Court Opinion

ID: 9369593
Source: CourtListenerOpinion
Date Created: 2023-02-09 15:00:35.933957+00
Date Added: 2024-06-11T17:16:16.144059
License: Public Domain

USCA11 Case: 21-14446    Document: 37-1      Date Filed: 02/09/2023   Page: 1 of 18

                                                    [DO NOT PUBLISH]
                                    In the
                 United States Court of Appeals
                         For the Eleventh Circuit

                           ____________________

                                 No. 21-14446
                           Non-Argument Calendar
                           ____________________

        UNITED STATES OF AMERICA,
                                                       Plaintiff-Appellee,
        versus
        CHYKEETRA MALTBIA, M.D.,

                                                    Defendant-Appellant.

                           ____________________

                  Appeal from the United States District Court
                     for the Southern District of Alabama
                    D.C. Docket No. 1:19-cr-00209-JB-MU-1
                           ____________________
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        2                      Opinion of the Court                 21-14446

        Before NEWSOM, BRANCH, and GRANT, Circuit Judges.
        PER CURIAM:
               Dr. Chykeetra Shinnyette Maltbia appeals her convictions
        for possession with intent to distribute controlled substances. She
        asserts that the district court erred for three reasons. First, she
        argues that the district court’s exclusion of “good patient care”
        evidence deprived her of the right to present a complete defense in
        violation of the Fifth and Sixth Amendments. Second, she argues
        that the district court erred by not giving the jury a “good faith”
        instruction. Third, she contends for the first time on appeal that
        the district court should have instructed the jury that the
        government is required to prove that Maltbia issued prescriptions
        without a legitimate medical purpose and was acting outside the
        usual course of medical practice.
               Because Maltbia is not entitled to relief on any of her claims,
        we affirm her convictions. We address each enumeration of error
        in turn.
                                  I.     Background
              In February 2020, a grand jury indicted Maltbia with one
        count of conspiracy to possess with intent to distribute controlled
        substances in violation of 21 U.S.C. § 846 (Count One); sixteen
        counts of possession with intent to distribute controlled substances
        in violation of 21 U.S.C. § 841(a)(1) (Counts Two through
        Seventeen); and eighteen counts of healthcare fraud in violation of
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        21-14446                   Opinion of the Court                                3

        18 U.S.C. § 1347 (Counts Eighteen through Thirty-Five). 1 Maltbia
        pleaded not guilty on all counts, and the district court set the case
        for trial. Before trial, the government moved to dismiss the
        healthcare fraud claims, and the court granted the motion.
                Maltbia is a physician who owned and operated a medical
        clinic in Mobile, Alabama. At trial, a special agent with the United
        States Drug Enforcement Administration (“DEA”) testified that he
        became familiar with Maltbia’s clinic through an investigation into
        several individuals for selling “oxycodone 30” prescription pills. 2
        He discovered that the individuals selling oxycodone 30 were
        Maltbia’s patients and observed them at Maltbia’s clinic. After
        searching Maltbia’s clinic and the electronic data stored on her
        computers pursuant to a search warrant, he learned that Maltbia
        regularly prescribed controlled substances to her patients—
        including oxycodone 30. Further investigation revealed that
        Maltbia had already signed prescriptions for patients that she was
        scheduled to see later in the day; that Maltbia charged her patients
        $300 per visit; that Maltbia’s patients “mainly” paid in cash or by
        credit card; and that Maltbia had issued prescriptions to patients
        while she was out-of-state on multiple occasions. A DEA

        1 In August 2019, a grand jury indicted Maltbia with five violations of 21 U.S.C.
        § 841(a)(1). Later that fall, Maltbia pleaded not guilty on all counts. A grand
        jury then returned a superseding indictment in February 2020.
        2 Testimony at trial explained that oxycodone 30 refers to the dosage of
        oxycodone (30 milligrams) and that oxycodone 30 has the “highest street
        value” for oxycodone.
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        4                          Opinion of the Court                      21-14446

        intelligence analyst testified that 58.7% of Maltbia’s patients
        received at least one prescription of oxycodone 30. And the
        government’s expert witness concluded that Maltbia prescribed
        opioids without properly assessing patients and that she falsified
        medical records.
                The jury found Maltbia guilty on Count Two and Counts
        Four through Seventeen. 3 After denying Maltbia’s motion for new
        trial, the district court sentenced her to five years’ probation for
        each count, with each probationary term to run concurrently, and
        ordered Maltbia to pay a $50,000.00 fine.
                Maltbia timely appealed.
                                       II.     Discussion
                    a. Whether the district court erred by excluding
                       “favorable patient testimony”
               First, Maltbia argues that the district court denied her the
        right to present a complete defense in violation of the Fifth and
        Sixth Amendments to the Constitution by excluding “favorable
        patient testimony.” We disagree.
              Prior to trial, the government filed a motion in limine to
        exclude testimony from Maltbia’s “good patient[s]” during opening
        statements or “during trial without first making an argument

