Larry Howell v. Wexford Health Sources, Inc., No. 19-3210 (7th Cir. 2021)
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While incarcerated, Howell tore his medial meniscus cartilage and his anterior cruciate ligament (ACL). Five months later, he had surgery to repair the meniscus. It was another 20 months before Howell had surgery to reconstruct his ACL, despite Howell’s continuing pain and efforts to have the surgery sooner. While his requests for the ACL surgery were still being rejected, Howell filed suit under 42 U.S.C. 1983 alleging Eighth Amendment violations. A jury ruled in favor of the physician but against Wexford, a private company that provides medical services at the prison. The court entered judgment as a matter of law in favor of Wexford.
The Seventh Circuit affirmed. The district court did not abuse its discretion in excluding the evidence about Wexford’s treatment of other incarcerated people. Howell did not show that their situations were fairly comparable to his. The court also did not err in granting Wexford’s Rule 50(b) motion for judgment as a matter of law. Howell blamed his pain and delayed surgery on Wexford’s “collegial review process,” which requires an off-site Wexford physician to review and approve an on‐site Wexford physician’s recommendation that an incarcerated person be referred to an off‐site healthcare provider. The collegial review process is not unconstitutional on its face, and Howell did not offer evidence that would let a reasonable jury find that the collegial review process caused any violation of his Eighth Amendment rights.
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In the United States Court of Appeals For the Seventh Circuit ____________________ No. 19 3210 LARRY HOWELL, Plaintiff Appellant, v. WEXFORD HEALTH SOURCES, INC. and JOHN TROST, M.D., Defendants Appellees. ____________________ Appeal from the United States District Court for the Southern District of Illinois. No. 3:16 CV 00160 RJD — Reona J. Daly, Magistrate Judge. ____________________ ARGUED OCTOBER 2, 2020 — DECIDED FEBRUARY 5, 2021 ____________________ Before RIPPLE, KANNE, and HAMILTON, Circuit Judges. HAMILTON, Circuit Judge. This appeal presents recurring is sues about the Eighth Amendment rights of incarcerated per sons to have their serious medical needs treated and to obtain remedies for violations of those rights. Plainti Larry Howell injured his knee while playing basketball in the Menard Cor rectional Center. He tore his medial meniscus cartilage and his anterior cruciate ligament (ACL). Five months later, he 2 No. 19 3210 had surgery to repair the torn meniscus. It was another twenty months later, however, before Howell had surgery to reconstruct his ACL, despite Howell’s continuing pain and ef forts to have the ACL surgery sooner. While his requests for the ACL surgery were still being re jected, Howell filed this suit under 42 U.S.C. § 1983 alleging violations of his Eighth Amendment right to be free of cruel and unusual punishment. Howell’s claims for delaying the ACL surgery were tried to a jury, which ruled in favor of de fendant Dr. John Trost but against defendant Wexford Health Sources, Inc. The district court later vacated the portion of the jury verdict against Wexford. The court entered judgment as a matter of law in favor of Wexford, as well as judgment for Dr. Trost based on the jury verdict. On appeal, Howell challenges only the portion of the judg ment in favor of Wexford. He argues that the district court erred by excluding his evidence of other incarcerated people’s delayed orthopedic care and erred both procedurally and substantively in granting Wexford’s motion for judgment as a matter of law. We a rm. First, the district court did not abuse its discre tion in excluding the evidence about Wexford’s treatment of other incarcerated people. Howell did not show that their sit uations were fairly comparable to his. The court also did not err in granting Wexford’s Rule 50(b) motion for judgment as a matter of law. As a procedural matter, Wexford properly in corporated its winning argument as one of the grounds for its Rule 50(a) motions before the verdict. Turning to substance, Howell blamed his pain and delayed surgery on Wexford’s so called “collegial review process,” which requires an o No. 19 3210 3 site Wexford physician to review and approve an on site Wex ford physician’s recommendation that an incarcerated person be referred to an o site healthcare provider. The collegial re view process is not unconstitutional on its face, and when we dig into the details of this case, we find that Howell did not o er evidence that would let a reasonable jury find that the collegial review process caused any violation of his Eighth Amendment rights. I. Factual and Procedural History A. Howell’s Knee Injury and Treatment On May 4, 2014, while confined at the Menard Correc tional Center, Howell su ered an acute knee injury while playing basketball. The next day, Howell saw defendant Dr. John Trost, a physician at Menard who was employed by de fendant Wexford Health Sources, Inc., a private company that contracted with the State of Illinois to provide healthcare ser vices to incarcerated people. Dr. Trost ordered an MRI of Howell’s knee, which showed a torn medial meniscus and a torn ACL. Dr. Trost referred Howell to Dr. Kevin Koth, an outside orthopedic surgeon who is not a party to this case. At How ell’s initial