                            In the

United States Court of Appeals
              For the Seventh Circuit

No. 07-2783

F LOYD K. H AYES,
                                              Plaintiff-Appellant,
                                v.

D ONALD N. S NYDER, JESSE M ONTGOMERY, M ARK A. P IERSON,
W ANDA L. B ASS, and W ILLIAM M. H AMBY,

                                           Defendants-Appellees.


           Appeal from the United States District Court
                 for the Central District of Illinois.
            No. 04-cv-1062—Michael M. Mihm, Judge.



      A RGUED M AY 30, 2008—D ECIDED O CTOBER 9, 2008




 Before B AUER, R IPPLE, and W OOD , Circuit Judges.
  W OOD , Circuit Judge. Since 2001, Floyd K. Hayes has
suffered from a medical condition that causes spasms
in the cremasteric muscle associated with the left side of
his scrotum. During these spasms, which occur at least
once, and often multiple times, each day, Hayes’s
cremasteric muscle cramps and retracts, compressing his
testicle and causing excruciating pain. When these
2                                               No. 07-2783

spasms began, around September 2001, Hayes was an
inmate at Illinois’s Hill Correctional Center (“Hill”). From
that time through August 2002, when Hayes was re-
leased from Hill and placed on parole, he repeatedly
sought medical treatment for this pain. In 2004, he brought
this lawsuit under 42 U.S.C. § 1983, alleging that Dr.
William M. Hamby, medical director at Hill during the
relevant time period, and various non-medical prison
officials were deliberately indifferent to his serious
medical needs in violation of the Eighth Amendment. The
district court granted summary judgment in favor of both
Dr. Hamby and the non-medical defendants. Hayes
challenges both rulings on appeal. We affirm the judg-
ment in favor of the non-medical prison officials, but we
reverse the judgment for Dr. Hamby and remand the
case for trial.


                             I
   Hayes, now in his early 60s, is a Vietnam War veteran
and former Kentucky State Trooper. In 1997, he began
serving a 10-year sentence in the Illinois Department of
Corrections, the bulk of which he spent at Hill. Hayes
first complained of testicular cysts in the fall of 2000. An
ultrasound ordered by Hill physician Dr. Mohammed
Choudry revealed that the cysts were benign; blood work
and urinalysis results were normal. Dr. Choudry did not
refer Hayes to a urologist, but he did discuss Hayes’s case
with a urologist in December 2000. Choudry concluded
that neither the removal of the cysts nor a referral for
a urology consult or biopsy was indicated.
No. 07-2783                                                 3

  As time went on, the cysts became larger and more
painful. Worried and experiencing intense discomfort,
Hayes asked in March 2001 to be seen by a urologist for
a biopsy of the cysts. His request and related grievance
were denied, and Hayes took no further action until
September 2001, when his pain began to bother him on a
daily basis. He sought treatment and was given a prophy-
lactic antibiotic and Tylenol III for the pain. As instructed,
Hayes visited the medical unit on October 4, 2001. He saw
Dr. Hamby that day, and also 10 days later. (Those were
his only two “in-person” visits with Dr. Hamby.) Dr.
Hamby wrote on Hayes’s chart that he observed “tender-
ness” and “discomfort,” but he did not use the word
“pain.” Hayes asserts that he complained of pain at those
visits; Dr. Hamby counters, based solely on his notes, that
he must not have thought Hayes was in much pain. (Dr.
Hamby asserted that he had no independent memory
of Hayes.)
  When Hayes returned to the medical unit on October 29,
2001, he saw Dr. Richard Shute for the first of several
times. Dr. Shute’s notes from those visits indicate that he
wanted to refer Hayes to a urologist and prescribe
prescription-strength pain medications, but that Dr.
Hamby refused to approve those treatments. Hayes’s
recollection of his visits with Dr. Shute suggests the
same: “[Dr. Shute] said he couldn’t make Doctor Hamby
give me those outside tests that he had asked for. . . . He
told me he couldn’t give me nothing different because
Hamby wouldn’t approve. Everything Shute did, okay,
Doctor Hamby had to approve or disapprove.”
4                                               No. 07-2783

