In the

    United States Court of Appeals
                 For the Seventh Circuit
                     ____________________
No. 23-1253
SHAWN RILEY,
                                                  Plaintiff-Appellant,
                                 v.

JOLINDA WATERMAN and SANDRA MCARDLE,
                                 Defendants-Appellees.
                     ____________________

         Appeal from the United States District Court for the
                    Eastern District of Wisconsin.
          No. 2:20-cv-01252 — Pamela Pepper, Chief Judge.
                     ____________________

  ARGUED SEPTEMBER 18, 2024 — DECIDED JANUARY 27, 2025
                ____________________


   Before RIPPLE, JACKSON-AKIWUMI, and KOLAR, Circuit
Judges.
    RIPPLE, Circuit Judge. Shawn Riley, formerly a prisoner at
the Wisconsin Secure Program Facility (“WSPF”), filed this
action under 

 against WSPF’s Health Services
Manager, Jolinda Waterman, and WSPF Nurse Practitioner
Sandra McArdle (“NP McArdle”), in the United States
2                                                           No. 23-1253

District Court for the Eastern District of Wisconsin, 1 alleging
they were deliberately indifferent to his serious medical needs
in violation of the Eighth Amendment. 2 The district court
granted the defendants’ motions for summary judgment and
denied Mr. Riley’s two motions to appoint counsel. In this ap-
peal, Mr. Riley contends that the district court erred in grant-
ing the summary judgment motions. He also submits that the
district court abused its discretion by denying his second mo-
tion to appoint counsel. For the reasons set forth in this opin-
ion, we affirm the judgment of the district court. 3
                                         I
                           BACKGROUND
                                     A.
    Ms. Waterman served as the WSPF Health Services Man-
ager from January 2015 until her retirement in May 2019. In
that capacity, she “managed the health care services provided
by the [Health Services Unit (‘HSU’)] and provided overall
administrative support and direction.” 4 She did not evaluate
or treat inmates, nor did she make referrals to or approve
treatment recommendations from offsite specialists. Ms. Wa-
terman also had no role in referring inmates’ special needs re-
quests to the Special Needs Committee (“SNC”). 5 Those tasks

1 The jurisdiction of the district court is predicated on 

and 1343.
2 The Eighth Amendment is applicable to the states through the Four-

teenth Amendment. See Robinson v. California, 

 (1962).
3 Our jurisdiction is secure under 

.

4 R.36 at 6 ¶ 26.

5 Mr. Riley did not dispute this fact.
No. 23-1253                                                           3

were reserved for Advanced Care Providers such as NP
McArdle. After an inmate visited an offsite provider, an Ad-
vanced Care Provider would record the offsite provider’s rec-
ommendations in the inmate’s medical file and, if the Ad-
vanced Care Provider agreed with the recommendation, or-
der the suggested treatment. Additionally, Advanced Care
Providers were to refer inmates’ special needs requests to the
SNC instead of ordering items.
   Mr. Riley first received medical treatment pertinent to this
case on July 27, 2016, when he visited the HSU for foot and
leg pain. A nonparty provider ordered ibuprofen, physical
therapy, knee braces, and stretching. The next month, he sub-
mitted a Health Services Request 6 (“HSR”) because he was
experiencing “serious” hip and back pain after playing bas-
ketball. 7 A nonparty provider replied, informing him that he
was scheduled to be seen in the HSU. In September 2016, Ms.
Waterman responded to another HSR from Mr. Riley in
which he had asked to consult with an orthopedist. 8 She indi-
cated that Mr. Riley previously had consulted with an ortho-
pedist, and that there were no additional consults ordered.
    NP McArdle first saw Mr. Riley for his pain on January 4,
2017. She ordered foot x-rays and ankle braces. 9 She also re-
ferred him to a podiatrist and a physical therapist. Later in
January 2017, another provider at the prison ordered

6 Inmates submit HSRs to receive nonemergency medical treatment.

7 R.42-1 at 25.

8 In her role as Health Services Manager, Ms. Waterman only saw and re-

sponded to HSRs when HSU staff specifically forwarded them to her.
9 Mr. Riley may not have received the ankle braces until April 2017, de-

spite NP McArdle’s contention that she provided them on January 4, 2017.
4                                                 No. 23-1253