appointment in August 2014, Dr. Koth discussed treatment options. He said that he was “not sure that doing an ACL reconstruction with a meniscal repair is in [Howell’s] best interest.” On October 7, 2014, Dr. Koth performed sur gery to repair the meniscus tear but not the ACL. Critical for this appeal, Dr. Koth continued to recommend against surgery to repair the ACL unless and until it became “absolutely necessary because I do not think that the rehab situation of being in prison is the most favorable for [Howell] 4 No. 19 3210 and, therefore, I would elect to hold o and not [do] an ACL reconstruction unless it becomes absolutely necessary.” At follow up appointments in October and November 2014, Dr. Koth continued to recommend against ACL surgery, saying that it “should be the last resort given [Howell’s] current sit uation [in prison].” To hold defendant Wexford itself liable for a violation of his constitutional rights, Howell seeks to show that the viola tion was caused by a Wexford corporate policy requiring “col legial review” before an incarcerated person can receive health care from an outside provider. In April 2015, Dr. Trost presented Howell’s case for collegial review seeking an out side orthopedic evaluation of his torn ACL. The reviewing o site Wexford physician denied it and instead recommended a physical therapy treatment plan. In November 2015, Dr. Trost again presented Howell for collegial review seeking an out side orthopedic evaluation. This too was denied. The o site physician instead requested “more information as to what kind of therapy has been completed.” In January 2016, Dr. Trost again presented Howell for collegial review to approve an MRI following his December 2015 complaints of knee pain. This referral was approved, and an MRI was performed o site in January. In February 2016, Dr. Trost presented Howell for collegial review, this time requesting an orthopedic consultation about those MRI results. This request was denied at first, but Dr. Trost appealed. The request was ultimately granted in March 2016. In April 2016, Howell discussed his MRI results with an outside physician’s assistant who recommended proceeding with ACL reconstruction surgery. In May 2016, Dr. Trost re quested and received approval for ACL surgery. Howell had No. 19 3210 5 ACL reconstruction surgery on June 23, 2016, approximately twenty months after his meniscus surgery and more than two years after his injury. B. Procedural History Howell filed a complaint in the district court on Febru ary 10, 2016, shortly after the MRI that eventually led to the ACL surgery. Defendants filed motions for summary judg ment, which were granted in part and denied in part. Before trial, defendants filed motions in limine, including one seek ing to bar evidence of Wexford’s medical treatment provided to other incarcerated people. The court granted this motion in limine on relevance grounds, ruling that the a davits of Howell’s four disclosed incarcerated witnesses did not su ciently indicate that they would testify to issues concerning the collegial review process as it related to orthopedic injuries. At the close of plainti ’s evidence and again when defend ants rested without presenting additional evidence, defend ants made oral motions under Federal Rule of Civil Procedure 50(a) for judgment as a matter of law. The court denied as to Dr. Trost and reserved decision as to Wexford. The jury re turned a verdict in favor of Dr. Trost and against Wexford, awarding plainti damages of $25,000. After the verdict, de fendants renewed their Rule 50 motions in writing. The court treated Dr. Trost’s motion as moot but granted judgment as a matter of law to Wexford. Howell has appealed the judgment in favor of Wexford but not the judgment against Dr. Trost. Howell contends that the district court erred by excluding evidence about Wex ford’s delays and failures in treating other patients, and by granting Wexford’s Rule 50 motion. The district court had 6 No. 19 3210 subject matter jurisdiction under 28 U.S.C. §§ 1331 and 1343 as to plainti ’s Eighth Amendment claims. This court has ju risdiction of the appeal under 28 U.S.C. § 1291. II. Monell Liability and the Wexford Collegial Review Process The district court’s decisions first to exclude evidence about other incarcerated people and then to grant judgment as a matter of law are two sides of the same coin. They both stem from doctrinal requirements under § 1983 that can make it di cult for a plainti to prove that a private corporation like Wexford should be held liable for violating his constitu tional rights. As we explain below, Howell needed to prove that a violation of his Eighth Amendment rights was caused not only by a Wexford agent or employee but by a corporate policy or widespread practice or custom. See generally Mo nell v. Dep’t of Social Servs., 436 U.S. 658, 690–91 (1978). Howell tried to meet that burden by showing that Wexford’s collegial review process, which requires a second, o site approval be fore referring a patient to an outside specialist, violated his rights and those of other incarcerated persons. We assume that this policy is widespread in Menard and other facilities where Wexford provides healthcare services. The question here is whether Howell o ered su cient evidence that Wex ford’s widespread collegial review policy caused a violation of his constitutional rights. Before engaging with the specifics of