Citation Nr: 0004563 Decision Date: 02/22/00 Archive Date: 02/28/00 DOCKET NO. 92-24 583 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, claimed as Crohn's disease. 2. Entitlement to an increased (compensable) evaluation for chronic prostatitis. 3. Entitlement to service connection for an acquired psychiatric disorder, claimed as secondary to his service- connected disabilities. 4. Entitlement to a total disability rating for compensation purposes based on individual unemployability. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD L.A. Howell, Associate Counsel INTRODUCTION The veteran served on active duty from August 1966 to May 1969 and from December 1976 to June 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO) in St. Petersburg, Florida, and Chicago, Illinois, which denied the benefits claimed on appeal. The St. Petersburg RO it the certifying RO. With respect to the issue of service connection for Crohn's disease, by decision dated in August 1994, the Board affirmed the RO's denial. Subsequently, the veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeals) (the Veterans Claims Court). By Order entered October 7, 1996, the Veterans Claims Court vacated the Board's August 1994 decision, and remanded the case pursuant to 38 U.S.C.A. § 7252(a). The claim underwent further development and is now ready for appellate review. While the above claim was pending, the veteran filed additional claims for an increased rating for prostatitis, service connection for an acquired psychiatric disorder on a secondary basis, and for individual unemployability. Those issues will be discussed only in the REMAND section of this Board decision. FINDINGS OF FACT 1. The RO has developed all evidence necessary for an equitable disposition of the veteran's claim as to this issue. 2. The evidence of record does not establish that the veteran's currently-diagnosed Crohn's disease was incurred in or aggravated by military service. 3. Crohn's disease was not established until many years after service, and the preponderance of evidence shows that it is not related to service or to any occurrence or event therein. CONCLUSION OF LAW A gastrointestinal disorder, claimed as Crohn's disease, was not incurred in or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1137, 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board concludes, based on the contentions advanced and the evidence of record that this claim s is well grounded. 38 U.S.C.A. § 5107. That is, the claim is not inherently implausible. Further, all relevant development has been accomplished as to this claim, and there is no indication of additional evidence that should be obtained. Id. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1999). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). However, continuity of symptoms is required where the condition in service is not, in fact, chronic or where diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (1999). In addition, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 1991 & Supp. 1999); 38 C.F.R. § 3.303(d) (1999). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Medical Records A review of the veteran's service medical records during his first period of service reveals no complaints, symptomatology, or findings of gastrointestinal complaints. The May 1969 separation examination report does not show any problems with the veteran's abdomen and viscera. In addition, there is no indication of any inservice history of bowel dysfunction or complaints. In January 1977, during the veteran's second period of service, he complained of low back pain, a discharge from his penis, and urinary urgency. The clinical impression was mild lumbosacral strain with probable prostatitis. In February 1977, he sought treatment for low back strain and prostatitis and reported edema to both legs and pain in his feet. He complained of suprapubic pain with urination but no reported problems with bowel functioning. In February 1977, the veteran's physician-father submitted a To-Whom-It-May-Concern letter regarding his son's medical problems. He related that the veteran was first treated for prostate disease without improvement, developed definite arthritis, probably myositis and neuritis, and was diagnosed with possible herniated disc with sciatica. He also noted a number of episodes of conjunctivitis. He questioned whether the veteran had Reiter's syndrome vs. rheumatoid arthritis vs. Stevens-Johnson syndrome vs. psoriatic arthritis. The father also noted that the veteran had been "shacking up" with a woman with severe ulcerative colitis and suggested that the veteran's relationship with the woman may have caused the veteran's problems. He discussed the possibility of Crohn's disease, which was thought to be an antigen/antibody disease, and that Reiter's disease was also thought to "be something like that." He discussed that these disorders were due to viruses, which was difficult to prove and outlined a course of treatment apparently not approved by the Federal Drug Administration (FDA). He concluded that the veteran had had prolonged contact with a woman with severe ulcerative colitis and now had "Reiter's syndrome, which could be virus caused, and even related to ulcerative colitis." He recommended the experimental treatment, which he represented would not be harmful, but maintained it could save the veteran "from being crippled in the future." A March 1977 treatment note reveals that the veteran sought treatment for a variety of complaints, including chills, cough, nasal congestion, body aches, diarrhea, nausea, and diminished appetite. After a physical examination, the clinical assessment included rule/out Reiter's syndrome, mild dehydration, and questionable effusion. Thereafter, he was referred to Internal Medicine for a consultation regarding migratory arthralgias and urinary complaints. It was noted that the veteran was in the process of receiving a medical discharge due to chronic back pain. Also, the letter from the veteran's physician-father was acknowledged. After a physical examination, which the examiner described as normal, he advised the veteran not to take the medications prescribed by his father as there was no definitive evidence of a disease process and the side effects of the medication could be significant. The examiner concluded that there was no other evidence of a disease process which would render the veteran unfit for military service. In June 1977, the veteran was discharged. Post-Service Medical Evidence Shortly after service separation, the veteran filed a claim for a back disorder. Of note, an October 1977 VA examination report related that the veteran's digestive system was normal. Medical records show treatment on several occasions for back pain throughout the 1980s but no diagnoses of gastrointestinal problems. As an example, in December 1984, he complained of a four to five day history of blood in the stool and constipation. He reportedly drove 500-1000 miles per week, had prolonged sitting, and had loose stool due to problems with his girlfriend. Physical examination showed no external hemorrhoids, two rectal lacerations, and irritation. The clinical assessment was rectal lacerations. There was no mention of Crohn's disease, either by history or at the time of the examination. Further, a February 1986 treatment note specifically indicated that his abdomen was benign. Moreover, in a July 1986 VA examination report, the veteran reported back pain, headaches, pain in the hands and thumb, pain in the neck, and trouble with his bowels but there were no findings made with respect to the nature of his gastrointestinal complaints. In addition, in December 1986, he sought treatment for back problems and related problems with his bowels. In 1987, he underwent back surgery and he reported an upset stomach but there was no specific gastrointestinal diagnosis made. Then, in November 1989, he complained of low back pain but denied any bowel or bladder dysfunction. In early February 1990, the veteran sought treatment because he had been on Motrin for three months and had developed blood in his stool. He related a history of occasional blood in the stool but it had increased in frequency. He underwent a flexible sigmoidoscopy which showed normal mucosa and no lesions. The examination was noted to be within normal limits and he was recommended to increase his fiber intake. A late February 1990 neurosurgical treatment note indicated that the veteran had no complaints of bowel dysfunction. In a July 1990 VA examination report, he complained primarily of problems with his back but also noted that he had some chronic gastrointestinal problems with hemorrhoids and rectal bleeding. In February 1991, he sought Vocational Rehabilitation and maintained that his unemployability was due to a back disorder. He reported that he injured his back in 1978 when he fell on some ice. There was no mention made of Crohn's Disease nor a connection between his back and Crohn's disease. In June 1991, the veteran was hospitalized due to back pain. There was specifically no bowel or bladder problems noted. In October 1991, the veteran sought treatment for bowel problems. An October 1991 barium enema apparently showed changes of the distal descending colon and sigmoid and non- specific colitis. An upper GI series reportedly showed changes of the ileal loop and terminal ileum suggestive of Crohn's disease. One examiner interpreted the results as "strongly suggestive" of Crohn's disease. The November 1991 barium report related a clinical impression of regional ileitis or Crohn's disease. Thereafter, the veteran filed the current claim. In December 1991, he reported a long history of intermittent diarrhea with occasional bright red blood per rectum. For years he apparently thought it was related to use of Motrin. He subsequently underwent a flexible sigmoidoscopy which showed normal mucosa and no lesions. Nonetheless, the clinical assessment was Crohn's disease. In March 1993, the veteran was hospitalized for evaluation of codeine for low back pain management. He