Citation Nr: 1639521 Decision Date: 09/30/16 Archive Date: 10/13/16 DOCKET NO. 96-45 455A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 (West 2014) for a psychiatric disability claimed as due to treatment received at the Albany, New York VA Medical Center (VAMC) in 1974. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran had active service in the United States Marine Corps from March 1971 to January 1973, including service in Vietnam. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in New York, New York. The Veteran's June 1992 claim of entitlement to compensation under 38 U.S.C.A. § 1151 for dental disability resulting from medical and dental treatment at VA facilities beginning in July 1974 was denied in a July 1995 rating decision. In March 1996, the Veteran stated that he was claiming that VA's denial of needed treatment had caused him emotional and mental stress. In March 2005, the RO issued a rating decision in which the Veteran's claim that a psychiatric illness was another additional disability he had developed due to the dental treatment he received at the VA Medical Center (VAMC) in Albany, New York in 1974 was denied. In September 2014, the Board issued a reconsideration decision in which the Veteran's claim of entitlement to compensation under 38 U.S.C.A. § 1151 for a dental disability resulting from medical and dental treatment was denied. That denial was not appealed by the Veteran.) The Board also remanded the issue of entitlement to compensation under 38 U.S.C.A. § 1151 for a psychiatric disability resulting from medical and dental treatment in September 2014. That matter has now been returned to the Board for appellate review. In April 2016, the Board requested a medical expert opinion through the Veterans Health Administration pursuant to 38 U.S.C.A. § 5107(a) and 38 C.F.R. § 20.901. A medical opinion from a VA physician board-certified in psychiatry and neurology was rendered in May 2016. That month, the Veteran and his representative were provided with a copy of the opinion and given 60 days in which to respond; a response was submitted by the Veteran's representative in August 2016. In addition to the paper claims files, there is an electronic file associated with the Veteran's 38 U.S.C.A. § 1151 claim. The Board has reviewed both the paper claims files and the electronic file. FINDINGS OF FACT 1. Post-service, in July 1974, the Veteran was involved in a serious motor vehicle accident that resulted in various injuries, including a closed head injury, multiple facial and nasal fractures, a shattered hip and bone splinters in his liver. 2. The Veteran was initially treated at a private facility and then transferred to the VAMC in Iowa City, Iowa where he underwent open reduction of his mandibular fractures, as well as open reduction and wiring of his maxillary fractures during July and August 1974. 3. The Veteran was thereafter treated at the VAMC in Albany, New York and he was scheduled to have his wires removed; however, the Veteran subsequently returned to the Iowa City VAMC for the wire removal, which was performed under anesthesia in September 1974. 4. The Veteran has a current psychiatric disorder diagnosed as dysthymia as well as a diagnosis of a dependent personality disorder. 5. VA treatment did not result in additional psychiatric disability to the Veteran. CONCLUSION OF LAW The criteria for compensation benefits under 38 U.S.C.A. § 1151 for a psychiatric disability resulting from medical and dental treatment at VA facilities since July 1974 have not been met. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 U.S.C.A. § 1151 (West 1991); 38 C.F.R. § 3.358 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). Proper notice from VA must inform the claimant and his representative, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the decision of the United States Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. The RO received the Veteran's claim for compensation under the provisions of 38 U.S.C.A. § 1151 in March 1996 - prior to enactment of the legislation that established the notice requirements. In June 2002 and August 2005 notice letters, the Veteran was notified of the information and evidence needed to substantiate his claim. The letters informed the Veteran of the criteria to establish entitlement to compensation under the provisions of 38 U.S.C.A. § 1151. Following that notice, the claim was readjudicated in the Supplemental Statement of the Case (SSOC) in January 2015 and he was provided with an opportunity to respond. In addition, a notice letter issued in September 2014 explained the criteria for assigning disability ratings or effective dates in accordance with the Dingess case. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). The duty to assist was met in this case. All pertinent available VA and private treatment records have been obtained and associated with the file. The Veteran was afforded a VA psychological examination in November 2014 and the Board obtained a VA medical expert opinion in May 2016, and both the psychologist and the expert reviewed the Veteran's medical records and history. 