Court Opinion

ID: 9905690
Source: CourtListenerOpinion
Date Created: 2023-11-29 21:01:31.39573+00
Date Added: 2024-06-11T09:23:50.450809
License: Public Domain

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                                                              [PUBLISH]
                                    In the
                 United States Court of Appeals
                         For the Eleventh Circuit

                           ____________________

                                 No. 20-13973
                           ____________________

        UNITED STATES OF AMERICA,
                                                       Plaintiﬀ-Appellee,
        versus
        KENDRICK EUGENE DULDULAO,
        MEDARDO QUEG SANTOS,

                                                  Defendants-Appellants.

                           ____________________

                  Appeal from the United States District Court
                       for the Middle District of Florida
                   D.C. Docket No. 8:17-cr-00420-MSS-AEP-4
                           ____________________
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        2                      Opinion of the Court                 20-13973

        Before JORDAN, JILL PRYOR, and TJOFLAT, Circuit Judges.
        JILL PRYOR, Circuit Judge:
                This multidefendant criminal appeal is before us on remand
        from the Supreme Court of the United States. After we affirmed
        the convictions of Kendrick Eugene Duldulao and Medardo Queg
        Santos for the roles they played in a Florida “pill mill,” the Supreme
        Court vacated our judgment and remanded for further considera-
        tion in light of Ruan v. United States, 142 S. Ct. 2370 (2022) (“Ruan
        II”). See United States v. Duldulao, No. 20-13973, 2021 WL 6071511
        (11th Cir. Dec. 21, 2021) (unpublished), vacated sub nom. Santos v.
        United States, 143 S. Ct. 350 (2022). With the benefit of the Supreme
        Court’s guidance, supplemental briefing, and oral argument, we
        now affirm in part, vacate in part, and remand in part for a new
        trial.
                              I.     BACKGROUND
                This appeal concerns the criminal convictions of two doc-
        tors, Duldulao and Santos, who participated in a “pill mill”—a pain
        management clinic that does not follow medical standards because
        its purpose is to prescribe controlled substances regardless of
        whether its patients have a medical need for them. See United States
        v. Azmat, 805 F.3d 1018, 1025 n.1 (11th Cir. 2015). Duldulao and
        Santos served sequentially as Medical Directors of a pain manage-
        ment clinic in Tampa, Florida called Health and Pain Clinic
        (“HPC”). HPC liberally dispensed controlled substances to its pa-
        tients, who paid with cash or credit, exhibited obvious signs of drug
        addiction, and received little attention from doctors. A jury
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        20-13973                   Opinion of the Court                          3

        convicted both Duldulao and Santos of conspiracy to distribute and
        dispense controlled substances not for a legitimate medical purpose
        and not in the usual course of professional practice, violating 21
        U.S.C. § 846. The jury also convicted Santos of multiple substantive
        counts of distributing controlled substances not for a legitimate
        medical purpose and outside the usual course of professional prac-
        tice, violating 21 U.S.C. § 841.
               Duldalao and Santos became involved with HPC in 2011 and
        2014, respectively, when Ernest Gonzalez, the de facto owner of
        HPC, hired them to work at his pill mill. Gonzalez knew that the
        patients “were coming in [] to get controlled substances,” so, at
        Duldulao’s and Santos’s respective job interviews, Gonzalez made
        it clear that HPC’s patients expected to receive controlled sub-
        stances during their visits. Doc. 382 at 38. 1 Gonzalez confirmed
        that Duldalao knew the clinic “need[ed] a doctor who was going to
        do controlled substances” and discussed specific controlled sub-
        stances that Duldulao would use to treat the clinic’s patients. Doc.
        382 at 36. Gonzalez also told Duldulao and Santos about key as-
        pects of the business model: very short, timed patient appoint-
        ments; high patient volume (30–40 patients per day); and up-front
        payment only—HPC did not accept insurance.
              Other characteristics suggested that the clinic was not a le-
        gitimate medical operation. The clinic had barely any medical
        equipment—only an exam table for the patients to sit on—or

        1 “Doc.” refers to the district court’s docket entries.
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        4                       Opinion of the Court                  20-13973

        supplies. HPC staff who ran the front desk and did patient intake
        had no medical or administrative training. Yet they wrote prescrip-
        tions for controlled substances for the doctor to sign after each pa-
        tient’s brief visit.
               HPC’s patients exhibited obvious signs of substance abuse.
        Witnesses described them as having bloodshot eyes, slurring their
        words, looking sleepy, and stumbling when they walked. Some pa-
        tients had visible track marks, indicating intravenous drug abuse.
        Others looked like they were going through opiate withdrawal—
        sweating, shaking, vomiting, and experiencing hot and cold flashes.
        People were “nodding out” in the waiting room and “shooting up”
        in the parking lot. Doc. 384 at 100; Doc. 387 at 42. Patients hung
        out in the parking lot and left behind trash like baggies, blunt wrap-
        pers, and syringes.
                The clinic administered drug tests, but patients sometimes
        bribed HPC staff to skip the drug test. The staff falsified test records
        after letting patients skip the test. When patients who actually took
        drug tests tested positive for illegal drugs, HPC staff would some-
        times mark a negative result in their file and allow the patients to
        receive prescriptions anyway.
               It was easy to get controlled substances at HPC: according
        to witnesses, HPC patients always left with new prescriptions for
        controlled substances. To obtain prescription medication, HPC pa-
        tients needed little documentation of a condition that required pain
        management—just an MRI within the last two years documenting
        a physical abnormality of some kind. That and a Florida driver’s
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        20-13973               Opinion of the Court                        5

        license got the patients prescriptions for controlled substances like
        oxycodone and methadone.
               Duldalao and Santos participated in these practices. During
        patient appointments, Duldulao conducted cursory medical exam-
        inations. Sometimes he spent up to five minutes on the physical
        exam; sometimes he simply did not perform one. He spent little
        time on patient medical history. When he went on vacation, his
        patients picked up prewritten, postdated prescriptions without any
        medical exam at all. He wrote prescriptions for controlled sub-
        stances for patients even when they bore visible track marks or had
        traveled from long distances—both red flags for controlled sub-
        stance abuse, according to the government’s medical expert wit-
        ness, Dr. Kevin Chaitoff. Duldulao prescribed controlled sub-
        stances in dangerous combinations, allowing his patients to mix
        Xanax, methadone, and a muscle relaxer called Soma. He even ad-
        mitted to his girlfriend that he worked at a “pain mill.” Doc. 386 at
        143.
                When Santos replaced Duldulao as HPC’s Medical Director,
        little changed at HPC. Like Duldulao, Santos prescribed controlled
        substances to people who looked like drug abusers. He saw them
        in brief appointments, timed by HPC staff. It did not matter if his
        patient’s medical history or drug test was missing. It did not matter
        if a patient told him she shared her pills with friends or family. He
        prescribed patients controlled substances nonetheless. He pre-
        scribed drugs in the same dangerous combinations that Duldulao
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        6                         Opinion of the Court                      20-13973

        had. Santos, too, went on vacations and left prewritten, postdated
        prescriptions for his patients.
               Unbeknownst to Santos, however, two of his patients were
        government agents: undercover DEA task force member Kathy
        Chin and her “boyfriend,” a confidential informant named Robert
        Vasilas. Over the course of a little over a year, Chin and Vasilas
        made a series of five visits to Santos that would later serve as the
        basis for three of Santos’s convictions.
               Chin (without Vasilas) made the first of these visits to HPC
        and Santos in July 2014. Chin presented as a new patient with no
        medical documentation and vague complaints of lower back pain
        lacking any obvious cause that over the counter medication would
        not alleviate. During a brief visit, Santos joked about DEA’s “pro-
        hibition” on controlled substances resulting in the closure of many
        pain clinics. Doc. 372-208 at 4:30–5:10. 2 And Chin used slang (“30s”
        and “15s” of “Oxy”) to describe quantities and types of controlled
        substances, suggesting a potential substance-abuse problem. Id. at
        5:10–5:20. Nevertheless, after a cursory examination in which San-
        tos discussed no alternative forms of treatment, Santos wrote Chin
        a prescription for hydrocodone, which Santos changed to a pre-
        scription for oxycodone a few days later. Chin told Santos that she
        would fill the prescriptions in Alabama.

        2 At trial, the government introduced videos of interactions between Santos
        and the agents. Our citations to Doc. 372 (the government’s trial exhibit list)
        refer to these videos by their exhibit numbers.
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        20-13973               Opinion of the Court                         7

                Santos saw Chin again a few months later. During her visit
        to HPC, Chin asked Santos for more controlled substances and told
        him that she had run out of oxycodone because—although she ex-
        perienced no increase in pain—she had been “doubling,” taking
        more than the prescribed amount. Doc. 372-212 at 11:00–12:15.
        Santos agreed to provide 10 extra pills. Chin also asked if Santos
        could provide her medication through a smaller number of pills at
        a higher dosage (30 mg) When Santos expressed surprise that Chin
        could get high-dose oxycodone, Chin explained that she and her
        boyfriend both received controlled substances from pain clinics by
        driving two hours round trip to Alabama, where pharmacies re-
        quired less stringent documentation to dispense large amounts of
        controlled substances. Chin said she was already receiving 30 mg
        pills there, implying she had multiple sources of controlled sub-
        stances. Id. at 0:42–0:44 (“In Alabama I’m gettin’ em.”). And Chin
        revealed that she lived in Panama City, meaning she travelled al-
        most 400 miles to HPC’s Tampa location. Nevertheless, Santos
        wrote Chin a prescription that increased the total amount of con-
        trolled substances she received and gave her access to higher-dose
        pills.
               At Chin’s next visit, Vasilas came with her. Vasilas, a return-
        ing patient, told Santos that Chin was “robbing” him of his pills
        when she ran out of hers. Doc. 386 at 173. Instead of investigating
        this red flag, Santos gave both of them prescriptions for greater
        quantities of oxycodone. He also wrote Vasilas a new prescription
        for Xanax without asking Vasilas about his history with anxiety or
        what tools he used to manage it. He started Vasilas on Xanax, even
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        8                      Opinion of the Court                 20-13973

        though most doctors would not have prescribed that drug to some-
        one who was also taking an opioid. At no point did Santos discuss
        alternative treatments or milder medications with either patient.
               Chin later made another visit to Santos without Vasilas. In
        an earlier visit, Santos had agreed to give Chin prescriptions to take
        to Vasilas, who said he would be out of town for work. Santos told
        Chin she would have to pay (cash, of course) for a visit for Vasilas,
        even though Vasilas would not be present. Santos gave her pre-
        scriptions for the absent Vasilas, even filling out Vasilas’s file as
        though Santos had examined him.
               In a final visit, Chin and Vasilas returned to see Santos to-
        gether. Vasilas told Santos that he had run out of his pills and had
        been getting medications from friends and family. Santos re-
        sponded by giving Vasilas extra prescriptions with a “do not fill un-
        til” date; Santos charged him for the prescriptions written in ad-
        vance.
              After collecting evidence (including videos) through these
        undercover visits, the government indicted Santos, Duldulao, and
        Gonzalez. Gonzalez pled guilty and testiﬁed against Santos and
        Duldulao. Based on their conduct at HPC, a second superseding
        indictment charged Duldulao and Santos each with one count of
        conspiracy to distribute and dispense oxycodone, hydromorphone,
        morphine, methadone, and hydrocodone (Schedule II controlled
        substances) and alprazolam (Xanax, a Schedule IV controlled sub-
        stance), not for a legitimate medical purpose and not in the usual
        course of professional practice, violating 21 U.S.C. § 846. It also
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        20-13973               Opinion of the Court                        9

