Opinion ID: 2639523
Heading Depth: 1
Heading Rank: 6

Heading: Failure to Weigh Material Evidence

Text: [¶ 23] This Court has on numerous occasions over a span of years stressed the importance of an agency fact-finder giving careful consideration to all material evidence presented by the parties. All of the material evidence offered by the parties must be carefully weighed by the agency as the trier of the facts; conflicts in the evidence must be resolved, and the underlying or basic facts which prompt the ultimate conclusion on issues of fact drawn by the agency in sustaining the prima facie case made, or in rejecting it for the reason it has been satisfactorily met or rebutted by countervailing evidence, must be sufficiently set forth in the decision rendered. Decker, ¶ 27, 124 P.3d at 695 (quoting Bush v. State ex rel. Wyoming Workers' Safety & Comp. Div., 2005 WY 120, ¶ 9, 120 P.3d 176, 180 (Wyo.2005) (quoting Pan Am. Petroleum Corp. v. Wyoming Oil & Gas Conservation Comm'n, 446 P.2d 550, 557 (Wyo.1968))); see also Olivas v. State ex rel. Wyoming Workers' Safety & Comp. Div., 2006 WY 29, ¶ 16, 130 P.3d 476, 485 (Wyo.2006) ([O]ur ability to review the hearing examiner's decision is further compromised by the hearing examiner's failure to make findings of fact and conclusions regarding all of the material evidence offered by [Claimant].). [¶ 24] This Court has been equally clear in its requirements for the consideration to be given medical opinion testimony. When presented with medical opinion testimony, the hearing examiner, as the trier of fact, is responsible for determining relevancy, assigning probative values, and ascribing the relevant weight to be given to the testimony. . . . In weighing the medical opinion testimony, the fact finder considers: (1) the opinion; (2) the reasons, if any, given for it; (3) the strength of it; and (4) the qualifications and credibility of the witness or witnesses expressing it. Decker, ¶ 33, 124 P.3d at 697 (quoting Baxter v. Sinclair Oil Corp., 2004 WY 138, ¶ 9, 100 P.3d 427, 431 (Wyo.2004) (quoting Bando v. Clure Bros. Furniture, 980 P.2d 323, 329 (Wyo.1999))). [¶ 25] In this case, the Medical Commission's order contains no indication that it considered and weighed all material evidence offered by the parties. Our review of the record revealed numerous records and opinions material to the issues before the Medical Commission that were not discussed in the Medical Commission's order. For example, the order does not reference in any manner the opinions offered by Rodgers' pain management specialist, Dr. John C. Oakley. Dr. Oakley testified as follows: Q. Could you be more specific on what type of problems you observe with prolonged medicine? A. Well, the most common side effect from a drug administration pump is constipation. The next most common thing that we see is a sense of underlying nausea, and not so much pain in the stomach as lack ofloss of appetite, subtle feeling of them being nauseated or ill all the time in terms of the GI tract. But the most common finding is constipation. Q. Do you have an opinion as to the mechanism or why these medicines cause these types of problems? A. Yeah. They decrease gastric motility fairly dramatically in some people. Q. Is that recognized pretty readily through the pain medicine specialists or is that  A. Yes, usually. Depends on level of suspicion, I suppose. Q. So that'syou don't believe that you're the minority to feel that way then. Is that correct? A. No. No, I'm definitely not the minority. Q. Is this specific medications, Doctor? A. Well, it's more classes of medications. The opioid analgesics, the narcotic analgesics that are used in the pump are the biggest offender for these. . . . Q. Doctor, you keep mentioning pump. Can oral pain medications cause the same gastric problem? A. Yeah. Yes, the side effect spectrum is identical between oral and intrathecal medication. [¶ 26] The Medical Commission's order fixated on the timing and effects of one particular pain medication, Fiorinal. While we do not suggest that Dr. Oakley's opinions had to be accepted by the Medical Commission, the opinions are clearly material to the question whether an isolated medication, Fiorinal, caused some or all of Rodgers' problems, or whether a class of narcotic medications caused the problems, and the opinions therefore should have at least been considered. This Court will not infer from the fact that the evidence was presented and not recited in the Medical Commission's order that the Medical Commission simply rejected the evidence. The Medical Commission, as hearing examiner, has a duty to explicitly explain what weight, if any, it gives evidence, and why. See Decker, ¶¶ 33-34, 124 P.3d at 696-97; Pan Am., 446 P.2d at 554-55. [¶ 27] Perhaps even more striking are the opinions not discussed in the Medical Commission's order that bear directly on the question of the cause of Rodgers' gastrointestinal problems. For example, Dr. Oakley provided several opinions concerning the cause of Rodgers' gastrointestinal condition: Q. . . . Do you have an opinion as to whether Milton's gastrointestinal problems are caused by his pain medicine? A. I think a lot of his gastrointestinal problems have been actually caused by his medication. There's been a lot of manipulations of medications over the years, and it's my opinion that the medications have directly contributed to his gastrointestinal problem.     Q. So I guess I should ask you, do you have an opinion whether Mr. Rodgers' current gastritis was caused by this spinal stroke? A. No, I don't think so. I think it's more a direct result of the medications for his chronic pain.     Q. Other than his medicine, his pain medicine, what are the other things that would cause his gastrointestinal problems? A. Well, I mean, I suppose he could have an ulcer from other reasons or something like that. I mean, you know, people who are on pain medicine get sick as well. It's unlikely that it's something like an influenza or a virus or something which is self-limited. It was kind of an ongoing problem for him, and it would seem to be related more to the drugs than to any kind of infectious disease or other things that we would think of. And, in fact, some of these drugs can also cause ulcer problems as well.     