How Probative Is Your Own Research On The Internet?

[Rockhound]

To Point: VA C&P Examiner quoted a diagnostic/information sight on the internet at (uptodate 2009) In my research of this site, I found the exact source or quote that the C&P examiner used. Going one step further I followed some of this particular subject using links it provided on the subject and differential diagnosises. In doing so, I found information that directly links my claim and subject, that had the Examiner, had know the correct reason and basis of my claim and gone further in their research, they would have found the same information I did.

My first objective at my upcoming DRO review is to make sure that the true nature of my claim is clairified and then to show how this new information applies directly to my claim.

My question is how much weight would my findings be against those of the C&P Examiner, using their own site source to rebut their reason and basis of their opinion?

My own medical background gives me a bit more insight to medical subjects than the average person, I was a Hospital Corpsman Third Class, and spent time aboard ship conducting unsupervised sick call to the enlisted personel, diagnosing similiar problems and dispensing medications for treatment as well. Also I was responsible in treating the on going problem with allergies to the XO, Giving shots for same. I think I know a bit about Sinusitis and Rhinitis and Allergies to be able to discuss these problems with some amount of expertise, enough at least to be able to diagnose and treat the same in a military setting at least. Oh yea, enter into the records of these same enlisted personel that the VA would use in further their claims.

I just want to know if I have a chance in getting my own information looked upon in at least an equal light to that of the examiner who was only a Nurse Practitioner.

Rockhound Rider ;)

[Vync]

Rockhound,

Proving the C&P examiner was not thorough is worth a shot.

However, if you can get a specialist doctor to opine in your favor, it would likely crush the C&P examiner's statement.

I remember an E-6 administering my allergy shots and tending to me when I would have bad reactions. Like you, I would assume you have at least a certain level of expertise in this field.

[cannoncocker]

I concur that your medical training, with any certification and documentation you possess would be most useful to prove at a glance that you have certain qualificationss to offer medical opinions. :At a glance is critical as they will not spend much time digging to reach the facts. It needs to be in front of them. I might suggest you complie two binders for the DRO Review, one for you and one for the DRO or your Rep.

Other part of this will be your Representative who in all likelihood has already walked over to the VARO if they are in the same building and if not called and prediscussed your case and have already come to some tentative agreement. I would call my Rep if the Review is nearing and ssk him specifically if he has already discussed your case with the VA, and if so what arrangement has been reached.

This is your claim and not anyone elses. If you wissh to offer evidence then I would do that. If they tell you the best thing for you to do is sit their with your mouth shut I would cinsider what I have to offer, what the rep is offering, and tyour own command of the beauracratic formailities and your ability to push your point across.

You are concerned about your claim. That would be about it, so keep that in mind. They have no intention on spending anymore time than humanly possible on it. That is the reason the rep and the VA have a pre arranged agreement, which may or may not transpire as your were lead to believe.

If you can prove your competence as a provider of evidence then roll on. But frequently you won't get that far.

These are my experiences and if you want something in the official record, you had better say it, submit it, whatever. But the idea that they are going to pour over pages of evidence, Gospel or not, just probably won't happen. I guess the most effective way to get all your evidence into the record is hand the binder to the DRO and verbally announce that you are submitting Binder marked??? with the following evidence, and state the outline. Bare in mind the rep will probably nix that from the top and tell you to take your binder and evidence with the exception of a few items and keep them out of sight.

Your experience may be 180% out but that is how it may go.

Best of luck and the best weapon you have is perserverance!

PS Obviouly a professional opinion stating they have reviewed your SMR.....and at least as likely as not...

My way is to listen carefully to your rep, make sure they can and will produce that which is offered and then weigh what I have to offer.

Edited May 20, 2010 by cannoncocker

[carlie]

Evaluating Evidence And Making A Decision, M21-1MR - Chapter 5

1. Guidelines for Evaluating Evidence

Introduction This topic includes information about the guidelines for evaluating evidence, including

· when to evaluate evidence

· points to consider when evaluating evidence

· provisions applied by the Rating Veterans Service Representative (RVSR)

· determining the value of testimony, and

· determining the issues.

Change Date December 13, 2005

a. When to Evaluate Evidence If VA’s duty to assist has been fulfilled, analyze the evidence for and against the claim.

