiff’s functional capacity in

other physical areas. Moreover, the doctor has not noted any specific objective findings – such

as range of motion findings or the like – supporting the general statement “pt. disabled.”1

Because Dr. Baron has not expressed any non-conclusory medical opinion

supported by reference to specific objective findings, the ALJ did not commit error regarding

evaluation of records from this source. 

B. Dr. Van Kirk

As to Dr. Van Kirk, the ALJ stated:

Dale H. Van Kirk, M.D., a State agency medical consultant, conducted an

orthopedic consultative examination on October 29, 2012. Dr. Van Kirk

observed that the claimant was pleasant. The claimant walked and

balanced with a cane. He sat comfortably during the examination. He

could get on and off the examination table without difficulty. His balance

was abnormal and he almost fell during the examination. He was unable

to squat or perform tandem walking. The range of motion in his lumbar

spine was diminished. The straight leg raising test was negative. The

motor strength and sensory functioning of his left lower extremity were

reduced. He had clonus of the left ankle. Dr. Van Kirk diagnosed status

post blunt trauma to the back, weakness of the left lower extremity with

poor balance, and clonus of the left ankle (Exhibit 3F). 

* * *

Dr. Van Kirk . . . opined that the claimant could lift and carry 20 pounds

frequently and 50 pounds occasionally. The claimant could stand and

walk for 4 hours in an 8-hour workday, 1 hour at a time. He could sit for 6

hours in an 8-hour workday, 1 hour at a time. He needed to use a cane for

ambulation. He could never balance, crouch, crawl, or climb ladders or

scaffolds. He could occasionally stoop, kneel, and climb ramps and stairs. 

He was limited to occasional operation of foot controls with the left foot. 

He could never tolerate exposure to unprotected heights and temperature

extremes. He could occasionally tolerate exposure to humidity and

In any event, whether plaintiff is disabled is a legal question, not a medical one. 1

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wetness. He could frequently tolerate exposure to moving mechanical

parts, pulmonary irritants, and vibrations. He could tolerate moderate

noise (Exhibit 15F). 

Dr. Van Kirk’s opinion is given little probative weight because it is

inconsistent with the medical evidence of record, which indicates that the

claimant indeed has some serious physical limitations, even though they

are not debilitating. Multiple diagnostic images showed a few positive

findings throughout the claimant’s spine, and relevant positive clinical

signs were detected during multiple physical examinations (Exhibits 3F,

8F, 12F, 13F, and 15F). In addition, Dr. Van Kirk did not adequately

consider the claimant’s subjective complaints, which reflect some physical

difficulties. The claimant can carry out no more than light household

chores (Exhibits 3E, 4E, 3F, 11F, 15F, and hearing testimony).

 

Plaintiff argues: “The ALJ’s rationale for discrediting Dr. Van Kirk’s opinion does not make

sense and therefore does not rise to the level of specific and legitimate reasons for discrediting

the opinion of the Agency’s own examining expert.” 

The court does not agree. In an analysis beneficial to plaintiff, the ALJ concluded

that Dr. Van Kirk’s opinion was not entitled to significant weight because it was less restrictive

than the evidence as a whole indicated. Specifically, the ALJ stated that Dr. Van Kirk’s opinion

did not account for plaintiff’s serious physical limitations or subjective complaints, both of which

indicate an ability to perform no more than light work. 

According to plaintiff, the ALJ erred by failing to consider those opinions offered

by Dr. Van Kirk which were more restrictive than the assessed residual functional capacity. 

Specifically, plaintiff points to Dr. Van Kirk’s opinions with respect to standing, walking, and

sitting. In these areas, Dr. Van Kirk opined as follows:

Standing - 4 hours in an 8-hour workday, 1 hour at a time

Walking - 4 hours in an 8-hour workday, 1 hour at a time

- Must use a cane for ambulation

Sitting - 6 hours in an 8-hour workday, 1 hour at a time

Plaintiff states that, contrary to the ALJ’s finding that plaintiff could perform light work (which

involves standing/walking for six hours), Dr. Van Kirk opined that plaintiff can only stand/walk

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for four hours and that the ALJ erred by not providing reasons for rejecting this more limiting

opinion. Plaintiff also argues that the ALJ erred by not providing reasons for rejecting Dr. Van

Kirk’s opinion that plaintiff must alternate positions every hour when standing, walking, or

sitting. Defendant essentially concedes that the ALJ failed to discuss these opinions but argues

that any error was harmless. 