   Dr. Hamby stated in his deposition that he never ap-
proved the urology referral or painkiller prescriptions
because he did not receive the proper forms. Nothing in
the record establishes whether such forms were in fact
filled out or, indeed, whether they were required at all.
What we do know is that Dr. Shute made notes in Hayes’s
chart about Hayes’s increasing pain, wrote at least once
that Hayes should have a urology referral, and also
prescribed ibuprofen and wrote permission slips that
allowed Hayes to have ice packs to ease his pain.
  These minimal remedies did not provide relief for
Hayes. Having been told by Dr. Shute that no more could
be done “because Hamby wouldn’t approve,” Hayes began
to write letters and to file grievances with non-medical
prison officials, complaining that he was not receiving
adequate treatment from the medical unit—specifically, Dr.
Hamby. He wrote a letter on April 16, 2002, addressed to
Assistant Administrative Director Jesse Montgomery. The
letter expressly asked to see a “specialist” in the appropri-
ate field of medicine “to determine what these growths
are.” He referred to a prior letter that he had sent to Hill
Director Donald Snyder, and then attempted to describe
his condition, asking Montgomery to “excuse my
graphic details”:
    My testicles swell abnormally. My left testicle draws
    upward like a leg cramp which causes my penis to
    bend upward into a fishhook position. In order to
    urinate, I must reach down and under to pull my
    testicle down to unbend my penis. As you can imagine,
    this is an extremely painful thing that I must do each
    time I go to the bathroom.
No. 07-2783                                                5

He reiterated that this was an “ongoing undiagnosed
condition”; noted that at least one examining physician
had said that Hayes should be seen by a urology specialist,
but Dr. Hamby had denied the request; and wrote that
“[i]n the meantime, I remain in constant pain with
new growths being discovered weekly.”
  After Montgomery received this letter, an administrative
assistant at Hill wrote the following email, sent May 9,
2002, to personnel in the medical unit:
   I am researching a response to inmate Hayes for ADD
   Montgomery. In Inmate Hayes’ correspondence he
   complains of insufficient care by health care staff, i.e.,
   testicles continue to swell, difficulty urinating due to
   bent penis, numbness in right palm and fingers . . . .
   Bottom line, he wants out early. Can you give me any
   update on his medical condition? When conducting
   prior review in December 2001, his condition was
   then reported as remaining stable and health care
   needs being addressed. Just a brief history/comments
   will suffice.
  Dr. Hamby responded to this email sometime in May
2002 with a three-page, single-spaced summary of Hayes’s
chart and medical history, starting in September 2000.
Dr. Hamby’s letter concluded by stating that Hayes had
“a right epididymal cyst” and a “small left epididymal
cyst. These have remained stable except for self-reported
swelling and occasional tenderness. . . . Telephone consul-
tation and length of follow-up indicate the epididymal
cysts are simply cysts. Biopsy and/or surgical excision are
not indicated at this time.”
6                                               No. 07-2783

  Assistant Warden Wanda Bass was placed in charge
of responding to Hayes’s complaint, and she sent a letter
to Hayes on May 24, 2002, stating that she had contacted
the medical unit director (Dr. Hamby), who in turn indi-
cated that Hayes was being “seen and monitored on a
regular basis.”
  Hayes wrote a response to Bass on June 10, 2002, reiterat-
ing that the problem was that he was being “seen and
monitored,” but not being treated. In addition to re-
peating his complaints about his “severe pain” and the
medical unit’s refusal to order a referral or tests, he added
that “[a]lthough I was given pain medication in the past,
they now refuse to do so.” He attached his medical files to
the letter, noting that they “clearly show the pain and
extreme changes” in his condition that he had to endure.
Bass responded to this letter on June 17, 2002:
    As indicated in my response to you dated 05/24/02,
    your medical concerns have been reviewed by appro-
    priate medical staff. However, upon receipt of your
    most recent correspondence, I had a discussion with
    the Health Care Unit Administrator. Your medical
    chart has again been reviewed.
    According to your medical records, you have a history
    of scrotal cysts which occasionally swell and cause
    you pain. These cysts do respond to ice packs and
    Ibuprofen. The Urologist you saw on December 16,
    2000 and the current medical Director indicate that
    you do not require further intervention. However, if
    you feel you need further education regarding cysts,
    please sign up for nurse sick call.
No. 07-2783                                                7