Note: Evaluate all the evidence, including oral testimony given under oath and certified statements submitted by claimants.

b. Points to Consider When Evaluating Evidence When evaluating evidence and making decisions

· maintain objectivity

· never allow personal feelings to enter into the process, and

· show fairness and courtesy at all times to claimants.

Example: An antagonistic, critical, or even abusive attitude on the part of the claimant should not in any way influence the handling of the case.

Reference: For more information on the attitude of the rating officers, see 38 CFR 4.23.

Continued on next page

1. Guidelines for Evaluating Evidence, Continued

c. Provisions Applied by the RVSR When making decisions or taking action on claims that require a rating decision, the Rating Veterans Service Representative (RVSR) must apply the provisions of all pertinent

· laws

· regulations

· schedules for rating disabilities

· policy statements

· procedures

· administrators’ decisions

· Secretaries’ decisions

· Court of Appeals for Veterans Claims (CAVC) precedents, and

· other legal precedents governing Department of Veterans Affairs (VA).

d. Determining the Value of Testimony The RVSR determines the probative value of medical or lay testimony.

e. Determining the Issues The issues in some claims will be clear and unambiguous, while others may involve interpreting difficult to understand claims.

Reference: For more information on determining the issues, see M21-1MR, Part III, Subpart iv, 6.B.

2. Evidence to Consider

Change Date December 13, 2005

a. Types of Evidence to Consider Consider the following evidence when making decisions:

· medical records, such as

- service medical records

- VA examination reports

- private and VA hospital reports, and

- outpatient treatment reports

· lay evidence, such as letters from

- veterans and claimants, including reports of specific traumatic experience related as stressors for post-traumatic stress disorder (PTSD) claims, and

- other people who have knowledge of the claimed disability or relevant events

· medical opinions by examining or treating physicians, and

· medical treatises regarding

- etiology of a disability

- complications of a disease process, and

- employment records.

3. Responsibility for Reviewing Evidence

Change Date December 13, 2005

a. Who Is Responsible The RSVR is responsible for reviewing the evidence, including

· recognizing the need for evidence in relation to a claim, and

· determining the

- admissibility of the evidence

- weight to be afforded evidence that is presented

- need for additional evidence, and

- need for a physical examination.

4. Credible and Probative Evidence

Introduction This topic contains information about credible and probative evidence, including

· evaluating the evidence

· definition of the term credible evidence

· definition of the term probative evidence

· assessing the credibility of evidence

· an example of credible evidence

· an example of non-credible evidence

· determining the probative value of evidence, and

· explaining the persuasiveness of evidence.

Change Date December 13, 2005

a. Evaluating Evidence Evaluating evidence

· is the heart of the Reasons for Decision section of a rating decision, and

· may entail assessing the credibility and probative value of evidence before weighing the evidence in order to arrive at a decision on the claim.

Notes:

· Accept evidence at face value unless called into question by other evidence of record or sound medical or legal principles.

· In the presence of questionable or conflicting evidence, further development may be needed to reconcile the disparity.

b. Definition: Credible Evidence Credible evidence refers to evidence that is inherently believable or has been received from a competent source.

Continued on next page

4. Credible and Probative Evidence, Continued

c. Definition: Probative Evidence Probative evidence must be

· relevant to the issue in question, and

· have sufficient weight, either by itself or in combination with other evidence, to persuade the decision-maker about a fact.

d. Assessing the Credibility of Evidence Weigh the evidence by assessing its credibility and probative value in regard to the pending issue or issues. Weigh only credible evidence in reaching the ultimate decision. Evidence that is incredible carries no weight or probative value.

Example: Joseph Smith, a World War II veteran, submitted a statement from his primary care physician that noted the veteran’s seizure disorder was secondary to his service-connected (SC) head injury.

Upon recent neurological examination, conducted at the VA Medical Center (VAMC) in West Palm Beach, the examiner opined there was no evidence linking the veteran’s current seizure disorder to the veteran’s head injury in service. Specifically, the neurologist stated that the veteran’s nonservice-connected (NSC) vascular condition was causing the seizures. He went on to say that this is one of the most common causes of seizures that have their onset after age 60.

e. Example of Credible Evidence VA receives a statement from a physician who expresses an opinion regarding the nexus, or link, between the veteran’s current disability and an injury or disease in military service.

Note: As a result of the physician’s medical expertise, the physician’s statement is considered credible.