Howell’s claims, some background on 42 U.S.C. § 1983 lia bility governed by Monell may be helpful. A. Monell Liability for Prison Healthcare Providers Under the Eighth Amendment, prison o cials are respon sible for providing healthcare to incarcerated persons who cannot obtain healthcare on their own. Estelle v. Gamble, 429 No. 19 3210 7 U.S. 97, 103−04 (1976). To prove a violation of that right, a plainti must prove that a defendant actually knew of a seri ous health need and acted with deliberate indi erence to the plainti ’s su ering. Farmer v. Brennan, 511 U.S. 825, 843 (1994); Gamble, 429 U.S. at 104−05. Denying or delaying appro priate treatment to an incarcerated person su ering from avoidable pain can violate the Eighth Amendment. E.g., Grieveson v. Anderson, 538 F.3d 763, 779 (7th Cir. 2008) (plain ti stated plausible claim for deliberate indi erence where jury could find that guards needlessly delayed treatment of plainti ’s broken nose for a day and a half); Edwards v. Snyder, 478 F.3d 827, 831 (7th Cir. 2007) (plainti stated plausible claim for deliberate indi erence where he was needlessly de nied treatment for painful dislocated finger for two days). Section 1983 grants a private right of action against a “per son” who acts under color of state law to deprive another of rights under federal law, including the Constitution. A key part of § 1983’s doctrinal structure is the di erence between individual and governmental liability. In Monroe v. Pape, 365 U.S. 167 (1961), the Supreme Court held that an individual could be held liable under § 1983 even if his conduct violated state law. That holding opened the door to the extensive mod ern use of this Reconstruction Era statute. But Monroe also held that a local government could not be held liable under § 1983. 365 U.S. at 187. In Monell, the Supreme Court overruled the latter holding in Monroe and held for the first time that a municipal govern ment could be a proper defendant under § 1983. Monell, 436 U.S. at 700–01. At the same time, Monell rejected the common law theory of respondeat superior liability for an employee’s actions. Instead, the Court crafted a new, more restrictive 8 No. 19 3210 standard to determine when a municipal government itself has caused a deprivation of constitutional rights. A plainti must show that the violation was caused by (1) an express government policy; (2) a widespread and persistent practice that amounted to a custom approaching the force of law; or (3) an o cial with final policymaking authority. 436 U.S. at 690–91; Glisson v. Indiana Dep’t of Correction, 849 F.3d 372, 379 (7th Cir. 2017) (en banc). But Wexford is not a municipal government. It is a private corporation that contracts with the Illinois Department of Corrections to provide healthcare services that the govern ment is obliged to provide to incarcerated persons. Circuit precedent establishes at this time that private corporations acting under color of law also benefit from Monell’s rejection of respondeat superior liability for an employee’s constitu tional violations. See Shields v. Illinois Dep’t of Corrections, 746 F.3d 782, 786 (7th Cir. 2014) (following precedent but criticiz ing extension of Monell to private corporations). In a case against a private contractor that provides healthcare to incar cerated people, the “critical question” for liability is “whether a municipal (or corporate) policy or custom gave rise to the harm (that is, caused it).” Glisson, 849 F.3d at 379. As we apply controlling precedent, we may recognize that the overall doctrinal structure grew case by case with incre mental improvisations, and that it is di cult to make sense of the overall structure. One scholar in the field expressed frus tration that the fracturing of constitutional torts into disparate liability rules does not reflect any plausible con ception of policy. Although the Court occasion ally makes functional arguments about one or No. 19 3210 9 another corner of this landscape, it has never at tempted to justify the overall structure in those terms. Nor could it. The proliferation of incon sistent policies and arbitrary distinctions ren ders constitutional tort law functionally unintel ligible. John C. Je ries, Jr., The Liability Rule for Constitutional Torts, 99 Va. L. Rev. 207, 208 (2013); see also Board of County Comm’rs of Bryan Cty. v. Brown, 520 U.S. 397, 430 (1997) (Breyer, J., dis senting) (Monell has “produced a highly complex body of in terpretive law”); Karen M. Blum, Section 1983 Litigation: The Maze, the Mud, and the Madness, 23 Wm. & Mary Bill Rts. J. 913, 913−14 (2015) (“There is a growing consensus among practi tioners, scholars, and judges that Section 1983 is no longer serving its original and intended function as a vehicle for rem edying violations of constitutional rights, that it is broken in many ways, and that it is sorely in need of repairs.”). The most important doctrinal elaborations—individual versus o cial liability, qualified immunity, and Monell liability rather than respondeat superior—bear only a tenuous connection to the text of § 1983, let alone to its history. Repair of the creaky doc trinal structure, however, will need to come from the Su preme Court or Congress. For now we do the best we can, recognizing the challenges that parties face in asserting and defending claims under the statute. B. Isolated Incidents Versus Widespread Problems In applying Monell and avoiding