        charged both men with multiple substantive counts of distributing
        controlled substances not for a legitimate medical purpose and not
        in the usual course of professional practice, violating 21 U.S.C.
        § 841. Santos faced ﬁve counts under § 841: one for each of the ﬁve
        visits made by Chin and Vasilas we have described.
               At trial, the government established the facts surrounding
        Duldulao’s and Santos’s conduct through the testimony of Gonza-
        lez, government agents, HPC patients, and HPC employees. The
        government also called Dr. Chaitoﬀ as an expert in pain manage-
        ment treatment. Dr. Chaitoﬀ testiﬁed about how he practices pain
        management, underscoring how it diﬀers from the conduct of the
        doctors and staﬀ of HPC. In his practice, Dr. Chaitoﬀ conducts a
        comprehensive physical exam on patients; speaks with them about
        their medical history, their current pain, and the narcotics agree-
        ment patients are required by law to sign; and typically allots 30 to
        35 minutes for an initial visit and 20 minutes for a follow-up—much
        longer than the appointments patients received with Duldulao or
        Santos. He testiﬁed that patients who are clearly abusing controlled
        substances should not be treated with more controlled substances,
        even if they have a legitimate pain problem.
               Dr. Chaitoff also opined that “most of” the prescriptions that
        Santos wrote for controlled substances “were provided for no le-
        gitimate medical purpose, [and] they were not issued in the course
        of one’s professional practice.” Doc. 388 at 20. Santos moved to
        strike his testimony, but the district court denied the motion,
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        10                     Opinion of the Court                20-13973

        noting that Santos could cross-examine Dr. Chaitoff to challenge
        his credibility.
               After the government rested its case, both Duldulao and
        Santos moved for a judgment of acquittal. At the trial’s conclusion,
        the district court granted Duldulao’s motion as to most of the sub-
        stantive counts of dispensing and distributing controlled substances
        but otherwise denied the motions.
               The jury convicted both Duldulao and Santos of the conspir-
        acy count. It also convicted Santos of three substantive violations
        of 21 U.S.C. § 841 and acquitted him of two others.
               Duldulao and Santos appealed on four grounds. Both men
        challenged the sufficiency of the evidence as to their conspiracy
        convictions under 21 U.S.C. § 846. Santos challenged the admission
        of Dr. Chaitoff’s expert testimony about his treatment of patients.
        Santos also challenged the district court’s denial of his motion to
        strike Dr. Chaitoff’s testimony. Finally, Santos challenged the cal-
        culation of his sentence. We considered each ground and, with the
        benefit of oral argument, affirmed. Duldulao, 2021 WL 6071511.
              After we affirmed, the Supreme Court addressed liability un-
        der 21 U.S.C. § 841 in Ruan v. United States, 142 S. Ct. 2370 (2022)
        (“Ruan II”). Ruan II overruled our precedent addressing the scienter
        requirement under that statute. Id. at 2382.
               Title 21 § 841 makes it a federal crime “except as authorized,
        for any person knowingly or intentionally to manufacture, distrib-
        ute, or dispense a controlled substance.” Id. at 2374–75 (internal
        quotation marks omitted) (alterations adopted). Federal
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        20-13973                Opinion of the Court                           11

        regulations in turn authorize doctors to prescribe controlled sub-
        stances “for a legitimate medical purpose . . . in the usual course of
        . . . professional practice.” 21 C.F.R. § 1306.04(a). Thus, a doctor vi-
        olates 21 U.S.C. § 841 when he distributes or dispenses a controlled
        substance either not for a legitimate medical purpose or outside the
        usual course of professional practice. See United States v. Abovyan,
        988 F.3d 1288, 1305 (11th Cir. 2021) (holding that a violation of ei-
        ther prong is sufficient to violate § 841); see also United States v. Hea-
        ton, 59 F.4th 1226, 1241 n.17 (11th Cir. 2023) (concluding that this
        holding of Abovyan survived Ruan II).
               Before Ruan II, our precedent required the government to
        show that a defendant subjectively knew he was acting not for a
        legitimate medical purpose under § 841. United States v. Tobin, 676
        F.3d 1264, 1282 (11th Cir. 2012). But it did not require the same
        showing with respect to whether a doctor violated § 841 by pre-
        scribing a controlled substance outside the usual course of profes-
        sional practice. Id.; see also United States v. Williams, 445 F.3d 1302,
        1309–10 (11th Cir. 2006); United States v. Merrill, 513 F.3d 1293,
        1305–06 (11th Cir. 2008). Instead, our cases explained that, when it
        came to whether a physician acted outside the usual course of pro-
        fessional practice, “the appropriate focus is not on the subjective
        intent of the doctor” but rather on “whether, from an objective
        standpoint, the controlled substances were dispensed in the usual
        course of professional practice.” Tobin, 676 F.3d at 1282 (internal
        quotation marks omitted) (alteration adopted).
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        12                        Opinion of the Court                     20-13973

               Ruan II rejected that distinction. Overruling our decision in
        United States v. Ruan, 966 F.3d 1101 (11th Cir. 2020) (“Ruan I”), the
        Supreme Court held that the scienter provision of 21 U.S.C.
        § 841(a) (“knowingly or intentionally”) applies to both prongs of
        the authorization exception. Ruan II, 142 S. Ct. at 2382. To establish
        criminal liability under § 841, it therefore is not enough for the gov-
        ernment to prove that a defendant acted outside the usual course
        of professional practice by violating an objective standard of care.
        Rather, Ruan II requires the government to prove that “the defend-
        ant knowingly or intentionally acted in an unauthorized man-
        ner”—that the defendant knew he was acting outside the usual
        course of professional practice or intended to. Id. The Supreme
        Court criticized an objective standard, like the one we had applied,
        as reducing the requirements for criminal culpability under
        § 841“to negligence.” Id. at 2381.
               After we affirmed Santos’s conviction (and while Ruan II was
        pending before the Supreme Court), Santos petitioned for a writ of
        certiorari. Pet. for Writ of Cert., Santos v. United States, 143 S. Ct.
        350 (2022) (No. 21-1418). Following its decision in Ruan II, the Su-
        preme Court granted the petition, vacated our judgment, and re-
        manded for further consideration in light of Ruan II. Santos, 143 S.
        Ct. at 350. This appeal is now before us again. 3

        3 Although only Santos petitioned for certiorari, we permitted both parties to
        participate in this remand. After all, we entered a single judgment as to both
        Santos and Duldulao. And the Supreme Court vacated “[t]he judgment.” Judg-
        ment, Santos v. United States, 143 S. Ct. 350 (No. 21-1418).
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        20-13973                   Opinion of the Court                               13

                           II.     STANDARD OF REVIEW
                 “We review the sufficiency of the evidence de novo when, as
        here, the defendant[s] have preserved [their] claim[s] by moving
        for . . . judgment[s] of acquittal.” Azmat, 805 F.3d at 1035.
               In a criminal appeal, we review issues not raised at trial for
        plain error, which “occurs if (1) there was error, (2) that was plain,
        (3) that affected the defendant’s substantial rights, and (4) that seri-
        ously affected the fairness, integrity, or public reputation of judicial
        proceedings.” United States v. Wright, 607 F.3d 708, 715 (11th Cir.
        2010) (internal quotation marks omitted); see also Fed. R. Crim. P.
        52(b). An error is plain if it is “clear” or “obvious.” United States v.
        Olano, 507 U.S. 725, 734 (1993). When “the explicit language of a
        statute or rule does not specifically resolve an issue, there can be
        no plain error where there is no precedent from the Supreme Court
        or this Court directly resolving it.” United States v. Chau, 426 F.3d
        1318, 1322 (11th Cir. 2005) (internal quotation marks omitted).
                We review the district court’s denial of a motion to strike
        testimony for an abuse of discretion. United States v. Woody, 567
        F.2d 1353, 1357 (5th Cir. 1978). 4 We will reverse only if we find an
        error that affected the defendant’s substantial rights. See United
        States v. Barton, 909 F.3d 1323, 1337 (11th Cir. 2018).

        4 Decisions of the Fifth Circuit issued before October 1, 1981 are binding prec-
        edent in this circuit. Bonner v. City of Prichard, 661 F.2d 1206, 1207 (11th Cir.
        1981) (en banc).
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        14                       Opinion of the Court                  20-13973

               We review a district court’s application of the Sentencing
        Guidelines de novo. United States v. Johnson, 980 F.3d 1364, 1374
        (11th Cir. 2020).
                                 III.      DISCUSSION
                On remand, Duldulao and Santos renew the challenges we
        addressed in our now-vacated opinion affirming their convictions
        and Santos’s sentence. For the first time, on remand, they add that
        the jury was improperly instructed. According to Duldulao and
        Santos, the instructions the jury received regarding the § 846 con-
        spiracy counts and the § 841 substantive counts failed to convey the
        mens rea Ruan II requires. We conclude that only the challenge to
        the § 841 jury instructions has merit. We therefore affirm
        Duldulao’s conviction under § 846, affirm Santos’s conviction un-
        der § 846, vacate Santos’s convictions under § 841, and vacate San-
        tos’s sentence.
                            A.          § 846 Jury Instructions
               The jury convicted both Duldulao and Santos of conspiracy
        to distribute and dispense controlled substances without authori-
        zation, violating 21 U.S.C. § 846. On remand, they challenge the
        propriety of the district court’s jury instruction on conspiracy un-
        der Ruan II. The United States responds that we cannot reach the
        jury instruction because the defendants invited any error. See
        United States v. Maradiaga, 987 F.3d 1315, 1322–23 (11th Cir. 2021).
              Invited or not, our decision on remand in United States v.
        Ruan, 56 F.4th 1291 (11th Cir. 2023) (“Ruan III”), cert. denied, 2023
        WL 7287134 (U.S. Nov. 6, 2023) (No. 22-1175), precludes us from
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        20-13973               Opinion of the Court                         15

        finding error in the district court’s conspiracy instruction. In Ruan
        III, we reviewed de novo (and upheld) a district court’s conspiracy
        instruction under 21 U.S.C. § 846. Id. at 1296, 1299. Although we
        found the jury instruction as to the substantive § 841 charge incon-
        sistent with Ruan II, we nevertheless concluded that the conspiracy
        instruction “conveyed the adequate mens rea.” Id. at 1299. We
        reached that conclusion because, despite any defect in the instruc-
        tion as to the substantive counts, “the conspiracy instructions al-
        ready required [the jury] to find that the defendant acted with sub-
        jective knowledge.” Id. Those instructions required the jury to find
        that the defendants “agreed to try and accomplish a shared unlaw-
        ful plan to distribute or dispense” controlled substances and that
        they “knew the unlawful purpose of the plan and willfully joined
        it.” Id. The jury was further instructed that “a person acts with will-
        fulness only when they act voluntarily and purposefully to do
        something the law forbids.” Id. (internal quotation marks omitted)
        (alterations adopted). Based on these instructions, we concluded
        the jury could not have convicted the Ruan defendants if it thought
        they subjectively believed their actions fell within the professional
        practice of medicine. Id.
              What was true of that conspiracy instruction is true of this
        one. The district court instructed the jury that the government was
        required to prove that:
               two or more persons in some way agreed to try to
               accomplish a shared and unlawful plan as charged in
               the second superseding indictment; and that the de-
               fendant knew the unlawful purpose of the plan and
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        16                     Opinion of the Court                 20-13973

              willfully joined in it; and that the object of the unlaw-
              ful plan was to distribute and dispense, and cause the
              distribution and dispensing of [controlled substances]
              for no legitimate medical purpose and outside the
              usual course of professional practice.