The Ninth Circuit has applied harmless error analysis in social security cases in a

number of contexts. For example, in Stout v. Commissioner of Social Security, 454 F.3d 1050

(9th Cir. 2006), the court stated that the ALJ’s failure to consider uncontradicted lay witness

testimony could only be considered harmless “. . . if no reasonable ALJ, when fully crediting the

testimony, could have reached a different disability determination.” Id. at 1056; see also Robbins

v. Social Security Administration, 466 F.3d 880, 885 (9th Cir. 2006) (citing Stout, 454 F.3d at

1056). Similarly, in Batson v. Commissioner of Social Security, 359 F.3d 1190 (9th Cir. 2004),

the court applied harmless error analysis to the ALJ’s failure to properly credit the claimant’s

testimony. Specifically, the court held:

However, in light of all the other reasons given by the ALJ for

Batson’s lack of credibility and his residual functional capacity, and in

light of the objective medical evidence on which the ALJ relied there was

substantial evidence supporting the ALJ’s decision. Any error the ALJ

may have committed in assuming that Batson was sitting while watching

television, to the extent that this bore on an assessment of ability to work,

was in our view harmless and does not negate the validity of the ALJ’s

ultimate conclusion that Batson’s testimony was not credible.

Id. at 1197 (citing Curry v. Sullivan, 925 F.2d 1127, 1131 (9th Cir. 1990)). 

In Curry, the Ninth Circuit applied the harmless error rule to the ALJ’s error with respect to the

claimant’s age and education. The Ninth Circuit also considered harmless error in the context of

the ALJ’s failure to provide legally sufficient reasons supported by the record for rejecting a

medical opinion. See Widmark v. Barnhart, 454 F.3d 1063, 1069 n.4 (9th Cir. 2006). 

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The harmless error standard was applied in Carmickle v. Commissioner, 533 F.3d

1155 (9th Cir. 2008), to the ALJ’s analysis of a claimant’s credibility. Citing Batson, the court

stated: “Because we conclude that . . . the ALJ’s reasons supporting his adverse credibility

finding are invalid, we must determine whether the ALJ’s reliance on such reasons was harmless

error.” See id. at 1162. The court articulated the difference between harmless error standards set

forth in Stout and Batson as follows:

. . . [T]he relevant inquiry [under the Batson standard] is not

whether the ALJ would have made a different decision absent any error. . .

it is whether the ALJ’s decision remains legally valid, despite such error. 

In Batson, we concluded that the ALJ erred in relying on one of several

reasons in support of an adverse credibility determination, but that such

error did not affect the ALJ’s decision, and therefore was harmless,

because the ALJ’s remaining reasons and ultimate credibility

determination were adequately supported by substantial evidence in the

record. We never considered what the ALJ would do if directed to

reassess credibility on remand – we focused on whether the error impacted

the validity of the ALJ’s decision. Likewise, in Stout, after surveying our

precedent applying harmless error on social security cases, we concluded

that “in each case, the ALJ’s error . . . was inconsequential to the ultimate

nondisability determination.”

Our specific holding in Stout does require the court to consider

whether the ALJ would have made a different decision, but significantly,

in that case the ALJ failed to provide any reasons for rejecting the

evidence at issue. There was simply nothing in the record for the court to

review to determine whether the ALJ’s decision was adequately supported. 

Carmickle, 533 F.3d at 1162-63 (emphasis in original; citations omitted).