respondeat superior lia bility, one key is to distinguish between the isolated wrong doing of one or a few rogue employees and other, more wide spread practices. Monell, 436 U.S. at 694. In our extensive case law on prison healthcare, we have not adopted bright line 10 No. 19 3210 rules regarding the quantity, quality, or frequency of conduct needed to prove a widespread custom or practice under Mo nell. Thomas v. Cook Cty. Sheri ’s Dep’t, 604 F.3d 293, 303 (7th Cir. 2010). “[W]hat is needed is evidence that there is a true municipal [or corporate] policy at issue, not a random event.” Grieveson, 538 F.3d. at 774 (quotations omitted); see also Palmer v. Marion Cty., 327 F.3d 588, 596 (7th Cir. 2003) (“proof of isolated acts of misconduct will not su ce; a series of vio lations must be presented to lay the premise of deliberate in di erence”); Cornfield v. Consolidated High Sch. Dist. No. 230, 991 F.2d 1316, 1326 (7th Cir. 1993) (requiring “a pattern or a series of incidents of unconstitutional conduct”). C. Proving an Unconstitutional Policy, Practice, or Custom in Prison Healthcare Institutional liability “can be proven in a number of ways, including but not limited to repeated actions. A single memo or decision showing that the choice not to act is deliberate” may establish liability under Monell. Glisson, 849 F.3d at 381 (emphasis added). “There is no magic number of injuries that must occur before [a defendant’s] failure to act can be consid ered deliberately indi erent.” Id. at 382. Through a bureaucracy that di uses individual responsi bility and accountability, healthcare in a prison or jail may be delivered (or not delivered) so that it is di cult or even im possible to assign the individual responsibility for deliber ately indi erent failure that o ers the simplest path to § 1983 liability. See, e.g., Daniel v. Cook Cty., 833 F.3d 728, 733−34 (7th Cir. 2016) (noting that individual defendants can put blame on “the system” where responsibility is so di used that no individual is accountable for failures to provide adequate healthcare); see also Shields, 746 F.3d at 799 (plainti may be No. 19 3210 11 “the victim not of any one human being’s deliberate indi er ence but of a system of medical care that di use[s] responsi bility for his care to the point that no single individual [is] re sponsible for seeing that he receive[s] the care he need[s] in a timely way”); Hildreth v. Butler, 960 F.3d 420, 437 (7th Cir. 2020) (Hamilton, J., dissenting) (“The law should not … re ward divided responsibility and deliberate ignorance by those who control prisoners’ only access to health care.”). In this case, for example, the jury could reasonably find that Dr. Trost as an individual was not deliberately indi erent to Howell’s pain. He repeatedly submitted Howell’s case for outside diagnosis and treatment, but his requests were turned down several times through Wexford’s collegial review pro cess. Glisson provided a fatal example of this sort of di used re sponsibility. The plainti su ered from several serious ill nesses that required comprehensive and coordinated care. He died of starvation, acute renal failure, and associated condi tions only 37 days after he entered custody where no individ ual was responsible for his overall care. We held in Glisson, however, that a jury could conclude that Wexford had adopted what amounted to a “policy of inaction” for which Wexford itself could be held liable. Glisson, 849 F.3d at 382. There are many other, less severe examples where incar cerated plainti s have adequately pleaded Monell liability al leging only their individual experiences.1 But the more com mon paths toward Monell liability require proof either of an 1 In the following cases, for example, district courts denied defend ants’ motions to dismiss Monell claims: Haywood v. Wexford Health Sources, 2017 WL 3168996 at *1, 4 (N.D. Ill. July 26, 2017) (alleging multiple Wex ford employees’ repeated indifference to plaintiff’s medical needs); 12 No. 19 3210 express policy that is unconstitutional or a widespread prac tice or custom a ecting other individuals or showing re peated deliberate indi erence toward the plainti . Despite the absence of bright line rules, there can be little doubt that a practice or custom theory will be more persua sive if a plainti can show that the defendant government or company treated other, similarly situated patients in similar unconstitutional ways. For example, Grieveson held the plain ti ’s allegations of four botched refills of his pain prescrip tions did not prove a widespread unconstitutional practice. 538 F.3d at 774 (“This simply is not enough to foster a genuine issue of material fact that the practice was widespread….”). Cf. Harper v. Wexford Health Sources, 2016 WL 1056661 at *3–4 (N.D. Ill. Mar. 17, 2016) (denying motion to dismiss where plainti ’s specific allegations that defendant maintained a widespread cost cutting policy were accompanied by refer ences to experiences of other incarcerated people). We re cently found that three incidents of late medication refills for an incarcerated plainti , resulting in painful withdrawal Baker v. Wexford Health Sources, Inc., 2014 WL 1346613 at *6 (N.D. Ill. Apr. 4, 2014) (plaintiff’s requests for treatment of arm injury repeatedly ignored for almost eight months); Ford v. Wexford Health Sources, Inc., 2013 WL 474494 at *1–3 (N.D. Ill. Feb. 7, 2013) (plaintiff alleged near