Mr. Riley a TheraBand for his physical therapy. And on Feb-
ruary 20, 2017, NP McArdle ordered soft shoe inserts for
Mr. Riley.
    Mr. Riley went to his first appointment with a podiatrist,
Dr. Michael Jacobs, on March 24, 2017. Dr. Jacobs diagnosed
him with plantar fasciitis in both feet, “[a]nkle equinus sec-
ondary to tight heel cord,” and “[p]es planovalgus.” 10 He rec-
ommended soft inserts and “high top athletic type shoes,” but
held off on prescription orthotics. 11 Reviewing Dr. Jacobs’s
recommendations, NP McArdle noted that Mr. Riley had soft
inserts and could purchase his own high-top shoes “per pol-
icy.” 12 WSPF’s personal property policy limits inmates’ pos-
sessions. All inmates receive one pair of state-issued shoes,
and three circumstances permit an inmate to wear other
shoes. First, an inmate may wear orthopedic shoes provided
by the HSU. Second, an inmate may buy shoes from an ap-
proved vendor catalog, spending no more than $75 per pair.
Third, an inmate may buy medically necessary shoes from a
non-approved vendor with permission from the SNC.
   Mr. Riley filed an HSR on March 24, stating that the inserts
alone would not suffice and requesting ankle and back braces.
He was placed on the HSU provider list for an evaluation. On
March 29, 2017, NP McArdle ordered x-rays of his spine, hip,
and right knee. On March 31, 2017, another inmate overheard
Ms. Waterman tell a corrections officer that a specialist had



10 R.42-1 at 43.

11 

12 

.
No. 23-1253                                                           5

recommended Mr. Riley receive a personal medical item, but
“Riley had another th[ing] coming.” 13
    Mr. Riley received ankle braces to wear “when up and
about” on April 11, 2017. 14 That same day, Mr. Riley submit-
ted an HSR addressed to Ms. Waterman, asking for guidance
on getting high-top shoes per Dr. Jacobs’s orders. He stated
that he could not find “adequate” shoes for $75. 15 A nonparty
provider responded, “You will need to adhere to policy.”16
On April 25, 2017, NP McArdle scheduled an appointment for
Mr. Riley to be fitted for custom orthotics. She also instructed
him not to play basketball or run, but instead to use the exer-
cise bike. Two days later, NP McArdle ordered an electromy-
ography (“EMG”) for Mr. Riley that came back negative. 17
    Mr. Riley saw Dr. Jacobs again on May 5, 2017. Dr. Jacobs
recommended prescription orthotics for Mr. Riley and told
him that he would need to break them in but to follow up if
he still had difficulty after one month. Dr. Jacobs also sug-
gested continued stretching, physical therapy, and, “if possi-
ble,” an “athletic type shoe, high-top in nature.” 18 NP
McArdle issued a physical therapy referral, but only noted the
shoe recommendation in Mr. Riley’s file. Mr. Riley saw a
physical therapist on May 23, 2017, who prescribed a
transcutaneous electrical nerve stimulation (“TENS”) unit to

13 R.46-1 at 99.

14 R.38-2 at 40.

15 R.42-1 at 20.

16 

17 A negative EMG indicates that Mr. Riley did not have neuropathy.

18 

.
6                                                     No. 23-1253

alleviate his pain. 19 The provider did not recommend further
sessions “[due to] lack of success [with] PT in past.” 20
    Mr. Riley received his custom orthotics on May 24, 2017.
The following day, he informed the HSU that they did not
“mitigate, address[,] nor correct” his pain, and the padding
tore off. 21 In June 2017, Mr. Riley reiterated that the orthotics
were “useless.” 22 NP McArdle recommended that he give
them at least a month but also indicated that she had re-
quested a follow-up podiatry appointment. Mr. Riley submit-
ted more HSRs during the summer of 2017. On June 19, 2017,
he indicated that he purchased high-top shoes from the cata-
log that were “actually mid,” 23 and asked to be seen by the
podiatrist within the week. NP McArdle replied that she had
scheduled an appointment. In July and August, he reported
persistent pain and alleged, among other things, that the HSU
delayed his seeing a specialist 24 and declined to evaluate him
for night splints. Ms. Waterman responded that a podiatry
follow-up was scheduled and night splints had been ordered.
She also noted that he had not requested more extra strength
Tylenol and informed him that the HSU has “NOTHING to
do with personal shoes.” 25

19 A few months passed before he received it.

20 

.