Thus, where the ALJ’s errs in not providing any reasons supporting a particular determination

(i.e., by failing to consider lay witness testimony), the Stout standard applies and the error is

harmless if no reasonable ALJ could have reached a different conclusion had the error not

occurred. Otherwise, where the ALJ provides analysis but some part of that analysis is flawed

(i.e., some but not all of the reasons given for rejecting a claimant’s credibility are either legally

insufficient or unsupported by the record), the Batson standard applies and any error is harmless

if it is inconsequential to the ultimate decision because the ALJ’s disability determination

nonetheless remains valid. 

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Defendant contends that, in light of the opinions of Drs. Thomas and Schwartz –

both agency physicians whose opinions were consistent with the ALJ’s residual functional

capacity determination – the “error was inconsequential to the determination” and that remanding

for further consideration of Dr. Van Kirk’s opinions “would not alter or change the outcome of

the case.” As a preliminary matter, the court disagrees with defendant’s statement of the

applicable harmless error standard. Defendant is citing the Batson standard, which applies when

the ALJ provides some analysis of the evidence at issue, but some part of the analysis is flawed. 

In this case, however, the ALJ failed to provide any analysis of Dr. Van Kirk’s sit/stand/walk

limitations. Given the lack of any analysis of these limitations, the Stout standard applies and the

error is harmless “. . . if no reasonable ALJ, when fully crediting the testimony, could have

reached a different disability determination.” Stout, 454 F.3d at 1056. 

Under this standard, the court cannot say that the error was harmless, especially

given that it ultimately led to an adverse disability finding. See Widmark, 454 F.3d at 1069 n.4. 

In other words, should a reasonable ALJ fully credit the sit/stand/walk limitations opined by Dr.

Van Kirk, particularly the requirement to alternate positions every hour, it is possible that

plaintiff would be found to be disabled. The court finds that a remand is necessary to allow the

agency to evaluate all of Dr. Van Kirk’s opinions. 

C. Drs. Wakefield and Chellsen

Regarding Dr. Wakefield, the ALJ stated:

James A. Wakefield, Jr., Ph.D., a State agency medical consultant,

conducted a psychological consultative examination on October 24, 2012. 

Dr. Wakefield observed that the claimant was adequately groomed and

dressed. The claimant was cooperative and talkative. He did not have

difficulty conversing with the examiner. He exhibited decreased motor

activity and walked with a cane. His affect was anxious but euthymic. 

His associations were generally direct and coherent. He had deficient

attention, concentration, and memory. He could perform only simple

mental calculations. His abstraction was generally concrete. His

judgment was deficient. His full scale IQ was measured to be 62, which

was in the deficient range. Psychometric tests also indicated deficient

memory. Dr. Wakefield diagnosed borderline intellectual functioning

provisionally, anxiety disorder, organic mental disorder, and polysubstance

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dependence in remission. Dr. Wakefield further assigned the claimant a

GAF score of 55 (Exhibit 14F). 

* * *

Dr. Wakefield . . . opined that the claimant could perform simple,

repetitive tasks. The claimant had difficulty with complex tasks. He was

capable of interacting with coworkers, supervisors, and the public at a

minimally acceptable level. His ability to reason and make occupational,

personal, and social decisions in his best interest was deficient. His pace

and verbal concentration were deficient. His persistence and visual

concentration were adequate. In terms of physical functioning, Dr.

Wakefield opined that the claimant could lift up to 20 pounds occasionally

and carry up to 10 pounds occasionally. The claimant could stand for 3

hours in an 8-hour workday, 1 hour at a time. He could walk for 2 hours

in an 8-hour workday, 1 hour at a time. He could sit for 2 hours in an 8-

hour workday, 15 minutes at a time. He needed to use a cane for

ambulation. He could never stoop, kneel, crouch, or climb ladders or

scaffolds. He could occasionally balance and climb stairs and ramps. He

was limited to no reaching with the left upper extremity. He was also

limited to occasional handling, fingering, feeling, pushing, and pulling

with the left upper extremity. He was limited to no operation of foot

controls with the left lower extremity. He could never tolerate exposure to

unprotected weights or moving mechanical parts. He could occasionally

operate a motor vehicle. He could tolerate loud noise (Exhibit 14F). 