Continued on next page

4. Credible and Probative Evidence, Continued

f. Example of Non-Credible Evidence VA receives a statement from a claimant’s spouse regarding the link between the veteran’s current disability and an injury in service. The spouse is not known to be a medical professional.

Note: Since the spouse is not a medical professional, and a lay person is not considered capable of answering questions of medical causation or diagnosis, the evidence is not considered credible.

Exception: If the spouse is a medical professional, then the evidence is considered credible and weighed during the decision-making process.

g. Determining the Probative Value of Evidence Determine the probative value of the evidence once the evidence has been determined credible.

Note: It is not necessary to accord equal weight to each item of evidence contained in the record.

h. Explaining the Persuasiveness of Evidence Clearly explain in the rating decision why the evidence is found to be persuasive or not.

Example: Service connection for a seizure disorder secondary to the veteran’s SC head injury is denied. Although the veteran’s private physician provided an opinion linking the veteran’s seizure disorder to his SC head injury, more weight was assigned to the VA examiner due to his specialization in neurological disorders.

5. Medical Evidence

Introduction This topic contains information about evaluating medical evidence, including

· non-adversarial adjudication

· weighing physicians’ opinions

· evaluating medical evidence

· rejecting medical evidence

· supporting medical conclusions

· considering the POW protocol examination report

· evaluating service medical records (SMRs)

· statements from physicians as acceptable evidence, and

· considering information in the claims folder.

Change Date December 13, 2005

a. Non-Adversarial Adjudication VA’s system of claims adjudication is non-adversarial.

Do not minimize the weight of a treating physician’s opinion based upon the idea that he/she has become an advocate for the patient, since doing so may appear adversarial and biased.

b. Weighing Physicians’ Opinions Greater weight may placed on one physician’s opinion than another’s, depending on several factors, such as

· the specialty of the physician

· the reasoning employed by the physician, and

· the extent to which the physician reviewed prior clinical records and other evidence.

An opinion may be discounted if it materially relies on a layperson’s unsupported history as the premise for the opinion.

Note: Treating physician records are not necessarily dispositive of an issue and must be analyzed and discussed like all other evidence.

Reference: For more information on discounting opinions based on unsupported history, see Wood v. Derwinski, 1 Vet. App. 190 (1991).

Continued on next page

5. Medical Evidence, Continued

c. Evaluating Medical Evidence Consider the key elements listed below when evaluating medical evidence.

· Basis for the physician’s opinion, such as

- theory

- observation

- practice

- clinical testing

- subjective report, and

- conjecture.

· Physician’s knowledge of the veteran’s accurate medical and relevant personal history.

· Length of time the physician has treated the veteran.

· Reason for the physician’s contact with the veteran, such as for

- treatment, or

- substantiation of a medical disability claim.

· Physician’s expertise and experience.

· Degree of specificity of the physician’s opinion.

· Degree of certainty of the physician’s opinion.

Reference: For more information on determining a physician’s expertise and experience, see Black v. Brown, 10 Vet. App. 279, (1997).

Continued on next page

5. Medical Evidence, Continued

d. Rejecting Medical Evidence Unless the historical facts upon which a medical conclusion is based are dubious or untenable, reject medical evidence only on the basis of other medical evidence.

The RSVR may not rely upon his/her own unsubstantiated medical conclusions to reject expert medical evidence provided by the claimant.

Reference: For more information on the basis for rejecting medical evidence, see

· Shipwash v. Brown, 8 Vet. App. 218, (1995), and

· Colvin v. Derwinski, Vet. App. 175 (1991).

e. Supporting Medical Conclusions Support medical conclusions with evidence in the claims folder.

Cite medical information and reasoning to

· link or separate two disabilities, or

· establish or refute prior inception or aggravation.

Cite recognized medical treatises or an independent medical opinion to support a conclusion.

Note: If evidence such as medical treatises or independent medical opinions were relied upon when the rating decision was made, explain this in the rating decision.

f. Considering the POW Protocol Examination Report Carefully consider the prisoner of war (POW) protocol examination reports, because they may provide sufficient background information to relate the veteran’s current symptomatology to the POW experience.

g. Evaluating SMRs Service medical records (SMRs) are generally highly probative, but not necessarily determinative, in the resolution of service connection.

