Opinion ID: 173191
Heading Depth: 3
Heading Rank: 1

Heading: The ALJ’s Rejection of Dr. Hall’s Opinion

Text: Mr. Gonzalez complains that the ALJ unjustifiably rejected opinions expressed by Dr. Timothy Hall, an independent medical examiner for the State of Colorado who evaluated Mr. Gonzalez in connection with his workers’ compensation claim. Dr. Hall’s notes from two examinations, in June 2002 and September 2004, constitute the primary evidence in support of Mr. Gonzalez’s claim. During those exams, Mr. Gonzalez complained of memory loss, throbbing headaches, and a humming in his ear. Dr. Hall found him to be both pleasant and believable, but he noted that Mr. Gonzalez was “slow to respond” and “seem[ed] a bit distant.” Admin. R. at 284. He also noted that Mr. Gonzalez was easily confused and provided “wandering” answers to his questions. Id. Dr. Hall diagnosed Mr. Gonzalez with a mild traumatic brain injury with probable visual and cognitive dysfunction, post traumatic headaches, and myofascial pain of the -4- cervicothoracic area. He acknowledged that these diagnoses conflicted with other opinions in Mr. Gonzalez’s records. But Dr. Hall believed the “marked change in [Mr. Gonzalez’s] functional status” following a significant blow to the head to be more than a mere coincidence. Id. And he noted after his second examination that despite the “difference of opinion between providers about [Mr. Gonzalez’s] closed head injury diagnosis,” he was “fairly convinced” that Mr. Gonzalez had such an injury and “continue[d] to suffer from consequences of it.” Id. at 280. This opinion conflicts with earlier opinions from Drs. John Tyler, Michael Schmidt, and Zvi Kalisky. Dr. Tyler first met Mr. Gonzalez in August 2001. He was sufficiently concerned with Mr. Gonzalez’s inability to concentrate during the exam that he sent him for a psychological evaluation with Dr. Schmidt in December 2001. Dr. Schmidt submitted Mr. Gonzalez to a series of cognitive tests. He concluded that the results “[did] not reflect normal functioning” but also that they were “not a perfect fit for residual effects of [a] mild closed head injury.” Id. at 147. He did allow it was possible Mr. Gonzalez was experiencing residual head injury symptoms. In January 2002, however, after conferring with Dr. Tyler and reviewing additional medical records, Dr. Schmidt changed his mind due to inconsistencies in Mr. Gonzalez’s case. Specifically, Dr. Schmidt noted that despite regular check-ups after the accident, Mr. Gonzalez did not complain of cognitive symptoms until over nine months later—at a time when most patients would have -5- fully recovered from a mild head injury. Dr. Schmidt observed that if Mr. Gonzalez’s “symptoms were bad enough to be reported nine months post injury, they would have been considerably worse earlier on and would very likely have been cause for significant concern.” Id. at 150. He also noted that Mr. Gonzalez had been inconsistent in reporting whether he had lost consciousness when he fell. Two days after the accident, he told his treating physician, Dr. Patrick Higgins, that he had not lost consciousness, but he later told Dr. Schmidt that he had lost consciousness. Based in part on the new information, Dr. Schmidt determined that the neuropsychological evaluation he conducted was “substantially influenced by inconsistent test-taking effort” and was therefore unreliable. Id. at 151. He therefore concluded that Mr. Gonzalez was not suffering from any residual effects of a closed head injury, an opinion that was shared by Dr. Tyler. Dr. Kalisky’s opinion is also in accord with this conclusion, although he did not personally examine Mr. Gonzalez. Upon reviewing the claimant’s medical file, Dr. Kalisky concluded that his subjective complaints were not “substantiated by objective physical, radiological, or electrophysiological findings.” Id. at 124. Dr. Kalisky found “no objective medical reason which would preclude [Mr. Gonzalez] from working . . . full time, without restrictions.” Id. at 127. -6- The most voluminous records are from Dr. Jeffrey Jenks and Dr. Glenn Kaplan, who treated Mr. Gonzalez in tandem throughout 2004. In January of that year, Mr. Gonzalez saw Dr. Jenks for headaches, cognitive difficulties and neck pain. Dr. Jenks noted that his patient presented with questionable symptoms related to a head injury and probable depression. He prescribed physical therapy and referred Mr. Gonzalez to Dr. Kaplan for psychological treatment. Upon meeting Mr. Gonzalez, Dr. Kaplan noted that although he had seen other psychologists, Mr. Gonzalez had yet to receive any treatment beyond testing. In January 2004, he diagnosed Mr. Gonzalez with a pain disorder and unspecified cognitive and anxiety disorders. After four additional sessions with Mr. Gonzalez, Dr. Kaplan concluded that he did “not appear to have any permanent psychological problems related to his work injury.” Admin. R. at 213. In March 2004, he remarked that Mr. Gonzalez was “motivated to return to work,” but was not sure he would be able to do construction-type work. Id. at 214. During their last session, Mr. Gonzalez reported he was thinking about looking for a job. Throughout his treatment with Dr. Kaplan, Mr. Gonzalez reported that his headaches, mood swings, and anxiety were all improving. Dr. Jenks’s treatment records reflect similar improvement. After his course of physical therapy, Mr. Gonzalez demonstrated an increased cervical range of motion and reported that he was in less pain. Based on a Functional Capacity Evaluation (“FCE”) completed on April 19, 2004, the physical therapist placed -7- Mr. Gonzalez in the light-medium work classification and noted in a letter to Dr. Jenks that he was able to work an eight-hour day. Dr. Jenks fully endorsed this FCE in June 2004, noting that in his opinion, Mr. Gonzalez was “in the light/medium work category.” Id. at 265. There is a lone entry in Mr. Gonzalez’s medical records from Dr. Anthony Ricci, a psychologist, whom he saw in January 2003. According to Dr. Ricci, Mr. Gonzalez was “manifesting very evident features of [p]ost-[c]oncussion sequelae;” was “clearly moderately to severely dysfunctional; and . . . unable to sustain consistent employment.” Id. at 202. He diagnosed chronic pain syndrome and mood disorder, and “strongly endorse[d]” the treatments recommended by Dr. Hall. Id. The ALJ gave this opinion little weight, emphasizing that it came from an examining, not a treating source, and that it was inconsistent with the opinions of Mr. Gonzalez’s treating physicians. He also noted that the ultimate issue of a claimant’s ability to work is reserved to the Commissioner. See Castellano v. Sec’y of Health & Human Servs., 26 F.3d 1027, 1029 (10th Cir. 1994). As for the weight given to Dr. Hall’s opinion, we have held that “[m]edical evidence may be discounted if it is internally inconsistent or inconsistent with other evidence.” Pisciotta v. Astrue, 500 F.3d 1074, 1078 (10th Cir. 2007) (internal quotation marks omitted). And we have reminded ALJs that in determining how to weigh an opinion, they “must consider the consistency -8- between that opinion and the record as a whole.” Id. In rendering his opinion, Dr. Hall intentionally departed from the opinions of Dr. Tyler, Dr. Schmidt, and Dr. Kalisky. But the ALJ was not persuaded, noting that Dr. Hall’s opinion was not supported by the treatment records or the examination findings; was inconsistent with other more persuasive medical opinions in the record, including the later opinions by Mr. Gonzalez’s treating physicians; and was inconsistent with the results of the functional capacity evaluation. We see no error in the ALJ’s treatment of Dr. Hall’s opinion. Taken as a whole, we agree with the ALJ’s assessment of the medical evidence and conclude it does not support a claim of total disability under the Social Security Act.