        Doc. 392 at 179. The court further instructed that “willfully means
        that the act was committed voluntarily and purposely, with the in-
        tent to do something the law forbids.” Id.at 183. Thus, the district
        court instructed the jury that it could convict Duldulao and Santos
        only if it found that they subjectively knew the object of the con-
        spiracy was to distribute controlled substances without authoriza-
        tion.
                In their supplemental reply briefs—ﬁled after Ruan III—
        Santos and Duldulao do not argue that the conspiracy jury instruc-
        tions here are distinguishable from those given in Ruan III. To the
        contrary, Santos (whose brief Duldulao joined) states that “[t]he in-
        structions in Ruan and this case aren’t diﬀerent in any material re-
        spect.” Santos Supp. Reply Br. at 6. Instead, they contend that Ruan
        III either ﬂunks our prior panel precedent rule or it should be re-
        considered. As a panel of this Court, we have no authority to revisit
        the holding of Ruan III. See Scott v. United States, 890 F.3d 1239,
        1256–57 (11th Cir. 2018). And under our prior panel precedent rule,
        Ruan III controls.
               Our prior panel precedent rule compels us to obey the hold-
        ing of “ﬁrst [panel] in this Circuit to address [an] issue.” Smith v.
        GTE Corp., 236 F.3d 1292, 1302 (11th Cir. 2001). That is so even if a
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        20-13973               Opinion of the Court                         17

        subsequent panel has reached a result contrary to the prior panel.
        Id. The rule governs “unless and until” the ﬁrst panel’s opinion “is
        overruled or undermined to the point of abrogation by the Su-
        preme Court or by this court sitting en banc.” United States v. Archer,
        531 F.3d 1347, 1352 (11th Cir. 2008). Duldulao and Santos point out
        that the Tenth Circuit—in a case consolidated with Ruan II before
        the Supreme Court—recently held that a faulty § 841 instruction
        “infected” each of the defendant’s convictions, including the con-
        spiracy conviction under § 846. United States v. Kahn, 58 F.4th 1308,
        1311, 1321–22 (10th Cir. 2023). But the Tenth Circuit’s decision in
        Kahn does not deny our prior precedent rule its force: “only the
        Supreme Court or this court sitting en banc can judicially overrule
        a prior panel decision.” United States v. Brown, 342 F.3d 1245, 1246
        (11th Cir. 2003) (internal quotation marks omitted). In deciding this
        appeal, we must adhere to Ruan III.
               Duldulao and Santos also try to direct us to United States v.
        High, 117 F.3d 464 (11th Cir. 1997), as the relevant prior panel prec-
        edent. Like this case, High was a criminal appeal involving a drug
        conspiracy. Id. at 465. But in High, the government alleged that the
        defendants conspired to launder drug proceeds (violating 18 U.S.C.
        § 1956), structure transactions to avoid regulatory scrutiny (violat-
        ing 31 U.S.C. § 5324), and defraud the United States (violating 18
        U.S.C. § 981). Id. at 469. Instead of charging the defendants with
        three separate conspiracy counts or seeking a special verdict iden-
        tifying the basis for each conviction, the government sought and
        obtained a general conspiracy verdict against the defendants. Id. at
        470. Because the district court wrongly instructed the jury on the
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        18                       Opinion of the Court                    20-13973

        mens rea requirement for the underlying structuring oﬀense and
        we could not determine which underlying oﬀense was the basis for
        conviction, we concluded that we needed to reverse. Id.
                High’s holding rested on our conclusion that the conspiracy
        instruction did not cure the erroneous instruction as to the conspir-
        acy’s object. Id. The conspiracy instruction, together with the
        structuring instruction, failed to convey the necessary mens rea for
        convicting the defendants of conspiracy to engage in structuring in
        violation of 31 U.S.C. § 5324. See Ratzlaf v. United States, 510 U.S.
        135, 136–37 (1994). In contrast, in Ruan III, we decided that the con-
        spiracy instruction adequately conveyed the required mens rea and
        was not erroneous, so Ruan III did not contradict High’s holding
        about how to proceed when instructional error does exist. Ruan III,
        56 F.4th at 1299 (concluding that “the instructions for the drug con-
        spiracy charges were not erroneous”). Nor would it be fair to say
        that High’s contextual analysis of one speciﬁc jury instruction re-
        quired the Ruan III panel to conclude that a very diﬀerent set of
        instructions also was error. See United States v. Cochran, 683 F.3d
        1314, 1319 (11th Cir. 2012) (explaining that we “analyze the ob-
        jected-to portion of [jury] instructions in light of the entire charge”
        (internal quotation marks omitted)). Ruan III does not conﬂict with
        High. 5

        5 Because we conclude Ruan III is the controlling prior panel precedent, we
        need not consider whether—as the government argues—intervening Su-
        preme Court precedent has abrogated High’s remedial holding.
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        20-13973                  Opinion of the Court                       19

               Ruan III controls and requires us to conclude that the instruc-
        tions the jury received describing the elements of a conspiracy un-
        der § 846 were proper.
                             B.      § 841 Jury Instructions
               Besides one count of § 846 conspiracy, the jury convicted
        Santos of three counts of dispensing and distributing, and causing
        the distribution and dispensing of, controlled substances not for a
        legitimate medical purpose and not in the usual course of profes-
        sional practice, in violation of 21 U.S.C. § 841. On remand, Santos
        challenges the district court’s instructions to the jury on these
        counts as inconsistent with Ruan II. The government argues that
        any instructional error was “invited” and thus cannot support re-
        versal. Because we agree with Santos that the jury instructions re-
        garding § 841 amounted to plain error, we address the govern-
        ment’s invited-error argument.
               Under the doctrine of invited error, on appeal, “a party may
        not challenge as error a ruling or other trial proceeding invited by
        that party.” Ford ex rel. Estate of Ford v. Garcia, 289 F.3d 1283, 1293–
        94 (11th Cir. 2002) (internal quotation marks omitted). Proposing
        the language of a jury instruction is “a textbook case of invited er-
        ror” under our precedent. Maradiaga, 987 F.3d at 1322. As the gov-
        ernment points out, the defense proposed at least some of the jury
        instruction to which it now objects. And, in an unpublished opin-
        ion, we have applied the invited error doctrine to a similar set of
        circumstances in a post-Ruan II case. United States v. Mencia, No. 18-
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        20                      Opinion of the Court                   20-13973

        13967, 2022 WL 17336503, at *13 (11th Cir. Nov. 30, 2022) (un-
        published).
                The doctrine of invited error applies when an error is “at-
        tributable to the action of the defense.” United States v. Jones, 743
        F.3d 826, 828 n.1 (11th Cir. 2014) (internal quotation marks omit-
        ted). It prevents litigants from sandbagging district courts by “in-
        troducing error at trial with the intention of creating grounds for
        reversal on appeal.” United States v. Stone, 139 F.3d 822, 839 (11th
        Cir. 1998). And it enforces the notion, rooted in fairness, that
        “someone who invites a court down the primrose path to error
        should not be heard to complain that the court accepted its invita-
        tion.” Doe v. Princess Cruise Lines, Ltd., 657 F.3d 1204, 1213 (11th Cir.
        2011).
               Considering the doctrine’s purposes, our sister circuits rec-
        ognize an exception where the “error” invited by a party “relied on
        settled law that changed while the case was on appeal.” United
        States v. Titties, 852 F.3d 1257, 1264 n.5 (10th Cir. 2017); see also
        United States v. Andrews, 681 F.3d 509, 517 n.4 (3d Cir. 2012). We join
        them in recognizing this exception and conclude that it applies in
        the harsh circumstances of this case.
                According to the government, Santos should have proposed
        jury instructions that were inconsistent with then-binding and
        longstanding circuit precedent holding that whether a physician
        acts in the usual course of professional practice is judged objec-
        tively. Before Ruan II, we reiterated that holding many times in pub-
        lished opinions dating back at least to 2006. Tobin, 676 F.3d at 1282–
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        20-13973                Opinion of the Court                         21

        83; Merrill, 513 F.3d at 1305–06; Williams, 445 F.3d at 1309–10. We
        maintained unﬂaggingly that “the law requires only that the jury
        ﬁnd the doctor prescribed a drug . . . not ‘in the usual course of
        professional practice’”—not that the doctor subjectively knew she
        was acting outside the practice of medicine. Abovyan, 988 F.3d at
        1308. We rejected jury instructions that attempted to say other-
        wise. United States v. Joseph, 709 F.3d 1082, 1097 (11th Cir. 2013); see
        also United States v. Ruan, 966 F.3d 1101, 1167 (11th Cir. 2020) (“This
        Court has repeatedly rejected [jury] instructions . . . [that] failed to
        include the objective standard by which to judge the physician’s
        conduct.”). And we turned away attempts to have us revisit the
        question sitting en banc. See Order Den. Pet. for Panel Reh’g or
        Reh’g En Banc, United States v. Ruan, No. 17-12653 (11th Cir. Nov.
        4, 2020). What is more, there was no indication during this trial that
        the Supreme Court might unwind that precedential juggernaut.
        The jury here reached its verdicts more than two years before the
        Supreme Court granted certiorari in Ruan II. Requiring litigants to
        propose jury instructions inconsistent with established circuit prec-
        edent on the oﬀ-chance of Supreme Court intervention would not
        promote the invited-error doctrine’s purpose. By acknowledging at
        trial that under our law “[w]hether the Defendant acted outside the
        usual course of professional practice is to be judged objectively,”
        Doc. 320 at 37, Santos demonstrated neither “a lack of diligence,”
        nor a desire to mislead the district court, “but merely a want of
        clairvoyance.” Joseph v. United States, 135 S. Ct. 705, 706 (2014) (Ka-
        gan, J., respecting the denial of certiorari).
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        22                     Opinion of the Court                  20-13973

               The government’s position diverges as well from broader
        principles governing our review. In this criminal appeal, applying
        the doctrine would undermine the principle that “[d]ecisions of the
        Supreme Court construing substantive federal criminal statutes
        must be given retroactive eﬀect.” United States v. Peter, 310 F.3d 709,
        711 (11th Cir. 2002); see also Griﬃth v. Kentucky, 479 U.S. 314, 328
        (1987) (“[A] new rule for the conduct of criminal prosecutions is to
        be applied retroactively to all cases, state or federal, pending on di-
        rect review or not yet ﬁnal . . . .”). And it would be inconsistent
        with our approach in other contexts. For instance (subject to plain
        error review), we allow an appellant to raise new arguments based
        on intervening precedent. United States v. Durham, 795 F.3d 1329,
        1330–31 (11th Cir. 2015) (en banc). Similarly, in the 28 U.S.C. § 2255
        context we excuse procedural default—which, like invited error,
        operates as a complete bar to review—when there has been an in-
        tervening change in the law, despite the strong ﬁnality interests at
        play in the habeas context. Seabrooks v. United States, 32 F.4th 1375,
        1384 (11th Cir. 2022). In these ways, we often recognize that the
        failure to anticipate an abrupt change in precedent is blameless and
        should not preclude appellate review.
                The government points to our decision in Maiz v. Virani, 253
        F.3d 641 (11th Cir. 2001), to argue that we may not craft an excep-
        tion to the application of invited error. Maiz was a civil case involv-
        ing RICO claims against a group of companies who engaged in an
        allegedly fraudulent real estate investment scheme. Id. at 650. In
        1990, we had adopted one approach to the statute of limitations for
        a civil RICO claim; other circuits had adopted another. Compare
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        20-13973                Opinion of the Court                         23