        3 Maltbia moved for acquittal during trial and at the close of evidence, and the
        district court granted her motions in part and dismissed Counts One and
        Three.
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        21-14446                Opinion of the Court                         5

        outside the jury’s presence.” The government explained that a
        common “defense tactic in trials where the defendant is a medical
        professional is for the defendant to attempt to call ‘good patient’
        witnesses—i.e., patients who will testify that they received proper
        medical care from the defendant.” The government argued that
        “[w]hile such testimony might appear to be relevant at first blush,
        ‘good patient’ testimony is actually impermissible character
        evidence.”
              Maltbia opposed the motion, arguing that excluding
        evidence of good patient care would deprive her of a fair trial and
        her right to present a full defense under the Fifth and Sixth
        Amendments.
               After a hearing, the district court granted the government’s
        motion and stated that “[a]ny request for the [c]ourt to revisit the
        issue of admissibility at trial shall occur outside the presence of the
        jury.”
               “Whether the exclusion of evidence violated a constitutional
        guarantee is a legal question reviewed de novo.” United States v.
        Sarras, 575 F.3d 1191, 1209 n.24 (11th Cir. 2009). And “[i]n assessing
        a defendant’s claims under the Fifth and Sixth Amendments to call
        witnesses in her defense, . . . [w]e first examine whether [the] right
        was actually violated, [and] then turn to whether [the] error was
        harmless.” United States v. Hurn, 368 F.3d 1359, 1362–63 (11th Cir.
        2004) (quotation omitted).
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        6                       Opinion of the Court                  21-14446

                “The Constitution guarantees criminal defendants a
        meaningful opportunity to present a complete defense.” United
        States v. Akwuba, 7 F.4th 1299, 1312 (11th Cir. 2021) (quotation
        omitted). But the right to present a complete defense is not
        absolute; rather, it is subject to reasonable restrictions. Id. “[S]tate
        and federal rulemakers have broad latitude under the Constitution
        to establish rules excluding evidence from criminal trials.” United
        States v. Mitrovic, 890 F.3d 1217, 1221 (11th Cir. 2018) (quoting
        United States v. Scheffer, 523 U.S. 303, 308 (1998)). “Such rules do
        not abridge an accused’s right to present a defense so long as they
        are not ‘arbitrary’ or ‘disproportionate to the purposes they are
        designed to serve.’” Id. (quoting Scheffer, 523 U.S. at 308). A trial
        judge’s role as gatekeeper is to “ensure that the factfinder bases its
        decision only on relevant and reliable information.” Id. at 1222.
        Thus, “while a criminal defendant must be given every meaningful
        opportunity to present a complete defense,” “[s]he must [also]
        comply with the procedural and evidentiary rules designed to
        facilitate a search for the truth” in doing so. Id. (quotation
        omitted). And, notably, the Supreme Court “has never held that a
        federal rule of evidence violated a defendant’s right to present a
        complete defense.” Id. (emphasis omitted).
               On appeal, Maltbia contends that the district court’s
        exclusion of testimony related to “good patient care” violated the
        Fifth and Sixth Amendments by depriving her of the ability to
        present a complete defense. She relies on United States v. Hurn,
        368 F.3d 1359 (11th Cir. 2004), to support her argument that “good
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        21-14446                  Opinion of the Court                               7

        patient testimony” had “the potential to ‘place the story presented
        by the [g]overnment in a significantly different light.’”
               In Hurn, we explained that a district court’s exclusion of
        evidence may violate the Constitution in four circumstances. 368
        F.3d at 1363. As relevant here, we stated that “a defendant must
        generally be permitted to introduce evidence that, while not
        directly or indirectly relevant to any of the elements of the charged
        events, nevertheless tends to place the story presented by the
        prosecution in a significantly different light, such that a reasonable
        jury might receive it differently.” 4 Id. Thus, Hurn recognizes that
        defendants have a right to combat “the government’s selective
        presentation of entirely truthful evidence” that can “cast a
        defendant in an inaccurate, unfavorable light, or make entirely
        legitimate, normal, or accepted acts appear unusual or suspicious.”

