United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

A.D., Appellant

and

DEPARTMENT OF STATE, BUREAU OF 

EUROPEAN & EURASIAN AFFAIRS, 

Washington, DC, Employer

__________________________________________

)

)

)

)

)

)

)

)

)

Docket No. 20-1265

Issued: November 18, 2022

Appearances: Case Submitted on the Record

Daniel M. Goodkin, Esq., for the appellant1

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

PATRICIA H. FITZGERALD, Deputy Chief Judge

JANICE B. ASKIN, Judge

JURISDICTION

On June 4, 2020 appellant, through counsel, filed a timely appeal from a March 27, 2020 

merit decision of the Office of Workers’ Compensation Programs (OWCP). Pursuant to the 

Federal Employees’ Compensation Act2(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board 

has jurisdiction over the merits of this case.

1

In all cases in which a representative has been authorized in a matter before the Board, no claim for a fee for legal 

or other service performed on appeal before the Board is valid unless approved by the Board. 20 C.F.R. § 501.9(e). 

No contract for a stipulated fee or on a contingent fee basis will be approved by the Board. Id. An attorney or 

representative’s collection of a fee without the Board’s approval may constitute a misdemeanor, subject to fine or 

imprisonment for up to one year or both. Id.; see also 18 U.S.C. § 292. Demands for payment of fees to a 

representative, prior to approval by the Board, may be reported to appropriate authorities for investigation.

2

5 U.S.C. § 8101 et seq.
2

ISSUE

The issue is whether appellant has met her burden of proof to establish a stress-related 

condition causally related to the accepted compensable employment factors.

FACTUAL HISTORY

On September 9, 2016 appellant, then a 41-year-old foreign service officer/press officer,

filed an occupational disease claim (Form CA-2) alleging that she sustained Cushing’s syndrome, 

left adrenal tumor, postoperative adrenal insufficiency, anxiety, and depression due to factors of 

her federal employment. She noted that she first became aware of her claimed conditions on 

September 27, 2013 and realized their relation to her federal employment on May 27, 2016. 

Appellant stopped work on April 25, 2014. In a May 27, 2016 statement, she claimed that, while 

working in the press office of the Bureau of European and Eurasian Affairs as a press officer, she 

would commonly work from 6:30 a.m. until 10:30 p.m. under high-pressure conditions, which 

included being in a position with top visibility and being subjected to tight deadlines. Appellant

asserted that she was expected to check her e-mails at least once in the morning and every hour in 

the evening including weekends to see if there was any breaking news that required her attention 

and response. She advised that, during a typical workday, she would get up and check her 

BlackBerry device at 6:30 a.m. and read the major headlines and stories of the day. Before 8:30 

a.m., appellant would have to read the major stories, select the biggest issues, and brief the office 

director before she went into her morning meeting with the Assistant Secretary. She asserted that 

her mornings were typically hectic. From her arrival at work at 8:00 a.m., appellant would 

“scramble” to find out what topics needed to be briefed to the spokesperson for the employing 

establishment, work with the other offices in her bureau to draft and clear press guidance, and then 

have the topics fully ready for the briefing to the Spokesperson at approximately 11:30 a.m. 

Appellant alleged that there was almost never any down time in the mornings, and she usually had 

to work on two or more press issues at the same time. 

Appellant further claimed that she was expected to stay in the office and wait for the Office 

Director to return from late afternoon religious services in order to attend the last meeting of the 

day and receive a briefing from her. In the meantime, she waited for the release of the daily press 

briefing transcript and then would distribute any messages regarding Eastern Europe to the 

appropriate offices. Appellant asserted that sometimes the transcript arrived before she left the 

office, and sometimes it would arrive after she left the office, and that she would have to send the 

information from home. She indicated that, after leaving work at approximately 6:00 p.m., she 

was required to check her BlackBerry every hour until approximately 10:30 p.m. Appellant 

claimed that it was common for her to have to process after-hour clearances or statements and that 

this task could consume hours of her evening. She asserted that the Office Director expected her 

to be responsive to e-mails at all hours and that she also was expected to be available to work on 

weekends. 