related a history of Crohn's disease and possible Reiter's syndrome during service. However, the note implied that he was not diagnosed with Crohn's disease until sometime after his back surgery in 1986. In a November 1993 hospitalization note, he related a long-history of Crohn's disease and a six to twelve month history of intermittent bright red blood per rectum. He was noted to have hemorrhoids and his weight was stable. A flexible sigmoidoscopy showed external hemorrhoids and shiny mucosa with no granularity or friability. It was recommended that he not undergo surgery for hemorrhoids and he was instructed to continue his regular course of treatment. In an ophthalmology consultation note dated in June 1994, the veteran related that he had been diagnosed with Crohn's disease since 1978. In August 1994, the Board denied the veteran's claim on the basis that it was not well grounded. The veteran appealed that decision to the Veterans Claims Court. Additional medical evidence submitted in support of the claim shows that during a July 1995 hospitalization, the veteran related that he had been diagnosed with Crohn's disease since 1979. In a December 1995 pre-operative note, the physician noted that the veteran was well-known to him and had been diagnosed with Crohn's disease by gastrointestinal X-ray. In October 1996, the Veterans Claims Court remanded the claim for further development. The Veterans Claim Court noted that the Board was proper in finding the claim not well grounded but that VA had a duty to inform the veteran that further development was needed in order to well ground his claim. As noted the requested development has been completed as to this issue and it has been returned to the Board for additional appellate review. In a November 1996 VA gastrointestinal examination, the veteran reported a history of Crohn's disease and indicated that he had been treated with a variety of medications. The final diagnosis was history of Crohn's disease in remission well controlled with diet. Parenthetically, the Board notes that the veteran challenged several of the findings of the examination, including his weight and the finding that the disease was under control. A November 1996 VA rectum and anus examination similarly noted a history of Crohn's disease, stable and in remission. Several other VA examinations not directly related to the disorder indicate a history of Crohn's disease. In May 1997, the Board remanded the claim for additional development, to include an attempt to associate additional medical evidence in support of the veteran's claim. In October 1997, the RO sent a letter to the veteran requesting that the veteran provide a statement from a physician that his Crohn's disease had its onset during active service. In response, the veteran submitted two statements from his father's former colleagues. The first, a letter from a VA physician dated in September 1996 (but not received at the RO until November 1997), indicated that he was a colleague of the veteran's physician-father from 1974 to 1978, then again in 1984. He recalled that the veteran's father treated the veteran in 1977 for symptoms of Crohn's disease using Flagyl and Colchicine. He recalled that there were no records available but he remembered discussing the "avant-garde" treatment with the veteran's father. He admitted that he had not actually treated the veteran. The second, a letter from a VA physician dated in November 1994, and received by the RO in November 1997, appeared to have been written in response to a request by the veteran for a "professional opinion" from someone that knew him. The letter, and accompanying consultation form, indicated that the veteran complained of right stomach pain, took Maalox, and had diarrhea. The veteran was noted to be chronically ill and known to the physician from previous encounters regarding Crohn's disease. The physician noted that the diagnosis was first made in 1990 but that the "symptoms clearly preced[ed] this date." The physician remarked that, based on symptoms of low back pain, gastrointestinal symptoms, and family history, he was convinced that the diagnosis of Crohn's disease should be back dated to about 1977. The examiner concluded that he had extensive experience dealing with Crohn's disease in 1973-1978 and was noted to be Board certified in Internal Medicine and Gastroenterology. Additional evidence included an undated letter from an LPN, who worked with the veteran's father from 1979 to 1983, indicated that the veteran's father sent the veteran medication for treatment of Crohn's disease. Also, his sisters (on two separate occasions) indicated that their father treated the veteran in the Navy and after service. They revealed that father and son were not speaking at the time the veteran became ill in the Navy but that they told the father of the veteran's illness. They reflected that their father talked with the Navy doctors and sent medication for back and joint pain, bone problems, cramps, diarrhea, rectal bleeding, constipation, and problems with