        4 Although not relevant to this appeal, the other three circumstances include:
               First, a defendant must generally be permitted to introduce
               evidence directly pertaining to any of the actual elements of
               the charged offense or an affirmative defense. Second, a
               defendant must generally be permitted to introduce evidence
               pertaining to collateral matters that, through a reasonable
               chain of inferences, could make the existence of one or more
               of the elements of the charged offense or an affirmative
               defense more or less certain. Third, a defendant generally has
               the right to introduce evidence that is not itself tied to any of
               the elements of a crime or affirmative defense, but that could
               have a substantial impact on the credibility of an important
               government witness.
        Hurn, 368 F.3d at 1363.
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        8                      Opinion of the Court                 21-14446

        Id. at 1366–67. “In these situations, the defendant has the right to
        introduce additional evidence to dispel this unjustified taint, even
        if that evidence does not directly or indirectly bear on a particular
        element of an offense.” Id. at 1367.
               For example, in United States v. Todd, 108 F.3d 1329, 1329
        (11th Cir. 1997), the defendant was convicted of embezzling from
        his company’s employee retirement fund. To prove “criminal
        intent” and show that the defendant was “motivated by greed and
        selfishness to fraudulently deprive the employees of the [p]lan’s
        funds,” the government presented evidence that the defendant and
        his family members who worked at the company received large
        salaries. Id. at 1332–33. We reversed the defendant’s conviction,
        concluding that the district court erred by prohibiting the
        defendant from introducing evidence that all employees who
        worked at the company, not just his family members, received
        large salaries and benefits. Id. at 1333–34. We reasoned that such
        evidence “could have put quite a different spin on the question of
        Todd’s intent and actions” and that “[b]y disallowing the disputed
        evidence, the district court deprived [the defendant] of a chance to
        rebut the government’s intent argument.” Id.
                Here, Maltbia fails to establish that evidence of good patient
        care constitutes the type of evidence contemplated by Hurn and
        Todd—i.e., evidence that “complete[s] the picture” of the charged
        crimes. Hurn, 368 F.3d at 1366–67. Maltbia argues that
        “[t]estimony of good patient care whose quality of life has
        improved after being treated by Maltbia was essential to refuting
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        21-14446                   Opinion of the Court                                9

        the [g]overnment’s claim that Maltbia was analogous to a street
        drug dealer[,] that she was only seeming to make her practice
        legitimate, and [that] she was not an honest and diligent doctor.”5
        But even if evidence of good patient care might have added some
        additional context, it would not have given the jury a reason in law
        not to convict. See United States v. Funches, 135 F.3d 1405, 1408
        (11th Cir. 1998) (affirming a conviction even though some
        contextual evidence was excluded because “[h]ad the jury heard
        [the excluded evidence], the jury nonetheless would have lacked a
        reason in law not to convict”). Indeed, “evidence introduced to
        ‘complete’ a potentially misleading story offered by the
        government is pertinent only when it might color a jury’s
        assessment of the material facts of the case.” Hurn, 368 F.3d at
        1367. Here, Maltbia does not explain how evidence of good care
        for some patients would change or otherwise affect the material
        facts that led to her convictions. Accordingly, because “good
        patient” evidence was not necessary to correct inaccuracies created
        by the government’s evidence or “complete the picture” of the
        charged crimes, we conclude that the district court’s exclusion of

        5 In its opening statement at trial, the government stated: (1) that “[t]he only
        difference in Maltbia and a street level drug dealer is that she used her medical
        license to do it” and (2) that “Maltbia and [her stepfather] worked together to
        make it seem like a legitimate clinic. But you will be able to tell from the
        undercover videos that it was anything but.” Then in its closing argument,
        the government asserted that “[w]e would not be here today if Maltbia had
        been a diligent and honest doctor.”
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        10                     Opinion of the Court                21-14446