Appellant submitted a September 8, 2016 report from Dr. Maximilian Oshalim, a Boardcertified internist, who indicated that she had been diagnosed with cyclical Cushing’s syndrome 

secondary to a left adrenal tumor as confirmed by testing in 2013. Dr. Oshalim advised that 

appellant first exhibited signs and symptoms of Cushing’s syndrome in 2012 and still had 

signs/symptoms of the condition, including adrenal insufficiency, cognitive deficits, profound 
3

fatigue, limited mental and physical stamina, memory loss, poor balance/coordination, muscle 

damage, pain, and hip issues. He advised that he was familiar with appellant’s written statements 

regarding her employment duties and conditions. Dr. Oshalim asserted that the scientific 

community was in agreement that stress worsens both Cushing’s syndrome and postoperative 

adrenal insufficiency. When stressful situations continue to occur for a person with Cushing’s 

syndrome, the body increases cortisol levels and the condition worsens with additional body 

damage, including muscle wasting, weakness, and bruising. Dr. Oshalim indicated that, when a 

patient’s cortisol levels drop after adrenal surgery, stress places additional demands on the body 

and causes the patient to burn more cortisol, a circumstance which increases vulnerability to 

adrenal crisis. He noted, “[w]e believe this process occurred with [appellant] based on our clinical 

examination.” Dr. Oshalim indicated that, based on her written and oral statements, appellant 

experienced physical, emotional, and mental stress while working as a press officer with a 

demanding portfolio. He asserted that stress from working more than 80 hours per week, combined 

with the pressure of the press officer role itself and meeting the high expectations of management, 

caused constant stress on appellant’s adrenal glands with a corresponding increased output of 

cortisol. Dr. Oshalim opined that this increased cortisol output caused an aggravation of 

appellant’s Cushing’s syndrome. He indicated that the overwork and stress appellant experienced 

after surgery caused a delay in her recovery since her body could not wean from the cortisol and 

she was more vulnerable to adrenal crisis and other infections.

In a January 4, 2017 statement, appellant’s immediate supervisor outlined appellant’s work 

duties, noting that she had been responsible for the preparation of daily press guidance covering 

the entire range of policy issues for the Bureau of European and Eurasian Affairs. He noted that 

the job required developing close contacts with a variety of journalists and foreign press officials, 

as well as briefing officials, including the agency’s spokesperson.

In a February 10, 2017 development letter, OWCP informed appellant of the deficiencies 

of her claim. It advised her as to the type of additional factual and medical evidence required and 

provided a questionnaire for her completion. By separate development letter of even date, OWCP 

requested additional information from the employing establishment, including comments from a 

knowledgeable supervisor regarding appellant’s allegations. It afforded both parties 30 days to 

respond.

In response, appellant submitted a March 7, 2017 statement in which she further discussed 

her work duties/conditions and detailed the course of her ongoing medical treatment. She advised 

that she underwent surgery in 2014 to remove an adrenal tumor.

Appellant submitted additional medical evidence, including reports dated between 

January 18 and March 13, 2017 fromDr. Michael B. Lee, a Board-certified internist, andDr. Mark 

Sklar, a Board-certified endocrinologist. In a September 30, 2013 report, Dr. Sklar advised that 

testing revealed that appellant appeared to have Cushing’s syndrome due to an autonomous left 

adrenal adenoma. In their reports, the physicians reported the findings of their periodic physical 

examinations and discussed their management of appellant’s medical condition.

On June 2, 2017 OWCP referred appellant for a second opinion examination and 

evaluation with Dr. Michael Emmer, a Board-certified endocrinologist. It provided Dr. Emmer 

with a copy of the case record and a current statement of accepted facts (SOAF) and a series of 
4

questions. The SOAF indicated that OWCP had accepted that, as a foreign service officer/press 

officer, appellant was responsible for covering press conditions and policies for 20 countries, and 

for managing daily press briefings, which were broadcast throughout the world. It also accepted 

that appellant’s job required long hours of work. OWCP requested that Dr. Emmer evaluate 

whether appellant sustained any employment-related conditions, including aggravation of 

Cushing’s syndrome.

