Rhinehart v. Scutt (894 F.3d 721, 2018)

JOHN K. BUSH, Circuit Judge.

The Eighth Amendment bars the "inflict[ion]" of "cruel and unusual punishments." U.S. Const. amend. VIII. This case addresses how that constitutional provision applies to the medical treatment rendered by two prison doctors to an inmate who suffered from end-stage liver disease ("ESLD").

Kenneth Rhinehart ("Rhinehart"), then a prisoner, filed this action under 42 U.S.C. § 1983, alleging that medical providers associated with the Michigan Department of Corrections ("MDOC") denied him necessary treatment for his ESLD. When he died, his brothers, Lewis and David Rhinehart (the "Rhineharts"), filed an amended complaint on behalf of his estate. After defendants filed motions to dismiss and motions for summary judgment, only the Rhineharts' Eighth Amendment claims against Dr. Adam Edelman and Dr. Vernon Stevenson (the "Defendant Doctors") remained. The district court granted summary judgment to the Defendant Doctors, and the Rhineharts appealed. For the reasons below, we AFFIRM the judgment of the district court.

I.

In the summer of 2009, Rhinehart was an inmate at Alger Maximum Correctional Facility ("Alger") in Munising, Michigan. He was 58 years old but in poor health. He had been suffering from many medical conditions, including liver disease, and for the past four years, he had been experiencing general malaise, weight loss, and poor appetite. In August 2009, his prison doctor, Aster Berhane, ordered a CAT ("CT") scan of his abdominal area, which revealed a suspicion of bile duct cancer. The parties agree that Rhinehart did not in fact have cancer then or at any other time before his death.

But that was unknown in the fall of 2009, so Dr. Berhane arranged to transfer Rhinehart downstate for further investigation of this potential cancer. She contacted defendant Dr. Edelman about transferring Rhinehart to Cotton Correctional Center ("Cotton"). Dr. Edelman was the medical director for utilization management at Corizon Health Inc. ("Corizon"), a company responsible for on-site medical services for all state inmates. He studied internal medicine, but his experience was mainly administrative. His job was to review requests for outside treatment, which other medical providers generally submitted on a form called a 407. Such requests were necessary for a prisoner to be referred to a specialist within Corizon's referral network.

Dr. Berhane arranged an expedited, doctor-to-doctor transfer from Alger to Cotton. She also submitted a 407 request to refer Rhinehart to an oncologist (cancer specialist) or hepatologist (liver specialist) for a biopsy of the potential cancer. Dr. Edelman approved the referral request.

Around that same time, Dr. Berhane also contacted defendant Dr. Stevenson-a general internist doctor, Corizon employee, and the senior doctor on staff at Cotton-to inform him about Rhinehart's medical issues. During his deposition, Dr. Stevenson testified that he understood that Rhinehart had "very urgent issues" and needed to be seen by a specialist for abnormal liver findings. R.263-3, Stevenson Dep., Page ID# 5025-26.

The Rhineharts presented evidence that the Cotton facility assigned inmates to doctors based on their prison number, and that generally, an assigned doctor was responsible for developing an inmate's treatment plan and examining that inmate (unless the doctor was unavailable to do so). Rhinehart's prison number revealed that he was assigned to Dr. Stevenson.

Rhinehart was transferred to Cotton on October 26, 2009, but saw no doctor until about two months later. This delay is attributable to a failure by the nursing staff at Cotton in processing Rhinehart's intake and scheduling him for a medical-provider visit. During the time that Rhinehart had not seen a doctor, he filed complaints and grievances expressing concern about not being referred for a biopsy of his liver to determine his cancer risk. He also asked to see a doctor because of increasing pain in his liver and abdominal area and consequent difficulty in performing his porter job.

Dr. Stevenson testified that he did not receive notifications of inmate complaints or copies of grievances. But he recalled that in mid-December 2009, Cotton's Health Unit Manager, Beth Gardon, told him that Rhinehart had been at Cotton for six weeks and had not been seen for an intake. Upon hearing this, Dr. Stevenson directed Gardon to bring Rhinehart in for an appointment. The Cotton staff scheduled Rhinehart to see Dr. Stevenson three weeks later. When it came time for Rhinehart's appointment, however, Dr. Stevenson was too busy, so he arranged for another doctor, Dr. Padmaja Vemuri, to examine Rhinehart.

From early January until the end of February 2010, Rhinehart had several appointments with prison medical providers but none with Dr. Stevenson. Dr. Vemuri first examined Rhinehart on January 4, 2010; he complained about weight loss and discomfort in his liver area. Dr. Vemuri noted that a request for Rhinehart to be referred to an oncologist had already been approved, and she set forth a plan to have the oncology appointment made, to have laboratory testing conducted, and for Rhinehart to have an appointment with the gastrointestinal clinic. After this appointment, Rhinehart attended several more doctor appointments in January 2010 with Dr. Vemuri and another prison doctor, Dr. Zivit Cohen. On February 3, 2010, Dr. Cohen obtained approval for an ultrasound of Rhinehart's liver, which was completed about a week later.

Rhinehart was not satisfied with the care that he had received. He filed a grievance related to his first appointment with Dr. Vemuri in which he stated that he was experiencing severe pain and she failed to prescribe him pain medication. After that, he sent letters of complaints to medical and legal officials and filed a pro se lawsuit raising his concerns about his risk for cancer and the lack of care he was receiving.

Rhinehart's grievance for lack of pain medication was upheld on January 22, 2010. A little less than a month later, Dr. Cohen saw him for his complaints of abdominal discomfort and prescribed him pain medication.

Shortly after that appointment, a Jackson, Michigan newspaper ran an article reporting that Rhinehart probably had cancer and was in pain but had not been given a referral to a specialist, a liver biopsy, a treatment plan, pain pills, or an explanation for the delay. The article was followed by a call from the ACLU to the Michigan Attorney General's Office. This call resulted in a few internal emails among prison medical staff that showed some confusion about whether Rhinehart's cancer risk had been ruled out.

Three days after this exchange of emails, on February 25, 2010, Dr. Stevenson and Dr. Eddie Jenkins (the Regional Medical Director) examined Rhinehart. Rhinehart complained of abdominal pain, nausea, bilateral back and flank pain, blood in his urine, and a decreased urine stream. Dr. Stevenson "reassured" Rhinehart that he had no mass or cancer, ordered urine and laboratory tests, and scheduled a follow-up appointment in three weeks.

After that, Dr. Cohen monitored Rhinehart. She regularly examined him, ordered laboratory tests, and treated his pain. On March 8, Dr. Cohen saw Rhinehart for his ESLD. Dr. Cohen conducted a physical exam and noted improvements, including that he presented with an "okay" appetite, stable weight, and a reduction in his pain under the prescribed pain medication. In April, Rhinehart had additional follow-up appointments. Dr. Cohen conducted another full examination, prescribed Ensure, ordered lab work, and scheduled a one-month follow-up appointment. Then in May, Dr. Cohen gave Rhinehart a detail for a "light duty" work assignment to accommodate his pain. And when Rhinehart reported increased pain, Dr. Cohen prescribed methadone for him, which, during his May follow-up appointment, Rhinehart reported was working well.