21 

.

22 

.

23 

.

24 The usual wait time for a podiatry appointment was six to twelve

weeks, though it could be longer.
25 

 at 11–12.
No. 23-1253                                                       7

    Because Mr. Riley had to wait to see Dr. Jacobs, HSU staff
offered Mr. Riley an appointment with “Dr. Miller.” 26 Mr. Ri-
ley’s medical file indicates that Dr. Miller recommended “air
bubbled athletic tennis shoes” at their August 15, 2017 ap-
pointment. 27 That recommendation was not approved.
Mr. Riley sent another HSR, asking that his medical file be up-
dated to reflect Dr. Miller’s additional recommendations for
air bubbled athletic sandals, personal socks, and an herbal
pain remedy. Ms. Waterman spoke with Dr. Miller and re-
plied to Mr. Riley: “You purely circumvented the shoe policy.
HSU does not purchase athletic shoes. You can purchase your
shower sandals and socks through canteen. There is no ap-
proval for herbal supplement turmeric in the” Department of
Corrections (“DOC”). 28
    Mr. Riley submitted another extensive HSR on August 25,
2017. In response, Ms. Waterman informed him that his podi-
atry appointment was scheduled. She also noted that “plantar
fasciitis is a chronic condition. It is not easily treated,” and di-
rected him to purchase shoes from the catalog.29 In late Sep-
tember 2017, NP McArdle ordered Mr. Riley a physical ther-
apy ball. Mr. Riley submitted more HSRs in October 2017, al-
leging that he was still suffering from untreated chronic pain.
Ms. Waterman and NP McArdle responded, refuting his alle-
gations that he was not being treated. Ms. Waterman noted
that he had not refilled his Naproxen prescription, and
NP McArdle reminded him of the EMG, physical therapy,

26 R.46-1 at 57.

27 R.38-2 at 29; see R.42-1 at 17.

28 R.42-1 at 17.

29 R.38-2 at 8.
8                                                             No. 23-1253

and medications he had received. On October 13, 2017, an-
other inmate witnessed Ms. Waterman telling a nurse, “What-
ever you do, don’t make any orders or notes about shoes, I’m
in hot water about it.” 30
    Mr. Riley saw Dr. Jacobs for the third time on November
17, 2017. Dr. Jacobs indicated that “a shock absorption shoe
with air-type shock absorption … would be optimum,” but
noted that this type of shoe may not be permissible. 31 On De-
cember 1, 2017, Mr. Riley received a memorandum from
“HSU Staff” that read, “HSU reviewed your request for a spe-
cial shoe restriction. … Your specific request has been
DENIED. You must follow the property guidelines.” 32 On De-
cember 14, 2017, Mr. Riley wrote an HSR asking why the HSU
was following all specialist recommendations except those for
medical shoes. NP McArdle referred him to the catalog be-
cause “HSU does not provide personal athletic shoes.” 33
    In January 2018, NP McArdle ordered a podiatry follow-
up to assess whether Mr. Riley needed APEX shoes, which are
orthopedic shoes provided by the HSU. She also referred him
to an orthopedist for his knee pain. Mr. Riley saw an orthope-
dic surgeon, Dr. Edward Riley, on March 23, 2018. Comment-
ing on Dr. Riley’s recommendation that Mr. Riley be allowed
to purchase non-catalog shoes, NP McArdle wrote, “Not