38 C.F.R. § 3.159(c)(4). The VA opinions obtained are adequate: they were predicated on a full reading of the Veteran's medical records, the examining psychologist and the reviewing physician considered all of the pertinent evidence of record and the statements of the Veteran, and they provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As a result, the Board finds that additional development by way of another medical opinion would be redundant and unnecessary. See 38 C.F.R. § 3.326 and 38 C.F.R. § 3.327 and Green v. Derwinski, supra. Therefore, the Board concludes that the Veteran was afforded an adequate examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A remand from the Board or from the United States Court of Appeals for Veterans Claims (Court) confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, pursuant to the September 2014 Board remand, pertinent medical records were obtained and added to the evidence of record. The Veteran was also afforded a psychological examination in November 2014. Therefore, substantial compliance has been achieved. The Veteran was provided with notice as to the medical evidence needed to support a 38 U.S.C.A. § 1151 claim, as well as the assistance VA would provide. Therefore, there is no duty to assist that was unmet and the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim decided below. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). All relevant facts with respect to the claim addressed in the decision below have been properly developed. Under the circumstances of this case, a remand would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). II. The Merits of the Claim In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The Veteran prevails in either event. However, if the weight of the evidence is against the Veteran's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he did not receive proper treatment for the removal of wires from his jaw at the Albany VAMC in 1974, or proper dental treatment thereafter and that, due to said mistreatment, he currently suffers from emotional and psychological distress. The Veteran contends that his currently diagnosed psychiatric problems were caused by his VA treatment since July 1974 and that he is therefore entitled to benefits under 38 U.S.C.A. § 1151 for said additional disability. In the alternative, he argues that his claim is for aggravation of his psychiatric problems, to include dysthymia. A. Evidence After separation from active duty, the Veteran was involved in a serious motor vehicle accident in July 1974; he incurred various injuries, including a closed head injury, multiple facial and nasal fractures, a shattered hip and bone splinters in his liver. The Veteran was initially treated at a private facility. After approximately one week, he was transferred to the VAMC in Iowa City, Iowa. While at that VAMC, he underwent open reduction of his mandibular fractures, as well as open reduction and wiring of his maxillary fractures, and was placed in intermaxillary fixation. The Veteran was subsequently treated at the VAMC in Albany, New York and was scheduled to have the wires removed. The records indicate that the Veteran returned to the Iowa City VAMC afterwards for the wire removal which was performed under anesthesia in September 1974. Although the Albany VAMC records do not document its attempt at removal, the Veteran has consistently reported that the Albany VAMC tried and failed to remove his upper wires, causing him considerable pain. He contends that this failed attempt to remove the wires caused him mental stress or exacerbation of his psychiatric problems. The Veteran underwent psychological testing at a VA facility in February 1975. It was immediately evident that he was somewhat depressed - the Veteran confirmed this by his own statements and the description of a number of losses and disappointments. The Veteran was heartbroken over the destruction of his sports car and he described being depressed over his lack of funds and inability to hold a job. There was no mention of the dental wire incident. Testing revealed that the Veteran had mild to moderate anxiety and depression; his depression and anxiety were attributed to situational stress (interrelated physical, economic, employment and family difficulties). In March 1975, the Veteran was diagnosed with anxiety reaction, posttraumatic (accident). The Veteran underwent inpatient psychiatric treatment at a VA facility in early 1976. He stated that he had come to the hospital to gain the motivation that he had lost since his 1974 accident. He also reported that he had been told that he had brain damage due to the accident. The March 1976 discharge diagnoses included passive dependent personality. The Veteran discussed this hospital stay during a hearing conducted at the RO in November 1996; he testified that he was not depressed at that time. The Veteran was treated at the VAMC in Long Beach, California between 1977 and 1979, but did not present with any psychiatric complaints. The Veteran underwent a VA psychiatric examination in October 1980; he reported that since the accident he had noted a major personality change in that his thought processes and speech were slowed considerably and his inability to handle minor frustrations was great. He denied experiencing symptoms of a depressive illness. On mental status examination, he appeared anxious but not depressed. The examiner noted apparent personality change, headaches and slowed mentation since major head trauma in 1974. The Veteran applied for Social Security