But that summer, Rhinehart's condition took a turn for the worse. On June 20, 2010, about eight months after his transfer to Cotton, the Cotton medical staff transferred Rhinehart to the emergency room of Allegiance Hospital. The Cotton staff sent him there because he had been complaining of bloating, increased pain in his spleen/liver, general malaise, and fatigue. At the hospital, he presented with constipation, hallucinating, and abdominal pain. He was admitted and treated until his discharge on June 30, 2010.

A brief review of the Rhineharts' medical literature and expert testimony is necessary here. Liver disease can lead to cirrhosis of the liver-the deterioration of the liver when scar tissue replaces healthy liver tissue. Cirrhosis causes increased pressure in the veins that carry blood to and from the liver. This increased blood pressure can cause the formation of dilated veins in the esophagus, esophageal varices. These varices carry the risk of bleeding, a risk that increases along with the pressure and sizes of the varices. One way for a specialist to diagnose esophageal varices is by inserting a scope into the esophagus-a procedure known in the medical field as Esophagogastroduodenoscopy ("EGD") scoping. When esophageal varices are found, "first level" treatment includes prescribing medications such as beta blockers (which decrease blood pressure), EGD scoping and ligation banding performed by a specialist (which obliterate the varices), or some combination of both.

After Rhinehart was admitted into the hospital, he underwent a series of tests, including a CT scan of his abdomen with contrast, an MRI, and an ultrasound. These tests revealed no liver mass but extensive portal venous thrombosis (blood clotting in the vein that carries blood to the liver). His hospital records show that "no definitive intervention was felt to be indicated other than beta blockers and an EGD to rule out/assess esophageal varices." R.259-2, Discharge Summary, Page ID# 4706. Dr. Lynn Schachinger, a hospital gastroenterologist, performed an EGD, which revealed four columns of esophageal varices with no active bleeding; he successfully placed seven ligation bands to obliterate the varices.

In his post-procedure report, Dr. Schachinger recommended that Rhinehart "followup [sic] as an outpatient with the prison gastroenterologist for additional EGD with esophageal banding as necessary." R.177, Endoscopy Report, Page ID# 2421. In his deposition, Dr. Schachinger testified that "the risk of [Rhinehart's] bleeding from [his varices] was higher because of the size of the varices" and that if he had a patient with Rhinehart's conditions under his exclusive control, he would have reevaluated Rhinehart's varices a month later. R.263-13, Schachinger Dep., Page ID# 5399-4000. He also testified that he "probably would have referred [such a patient] to a tertiary care center that performs a liver transplant to see if at some point that might become necessary," but emphasized that the decision to order a transplant would be "up to the hepatologist" as "they deem necessary." Id. at 4000. The Rhineharts' expert witness, gastroenterologist Dr. Stuart Finkel, agreed. In his deposition, he testified that in the weeks and months after Rhinehart's June 2010 hospitalization, "[i]n the private world setting, Dr. Schachinger would have recalled the patient in a timely fashion for a repeat [EGD] and banding session." R.263-14, Finkel Dep., Page ID# 5442. He also agreed with Dr. Schachinger's opinion that he would have referred Rhinehart for evaluation for a liver transplant. Id.

The day after his discharge from the hospital, Dr. Cohen saw Rhinehart. She reviewed his hospital records, ordered lab work, prescribed a beta-blocker medication (Propranolol ) to reduce his blood pressure, and scheduled a one-week follow-up appointment. Rhinehart was not referred for follow-up appointments with a gastroenterologist. Instead, Dr. Cohen continued to monitor Rhinehart that month, examining him on July 8 and again on July 19.

The next month, August 2010, Dr. Stevenson left his employment with Corizon. At that time, Dr. Edelman was still working for Corizon, but he did not become re-involved in Rhinehart's healthcare until May 17, 2011.

In June 2011, the Cotton medical staff again sent Rhinehart to Allegiance Hospital's emergency room after he complained of increased abdominal pain. R.178, Progress Note, Page ID# 2437-40. An MRI showed "progression of disease on comparison with previous imaging from June of 2010." Id . at Page ID# 2437. A CT-guided biopsy was negative for a malignancy. The gastroenterologist's discharge plan included a repeat MRI of Rhinehart's abdomen in four weeks and, if Rhinehart's tumor worsened, an evaluation at a tertiary care center. Id . at Page ID# 2437, 2439. Dr. Edelman approved the request for Rhinehart to have an MRI of his liver on July 5, 2011. The results were unchanged in comparison to the MRI completed a month earlier. The MRI also showed blockage of the portal vein (the vein that carries blood to the liver). After Rhinehart had blood drawn, Dr. Nancy McGuire, who was now Rhinehart's medical provider, discussed his case with Dr. Edelman.

Around this same time, Rhinehart had moved for a temporary restraining order requesting that he be seen by a hepatologist, oncologist, or qualified liver specialist to be evaluated for a liver transplant-the only curative treatment option for ESLD. In responding to the motion, Dr. Edelman and Dr. Kosierowski (an oncologist and Corizon consultant) signed affidavits. They declared that they had discussed Rhinehart's case and had determined that there was no need to send Rhinehart to a specialist. R.258-4, Affidavits of Dr. Edelman and Dr. Kosierowski, Page ID# 4500-09. Both Dr. Edelman and Dr. Kosierowski stated in their affidavits that Rhinehart likely did not have cancer. Id. As for a liver transplant, they avowed that Rhinehart was an unlikely candidate. Id. In his affidavit, Dr. Edelman explained how liver transplants are assigned and why Rhinehart was not realistically eligible to receive one:

Liver transplants are judged by the Model for End-State Liver Disease (MELD) system to prioritize patients waiting for a liver transplant. The range is from 6 (less ill) to 40 (gravely ill). The individual score determines how urgently a patient needs a liver transplant within the next three months. The number is calculated using the most recent laboratory tests. Mr. Rhinehart, based on his most recent laboratory tests, would likely score very low on the scale and therefore would not be considered for transplant at this time.

Id. at 4507-08.

In his deposition years later, Dr. Finkel disputed Dr. Edelman's and Dr. Kosierowski's opinions about Rhinehart's eligibility for a liver transplant. He opined that "livers are allocated to patients who are in the worst condition. And then, if nobody is available who is a match, it goes down the line to better candidates. Maybe he would have received a liver, maybe he wouldn't have received a liver, but he would have been a candidate." R.263-14, Finkel Dep., Page ID# 5442. Dr. Finkel admitted that Rhinehart's MELD score of 7 (out of 40) "would not have placed him at the top of the list for [a] liver transplant" but opined that "contrary to Dr. Edelman's testimony, it would not have eliminated him or knocked him out of contention." Id. Dr. Finkel also testified that because Rhinehart had such a low MELD score, he "probably would have done very well with a liver transplant." Id.