Warden Mark Pierson concurred with Bass’s conclusions
in a letter dated July 1, 2002.
  The conclusion of the non-medical prison officials,
based on the information they had received from Hill’s
medical staff, was that nothing further needed to be done
about Hayes’s medical complaints. For the sake of accu-
racy, however, we note that Bass was in error when she
referred in her letter of June 17 to Hayes’s seeing a urolo-
gist on December 16, 2000. Hayes never “saw” a urologist
while he was at Hill; Dr. Choudry, a non-specialist, simply
noted in Hayes’s chart that he had discussed Hayes’s
case with a urologist. Furthermore, although Bass was
correct that Hayes’s pain often responded to ice packs
and ibuprofen, even those minimal treatments were
taken away from him at some point.
   Although Hayes did not find Bass’s response satisfac-
tory, he did as she suggested and filed four “nurse sick
call” requests between May and July of 2002. These efforts
were unavailing. In addition to writing letters, Hayes also
filed a formal grievance on June 20, 2002, stating that he
had repeatedly complained about his “extreme pain,
cancer, and swollen testicals [sic], and lack of medical care
to all concerned parties.” He further noted that “I’m in
extreme Pain” and requested “Pain Medication, Proper
cancer test, po[ss]ible removal of growths on testicals [sic]
[,] Ice for Swollen Testicals [sic], Proper outside medical
Care.”
  The grievance officer denied this grievance on July 12,
2002, stating that “Dr. Hamby (MD) responds [that] inmate
Hayes’ [sic] first complained of testicle problems on
8                                              No. 07-2783

9/18/00. Was treated and tested accordingly.” This indi-
cates that despite Dr. Hamby’s assertion that he was not
involved with Hayes’s case at any time after October 2001
and that he “would never have seen” Hayes’s June 20,
2002, grievance, a trier of fact could conclude otherwise.
The grievance report makes several references to Dr.
Hamby, and it states that Dr. Hamby was the source
from which the grievance officer received the informa-
tion upon which he based the denial. The response
Dr. Hamby supplied to assist with Bass’s reply to Hayes’s
April 16, 2002, letter also was apparently used as the
basis for denying the formal grievance that Hayes filed on
June 20. Warden Pierson concurred in the denial of that
grievance on July 18, 2002.
  Hayes was released from Hill on August 15, 2002. The
same day, he went directly from the prison to the Veterans’
Administration (“VA”) Hospital in Danville, Illinois,
seeking treatment for his pain. When he arrived, the
hospital staff thought that his chief issues involved his
mental, not physical, health. The reason is simple: three
days before Hayes’s release from Hill, the hospital
received a call from Hill informing it that Hayes likely
would be going there upon his release and that his “pri-
mary problems are psychiatric.” Hayes does suffer from
post-traumatic stress disorder on account of both child-
hood trauma and his service in Vietnam, but his reasons
for visiting the hospital that day had nothing to do with
post-traumatic stress disorder. The progress notes from
the date he was admitted report that Hayes was “admitted
on 8/15/02 with the chief complaint of testicular pain.”
Notwithstanding that complaint, the hospital sent Hayes
No. 07-2783                                               9

straight to the psychiatry ward and gave him only
15 minutes with a urologist, Dr. Narayan R. Amin. The
Danville hospital did, however, provide Hayes with
prescriptions for ibuprofen and Darvocet (a narcotic) for
his pain before discharging him on August 25, 2002.
  Hayes then left Danville and went on to his final destina-
tion, Kentucky, where his family is. There, Hayes saw a
nurse practitioner at the Lexington VA Hospital on Sep-
tember 12, 2002. She evaluated him and ordered a
testicular ultrasound and urology consult. On September
30, 2002, he saw primary care physician Dr. Alicia Bigham,
who prescribed Lortab (another narcotic) for his pain; he
then saw urologist Dr. William Terence Connor on
October 10, 2002. Dr. Connor diagnosed Hayes with
“crema[s]tic muscle spasm with chronic pain and peronies
[sic] disease.” Peyronie’s disease is a connective tissue
disorder involving the growth of fibrous scar tissue in
the soft tissue of the penis. The hardened scar tissue
prevents the normal tissue from moving where it other-
wise would in a healthy organ, and this causes an abnor-
mal (and often painful) curvature of the penis. Urologists
can diagnose this condition, though it sometimes takes
an even higher degree of specialty because “the disease
and its current treatments are not well understood
by m ost urologists in general practice.” See
http://en.wikipedia.org/wiki/Peyronie’s_disease. After
getting this diagnosis, Hayes was referred to a pain-
management specialist, Dr. Joseph Atallah, for treatment.
He remains under Dr. Atallah’s care and continues to
receive treatments and medication to manage his chronic
pain.
10                                              No. 07-2783