        “good patient” evidence did not violate Maltbia’s constitutional
        right to present a complete defense.
                  b. Whether the district court erred by not giving the
                     jury a good faith instruction
               Next, Maltbia argues that the district court erred by not
        giving the jury a good faith defense charge. After reviewing for
        plain error, we conclude that Maltbia fails to carry her burden.
                When instructing the jury at the close of trial, the district
        court explained that under 21 U.S.C. § 841(a)(1) of the Controlled
        Substances Act (“CSA”), “[f]or a controlled substance to be lawfully
        distributed or dispensed by prescription, the prescription must
        have been issued by a practitioner both for a legitimate medical
        purpose and within the usual course of professional practice.” The
        district court explained that this determination was to be made
        using an objective—not subjective—standard:
              Whether a prescription was issued in the usual course
              of professional practice must be evaluated based on
              an objective standard. Thus, you must not focus on
              the subjective intent of the prescriber. Rather, your
              focus must be on whether the controlled substance
              identified in each count was prescribed by [Maltbia]
              in accordance with an objective standard of medical
              practice generally recognized and accepted in the
              United States.
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        21-14446                   Opinion of the Court                               11

        Maltbia never objected to the instruction. 6
                Months later, Maltbia filed an untimely motion for new trial,
        explaining that the Supreme Court had granted a petition for a writ
        of certiorari in Ruan v. United States, -- U.S. --, 142 S. Ct. 457 (2021)
        (“Ruan II”), and a consolidated case and that the issues in those
        cases were “directly applicable” to the legal issues of her case. She
        contended that the petitions for certiorari addressed “the issue of
        ‘good faith’ as a defense to allegations of the nature contained in
        the indictment against [Maltbia].” Maltbia urged the district court
        to accept her out-of-time motion and to delay ruling on the motion
        and conducting sentencing until the Supreme Court decided Ruan
        II. The government opposed her motion, arguing that the motion
        was untimely, that Maltbia was making these arguments for the
        first time, and that “a delayed motion for a new trial should not be
        a substitute for timely objections during trial.” The district court
        denied Maltbia’s motion, and Maltbia appealed.
              Because Maltbia did not timely file her motion for new trial,
        we review the district court’s denial of the motion for plain error.

        6 Although the parties and the district court discussed a good faith instruction
        at the charge conference, the district court ultimately did not give a good faith
        instruction to the jury—stating that it had “to follow the [then-binding]
        Eleventh Circuit’s law on [the issue],” which required that the “usual course
        of professional practice” prong be evaluated under an objective standard.
        Maltbia never requested a good faith instruction at the charge conference and
        never objected to the district court’s conclusion that it was not “an appropriate
        defense to be instructed to the jury.”
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        12                      Opinion of the Court                 21-14446

        See United States v. Little, 864 F.3d 1283, 1289 (11th Cir. 2017).
        Under plain error review, “[w]e may reverse an error that was plain
        and that affects [a] defendant’s substantial rights, provided it also
        seriously affects the fairness, integrity, or public reputation of
        judicial proceedings.” United States v. Innocent, 977 F.3d 1077,
        1081 (11th Cir. 2020). Importantly, “[t]he party challenging the
        error bears the burden of proving that [she] had a ‘reasonable
        probability of a different result’ absent the error.” Id. (quoting Dell
        v. United States, 710 F.3d 1267, 1276 (11th Cir. 2013)).
              After Maltbia appealed to us, the Supreme Court decided
        Ruan II. A bit of background is helpful.
               The statute under which Maltbia was convicted—21 U.S.C.
        § 841(a)—prohibits the “knowing[] or intentional[]” dispensing of
        controlled substances “[e]xcept as authorized.” Certain controlled
        substances are “authorized” to be dispensed by prescription if the
        prescription is made for a “legitimate medical purpose by an
        individual practitioner acting in the usual course of his professional
        practice.” 21 C.F.R. § 1306.04(a). Prior to the Supreme Court’s
        decision in Ruan II, we had repeatedly rejected defendants’
        requests for a good faith jury instruction—specifically, an
        instruction that a defendant’s good faith could be a defense to an
        allegation that she acted outside the “usual course of professional
        practice.” See United States v. Ruan, No. 17-12653, 2023 WL
        106451, at *1 (11th Cir. Jan. 5, 2023) (“Ruan III”) (citing cases). In
        those cases, we held that the “usual course of professional practice”
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        21-14446              Opinion of the Court                      13