On October 12, 2011, Dr. Edelman had a telemedicine appointment with Rhinehart. During the appointment, Dr. Edelman rejected Rhinehart's request to see an outside liver specialist for evaluation for a liver transplant. He reiterated that based on Rhinehart's blood work, his liver health was too good for him to qualify, and Dr. Edelman assured Rhinehart that the prison medical staff could provide his necessary treatment.

Two weeks later, on October 26, 2011, Rhinehart was rushed to Allegiance Hospital after he reported abdominal pain and vomiting large amounts of blood. Dr. Schachinger performed an emergency EGD, discovered four columns of severe esophageal varices that were bleeding, and successfully treated them with ligation banding. At his deposition, Dr. Schachinger testified that if Rhinehart's varices had been monitored after the first banding procedure in June 2010, and if additional banding had occurred, it was possible that this bleed could have been prevented. Dr. Finkel agreed. In his deposition, he opined that the likelihood of Rhinehart's esophagus bleeding in October 2011 "would have been reduced or eliminated entirely" if Dr. Schachinger's recommendation for follow-up gastroenterologist appointments in June 2010 were followed. R.263-14, Finkel, Dep., Page ID# 5441.

After treating Rhinehart in October 2011, Dr. Schachinger laid out a recommended plan of care in his post-procedure report. One of his recommendations was that Rhinehart's prison doctors transfer him to a tertiary care institution to undergo a transjugular intrahepatic portosystemic shunt ("TIPS") procedure, which is used to decompress the pressure in the portal vein to decrease the risk of esophageal bleeding. R.259-2, Endoscopy Report, Page ID# 4713. He recommended that "the transfer should occur if [Rhinehart] has additional bleeding" because more banding would not be an option. Id. He summarized Rhinehart's condition: "The patient's prognosis is quite poor and guarded at this time and there is a fair chance that this is going to bleed again and he may bleed to death and I recommend that he be transferred." Id.

In his deposition, Dr. Schachinger testified that he recommended that Rhinehart's healthcare providers "consider a TIPS procedure" because it was "medically ... the right move," as Rhinehart had severe varices, which had bled, and a TIPS has been shown to decrease his risk of bleeding. R.263-13, Schachinger Dep., Page ID# 5403. He opined that this procedure would have stopped esophageal bleeding. Id. But he also recognized that there are serious risks in performing a TIPS, including a chance of the patient developing brain disease. Id. at Page ID# 5407.

Dr. Finkel testified that a TIPS is the "gold standard" of treatment for patients with esophageal varices. R.263-14, Finkel Dep., Page ID# 5435. He opined that a TIPS is "a minimally invasive procedure," that a patient with Rhinehart's MELD score would "have a 100 percent chance of survival following [a] TIPS for the first year," and that Rhinehart "had the potential of living for another five years without a liver transplant" had he received the TIPS. Id. at Page ID# 5440. Dr. Finkel recognized a risk of hepatic encephalopathy-a form of brain disease-from a TIPS procedure but estimated Rhinehart's risk at "less than 20 percent." Id.

The day after Rhinehart's esophageal banding, a hospitalist, Dr. Mohmmed Al-Shihabi, contacted Dr. Edelman and Dr. Stieve about the possibility of transferring Rhinehart to a tertiary center for an evaluation and possible TIPS procedure. R.259-2, Progress Note, Page ID# 4715-16. In his report, Dr. Al-Shihabi wrote that Dr. Edelman "denied this transfer and he said that we just need to continue monitoring the patient here, even though Dr. Schachinger said that if the patient bleeds he cannot do to [sic] anything and the patient will be unstable to be transferred or do anything and the patient will definitely die." Id. at 4715. Dr. Al-Shihabi noted that Dr. Stieve also denied the transfer. Id.

In his deposition, Dr. Edelman testified that he had "denied the transfer because [he] talked to Dr. Stieve about it." R.263-2, Edelman Dep., Page ID# 5001. Indeed, in an internal administrative progress note, Dr. Stieve explained that he and Dr. Edelman discussed the merits of transferring Rhinehart for a TIPS evaluation. R.259-1, Progress Note, Page ID# 4689. According to Dr. Stieve's note, the doctors recognized that a TIPS could reduce a "hypothetical" risk of re-bleed but that the procedure would not prolong Rhinehart's life and came with an increased risk of brain disease. Id.

During his deposition, Dr. Stieve discussed his familiarity with the medical issues involved in the decision. He testified that he dealt daily with patients who had esophageal varices and that "[e]sophageal varices banding was a very common thing for me to be involved with[.]" R.340-1, Stieve Dep., Page ID# 8589. He likewise testified that he "had been involved with approving other TIPS procedures for other inmates," but considered those inmates to have "different circumstances" because "[t]hey were being released so that they could get a liver transplant." Id. at Page ID# 8590, 8589 ("I would often evaluate inmates to see whether they were a candidate for a TIPS procedure"). And although he conceded that he was not a gastroenterologist, radiologist, or hepatologist, he could explain how TIPS and banding procedures were performed and what they entailed. Id. at Page ID# 8589-90.

Dr. Stieve testified that he and Dr. Edelman disapproved transferring Rhinehart for evaluation for a TIPS because he "was stable, hadn't rebled, and we had a treatment plan that we thought would be effective in controlling further bleeds, that giving nonspecific beta-blocker therapy and 24 hour health care surveillance, which is available in all of our prisons." Id. at Page ID# 8613. He emphasized that Dr. Schachinger recommended that the transfer occur "if he has additional bleeding, and I have no evidence that after he performed the banding there was any additional bleeding." Id. at Page ID# 8608, 8612. And he testified that he and Dr. Edelman agreed that "[i]f the patient had needed the TIPS procedure, we would have agreed on it and approved it but neither one of us thought that [a TIPS] was an appropriate procedure at that particular clinical junction." Id. at Page ID# 8590.

In February 2012, a few months after denying the request for a TIPS-procedure consult, Dr. Edelman left Corizon. Almost a year later, in January 2013, Rhinehart slipped and fell on a wet surface and broke his hip. Rhinehart agreed to undergo surgery to repair the injury, but unfortunately, he did not survive the recovery. He died of a morphine overdose in February 2013 because his liver could not metabolize the morphine used to control his pain. He suffered no esophageal bleed between October 2011 and his death.

II.

This action began on March 29, 2011, when Rhinehart filed a pro se lawsuit alleging that his medical providers were ignoring his pain, fear of cancer, and his desire to receive a liver transplant. The district court denied his emergency injunctive motions, and this court affirmed. See Rhinehart , 509 F. App'x at 516. Soon after, Rhinehart passed away, and his brothers (as joint personal representatives of his estate) then filed an amended complaint.