  Hayes filed this lawsuit under 42 U.S.C. § 1983 on
March 3, 2004, alleging that Dr. Hamby knew that Hayes
was enduring excruciating pain and nonetheless refused to
provide readily available prescription-strength pain
medication or to refer Hayes to a urology specialist who
could diagnose and properly treat him. He further
asserted that Dr. Hamby and his subordinates provided
only non-prescription medication and ice packs, and
that Dr. Hamby terminated even this minimal treatment
for Hayes’s pain after finding out that Hayes had com-
plained to non-medical prison officials about his pain
and filed formal grievances about his medical care. In
addition, Hayes contended that the non-medical prison
officials also violated his constitutional rights when they
failed properly to respond to his serious medical condition.
  On March 19, 2007, the district court granted the defen-
dants’ motions for summary judgment, ruling both on the
merits and on the basis of qualified immunity. It denied
Hayes’s motion to alter the judgment, and this appeal
followed. We note that although Hayes’s complaint
initially named four non-medical defendants, he has
voluntarily withdrawn two of them (Director Snyder
and Assistant Administrative Director Montgomery),
leaving only Warden Pierson and Assistant Warden
Bass for this appeal.


                             II
  We review the district court’s grant of summary judg-
ment de novo, examining the record in the light most
favorable to the non-moving party. Koger v. Bryan, 523
No. 07-2783                                                11

F.3d 789, 796 (7th Cir. 2008). “Prison officials violate the
Eighth Amendment’s proscription against cruel and
unusual punishment when they display ‘deliberate indif-
ference to serious medical needs of prisoners.’ ” Greeno v.
Daley, 414 F.3d 645, 652 (7th Cir. 2005) (quoting Estelle v.
Gamble, 429 U.S. 97, 104 (1976)). In Greeno, we spelled out
the two-part test that applies to these claims:
    A claim of deliberate indifference to a serious medical
    need contains both an objective and a subjective
    component. To satisfy the objective component, a
    prisoner must demonstrate that his medical condi-
    tion is “objectively, sufficiently serious.” Farmer v.
    Brennan, 511 U.S. 825, 834 (1994) (internal quotations
    omitted); see also Walker v. Benjamin, 293 F.3d 1030, 1037
    (7th Cir. 2002). A serious medical condition is one that
    has been diagnosed by a physician as mandating
    treatment or one that is so obvious that even a lay
    person would perceive the need for a doctor’s atten-
    tion. See Foelker v. Outagamie County, 394 F.3d 510,
    512-13 (7th Cir. 2005). To satisfy the subjective compo-
    nent, a prisoner must demonstrate that prison offi-
    cials acted with a “ ‘sufficiently culpable state of
    mind.’ ” Farmer, 511 U.S. at 834 (quoting Wilson v.
    Seiter, 501 U.S. 294, 297 (1991)). The officials must
    know of and disregard an excessive risk to inmate
    health; indeed they must “both be aware of facts
    from which the inference could be drawn that a sub-
    stantial risk of serious harm exists” and “must also
    draw the inference.” Farmer, 511 U.S. at 837. This is not
    to say that a prisoner must establish that officials
    intended or desired the harm that transpired. Walker,
12                                               No. 07-2783

     293 F.3d at 1037. Instead, it is enough to show that the
     defendants knew of a substantial risk of harm to the
     inmate and disregarded the risk. Id. Additionally, “a
     factfinder may 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.
Id. at 653 (parallel citations omitted).


                              A
  We consider first whether, as an objective matter, Hayes
has presented enough evidence to support a finding that
he suffered from a serious medical condition. In Gutierrez
v. Peters, 111 F.3d 1364, 1373 (7th Cir. 1997), we explained
that a prisoner’s medical need is “serious” where “the
failure to treat a prisoner’s condition could result in
further significant injury or the unnecessary and wanton
infliction of pain,” and we noted, with approval, that other
courts had found the following circumstances to be
indications that a prisoner has a serious medical need:
“The existence of an injury that a reasonable doctor or
patient would find important and worthy of comment
or treatment; the presence of a medical condition that
significantly affects an individual’s daily activities; or
the existence of chronic and substantial pain.” Id. (cita-
tions and quotation marks omitted).
  The non-medical defendants did not brief the issue of
serious medical need; they rely for that point on the
reasoning of the district court and whatever Dr. Hamby
had to say in his brief. They focus instead on their argu-
No. 07-2783                                                13