urination. They related that they both had colitis and shared many, but not all, of the same symptoms that their brother did. They concluded that the veteran's symptoms began to escalate in the late 1980s until he could no longer work. In a June 1992 statement, the veteran's mother indicated that her husband had treated the veteran for Crohn's disease since 1977. A former employee indicated that he worked for the veteran's father for several months in 1984 and recalled several conversations concerning the father's treatment of the son for Crohn's disease. The veteran also submitted an undated article from the Crohn's and Colitis Foundation on the "new" and "controversial" treatment of Crohn's disease with Flagyl and Purinethol. Most recently, the Board requested the opinion of a medical expert by letter dated in August 1999. In response, the Board received a letter from an independent medical expert (IME) dated in September 1999. As an initial matter, the IME reviewed the claims file and stressed that there was no evidence of Crohn's disease shown. He further addressed the veteran's physician-father's 1977 letter and disputed the conclusion that intimate exposure to a woman with ulcerative colitis caused the veteran the to develop Crohn's disease. The IME opined that cohabitation with a patient with colitis was not a known or accepted risk factor for the development of inflammatory bowel disease. Further, the IME related that nothing the veteran complained about during service remotely supported symptoms of Crohn's disease, even in retrospect. Again stressing that there was no evidence that the veteran currently had Crohn's disease, the IME observed that the veteran's complaints of back pain in service could not be ascribed to Crohn's disease as there were many caused of back pain and the veteran had confirmed disc disease by CT scan and X-ray. The IME indicated that the in-service reports of prostatitis was not a feature of Crohn's disease, although urinary problems and fistulization between the bowel and urinary tract were occasionally seen in Crohn's disease. The IME also questioned the Board's characterization that the veteran had Crohn's disease and indicated that he saw no objective evidence of Crohn's disease present. He reflected that a barium study showed some narrowing of the small bowel but opined that this finding did not constitute a confirmed diagnosis of Crohn's disease. The IME stressed that any back pain was not tantamount to Crohn's disease-related arthropathy of the axial skeleton and the available evidence was against the pain being related to Crohn's disease, even if the veteran had objective evidence for Crohn's disease in the small bowel. Similarly, there was no evidence of chronic prostatitis, and even if present, could not be linked to Crohn's disease. The IME concluded that even if the veteran had Crohn's disease, which he again observed was not apparent in the claims file, he could not link prostatitis and chronic back pain to the illness. Legal Analysis As an initial matter, the Board acknowledges the IME's concern about whether the veteran currently has Crohn's disease. The IME correctly points out the lack of definitive diagnostic procedures which might otherwise confirm the diagnosis. Nonetheless, for purposes of this decision the Board will assume, without deciding, that the veteran does have Crohn's disease. Particularly, the Board notes a clinical impression "strongly suggestive" of Crohn's disease after an October 1991 upper GI. In addition, a December 1991 clinical assessment was also noted to be Crohn's disease after a flexible sigmoidoscopy, even though the examiner remarked that the mucosa was normal and there were no lesions. Further, several treating physicians have diagnosed Crohn's disease based on a reported long-time familiarity with the veteran's medical history. For those reasons, the Board will proceed as if the veteran has a confirmed diagnosis of Crohn's disease. Several pieces of evidence have been submitted in support of the veteran's claim including a February 1977 statement from his physician-father, written statements from his family, and letters from his father's colleagues and former employees. Turning first to the February 1977 letter from his father, the veteran relies heavily on this letter for the proposition that he was diagnosed with Crohn's disease in service. However, the Board is not similarly persuaded. After a careful review of the letter, it appears that the father offered his medical opinion without ever examining the veteran nor did he apparently perform any diagnostic tests. In addition, the father focused the discussion on Reiter's syndrome, not Crohn's disease. As noted by the Veteran's Claims Court in the decision to vacate the Board's original decision, Crohn's disease is a chronic granulomatous inflammatory disease of unknown etiology involving any part of the gastrointestinal tract (citing Dorland's Illustrated Medical Dictionary 480 (28th ed. 1994). On the other hand, Reiter's syndrome consists of a triad