The Defendant Doctors moved for summary judgment on the Rhineharts' claims of deliberate indifference to Rhinehart's serious medical needs. The magistrate judge issued a Report and Recommendation to deny summary judgment, and the district court adopted the Report and Recommendation in full.

About a year later, with the case going on to trial, the Defendant Doctors raised a Daubert challenge against Dr. Finkel. They objected to Dr. Finkel's testifying about Rhinehart's alleged fear of cancer and pain and suffering from not being evaluated for a TIPS procedure. The district court granted the motion in part. It decided that Dr. Finkel could testify "consistent with his expertise," about "Rhinehart's fears" because "any emotional or physical harm he suffered as a result of their indifference is relevant to the damages Plaintiffs seek." But the court precluded testimony on whether "Rhinehart suffered physical pain due merely to hypertension" because "[n]one of the materials before the Court ... assures the Court that [Dr.] Finkel's opinion [on that topic] is based upon sufficient facts and reliable methods." The district court ordered the Rhineharts to give "one day's notice before calling Finkel" to testify so that the court could hold "a short hearing" on "precisely what Finkel intends to offer and to make any necessary rulings that will curb impermissible testimony."

While the Daubert motion was still pending, the Defendant Doctors filed their second motion for summary judgment. They argued that this court's decision in Mattox v. Edelman clarified the requirements for establishing a deliberate-indifference claim based on a medical need that "has been diagnosed by a physician as mandating treatment." 851 F.3d 583, 598 (6th Cir. 2017). They also relied on the de bene esse trial depositions of Dr. Stieve and Dr. Kosierowski. After the district court ruled on the Defendant Doctors' Daubert motion, it granted summary judgment in their favor. Rhinehart v. Scutt , 2017 WL 3913333, at *1 (E.D. Mich. Sept. 7, 2017).

The district court held that because the Rhineharts' case was based on the treatments Rhinehart did and did not receive for his ESLD, they had to show "that Rhinehart's needs were diagnosed by physicians as mandating treatment and that Defendants failed to treat him or so inadequately treated him that he suffered a verified medical injury." Id. at *2. The court determined that at all relevant times Rhinehart received some treatment for his ESLD. Id. at *4-10. It rejected the Rhineharts' claims against Dr. Stevenson because they presented no "verified medical evidence" that Rhinehart suffered a harm because of Dr. Stevenson's alleged failings. Id. at *3-7. Similarly, the court determined that the Rhineharts failed to introduce "verified medical evidence" showing harm from either Dr. Edelman's failure to ensure that Rhinehart saw a specialist in early 2010 or his failure to refer him for evaluation for a liver transplant in October 2011. Id. at *7, *10-11. Finally, in addressing Dr. Edelman's denial of a specialist's request for Rhinehart to be evaluated for a TIPS procedure, the court determined that this "amounted to a mere disagreement among medical professionals" and thus did not constitute deliberate indifference to Rhinehart's serious medical needs. Id. at *9.

The Rhineharts appealed and challenge the district court's decisions on the Defendant Doctors' second motion for summary judgment and Daubert motion.

III.

We review a district court's grant of summary judgment de novo. Richmond v. Huq , 885 F.3d 928, 937 (6th Cir. 2018). Summary judgment is appropriate only when there is "no genuine dispute as to any material fact" and defendants are "entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). A genuine issue of material fact exists when "the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Anderson v. Liberty Lobby, Inc. , 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). In determining "whether the evidence presents a sufficient disagreement to require submission to a jury or whether it is so one-sided that one party must prevail as a matter of law," this Court must view all the evidence and draw all reasonable inferences in the light most favorable to the non-moving party. Id. at 251-52, 255, 106 S.Ct. 2505.

Section 1983 provides a federal cause of action against government officials who, while acting under color of state law, "deprived the claimant of rights, privileges or immunities secured by the Constitution or laws of the United States." Bennett v. City of Eastpointe , 410 F.3d 810, 817 (6th Cir. 2005) (citing McKnight v. Rees , 88 F.3d 417, 419 (6th Cir. 1996) ). The Rhineharts assert that the Defendant Doctors deprived Rhinehart of his constitutional rights by acting deliberately indifferent to his serious medical needs. The Defendant Doctors do not dispute that they acted under color of state law but deny that they violated Rhinehart's constitutional rights.

The Eighth Amendment prohibits the "inflict[ion]" of "cruel and unusual punishments" against those convicted of crimes. U.S. Const. amend. VIII. Incarceration is a form of criminal punishment subject to the Eighth Amendment's protections. See generally Howard v. Fleming , 191 U.S. 126, 135-36, 24 S.Ct. 49, 48 L.Ed. 121 (1903). There is a paucity of evidence from the Founding era, however, about how the Eighth Amendment was commonly understood to operate in the prison context. Imprisonment was not a typical form of punishment in this country during the eighteenth century. "Jails were used primarily to hold for trial people who could not make bail and for debtors who could not pay off their creditors." J. Filter, Prisoners' Rights: The Supreme Court and Evolving Standards of Decency 46 (2001); see also M. Mushlin, Rights of Prisoners § 1.2, at 5-6 (5th ed. 2017). "Persons who had been convicted of crimes rarely were imprisoned; instead they were fined, whipped, placed in the stockade, banished, or hanged, depending on the seriousness of their offense." Mushlin at 5-6. Because incarceration as a form of criminal punishment was not the norm, the Founding generation did not have much context in which to consider what Eighth Amendment protections, if any, existed for prisoners.

We do know from the Founding era that "the primary concern of the drafters" of the Eighth Amendment "was to proscribe 'torture[s]' and other 'barbar[ous]' methods of punishment." Estelle v. Gamble , 429 U.S. 97, 102, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976) (alterations in original) (citation omitted). Indeed, when the Supreme Court interpreted the cruel and unusual punishments language for the first time, it remarked that "it is safe to affirm that punishments of torture ... and all others in the same line of unnecessary cruelty, are forbidden by that amendment to the Constitution." Wilkerson v. State of Utah , 99 U.S. 130, 136, 25 L.Ed. 345 (1878) ; see also O'Neil v. State of Vermont , 144 U.S. 323, 339, 12 S.Ct. 693, 36 L.Ed. 450 (1892) (Field, J., dissenting) (describing punishments that the Eighth Amendment prohibited, such as "the rack, the thumb-screw, the iron boot, the stretching of limbs, and the like, which are attended with acute pain and suffering"). The Supreme Court later interpreted the Eighth Amendment's reach to, among other things, protect prisoners from the government's imposition of "unnecessary and wanton infliction of pain." Gregg v. Georgia , 428 U.S. 153, 173, 96 S.Ct. 2909, 49 L.Ed.2d 859 (1976).