Administration (SSA) disability benefits and a February 1980 psychological evaluation performed for the Disability Determination Service (DDS) yielded diagnoses of brain trauma and depressive disorder. A September 1980 SSA psychiatric consultant report stated that the Veteran had been in a traumatic automobile accident and that he had an inability to deal with the death of his father. A January 1981 DDS psychiatric evaluation revealed that the Veteran had stated that he was often depressed when he considered his present situation. The psychiatrist stated that test results, especially the IQ scores, were certainly indicative of organic brain damage and that the psychological tests also indicated that the Veteran felt lost, depressed and overwhelmed by pressures. The psychiatrist rendered a diagnosis of dementia secondary to brain trauma. SSA found the Veteran to be disabled due to organic brain syndrome and depression, along with residuals of his physical injuries. The date the disability began was determined by SSA to be the date of the 1974 accident. SSA also determined that the Veteran was unable to manage his benefits. The Veteran subsequently underwent a DDS neuropsychological evaluation in June 1983. He reported that he had been consistently depressed since his wife left him and took the children. A January 1995 VA treatment note indicates that the Veteran felt that his depression was getting aggravated due to his present disability. The Veteran subsequently received mental health treatment at a VA facility in 1996. A March 1996 off-service note indicates that the Veteran was being followed for the difficulties he was encountering in daily life and that he also remained preoccupied with his surgery related to the 1974 accident. The Veteran was noted to not be taking any medication for his psychiatric disorders diagnosed as dysthymia and dependent personality disorder. An October 1996 written statement from a VA psychologist who had treated the Veteran indicated that the psychologist thought that the Veteran might suffer from residual cognitive and personality effects of the 1974 accident. The report of a July 1997 DDS psychological evaluation indicated that the Veteran reported that he had a mild mood disturbance and that he was not currently receiving treatment at VA. His full scale IQ was listed as 104. The examiner rendered a diagnosis of dysthymia and stated that the Veteran had the cognitive abilities to do the work it had been reported he was pursuing. The examiner also stated that the Veteran should be able to independently manage his benefits. A September 1998 VA psychology note indicates that the Veteran presented with complaints of a mild to moderate depression over the prior few months. The Veteran described the depression as being precipitated by a respiratory illness that occurred in April and May. An October 2000 VA mental health note includes a clinical impression of depression NOS and cognitive deficits NOS. The report of a DDS psychiatric evaluation conducted in January 2001 included diagnoses of dysthymic disorder and cognitive disorder NOS. An November 2004 VA treatment note, the Veteran stated that following the 1974 accident he was not as popular any more, was difficult to get along with and no longer found himself to be a go-getter. Although he had been referred for evaluation for depression, the Veteran's current chief complaint was related to ongoing difficulties with managing chronic pain. He expressed dissatisfaction with his long-term and present care with VA. He also reported family difficulties and not being able to clean up his yard as ordered by code officials because of pain. The clinical impression was a dysthymic disorder. The Veteran was noted to have symptoms of depression that were complicated by chronic physical and psychosocial problems and cognitive/behavioral problems from head trauma, chronic degenerative pain, inability to maintain restorative sleep and difficulties in his family environment. That same month, the Veteran also complained of a lack of sleep and pain. A March 2005 VA behavioral health note reflects that the Veteran had been diagnosed with organic brain syndrome and dysthymia. He reported that he was depressed and related his dysthymia to adverse life events. The Veteran was described as having overwhelming stresses involving legal problems with his son as well as his own health issues. An August 2005 note described the Veteran as having dysthymia and memory/cognitive problems secondary to a severe closed head injury. The report of a DDS psychiatric evaluation conducted in August 2005 included diagnoses of major depressive disorder and personality disorder NOS with paranoid features. The examiner also stated that the Veteran was able to manage his own funds. More recent VA treatment records, dated between 2011 and 2014, include notations of history of depression, dysthymia and traumatic brain injury (TBI); the Veteran was not on any psychotropic medications. A June 2012 VA mental health consult note indicates that the Veteran complained of depressive symptoms. He was noted to have been seen intermittently by behavioral health providers since 2000. The Veteran reported continued physical limitations. An August 2012 mental health note indicated that the Veteran had multiple medical issues as well as situational stressors