of symptoms of unknown etiology comprising of urethritis, conjunctivitis, and arthritis (citing Dorland's at 1638). Further, although Crohn's disease was mentioned in the February 1977 letter, it was in the context of explaining it as an antigen/antibody disease similar to Reiter's syndrome which affected the entire gastrointestinal tract. There was no clear indication by the father that he believed that the veteran had Crohn's disease, rather it appeared that he raised the disease pathologies as differential diagnoses. Moreover, the father suggested that the veteran's disease process was due to an intimate relationship with a woman who suffered from severe ulcerative colitis. However, there was no scientific or medical evidence presented at the time or has any been offered since that intimate contact with a person with ulcerative colitis could cause anther to develop Crohn's disease. In addition, although the physician-father apparently prescribed medication for the veteran, it appeared to be based on an it-won't-hurt-and-might-help approach, not on a confirmed diagnosis. When asked to review the February 1977 letter as part of an independent medical opinion, the IME, while sympathetic to the father's concern about his son, essentially rejected the letter on the basis that the premise of the letter, i.e. the veteran's cohabitation with a patient with colitis, was not a known or accepted risk factor for the development of inflammatory bowel disease. The Board similarly rejects the veteran's physician-father's opinion that the veteran developed a gastrointestinal disorder due to intimate contact with a woman with ulcerative colitis because the Board finds no support for such a proposition even by the physician statements finding Crohn's disease. Further, the IME opined that nothing contained in the veteran's complaints during service remotely supported symptoms of Crohn's disease, even in retrospect. Accordingly, the Board finds that the February 1977 letter from the veteran's physician-father is simply too vague and without foundation to form the basis of a diagnosis of Crohn's disease in service. Similarly, the Board finds that statements made in support of the veteran's claim which are based on statements made by the veteran's father less persuasive. This includes statements from the father's former employees, including an undated letter from an LPN who related that the veteran's father sent the veteran medication for treatment of Crohn's disease and a letter from an office scheduler who recalled having conversations with the father concerning his son's treatment for Crohn's disease. These statements are no more than recitations of the veteran's father's views on his son's disorder and, as noted above, do not appear to be based on a definitive diagnosis of Crohn's disease. The Board has also considered the statement of the veteran's sisters and his mother to the effect that his father treated him for Crohn's disease. These statements, dated well after service, do not provide a basis for relating any symptomatology in service to Crohn's disease apparently diagnosed in 1991. Although the veteran's family may be competent to describe symptomatology, the statements are not competent or credible evidence of a diagnosis, date of onset, or medical causation of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); Miller v. Derwinski, 2 Vet. App. 578, 580 (1992). The veteran's family, except for his late-father, lacks the medical expertise to offer an opinion as to the existence of current gastrointestinal pathology, as well as to medical causation of any current disability. Id. Thus, the family statements, while indicating that the veteran's father treated the veteran, cannot be used to establish a causal connection between in-service symptomatology and Crohn's disease. The other primary medical evidence in support of the veteran's claim are two letters from physician-colleagues of the veteran's father. The first letter, dated in September 1996, essentially indicated that he recalled the veteran's father treating the veteran for Crohn's disease in 1977. However, he acknowledged that he did not actually treat the veteran's himself and it appears that his statements are based only on conversations with the veteran's father. The physician-colleague suggested, but did not state, that the veteran's Crohn's disease started in military service. While inconclusive medical language on causation can sometimes be held to well ground a claim, see Mattern v. West, 12 Vet. App. 222 (1999), unenhanced medical information unverified by an examiner is generally not considered competent. See Grover v. West, 12 Vet. App. 109 (1999). This statement does not even satisfy that criteria. Specifically, as noted, the physician-colleague admitted that he did not treat the veteran and, by inference, had no first hand knowledge of either the veteran's symptomatology or diagnosis. Further, there is no evidence that the physician-colleague obtained his information directly from the veteran; therefore, there was