How do these directives apply in today's prison context and, in particular, to the medical needs of an inmate? In Estelle , the Supreme Court "first acknowledged that" the Eighth Amendment "could be applied to some deprivations that were not specifically part of the sentence but were suffered during imprisonment." Wilson v. Seiter , 501 U.S. 294, 297, 111 S.Ct. 2321, 115 L.Ed.2d 271 (1991). But because "only the unnecessary and wanton infliction of pain implicates the Eighth Amendment," id. (internal quotation marks and citation omitted), "a prisoner advancing such a claim must, at a minimum, allege 'deliberate indifference' to his 'serious' medical needs," id. (quoting Estelle , 429 U.S. at 106, 97 S.Ct. 285 ). "It is only such indifference that can violate the Eighth Amendment." Id. (internal quotation marks and citation omitted). Thus, "allegations of 'inadvertent failure to provide adequate medical care,' " id. (quoting Estelle , 429 U.S. at 105, 97 S.Ct. 285 ), "or of a 'negligent ... diagnos[is],' " id. (alteration in original) (quoting Estelle , 429 U.S. at 106, 97 S.Ct. 285 ), "simply fail to establish the requisite culpable state of mind," id.

Why is a "requisite culpable state of mind" necessary to establish in an Eighth Amendment medical-needs case? It all goes back to the text of the Eighth Amendment. Because the provision of medical care for a prisoner is not explicitly part of the sentence imposed, that care's inadequacy constitutes a "cruel and unusual punishment[ ]" only if the government actor, at a minimum, knew the care provided or withheld presented a serious risk to the inmate and consciously disregarded that risk. See Wilson , 501 U.S. at 300, 111 S.Ct. 2321 ("If the pain inflicted is not formally meted out as punishment by the statute or the sentencing judge, some mental element must be attributed to the inflicting officer before it can qualify."). As a result, "[a]n accident, although it may produce added anguish, is not on that basis alone to be characterized as wanton infliction of unnecessary pain." Estelle , 429 U.S. at 105, 97 S.Ct. 285. Instead, the government actor must act with "deliberate indifference to serious medical needs of prisoners," id. at 104, 97 S.Ct. 285, in order for the alleged inadequacy of care to be considered "cruel and unusual punishment[ ]."

The government has an "obligation to provide medical care for those whom it is punishing by incarceration." Estelle , 429 U.S. at 103, 97 S.Ct. 285. But mere failure to provide adequate medical care to a prisoner will not violate the Eighth Amendment. In those circumstances, a constitutional violation arises only when the doctor exhibits "deliberate indifference to a prisoner's serious illness or injury," id. at 105, 97 S.Ct. 285 (emphasis added), that can be characterized as "obduracy and wantonness" rather than "inadvertence or error in good faith," Wilson , 501 U.S. at 299, 111 S.Ct. 2321 (quoting Whitley v. Albers , 475 U.S. 312, 319, 106 S.Ct. 1078, 89 L.Ed.2d 251 (1986) ). To establish a prison official's deliberate indifference to a serious medical need, an inmate must show two components, one objective and the other subjective. Farmer v. Brennan , 511 U.S. 825, 834, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994). The plaintiff must show both that the alleged wrongdoing was objectively harmful enough to establish a constitutional violation and that the official acted with a culpable enough state of mind, rising above gross negligence. Id. at 834-35, 114 S.Ct. 1970.

A. Objective Component

The objective component requires a plaintiff to prove that the alleged deprivation of medical care was serious enough to violate the Eighth Amendment. Id. at 834, 114 S.Ct. 1970. Sometimes this inquiry is a simple one. For example, because a serious medical condition carries with it a serious medical need, when prison officials fail to provide treatment for an inmate's serious medical condition, the inmate has endured an objectively serious deprivation. See Blackmore v. Kalamazoo Cty. , 390 F.3d 890, 896-899 (6th Cir. 2004) ; see also Leavitt v. Corr. Med. Servs., Inc. , 645 F.3d 484, 500 (1st Cir. 2011) ; Smith v. Carpenter , 316 F.3d 178, 185-86 (2d Cir. 2003). So we have said that when an inmate had a medical need "diagnosed by a physician as mandating treatment," the plaintiff can establish the objective component by showing that the prison failed to provide treatment, Blackmore , 390 F.3d at 897 (quoting Gaudreault v. Municipality of Salem , 923 F.2d 203, 208 (1st Cir.1990) ), or that it provided treatment "so cursory as to amount to no treatment at all," Dominguez v. Correctional Med. Servs. , 555 F.3d 543, 551 (6th Cir. 2009) (quoting Terrance v. Northville Reg'l Psychiatric Hosp. , 286 F.3d 834, 843 (6th Cir. 2002) ).

But when an inmate has received on-going treatment for his condition and claims that this treatment was inadequate, the objective component of an Eighth Amendment claim requires a showing of care "so grossly incompetent, inadequate, or excessive as to shock the conscience or to be intolerable to fundamental fairness." See Miller v. Calhoun Cty. , 408 F.3d 803, 819 (6th Cir. 2005) (quoting Waldrop v. Evans , 871 F.2d 1030, 1033 (11th Cir. 1989) ). The plaintiff must present enough evidence for a factfinder to evaluate the adequacy of the treatment provided and the severity of the harm caused by the allegedly inadequate treatment. There must be "medical proof that the provided treatment was not an adequate medical treatment of [the inmate's] condition or pain." Santiago v. Ringle , 734 F.3d 585, 591 (6th Cir. 2013). This will often require "expert medical testimony ... showing the medical necessity for" the desired treatment and "the inadequacy of the treatments" the inmate received. Anthony v. Swanson , 701 F. App'x 460, 464 (6th Cir. 2017) ; see Pearson v. Prison Health Serv. , 850 F.3d 526, 535 (3d Cir. 2017) (explaining that adequacy-of-care claims may require expert testimony "to create a genuine dispute that the prisoner's medical needs are serious"). The plaintiff also must "place verifying medical evidence in the record to establish the detrimental effect" of the inadequate treatment. Blackmore , 390 F.3d at 898 (quoting Napier v. Madison Cty., Ky. , 238 F.3d 739, 742 (6th Cir. 2001) ); cf. Broyles v. Corr. Med. Servs., Inc. , 478 F. App'x 971, 975 (6th Cir. 2012) (holding that defendant had "met this requirement" at the motion-to-dismiss stage "by alleging statements by [doctors] linking the delay in treatment to the permanency of his vision impairment").

B. Subjective Component

In addition to showing a sufficient harm, a plaintiff must show that the defendants acted with deliberate indifference. We address this subjective component individually for each defendant. Garretson v. City of Madison Heights , 407 F.3d 789, 797 (6th Cir. 2005).