that could affect his mood. A diagnosis of chronic pain syndrome was rendered in October 2013. A diagnosis of depressive disorder, not elsewhere classified (NEC) was rendered in December 2013. The Veteran was afforded an examination by a VA psychologist in November 2014; the psychologist rendered an Axis I diagnosis of dysthymia and noted that the Veteran had a relevant medical diagnosis of TBI. The examiner also rendered a clinical impression of a dependent personality disorder, but further stated that the Veteran's primary complaint was of depression/dysthymia. The psychologist concluded that the Veteran's affective difficulties, personality difficulties and cognitive difficulties were the result of, or were aggravated by, the major head trauma in 1974. In a December 2014 addendum, the psychologist who examined the Veteran in November 2014 noted that, according to the DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (DSM-V), a personality disorder was often manifested by an enduring pattern involving the range, intensity, lability and appropriateness of emotional response. The psychologist opined that the Veteran's mental health treatment notes suggested that his presentation of distress/dysthymia and/or depression over the years had been a focus of things other than the 1974 dental wire incident. The psychologist opined that it was less likely than not that the claimed psychiatric condition was incurred in, caused by, or aggravated beyond its natural course by the dental wire incident. In May 2016, the Board obtained an opinion from a VA physician who is board-certified in psychiatry and neurology. The VA physician reviewed the Veteran's records and opined that none of the Veteran's psychiatric pathology diagnosed since 1974 was causally or etiologically related to the dental wire removal attempt. The medical expert further opined that the described incident would not result in life-long psychological pain. The physician noted that dysthymia was chronic, low-grade depression and that the Veteran's dysthymia diagnosis reflected a lot of losses and other suffering stretching from 1974 to 2016, including his father's death, his wife leaving him and taking away his children and other medical problems. Given the observations recorded in most of the Veteran's medical treatment charts that the Veteran presented as a pleasant person with no significant anger outbursts, the reviewing physician concluded that the single incident with the dental wires was not likely to have caused severe lifelong psychological and emotional trauma. The medical expert opined that the dental wire incident did not aggravate, contribute to or accelerate any preexisting psychiatric pathology. B. Analysis The Board notes that effective October 1, 1997, 38 U.S.C.A. § 1151 was amended such that negligence or similar instance of fault by VA would generally have to be shown for a claimant to obtain compensation under the statute. This amendment, however, does not apply to cases filed prior to October 1, 1997. Pub. L. No. 104- 204, § 422(a)-(c) (1996). See Brown v. Gardner, 115 S. Ct. 552 (1994). As this claim was filed prior to the effective date, the former statute must be applied. VAOPGCPREC 40-97. In pertinent part, 38 U.S.C.A. § 1151 (as in effect prior to October 1, 1997) provides that where any veteran shall have suffered an injury, or an aggravation of an injury, as the result of hospitalization, medical or surgical treatment, and not the result of such veteran's own willful misconduct, and such injury or aggravation results in additional disability, disability or death compensation shall be awarded in the same manner as if such disability, aggravation, or death were service-connected. 38 C.F.R. § 3.358, the regulation implementing that statute (as in effect prior to October 1, 1997) provides, in pertinent part: (c) Cause. In determining whether such additional disability resulted from a disease or injury or an aggravation of an existing disease or injury suffered as a result of . . . hospitalization, medical or surgical treatment . . . the following considerations will govern: (1) It will be necessary to show that the additional disability is actually the result of such disease or injury or an aggravation of an existing disease or injury and not merely coincidental therewith. (2) The mere fact that aggravation occurred will not suffice to make the additional disability compensable in the absence of proof that it resulted from disease or injury or an aggravation of an existing disease or injury suffered as the result of . . . hospitalization, medical or surgical treatment, . . . (3) Compensation is not payable for the necessary consequences of medical or surgical treatment . . . properly administered. . . "Necessary consequences" are those which are certain to result from, or were intended to result from, the . . . medical or surgical treatment administered. Thus, neither evidence of an unforeseen event nor evidence of VA negligence would be required in order for this claim to be granted. The provisions of 38 U.S.C.A. § 1151 required merely that there be a causal connection between the medical or surgical treatment and the injury. As reflected in his November 1996 personal hearing testimony and various written statements, the Veteran contends that his diagnosis of dysthymic disorder specifically emanates