ment that they lacked the subjective component of deliber-
ate indifference, and so we postpone our consideration
of Hayes’s claim against them until we reach that issue.
Dr. Hamby urges us to find that Hayes did not have a
serious medical need. He also characterizes Hayes’s
position as a request for a rule under which “a prison
physician violates the Eighth Amendment when he or
she fails to diagnose at the very first stage a rare, progres-
sively worsening condition that masquerades in its early
stages as an insignificant medical condition.” The Eighth
Amendment, he concludes, requires no such thing.
  But Dr. Hamby is asking us to disregard important
parts of the record. As we have detailed above, Dr.
Hamby’s involvement in Hayes’s case was much greater
than he is implying here. Although Dr. Hamby gave
Hayes’s complaints of pain little weight, we have recog-
nized that “self-reporting is often the only indicator a
doctor has of a patient’s condition,” and so there “is no
requirement that a prisoner provide ‘objective’ evidence of
his pain and suffering.” Greeno, 414 F.3d at 655. Hayes did
try to obtain a referral to a specialist, who presumably
could have provided (one way or the other) the kind of
“objective” evidence that Dr. Hamby thinks was lacking.
Hayes was never permitted to see a specialist, however,
because Dr. Hamby refused to authorize a referral. See id.
(“[T]he defendants fail to acknowledge that Greeno spent
two years trying to obtain ‘objective’ evidence, but was
prevented from doing so by Dr. Daley and the other
medical providers.”); see also Cooper v. Casey, 97 F.3d 914,
916-17 (7th Cir. 1996).
14                                              No. 07-2783

  The district court concluded that because a layperson
would not be able to “diagnose” Hayes’s malady or
“determine what treatment was needed,” Hayes’s condi-
tion was not objectively serious. This is not the correct
standard. The Eighth Amendment’s protections are not
triggered only by conditions that a layperson would be
able to diagnose and treat, especially when the defendant
is not a layperson but is instead a physician. A trier of
fact could conclude in Hayes’s case that even a layperson
would realize that a man with cysts and growths on
his testicles, who could not even urinate without extra-
ordinary measures and who repeatedly complained of
excruciating and increasing pain, would require “a doctor’s
attention.” Even more so, a reasonable physician should
have realized that the patient was trying to bring a
serious condition to his or her attention. See Gutierrez,
111 F.3d at 1373 (recognizing that a “serious medical need”
exists where the condition features “chronic and sub-
stantial pain”). Hayes has met his burden of showing, for
purposes of summary judgment, that he was suffering
from a serious medical condition.


                             B
  The subjective component of Hayes’s Eighth Amendment
claims requires him to present facts from which a jury
could find that the relevant officials knew of Hayes’s
serious medical condition but intentionally or recklessly
disregarded it. Greeno, 414 F.3d at 653 (citing Farmer,
511 U.S. at 837); Walker v. Benjamin, 293 F.3d 1030, 1039-40
(7th Cir. 2002) (collecting cases). Hayes does not need to
No. 07-2783                                              15

prove that his complaints of severe pain were “literally
ignored,” see Sherrod v. Lingle, 223 F.3d 605, 611 (7th Cir.
2000); rather, he must show only that the defendants’
responses to it were so plainly inappropriate as to
permit the inference that the defendants intentionally or
recklessly disregarded his needs. Greeno, 414 F.3d at 653
(citing Farmer, 511 U.S. at 837). We begin our analysis of
this component with Dr. Hamby, and then consider the
non-medical defendants.


                             1
  Dr. Hamby argues that he cannot be deemed deliberately
indifferent because the diagnosis that Hayes eventually
obtained was for a “rare, progressively worsening condi-
tion which objectively appears in its early stages as an
insignificant medical condition.” He argues that Hayes’s
condition when he arrived at the Lexington VA Hospital
in late September 2002 was not the same as what Dr.
Hamby saw when he examined Hayes in October 2001. He
identifies the critical question presented here as: “was Dr.
Hamby’s medical treatment of this prisoner was [sic] so
blatantly inappropriate as to evidence intentional mis-
treatment?” This is almost correct, but it is missing a
crucial point. This case comes to us on summary judg-
ment. Thus, the complete question is whether, when
viewing the record in the light most favorable to Hayes, a
reasonable trier of fact could conclude that Dr. Hamby
was subjectively aware of Hayes’s serious medical condi-
tion and either knowingly or recklessly disregarded it.
16                                              No. 07-2783