In a June 18, 2017 report, Dr. Emmer discussed appellant’s factual and medical history, 

noting that in 2012 she began to display symptoms of Cushing’s disease, including hypertension, 

60-pound weight gain, obesity around the face, unusual fat deposition in the cervicodorsal/

supraclavicular areas, muscle weakness, easy bruising, and skin fragility. He advised that in 

September 2013 testing confirmed that appellant had Cushing’s syndrome and that in 

January 2014 a left adrenal adenoma (tumor) was surgically removed. Dr. Emmer reported the 

findings of his physical examination and indicated that appellant still displayed some 

residuals/symptoms of Cushing’s disease, including decreased stamina, muscle weakness, truncal 

obesity, cognitive difficulties, word choice problems, depression and anxiety. He opined that it 

could not be determined with certainty whether appellant’s extreme job stress was the true cause

of her developing Cushing’s syndrome since the true cause of the condition was the development 

of the left adrenal adenoma, which is not known to be a stress-related condition. Dr. Emmer noted, 

“[a]gain, I cannot state with certainty that job stress was a true cause of her Cushing’s, but certainly 

added [sic] to her symptomatology.” He opined that there was no aggravation of Cushing’s disease 

with the January 2014 surgical resection of the adrenal gland. Dr. Emmer indicated that the 

residuals of the Cushing’s syndrome included overproduction of adrenocortisol hormone, but that 

these residuals were related to the adrenal tumor and “could not be specifically attributed to a 

work-related condition.” He further noted, “I believe that [appellant’s] illness was entirely caused 

by the adrenocortical tumor and, in that sense, is not and has not been a work-related illness.”

Dr. Emmer advised that, while it was true that stress can worsen Cushing’s syndrome, he did not 

believe that appellant’s condition “was truly a work-related condition.” In a June 18, 2017 work 

capacity evaluation (Form OWCP-5c), Dr. Emmer indicated that appellant could work two hours 

per day with restrictions including lifting, pushing, and pulling no more than five pounds.

By decision dated July 18, 2017, OWCP indicated that it had accepted compensable 

employment factors in the form of appellant’s duties as a foreign service officer/press officer. 

However, it denied appellant’s claim, finding that the medical evidence of record was insufficient 

to establish causal relationship between a diagnosed medical condition and the accepted 

employment factors. 

On July 17, 2018 appellant, through counsel, requested reconsideration of the July 18, 2017 

decision. Appellant submitted an October 10, 2018 report from Dr. Samuel Potolicchio, a Boardcertified neurologist, who discussed the symptoms of Cushing’s syndrome experienced by 

appellant and noted that the condition had profound and pervasive impacts on neurological 

symptoms, which were long-lasting and did not resolve with surgery. He indicated that the high 

levels of cortisol caused by Cushing’s syndrome “fry” the brain and neurological networks, leading 

to permanent changes on a molecular level and even changes in brain volume. Dr. Potolicchio 

indicated that a magnetic resonance imaging (MRI) scan of appellant’s brain showed focal white 

matter signal abnormality. He noted that, in line with other Cushing’s syndrome patients, appellant 

experienced fibromyalgia, cognitive deficits, poor mental/poor concentration, profound physical 
5

fatigue, and an altered stress response. Dr. Potolicchio opined that appellant’s work stress, 

including the high volume of her work, her long hours, her inability to rest due to the demands of 

her job, and the constant need for her to be available at all hours, aggravated her Cushing’s 

syndrome and her neurological symptoms. He noted errors in Dr. Emmer’s June 18, 2017 report, 

such as Dr. Emmer’s interchangeable references to Cushing’s syndrome versus Cushing’s disease.

In November 2018 OWCP received additional medical evidence from the early stages of 

the evaluation and treatment of appellant’s Cushing’s syndrome commencing in 2012. In periodic 

progress reports dated between 2013 and 2017, Dr. Sklar continued to diagnose appellant with 

Cushing’s syndrome.