30 R.51-1 at 61.

31 R.42-1 at 38.

32 R.38-2 at 1. This form differed from the DOC-3758 “Notice of Special

Needs Committee Decision” forms he had received in response to his re-
quests to eat in his cell and receive an extra pillow. R.38-2 at 37; R.51-1 at
10.
33 R.42-1 at 5.
No. 23-1253                                                  9

allowed per DOC policy.” 34 But she did recommend him for
APEX shoes.
    Mr. Riley saw Dr. Jacobs for the fourth time on April 20,
2018. Dr. Jacobs recommended “air-filled athletic shoe gear,”
commenting that Mr. Riley could be allowed to purchase
from a non-catalog supplier and exceed the $75 price limit.35
But he noted that “these are simply recommendations.” 36 In
Mr. Riley’s Progress Notes, Ms. Waterman wrote, “Personal
shoes are not provided through HSU medical restrictions.”37
On May 9, 2018, NP McArdle explained again that Mr. Riley
could purchase personal athletic shoes that would address his
plantar fasciitis from the catalog. Later that month, she re-
ferred him to the University of Wisconsin’s podiatry clinic for
a second opinion on his foot and ankle pain. On May 15, 2018,
Mr. Riley received another memorandum from HSU Staff in-
forming him that his shoe request had been denied.
    Mr. Riley submitted an HSR on June 13, 2018, alleging that
the HSU was “refusing the ordered care.” 38 He stated that the
Naproxen, cream, braces, wraps, and TENS treatments were
“all of no use.” 39 NP McArdle responded that specialists’ rec-
ommendations “are just that.”40 She also suggested that he ice


34 R.38-2 at 26.

35 R.42-1 at 37.

36 

37 R.38-2 at 25.

38 R.42-1 at 6.

39 

40 

10                                                  No. 23-1253

and strengthen his feet and ankles. He sent another HSR the
next day, asking whether WSPF would “honor UW’s ser-
vices.” 41 NP McArdle informed him that specialist recom-
mendations are fulfilled “if allowed by DOC policy … and se-
curity concerns.” 42
   On July 11, 2018, Mr. Riley saw a podiatrist, Dr. Audra
Smith, at the University of Wisconsin’s clinic. Assessing his
condition, she explained, “this is about proper support and
until he gets the right shoes and inserts, this pain will not go
away and it will continue to get worse.” 43 Dr. Smith recom-
mended that Mr. Riley be allowed to purchase shoes from
outside the catalog that exceeded the $75 limit, but did note
that some shoes in the catalog may be suitable. She wrote,
“There are a lot of shoes out there … that work for orthotics
and the condition that he has, so I believe from the catalog
some of the New Balance options work for guys.” 44 She also
suggested Naproxen twice a day and physical therapy. A
week later, NP McArdle advised Mr. Riley that the DOC’s
rule against purchasing outside shoes was a security rule, not
an HSU rule, and “[t]he warden is the only person who can
waive a security rule.” 45
     A year later, Mr. Riley was transferred to a new facility.




41 

.

42 

43 R.38-2 at 45.

44 

45 R.42-1 at 26.
No. 23-1253                                                   11

                               B.
    After Mr. Riley filed his pro se complaint, he filed a motion
to appoint counsel, noting that expert witnesses probably
would be required at trial for his medical claim. He also em-
phasized the case’s factual complexity, his limited legal
knowledge, and his transfer to a new institution. He informed
the court that he had tried to obtain counsel, attaching the let-
ter AA Sabel Law Office had sent declining assistance and the
letter he had sent to attorney Michael Witt that was returned
to Mr. Riley as not deliverable. The district court denied his
motion without prejudice on October 30, 2020, concluding
that his concerns about expert testimony were premature, and
that the case’s complexity and his limited knowledge of the
law were not unique. The court also screened his complaint
and ordered him to file an amended complaint, which he did
on December 9, 2020.
    As his case progressed, Mr. Riley again tried to obtain
counsel. In an August 2021 letter, attorney Lonnie D. Story in-
dicated that he was sending a retainer agreement for Mr. Ri-
ley to execute. Mr. Story sent another letter on September 21,
2021. In that letter, he declined to represent Mr. Riley in an-
other matter but confirmed that he would continue to repre-
sent Mr. Riley in his civil suit. Mr. Story corrected himself a
month later and informed Mr. Riley that the September letter
had been sent in error. He indicated that his firm would not
represent Mr. Riley and that he would return Mr. Riley’s doc-
uments shortly. Mr. Riley received this letter “on or around
October 25, 2021,” after the discovery deadline. 46