no way for him to verify the veteran's medical condition. Finally, although the physician-colleague could offer a statement as to what the veteran's physician-father told him, this information is too tangential to establish that the veteran, in fact, had Crohn's disease during service or immediately thereafter. Another statement from a physician-colleague of the veteran's father, dated in November 1994, indicated that the veteran was first diagnosed with Crohn's disease in 1990 but that the symptoms preceded that date. He observed that the diagnosis of Crohn's disease should be made retroactive to 1977. However, the Board is compelled to find the statement less persuasive because the medical records created contemporaneously with the veteran's various treatments in- service and since separation from service do not support the physician-colleague's conclusion. First, the physician-colleague represented that his opinion was based on the veteran's symptoms of low back pain, gastrointestinal symptoms, and family history; however, the evidence indicates that the veteran sustained a traumatic injury to his back in service and that he essentially had no diagnosed gastrointestinal disorder until October 1991. Specifically, service medical records indicate that the veteran fell on ice and injured his back. He sought treatment nearly immediately, which was on-going, based on that fall until service separation. Post-service clinical records also reveal on-going treatment for back pain, which was related by the veteran either to an in-service fall on ice and/or to a post-service work-related back injury in the mid-1980s. Further, other than the veteran's father suggesting a connection between what he apparently believed to be Reiter's syndrome, the veteran's intimate contact with a woman with ulcerative colitis, and the antibody/antigen similarities between Reiter's syndrome and Crohn's disease, the service medical records are essentially negative for gastrointestinal symptomatology. In a March 1977 treatment note, the veteran reported having diarrhea, but it appeared to be interrelated with complaints of chills, fever, nasal congestion, body aches, etc. Similarly, because the veteran experienced fairly frequent episodes of back pain and ultimately underwent back surgery, post-service medical evidence specifically notes on multiple occasions that he had no problems with his bowels or bladder, even when directly asked. Such reported history was given in conjunction with necessary medical treatment, and is therefore highly probative. Moreover, an episode of rectal bleeding in December 1984 was attributed to prolonged sitting and personal stress. In addition, in a July 1990 VA examination report, he reported chronic gastrointestinal problems but defined them as hemorrhoids and rectal bleeding. It was not until October 1991, when the veteran sought treatment for problems with his bowels, that an upper GI series reportedly showed changes consistent with Crohn's disease. This was essentially the first time since his separation from service over 14 years before that a medical diagnosis was made with respect to the veteran's gastrointestinal problems. The Board notes that a physician's opinion based on the veteran's layman account of an illness from many years ago, which is otherwise uncorroborated by competent medical evidence of record, can be no better than the veteran's bare contentions. See Swann v. Brown, 5 Vet. App. 229, 233 (1993); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Further, a physician's opinion based upon an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Accordingly, because the post-service medical evidence of record is essentially devoid of unexplained low back pain or a gastrointestinal disorder for many years after service and the physician-colleague's opinion is unaccompanied by any medical information concerning how his decision was made. Moreover, the Board accords greater weight to the IME's opinion because he was requested to address the specific on appeal, i.e. whether the veteran's gastrointestinal disorder, claimed as Crohn's disease, was incurred in or aggravated by military service. The Board particularly notes that, unlike the other physicians offering opinions, the IME reviewed the entire claims file, including service medical records and post-service medical evidence. Further, the IME specifically opined that the veteran's symptoms in service were not the manifestations of Crohn's disease. Thus, the Board finds the contemporaneous medical records and the IME's opinion more persuasive than statements made on the veteran's behalf years after the veteran's separation from service. Since October 1991, the veteran has reported a long history of Crohn's disease, primarily relating it to military service, but at one point suggesting that he was not diagnosed until after his back surgery in 1986, and on other occasions indicated that he was diagnosed in 1978 (a year after service separation), or in 1979 (two years after service). Since 1991, multiple medical