        prong must be evaluated using an objective standard, not a
        subjective one. Id.
               The Supreme Court reversed. Ruan II, 142 S. Ct. at 2376.
        Rejecting our objective standard, the Supreme Court held that
        § 841(a)’s “knowingly or intentionally” mens rea requirement
        applies to both the dispensing element and to the “except as
        authorized” clause. Id.; Ruan III, 2023 WL 106451, at *2. The
        Supreme Court’s holding means that, to obtain a conviction under
        § 841(a), the “government must prove beyond a reasonable doubt
        that a defendant (1) knowingly or intentionally dispensed a
        controlled substance; and (2) knowingly or intentionally did so in
        an unauthorized manner.” Ruan III, 2023 WL 106451, at *2; see
        also Ruan II, 142 S. Ct. at 2376. The Supreme Court explained that
        an objective standard inappropriately imported a civil negligence
        standard into a criminal prosecution. Ruan III, 2023 WL 106451, at
        *2. “Instead, what matters is the defendant’s subjective mens rea.”
        Id.
               On remand, we held that the district court’s denial of the
        defendants’ request for a good faith instruction, which reflected a
        subjective intent, was error. Id. And because “the district court’s
        instruction for the substantive drug charges inadequately conveyed
        the required mens rea to authorize conviction under § 841(a),” we
        vacated the defendants’ substantive drug convictions under
        § 841(a). Id. at *3.
              Turning back to the case at hand, we conclude that Maltbia
        cannot meet her burden to establish each element of plain error.
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        14                          Opinion of the Court                         21-14446

        Even if Maltbia could meet the first two prongs of the test, she
        cannot satisfy the third prong. 7 Namely, she cannot satisfy her
        burden to prove that there is a reasonable probability that she
        would have obtained a different result but for the error. Innocent,
        977 F.3d at 1082.
               As the party challenging the alleged error, Maltbia bears the
        burden of persuasion. See United States v. Monroe, 353 F.3d 1346,
        1352 (11th Cir. 2003) (explaining that plain error review, unlike
        harmless error review, puts “the burden of persuasion with respect
        to prejudice or the effect on substantial rights” on the defendant,
        not the government). And the “burden of showing prejudice to
        meet the third-prong requirement is anything but easy.” United
        States v. Rodriguez, 398 F.3d 1291, 1299 (11th Cir. 2005). She must
        prove that she had a “reasonable probability of a different result”
        absent the error. Innocent, 977 F.3d at 1082; United States v. Reed,
        941 F.3d 1018, 1021 (11th Cir. 2019) (explaining that a defendant

        7 Even though Maltbia fails on the third prong of the plain error test, we note
        that she could have potentially succeeded on the first two. Although we do
        not have any language for a good faith instruction to evaluate because none
        was proposed in this case, we do know that the jury instruction given was
        erroneous because it used an objective standard, rather than the subjective
        standard that is now required. See Ruan II, 142 S. Ct. at 2376. And “[t]he error
        was plain because it is evident at the time of appellate review.” Innocent, 977
        F.3d at 1082; see Henderson v. United States, 568 U.S. 266, 279 (2013)
        (explaining that “whether a legal question was settled or unsettled at the time
        of trial,” the second prong of the plain error test is satisfied if an error is plain
        “at the time of appellate consideration” (quotation omitted)).
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        21-14446                  Opinion of the Court                              15

        “must prove that an error occurred that was both plain and that
        affected [her] substantial rights”).
               In the face of this burden, Maltbia makes no argument and
        presents no evidence that she was prejudiced by the error. 8 See
        Monroe, 353 F.3d at 1352; see also United States v. Duncan, 400
        F.3d 1297, 1304 (11th Cir. 2005) (concluding that the defendant
        could not meet his burden of persuasion when he “[did] not point
        to anything indicating a reasonable probability of a different result”
        (quotation omitted)). And we decline to construct a prejudice
        argument for Maltbia from a blank slate. Accordingly, we conclude
        that Maltbia fails to meet her burden and cannot survive plain error
        review when she provides no showing of prejudice and makes no
        attempt to argue that a different result would have occurred absent
        the error. See Duncan, 400 at 1304 (explaining that the defendant
        bears the burden of “persuasion with respect to prejudice”).
                   c. Whether the district court erred by giving a
                       disjunctive jury instruction
               At the close of trial, the district court instructed the jury that
        the government must prove that “the defendant knowingly and
        intentionally dispensed or distributed or caused to be dispensed or
        distributed a controlled substance by prescription and [(1)] the
        prescription was issued not for a legitimate medical purpose or [(2)]