daily requests for medical attention to back injury, defendants’ denial of permits for suf ficient medical restraints, and delays in scheduling medical appoint ments); Quinn v. Hardy, 2013 WL 4836262 at *1 (N.D. Ill. Sept. 10, 2013) (following plaintiff’s foot and back injuries and Wexford employees’ re peated denials of requests for treatment resulting in hunger strikes and attempted suicide); see also Neely v. Randle, 2013 WL 3321451 at *6 (N.D. Ill. June 29, 2013) (“[A]llegations of routine delays and denials of medical care and nonresponsiveness to requests for care, combined with … spe cific factual allegations regarding how he was dealt with … are sufficient to state claims under Monell.”). No. 19 3210 13 symptoms, could not survive summary judgment in part be cause the plainti failed to o er evidence of medication de lays for other incarcerated people. Hildreth, 960 F.3d at 429 (af firming summary judgment for defendants); but see id. at 432, 441 (Hamilton, J., dissenting). III. Defendants’ Motion in Limine With this background, we turn to Howell’s first appellate challenge. To prove a Monell claim against Wexford for delib erate indi erence to his medical needs, Howell sought to o er evidence that Wexford’s collegial review process had caused four other incarcerated persons to experience similarly avoid able pain by delaying needed orthopedic care. That evidence was the target of defendants’ motion in limine. The district court reviewed the four a davits and concluded that none was a suitable comparator. A. Standard of Review We review such evidentiary rulings for abuse of discre tion. Morgan v. City of Chicago, 822 F.3d 317, 338–40 (7th Cir. 2016), citing Young v. James Green Mgmt., Inc., 327 F.3d 616 (7th Cir. 2003). “[W]e will not find error unless the court’s decision is based on an erroneous conclusion of law or the record con tains no evidence on which the court rationally could have based its decision….” Van Stan v. Fancy Colours & Co., 125 F.3d 563, 570 (7th Cir. 1997) (noting special deference to eviden tiary rulings). In exercising that discretion in a prison healthcare case, however, a district court must take into account the burden an incarcerated plainti faces in asserting Monell claims under the Eighth Amendment. Because of the doctrinal burdens of Monell discussed above, a plainti who has direct access only 14 No. 19 3210 to his own medical records may well need discovery concern ing the healthcare provided to others. Such discovery may also encounter issues of healthcare privacy and a need for an appropriate protective order. In deciding how far such dis covery should go and whether evidence of others’ treatment should be admitted at trial, employment discrimination law may provide a helpful guide. Employees often try to prove discrimination by showing that they were treated less favorably than similarly situated employees who did not share their race, sex, religion, or other protected status. To determine whether other employees are similarly situated, “courts ask ‘whether the other employees’ situations were similar enough to the plainti ’s that it is rea sonable to infer, in the absence of some other explanation, that the di erent treatment was a result of race or some other un lawful basis.’” de Lima Silva v. Dep’t of Corrections, 917 F.3d 546, 559 (7th Cir. 2019), quoting Luster v. Illinois Dep’t of Correc tions, 652 F.3d 726, 730 (7th Cir. 2011). This inquiry is “flexible, common sense, and factual. It asks, ‘essentially, are there enough common features between the individuals to allow a meaningful comparison?’” Coleman v. Donahoe, 667 F.3d 835, 841 (7th Cir. 2012), quoting Humphries v. CBOCS West, Inc., 474 F.3d 387, 405 (7th Cir. 2007), a ’d, 553 U.S. 442 (2008). Fair comparability often presents a jury question: “While the comparability of other employees is a context dependent question often suitable for a jury, when the facts of a case sug gest that no reasonable jury could see enough commonality for a meaningful comparison between the employees, sum mary judgment is appropriate.” Rozumalski v. W.F. Baird & As sociates, Ltd., 937 F.3d 919, 927 (7th Cir. 2019). In employment cases, courts look for comparators who di er primarily with No. 19 3210 15 respect to the protected category, and a plainti typically needs only one comparator to avoid summary judgment or judgment as a matter of law. See Humphries, 474 F.3d at 406– 07 (“A single comparator will do; numerosity is not re quired.”). In applying Monell to prison healthcare, the issue is whether the similarities show a widespread practice that sup ports a finding of an unconstitutional custom or practice. However, the comparator need not be perfect in either con text. See, e.g., Coleman, 667 F.3d at 841 (concluding in employ ment context that comparators’ “case is close enough to [plain ti ’s] to provide a ‘meaningful comparison’ and to permit a reasonable jury to infer discrimination”) (emphasis added), quoting Humphries, 474 F.3d at 405. B. Procedural History Before trial, defendants filed a motion in limine seeking to exclude “any and all argument and evidence of other medical treatment provided to inmates.” In response, Howell sought to add four witnesses to his witness list. All had been incar cerated patients treated by Wexford. With his response, How ell submitted an a davit from each to show Wexford’s prac tice of “o ering ine ective physical therapy for any and