examiners have diagnosed a history of Crohn's disease, including a November 1996 VA gastrointestinal examination. However, the veteran took exception to the findings that the disease was stable and in remission. Nonetheless, the Veterans Claims Court has held that the Board is not obligated to accept medical opinions premised on the veteran's recitation of medical history. See Godfrey v. Brown, 8 Vet. App. 113 (1995). In this case, the Board is persuaded by the lack of medical evidence indicating symptomatology, diagnosis, or treatment for what is generally now found to be Crohn's disease until many years after service separation. Finally, the Board has considered the veteran's own statements that his Crohn's disease incurred during military service. Like the statements of his family, although probative of symptomatology, they are not competent or credible evidence of a diagnosis, date of onset, or medical causation of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); Miller v. Derwinski, 2 Vet. App. 578, 580 (1992). The veteran's assertions alone are not deemed to be credible in light of the preponderance of evidence showing no medical causation between symptomatology in service and any current disability. Id. In the absence of competent, credible evidence of a causal relationship, the Board must conclude that the preponderance of the evidence is against the veteran's claim and the claim is denied. ORDER The claim for entitlement to service connection for a gastrointestinal disorder, claimed as Crohn's disease, is denied. REMAND The Board has a duty to assist the veteran in the development of facts pertinent to his claim and ensure full compliance with due process. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. § 3.159 (1999). This duty to assist involves obtaining potentially relevant medical reports. Lind v. Principi, 3 Vet. App. 493, 494 (1992) (federal agencies); White v. Derwinski, 1 Vet. App. 519, 521 (1991) (private records); Murincsak v. Derwinski, 2 Vet. App. 363 (1992) (Social Security records). It also includes a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994); Abernathy v. Principi, 3 Vet. App. 461 (1992); Roberts v. Derwinski, 2 Vet. App. 387 (1992); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Littke v. Derwinski, 1 Vet. App. 90 (1990); Murphy v. Derwinski, 1 Vet. App. 78 (1990). With respect to the issue of an increased rating for prostatitis, the Board determines that the veteran's claim for an increased rating is well-grounded by virtue of his statements that he has suffered an increase in disability. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997). However, the Board notes that the veteran has not had an examination for nearly four years. Further, there appears to be some ambiguity, which must be clarified before the Board can enter a fully informed decision on this issue. Specifically, there is a question whether the veteran's claimed urinary frequency is due to a tumor of the bladder or due to chronic prostatitis. When an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Abernathy v. Principi, 3 Vet. App. 461, 464 (1992). Accordingly, the Board finds that an additional examination is warranted in this instance. With respect to the claim for entitlement to service connection for an acquired psychiatric disorder, the RO found the claim to be well grounded and the Board agrees. The veteran has not claimed entitlement to service connection for a psychiatric disorder on a direct service connection basis; rather, he asserts that he developed a psychiatric disorder as a result of his service-connected disabilities, specifically a low back disability and chronic prostatitis. However, the most recent VA psychiatric examination report, dated in April 1996, does not adequately discuss the relationship between the veteran's psychiatric disorder and his nonservice-connected disorders vs. his service-connected disabilities. Accordingly, another examination is warranted. With respect to the claim for individual unemployability, the Board finds that a formal decision with respect to well- groundedness need not be made at this time. First, the RO apparently has considered this claim to be well-grounded and undertook review of the claim on the merits. The Board agrees with this analysis and will do likewise. Further, the Board finds that a physician's statement that the veteran is disabled is sufficient to well ground a claim for individual unemployability. Nonetheless, it is unclear to the Board to what degree the veteran's unemployment can be attributed to only his service-connected disabilities and how much is based on nonservice-connected disabilities and additional development is needed in this area. Finally, in order to make certain that all records are on file, while the case is undergoing other development, a determination should be made as to whether there has been recent medical care, and whether there are any additional records that should be obtained. While the Board regrets the delay involved in remanding this case, proceeding