        Bivens Garden Oﬀ. Bldg., Inc. v. Barnett Bank of Fla., Inc., 906 F.2d
        1546, 1554 (11th Cir. 1990) (adopting one accrual rule), with Rotella
        v. Wood, 147 F.3d 438, 440 (5th Cir. 1998) (adopting another accrual
        rule). Ten years later, the Supreme court settled the debate, over-
        turning our civil RICO accrual rule. Rotella v. Wood, 528 U.S. 549,
        553–54 (2000).
                Against that backdrop, the defendants in Maiz raised the
        four-year limitations period for civil RICO claims as an aﬃrmative
        defense. 253 F.3d at 676; see also Agency Holding Corp. v. Malley-Duﬀ
        & Assocs., Inc., 483 U.S. 143, 156 (1987) (establishing limitations pe-
        riod). To deﬁne that aﬃrmative defense, the defendants crafted and
        proposed a jury instruction consistent with our accrual rule in
        Bivens Garden, which the district court adopted. Maiz, 253 F.3d at
        676. The jury then rejected the defense and found the defendants
        liable. Id. While their appeal was pending, the Supreme Court de-
        cided Rotella and clariﬁed the accrual rule for a civil RICO claim. Id.
        at 676–77.
                The defendants argued that invited error does not apply
        when a jury “instruction is rendered incorrect by an intervening
        change in the governing law” and that “Rotella [was] such a change
        in the law.” Id. at 677. We did not reject such a rule outright; rather,
        we determined that Maiz was not “an appropriate [case] to carve
        out an exception to the invited error rule.” Id. We noted that the
        defendants in Maiz had not shown “that the district court’s instruc-
        tion was probably responsible for an incorrect verdict.” Id. (internal
        quotation marks omitted). And the defendants had not shown that
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        24                     Opinion of the Court                  20-13973

        theirs was the “exceptional” civil case justifying reversal on plain
        error review. Id. We also observed that the defendants in Maiz “had
        reasonable grounds for declining to propose—and, if necessary,
        stating an objection to—the [accrual] instruction that instead they
        asked the court to give.” Id.
               Unlike Maiz, we view this as the appropriate case to recog-
        nize an exception to the ordinary rule. The change in law asserted
        in Maiz concerned a limitations defense to a civil action; in contrast,
        this case involves the substantive elements of a criminal oﬀense.
        And, as we conclude below, on this case’s facts we harbor grave
        doubts that the jury would have reached the same outcome had it
        been properly instructed. Moreover, distinct from Maiz, where the
        defendant was solely responsible for the challenged instruction, the
        government bears some of the blame for this error, too. Our review
        of the record indicates that although the government is correct that
        the defense proposed language to which it now objects, the govern-
        ment proposed the same language. This was unsurprising be-
        cause—as the government noted in its proposed jury instruc-
        tions—it was the very same language we had approved in at least
        four prior cases. The defense did not craft this error itself.
               To be clear, we are not authorizing a free-roving change-in-
        law exception to the rule of invited error. We hold only that on the
        facts of this case—a criminal appeal involving an instructional error
        in deﬁning a substantive oﬀense ﬂowing directly from our long-
        standing and clear precedent and attributable to both parties—we
        will not invoke the doctrine.
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        20-13973                 Opinion of the Court                             25

               Because we reject the government’s invitation to apply the
        doctrine of invited error, we instead review the district court’s jury
        instructions for plain error.6 See Greer v. United States, 141 S. Ct.
        2090, 2096 (2021). A defendant bears the “burden of establishing
        entitlement to relief for plain error.” Id. at 2097 (internal quotation
        marks omitted). To do so, a defendant must show four things:
        “First, there must be an error. Second, the error must be plain.
        Third, the error must aﬀect substantial rights, which generally
        means that there must be a reasonable probability that, but for the
        error, the outcome of the proceeding would have been diﬀerent.”
        Id. at 2096 (internal quotation marks and emphasis omitted).
        Fourth—if a defendant makes these ﬁrst three showings—we con-
        sider whether the error “seriously aﬀects the fairness, integrity or
        public reputation of judicial proceedings.” United States v. Olano,
        507 U.S. 725, 736 (1993) (internal quotation marks omitted) (altera-
        tion adopted). Meeting this test is “diﬃcult.” Greer, 141 S. Ct. at
        2097 (internal quotation marks omitted). Nevertheless, after con-
        sidering each required showing in turn, we conclude that we must
        vacate Santos’s § 841 convictions.
               Taking the ﬁrst two showings together, the district court’s
        instruction was error, and the error is plain. Consistent with our
        since-overruled precedent, the district court instructed the jury that

        6 Santos and the government agree that if the invited error doctrine does not
        apply, then plain error does.
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        26                     Opinion of the Court                  20-13973

        to obtain a conviction under 21 U.S.C. § 841, the government
        needed to prove:
               First, that the defendant distributed, dispensed and
               caused to be distributed and dispensed the controlled
               substances as charged; and [second], that at the time
               of the distribution and dispensing, the defendant
               knew that he was distributing and dispensing a con-
               trolled substance not for a legitimate medical purpose
               and not in the usual course of professional practice.

        Doc. 392 at 181–82. Immediately after, the district court told the
        jury that “[w]hether the defendant acted outside the usual course
        of practice is to be judged objectively by reference to standards of
        medical practice.” Id. at 182. The court distinguished this question
        from whether the defendant acted for a legitimate medical pur-
        pose, which was to be judged “subjective[ly].” Id. The court also
        gave a “good faith” instruction. Id. at 177. Speciﬁcally, it instructed
        the jury that it could consider whether the defendant’s “conduct
        [was] in accordance with what the physician believe[d] to be proper
        medical practice” as a defense. Id. at 178. But the district court lim-
        ited this defense to the § 846 conspiracy charge (because it had an
        element of willfulness) and the “legitimate medical purpose”
        prong of the § 841 substantive counts. Id. at 177. It did not apply
        this instruction to the usual course of professional practice prong
        of the § 841 counts: the district court instructed the jury that it
        must not consider “what [Santos] believe[d] to be proper medical
        practice,” id. at 178, under the usual course of professional practice
        prong.
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        20-13973                Opinion of the Court                         27

                Under our decisions in Ruan III and Heaton, this instruction
        was error, and the error is plain. Greer, 141 S. Ct. at 2096. “An error
        is plain if it is obvious and clear under current law.” United States v.
        Johnson, 981 F.3d 1171, 1179 (11th Cir. 2020) (internal quotation
        marks omitted). Current law for this purpose includes intervening
        decisions: “an intervening decision by this Court or the Supreme
        Court squarely on point may make an error plain.” United States v.
        Jones, 743 F.3d 826, 829–30 (11th Cir. 2014) (internal quotation
        marks omitted); see also Dell v. United States, 710 F.3d 1267, 1273
        (11th Cir. 2013).
               In Ruan III, we concluded that a district court’s jury instruc-
        tion was error because it “inadequately conveyed the required
        mens rea to authorize conviction under § 841(a).” Ruan III, 56 F.4th
        at 1298. Although the jury instruction in Ruan III conveyed that the
        defendants had to act “knowingly and intentionally” when they
        “dispensed the controlled substance,” it did not make clear that the
        same requirement applied to the authorization prong. Id. at 1297.
        That was so even though the jury instruction in Ruan III did not
        state outright that “[w]hether the defendant acted outside the usual
        course of practice is to be judged objectively.” Doc. 392 at 182. It
        merely left open the possibility.
               In Heaton, we confronted a jury instruction that—like the
        one the district court gave here—stated that “whether [the defend-
        ant] dispensed the controlled substances outside the usual course
        of professional practice is to be judged objectively.” 59 F.4th at 1241
        (internal quotation marks omitted). We concluded this instruction
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        28                      Opinion of the Court                   20-13973

        was error under Ruan II because “this instruction allowed the jury
        to convict [the defendant] without considering whether he know-
        ingly or intentionally issued prescriptions outside the usual course
        of professional practice.” Id.
                 In sum, Ruan II holds that a defendant acts outside the “usual
        course of professional practice” under 21 U.S.C. § 841 only when a
        knowing or intentional scienter requirement is satisﬁed. Ruan II.
        142 S. Ct. at 2375. Applying that holding in Ruan III and Heaton, we
        concluded that a district court errs by instructing a jury to “apply
        an objective standard to the outside the usual course of profes-
        sional practice requirement,” Heaton, 59 F.4th at 1240 (internal quo-
        tation marks omitted), or failing to “convey that a subjective analy-
        sis [is] required,” Ruan III, 56 F.4th at 1297.
               It is true that the district court’s instruction required the gov-
        ernment to prove that Santos “knew that he was distributing and
        dispensing a controlled substance not for a legitimate medical pur-
        pose and not in the usual course of professional practice.” Doc. 392
        at 181–82. But many other aspects of the instruction undercut the
        idea that this knowledge requirement applied to the “usual course
        of professional practice” prong. Although the district court repeat-
        edly clariﬁed that the jury had to consider Santos’s subjective intent
        to determine whether he acted without legitimate medical pur-
        pose, it juxtaposed this requirement with an instruction that
        “[w]hether the defendant acted outside the usual course of practice
        is to be judged objectively by reference to standards of medical
        practice.” Id. at 182. And it instructed the jury not to consider
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        20-13973                Opinion of the Court                          29

        whether Santos acted in good faith when determining whether he
        acted outside the usual course of practice. Taken as a whole, the
        jury instructions failed to adequately convey that a defendant acts
        outside the “usual course of professional practice” under 21 U.S.C.
        § 841 only when a knowing or intentional scienter requirement is
        satisﬁed. See Christopher v. Cutter Lab’ys, 53 F.3d 1184, 1191 (11th Cir.
        1995) (We “examine[] jury instructions as a whole to determine
        whether they fairly and adequately addressed the issue and cor-
        rectly stated the law.”) This failure is clearly and obviously (and thus
        plainly) error under Ruan II, Ruan III, and Heaton. Johnson, 981 F.3d
        at 1179.
                 Next, we consider whether the error aﬀected Santos’s sub-
        stantial rights—that is, whether there is “a reasonable probability
        that, but for the error, the outcome of the proceeding would have
        been diﬀerent.” Greer, 141 S. Ct. at 2096 (internal quotation marks
        omitted). “A reasonable probability is a probability suﬃcient to un-
        dermine conﬁdence in the outcome.” Strickland v. Washington, 466
        U.S. 668, 694 (1984); see also United States v. Dominguez Benitez, 542
        U.S. 74, 81–82 (2004) (applying Strickland’s reasonable probability
        prejudice standard to plain error review). A reasonable probability
        is less than a preponderance. See Holland v. Jackson, 542 U.S. 649, 654
        (2004). But if a “defendant’s guilt would have been clear under the
        correct instruction, he loses under the substantial rights third prong
        of plain error review.” United States v. Iriele, 977 F.3d 1155, 1179
        (11th Cir. 2020). Because we lack conﬁdence that the outcome of
        Santos’s trial would have been the same on the § 841 counts but for
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        30                     Opinion of the Court                 20-13973