On December 12, 2018 OWCP requested clarification from Dr. Emmer of his June 18, 

2017 report. In a supplemental January 8, 2019 report, Dr. Emmer indicated that he continued to 

stand by the opinions expressed in his June 18, 2017 report. He clarified that appellant had 

Cushing’s syndrome, not Cushing’s disease and noted that the two conditions had similar 

symptoms. Dr. Emmer noted that, while he did reject the notion that work stress played a role in 

appellant developing Cushing’s syndrome, he did concur with her physicians that she was 

continuing to suffer the sequelae of longstanding undiagnosed Cushing’s syndrome and indicated 

that he could not anticipate the length of time required for adequate recovery enabling her to return 

to work. 

By decision dated January 17, 2019, OWCP denied modification of the July 18, 2017 

decision.

On March 12, 2019 appellant, through counsel, requested reconsideration of the 

January 17, 2019 decision. 

By decision dated April 17, 2019, OWCP denied appellant’s request for reconsideration of 

the merits of her claim pursuant to 5 U.S.C. § 8128(a).

On January 16, 2020 appellant, through counsel, again requested reconsideration. 

Appellant submitted a January 11, 2020 report from Dr. Sklar, who opined that appellant’s 

unrelenting work schedule and volume significantly contributed to her poor health and to the 

difficulty of tapering off hydrocortisone after her surgery for Cushing’s syndrome. Dr. Sklar

advised that the large amount of stress that appellant was under required her to have a high output 

of cortisol from her remaining adrenal gland. The remaining adrenal gland could not meet her 

needs for cortisol production because it was dormant due to being turned off for so many years by 

the over-functioning of her adrenal tumor. Dr. Sklar indicated that, as a result, appellant would 

feel as though her body was frequently “crashing” with symptoms of adrenal insufficiency 

including nausea and dizziness. He noted that the high doses of hydrocortisone taken by appellant 

to treat the symptoms of Cushing’s syndrome significantly delayed the recovery of her remaining 

adrenal gland. Dr. Sklar indicated, “[f]rom what I have stated above, it should now be clear that 

[appellant’s] work situation played a significant role in making the process of recovery from 

adrenal Cushing’s syndrome difficult and very prolonged.”

In a January 16, 2020 report, Dr. Potolicchio indicated that overwork aggravated 

appellant’s Cushing’s syndrome, delayed her postoperative recovery, delayed the successful 
6

completion of her wean from cortisol, and made her more susceptible to adrenal crises. He asserted 

that if Dr. Emmer was correct that appellant’s condition was only caused by her tumor, then she 

should have recovered completely soon after the surgery that removed the tumor. Dr. Potolicchio 

opined that the postoperative healing process was delayed primarily because of appellant’s 

stressful job and work situation.

By decision dated March 27, 2020, OWCP denied modification of its prior decision, 

finding that the medical evidence of record was insufficient to establish a diagnosed stress-related 

condition causally related to the accepted employment factors.

LEGAL PRECEDENT

An employee seeking benefits under FECA3 has the burden of proof to establish the 

essential elements of his or her claim, including the fact that the individual is an employee of the 

United States within the meaning of FECA, that the claim was filed within the applicable time 

limitation, that an injury was sustained while in the performance of duty as alleged, and that any 

disability or specific condition for which compensation is claimed is causally related to the 

employment injury.4 These are the essential elements of each and every compensation claim 

regardless of whether the claim is predicated on a traumatic injury or an occupational disease.5

To establish a stress-related or emotional condition in the performance of duty, a claimant 

must submit: (1) factual evidence identifying an employment factor or incident alleged to have 

caused or contributed to his or her claimed stress-related or emotional condition; (2) medical 

evidence establishing that he or she has a diagnosed stress-related or emotional condition; and 

(3) rationalized medical opinion evidence establishing that the accepted compensable employment 

factors are causally related to the diagnosed stress-related or emotional condition.6

Workers’ compensation law does not apply to each and every injury or illness that is 

somehow related to an employee’s employment. There are situations where an injury or an illness 

has some connection with the employment, but nevertheless does not come within the concept or 

coverage of workers’ compensation. Where the disability results from an employee’s emotional 

reaction to his or her regular or specially assigned duties or to a requirement imposed by the 

employment, the disability comes within the coverage of FECA.7 On the other hand, the disability 

is not covered where it results from such factors as an employee’s fear of a reduction-in-force or 

3

5 U.S.C. § 8101 et seq.

4 A.J., Docket No. 18-1116 (issued January 23, 2019);Gary J. Watling, 52 ECAB 278 (2001).

5

20 C.F.R. § 10.115(e); M.K., Docket No. 18-1623 (issued April10, 2019); see T.O.,Docket No. 18-1012 (issued 

October 29, 2018); see Michael E. Smith, 50 ECAB 313 (1999).