Continued on next page

5. Medical Evidence, Continued

h. Statements From Physicians as Acceptable Evidence A statement from any physician can be accepted for rating purposes without further examination if it

· is otherwise adequate for rating purposes, and

· includes clinical manifestations and substantiation of diagnosis by findings of diagnostic techniques generally accepted by medical authorities.

Examples: Diagnostic techniques generally accepted by medical authorities are

· pathological studies

· x-rays, and

· appropriate laboratory tests.

i. Considering Information in the Claims Folder The information in the claims folder must support the medical conclusions.

Consider the following information in the claims folder:

· applicable dates of events such as

- treatment reports, and

- hospitalizations

· dates covered by the service medical record, identifying at least the month and year

· names of

- VA and private medical facilities

- private physicians, and

- other information sources, and

· items of evidence that were requested but not received.

6. Insufficient Examinations

Introduction This topic contains information about insufficient examinations, including

· improper denials, and

· explaining necessary but unscheduled examinations.

Change Date December 13, 2005

a. Improper Denials Do not deny a claim or reduce an evaluation based upon an insufficient examination.

b. Explaining Necessary But Unscheduled Examinations If the rating activity decides to rate a case where a specialist exam has been recommended by the medical examiner but not scheduled by the Veterans Health Administration (VHA), explain the reason in the rating decision.

7. Reviewing Hospital Reports for Adequacy

Introduction This topic contains information about reviewing hospital reports, including

· handling inadequate VA hospital reports, and

· handling inadequate non-VA hospital reports.

Change Date December 13, 2005

a. Handling Inadequate VA Hospital Reports Request the original clinical records, including the nurses’ and doctors’ orders, if a VA report of hospitalization is inadequate for rating purposes in cases involving either

· injury, aggravation of injury, or death as the result of

- hospitalization

- medical treatment

- surgical treatment, or

- examination, or

· the death of a veteran from NSC causes if

- the veteran had an SC neuropsychiatric disability that reasonably may have impeded, obstructed, or otherwise interfered with the treatment of the condition that caused death , and

- the hospital report does not clarify this issue.

b. Handling Inadequate Non-VA Hospital Reports Request clarification of any hospital report that is inadequate for rating purposes and is received from a

· State hospital

· county hospital

· municipal hospital

· contract hospital, or

· private hospital.

Important: Authorize a VA examination if a satisfactory corrected report cannot be obtained within a reasonable period of time.

8. Reviewing Testimony

Introduction This topic contains information on sworn or certified testimony, including

· using testimony, and

· handling unsworn or uncertified testimony.

Change Date December 13, 2005

a. Using Testimony To be admitted as proper evidence, certain types of testimony must be sworn under oath or properly certified.

Examples: Evidence from court proceedings, depositions, and so on.

b. Handling Unsworn or Uncertified Testimony Make an exact copy of unsworn or uncertified testimony and return the original copy for notarization or certification to the

· claimant

· representative, or

· person testifying.

Note: Return unsworn or uncertified testimony only if the RVSR or Decision Review Officer (DRO) considers the evidence material to a favorable determination of a claim.

Reference: For more information on certifying testimony, see M21-1MR, Part III, Subpart iii, 1.B.8.

9. Lay Evidence

Introduction This topic contains information about lay evidence, including

· acceptable lay evidence, and

· when to use lay evidence.

Change Date December 13, 2005

a. Acceptable Lay Evidence Lay evidence is acceptable for the purpose of establishing service incurrence or aggravation, in the absence of SMRs, for a combat veteran or former POW, if the evidence

· is satisfactory

· is consistent with the circumstances, conditions, or hardships of combat or POW internment, and

· can prevail in spite of the absence of official records showing incurrence or aggravation of the disease or injury during service.

Important: Medical evidence of a link to a current condition is still needed to establish service-related incurrence or aggravation.

Reference: For more information on lay evidence, see the Judicial Review Conference Call dated April 4, 1996.

Continued on next page

9. Lay Evidence, Continued

b. When to Use Lay Evidence A medically untrained individual is not competent to offer medical opinion regarding the etiology of disorders, and such an opinion is generally assigned to little probative weight.

The value accorded to other types of lay evidence depends on such factors as

· the accuracy or clarity of the individual’s memory

· direct personal knowledge or experience, and

· the competence of the reporting person.