        the erroneous jury instruction, we conclude the error aﬀected San-
        tos’s substantial rights.
                Consistent with our precedent, the district court instructed
        the jury that it could consider whether a prescription was author-
        ized based on disjunctive reading of the term not for a legitimate
        medical purpose and not in the usual course of professional prac-
        tice. See Heaton, 59 F.4th at 1239–40; Doc. 392 at 183 (“[I]f only one
        of the alternatives is proved beyond a reasonable doubt, that is suf-
        ﬁcient for conviction . . . .”). In other words, the jury was allowed
        to convict Santos either because he wrote a prescription that was
        not for a legitimate medical purpose or because it was not in the
        usual course of professional practice; the jury did not need to ﬁnd
        both. As the government put it to the jury, “if you ﬁnd that there
        might have been a legitimate medical purpose to a prescription but
        you think Dr. Duldulao or Dr. Santos still issued it outside the scope
        of professional practice, they are guilty.” Doc. 393 at 47. The jury’s
        verdict form did not specify which theory it relied on when it con-
        victed Santos. So the jury could have rested its convictions solely
        on an impermissible theory of liability: that Santos’s actions did not
        comply with objective professional norms of medicine. Under the
        circumstances, we think this possibility is great enough to “under-
        mine conﬁdence in the outcome” of the trial. Strickland, 466 U.S. at
        694.
               Two principal reasons support our conclusion. First, the
        government’s trial presentation emphasized the theory that San-
        tos’s actions deviated from objective professional norms of
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        20-13973                Opinion of the Court                         31

        medicine, giving the jury reason to convict Santos on an impermis-
        sible theory of liability. Second, the jury’s split verdict on the § 841
        counts against Santos illustrates that the jury viewed this case as a
        close call—not a slam dunk. C.f. Iriele, 977 F.3d at 1179 (a defend-
        ant’s substantial rights are unaﬀected by instructional error if “the
        defendant’s guilt would have been clear under the correct instruc-
        tion”).
               At trial, the government told the jury that “prescribing
        within the scope of professional practice means within generally
        accepted standards of medical practice, such as under Florida laws
        or Federal Rules and regulations.” Doc. 393 at 30. It put on an ex-
        pert witness (Dr. Chaitoﬀ) to elaborate on those standards. And it
        told the jury Santos transgressed them.
                 Over four days of testimony, Dr. Chaitoﬀ outlined standards
        that, in his opinion, constituted the relevant standards of medical
        practice. For instance, Dr. Chaitoﬀ told the jury that a doctor who,
        “knowing that a patient is intentionally diverting,” nevertheless “is-
        sue[s] them a prescription for a controlled substance” acts outside
        “generally acceptable medical practice.” Doc. 388 at 21. The same
        is true, he opined, for a doctor who “exchange[s] . . . controlled sub-
        stance for monetary remuneration” or violates rules contained in
        “the DEA manual 2006” or “Rule 64B8-9.013”—a provision of the
        Florida Administrative Code requiring physicians who prescribe
        controlled substances to manage pain to adopt practices including
        adequate evaluation, periodic review, and thorough recordkeeping.
        Id.; see also Fla. Admin. Code Ann. r. 64B8-9.013.
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        32                     Opinion of the Court                  20-13973

                 Dr. Chaitoﬀ also told the jury that Santos violated these
        standards. He testiﬁed that “100 percent” of Santos’s patient ﬁles
        “fell below the standard of care” and that in “most of them, pre-
        scriptions for controlled substances . . . were not issued in the
        course of . . . professional practice.” Doc. 388 at 20. For example,
        Dr. Chaitoﬀ testiﬁed that when Santos ﬁrst prescribed Chin—the
        undercover agent—controlled substances, he relied on “an inade-
        quate history,” and a “physical examination” that was “incom-
        plete.” Id. at 167. He testiﬁed that during Chin and Vasilas’s ﬁrst
        joint visit to Santos (the basis for Santos’s conviction on count seven
        of the second superseding indictment), Santos prescribed con-
        trolled substances “outside the scope of professional practice” be-
        cause Santos failed to take a patient “history, [conduct a] complete
        physical examination,” consider “medical necessity” or “other
        medications,” or address that the medication failed to improve Va-
        silas’s reported pain. Id. at 194. Dr. Chaitoﬀ oﬀered similar opinions
        on later visits Chin and Vasilas made to Santos. See, e.g., id. at 213
        (“Based upon the lack of history, lack of physical examination, lack
        of discussion of any alternative medical care . . . those medications
        were prescribed . . . outside the practice of medicine.”) (count
        nine).
               Dr. Chaitoﬀ’s testimony was the heart of the government’s
        trial presentation. As the government argued during trial, Dr.
        Chaitoﬀ’s testimony was “critical evidence for purposes of [its]
        case-in-chief,” and without Dr. Chaitoﬀ, the government would
        struggle “[i]n terms of being able to present [its] case.” Id. at 86.
        Indeed, after the district court struck the bulk of Dr. Chaitoﬀ’s
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        20-13973               Opinion of the Court                         33

        testimony about Duldulao (but not Santos) for violating an in
        limine order, it entered a judgment of acquittal on most of the sub-
        stantive § 841 counts against Duldulao. Without Dr. Chaitoﬀ, that
        aspect of the government’s case failed. The jury also took copies of
        some of the standards Chaitoﬀ testiﬁed Santos violated into its de-
        liberations. And in its closing arguments the government put these
        standards in front of the jury and recounted how Santos violated
        them, arguing “[t]hat is not the practice of medicine. That’s crimi-
        nal.” Doc. 393 at 115. In sum, the government presented its case in
        a manner that encouraged the jury to convict Santos based on what
        the Supreme Court has since clariﬁed is an improper view of the
        scienter requirement under § 841.
                Notwithstanding its trial presentation, the government ar-
        gues that Santos loses on the substantial-rights prong of plain error
        review because his guilt is clear, even under the correct jury instruc-
        tion. See Iriele, 977 F.3d at 1179. The government relies on circum-
        stantial evidence regarding the clinic’s overall operations to argue
        Santos acted knowingly. That misses the point. For the § 841
        counts, the government obtained convictions based on Santos’s
        speciﬁc interactions with patients on speciﬁed occasions—not the
        broader conspiracy or the misdeeds of the clinic. Ruan II means
        that the government needed to show that Santos knew he was act-
        ing in an unauthorized manner on each of these occasions, not that
        he knew generally that the clinic was engaging in unlawful activity.
               Recall that Santos’s three substantive convictions (counts
        seven, eight, and nine of the second superseding indictment) were
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        34                     Opinion of the Court                20-13973

        based on a series of speciﬁc visits with a DEA agent, Chin, and a
        conﬁdential informant posing as her boyfriend, Vasilas. Yet the jury
        acquitted Santos of two counts of substantive violations of § 841
        (counts ﬁve and six) based on Chin’s earlier visits to Santos. The
        jury convicted Santos on count seven based on prescriptions of ox-
        ycodone—but not the also-charged alprazolam (Xanax) prescrip-
        tion. And the jury convicted Santos on counts eight and nine, based
        on two later visits.
               During each of the ﬁve visits underlying the indictment,
        Santos ignored red ﬂags suggesting that Chin (and later Vasilas,
        too) was engaged in drug-seeking behavior and potentially abusing
        controlled substances. During the visit that the government
        charged as count six, Chin told Santos she had been taking more
        than the prescribed amount of oxycodone, traveling hundreds of
        miles to HPC, and receiving opioids from multiple sources. Santos
        responded by writing her a prescription for even more opioids.
        During the visit that the government charged as count seven, San-
        tos wrote another prescription for Chin even after Vasilas said Chin
        had been taking pills from him.
               But the jury did not respond to this evidence or the evidence
        of the larger conspiracy by ﬁnding that in each instance Santos vi-
        olated the law: the jury acquitted on two counts, split on the third,
        and convicted on two further counts. This split verdict demon-
        strates that the jury did not infer from Santos’ general knowledge
        of the conspiracy that he knew the prescriptions he wrote were al-
        ways for no legitimate medical purpose or always outside the usual
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        20-13973               Opinion of the Court                         35

        course of professional practice. If the jury had drawn such an in-
        ference, it would have convicted on counts ﬁve and six. This seri-
        ously undercuts that government’s reliance on the general evi-
        dence of the conspiracy—rather than evidence speciﬁc to the dis-
        crete prescriptions that underlie the § 841 counts—to argue that
        Santos could not have suﬀered prejudice. The jury’s split verdict
        also suggests that the jury viewed each of the substantive counts as
        a close call. As we have described, Santos repeatedly ignored red
        ﬂags that Chin and Vasilas were abusing their prescriptions. But the
        jury found that, across ﬁve charged visits with Chin and Vasilas,
        Santos only sometimes crossed the criminal line drawn by § 841;
        other times, he did not. The district court’s instructions to the jury
        allowed it to draw that line short. Under these circumstances, the
        district court’s instructional error “undermine[s] [our] conﬁdence
        in the outcome” of the trial. Strickland, 466 U.S. at 694.
                The fourth and ﬁnal prong of plain error review requires us
        to consider whether the error “seriously aﬀects the fairness, integ-
        rity or public reputation of judicial proceedings.” Olano, 507 U.S. at
        736 (internal quotation marks omitted) (alteration adopted). This
        error does.
               In the context of sentencing errors, the Supreme Court has
        explained that “[t]he risk of unnecessary deprivation of liberty par-
        ticularly undermines the fairness, integrity, or public reputation of
        judicial proceedings” when the court is responsible for the error.
        Rosales-Mireles v. United States, 138 S. Ct. 1897, 1908 (2018). The re-
        sponsibility is ours: over the last decades, we repeatedly, in
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        36                      Opinion of the Court                  20-13973

        published opinions, upheld jury instructions that misstated the
        mens rea requirement under 21 U.S.C § 841. See, e.g., Tobin, 676 F.3d
        at 1282–83; Merrill, 513 F.3d at 1305; Williams, 445 F.3d at 1309–10.
        A jury then convicted Santos based in part on that misstatement.
        Santos received a prison sentence on these counts, and “the possi-
        bility of additional jail time . . . warrants serious consideration in a
        determination whether to exercise discretion under Rule 52(b).”
        Rosales-Mireles, 138 S. Ct. at 1907.
               Ignoring this error would also undermine the policy inter-
        ests the Supreme Court articulated in Ruan II. The Court empha-
        sized that scienter requirements are fundamental to our criminal
        law as the element that generally separates merely negligent con-
        duct from conduct worthy of criminal punishment. Ruan II, 142 S.
        Ct. at 2376–77 (“[C]onsciousness of wrongdoing is a principle as
        universal and persistent in mature systems of criminal law as belief
        in freedom of the human will and a consequent ability and duty of
        the normal individual to choose between good and evil” (internal
        quotation marks omitted) (alteration adopted)).
              We will not run the risk that the jury transgressed that line.
        We vacate Santos convictions under § 841—counts seven, eight,
        and nine of the second superseding indictment.
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        20-13973                  Opinion of the Court                              37