  Subjective awareness and deliberate indifference nor-
mally can be proved only with circumstantial evidence.
Here, the record includes a number of facts that would
support those findings with respect to Dr. Hamby. First, as
we already have pointed out, Dr. Hamby’s involvement
in Hayes’s treatment at Hill was not limited to his two in-
person examinations of Hayes in October 2001. He was
monitoring Hayes’s treatment at least enough to be in a
position to provide the non-medical prison officials with
a thorough summary of Hayes’s chart in May 2002.
In addition, Dr. Hamby’s approval was required before
various treatments, such as prescription-strength med-
icine or a referral to a specialist, could be administered to
Hayes, and he refused to give that approval. Dr. Hamby
acknowledged in his deposition that other physicians
at Hill had requested these treatments for Hayes. He
asserted that the reason he denied their requests was
that he did not receive the proper paperwork. That may or
may not be true—it depends on whether a trier of fact
would believe Dr. Hamby’s explanation. What is important
at this point is that this testimony reveals that Dr. Hamby
continued to be aware of Hayes’s condition and
involved in his treatment long after October 2001.
  Dr. Hamby’s deposition testimony also suggests that
even if he had received formal paperwork requesting the
additional treatments, he probably would have done
nothing differently. Dr. Hamby stated flatly in his deposi-
tion that no pain experienced by any prisoner ever war-
rants prescription-strength painkillers. He acknowledged
that the “policy for all physicians in [the Department of
Corrections]” is to dispense prescription-strength pain
No. 07-2783                                               17

medications (opiates) only when the physician “absolutely
felt they were necessary.” He went on, however, to state
his belief that prisoners never needed such drugs, and so
he personally never prescribed them. When asked what he
would do if he saw a patient “whose level of pain or whose
condition warranted an opiate level of pain medication,”
Dr. Hamby replied that he would “[p]ut them in the
infirmary and observe them and you very rapidly found
that Tylenol was all they needed. That was my experience.”
This suggests that even if the allegedly required forms
had been submitted to Dr. Hamby, he would not have
signed off on a request to provide Hayes with prescription-
strength pain medicine. (Dr. Hamby never distinguished
between opiates and other types of prescription pain
medications, and so a trier of fact would not be com-
pelled to conclude that his concerns extended to opiates
alone.)
  Dr. Hamby’s attorney objected to any line of questioning
relating to his client’s prescribing methods, arguing that
“[t]here’s no evidence in this case that [Hayes] ever
needed any other medication during the time frame that
Dr. Hamby was treating him . . . .” That objection strikes us
as bizarre, given the evidence Hayes has presented.
Furthermore, Hayes showed that he stopped receiving
even the minimal treatment of over-the-counter ibuprofen
and ice packs in May 2002, right after Dr. Hamby learned
from the non-medical prison officials that they were
investigating a complaint from Hayes about inadequate
medical care. Hayes argues that Dr. Hamby revoked these
treatments in retaliation for his complaints. If believed
18                                               No. 07-2783

by a trier of fact, that could factor into a finding that Dr.
Hamby was deliberately indifferent to Hayes’s condition.
  Dr. Hamby’s testimony is also revealing with respect to
his denials of Hayes’s persistent requests to see a
specialist in urology. During his deposition, Dr. Hamby
was shown a note in Hayes’s chart from another
physician at Hill, Dr. Shute, who had recommended
that Hayes be given a urology referral:
     Q [Hayes’s counsel]: . . . And it says referral for urol-
     ogy. Now can you see where it says that?
     A [Dr. Hamby]: It says referral for urology work-up.
     Q: Okay.
     A: Whatever that means.
     Q: So you don’t know what that means?
     A: I have no idea. He didn’t fill out any form. He didn’t
     spell out anything.
Here, Dr. Hamby professed to “have no idea” what it
means for a physician to write “referral for urology work-
up” on Hayes’s chart. A trier of fact could reject the
assertion that the director of a medical unit is not aware
of the meaning of that phrase, as well as the notion that
the medical director knows nothing until a subordinate
physician fills out a form explaining the concept of a
referral to a specialist. Even if some type of form was
required before a Hill physician could provide Hayes
with an outside referral to a urologist, a fact-finder could
infer from Dr. Hamby’s responses on this point that he
was hostile and dismissive to Hayes’s needs. The
following exchange is telling:
No. 07-2783                                                19

