Opinion ID: 64036
Heading Depth: 3
Heading Rank: 1

Heading: Lack of Expert Testimony

Text: Armstrong and Dr. Cullins argue that because the Government failed to present expert testimony regarding what the professional standard of care should be for a physician prescribing controlled substances to chronic pain patients, there was insufficient evidence for the jury to find beyond a reasonable doubt that Appellants' conduct was outside the course of professional conduct.
In evaluating whether the evidence produced at trial is sufficient to support a jury conviction, this Court examines whether a rational jury, viewing the evidence in the light most favorable to the prosecution, could have found the essential elements of the offense to be satisfied beyond a reasonable doubt. See United States v. Miles, 360 F.3d 472, 476-77 (5th Cir.2004). In reviewing the evidence, all reasonable inferences are drawn in favor of the jury's verdict. Id. This Court does not evaluate whether the jury's verdict was correct, but rather, whether the jury's decision was rational. Id. If the evidence gives `equal or nearly equal circumstantial support to a theory of guilt or innocence, we must reverse the conviction, as under these circumstances a reasonable jury must necessarily entertain a reasonable doubt.' United States v. Rivera, 295 F.3d 461, 466 (5th Cir.2002) (internal citations omitted).
The evidence presented at trial, viewed in the light most favorable to the Government, supports the jury's guilty verdicts as to Armstrong and Dr. Cullins on the conspiracy charge under § 846 (count one) and on the substantive violations under § 841 (counts 2-27). Even without expert testimony, the Government demonstrated at trial that Armstrong and her co-conspirators organized and ran a continuous scheme of delivering controlled substances to a high volume of individuals for profit rather than a valid medical purpose. Although Armstrong and Dr. Cullins argue that the Government did not meet its evidentiary burden because it did not put on expert testimony, expert testimony is not always required in order to show that a physician is acting for other than proper medical purposes [in violation of § 841]. United States v. Chin, 795 F.2d 496, 503 (5th Cir.1986) (citing United States v. Rosen, 582 F.2d 1032, 1037 n. 10 (5th Cir. 1978)). While expert testimony may be both permissible and useful, a jury can reasonably find that a doctor prescribed controlled substances not in the usual course of professional practice or for other than a legitimate medical purpose from adequate lay witness evidence surrounding the facts and circumstances of the prescriptions. United States v. Rogers, 609 F.2d 834, 839 (5th Cir.1980). There are § 841 cases in which the trier of fact does not need outside, specialized knowledge to understand the evidence or determine the facts. [10] See United States v. Word, 806 F.2d 658, 663-64 (6th Cir.1986) (finding that expert testimony about the usual course of professional conduct and legitimate medical purposes may help a jury, it was not necessary on the facts of the case on appeal); United States v. Smurthwaite, 590 F.2d 889, 892 (10th Cir.1979) (finding expert testimony unnecessary to prove prescriptions were outside of professional practice where evidence included visits less than five minutes in length, charging patients per prescriptions, little or no physical examination of patients at initial or follow-up visits, and defendant had some knowledge that prescriptions pills were used for parties rather than weight-loss); United States v. Larson, 507 F.2d 385, 387 (9th Cir.1974) (similar). Jurors have had a wide variety of their own experiences in doctors' care over their lives, thus and expert testimony is not necessarily required for jurors to rationally conclude that seeing patients for as little as two or three minutes before prescribing powerful narcotics is not in the usual course of professional conduct. There are also undoubtably situations where evidence as to the usual course of professional conduct might be essential proof of the Government's case. But here there is ample evidence of conduct outside the usual course of any professional practice and/or without medical purpose. Specifically, the Government presented evidence of: (1) long-term rather than short-term treatment, which conflicted with the clinics' own medical guidelines regarding chronic pain management; [11] (2) an extremely high volume of patients seen each day (as many as 300 patients in a four-to-six hour time frame); (3) short durations for patient visits; [12] (4) a lack of individualization of the prescriptions; [13] (5) prescriptions prepared in advance requiring only the doctor's signature; (6) phony pre-printed doctor's medical comments placed in patient files; (7) a lack of meaningful physical examination on initial and repeat visits; [14] (8) a lack of required documentation of a physical injury; (9) false documentation and outdated MRIs presented by patients and accepted by treating physicians who continued to dispense the trinity drugs; (10) sham physical therapy sessions; [15] (11) a cash-only payment policy; and (12) clinic-hopping among Armstrong's clinics. [16] Dr. Guenther also testified that each time he attempted to discuss clinic problems with Armstrong, such as the lack of physical therapy or clinic-hopping, Armstrong told him that she would take care of it, although no changes were made, and on one such occasion Armstrong suggested Dr. Guenther simply stop taking notes. Such evidence demonstrates conduct outside of the usual course of professional practice. And although the Government failed to present expert testimony regarding the recognized practices of chronic pain management facilities, the jury did hear from fact witnesses about their discomfort with the clinics' operations. Dr. Hope Ewing testified that within an hour of meeting Armstrong about bringing her pain management patients to the clinics, she had a strong feeling that this was not a suitable place for pain management, because she was told that she would have to see six to seven patients an hour, which she believed was insufficient for pain management. The Government also presented testimony of two physicians detailing the irregularities that caused them to stop working at the clinics. Dr. Michael Hunter, who quit after only a month at the clinics, stated that Armstrong told him that she gave prescriptions to patients because they expected to receive them. After seeing Armstrong in the parking lot exchanging money with a patient for whom he had refused to write a prescription, Dr. Hunter believed that patients were getting drugs without seeing a doctor. Dr. Gilbert Mason, who departed after six weeks, testified that he felt pressured by Armstrong to write prescriptions and to see more patients. [17] Additionally, Dr. Cullins admitted at trial that she had: (1) made poor medical judgments; (2) identified patients as clinic hoppers; (3) issued multiple prescriptions for overlapping treatment periods to patients; (4) violated the Louisiana Pain Management Standards; and (5) been warned in March by Armstrong that the DEA might be sending in undercover agents since it had publicly shut down some other pain clinics. Despite having previously caught DEA informant Buckeridge clinic hopping and noting the word jumper multiple times in the clinics' files, Dr. Cullins continued to see Buckeridge and write her trinity drug prescriptions. Dr. Cullins even signed two post-dated prescriptions, seized from one of the pharmacies on April 11, 2005. The prescriptions purported to have been written April 23, 2005, but were filled by the pharmacy on April 9, 2005. Further, an analysis of prescriptions written by Dr. Cullins was presented to the jury. It showed that Dr. Cullins was seeing and prescribing the trinity drugs for several hundred patients a day, with a high of 302 in one day. Although Dr. Cullins offered explanations for her conduct, the jury was entitled to reject most of her explanations. [18] Yet Armstrong and Dr. Cullins contend that in this case expert testimony was necessary because the facts and circumstances surrounding the prescriptions could not establish that they acted outside the scope of professional practice in dispensing the controlled substances. Appellants' reliance on two cases from other circuits, United States v. Bek, 493 F.3d 790 (7th Cir.2007), and United States v. Cuong, 18 F.3d 1132 (4th Cir.1994), as support for this proposition is misplaced. In Bek, the Seventh Circuit addressed a sufficiency of the evidence challenge to convictions for illegally dispensing controlled substances to three deceased patients because they were unavailable to testify at trial. Bek, 493 F.3d at 799. That court reversed only one substantive count where the Government did not present expert testimony, medical records, or other evidence regarding the deceased patient's condition or the doctor's treatment of her. Id. In fact, the court recited the evidence presented that it considered sufficient to satisfy the criminal standard to convict a practitioner under § 841(a)(1), reflecting many of the same facts in the present case, such as uniform and careless medical exams and a disregard for signs of drug abuse. See id. Similarly in Cuong, the Fourth Circuit reversed multiple § 841 convictions where the Government failed to present testimony from any of the patients to whom the illegal dispensations were made. 18 F.3d at 1142-43. Thus, Bek and Cuong propose that evidence regarding the particular patient visit or treatment giving rise to the § 841 charge should be presented at trial in order for a conviction on the charge to withstand a motion for acquittal. See id. In this case, all of the substantive § 841 counts (counts 2-27) were based on occasions in which practitioners dispensed controlled substances to either DEA informant Buckeridge or undercover DEA Agent David Gauthreaux. Because both testified at trial as to each of their clinic visits and the treatment they received, recordings of the visits with Dr. Cullins were played for the jury, and medical records were introduced into evidence respecting counts 2-27, the reasoning of neither Bek nor Cuong would require acquittal. Therefore, we are not persuaded that expert testimony was required to establish criminal liability on the facts of this case.