Note: An opinion may be discounted if it materially relies on a layperson’s unsupported history as the premise for the opinion.

References: For more information on

· discounting opinions that rely upon a layperson’s history, see Wood v. Derwinski, 1 Vet. App. 190 (1991), and

· using lay evidence to support a claim, see Espiritu v. Derwinski, 2 Vet. App. 492 (1992).

10. Requiring Further Development

Change Date December 13, 2005

a. Evidence Requiring Further Development Further development may be needed to corroborate testimony if the evidence is questionable or conflicting.

This development may include field examinations and/or social surveys to obtain transcripts of original or other appropriate records.

11. Evidence From Non-Department of Veterans Affairs (VA) Sources

Introduction This topic contains information about evidence from non-VA sources, including

· evaluating evidence from non-VA sources, and

· considering conflicting evidence.

Change Date December 13, 2005

a. Evaluating Evidence From Non-VA Sources When evaluating medical and lay evidence from non-VA sources

· accept it at face value unless there is reason to question it, and

· question it if it is conflicting.

b. Considering Conflicting Evidence Use good judgment when evaluating conflicting evidence.

Consider the following issues:

· whether witnesses have a personal interest in the issue

· if there is a basis for bias

· if one party had a better opportunity to know the facts, and

· which version is more reasonable and probable.

12. Weighing the Evidence

Introduction This topic contains information about weighing the evidence, including

· assigning weight to the evidence

· questions to ask when weighing evidence

· handling imbalanced evidence

· handling evidence in equipoise

· considering reasonable doubt

· an example of evidence in equipoise, and

· reaching a conclusion.

Change Date December 13, 2005

a. Assigning Weight to the Evidence After assigning weight to the evidence

· review the evidence in its totality, and

· determine the balancing of scales.

Note: Do not assign weight unjustly or arbitrarily.

b. Questions to Ask When Weighing Evidence Ask the questions listed below when weighing evidence.

· Did the evidence originate in service or in close proximity to service?

· Is the medical opinion supported by clinical data?

· How detailed is the opinion?

· Is the opinion based on personal knowledge or on history provided by another person?

c. Handling Imbalanced Evidence If the evidence shows an overwhelming imbalance, then the evidence requires a decision in that direction, either for or against.

Note: The claim must be granted if all of the evidence is favorable.

Continued on next page

12. Weighing the Evidence, Continued

d. Handling Evidence in Equipoise Resolve reasonable doubt in favor of the claimant if all procurable evidence, after being weighed, is found in approximate balance or equipoise. 38 CFR 3.102 dictates that the veteran prevails when the evidence neither satisfactorily proves nor disproves an issue.

Reference: For more information on applying reasonable doubt, see Alemany v. Brown, 9 Vet. App. 518 (1996).

e. Considering Reasonable Doubt Consider reasonable doubt only when the evidence is in equipoise, not when the evidence weighs either in favor or against the claimant.

f. Example of Evidence in Equipoise In the following example there is no compelling justification to side with either expert:

“Evidence supportive of the claim includes the July 1991 opinion of Dr. T., who treated the veteran for several years prior to his death, that PTSD had been the major factor in the veteran’s suicide. Evidence against the claim includes the January 1992 opinion of the VA physician that the evidence did not point to PTSD as the actual cause of suicide and that the veteran’s suicide had occurred in the setting of alcohol dependence, family breakdown, and depression.”

g. Reaching a Conclusion When weighing the evidence to reach a conclusion

· discuss the evidence in favor of the claim

· discuss the evidence against the claim, and

· explain that

- one set of evidence outweighs the other set, or

- the evidence is in equal balance for and against the claim.

13. Handling Other Considerations in the Analysis

Introduction This topic contains information about miscellaneous concerns that should be addressed in the analysis, including

· explaining grants

· explaining denials

· supporting denials

· the danger of paraphrasing

· addressing complex issues, and

· handling inferred issues.

Change Date December 13, 2005

a. Explaining Grants Grants may not require as extensive an explanation as denials and may be simply explained with a statement, such as “The service medical records demonstrate that the veteran fractured his left leg in service.”

b. Explaining Denials Provide a more in-depth recitation of the facts and a citation or paraphrase of pertinent law and regulations to explain the basis for a denial. Carefully craft the explanation to provide basic information as succinctly as possible.

c. Supporting Denials Support the denial of NSC pension or individual unemployability due to failure to meet the schedular requirements by explaining

· how the disability percentages were assigned for each disability by applying the pertinent diagnostic codes to the evidence, and

· why the veteran is considered to be able to perform work duties, given his/her employment background, and the degree or nature of the SC or NSC disabilities.