6

See S.K., Docket No. 18-1648 (issued March 14, 2019); M.C., Docket No. 14-1456 (issued December 24, 2014); 

Debbie J. Hobbs, 43 ECAB 135 (1991); Donna Faye Cardwell, 41 ECAB 730 (1990).

7 Lillian Cutler, 28 ECAB 125 (1976).
7

his or her frustration from not being permitted to work in a particular environment or to hold a 

particular position.8

A claimant has the burden of proof to establish by the weight of the reliable, probative, and 

substantial evidence that the condition for which he or she claims compensation was caused or 

adversely affected by employment factors.9 This burden includes the submission of a detailed 

description of the employment factors or conditions, which he or she believes caused or adversely 

affected a condition for which compensation is claimed, and a rationalized medical opinion 

relating the claimed condition to compensable employment factors.10

In cases involving stress-related or emotional conditions, the Board has held that, when 

working conditions are alleged as factors in causing a condition or disability, OWCP, as part of its 

adjudicatory function, must make findings of fact regarding which working conditions are deemed 

compensable factors of employment and are to be considered by a physician when providing an 

opinion on causal relationship, and which working conditions are not deemed factors of 

employment and may not be considered.11 If a claimant does implicate a factor of employment, 

OWCP should then determine whether the evidence of record substantiates that factor. When the 

matter asserted is a compensable factor of employment and the evidence of record establishes the 

truth of the matter asserted, it must base its decision on an analysis of the medical evidence. 12

ANALYSIS

The Board finds that this case is not in posture for decision.

In a June 18, 2017 report, OWCP referral physician Dr. Emmer opined that it could not be 

determined with certainty whether appellant’s extreme job stress was the true cause of her 

developing Cushing’s syndrome since the true cause of the condition was the development of the 

left adrenal adenoma, which is not known to be a stress-related condition. He opined that there 

was no aggravation of Cushing’s disease with the January 2014 surgical resection of the adrenal 

gland. Dr. Emmerindicated that the residuals of the Cushing’s syndrome included overproduction 

of adrenocortisol hormone, but that these residuals were related to the adrenal tumor and “could 

not be specifically attributed to a work-related condition.” In a supplemental January 8, 2019 

report, he indicated that he continued to stand by the opinions expressed in his June 18, 2017 

report. Dr. Emmer noted that, while he did reject the notion that work stress played a role in 

appellant developing Cushing’s syndrome, he did concur with her physicians that she was 

continuing to suffer the sequelae of longstanding undiagnosed Cushing’s syndrome.

8 A.E., Docket No. 18-1587 (issued March 13, 2019); GregorioE. Conde, 52 ECAB 410 (2001).

9 B.S., Docket No. 19-0378 (issued July 10, 2019); PamelaR. Rice, 38 ECAB 838, 841 (1987).

10 P.B., Docket No. 17-1912 (issued December 28, 2018); Effie O. Morris, 44 ECAB 470, 473-74 (1993).

11 See O.G., Docket No. 18-0359 (issued August7, 2019); Norma L. Blank, 43 ECAB 384, 389-90 (1992).

12 Id.
8

In contrast, Dr. Oshalim indicated in a September 8, 2016 report that the stress from 

appellant working extended hours per week, combined with the pressure of the press officer role 

itself and meeting the high expectations of management, caused constant stress on her adrenal 

glands with a corresponding increased output of cortisol. He opined that this increased cortisol 

output caused an aggravation of appellant’s Cushing’s syndrome. Dr. Oshalim indicated that the 

overwork and stress appellant experienced after surgery caused a delay in her recovery since her 

body could not wean from the cortisol and she was more vulnerable to adrenal crisis and other 

infections. 