A doctor's errors in medical judgment or other negligent behavior do not suffice to establish deliberate indifference. See Estelle , 429 U.S. at 107-08, 97 S.Ct. 285. Instead, the plaintiff must show that each defendant acted with a mental state "equivalent to criminal recklessness." Santiago , 734 F.3d at 591 (citing Farmer , 511 U.S. at 834, 839-40, 114 S.Ct. 1970 ). This showing requires proof that each defendant "subjectively perceived facts from which to infer substantial risk to the prisoner, that he did in fact draw the inference, and that he then disregarded that risk" by failing to take reasonable measures to abate it. Comstock v. McCrary , 273 F.3d 693, 703 (6th Cir. 2001) (citing Farmer , 511 U.S. at 837, 114 S.Ct. 1970 ).

A plaintiff may rely on circumstantial evidence to prove subjective recklessness: A jury is entitled to "conclude that a prison official knew of a substantial risk from the very fact that the risk was obvious." Farmer , 511 U.S. at 842, 114 S.Ct. 1970. And if a risk is well-documented and circumstances suggest that the official has been exposed to information so that he must have known of the risk, the evidence is sufficient for a jury to find that the official had knowledge. Id. at 842-43, 114 S.Ct. 1970.

But the plaintiff also must present enough evidence from which a jury could conclude that each defendant "so recklessly ignored the risk that he was deliberately indifferent to it." Cairelli v. Vakilian , 80 F. App'x 979, 983 (6th Cir. 2003) ; see Rouster v. Cty. of Saginaw , 749 F.3d 437, 447 (6th Cir. 2014). A doctor is not liable under the Eighth Amendment if he or she provides reasonable treatment, even if the outcome of the treatment is insufficient or even harmful. See Farmer , 511 U.S. at 844, 114 S.Ct. 1970. A doctor, after all, is bound by the Hippocratic Oath, not applicable to the jailor, and the physician's job is to treat illness, not punish the prisoner. Accordingly, when a claimant challenges the adequacy of an inmate's treatment, "this Court is deferential to the judgments of medical professionals." Richmond , 885 F.3d at 940. That is not to say that a doctor is immune from a deliberate-indifference claim simply because he provided "some treatment for the inmates' medical needs." Id. But there is a high bar that a plaintiff must clear to prove an Eighth Amendment medical-needs claim: The doctor must have "consciously expos[ed] the patient to an excessive risk of serious harm." Id. (emphases added) (citation and internal quotation marks omitted).

IV.

The Rhineharts' claims are based on Rhinehart's ESLD diagnosis. The Defendant Doctors do not dispute that Rhinehart had ESLD or that his condition required medical care. But they argue that he received constitutionally adequate medical treatment and that they did not possess the mental state necessary for Eighth Amendment liability. We address the Rhineharts' claims against Dr. Stevenson and Dr. Edelman below.

A. Dr. Stevenson

Dr. Stevenson was a general internist doctor at Cotton and the senior doctor on staff. The Rhineharts presented evidence that he was Rhinehart's assigned doctor and that he was responsible for examining Rhinehart and developing his treatment plan. His involvement in Rhinehart's medical care occurred between late 2009 and August 2010.

The Rhineharts argue that while Rhinehart was assigned as one of Dr. Stevenson's patients the treatment he received was "so cursory as to amount to no treatment at all." See, e.g. , Appellants' Br. at 21, 22. The district court disagreed with this characterization of Rhinehart's care and found that he received treatment for his ESLD at all relevant times. See Rhinehart , 2017 WL 3913333, at *4-10. We agree with the district court; this is not a case involving cursory treatment amounting to no treatment at all.

Rhinehart's long prison medical file shows that his Cotton medical providers monitored and treated his ESLD and its symptoms, including esophageal varices and ascites. He had regular appointments with medical providers who examined him, noted his liver disease, and evaluated his symptoms. He underwent lab tests, ultrasounds, MRIs, and CT scans. His prison doctors prescribed him medication for his pain, and when he reported increased pain, his doctors prescribed stronger medication. When his condition worsened, his medical providers sent him to the hospital, where he received specialist treatment, including EGD scoping and ligation banding for his esophageal varices and paracentesis for his ascites (a process for draining accumulated fluid from the abdomen). And after his varices were discovered, he was prescribed beta blockers to reduce his blood pressure, a recognized "first-level" treatment for that condition. No reasonable jury could find that Rhinehart's ESLD treatment amounted to no treatment at all with respect to when Dr. Stevenson was involved in Rhinehart's care. See, e.g. , Dominguez , 555 F.3d at 550-51 (finding that inmate's care amounted to no treatment at all when inmate presented with severe heat exhaustion and vomited during examination, but nurse provided only cursory examination and returned him to his non-air-conditioned cube with instructions to drink water and take aspirin).

Thus, the Rhineharts' claim against Dr. Stevenson is properly considered an adequacy-of-care claim. To go on to trial, they must show that there is a genuine issue of fact over the adequacy of the care Rhinehart received and that he suffered a verified medical injury because of the inadequate treatment. See Santiago , 734 F.3d at 591 ; Blackmore , 390 F.3d at 897-98.

In assessing the Rhineharts' claims, we must keep in mind the distinction "between cases where the complaint alleges a complete denial of medical care and those cases where the claim is that a prisoner received inadequate medical treatment." Alspaugh v. McConnell , 643 F.3d 162, 169 (6th Cir. 2011) (quoting Westlake v. Lucas , 537 F.2d 857, 860 n. 5 (6th Cir. 1976) ). An inmate's "disagreement with the testing and treatment he has received ... does not rise to the level of an Eighth Amendment violation." Dodson v. Wilkinson , 304 F. App'x 434, 440 (6th Cir. 2008) (citing Estelle , 429 U.S. at 107, 97 S.Ct. 285 ). Nor does "a desire for additional or different treatment ... suffice to support an Eighth Amendment claim." Anthony , 701 F. App'x at 464. The Rhineharts must present evidence from which a reasonable jury could find that Rhinehart's care was "so grossly incompetent, inadequate, or excessive as to shock the conscience or to be intolerable to fundamental fairness." See Miller , 408 F.3d at 819 (quoting Waldrop , 871 F.2d at 1033 ).

The Rhineharts allege that Dr. Stevenson deprived Rhinehart of adequate treatment at two distinct times: (1) before his hospitalization in June 2010, when Dr. Stevenson failed to refer Rhinehart for prompt and consistent specialist care; and (2) in July and August 2010, when, after his hospitalization, a specialist recommended that Rhinehart be prescribed beta blockers and further EGD scoping and ligation banding as needed, but he instead received beta blockers and general internist monitoring and care.

i. Pre-Hospitalization

Before his hospitalization in June 2010, prison medical providers monitored Rhinehart. And when he complained of increased discomfort, he was sent to the hospital, where he received specialist treatment. The Rhineharts argue, however, that this monitoring and as-needed specialist treatment was inadequate. To go on to trial on their Eighth Amendment claim, they needed to present medical proof from which a jury could find that their proposed treatment plan-prompt and regular specialist monitoring-was necessary. See Anthony , 701 F. App'x at 464 ("Anthony claims that he was denied a specific type of treatment-a colostomy. Consequently, Anthony must present a medical expert who can speak to the necessity of such a treatment and evaluate it vis-à-vis the treatment he received. Because Anthony has not come forward with such medical testimony, his claim cannot succeed as a matter of law."); Santiago , 734 F.3d at 591 (affirming summary judgment in favor of prison medical providers because inmate's claim was based on the delay in receiving a specific type of medical treatment and he failed to show that treatment he received was inadequate).

