Opinion ID: 715825
Heading Depth: 4
Heading Rank: 1

Heading: Smolen's Subjective Symptom Testimony

Text: 25 Smolen presented extensive testimony about her fatigue and pain and the effect those symptoms had on her ability to function during the relevant period. However, the ALJ rejected her testimony on the grounds that her complaints regarding incapacitating fatigue ... and severe back pain were [n]ot supported by contemporaneous medical evidence and were not credible. 26 In deciding whether to accept a claimant's subjective symptom testimony, an ALJ must perform two stages of analysis: the Cotton analysis and an analysis of the credibility of the claimant's testimony regarding the severity of her symptoms. 1 The Cotton analysis is a threshold test that we set out in Cotton v. Bowen, 799 F.2d 1403 (9th Cir.1986), and reaffirmed in Bunnell v. Sullivan, 947 F.2d 341 (9th Cir.1991) (en banc); see also Orteza v. Shalala, 50 F.3d 748, 749-50 (9th Cir.1994) (applying Cotton standard to disability determination based on pain and fatigue); Swenson v. Sullivan, 876 F.2d 683, 687 (9th Cir.1989) (rules developed to assure proper consideration of excess pain apply equally to other symptoms). If the claimant produces evidence to meet the Cotton test and there is no evidence of malingering, the ALJ can reject the claimant's testimony about the severity of her symptoms only by offering specific, clear and convincing reasons for doing so. See Dodrill v. Shalala, 12 F.3d 915, 918 (9th Cir.1993). 27 a) The Cotton Test. 28 1) Applicable standards. 29 Under the Cotton test, a claimant who alleges disability based on subjective symptoms must produce objective medical evidence of an underlying impairment 'which could reasonably be expected to produce the pain or other symptoms alleged....'  Bunnell, 947 F.2d at 344 (quoting 42 U.S.C. § 423(d)(5)(A) (1988)); Cotton, 799 F.2d at 1407-08. The Cotton test imposes only two requirements on the claimant: (1) she must produce objective medical evidence of an impairment or impairments; and (2) she must show that the impairment or combination of impairments could reasonably be expected to (not that it did in fact) produce some degree of symptom. 30 The claimant need not produce objective medical evidence of the pain or fatigue itself, or the severity thereof. Bunnell, 947 F.2d at 347-48. Nor must the claimant produce objective medical evidence of the causal relationship between the medically determinable impairment and the symptom. Id. at 345. By requiring that the medical impairment could reasonably be expected to produce pain or another symptom, the Cotton test requires only that the causal relationship be a reasonable inference, not a medically proven phenomenon. See Howard v. Heckler, 782 F.2d 1484, 1488 (9th Cir.1986) ([W]e have never required that the medical evidence identify an impairment that would make the pain inevitable.). 31 Finally, the claimant need not show that her impairment could reasonably be expected to cause the severity of the symptom she has alleged; she need only show that it could reasonably have caused some degree of the symptom. Orteza, 50 F.3d at 749-50; Fair v. Bowen, 885 F.2d 597, 601 (9th Cir.1989). This approach reflects the highly subjective and idiosyncratic nature of pain and other such symptoms. See, e.g., Cotton, 799 F.2d at 1407; Fair v. Bowen, 885 F.2d at 601. The amount of pain caused by a given physical impairment can vary greatly from individual to individual. Fair, 885 F.2d at 601. This is also true for fatigue. Thus, the ALJ may not reject subjective symptom testimony under the Cotton analysis simply because there is no showing that the impairment can reasonably produce the degree of symptom alleged. 2 32 2) Evidence of underlying impairments. 33 Smolen produced uncontradicted objective medical evidence of the following physical impairments existing during the relevant period: (1) loss of one kidney; (2) loss of part of her left lung; (3) mild anemia; (4) suppression of her bone marrow production (as evidenced by anemia); (5) changes in her left lung tissue; and (6) spinal scoliosis. 