Q. So when we boil this all down, we really do speculate on this gastrointestinal problem being related to his work injury. A. Yes. You try to manipulate the drugs and see if it goes away, but unfortunately in his case it's a balance between the medicine we give him and not being able to really stop them, so we haven't been able to really test the theory. [¶ 28] Dr. Kuckel likewise testified concerning causation, providing opinions on the causes of both Rodgers' gastrointestinal problems as well as his esophageal stricture. While the Medical Commission's order quoted sparingly from Dr. Kuckel's examination notes and his deposition testimony, the following material opinions are absent from the Medical Commission's findings: Q. And again, under your impressions, could you give me your impressions according to that document? A. Secondary to the medications that he was taking, I had thought that he had symptoms of what was called gastroparesis secondary to his pain medications. Pain medications, narcotics, just about every single one of them, with the exception of a medication he is not on, will cause slowdown of contractions in the gastrointestinal tract. What will happen is there will be no forward motion of food or secretions or acid, and I felt that his problems were secondary to that. When I had gone and done some of his procedures, although it was not readily obvious in the reports, there were times when there were some retained contents which would not have been there had this patient had normal gastroparesis. So my assumption was presumptively and with good reason that his chronic use of narcotic medications was causing gastroparesis. He was retaining food secretions and acid, and these acids, secondary to his hiatal hernia and other complications, were refluxing back into his esophagus. He was structuring down, and this necessitated me to perform esophageal dilatations on him in order for him to eat properly.     Q. Now, as you testify today, do you have, I guess, a medical opinion as to what you believe causes his gastrointestinal problems? A. At the time when I saw him, part of his dyspeptic symptoms were caused by H. pylori. H. pylori as an infection is implicated in causing acid peptic disease and is implicated in causing ulcers. However, it is not implicated in causing gastroparesis. It is not implicated in causing gastroesophageal reflux disease and strictures, so part of his dyspeptic symptoms and part of his pain and I say a small portion of that was caused by that, but once that was treated, that was eliminated. His problems were directly caused by hiswere triggered and I think maintained by his pain medications resulting in gastroparesis, and therefore, he could not clear his acids.     Q. Doctor, you briefly hit on this, I know, but could you explain to me in detail more how you believe pain medications can cause this type of problems? A. Sure. Pain medications in general are CNS depressants, and one of the effects that pain medications have are decreased motility of the gastrointestinal tract. In particular, the large intestine as well as the stomach have decreased motility. This is evidenced by many people who have chronic narcotic use and/or abuse are extremely constipated. People with chronic narcotic use and abuse have what they call gastroparesis. The stomach does not empty in a timely manner. Gastric emptying time is directly reduced almost directly in proportion to amount and duration of narcotic agents used. Of course, it depends on which kind of narcotic agents you're using. Some are stronger than others, but in his case, he was on multiple agents and his ability to clear theclear his gastric contents is severely compromised.     Q. Do you have an opinion as to what caused this stricture? A. My opinion as to what caused the stricture is that reflux of acid and gastric contents up into the esophagus as they were not cleared would cause the stricture. Continuous acid bathing on the distal portion of the esophagus is well documented in causing esophageal strictures.     Q. And that stricture is caused by the pain medicine he takes? A. No. The pain medication in and of itself does not cause it. The pain medication causes gastroparesis, a slowdown in the clearing of the stomach. And therefore, the acid and anything that is left inside the stomach will reflux. It has to go somewhere. [¶ 29] The above-quoted opinions are clearly material to the issues before the Medical Commission, and we find their absence from the Medical Commission's order inexplicable. The Division nonetheless argues the Medical Commission's order reflects a careful consideration and weighing of the material evidence in this case, first, because the order itself states the Medical Commission performed a careful review of all the evidence presented in the case, and, second, because the order references evidence from Drs. Smith, Tietjen, McElwee, Kuckel, and Perakos. We disagree. If an agency does not provide detailed findings of fact outlining the material evidence received and considered and some explanation for the weight or lack thereof given that evidence, this Court has no meaningful way to assess the agency's careful review of the evidence. See Decker, ¶ 34, 124 P.3d at 697. Furthermore, although the Medical Commission undoubtedly reviewed the voluminous medical records in this case, and the testimony of the deposed physicians, the absence of material opinions from the Medical Commission's findings of fact illustrates the incomplete consideration the Medical Commission gave the evidence. The Division's citation in its appellate brief of evidence that was presented to the Medical Commission but not included in its order only highlights the order's deficiencies. If the evidence were material, it should have been included in the findings of fact. As we have repeatedly cautioned: Appellate briefing is not the place to articulate sufficient findings of fact. It is not the duty of this court to analyze and assess evidence presented to an administrative body to determine the weight to be given evidence or the credibility to be afforded witnesses. Decker, ¶ 35, 124 P.3d at 697 (quoting Bush, ¶ 11, 120 P.3d at 180 (quoting Billings v. Wyoming Bd. of Outfitters and Guides, 2001 WY 81, ¶ 19, 30 P.3d 557, 567 (Wyo.2001))). [¶ 30] Because the Medical Commission omitted material evidence from its findings of fact, its decision is arbitrary and capricious and must be reversed. See Olivas, ¶ 16, 130 P.3d at 485; Decker, ¶ 24, 124 P.3d at 694; Padilla, ¶ 6, 84 P.3d at 962.