with a decision on the merits at this time would not ensure full compliance with due process. In view of the foregoing, this case is REMANDED for the following actions: 1. The RO should contact the veteran to determine the names, addresses, and dates of treatment of any physicians, hospitals, or treatment centers (private, VA or military) who have provided him with medical treatment not already associated with the claims file. After obtaining the appropriate signed authorization for release of information forms from the veteran, the RO should contact each physician, hospital, or treatment center specified by the veteran, to request any and all medical or treatment records or reports relevant to his service-connected and nonservice- connected disabilities. All pieces of correspondence, as well as any medical or treatment records obtained, should be made a part of the claims folder. If private treatment is reported and those records are not obtained, the veteran and his representative should be provided with information concerning the negative results, and afforded an opportunity to obtain the records. 38 C.F.R. § 3.159 (1999). 2. The veteran should be advised that while the case is on remand status, he is free to submit additional evidence and argument. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). 3. The veteran should be scheduled for a VA examination of his prostate pathology. All indicated tests should be accomplished and all clinical findings should be reported in detail. The claims folder should be provided to the examiner for review prior to the examination. It should be indicated whether there is objective evidence of pain or spotting of blood and the history of the frequency and/or leakage of urination, both day and night, should be recorded. The examiner is also requested to review the claims file and offer a medical opinion of whether the veteran has a bladder tumor and the extent to which that effects his prostate symptomatology. 4. The RO should also schedule the veteran for a VA psychiatric examination to determine the nature and etiology of any psychiatric disorder. All indicated tests should be accomplished and all clinical findings should be reported in detail. The claims folder should be provided to the examiner for review prior to the examination. Specifically, a determination should be made as to the nature of the veteran's psychiatric disorder. Assuming a psychiatric disorder is identified, the examiner is requested to enter an opinion as to whether the psychiatric disorder can be said to be related to the veteran's service-connected prostatitis and/or low back disability. 5. Thereafter, the veteran should be scheduled for a VA examination to determine the degree of industrial impairment caused by his service- connected disabilities, with consideration given to any favorable results based on the above examinations. The claims folder should be made available to the examiner for review. The examiner is asked to offer an opinion addressing the impact of only the veteran's service-connected disabilities on his employability. Consideration should be given to the impact of the veteran's various nonservice-connected disabilities on his employment. Specifically, the examiner is asked to generally address the extent of functional and industrial impairment from the veteran's identified service- connected disabilities, as distinguished from the various nonservice-connected disabilities. If it is determined that additional examination(s) are needed, such examination(s) should be scheduled and conducted. Any significant impairment of health should be set forth in detail. 6. Following completion of the above actions, the RO must review the claims folder and ensure that all of the foregoing developments have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. See Stegall v. West, 11 Vet. App. 268 (1998) (compliance of a Court or Board directive is neither optional nor discretionary). Where the remand orders of the Board or the Veterans Claims Court are not complied with, an error exists as a matter of law for failure to ensure compliance. Specific attention is directed to the examination reports. If the examination reports do not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the reports must be returned for corrective action. 38 C.F.R. § 4.2 (1999) (if the report does not contain sufficient detail, the rating board must return the report as inadequate for evaluation purposes). 7. Thereafter, the RO should readjudicate the current claims on appeal. To the extent the benefits sought are not granted, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable opportunity to respond thereto. Thereafter, the case should be returned for further appellate consideration to the extent such action is in order. No action is required of the appellate until he is notified. The Board intimates no opinion as to the ultimate outcome in this case by the action taken herein. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. MICHAEL D. LYON Member, Board of Veterans' Appeal