The Rhineharts point to no medical proof that Rhinehart, or ESLD patients like him, require regular specialist monitoring and care. Their expert did not so testify, and they point to no medical articles showing that this desired treatment plan was necessary. Lacking that evidence, they argue that a jury could find that specialist treatment was necessary based on Dr. Berhane's 2009 request for Rhinehart to be transferred to another prison on an expedited basis coupled with her 407 request that Rhinehart be referred to a specialist for a liver biopsy. But neither the context of Rhinehart's transfer nor Dr. Berhane's specialist consultation request advances the Rhineharts' argument that Rhinehart needed prompt and regular specialist treatment for his ESLD.

Dr. Berhane's requests were based on a suspicious tumor, not a need for ESLD treatment. The record shows that in September 2009, after Rhinehart underwent a CT scan that revealed a high suspicion for cancer, Dr. Berhane contacted Dr. Edelman, discussed Rhinehart's medical needs, and submitted a formal consultation request. Dr. Berhane recommended that Rhinehart be approved to see an oncologist or hepatologist for a tissue biopsy of his liver. R.263-9, Consultation Request, Page ID# 5193-94. The 407 form that Dr. Berhane submitted provides: "Request consult for tissue biopsy of these highly suspicious findings for a ... tumor." Id. at 5193. Of course, Rhinehart never had cancer, and the Rhineharts' Eighth Amendment claim is not based on harm caused by this tumor. Yet the Rhineharts argue that this request for a prompt specialist referral and biopsy would allow a jury to find that Rhinehart needed to see a specialist for his ESLD. But Dr. Berhane's request that Rhinehart see a specialist to evaluate his potential cancer says nothing about a need for ESLD treatment. The 407 listed ESLD under "Presumed Diagnosis" but never mentioned any need for Rhinehart to see a specialist for treatment for his ESLD. Id. In sum, Dr. Berhane's requests do not support the Rhineharts' claim that prompt and regular specialist treatment was necessary.

Without evidence that Rhinehart's ESLD required regular specialist monitoring, the Rhineharts argue that Rhinehart's ESLD included a "high" probability of his developing esophageal varices and that this condition can be discovered by EGD scoping, which can be done by only a specialist. Thus, they argue, Rhinehart required prompt and regular specialist care to monitor for esophageal varices, and because he did not receive it, a jury could find that his treatment was inadequate.

But the fact that esophageal varices can be diagnosed by EGD scoping does not establish that specialist monitoring and EGD scoping were "medical necessit[ies]" when Rhinehart was transferred to Cotton. Anthony , 701 F. App'x at 464. For starters, the Rhineharts' medical literature explains that these treatments constitute only one method for discovering varices, along with x-rays and lab tests. R. 315-3, Medical Lit., Page ID# 7803. Rhinehart saw his prison doctors regularly and underwent several lab tests. And when Rhinehart complained of increasing discomfort in June 2010, his prison medical providers transferred him to the hospital, where his esophageal varices were discovered during an EGD scoping procedure. Allegations "that more should have been done by way of diagnosis and treatment" and "suggest[ions]" of other "options that were not pursued" raise at most a claim of medical malpractice, not a cognizable Eighth Amendment claim. Estelle , 429 U.S. at 107, 97 S.Ct. 285.

The Rhineharts' medical literature says nothing about when, how often, or even if an ESLD patient should see a specialist before he is diagnosed with esophageal varices. And they presented no expert medical testimony on this. The Rhineharts have thus shown only a desire for a more aggressive treatment, and they have failed to introduce the requisite evidence for a jury to find that this treatment was necessary. See Anthony , 701 F. App'x at 464 (requiring a plaintiff to show the need for a more aggressive treatment than the one he received).

ii. Post-Hospitalization

When Rhinehart was in the hospital in June 2010, Dr. Schachinger performed an EGD scope, which revealed four columns of esophageal varices with no active bleeding, and he successfully placed seven esophageal bands to obliterate the varices. In his post-procedure report, he recommended that Rhinehart continue taking Propranolol (a beta-blocker medication that reduces blood pressure) and "followup [sic] as an outpatient with the prison gastroenterologist for additional EGD with esophageal banding as necessary." R.177, Endoscopy Report, Page ID# 2421.

When Rhinehart was discharged from the hospital, his "discharge instructions" included an order for blood work that morning and "[p]rimary care provider followup [sic] within one week." R.259-2, Discharge Instructions, Page ID# 4706. In accord with these instructions, Dr. Cohen examined Rhinehart at the prison the day after his discharge. Dr. Cohen reviewed Rhinehart's hospital records, ordered blood work, and started Rhinehart on Propranolol to reduce his blood pressure and prevent esophageal bleeding. Rhinehart was not referred for follow-up appointments with a gastroenterologist. Instead, Dr. Cohen monitored him, examining him on July 8 and July 19. Dr. Stevenson's employment with Corizon ended the next month, August 2010.

Given Dr. Schachinger's recommendation, the Rhineharts argue that before Dr. Stevenson's departure he provided Rhinehart with inadequate care because he failed to refer Rhinehart to a specialist for further EGD scoping and ligation banding. They contend that specialist monitoring and EGD scoping were the only appropriate treatments and assert that because Dr. Stevenson did not order these, Rhinehart endured an esophageal bleed fourteen months later.

The Rhineharts' medical literature shows that, once discovered, the "first level" treatment for esophageal varices is either use of medications such as beta blockers or EGD scoping and ligation banding performed by a specialist, or a combination of the two. In his post-procedure report, Rhinehart's hospital doctor, Dr. Schachinger, recommended both. Dr. Schachinger later testified that the risk of Rhinehart's bleeding from his varices was "higher because of the size of the varices" and that if he had a patient with Rhinehart's conditions under his exclusive control, he probably would have reevaluated Rhinehart's varices a month later and treated them if necessary. R.263-13, Schachinger Dep., Page ID# 5399-400. During his deposition, Dr. Finkel testified that he agreed with Dr. Schachinger. He explained that in the weeks and months after his hospitalization, "[i]n the private world setting, Dr. Schachinger would have recalled the patient in a timely fashion for a repeat [EGD] and banding session." R.263-14, Finkel Dep., Page ID# 5442.