Dr. Wakefield’s opinion regarding the claimant’s mental functioning is

given substantial probative weight because it is consistent with the mental

health evidence of record, which indicates that the claimant’s mental

symptoms are not debilitating. The claimant was observed to have good

grooming and cooperative behaviors during the mental consultative

examination conducted on July 5, 2012, and October 24, 2012 (Exhibits

11F and 14F). In addition, Dr. Wakefield’s opinion is consistent with the

general absence of evidence of mental health treatment in the record,

which indicates that the claimant’s mental conditions are not debilitating. 

Moreover, Dr. Wakefield’s opinion is consistent with the claimant’s

admitted daily living and social activities, which indicate considerable

mental capacity. The claimant is independent in self-care and can carry

out light household chores. He can shop at stores, go to church, and go out

alone, which suggests that he can be around people. He spends time with

others once or twice a week, which indicates adequate social functioning. 

He reports having no problems getting along with others. He admittedly

can follow written and spoken instructions, which indicates some

concentration ability. His daily routine consists of watching television for

long periods and reading, both of which require some concentration. He

also has the ability to drive, which requires a considerable degree of

concentration (Exhibits 3E, 4E, 3F, 11F, 14F, 15F, and hearing testimony). 

Furthermore, Dr. Wakefield personally observed and examined the

claimant, which augments the reliability of the opinion. In addition, Dr.

Wakefield’s opinion is not contradicted by the opinion of any treating

psychiatrist or psychologist. However, the weight assigned to Dr.

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Wakefield’s opinion concerning the claimant’s concentration ability is

reduced because Dr. Wakefield used vague terms such as “deficient.” 

Dr. Wakefield’s opinion regarding the claimant’s physical functioning is

given little probative weight because physical impairments are outside the

expertise of a psychologist. In addition, Dr. Wakefield did not conduct a

detailed physical examination and his opinion was thus not based on

objective clinical signs.

 

Regarding Dr. Chellsen, the ALJ sated:

The claimant was referred by his representative to John A. Chellsen,

Ph.D., who examined the claimant on July 5, 2012. Dr. Chellsen observed

that the claimant was adequately groomed. The claimant walked slowly

with a cane. His demeanor was pleasant. His associations were intact,

linear, and coherent. His affect was mobile in range, normal in intensity,

and appropriate in content. He showed adequate judgment. His full scale

IQ was measured to be 70. Dr. Chellsen diagnosed post-traumatic stress

disorder provisionally and borderline intellectual functioning. Dr.

Chellsen further assigned the claimant a Global Assessment of

Functioning (GAF) score of 60 (Exhibit 11F). 

* * *

Dr. Chellsen, who conducted the psychological consultative examination

of July 5, 2012, opined that the claimant had “mild personal, moderate

social, and marked occupational limitations.” The claimant also had a

“borderline” ability to maintain pace and quality. Dr. Chellsen further

opined that it was “doubtful” whether the claimant would be “capable of

tolerating or adapting to even simple part-time work stressors or routines”

(Exhibit 11F). 

Dr. Chellsen’s opinion is given little probative weight because it is vague. 

Dr. Chellsen’s opinion does not provide a clear definition of terms such as

“mild,” “moderate,” “marked,” “personal,” “occupational,” “borderline,”

and “doubtful.” As a result, it is unclear as to what the claimant’s

limitations are. In addition, Dr. Chellsen’s opinion is inconsistent with the

mental health evidence of record, which indicates that the claimant’s

mental symptoms are not debilitating. The claimant was observed to have

good grooming and cooperative behaviors during the mental consultative

examination conducted on July 5, 2012, and October 24, 2012 (Exhibits

11F and 14F). Moreover, Dr. Chellsen’s opinion is inconsistent with the

general absence of evidence of mental health treatment in the record,

which indicates that the claimant’s mental conditions are not debilitating. 

Furthermore, Dr. Chellsen’s opinion is inconsistent with the claimant’s

admitted daily living and social activities, as described above, which

indicate considerable mental capacity (Exhibits 3E, 4E, 3F, 11F, 14F, 15F,

and hearing testimony). 