all injuries and denying outside consultations with physicians.” The district court granted the motion to exclude these wit nesses, finding that because the “a davits have not indicated they would testify to issues and delays concerning the colle gial review process as it relates to an orthopedic injury, their testimony is not relevant.”2 2 Howell’s response to this motion in limine was the first time these four witnesses were identified, even though some of their affidavits dated 16 No. 19 3210 C. The A davits The admissibility of such evidence lies within the discre tion of the trial judge, who must weigh the dangers of unfair ness, confusion, and undue expenditure of time in the trial of collateral issues against the factors favoring admissibility. Nachtsheim v. Beech Aircraft Corp., 847 F.2d 1261, 1269 (7th Cir. 1988) (finding no abuse of discretion in excluding evidence of other airplane accidents that were not su ciently similar to accident at issue). In exercising that discretion, the judge may not reflexively refuse to conduct a “trial within a trial” but must consider carefully the probative value of the evidence and the o ering party’s need to o er it. See id. at 1268 (closely examining specific reasons for excluding evidence). The court must remain aware of the challenge a plainti faces in prov ing a widespread custom or practice and must give the plain ti a fair opportunity both to discover and then to prove sim ilar wrongs. The judge here showed that she was aware of those requirements. In the end, however, she found that How ell’s evidence did not show su cient similarity to permit a reasonable inference that Howell and these four witnesses su ered similar constitutional violations caused by a com mon, widespread practice. Howell’s first witness said he received inadequate physi cal therapy following knee surgery. Similarly, the second wit ness alleged knee pain and inadequate physical therapy. But neither mentioned Wexford’s collegial review process; they addressed only inadequate physical therapy. The third wit from 2017. The district court did not rely on the delayed disclosure in granting the motion in limine, however, so we also bypass the timing. No. 19 3210 17 ness had injured his bicep. He testified that he requested cor rective surgery but was given pain medication and physical therapy instead. The problem here is that he never claimed he was denied medical care through the collegial review process, or even that a physician submitted a collegial review referral on his behalf. These first three witnesses o ered essentially no relevant support for Howell’s attack on Wexford’s collegial re view process. The fourth witness presented a closer question. He testi fied that he su ered a knee injury and sought surgery, which was rejected through the collegial review process. But the dec laration is sparse on details and does not include evidence of a request for collegial review. It is not even clear whether any physician ever recommended surgery for this fourth witness. A proponent seeking to demonstrate an unconstitutional harm caused by the collegial review process must present ev idence that the requested treatment was medically appropri ate and that denial was not justifiable. The comparator evi dence is not su cient if it relies solely on the incarcerated per son’s own assessment of the appropriateness of the treatment. Saying “I was unhappy with my treatment” is not enough. Given the meager details concerning the fourth witness’s condition and medical treatment, we conclude that the district court did not abuse its discretion in excluding his testimony. The Monell claim against Wexford challenges the collegial re view process, not other aspects of prison healthcare, such as the adequacy of on site physical therapy. Neither the fourth a davit nor the first three showed situations similar enough to Howell’s to find an abuse of discretion in excluding the wit nesses. 18 No. 19 3210 IV. Wexford’s Rule 50(b) Motion After the Jury Verdict At the close of plainti ’s evidence and again at the close of all evidence, defendants made oral Rule 50(a) motions for judgment as a matter of law. The court denied the motions as to Dr. Trost’s liability and reserved a decision as to Wexford’s liability. The jury returned a verdict in favor of Dr. Trost and against Wexford, awarding damages of $25,000. After the ver dict, defendants relied on Rule 50(b) to file written versions of their oral Rule 50(a) motions. The court found that Dr. Trost’s motion was moot but granted Wexford’s motion, finding that Howell had failed to o er evidence that his “experience with the collegial review process was widespread or systemic.” The court then vacated the jury verdict and award and en tered judgment in favor of both Wexford and Dr. Trost. Federal Rule of Civil Procedure 50(a)(1) allows a district court to enter judgment against a party who has been fully heard on an issue during a jury trial “if a reasonable jury would not have a legally su cient evidentiary basis to find for the party on that issue.” We engage in “rigorous and de novo review” of a district court’s ruling on a Rule 50 motion. Passananti v. Cook Cty., 689 F.3d 655, 659 (7th Cir. 2012). The appellate court does not weigh evidence or make credibility determinations, id., and construes evidence “strictly in favor of the party who prevailed before the jury.” Empress Casino Joliet Corp. v. Balmoral Racing