   A [Dr. Hamby]: The limitation for a referral was
   medical necessity and that’s the way it has been and
   it is everywhere you go. The practice of medicine
   within the prison system and outside the prison
   system is essentially the same.
   Q [Hayes’s counsel]: When you speak of medical
   necessity, if somebody’s having pain, even extreme
   pain but the pain is not—is not related to a fatal
   illness or a deteriorating sort of illness, could that pain
   nonetheless be considered a medical necessity?
   A: The pain could be and I emphasize could be listed
   as a medical necessity if I could document a cause
   for the pain.
   Q: So if somebody were complaining about a severe
   pain or substantial pain and you couldn’t document
   a cause, then would that person then not—not be able
   to see a specialist?
   A: I wouldn’t know which specialist to send him to if
   I can’t come up with a documented cause for pain such
   as reaching up, grabbing a testicle and pulling it down
   and having the guy go into spasm. . . . Or something
   like that. I don’t—I don’t need to come up with a
   documented diagnosis. I need to come up with some-
   thing that I don’t know what it is [that] is causing
   pain that I can document.
  These are troubling statements. Dr. Hamby’s assertion
that a patient’s report of extreme pain without a docu-
mented cause does not constitute a “medical necessity,”
and his insistence that a referral to a specialist is not
20                                              No. 07-2783

appropriate when “I don’t know what it is [that] is causing
the pain,” make no sense. The fact that a general practitio-
ner is unable to identify or document the cause of a pa-
tient’s pain does not strike us as a reason to reject a
request to see a specialist; indeed, as Hayes’s counsel
observed, it suggests just the opposite. Dr. Hamby essen-
tially said that he will not refer a patient to a specialist
unless he already knows what the problem is (and thus
does not need the specialist’s input). But the very reason
why a specialist would be called in is that a generalist
is unable to identify the cause of a particular ailment. If
what Dr. Hamby was saying was that no referral was
needed because Hayes was not “really” in substantial
pain, there is a different problem. That takes us back to
the evidence indicating that Dr. Hamby knew of, but
disregarded, Hayes’s repeated reports of severe, progres-
sively worsening pain. And while Dr. Hamby said, implau-
sibly, that he would not “know which specialist to
send [Hayes] to if I can’t come up with a documented
cause for pain,” no one here disputes that the proper
specialist for an evaluation of Hayes’s testicular pain
was a urologist. The record shows that Dr. Hamby knew
that Dr. Shute requested a urology referral in 2001, and
that as early as September 2000, Dr. Choudry had done
a urology work-up and consulted with a urologist
about Hayes’s case. Hayes’s medical records show a
universal awareness of the fact that these problems
were the domain of a urologist.
  Though we could say more, this is enough to show that
a reasonable trier of fact could conclude that Dr. Hamby’s
treatment of Hayes constituted deliberate indifference to
No. 07-2783                                               21

a serious medical need. Summary judgment was there-
fore an inappropriate resolution of Hayes’s case against
Dr. Hamby.


                             2
  The position of the non-medical defendants is different.
Here again, our prior decision in Greeno is instructive.
Greeno, like Hayes, had complained to non-medical
prison officials, both in letters and by filing formal griev-
ances, that he was receiving inadequate care from the
prison’s medical unit. The district court granted summary
judgment or dismissal for all of the defendants. We
concluded that summary judgment was appropriate
for some of them, but not all. When discussing Greeno’s
claims against the grievance officer who handled “at least
seven” of Greeno’s inmate complaints (Charles Miller, a
non-medical official), we stated:
    Greeno contends that Miller was deliberately indiffer-
    ent to his medical needs because he failed to investi-
    gate the complaints or remedy the medical defen-
    dants’ failure to provide appropriate treatment. Our
    review of the record, however, reveals that Miller
    reviewed Greeno’s complaints and verified with the
    medical officials that Greeno was receiving treatment.
    We do not think Miller’s failure to take further
    action once he had referred the matter to the medical
    providers can be viewed as deliberate indifference.
414 F.3d at 655-56. We went on to adopt the reasoning of
the Third Circuit in Spruill v. Gillis, 372 F.3d 218, 236 (3d
Cir. 2004), which held that
22                                                No. 07-2783