/ / /

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In response to the consultative examination reports dated October 24,

2012, and October 29, 2012, the claimant’s representative argued in a

letter dated November 26, 2012, that Dr. Chellsen’s assessment of the

claimant’s functional limitations would preclude the claimant from all

work. However, as discussed above, Dr. Chellsen’s assessment is

ambiguous and is inconsistent with other evidence in the record. . . .

Plaintiff argues that the ALJ erred in finding that Dr. Wakefield’s opinion

regarding plaintiff’s concentration was rendered vague by use of the word “deficient.”

According to plaintiff, the ALJ should have recontacted Dr. Wakefield for clarification of his

opinion. 

The ALJ has an independent duty to fully and fairly develop the record and assure

that the claimant’s interests are considered. See Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th

Cir. 2001). When the claimant is not represented by counsel, this duty requires the ALJ to be

especially diligent in seeking all relevant facts. See id. This requires the ALJ to “scrupulously

and conscientiously probe into, inquire of, and explore for all the relevant facts.” Cox v.

Califano, 587 F.2d 988, 991 (9th Cir. 1978). Ambiguous evidence or the ALJ’s own finding that

the record is inadequate triggers this duty. See Tonapetyan, 242 F.3d at 1150. The ALJ may

discharge the duty to develop the record by subpoenaing the claimant’s physicians, submitting

questions to the claimant’s physicians, continuing the hearing, or keeping the record open after

the hearing to allow for supplementation of the record. See id. (citing Tidwell v. Apfel, 161 F.3d

599, 602 (9th Cir. 1998)). 

Here, the ALJ indicated that Dr. Wakefield’s opinion regarding plaintiff’s

concentration ability is vague because he used the word “deficient.” Thus, the ALJ himself

acknowledged that this evidence is ambiguous. Defendant agrees by stating that the “ALJ

properly recognized” that the word “deficient,” standing alone as it does in Dr. Wakefield’s

opinion, is vague. Given that the ALJ cited no other reasons for discounting Dr. Wakefield’s

opinion regarding concentration, the court agrees with plaintiff that a remand is appropriate to

allow further development of the record in this regard. 

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As to Dr. Chellsen, plaintiff argues that the ALJ erred in concluding that use of

terms such as “mild,” “moderate,” and “marked” rendered the doctor’s opinions vague. 

Regardless of whether the use of these terms were vague, the court finds that the ALJ’s analysis

is based on other reasons supported by the record. As the ALJ noted, in addition to the use of

what were characterized as vague terms, Dr. Chellsen’s opinion is inconsistent with other mental

health evidence, as well as observations of plaintiff made during the consultative examinations

on July 5, 2012, and October 24, 2012. Moreover, the limitations opined by Dr. Chellsen are not

consistent with the absence of evidence of mental health treatment. Finally, as the ALJ noted,

Dr. Chellsen’s opinions are inconsistent with plaintiff’s activities of daily living which do not

reveal disabling mental health problems. Given these additional reasons for rejecting the

opinions of Dr. Chellsen, the court finds no error in the ALJ’s analysis. 

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IV. CONCLUSION

For the foregoing reasons, this matter should be remanded under sentence four of

42 U.S.C. § 405(g) for further development of the record and/or further findings addressing the

deficiencies noted above. Accordingly, the undersigned recommends that:

1. Plaintiff’s motion for summary judgment (Doc. 13) be granted;

2. Defendant’s cross-motion for summary judgment (Doc. 14) be denied; and

3. The matter be remanded to the agency for further development of the

record and further findings, specifically regarding the opinions of Drs. Van Kirk and Wakefield.

These findings and recommendations are submitted to the United States District

Judge assigned to the case, pursuant to the provisions of 28 U.S.C. § 636(b)(l). Within 14 days

after being served with these findings and recommendations, any party may file written

objections with the court. Responses to objections shall be filed within 14 days after service of

objections. Failure to file objections within the specified time may waive the right to appeal. 

See Martinez v. Ylst, 951 F.2d 1153 (9th Cir. 1991).

DATED: September 2, 2015

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CRAIG M. KELLISON

UNITED STATES MAGISTRATE JUDGE

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