                             C.      Sufficiency of the Evidence
               On remand, the parties again challenge the suﬃciency of the
        evidence for the conspiracy counts under 21 U.S.C. § 846. 7 We
        again ﬁnd the evidence suﬃcient.
               A preserved challenge to the suﬃciency of the evidence re-
        quires us to examine “whether the evidence, when viewed in the
        light most favorable to the government, and accepting reasonable
        inferences and credibility choices by the fact-ﬁnder, would enable
        the trier of fact to ﬁnd the defendant guilty beyond a reasonable
        doubt.” United States v. Monroe, 866 F.2d 1357, 1365 (11th Cir. 1989).
        We will aﬃrm a conviction unless there is “no reasonable construc-
        tion of the evidence” from which the jury could have found the
        defendant guilty beyond a reasonable doubt. United States v. Garcia,
        405 F.3d 1260, 1269 (11th Cir. 2005).
               The government does not need direct evidence to prove con-
        spiracy; circumstantial evidence can prove each element. The ﬁrst
        element, the existence of an agreement, “may be proved by infer-
        ences from the conduct of the alleged participants or from circum-
        stantial evidence of a scheme.” Azmat, 805 F.3d at 1035 (internal
        quotation marks omitted). The second element, knowledge of an
        agreement, is satisﬁed if “the circumstances surrounding a person’s
        presence at the scene of conspiratorial activity are so obvious that

        7 Santos does not challenge the sufficiency of the evidence for his substantive
        convictions under § 841. We therefore do not address the issue.
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        38                      Opinion of the Court                  20-13973

        knowledge of its character can fairly be attributed to him.” Id. (in-
        ternal quotation marks omitted). As for the third element, that the
        defendant voluntarily joined in the agreement, circumstantial evi-
        dence can show a defendant participated in a conspiracy “by show-
        ing that he committed acts that furthered the purpose of the con-
        spiracy.” United States v. Iriele, 977 F.3d 1155, 1172 (11th Cir. 2020).
        Our cases sometimes merge the ﬁrst two elements and abbreviate
        the elements of conspiracy as “knowledge” and “participation.”
        See, e.g., id. at 1169–73.
               Circumstantial evidence of conspiracy to distribute and dis-
        pense controlled substances not for a legitimate medical purpose
        and not in the usual course of professional practice includes “red
        ﬂags” that would have put a reasonable doctor on notice of the il-
        legitimacy of the operation. See, e.g., Azmat, 805 F.3d at 1036 (“All
        of the witnesses with medical backgrounds also testiﬁed that there
        was an abundance of red ﬂags that should have tipped oﬀ any doc-
        tor that his patients were seeking pills.”). Where, as here, the de-
        fendant is a doctor who allegedly participated in a pill mill conspir-
        acy, we have looked to evidence of the doctor’s interaction with
        patients to conclude “that a defendant distributed a prescription
        without a legitimate medical purpose and outside the usual course
        of professional practice.” Joseph, 709 F.3d at 1104. These aspects in-
        clude inordinately large quantities of controlled substances pre-
        scribed, brief or nonexistent physical examinations, failure to re-
        view patient history before prescribing medications, issuance of
        prescriptions to a patient known to be delivering the drugs to oth-
        ers, and a lack of a logical relationship between the drugs
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        20-13973               Opinion of the Court                         39

        prescribed and treatment of the allegedly existing condition. See id.;
        Azmat, 805 F.3d at 1036.
               Viewing the evidence in the light most favorable to the gov-
        ernment, see Monroe, 866 F.2d at 1365, there were suﬃcient red ﬂags
        in evidence to establish the defendants’ knowledge of an unlawful
        scheme. Combined with the evidence of the defendants’ own con-
        duct, ample evidence showed that Duldulao and Santos knowingly
        joined an agreement to unlawfully dispense controlled substances.
                At the outset, we brieﬂy address the relationship between
        Ruan II and our analysis. As we explained in Ruan III, “a conviction
        under § 846 requires the jury to ﬁnd that the defendant[] knew of
        the illegal nature of the scheme.” Ruan III, 56 F.4th at 1299. In other
        words, independent of the scienter requirement applicable to the
        substantive oﬀense under § 841, our treatment of the elements of
        a conspiracy under § 846 has always required the jury to ﬁnd that
        the defendant knew the object of the conspiracy was “dispensing a
        controlled substance . . . in an unauthorized manner.” Id. That is
        why we previously considered whether the evidence was suﬃcient
        for a jury to conclude that both Duldulao and Santos knew of the
        unlawful nature of the conspiracy they agreed to join: if the de-
        fendants lacked subjective knowledge that the prescriptions were
        unauthorized, they could not appreciate the unlawful nature of the
        conspiracy. Thus, we restate much of our prior analysis, and we are
        conﬁdent that analysis remains correct following Ruan II.
                      1.     Duldulao’s Suﬃciency Challenge
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        40                     Opinion of the Court                 20-13973

               Duldulao argues that there was insuﬃcient evidence to sup-
        port the elements of the conspiracy charge and, speciﬁcally, that
        the red-ﬂag evidence was weak. We agree with the district court
        that there was suﬃcient evidence for the jury to ﬁnd that he know-
        ingly joined an agreement to unlawfully dispense controlled sub-
        stances. The district court relied on the following types of evi-
        dence: HPC owner Ernest Gonzalez’s testimony that Duldulao
        agreed to write narcotics prescriptions; staﬀ and patient testimony
        about Duldulao’s adherence to the plan to write controlled sub-
        stance prescriptions to most of the clinic’s clientele; staﬀ testimony
        regarding HPC’s operations while Duldulao served as Medical Di-
        rector; patient testimony that conﬁrmed the clinic’s standard oper-
        ating scheme under Duldulao; and Duldulao’s statements to his
        then-girlfriend Kelly Schleisner about the clinic, including that it
        was a “pain mill.” Doc. 376 at 6–9. This evidence was suﬃcient to
        establish that Duldulao knowingly and voluntarily joined an agree-
        ment to unlawfully distribute controlled substances.
               From this evidence, the jury reasonably could have found
        that the government proved all three elements of the conspiracy
        charge. As this Court has in other cases, we treat the ﬁrst and sec-
        ond elements, agreement to commit a crime and knowledge of the
        agreement, as a single knowledge element here. The jury reasona-
        bly could have inferred that Duldulao knew the criminal object of
        the conspiracy based on Gonzalez’s testimony about his interview
        with Duldulao for the position of Medical Director, HPC staﬀ’s tes-
        timony about Duldulao’s conduct at the clinic, staﬀ and patient tes-
        timony about the clinic’s patients, and Duldulao’s statements to
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        20-13973                Opinion of the Court                         41

        Schleisner. For the third element, voluntary participation, the jury
        reasonably could have found from the testimony concerning his
        conduct and interactions with patients that Duldulao willingly
        agreed to and did participate in the conspiracy.
                First, we turn to the knowledge element. Gonzalez’s testi-
        mony was evidence that Duldulao knew about the suspicious na-
        ture of HPC from the beginning and nevertheless agreed to get
        involved. During Duldulao’s job interview, Gonzalez showed him
        a ﬁle that listed the types of controlled substances HPC had previ-
        ously prescribed for patients. Gonzalez told Duldulao that patient
        visits were timed and that it was “expected that he would probably
        take about ten minutes” for each patient. Doc. 382 at 41. To “expe-
        dite things,” the staﬀ would write out prescriptions before the pa-
        tient’s visit that Duldulao could sign afterward. Id. at 41–42. This is
        circumstantial evidence of a scheme to get controlled substances
        into patients’ hands as quickly as possible without regard to medi-
        cal need. From this evidence, a jury could ﬁnd that Duldulao
        agreed to join the conspiracy when he agreed to prescribe opiates
        under those conditions.
               Besides what he knew before accepting his position as Med-
        ical Director of HPC, in treating his patients Duldulao would have
        seen that they exhibited signs of drug addiction, which are red ﬂags
        for doctors. See Iriele, 977 F.3d at 1170; Azmat, 805 F.3d at 1036. Wit-
        nesses described patients as looking like drug abusers—for exam-
        ple, they were “a little too sleepy,” slurred their speech, had blood-
        shot eyes or dilated pupils, had visible track marks, smelled of
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        42                    Opinion of the Court                20-13973

        marijuana, and “nodd[ed] out” in the waiting room. Doc. 382 at 92,
        96. One employee testiﬁed that some patients looked “like they
        were sleepy and like falling when they would walk.” Doc. 382 at
        155. Another described the waiting room as “[s]ometimes chaos”
        with “people nodding out.” Doc. 384 at 100. One witness testiﬁed
        that he was addicted to drugs while he was a patient at HPC and
        looked like “death warmed over.” Id. at 257. Nevertheless, he and
        others like him left Duldulao’s oﬃce with prescriptions for opiates
        and other controlled substances.
               Beyond the patients’ appearances, Duldulao heard from
        HPC staﬀ that some patients had tested positive for illegal drugs.
        Staﬀ also told him that some patients traveled long distances to
        reach the clinic, bypassing other pain management doctors and
        spending hours in a car despite their supposed chronic pain. Again,
        our precedent in Azmat warns that these red ﬂags suggest the pa-
        tients were seeking drugs without a legitimate medical purpose.
        805 F.3d at 1036. Yet Duldulao prescribed them the drugs. A jury
        could reasonably infer that he knew the patients were likely drug
        abusers and knew that he was participating in a conspiracy to un-
        lawfully prescribe controlled substances.
               Other circumstances surrounding Duldulao’s presence at
        HPC allowed a reasonable jury to attribute knowledge of the con-
        spiracy’s unlawful character to him. Duldulao knew that the clinic’s
        parking lot was covered with trash, including drug paraphernalia,
        and that the clinic had little medical supplies or equipment. He
        knew that the staﬀ had no training for or experience with working
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        20-13973                Opinion of the Court                         43

        in a medical oﬃce, yet they prewrote prescriptions for him to sign.
        He knew that HPC did not accept insurance: patients could only
        pay by cash or credit card. And he even told his girlfriend that he
        worked at a “pain mill.” Doc. 386 at 143. The jury therefore could
        infer that he had “knowledge of the conspiracy due to his presence
        at” the clinic. See Azmat, 805 F.3d at 1036.
               Second, the element of active participation in the conspiracy
        found support in the evidence of Duldulao’s conduct and interac-
        tions with the patients. Some HPC patients testiﬁed that Duldulao
        did not review their medical history forms and that his physical ex-
        ams were as brief as two minutes—if they happened at all. See id.
        Duldulao sometimes prescribed combinations of opioids, Xanax,
        and Soma, drugs “described in the . . . medical literature as the un-
        holy holy trinity for substance abuse.” Iriele, 977 F.3d at 1170 (inter-
        nal quotation marks omitted). When he went on vacation,
        Duldulao signed prewritten and postdated prescriptions and left
        them with HPC staﬀ so that patients could come in to pick them
        up without a physician present or any medical exam. See Joseph, 709
        F.3d at 1090–91 (“[E]very ‘legitimate doctor’ . . . knows that he may
        not pre-sign prescriptions.”). A jury could reasonably infer from
        this conduct that Duldulao actively participated in the conspiracy.
                Duldulao argues that this evidence was insuﬃcient to sup-
        port his conspiracy conviction. He points out that Gonzalez did not
        testify to telling Duldulao that HPC was a pill mill, that the job was
        contingent on Duldulao’s agreement to exclusively write prescrip-
        tions for controlled substances, or that the patients would not have
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        44                     Opinion of the Court                20-13973