Continued on next page

13. Handling Other Considerations in the Analysis, Continued

d. Danger of Paraphrasing Paraphrasing in easy-to-understand language requires care because the paraphrase might

· misstate the law, or

· misstate or mistake medical facts.

Example: Use paraphrased language to help explain why the claim has been disallowed, but do not expressly state, “The law says that….” Simply insert the paraphrase.

e. Addressing Complex Issues Discuss complex issues, such as secondary service connection and aggravation of NSC disabilities by SC disabilities, more thoroughly than simple issues of service connection.

Example: In claims for secondary service connection, address the relationship of the disability claimed by the veteran to the condition for which service connection has already been established.

f. Handling Inferred Issues When an inferred issue is considered in a rating decision, explicitly address the inferred issue in the Reasons for Decision.

If the inferred issue and the primary issue

· share the same fact pattern, then the inferred issue may be incorporated in the same Issue, Decision, and Reasons for Decision numbered item as the primary issue, or

· are each itemized in a separate Decision and Reasons for Decision paragraph, then the discussion of the common fact pattern may be confined to the Reasons for Decision of the primary issue.

Example: The issue statement on the rating decision could be worded as follows: “1. Evaluation of psychotic disorder currently evaluated as 30 percent disabling; Competency to handle disbursement of funds.”

Reference: For more information on inferred issues, see M21-1MR, Part III, Subpart iv, 6.B.3.

[vmo]

To Point: VA C&P Examiner quoted a diagnostic/information sight on the internet at (uptodate 2009) In my research of this site, I found the exact source or quote that the C&P examiner used. Going one step further I followed some of this particular subject using links it provided on the subject and differential diagnosises. In doing so, I found information that directly links my claim and subject, that had the Examiner, had know the correct reason and basis of my claim and gone further in their research, they would have found the same information I did.

My first objective at my upcoming DRO review is to make sure that the true nature of my claim is clairified and then to show how this new information applies directly to my claim.

My question is how much weight would my findings be against those of the C&P Examiner, using their own site source to rebut their reason and basis of their opinion?

My own medical background gives me a bit more insight to medical subjects than the average person, I was a Hospital Corpsman Third Class, and spent time aboard ship conducting unsupervised sick call to the enlisted personel, diagnosing similiar problems and dispensing medications for treatment as well. Also I was responsible in treating the on going problem with allergies to the XO, Giving shots for same. I think I know a bit about Sinusitis and Rhinitis and Allergies to be able to discuss these problems with some amount of expertise, enough at least to be able to diagnose and treat the same in a military setting at least. Oh yea, enter into the records of these same enlisted personel that the VA would use in further their claims.

I just want to know if I have a chance in getting my own information looked upon in at least an equal light to that of the examiner who was only a Nurse Practitioner.

Rockhound Rider ;)

* Is it not interesting that when the veteran submits internet research or quotes medical articles, the VA discredits/downplays them by reminding us we are not physicians?? However, they use them when they are not. The only luck I ever had with quoting or using internet articles, etc., is when I obtained physician's opinion referencing them.

[Chuck75]

We know that a VA examiner often feels that they should attempt to minimize. The reasons behind this may be speculated on, although the end results are the same. We also know that the VA as an entity does not follow veteran's compensation law when it thinks it can get away with it.

Even worse, when the VA has a obvious pattern of unjustified denials, they cannot be easily fought by a group (class action).

Just think what would happen if a federal court ordered a complete review of all denied cases for a year, and, based upon the review results, go back to preceding years one by one, until the error rate was minimal.

I'd get a "qualified" licensed treating physician to comment (IMO?) and reference the information.

Edited May 27, 2010 by Chuck75

[Chuck75]

If the information is not favorable to a claim, the VA will accept it in a heartbeat!

* Is it not interesting that when the veteran submits internet research or quotes medical articles, the VA discredits/downplays them by reminding us we are not physicians?? However, they use them when they are not. The only luck I ever had with quoting or using internet articles, etc., is when I obtained physician's opinion referencing them.