Club, Inc., 831 F.3d 815, 822 (7th Cir. 2016), quoting Passananti, 689 F.3d at 659. A. Procedural Challenge Howell argues that the district court granted Wexford’s Rule 50(b) motion on a basis not raised in a Rule 50(a) motion. No. 19 3210 19 A Rule 50(b) motion may be granted “only on grounds ad vanced in the pre verdict motion.” Abellan v. Lavelo Property Mgmt., LLC, 948 F.3d 820, 827 (7th Cir. 2020). Wexford argued to the judge that Howell had failed to present evidence that Wexford had an unconstitutional widespread practice or pol icy. Wexford incorporated its oral argument into its Rule 50(a) motion at the close of Howell’s evidence, and into its Rule 50(a) motion at the close of all evidence. The court was enti tled to grant Wexford’s Rule 50(b) motion on grounds ad vanced in a pre verdict motion under Rule 50(a). B. The Substance Howell argues that the district court erred in granting Wexford’s Rule 50(b) motion because the collegial review pro cess was a company policy or widespread practice that caused the violation of his Eighth Amendment rights. We agree with the district court that Wexford’s collegial review process is not unconstitutional on its face. We recognize that the collegial re view process could be a mechanism for denying or delaying medical care that inmates need. In this case, however, Howell did not o er evidence that would let a reasonable jury find that Wexford’s collegial review process is used in a wide spread or systemic way to violate constitutional rights. 1. Howell’s Experience with Collegial Review After Howell injured his knee, Dr. Trost requested ap proval for referrals to outside specialists through the collegial review process a number of times. The first led to the diagno sis of the torn meniscus and torn ACL and to Howell’s first surgery to repair the torn meniscus. Earlier in this suit, How ell asserted that defendants were deliberately indi erent to his medical needs in the five months between his knee injury 20 No. 19 3210 and the meniscus surgery. The district court granted sum mary judgment for the defendants regarding those five months, and Howell does not challenge that decision on ap peal. Our focus is on the twenty additional months before Howell had surgery to repair his torn ACL. During those twenty months, Dr. Trost’s requests were de nied on two occasions, in April and November 2015. Both times, he sought approval for ACL reconstruction surgery. Both times the reviewing physician denied the request and directed Howell to physical therapy. It is not di cult to im agine how such denials might be deemed evidence of delib erate indi erence. Howell says he was in pain, there is little evidence of a viable program of physical therapy to address his ACL tear, and avoiding surgery was likely to save money for Wexford and/or the State. In this case, however, the undisputed evidence shows that these two denials were consistent with the medical advice from the outside orthopedic surgeon, Dr. Koth, to avoid ACL reconstruction surgery unless and until it became “absolutely necessary.” This exercise of medical judgment by the outside specialist makes it di cult at best to show that Wexford’s de lay in going through with the surgery amounted to deliberate indi erence to Howell’s serious medical needs. See, e.g., Es tate of Cole v. Fromm, 94 F.3d 254, 261–62 (7th Cir. 1996) (even negligent exercise of medical judgment does not show delib erate indi erence; plainti must show decision so far outside bounds of medical judgment as to support inference that medical judgment was not actually exercised). Undisputed evidence also shows three approvals for Howell’s outside referrals through the collegial review pro No. 19 3210 21 cess during this period. First, Dr. Trost requested and re ceived approval for a new MRI in January 2016. The next month, Dr. Trost requested an outside consultation about those MRI results. This request was initially denied, but Dr. Trost appealed and Wexford ultimately approved it. As a re sult, Howell consulted with an outside physician’s assistant to determine whether ACL reconstruction surgery was medi cally needed. And third, after that medical professional rec ommended proceeding with ACL reconstruction surgery, Howell was approved for the surgery, which occurred in June 2016. Howell claims an unconstitutional violation based on an alleged refusal to follow the advice of a specialist. Failure to follow the recommendations of a specialist, including for pain relief, can establish deliberate indi erence. See, e.g., Arnett v. Webster, 658 F.3d 742, 753 (7th Cir. 2011); Jones v. Simek, 193 F.3d 485, 490 (7th Cir. 1999). In this case, however, there is no evidence that Wexford personnel refused to follow the advice of a specialist, let alone that they did so pursuant to an uncon stitutional policy. Again, Dr. Koth’s advice to delay the ACL surgery on medical grounds is vital evidence.3 Even considering the evidence in the light most favorable to Howell, the delay of his ACL reconstruction surgery caused 3 Howell argues that Wexford’s refusal to provide a hard plastic or metal ACL brace was a refusal to follow the advice of a specialist. After Howell’s meniscus repair surgery, Dr. Koth did recommend an ACL knee brace. When Howell requested the knee brace in December 2014, he re ceived a sleeve instead of a hard plastic or metal brace. As best we can tell, the refusal was based on restrictive security protocols in the facility, not because of deliberate indifference by Wexford to Howell’s medical needs. 