        a medical need for these drugs. And, despite his own guilty plea,
        Gonzalez testiﬁed that he “[n]ever” conspired “with Dr. Duldulao
        to have him write scripts for no legitimate medical purpose.” Doc.
        383 at 214. But the jury was free to believe parts of Gonzalez’s tes-
        timony and disregard others. See United States v. Takhalov, 827 F.3d
        1307, 1321 n.10 (11th Cir. 2016). Thus, the jury reasonably could
        have found that Duldulao did, in fact, agree to and participate in
        the conspiracy to unlawfully distribute controlled substances.
               Duldulao is correct that the jury heard countervailing evi-
        dence. For instance, videos of undercover oﬃcers’ appointments
        with Duldulao showed him asking about their medical history and
        performing a physical exam. In these videos, he asked about their
        current medications and advised them not to mix the opiates with
        alcohol. But Duldulao’s then-girlfriend Schleisner testiﬁed that he
        told her that he was “pretty sure” some patients were undercover
        oﬃcers. Doc. 386 at 132. Construing the evidence in the govern-
        ment’s favor, as we must, we conclude that a reasonable jury could
        have found that these recorded exams were anomalies based on
        Duldulao’s suspicions that he was dealing with undercover law en-
        forcement and that most of the time he adhered to the agreement
        to write prescriptions for controlled substances for no legitimate
        medical purpose and outside the usual course of professional prac-
        tice.
              Duldulao also argues that his conspiracy conviction cannot
        stand because he was acquitted of the underlying substantive
        charges. Not so. Juries sometimes render inconsistent verdicts;
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        20-13973                Opinion of the Court                         45

        inconsistency alone is not a suﬃcient reason for setting the verdict
        aside. See United States v. Powell, 469 U.S. 57, 64–65 (1984). We have
        upheld a defendant’s conviction where he was found guilty of con-
        spiracy only and not the underlying substantive oﬀenses. United
        States v. Brito, 721 F.2d 743, 749–50 (11th Cir. 1983) (“[I]nconsistency
        in a jury’s verdict does not require reversal.”). “[A]s long as the
        guilty verdict is supported by suﬃcient evidence, it must stand,
        even in the face of an inconsistent verdict on another count.” United
        States v. Mitchell, 146 F.3d 1338, 1345 (11th Cir. 1998). Having exam-
        ined the evidence that supports Duldulao’s conspiracy conviction
        and found it to be suﬃcient, we reject this challenge and aﬃrm the
        district court.
               And, in any event, the jury’s verdict was not inconsistent.
        The § 841 charge on which the jury acquitted Duldulao required
        the jury to ﬁnd that Duldulao knowingly distributed a controlled
        substance in an unauthorized manner on a particular occasion. The
        jury was reasonably able to ﬁnd that—based on the evidence at
        trial—the government had not shown beyond a reasonable doubt
        that Duldulao violated § 841 on that occasion but had nevertheless
        knowingly joined a conspiracy to unlawfully distribute controlled
        substances in the abstract and on other occasions.
                       2.      Santos’s Suﬃciency Challenge
               Turning to Santos, we agree with the district court that there
        was suﬃcient evidence to support the jury’s ﬁnding that he know-
        ingly joined an agreement to unlawfully dispense controlled sub-
        stances. The district court relied on the following types of
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        46                        Opinion of the Court                       20-13973

        evidence: Gonzalez’s testimony, including his admission that
        “[t]hat’s what I’m pleading to,” Doc. 383 at 224, when asked on
        cross examination whether he conspired with Santos; staﬀ and pa-
        tient testimony about Santos’s conduct and interactions with pa-
        tients; staﬀ testimony about HPC’s operations while Santos served
        as Medical Director, which included brief, timed patient visits, pre-
        written prescriptions, little to no medical equipment, and no expe-
        rienced staﬀers; patient testimony about their experiences, con-
        ﬁrming that the clinic’s standard operating scheme under Santos
        featured “high patient volume, long-distance patients, brief medi-
        cal visits, little to no medical documentation needed to see the doc-
        tor, cash payments, no insurance, cursory physical examinations,
        papered and/or inaccurate patient records, and patients presenting
        with signs of apparent drug abuse.” Doc. 377 at 8. 8 This evidence
        was suﬃcient to establish that Santos knowingly and voluntarily

        8 The district court also relied on another piece of evidence: Santos’s testi-
        mony admitting that he agreed to write prescriptions for controlled substances
        at HPC, despite the many indicators that it was not a legitimate operation. We
        agree with Santos that the district court erred when it relied on his testimony.
        When a district court reserves ruling on a motion for a judgment of acquittal
        made after the government’s case-in-chief, the district court’s analysis of the
        evidence and our review on appeal is limited to the evidence the government
        presented. United States v. Moore, 504 F.3d 1345, 1346 (11th Cir. 2007). Because
        Santos moved for a judgment of acquittal at the close of the government’s
        evidence, the district court had to follow this snapshot rule and judge the suf-
        ficiency of the evidence based only on the government’s case. But this is harm-
        less error; the remaining evidence was sufficient to deny the motion and con-
        vict Santos. See Barton, 909 F.3d at 1337.
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        20-13973               Opinion of the Court                       47

        joined an agreement to unlawfully distribute controlled sub-
        stances.
               Santos argues that the government failed to prove that he
        knowingly agreed to write illegal prescriptions. As we noted above,
        the agreement element of conspiracy merges with the knowledge
        element, and we treat them as a single knowledge requirement. We
        agree with the district court that there was suﬃcient evidence to
        support the jury’s ﬁnding that Santos knowingly joined an agree-
        ment to unlawfully dispense controlled substances. Gonzalez’s tes-
        timony shows that Santos knew about the suspicious circum-
        stances at HPC. Santos’s tenure at HPC featured the same red ﬂags
        that support Duldulao’s conspiracy conviction.
                Gonzalez’s testimony was evidence that Santos knew he was
        agreeing to work at a clinic with an unlawful criminal purpose.
        When Gonzalez interviewed Santos for the Medical Director posi-
        tion, he made it clear that he wanted a doctor who would write
        controlled substance prescriptions because when “[t]he patients
        would come in, they wanted their controlled substances.” Doc. 383
        at 67. Just like he did with Duldulao, Gonzalez showed Santos a ﬁle
        that contained the types of drugs HPC had prescribed. Santos “was
        okay with all of it except for he didn’t like the methadone and the
        Xanaxes together.” Id. Gonzalez notiﬁed Santos of the “same for-
        mat” for timed visits as he had done with Duldulao, and Santos
        agreed to write prescriptions under those conditions. Id. at 68. San-
        tos’s job interview presented circumstantial evidence that he knew
        about the criminal scheme.
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        48                     Opinion of the Court                20-13973

               Other circumstantial evidence about HPC supported an in-
        ference that Santos knew about and agreed to the conspiracy. This
        evidence included many red ﬂags, which we discussed as to
        Duldulao and which “all stayed the same” under Santos: the oﬃce
        had minimal medical equipment or supplies; the staﬀ was un-
        trained; patients traveled long distances to the clinic; the parking
        lot was littered with trash, including syringes; and HPC only ac-
        cepted cash or credit card—not insurance. Doc. 384 at 117–18. Pa-
        tients showed signs of drug addiction, including slurred speech,
        “nodding out,” and track marks on their arms. Doc. 383 at 113. Re-
        gardless, “they got their medications” from Santos. Id. at 115. A
        jury could reasonably conclude from this evidence that Santos
        knew the nature of the conspiracy and agreed to join it.
               The knowledge element also found support in the evidence
        of Santos’s conduct. Santos, like Duldulao, signed and postdated
        prescriptions when he went on vacations. Patients did not see San-
        tos while he was on vacation, but they came to HPC and picked up
        their postdated prescriptions nonetheless. Santos also left blank,
        pre-signed prescriptions for HPC staﬀ to issue. His conduct sup-
        ported an inference that he knew he had agreed to participate in
        the conspiracy to unlawfully distribute controlled substances.
               Further, at one point, Santos came into the clinic “real nerv-
        ous” and told Gonzalez “that [they] had to start dropping the med-
        ications” to lower doses. Id. at 125. Gonzalez responded that pa-
        tients who had been taking high doses could not simply decrease
        their doses overnight; they could suﬀer a heart attack or a seizure.
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        20-13973                  Opinion of the Court                             49

        Santos began lowering prescription doses anyway, telling Gonzalez
        there were new guidelines from the federal government to comply
        with. In fact, the Drug Enforcement Administration (DEA) had re-
        cently seized patient records and shut down a clinic Santos’s wife
        operated. The jury could have inferred that Santos was worried
        that the DEA would raid HPC and discover that he had been pre-
        scribing abnormally high doses of controlled substances. See Az-
        mat, 805 F.3d at 1028, 1036–37 (upholding the conviction of a doc-
        tor who sometimes decreased patients’ medications for self-serving
        reasons).
               Although we vacate Santos’s § 841 convictions that were
        based on his interactions with purported patients who were actu-
        ally government agents, the circumstances surrounding those visits
        gave additional inferential support to the ﬁnding that Santos knew
        of the unlawful conspiracy.9 An undercover video with conﬁdential

        9 We note the different standards of review for determining whether to vacate
        these convictions based on the erroneous jury instructions and whether the
        evidence was sufficient. We vacate these convictions because we lack confi-
        dence that the jury would have reached the same outcome but for the district
        court’s erroneous jury instructions regarding the scienter requirement of
        § 841. But here, assessing the sufficiency of the evidence underlying Santos’s
        § 846 conviction, we view all the evidence in the light most favorable to the
        government and ask whether there is any “reasonable construction of the ev-
        idence” from which the jury could have found the defendant guilty. Garcia,
        405 F.3d at 1269. The evidence of Santos’s conduct—repeatedly ignoring red
        flags suggesting Chin and Vasilas were abusing controlled substances and writ-
        ing them prescriptions anyway—underlying counts five through nine could
        reasonably be construed to support the inference that Santos knowingly
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        50                        Opinion of the Court                       20-13973

        informant Vasilas showed that when Santos asked how Vasilas’s
        supply of narcotics had held up in the months since his last visit,
        Vasilas said, “I know that I’m not supposed to be saying this but I
        had to ask friends and family, you know, to help me out.” Doc. 372-
        213 at 2:30–2:50. Santos gave him prescriptions anyway—in fact,
        Santos gave him three months’ worth of prescriptions, made him
        pay three times as though he were coming back in for two follow-
        ups, and let his girlfriend pick up his prescriptions, even though Va-
        silas had just admitted to sharing medication. When Chin asked for
        an increase in her dosage, Vasilas told Santos “I know we’re not
        supposed to talk about this, doc, but, you know, . . . she runs out
        because it’s not enough for her, so I have to help her out some-
        times.” Id. at 15:30–15:38. These admissions showed that the pa-
        tients were diverting their medication, a serious red ﬂag that sug-
        gested they were abusing drugs. See Azmat, 805 F.3d at 1032; Joseph,
        709 F.3d at 1090. But Santos did not even react. Instead, he gave his
        patients the increased quantities they wanted.
              Santos contends that “patient testimony and resort to red
        ﬂags cannot mend the evidentiary gap [as to an agreement] be-
        cause it does not show any agreement between Dr. Santos and
        Gonzalez.” Santos Appellant’s Br. at 54. We disagree. Just as with
        Duldulao, the jury was entitled to rely on “inferences from the con-
        duct of the alleged participants or from circumstantial evidence of

        participated in a conspiracy to distribute controlled substances without au-
        thorization. So this conduct remains relevant to a sufficiency analysis notwith-
        standing our conclusion that his § 841 convictions cannot stand after Ruan II.
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        20-13973                Opinion of the Court                       51