     [i]f a prisoner is under the care of medical experts . . .
     a non-medical prison official will generally be justified
     in believing that the prisoner is in capable hands. This
     follows naturally from the division of labor within a
     prison. Inmate health and safety is promoted by
     dividing responsibility for various aspects of inmate
     life among guards, administrators, physicians, and so
     on. Holding a non-medical prison official liable in a
     case where a prisoner was under a physician’s care
     would strain this division of labor.
372 F.3d at 236. We added that we “decline[d] to extend
responsibility for Greeno’s medical care to Miller. Perhaps
it would be a different matter if Miller had ignored
Greeno’s complaints entirely, but we can see no
deliberate indifference given that he investigated the
complaints and referred them to the medical providers
who could be expected to address Greeno’s concerns.” 414
F.3d at 656 (citing Hernandez v. Keane, 341 F.3d 137, 148 (2d
Cir. 2003)). Accord, Johnson v. Doughty, 433 F.3d 1001, 1012
(7th Cir. 2006).
  Like Miller in Greeno, the non-medical defendants in
this case investigated Hayes’s complaints and referred
them to the responsible medical providers. Hayes recog-
nizes the hurdle that Greeno presents, but he argues that his
case is different, because, as Spruill recognized, non-
medical officials can “be chargeable with the Eighth
Amendment scienter requirement of deliberate indiffer-
ence” where they have “a reason to believe (or actual
knowledge) that prison doctors or their assistants are
mistreating (or not treating) a prisoner.” Spruill, 372 F.3d
No. 07-2783                                              23

at 236; see also Greeno, 414 F.3d at 655-56; Johnson, 433
F.3d at 1012. Here, Hayes argues, Bass and Pierson did
have actual knowledge, or at least reason to believe, that
the prison doctors were “mistreating (or not treating)” him.
He notes that he told Bass about his pain and about
the doctors’ refusal to respond to his pleas for treatment.
  The non-medical defendants counter that they investi-
gated Hayes’s complaints, sought reports from medical
officials, and relied on the judgment of the prison physi-
cians. They note that although Greeno and Johnson
reversed summary judgments for certain medical officials
in each case, those cases affirmed the judgments for non-
medical defendants because the latter had investigated
“and verified with the medical officials that [the
inmates were] receiving treatment, and were entitled to
rely on the judgments of medical staff.”
  The question is whether the non-medical defendants
had any duty to do more than they did, in light of their
knowledge of the situation. We think not. The policy
supporting the presumption that non-medical officials are
entitled to defer to the professional judgment of the facil-
ity’s medical officials on questions of prisoners’ medical
care is a sound one. Here, the non-medical officials re-
sponded readily and promptly to each of Hayes’s letters
and grievances. They contacted Medical Director Hamby
and the administrator, requesting reports and summaries
about the care that Hayes had received in order to ensure
themselves that his complaints did not require further
action. At worst, they may have been negligent in failing
to investigate further after receiving the summaries
24                                              No. 07-2783

from the medical staff, but negligence is not deliberate
indifference. Because the non-medical defendants were
entitled to rely on the professional judgment of medical
prison officials, and because nothing in Dr. Hamby’s
reports made it obvious that Hayes might not be
receiving adequate care, the district court correctly
granted summary judgment in favor of the non-medical
defendants.


                             C
  Before concluding, we must say a word about qualified
immunity, because Dr. Hamby argued in the alternative
that he was entitled to judgment on that ground. The
district court concluded that all of the defendants were
entitled to qualified immunity. It based that conclusion
solely on its determination that none of the defendants
had violated Hayes’s Eighth Amendment rights. Because
Hayes had “failed to establish the violation of a federal
right,” the court found, he could not defeat the defendants’
claims for qualified immunity. On appeal, Dr. Hamby
has not presented an alternative argument to support a
finding of qualified immunity. We have rejected the
district court’s conclusion that Hayes failed to state a
claim under the Eighth Amendment, or that he failed to
come forward with enough evidence to support such a
claim. It has been established for decades that prison
physicians violate inmates’ constitutional rights when
they deliberately disregard an inmate’s serious medical
condition, and only a trial can resolve the facts that are
in dispute.
No. 07-2783                                            25

                           III
  The judgment in favor of Mark A. Pierson and Wanda L.
Bass is A FFIRMED . The judgment in favor of William M.
Hamby is R EVERSED and R EMANDED for further pro-
ceedings consistent with this opinion. The costs on appeal
shall be divided equally between appellant Hayes and
appellee Hamby.




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