46 R.33 at 2.
12                                                  No. 23-1253

    On November 16, 2021, Mr. Riley filed his second motion
to appoint counsel. He again stated that the legal and factual
issues were too complex for him to litigate. He also recounted
his confusion with Mr. Story, attaching Mr. Story’s three let-
ters. Ms. Waterman and NP McArdle filed motions for sum-
mary judgment the following week.
    On August 16, 2022, the district court granted the defend-
ants’ motions for summary judgment and denied Mr. Riley’s
second motion to appoint counsel. Addressing Mr. Riley’s
Eighth Amendment claim, the court acknowledged that his
chronic pain was an objectively serious medical condition of
which Ms. Waterman and NP McArdle were aware. How-
ever, held the court, neither of these defendants was deliber-
ately indifferent to his serious medical needs. The court noted
the repeated treatment of his plantar fasciitis. It also rejected
his contention that they had ignored the specialists’ recom-
mendations, because none of the podiatrists prescribed a spe-
cific shoe for Mr. Riley. Moreover, the court found that the
SNC had reviewed and denied Mr. Riley’s special shoe re-
quests twice. And the court did not interpret Ms. Waterman’s
comments regarding Mr. Riley’s shoes as malicious—at most,
they indicated frustration.
    The court then addressed Mr. Riley’s motion to appoint
counsel, first noting that Mr. Riley had made a reasonable at-
tempt to secure counsel. However, in the court’s view, he was
sufficiently competent to litigate the case himself. He could
communicate effectively with the court and follow instruc-
tions, and his amended complaint was “clear and straightfor-
ward.” Riley v. Waterman, No. 20-cv-1252, 

,
at *19 (E.D. Wis. Aug. 16, 2022). Furthermore, his misunder-
standing with Mr. Story was “not a basis for the court to
No. 23-1253                                                    13

recruit counsel.” 

 It may have warranted deadline exten-
sions, but Mr. Riley had not requested them.
                                II
                        DISCUSSION
                               A.
    We review the district court’s order granting summary
judgment de novo, viewing the facts in the light most favora-
ble to Mr. Riley and drawing all reasonable inferences in his
favor. See Clemons v. Wexford Health Sources, Inc., 

 (7th Cir. 2024). Summary judgment is appropriate if
“there is no genuine dispute as to any material fact” and the
moving party “is entitled to judgment as a matter of law.”
Fed. R. Civ. P. 56(a).
    Prison officials’ deliberate indifference to an inmate’s seri-
ous medical needs violates the Eighth Amendment. See Estelle
v. Gamble, 

 (1976). To prevail on a deliberate
indifference claim, the plaintiff must prove (1) that he had an
objectively serious medical condition (2) to which prison offi-
cials were “deliberately, that is subjectively, indifferent.”
Johnson v. Dominguez, 

 (7th Cir. 2021) (quoting
Whiting v. Wexford Health Sources, Inc., 

 (7th
Cir. 2016)). The defendants do not dispute that plantar
fasciitis-related pain is an objectively serious medical condi-
tion. We therefore focus on the second element of the claim.
   Prison officials are deliberately indifferent when they
know of and disregard a substantial risk to the inmate’s
health. See Farmer v. Brennan, 

 (1994). Medical
negligence is not enough; the chosen treatment plan must
“represent[] so significant a departure from accepted profes-
sional standards or practices that it calls into question
14                                                   No. 23-1253

whether the [provider] actually was exercising … profes-
sional judgment.” Pyles v. Fahim, 

 (7th Cir.
2014). In assessing a claim that a prisoner was subjected to
such treatment, “we look at the totality of an inmate’s medical
care when considering whether that care evidences deliberate
indifference to serious medical needs.” Petties v. Carter, 

 (7th Cir. 2016) (en banc).
    An inmate may establish deliberate indifference by
demonstrating that prison officials ignored a specialist’s in-
structions. See Zaya v. Sood, 