34 The ALJ limited his review of the medical records to a search for anemia, scoliosis, back pain, and fatigue. Without explanation, he ignored medical evidence of Smolen's other impairments and thereby erred. See, e.g., Cotton, 799 F.2d at 1408-09 (legal error where ALJ's findings completely ignore medical evidence without giving specific, legitimate reasons for doing so). The ALJ also erred by rejecting Smolen's symptom testimony on the ground that her medical charts did not document prior statements corroborating her fatigue and pain; such evidence is not required to satisfy the Cotton test. 35 In addition, the ALJ failed to find Smolen anemic during the relevant period, even though substantial and undisputed evidence supported such a finding. Smolen produced hemoglobin levels demonstrating that she was anemic in 1967 and 1968, after her childhood cancer treatment, and that she was still anemic in 1987, prior to her adult chemotherapy, and thereafter. The fact that Smolen could not produce hemoglobin levels for the interim period does not support the ALJ's failure to find Smolen anemic. Once Smolen produced hemoglobin levels to prove she was anemic in early 1987, SSR 83-20 required the ALJ to consider other evidence to infer the onset date of the anemia. Three physicians, including the ALJ's expert whose testimony the ALJ credited, testified without contradiction that the hemoglobin levels Smolen produced indicated that she likely suffered anemia throughout the period from 1968 to 1987 and thereafter. 36 3) Causal relationship between impairments and symptoms. 37 Smolen offered uncontroverted medical opinions establishing that her medical impairments could reasonably be expected to have caused fatigue and pain. 3 Dr. Harry Smolen stated that Smolen's fatigue could reasonably have resulted from her childhood cancer treatment which, he explained, caused the combination of impairments from which Smolen suffered. 4 Dr. Bert Hoeflich stated that Smolen's fatigue could reasonably have been caused by her childhood chemotherapy and radiation treatment. Finally, although Dr. Winston Maxwell testified that mild anemia by itself, in an otherwise well  person, would not have caused disabling fatigue, (emphasis added), he also indicated that mild anemia by itself would cause some degree of fatigue 5 and that all of Smolen's conditions combined could have been disabling. More specifically, Dr. Maxwell concluded that a perfectly good hypothesis is that everything Smolen went through related to her childhood cancer--including horrendous illness, two major surgeries, chemotherapy and x-ray therapy--impaired her ability to function. 38 Although the evidence showed that Smolen's impairments could reasonably have caused her symptoms, as required by Cotton, the ALJ failed to take into account all the evidence and misapplied the Cotton test. First, the ALJ focused his questioning of Dr. Maxwell on whether mild anemia by itself, in an otherwise well person, would have caused the fatigue about which Smolen complained. However, Smolen did not have mild anemia alone and she was not an otherwise well person. The ALJ ignored the objective medical evidence of Smolen's other impairments and failed to develop the record, as he was required to do, by asking Dr. Maxwell whether the combination of those impairments could reasonably have caused fatigue. See Brown v. Heckler, 713 F.2d 441, 443 (9th Cir.1983) (ALJ has special duty to fully and fairly develop record). 39 Second, the ALJ focused on whether Smolen's impairments could have caused the severity of fatigue Smolen alleged; however, Smolen only had to prove that her impairments could reasonably have caused some degree of fatigue. See Fair, 885 F.2d at 601. As noted above, Dr. Maxwell testified that mild anemia alone would have caused some level of fatigue, just not the degree Smolen alleged. See supra p. 1283. Under the Cotton test, no more was required. See supra pp. 1281-82. 40 Finally, the ALJ erroneously focused on whether the causal relationship was medically determinable through scientific studies, instead of whether it was reasonable to expect such a relationship. See Bunnell, 947 F.2d at 344-45 (test is whether impairment could reasonably be expected to have caused the subjective symptom); Howard, 782 F.2d at 1488 ([W]e have never required that the medical evidence identify an impairment that would make the pain inevitable.). 41 The opinions of these physicians were sufficient to establish that the combination of impairments from which Smolen suffered during this period could reasonably have caused her fatigue and pain, thus satisfying the Cotton test. 42 b) Credibility Analysis. 