        8 Indeed, Maltbia’s brief does not reference “plain error,” “prejudice,” or
        “substantial rights.” Instead, she largely summarizes the state of the law pre-
        Ruan II and “urges [this] Court to be mindful of the Ruan ruling.”
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        16                      Opinion of the Court                  21-14446

        the prescription was issued outside the usual course of professional
        practice.” For the first time on appeal, Maltbia argues that the
        district court erred by not charging the “legitimate medical
        purpose” and “usual course” “requirements in the conjunctive.”
        After reviewing for plain error, we conclude that Maltbia fails to
        carry her burden.
               Because Maltbia raises this jury instruction issue for the first
        time on appeal, we review her claim for plain error. United States
        v. Guevara, 894 F.3d 1301, 1309 (11th Cir. 2018). Under plain error
        review, we may exercise our discretion and correct an unpreserved
        error where there is (1) an error; (2) the error is plain; (3) the error
        affects substantial rights; and (4) the error seriously affects the
        fairness or integrity of the judicial proceedings. Id. Maltbia’s
        argument fails on all fronts.
               As we explained above, under 21 U.S.C. § 841(a)(1) of the
        CSA, it is unlawful for a person to knowingly or intentionally
        distribute or dispense a controlled substance except as authorized.
        One authorized exception permits licensed doctors to dispense
        certain controlled substances with prescriptions. 21 U.S.C.
        § 829(a), (b). The regulations explain that for such a prescription to
        be effective, it “must be issued for a legitimate medical purpose by
        an individual practitioner acting in the usual course of his
        professional practice.” 21 C.F.R. § 1306.04(a). And we have
        interpreted this regulation to be disjunctive, meaning that a doctor
        unlawfully distributes a controlled substance by prescription if (1)
        “the prescription was not for a legitimate medical purpose” or (2)
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        21-14446                   Opinion of the Court                               17

        “the prescription was not made in the usual course of professional
        practice.” United States v. Abovyan, 988 F.3d 1288, 1305 (11th Cir.
        2021) (quotations omitted) (explaining that “[t]he rule is
        disjunctive, and a doctor violates the law if he falls short of either
        requirement”). Indeed, we have repeatedly affirmed jury
        instructions that were given in this disjunctive format. See, e.g., id.
        at 1305, 1308; United States v. Joseph, 709 F.3d 1082, 1094–96 (11th
        Cir. 2013), abrogated on other grounds by Ruan III, 2023 WL
        106451, at *1; United States v. Tobin, 676 F.3d 1264, 1282–83 (11th
        Cir. 2012), abrogated on other grounds by Ruan III, 2023 WL
        106451, at *1. Thus, considering that we have affirmed this jury
        instruction in the past, and that the Supreme Court did not address
        it in Ruan II, we conclude that no plain error exists. 9 See United
        States v. Sanchez, 940 F.3d 526, 537 (11th Cir. 2019) (“An error
        cannot be plain unless the issue has been specifically and directly
        resolved by the explicit language of a statute or rule or on point
        precedent from the Supreme Court or this Court.”).

        9 We note that our conclusion is limited to the plain error review context. We
        do not address what impact Ruan II may have on this issue, if any, if it is
        preserved and raised on appeal in a future case.
                Additionally, Maltbia argues, in a conclusory manner, that “[t]he
        phrase ‘usual course of professional practice,’ when separated from ‘medical
        purpose,’ is unconstitutionally vague.” Again, Maltbia did not raise this issue
        below, so it is subject to plain error review. And where we have repeatedly
        affirmed this disjunctive jury instruction, we cannot say that it was plain error
        for the district court to give such an instruction. See United States v. Sanchez,
        940 F.3d 526, 537 (11th Cir. 2019).
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        18                     Opinion of the Court                21-14446

               Additionally, Maltbia cannot establish the third prong of the
        plain error test because she fails to argue how she was prejudiced
        and because she has not demonstrated that the outcome would
        have been different if a conjunctive instruction, rather than a
        disjunctive instruction, was given. The government urges us not
        to “create a prejudice argument from whole cloth” when Maltbia
        “does not . . . engage [the] heavy burden [of proving she received
        an unfair trial] on appeal,” and we will not do so. Considering that
        Maltbia bears the difficult burden of persuasion on this point, see
        Rodriguez, 398 F.3d at 1299, we conclude that she cannot survive
        plain error review when she makes no argument on this prong, see
        Duncan, 400 F.3d at 1304.
                                  III.   Conclusion
              Because Maltbia is not entitled to relief on any of her claims,
        we affirm her convictions and the district court’s denial of her
        motion for new trial.
              AFFIRMED.