from his lack of dental treatment over the years. The record reflects that the Veteran has been denied entitlement to dental treatment on several occasions over the years since 1974. However, an adjudicative determination that an individual is not eligible to receive VA medical care is not VA medical treatment as contemplated by 38 U.S.C.A. § 1151. See Jimison v. West, 13 Vet.App.75 (1999). Accordingly, the contention that the Veteran should be awarded compensation benefits under 38 U.S.C.A. § 1151 on the theory his psychiatric condition was caused by any decision that he was not eligible for VA treatment or worsened following any decision that he was not eligible for VA treatment is without merit. Turning to the Veteran's contention that his depression or dysthymia was caused by the failed dental wire removal in 1974, it is clear from a review of the clinical evidence of record that the Veteran incurred a severe closed head trauma and multiple other serious injuries in a car accident that occurred prior to the dental wire incident and that the those injuries and the head trauma are the etiological cause of the onset of the Veteran's psychiatric pathology. There are several medical opinions of record indicating that the etiology and onset of the psychiatric problems were related to the 1974 car accident. The report from the psychologist who examined the Veteran in November 2014, along with the associated December 2014 addendum, indicates that it was less likely than not that the claimed psychiatric condition was incurred in, caused by, or aggravated beyond its natural course by the dental wire incident. Furthermore, after a complete review of the claims file, the May 2016 opinion rendered by a VA physician board-certified in psychiatry and neurology was that it was not likely that the Veteran's psychiatric pathology was caused by or made worse by the 1974 unsuccessful attempt to remove the dental wires at the Albany VAMC. Given that there is no competent evidence to contradict these opinions, the claim must be denied. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, supra. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, psychiatric pathology is not the type of disorder as to which a lay person can provide competent evidence on questions of etiology or diagnosis. See Robinson v. Shinseki, 557 F.3d 1355 (2009). The Veteran is competent to provide statements as to matters within his observation and personal knowledge, such as his symptoms and medical history. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (holding that competent evidence is not required when the issue involves either the diagnosis or the etiology of a disability); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (listing situations in which lay evidence is competent and sufficient to establish the diagnosis of a condition); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that Veteran was competent to testify as to factual matters of which he had first-hand knowledge such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (holding that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witness's personal knowledge). However, unlike the Veteran's symptoms and medical history, whether there is a relationship between the Veteran's current psychiatric complaints and the 1974 attempted removal of dental wires is a determination that is medical in nature because it cannot be made based on lay observation alone. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, such as the presence of varicose veins, but not with respect to determinations that are "medical in nature"), overruled on other grounds Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that unlike varicose veins, rheumatic fever is not a condition capable of lay diagnosis); Layno, 6 Vet. App. at 469-71 (noting that a veteran is competent to report difficulty breathing, but not to diagnose the condition as bronchial asthma). A person making a determination that is medical in nature must have the appropriate medical training or expertise in order for his opinion to be considered as competent evidence. See Layno, 6 Vet. App. at 469-70 (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Because the Veteran has not been shown to have such specialized training or expertise, his lay opinions as to whether there is additional disability present and whether there is any relationship between the alleged additional disability and the 1974 attempted removal of dental wires are not competent and therefore have no probative value. See Id. Thus, the Board cannot give decisive probative weight to the opinions of the Veteran as to the etiology of the claimed psychiatric pathology because he is not qualified to offer such opinions. Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Indeed, even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive and, thus, not ultimately probative. Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the Veteran's psychiatric claim under 38 U.S.C.A. § 1151. Since the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). (CONTINUED ON NEXT PAGE) ORDER Compensation under the provisions of 38 U.S.C.A. § 1151 for additional psychiatric disability claimed as a result of medical and dental treatment rendered by VA healthcare personnel beginning in July 1974 is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs