Opinion ID: 3049417
Heading Depth: 3
Heading Rank: 1

Heading: Opinions of Treating Physicians

Text: Orn argues that the ALJ improperly disregarded the opinions of his treating physicians, Drs. Doerning and Nguyen. Both Drs. Doerning and Nguyen offered diagnoses of Orn’s medical conditions, prognoses for his conditions, and assessments of his ability to work. The record contains numerous reports and forms completed by Orn’s two treating physicians from 1999 through 2003. However, the ALJ chose to rely on the opinion of a consulting physician, Dr. Karamlou, who performed one physical examination of Orn in 2000. Based on 8464 ORN v. ASTRUE that examination, Dr. Karamlou opined that Orn could stand and walk for six hours in an eight-hour workday. [1] By rule, the Social Security Administration favors the opinion of a treating physician over non-treating physicians. See 20 C.F.R. § 404.1527. If a treating physician’s opinion is “well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record, [it will be given] controlling weight.” Id. § 404.1527(d)(2). If a treating physician’s opinion is not given “controlling weight” because it is not “well-supported” or because it is inconsistent with other substantial evidence in the record, the Administration considers specified factors in determining the weight it will be given. Those factors include the “[l]ength of the treatment relationship and the frequency of examination” by the treating physician; and the “nature and extent of the treatment relationship” between the patient and the treating physician. Id. § 404.1527(d)(2)(i)-(ii). Generally, the opinions of examining physicians are afforded more weight than those of nonexamining physicians, and the opinions of examining nontreating physicians are afforded less weight than those of treating physicians. Id. § 404.1527(d)(1)-(2). Additional factors relevant to evaluating any medical opinion, not limited to the opinion of the treating physician, include the amount of relevant evidence that supports the opinion and the quality of the explanation provided; the consistency of the medical opinion with the record as a whole; the specialty of the physician providing the opinion; and “[o]ther factors” such as the degree of understanding a physician has of the Administration’s “disability programs and their evidentiary requirements” and the degree of his or her familiarity with other information in the case record. Id. § 404.1527(d)(3)-(6). The Administration has explained § 404.1527 in Social Security Ruling 96-2p. That ruling provides, in relevant part: [A] finding that a treating source medical opinion is not well-supported by medically acceptable clinical ORN v. ASTRUE 8465 and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the case record means only that the opinion is not entitled to “controlling weight,” not that the opinion should be rejected. Treating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in 20 C.F.R. 404.1527 . . . . In many cases, a treating source’s medical opinion will be entitled to the greatest weight and should be adopted, even if it does not meet the test for controlling weight. S.S.R. 96-2p at 4 (Cum. Ed. 1996), available at 61 Fed. Reg. 34,490, 34,491 (July 2, 1996). In turn, we have explained: The opinions of treating doctors should be given more weight than the opinions of doctors who do not treat the claimant. Lester [v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (as amended).] Where the treating doctor’s opinion is not contradicted by another doctor, it may be rejected only for “clear and con- vincing” reasons supported by substantial evidence in the record. Id. (internal quotation marks omitted). Even if the treating doctor’s opinion is contradicted by another doctor, the ALJ may not reject this opinion without providing “specific and legitimate reasons” supported by substantial evidence in the record. Id. at 830, quoting Murray v. Heckler, 722 F.2d 499, 502 (9th Cir. 1983). This can be done by setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings. Magallanes [v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989).] The ALJ must do more than offer his conclusions. He must set forth his own interpretations and explain why they, rather than the doctors’, are correct. 8466 ORN v. ASTRUE Embrey v. Bowen, 849 F.2d 418, 421-22 (9th Cir. 1988). Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998); accord Thomas, 278 F.3d at 957; Lester, 81 F.3d at 830-31. [2] When an examining physician relies on the same clinical findings as a treating physician, but differs only in his or her conclusions, the conclusions of the examining physician are not “substantial evidence.” As we explained in Murray, “In this case, . . . the findings of the non-treating physician were the same as those of the treating physician. It was his conclusions that differed. . . . If the ALJ wishes to disregard the opinion of the treating physician, he or she must make findings setting forth specific, legitimate reasons for doing so that are based on substantial evidence in the record.” 722 F.2d at 501-02 (emphases in original). By contrast, when an examining physician provides “independent clinical findings that differ from the findings of the treating physician,” such findings are “substantial evidence.” Miller v. Heckler, 770 F.2d 845, 849 (9th Cir. 1985); accord Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995); Magallanes, 881 F.2d at 751; Allen v. Heckler, 749 F.2d 577, 579 (9th Cir. 1985) (as amended). Independent clinical findings can be either (1) diagnoses that differ from those offered by another physician and that are supported by substantial evidence, see Allen, 749 F.2d at 579, or (2) findings based on objective medical tests that the treating physician has not herself considered, see Andrews, 53 F.3d at 1041. If there is “substantial evidence” in the record contradicting the opinion of the treating physician, the opinion of the treating physician is no longer entitled to “controlling weight.” 20 C.F.R. § 404.1527(d)(2). In that event, the ALJ is instructed by § 404.1527(d)(2) to consider the factors listed in § 404.1527(d)(2)-(6) in determining what weight to accord the opinion of the treating physician. Even when contradicted by an opinion of an examining physician that constitutes subORN v. ASTRUE 8467 stantial evidence, the treating physician’s opinion is “still entitled to deference.” S.S.R. 96-2p at 4, 61 Fed. Reg. at 34,491. “In many cases, a treating source’s medical opinion will be entitled to the greatest weight and should be adopted, even if it does not meet the test for controlling weight.” Id. As we stated in Reddick, “Even if the treating doctor’s opinion is contradicted by another doctor, the ALJ may not reject this opinion without providing ‘specific and legitimate reasons’ supported by substantial evidence in the record.” 157 F.3d at 725 (quoting Murray, 772 F.2d at 502). 1. Treating Physicians’ Opinions are Entitled to Weight The Commissioner argues that Dr. Karamlou’s opinion constitutes per se substantial evidence to support the ALJ’s disregard of the opinions of Drs. Doerning and Nguyen. We disagree. Dr. Karamlou’s opinion that Orn could stand and walk for six hours did not rely on “independent findings.” In addition, the criteria established by § 404.1527 indicate that the opinions of Drs. Doerning and Nguyen are entitled to weight in Orn’s disability determination. [3] Dr. Karamlou, like Drs. Doerning and Nguyen, performed a physical examination of Orn. Dr. Karamlou agreed with the diagnoses provided by Orn’s treating physicians and offered no alternative diagnosis. Dr. Karamlou’s opinion did not rest on results from objective clinical tests that Drs. Doerning and Nguyen had not considered. Dr. Karamlou’s findings “were the same as those of the treating physician[s]. It was his conclusions that differed.” Murray, 722 F.2d at 501 (emphasis in original). Therefore, his conclusion concerning Orn’s ability to stand or walk based on that examination was not an “independent finding,” and his opinion does not alone constitute substantial evidence to support the rejection of Orn’s treating physicians’ opinions. See Reddick, 157 F.3d at 725; see also Robbins, 466 F.3d at 882 (prohibiting affirmance in Social Security disability cases “simply by isolating 8468 ORN v. ASTRUE a ‘specific quantum of supporting evidence’ ” (citation omitted)). [4] A second, independent reason precludes the ALJ from disregarding the opinions of the treating physicians in this case. Even if Dr. Karamlou’s opinion were “substantial evidence,” § 404.1527 still requires deference to the treating physicians’ opinions. 20 C.F.R. § 404.1527; see S.S.R. 96-2p at 1 (“A finding that a treating source’s medical opinion is not entitled to controlling weight does not mean that the opinion is rejected.”), 61 Fed. Reg. at 34,490; see also Green-Younger v. Barnhart, 335 F.3d 99, 106 (2d Cir. 2003); McGoffin v. Barnhart, 288 F.3d 1248, 1252 (10th Cir. 2002). As discussed above, § 404.1527 lists several factors that increase the weight afforded to Orn’s treating physicians’ opinions in this case. For example, the treating relationship of both physicians provides a “unique perspective” on Orn’s condition. See 20 C.F.R. § 404.1527(d)(2). In addition, the nature and extent of the physicians’ relationships with Orn adds significant weight to their opinions. Id. § 404.1527(d)(2)(i)-(ii). Dr. Doerning was Orn’s treating physician between 1999 through 2002, and his reports cover that entire period. Dr. Nguyen was Orn’s primary physician during his 2003 hospitalization and provided his post-hospitalization follow-up treatment. His questionnaire was the most recent report in the record. It was also the only report describing the effects of two significant medical events: Orn’s latest hospitalization and his reliance on continuous supplemental oxygen. [5] The “[s]upportability” of Orn’s treating physicians’ opinions adds further weight. See id. § 404.1527(d)(3). The primary function of medical records is to promote communication and recordkeeping for health care personnel — not to provide evidence for disability determinations. We therefore do not require that a medical condition be mentioned in every report to conclude that a physician’s opinion is supported by ORN v. ASTRUE 8469 the record. When viewed in its entirety, the record provides ample support for the opinions of Drs. Doerning and Nguyen. The record contains numerous reports from Orn’s health care providers, as well as results from medical tests and laboratory findings, that support the questionnaires completed by Drs. Doerning and Nguyen. [6] Finally, the consistency of Orn’s treating physicians’ reports merits additional weight. See id. § 404.1527(d)(4). Consistency does not require similarity in findings over time despite a claimant’s evolving medical status. Rather, as required by the applicable regulation, the opinions of Drs. Doerning and Nguyen were consistent “with the record as a whole.” See id. The physicians offered opinions that were substantiated by the contemporaneous medical tests and Orn’s medical condition. The gradual decrease in Orn’s physical capacity, as illustrated by the evaluations of his treating physicians, is supported by the record. As Dr. Doerning stated, Orn’s condition was “progressively worsening.” 2. No “Specific, Legitimate Reasons” Supported by Substantial Evidence [7] The two reasons provided by the ALJ for rejecting the opinions of Orn’s treating physicians are insufficient. The reasons are not “specific, legitimate reasons” that are supported by “substantial evidence.” See Thomas, 278 F.3d at 957. In fact, the record contradicts them. [8] The ALJ’s first reason for rejecting both treating physicians’ opinions of Orn’s functional capacity was that those physicians had “fail[ed] to indicate what claimant could do despite his limitations.” The record shows the opposite. Dr. Doerning’s multiple impairments questionnaire, completed on April 5, 2002, indicates that Orn could sit for four hours a day and could stand and walk for one hour per day. It also reports that Orn had no limitations in reaching, handling, fingering, or lifting, and that he could occasionally lift and carry up to 8470 ORN v. ASTRUE ten pounds. Similarly, Dr. Nguyen’s questionnaire dated one year later reported no limitations in Orn’s ability in fine manipulations with fingers and hands or in reaching. It described Orn as able to sit or stand for one hour in a competitive work environment. See Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996) (stating that ALJ has a duty to “conduct an appropriate inquiry” if the ALJ determines that it is necessary to know the basis of the treating physician’s opinion). The ALJ’s second reason for rejecting the treating physicians’ opinions was lack of objective support. After describing Dr. Doerning’s assessment of Orn’s limitations, the ALJ stated that “there is no objective evidence of decreased range of motion or neurological deficits to support such severe limitations in standing and walking.” The ALJ’s statement is correct as far as it goes, but it does not warrant the rejection of Dr. Doerning’s opinion. Dr. Doerning never claimed that “decreased range of motion” or “neurological deficits” caused Orn’s limitations in standing and walking. Rather, Dr. Doerning indicated that Orn’s ability to work was limited by his respiratory conditions. [9] Dr. Doerning diagnosed Orn with “asthma and severe obstructive pulmonary disease” and reported that Orn’s “symptoms and functional limitations [were] reasonably consistent with” the impairments described in his evaluation. The record provides voluminous support for Dr. Doerning’s opinion that Orn’s respiratory diseases adversely affected his ability to work. Orn stopped working after suffering an asthma attack. His medical records contain physical examinations which reveal wheezing and other respiratory abnormalities. He has abnormal pulmonary functional tests. Orn takes medications for his respiratory diseases and, since 2003, requires continuous supplemental oxygen. He has been hospitalized twice in four years for respiratory problems. The ALJ’s reason for rejecting Dr. Doerning’s opinion — that the record did not contain evidence of “decreased range of motion” or “neurological deficits” — is not “legitimate because it is not ORN v. ASTRUE 8471 responsive to Dr. Doerning’s opinion based on Orn’s respiratory problems. Compare Magallanes, 881 F.2d at 751-52 (upholding rejection of treating physician’s opinion that claimant was “disabled” when it was contradicted by the opinions of four other physicians, EMG studies, and other medical tests). Similarly, the ALJ stated that there was “no clinical evidence” to support the sitting and standing limitations assessed by Dr. Nguyen. The ALJ then described a host of other conditions for which Orn had not been diagnosed, including “disc herniation, stenosis or nerve root compression.” Missing from the ALJ’s list is any mention of Orn’s respiratory disorders, obesity, and diabetes, which Dr. Nguyen cited as causing Orn’s limitations and which are amply supported in the record. [10] An ALJ may not exclude a physician’s testimony for a lack of objective evidence of impairments not referenced by the physician. Rather, an ALJ must evaluate the physician’s assessment using the grounds on which it is based. The ALJ thus erred in rejecting the opinions of Drs. Doerning and Nguyen. See Andrews, 53 F.3d at 1043.