Wise: PTSD and Cardiovascular disease, and a primer on the benefit of the doubt rule

Ouida Wise v. Shinseki, Opinion Number 12-2764, was decided April 16, 2014 and concerns several issues of importance: VA physician competence, medical treatises, and the benefit of the doubt rule.

This opinion is a true tutorial on many facets of VA law.  It concerns a denied application of DIC.  The WWII veteran had been rated 100% for PTSD and ultimately died from an arrhythmia due to arteriosclerotic  cardiovascular disease, congestive heart failure, and COPD.

The veteran’s surviving spouse submitted a letter from the treating VA physician who stated it was more likely than not the veteran’s PTSD aided and assisted in his death from heart disease as PTSD is a risk factor for heart disease.  The letter also referred to a 2007 JAMA article finding that male veterans with PTSD were more likely to develop coronary heart disease and suggested that higher levels of PTSD pose an even greater cardiovascular risk.

The VA requested a VA staff cardiologist to offer an opinion.  The cardiologist opinion started by stating the cardiologist had no formal training in psychiatry besides a month long rotation in medical school and noted some VA medical records were not available for review, most importantly medical records from cardiology appointments.  The VA cardiologist then stated that due to other risk factors (hypertension, family history, obesity) and the fact that PTSD was not a widely accepted risk factor within the medical community, she did not believe the PTSD was a contributing factor in the veteran’s death.

The veteran’s spouse responded by submitting a 2011 medical article discussing the “growing number of studies” finding positive associations between PTSD and cardiovascular disease. 

The Board denied the appeal.  In its decision it found the VA cardiologist’s opinion more persuasive because it was based on known risk factors and “not [the] yet accepted notion that PTSD causes heart disease.”

The Court first addressed the cardiologist’s competence.  The Court noted that usually a physician’s competence is assumed unless it is raised by the veteran.  However, in this case “the Court holds that where, as here, a medical professional admits that he or she lacks the expertise necessary to provide the opinion requested by the Board—in this case, expressly deeming her view of the matter as that of a non-expert layperson—the opinion itself creates the appearance of irregularity in the process resulting in the selection of that medical profession that prevents the presumption of competence from attaching, and the Board must therefore address the medical professional’s competence before relying on his or her opinion.”  Id. at *11.

The Court next addressed deficiencies in the cardiologist’s opinion.  The Court noted medical cardiology appointments were made but these cardiology records were obtained by the VA or reviewed by the cardiologist.  However, the cardiologist repeatedly stated that based on a 1993 study, the veteran did not have coronary artery disease.  The Court found this at odds with the fact the study was conducted 15 years prior to the veteran’s death and fact the death certificate listed the veteran as suffering from arteriosclerotic cardiovascular disease.  The Court also was offended by the fact the cardiology relied on a 2000 medical article to refute the supporting 2007 medical article and asked why a 2000 article was more representative of the state of medical science than a 2007 article.

Next, the Court noted the VA did not attempt to find the cardiology records even though the lack of them in the file was raised by their own cardiologist.

Finally, the Court addressed the benefit of the doubt rule.  Specifically, the Board and VA cardiologist had found it was not generally accepted within the medical field that PTSD was a risk factor for cardiovascular disease.  The Court noted the benefit of the doubt rule is a standard lower than others and stated “Congress has not mandated that a medical principle have reached the level of scientific consensus to support a claim for VA benefits.”  Id. at *16.  The Court stated “[t]his is not to say that the Board is precluded from considering the extent to which a scientific theory is accepted in the scientific community when evaluating the evidence of record; this is simply to make clear that the Board, when evaluating that evidence, cannot demand a level of acceptance in the scientific community greater than the level of proof required by the benefit of the doubt rule.”  Id. at *17.  The Court then noted the existence of these contradicting articles indicates the evidence may be in approximate balance, triggering the benefit of the doubt rule.

Again, this is a major decisions that can be a touchstone for arguments as to DIC and application of benefit of the doubt rule, and more specifically on how PTSD might cause cardiovascular disease—an issue that can be valuable in both DIC and service-connection claims.

Opinion by Judge Bartley, joined by Judges Davis and Schoelen.