        [the] scheme” to ﬁnd an agreement. Azmat, 805 F.3d at 1035 (inter-
        nal quotation marks omitted). Gonzalez’s testimony, the multiple
        red ﬂags, and Santos’s conduct together constitute suﬃcient evi-
        dence that Santos agreed to work at a pill mill and unlawfully dis-
        tribute controlled substances. A reasonable jury could ﬁnd from
        this evidence that Santos agreed to be part of a conspiracy to dis-
        tribute controlled substances with no legitimate medical purpose
        and outside the scope of professional practice. We reject his chal-
        lenge to the suﬃciency of the evidence supporting his conspiracy
        conviction.
                        D.      Dr. Chaitoff’s Expert Testimony
               To meet its burden of proving that a doctor knowingly is-
        sued prescriptions with no legitimate medical purpose or outside
        the usual course of professional practice, the government often
        uses the testimony of a medical expert witness to help satisfy its
        burden. See, e.g., Azmat, 805 F.3d at 1036. But we have also held
        that expert medical testimony is unnecessary for a conviction. Jo-
        seph, 709 F.3d at 1100. In this case, the government called an expert
        witness, Dr. Chaitoff, who testified about the definitions of “legiti-
        mate medical purpose” and “the usual course of professional prac-
        tice.”
                Although Santos failed to raise these objections before the
        district court, he argues to us now that Dr. Chaitoff’s testimony
        violated the rules of evidence in two ways: first, by opining on San-
        tos’s subjective mental state, and second, by reaching a legal con-
        clusion. Reviewing Santos’s arguments under the standard of plain
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        52                     Opinion of the Court                 20-13973

        error, we conclude the district court’s decision to admit the testi-
        mony was not contrary to binding precedent directly resolving
        these legal issues. United States v. Lejarde–Rada, 319 F.3d 1288, 1291
        (11th Cir. 2003). Therefore, we discern no plain error.
                A district court may admit expert testimony that “help[s] the
        trier of fact to understand the evidence or to determine a fact in
        issue.” Fed. R. Evid. 702(a). Generally, “[a]n opinion is not objec-
        tionable just because it embraces an ultimate issue.” Fed. R. Evid.
        704(a). But “[i]n a criminal case, an expert witness must not state
        an opinion about whether the defendant did or did not have a men-
        tal state or condition that constitutes an element of the crime
        charged or of a defense. Those matters are for the trier of fact
        alone.” Fed. R. Evid. 704(b). Rule 704 bars a witness from giving
        legal opinions (e.g., “the defendant broke the law”) and from dis-
        cussing culpable mental states (e.g., “and he did it knowingly”). An
        expert witness can give his opinion about an ultimate issue so long
        as he does not tell the jury what result to reach. See Fed. R. Evid.
        704 advisory committee’s note. There is a difference between opin-
        ing on an ultimate issue and impermissibly directing the jury to a
        result, however. See United States v. Grzybowicz, 747 F.3d 1296, 1310
        (11th Cir. 2014).
              We reject Santos’s first argument—that Dr. Chaitoff’s testi-
        mony violated Federal Rule of Evidence 704(b) and impermissibly
        opined on Santos’s subjective mental state—because it is unsup-
        ported by the record. Although Dr. Chaitoff testified about Santos’s
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        20-13973               Opinion of the Court                         53

        conduct and his professional opinion of that conduct, he did not
        speculate about what was going on in Santos’s mind.
                Santos also fails to show that it was plain error to admit Dr.
        Chaitoff’s testimony even though the testimony reached the ulti-
        mate issue of whether Santos prescribed drugs for no legitimate
        medical purpose and outside the usual course of professional prac-
        tice—the standards of medical care relevant here. See 21 C.F.R. §
        1306.04(a). To summarize Dr. Chaitoff’s testimony, he first gave
        background testimony about these standards, explaining that he
        derived their meanings from the DEA manual, state and federal
        regulations, and his own pain management practice. Giving exam-
        ples from his experience, he explained the process he follows before
        prescribing controlled substances as follows: finding out who re-
        ferred the patient; verifying that the patient has insurance; detailing
        the patient’s pain complaints and medical and social history, touch-
        ing on whether there is a history of substance abuse; and complet-
        ing an extensive physical examination. Before starting a patient on
        controlled substances, he discusses the medication’s risks and coun-
        sels the patient about alternative pain management treatments. He
        emphasized that there is no one-size-fits-all approach to treating a
        patient’s pain.
                He also testified about red flags that would warn him that
        patients might be abusing their medication: patients with no med-
        ical records or no referral, those who traveled long distances, and
        those who shared their medication or ran out early. These are all
        examples of patients who would prompt further investigation,
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        54                     Opinion of the Court                 20-13973

        according to Dr. Chaitoff. He found red flags when he watched vid-
        eos of undercover officer Chin and confidential informant Vasilas
        visiting Santos’s office. Santos had prescribed opiates to Chin for
        four months. She then missed two months of appointments,
        which, Dr. Chaitoff testified, would prompt most doctors to ask
        her how she had been managing the pain without medication and
        whether she had gone through withdrawal.
               Dr. Chaitoff also noted that it is unusual for a doctor to see
        a couple together and perform a brief physical exam on both sim-
        ultaneously, as Santos did in the video. Reviewing Santos’s notes,
        Dr. Chaitoff testified that there was little documentation about the
        results of the physical examinations and why the injuries warranted
        treatment with controlled substances. Strikingly, Vasilas said that
        Chin had taken some of his medication, clear evidence of diversion
        that Santos did not follow up on. Instead, he increased her quantity
        of oxycodone tablets. Dr. Chaitoff gave his opinion about an ulti-
        mate issue when he testified that, at that visit, Santos prescribed
        Chin and Vasilas controlled substances for no legitimate medical
        purpose and outside the scope of professional practice. Dr. Chaitoff
        came to the same conclusion about the pair’s two other visits.
              Although we vacate Santos’s convictions under § 841 based
        on those three patient visits, the jury also considered Dr. Chaitoff’s
        testimony when it convicted Santos on the § 846 conspiracy
        charge, a conviction we affirm. It was not plain error to admit Dr.
        Chaitoff’s ultimate-issue evidence. Our precedent allows medical
        experts to testify about the ultimate issue of the appropriate
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        20-13973               Opinion of the Court                        55

        standard of care. In Azmat, the government’s medical expert testi-
        fied that the patients exhibited an “abundance of red flags” and
        opined that the doctor did not write prescriptions for them for a
        legitimate medical purpose or in the usual course of professional
        practice. 805 F.3d at 1036. The defense’s medical expert concluded
        that the doctor “act[ed] appropriately under medical standards,”
        but the jury determined that the government’s expert was more
        credible and convicted the defendant. Id. We accepted both ex-
        perts’ testimony as properly admitted and affirmed the doctor’s
        conviction. See id. at 1042–44, 1049. Just like in Azmat, it was not
        plain error here for the district court to admit Dr. Chaitoff’s testi-
        mony for the jury’s consideration.
               Ruan II does not undermine that conclusion. As Santos con-
        cedes, Ruan II “left the door ajar about how to prove mens rea.”
        Supp. Br. of Appellant Santos at 13. But a finding of plain error must
        be justified by on-point authority. Lejarde–Rada, 319 F.3d at 1291. If
        anything, Ruan II weakens an ultimate-issue objection to testimony
        of the kind offered by Dr. Chaitoff. Ruan II makes clear that the
        mere fact a doctor acts outside the course of professional practice
        or without a legitimate medical purpose does not suffice for a con-
        viction under § 841: “the Government must prove beyond a rea-
        sonable doubt that the defendant knew that he or she was acting in
        an unauthorized manner, or intended to do so.” Ruan II, 142 S. Ct.
        at 2375. Thus, post-Ruan II, a jury that accepted Dr. Chaitoff’s tes-
        timony as true would not be required to convict. So Ruan II dis-
        tances a medical expert’s opinion on whether a doctor acted with-
        out a legitimate medical purpose or outside the course of
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        56                     Opinion of the Court                 20-13973

        professional practice from the question of guilt under § 841. Santos
        cannot show plain error.
              E.     Santos’s Motion to Strike Dr. Chaitoff’s Testimony
                During trial, Dr. Chaitoff offered basically two types of tes-
        timony: first, he explained the medical and regulatory standards
        that govern the prescription of controlled substances, and second,
        he offered his opinion on whether Duldulao’s and Santos’s conduct
        conformed to those standards. During trial, a problem emerged. In
        forming his opinion about Duldulao, Dr. Chaitoff had relied on ma-
        terial relating to Duldulao’s activities at a second pain clinic and
        alleged pill mill that the district court excluded from evidence after
        granting a motion in limine. Dr. Chaitoff’s reliance on these ex-
        cluded materials put Duldulao in a bind. He could not fully cross-
        examine Dr. Chaitoff on the basis for his opinion without also dis-
        cussing material the district court excluded. Duldulao and Santos
        both moved to strike Dr. Chaitoff’s testimony. The district court
        granted Duldulao’s motion in part, striking Dr. Chaitoff’s testi-
        mony regarding Duldulao’s conduct but not his testimony regard-
        ing the general standard of care nor his testimony regarding Santos,
        about whom Dr. Chaitoff had not considered excluded evidence.
               Santos argues the district court abused its discretion by not
        striking Dr. Chaitoff’s testimony about him, too. We disagree. Alt-
        hough the court deemed Dr. Chaitoff a “less than reliable witness”
        because of his memory problems and lack of candor, it was within
        the court’s discretion to deny Santos’s motion to strike. Doc. 388
        at 97. Only one topic was off-limits in Santos’s cross-examination:
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        20-13973               Opinion of the Court                        57

        the evidence about Duldulao’s other pain clinic that the court’s in
        limine order excluded. That limit did not substantially affect San-
        tos’s right to cross-examine the witness; Dr. Chaitoff had not relied
        on the excluded evidence in forming his opinions about Santos and
        the general standard of care, and Santos could mitigate any preju-
        dice from Dr. Chaitoff’s other shortcomings through thorough
        cross-examination. See United States v. Williams, 865 F.3d 1328, 1341
        (11th Cir. 2017).
                              F.     Santos’s Sentence
               Santos previously challenged his sentence, and we aﬃrmed.
        On remand, we need not reconsider the merits of his arguments in
        light of Ruan II. Because we vacate Santos’s convictions on counts
        seven, eight, and nine, we vacate his sentence, too. See United States
        v. Fowler, 749 F.3d 1010, 1015–16 (11th Cir. 2014) (explaining that,
        on direct appeal, “we have routinely, without hesitation and as a
        matter of course, vacated entire sentences and remanded for resen-
        tencing on all surviving counts after vacating a conviction or sen-
        tence on some, but not all, of the counts” because a “multicount
        sentence is a package” (internal quotation marks omitted)).
                              IV.    CONCLUSION
              For the above reasons, we AFFIRM Duldulao’s conviction
        on count one of the second superseding indictment. We AFFIRM
        Santos’s conviction on count one, VACATE Santos’s convictions on
        counts seven, eight, and nine, VACATE Santos’s sentence,
        REMAND for resentencing, and REMAND for a new trial on
        counts seven, eight, and nine.