43 Once a claimant meets the Cotton test and there is no affirmative evidence suggesting she is malingering, 6 the ALJ may reject the claimant's testimony regarding the severity of her symptoms only if he makes specific findings stating clear and convincing reasons for doing so. Dodrill, 12 F.3d at 918. The ALJ must state specifically which symptom testimony is not credible and what facts in the record lead to that conclusion. Id. 44 To determine whether the claimant's testimony regarding the severity of her symptoms is credible, the ALJ may consider, for example: (1) ordinary techniques of credibility evaluation, such as the claimant's reputation for lying, prior inconsistent statements concerning the symptoms, and other testimony by the claimant that appears less than candid; (2) unexplained or inadequately explained failure to seek treatment or to follow a prescribed course of treatment; and (3) the claimant's daily activities. 7 See, e.g., Fair, 885 F.2d at 602-04; Orteza, 50 F.3d at 750; Bunnell, 947 F.2d at 346-47. In evaluating the credibility of the symptom testimony, the ALJ must also consider the factors set out in SSR 88-13. See Bunnell, 947 F.2d at 346. Those factors include the claimant's work record and observations of treating and examining physicians and other third parties regarding, among other matters, the nature, onset, duration, and frequency of the claimant's symptom; precipitating and aggravating factors; functional restrictions caused by the symptoms; and the claimant's daily activities. See SSR 88-13. 8 45 According to the ALJ's ultimate findings, he rejected Smolen's complaints of severe fatigue and severe back pain because they were not credible and were not supported by contemporaneous medical evidence. The ALJ also made the following subsidiary findings: (1) that Smolen's daily activities were quite limited; (2) that, although Smolen graduated from high school and earned a college certificate, those activities could be compatible with her symptoms; (3) that Smolen was not taking pain medication; and (4) that contemporaneous medical records contradict severe back pain or dysfunction or severe anemia-based fatigue. 46 The first of these subsidiary findings supports a finding that Smolen's testimony was credible. The second is not persuasive in either direction. 47 As to the third, Smolen presented testimony at the hearing that she had not sought treatment (and therefore was not taking medication) for her chronic fatigue and pain because, as a result of not being able to maintain a job, she had no insurance and could not afford treatment. Where a claimant provides evidence of a good reason for not taking medication for her symptoms, her symptom testimony cannot be rejected for not doing so. See Bunnell, 947 F.2d at 346; Fair, 885 F.2d at 602. Thus, the fact that Smolen was not taking medication is not a clear and convincing reason for discrediting her symptom testimony. 48 As to the fourth, although Smolen's sparse medical records during the relevant period do not contain prior consistent statements to corroborate Smolen's claims of pain and fatigue, nothing in them appears to contradict Smolen's statements, and the ALJ made no finding identifying a contradiction. 49 Furthermore, in evaluating a claimant's subjective complaints of pain [or other symptoms], the adjudicator must give full consideration to all of the available evidence, medical and other, that reflects on the impairment and any attendant limitations of function. SSR 88-13 (emphasis added). Such other evidence includes the claimant's prior work record, her daily activities, and observations by treating and examining physicians and third parties about the claimant's symptoms and their effects. See SSR 88-13, quoted in part at supra p. 1284 n. 8. Here, Smolen offered substantial other evidence to corroborate her subjective symptom testimony, including her work history; lay testimony from family members regarding her daily activities at home and her ability to function at school; observations of her high school guidance counselor regarding her energy level in school; and opinions and observations from treating and examining physicians. 9 Given this substantial corroborating evidence, the fact that Smolen's few available medical records do not document prior consistent statements regarding her symptoms does not constitute a clear and convincing reason to reject her symptom testimony. 50 In conclusion, having failed to find clear and convincing reasons for rejecting Smolen's subjective symptom testimony, the ALJ erred in doing so. 51