In an October 10, 2018 report, Dr. Potolicchio indicated that patients with Cushing’s 

syndrome have high levels of cortisol that “fry” the brain and neurological networks, leading to 

permanent changes on a molecular level and even changes in brain volume. He advised that an 

MRI scan of appellant’s brain showed focal white matter signal abnormality. Dr. Potolicchio

opined that appellant’s work stress, including the high volume of her work, her long hours, her 

inability to rest due to the demands of her job, and the constant need for her to be available at all 

hours, aggravated her Cushing’s syndrome and her neurological symptoms. In a January 16, 2020 

report, he indicated that overwork aggravated appellant’s Cushing’s syndrome, delayed her 

postoperative recovery, delayed the successful completion of her wean from cortisol, and made 

her more susceptible to adrenal crises. Dr. Potolicchio asserted that if Dr. Emmer was correct that 

appellant’s condition was only caused by her adrenal tumor, then she should have recovered 

completely soon after the surgery, which removed the tumor. He opined that the postoperative 

healing process was delayed primarily because of appellant’s stressful job and work situation.

In addition, Dr. Sklar opined in a January 11, 2020 report that appellant’s unrelenting work 

schedule and volume significantly contributed to her poor health and to the difficulty of tapering 

off hydrocortisone after her surgery for Cushing’s syndrome. He advised that the large amount of 

stress that appellant was under required her to have a high output of cortisol from her remaining 

adrenal gland. Dr. Sklar indicated that, as a result, appellant would feel as though her body was 

frequently “crashing” with symptoms of adrenal insufficiency including nausea and dizziness. He

noted that the high doses of hydrocortisone taken by appellant to treat the symptoms of Cushing’s 

syndrome significantly delayed the recovery of her remaining adrenal gland. Dr. Sklar indicated, 

“[f]rom what I have stated above, it should now be clear that [appellant’s] work situation played a 

significant role in making the process of recovery from adrenal Cushing’s syndrome difficult and 

very prolonged.”

Section 8123(a) of FECA provides that if there is a disagreement between the physician 

making the examination for the United States and the physician of an employee, the Secretary shall 

appoint a third physician (known as a referee physician or impartial medical specialist) who shall 

make an examination.13 This is called an impartial medical examination and OWCP will select a 

physician who is qualified in the appropriate specialty and who has no prior connection with the 

case.14 When there exist opposing medical reports of virtually equal weight and rationale and the 

case is referred to an impartial medical specialist for the purpose of resolving the conflict, the 

13 5 U.S.C. § 8123(a); see R.S., Docket No. 10-1704 (issued May 13, 2011); S.T., Docket No. 08-1675 (issued 

May 4, 2009).

14 20 C.F.R. § 10.321.
9

opinion of such specialist, if sufficiently well rationalized and based upon a proper factual 

background, must be given special weight.15

The Board finds that a conflict exists in the medical opinion evidence between the OWCP 

referral physician, Dr. Emmer, and the attending physicians, Dr. Oshalim, Dr. Potolicchio, and

Dr. Sklar, on the issue of whether appellant sustained an employment-related condition, including 

the question of whether her Cushing’s syndrome was aggravated by the accepted employment 

factors.

Because there remains an unresolved conflict in the medical opinion evidence regarding 

whether appellant has an employment-related stress condition, pursuant to 5 U.S.C. § 8123(a), the 

case will be remanded to OWCP for referral of appellant, together with the medical record and a 

statement of accepted facts, to an appropriate Board-certified specialist for an impartial medical 

examination to evaluate whether appellant has a diagnosed stress condition casually related to the

accepted employment factors. Following this and other such further development as deemed 

necessary, OWCP shall issue a de novo decision regarding appellant’s claim for a work-related 

stress condition.

CONCLUSION

The Board finds that this case is not in posture for decision.

15 S.S., Docket No. 19-0766 (issued December 23, 2019); DarleneR. Kennedy, 57 ECAB 414 (2006); Gloria J. 

Godfrey, 52 ECAB 486 (2001).
10

ORDER

IT IS HEREBY ORDERED THAT the March 27, 2020 decision of the Office of 

Workers’ Compensation Programs is set aside and the case is remanded for further proceedings 

consistent with this decision of the Board.

Issued: November 18, 2022

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Deputy Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board