A prison doctor's failure to follow an outside specialist's recommendation does not necessarily establish inadequate care. For example, in Santiago v. Ringle , 734 F.3d 585, 591 (6th Cir. 2013), we held that even though an inmate showed that he had a serious skin condition and that his prison doctors failed to prescribe him the treatment that a specialist had recommended, he could not proceed past summary judgment on his deliberate-indifference claim because his prison doctors prescribed an alternative treatment, and he produced no "medical proof" showing that the medications that his prison doctors prescribed were inadequate. 734 F.3d at 591. The same was true here. Though Dr. Cohen did not follow all of Dr. Schachinger's recommendations, she examined Rhinehart and prescribed a recognized medication for his esophageal varices, beta-blocker medication. As in Santiago , the Rhineharts had the burden of introducing medical proof that this was inadequate treatment.

We need not decide whether Dr. Schachinger's and Dr. Finkel's respective testimony about what they would have done is enough to create a fact dispute about the adequacy of Rhinehart's care. Even if it were, and assuming that the Rhineharts' evidence would allow a jury to find that he suffered a "detrimental effect" from the treatment he received, the Rhineharts' claim would still fail because they cannot establish the subjective component of their claim against Dr. Stevenson.

As noted above, the subjective component of a deliberate-indifference claim "must be addressed for each officer individually." Garretson , 407 F.3d at 797 ; see Gibson v. Matthews , 926 F.2d 532, 535 (6th Cir. 1991). The record shows that Dr. Cohen was the doctor who received, interpreted, and acted on Dr. Schachinger's recommendation. R.259-1, Medical Record, Page ID# 4663-65. She determined and implemented Rhinehart's treatment plan after his hospitalization, examining him three times in July and prescribing medication for his esophageal varices. The Rhineharts presented no evidence that Dr. Stevenson examined Rhinehart after his return from the hospital, or that he reviewed Dr. Schachinger's postprocedure report. They have failed to put forward evidence suggesting that Dr. Stevenson had any knowledge of Dr. Schachinger's recommendation that Rhinehart be referred for follow-up appointments with a gastroenterologist. In other words, the Rhineharts can point to nothing showing that Dr. Stevenson "subjectively perceived facts from which to infer substantial risk to [Rhinehart]"-that without follow-up specialist appointments Rhinehart was at a high risk of suffering an esophageal bleed. Comstock , 273 F.3d at 703 (citing Farmer , 511 U.S. at 837, 114 S.Ct. 1970 ).

Even if the Rhineharts could show that Dr. Stevenson knew about Dr. Schachinger's recommendation, they failed to show that the treatment Rhinehart received amounted to a conscious disregard of the risk that Rhinehart faced. Id. When "a doctor orders treatment consistent with the symptoms presented and then continues to monitor the patient's condition, an inference of deliberate indifference is unwarranted." Self v. Crum , 439 F.3d 1227, 1232-33 (10th Cir. 2006). Rhinehart received the plan of care directed in his discharge instructions. He was seen by Dr. Cohen the day after his discharge. She specifically referenced and implemented Dr. Schachinger's recommendation that Rhinehart be prescribed a beta-blocker medication to prevent esophageal bleeding. And the Rhineharts' medical literature confirms that prescribing this medication is a recognized treatment for reducing the recurrence of esophageal varices. R.315-3, Medical Lit., Page ID# 7802-07. The Defendant Doctors' expert, Dr. Duffy, also stated in his expert report that this treatment plan was appropriate. R.258-9, Expert Report, Page ID# 4545-47. After implementing this plan, Dr. Cohen continued to monitor Rhinehart, seeing him several times in July 2010. This treatment plan shows no disregard for Rhinehart's health risks.

Nor does Dr. Schachinger's recommendation support an inference of deliberate indifference. Dr. Schachinger's recommendation for follow-up specialist care was not a prescribed treatment plan. See Richmond , 885 F.3d at 940 (distinguishing between an inmate's claim based on a "fail[ure] to provide the care that was ordered" and one based on "the adequacy" of an inmate's treatment); cf. Boretti v. Wiscomb , 930 F.2d 1150, 1154 (6th Cir. 1991) (reversing district court's grant of summary judgment for prison nurse who interrupted prescribed plan of treatment for inmate who had recently had surgery for gunshot wound ). Though we have held that a prison doctor may not "escape liability simply because the treatment was recommended rather than prescribed," Santiago , 734 F.3d at 590, this is not a case in which a prison doctor ignored a specialist's recommendations. See, e.g. , Verser v. Elyea , 113 F.Supp.2d 1211, 1215 (N.D. Ill. 2000) (allowing deliberate-indifference claim to proceed where doctor "declined to follow the recommendations of [a] specialist ... without even examining the patient"). Instead, Dr. Cohen, who was Rhinehart's treating doctor, reviewed Rhinehart's hospital record, examined him, and implemented a recognized course of treatment. Then, she continued to monitor him. Implementing this plan instead of that recommended by Dr. Schachinger did not amount to a conscious disregard for Rhinehart's condition. See Farmer , 511 U.S. at 844, 114 S.Ct. 1970 ; cf. Blank v. Bell , 634 F. App'x 445, 449 (5th Cir.), cert. denied , --- U.S. ----, 136 S.Ct. 2036, 195 L.Ed.2d 236 (2016) (holding that prison medical provider's failure to refer inmate with Crohn's disease to a specialist did not amount to deliberate indifference despite discharge instructions recommending such a referral because the inmate was seen by his prison doctor who prescribed medications indicated on inmate's discharge instructions and the referral decision remained with prison doctor); Heidtke v. Corr. Corp. of Am. , 489 F. App'x 275, 281 (10th Cir. 2012) (holding that prison doctor was not deliberately indifferent to inmate's serious medical needs for failing to follow discharge instructions directing that inmate be returned to hospital if some symptoms were observed because prison doctor examined inmate on three occasions, ordered x-rays, prescribed medication, and monitored inmate's condition).

The Rhineharts' reliance on Dr. Schachinger's and Dr. Finkel's respective testimony about what would have happened were Rhinehart a private patient of Dr. Schachinger's at most raises "a simple question of whether [Rhinehart's prison doctors] made the right medical judgment in treating him." LeMarbe v. Wisneski , 266 F.3d 429, 439 (6th Cir. 2001). A disagreement with a course of medical treatment does not rise to the level of a federal constitutional claim under the Eighth Amendment. Alspaugh , 643 F.3d at 169. Indeed, as the Supreme Court has instructed, "forms of treatment" are generally "a classic example of a matter for medical judgment" that "does not represent cruel and unusual punishment."

Estelle , 429 U.S. at 107, 97 S.Ct. 285 ; see also Richmond , 885 F.3d at 941 (holding that "it would be improper for this court to overturn [a doctor]'s medical judgment").

The Rhineharts argue that Dr. Stevenson's failure amounts to more than