22 No. 19 3210 by the collegial review process cannot be attributed to delib erate indi erence. A negligent exercise of medical judgment is not enough to show deliberate indi erence. Plainti must show a failure to exercise medical judgment at all. E.g., Estate of Cole, 94 F.3d at 261−62. And Howell has not shown even negligence here. It is not unusual outside of prisons for pa tients with painful orthopedic problems to be told to try more conservative treatment, delaying surgery until it appears that nothing less will o er e ective relief. Given Dr. Koth’s advice to use ACL surgery as a last resort, the Wexford doctors at worst disagreed about whether the surgery was medically ap propriate. A jury could not reasonably find that this choice amounted to a failure to exercise medical judgment.4 2. Delays in Receiving Treatment Howell argues that the collegial review process delayed his ability to receive treatment and that this delay itself was unconstitutional. “[T]he dangers of delayed responses to medical requests are readily apparent.” Thomas v. Cook Cty. Sheri ’s Dep’t, 604 F.3d 293, 304 (7th Cir. 2010) (a rming 4 The record of Howell’s knee rehabilitation and occasional com plaints of pain does not reveal deliberate indifference to his medical needs. In August 2014, when Howell first saw Dr. Koth, there was no evidence of a limp, leading Dr. Koth to conclude that ACL reconstruction surgery may not be the best path. After Howell’s meniscus surgery, Dr. Koth observed that his swelling had improved but that Howell complained of muscle at rophy after disuse. In December 2015, Howell complained to Wexford nursing staff of knee pain. However, one week later, Howell was observed doing full squats with approximately 300 pounds of weights. In January 2016, Wexford’s Dr. Rankin reported that Howell “walks well, can do about 60% of full squat…no tenderness.” And in February 2016, Howell admitted that he did not comply with the recommended physical therapy. No. 19 3210 23 plainti ’s verdict in relevant part; systemic delays in receiv ing treatment can constitute a widespread custom or practice resulting in constitutional violations). The problem for How ell is factual. From the very beginning, the outside specialist (Dr. Koth) was reluctant to proceed with ACL surgery based on his medical judgment concerning Howell’s limited ability to recover from the surgery while in prison. Throughout the months following Howell’s meniscus surgery, Dr. Trost regu larly submitted requests for outside treatment and diagnosis on Howell’s behalf. The reviewing doctors regularly assessed whether it was yet medically appropriate or “absolutely nec essary” for him to receive ACL surgery, frequently advising instead that Howell continue with the recommended physical therapy. Howell’s situation is distinguishable from Shields, where delay made the necessary shoulder surgery impossible and resulted in a serious and permanent impairment that could have been avoided. Shields v. Illinois Dep’t of Corrections, 746 F.3d 782, 785 (7th Cir. 2014) (a rming summary judgment for Wexford because isolated incidents such as a referral to the wrong doctor and a failure to promptly discipline for that mistake did not add up to a pattern to support an inference of unconstitutional custom or practice under Monell). Howell ul timately did receive ACL reconstruction surgery. There is no evidence that the delay resulted in permanent impairment. Not treating pain can be an Eighth Amendment violation, of course, even if it is a matter of only minutes or hours. See, e.g., Estelle v. Gamble, 429 U.S. 97, 103 (1976) (“The infliction of such unnecessary su ering is inconsistent with contemporary standards of decency....”); Grieveson v. Anderson, 538 F.3d 763, 778–80 (7th Cir. 2008) (guards could be liable for delaying 24 No. 19 3210 treatment for painful broken nose by at least a day and a half); Edwards v. Snyder, 478 F.3d 827, 830–32 (7th Cir. 2007) (plain ti stated a claim against prison doctor for deliberate indi er ence after two day delay in treatment for open dislocated fin ger for no medical reason); Cooper v. Casey, 97 F.3d 914, 916– 17 (7th Cir. 1996) (presenting jury question “whether the plainti s were in su cient pain to entitle them to pain medi cation within the first 48 hours after the beating”). But the ev idence shows beyond reasonable dispute here that decisions about how best to treat Howell’s knee were based on medical judgment, primarily Dr. Koth’s recommendation to proceed to ACL surgery only if and when it became “absolutely nec essary.” With that in mind, the delays caused by Wexford’s collegial review process do not show deliberate indi erence to Howell’s medical needs. One final note: Howell also argued on appeal that the dis trict court erred by granting defendants judgment as a matter of law on his demands for punitive damages. Howell points out that we have said that the high deliberate indi erence standard for liability under the Eighth Amendment is not lower than the standard for punitive damages. See Walsh v. Mellas, 837 F.2d 789, 801–02 (7th Cir. 1988). Because defend ants are entitled to judgment as to liability, however, we need not reach the issue of punitive damages. The judgment of the district court is AFFIRMED.
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