, 805–06 (7th Cir.
2016). But “[d]isagreement … between two medical profes-
sionals[] about the proper course of treatment generally is in-
sufficient, by itself, to establish an Eighth Amendment viola-
tion.” Pyles, 

 (citing Johnson v. Doughty, 

 (7th Cir. 2006)). In Zaya, we reversed a grant of
summary judgment where the prison physician waited seven
weeks to send an inmate for a follow-up appointment, which
was four weeks longer than the specialist had recommended.
Because the specialist had “actually described the risks of fur-
ther delay,” there was a genuine dispute about whether the
prison doctor “simply ignored”—as opposed to disagreed
with—the specialist’s instructions. 836 F.3d at 806–07.
   Persisting with an ineffective course of treatment also can
constitute deliberate indifference. In Greeno, we reversed a
grant of summary judgment where the defendants refused to
change the inmate’s medication despite his repeated reports
that it was not working. See Greeno v. Daley, 

, 654–
55 (7th Cir. 2005). However, in Reck, we affirmed a grant of
summary judgment where the defendant physician referred
the inmate to a specialist and prescribed medications to
No. 23-1253                                                             15

manage his condition in the meantime. See Reck v. Wexford
Health Sources, Inc., 

 (7th Cir. 2022).
    With those standards in mind, we now turn to Mr. Riley’s
claims against Ms. Waterman and NP McArdle. Mr. Riley
submits that the district court erred in granting summary
judgment for the defendants because they ignored specialists’
recommendations to allow him to buy high-top shoes, per-
sisted with an ineffective course of treatment, and denied him
access to the SNC.
    Considering the totality of medical care Mr. Riley re-
ceived, there was no Eighth Amendment violation. First, the
record supports the district court’s conclusion that Ms. Wa-
terman and NP McArdle did not ignore the specialists’ rec-
ommendations that Mr. Riley be permitted to acquire high-
top shoes. Instead, they sought to comply with both DOC pol-
icy and the treatment recommendations by instructing Mr. Ri-
ley to order suitable shoes from the catalog.47 But, even if their
refusal to permit Mr. Riley to order shoes from outside the
approved catalog constitutes a disagreement with specialists’
recommendations, disagreements between medical profes-
sionals about the proper course of treatment rarely amount to
deliberate indifference. See Pyles, 

; Zaya, 

. There is certainly nothing in this record to justify
departure from that general rule.
   Nor does the record support the view that the defendants
doggedly persisted in an ineffective course of treatment.


47 Indeed, one specialist, Dr. Smith, acknowledged that there were suitable

shoes in the catalog: “There are a lot of shoes out there … that work for
orthotics and the condition that he has, so I believe from the catalog some
of the New Balance options work for guys.” R.38-2 at 45.
16                                                       No. 23-1253

When NP McArdle first saw Mr. Riley for foot pain, she or-
dered ankle braces and foot x-rays. She later ordered soft shoe
inserts, then custom orthotics when the inserts did not allevi-
ate his pain. When Mr. Riley’s discomfort persisted, she did
more diagnostic testing in the form of x-rays and an EMG. To
help him manage the pain, she also ensured that Mr. Riley re-
ceived pain medications, ice, and a TENS unit. In addition to
these treatments, she referred Mr. Riley to offsite specialists
on six occasions. See Reck, 

. Overall,
NP McArdle provided extensive medical care in accordance
with the specialists’ recommendations. 48 The record contains
no evidence from which a jury could infer that the defendants
knew these treatments would be ineffectual but persisted an-
yway.
    Moreover, a reasonable jury could not conclude that the
defendants were deliberately indifferent in declining to ele-
vate Mr. Riley’s shoe requests to the SNC. Because Ms. Wa-
terman was not an Advanced Care Provider, she was not re-
sponsible for referring special needs requests to the SNC.49
NP McArdle was an Advanced Care Provider and could have
referred his requests. As we stated in Petties, deviation from
an established protocol can be circumstantial evidence of de-
liberate indifference. 836 F.3d at 729. But as we also empha-
sized in that case, an overarching consideration in assessing a
deliberate indifference claim is an examination of the totality

48 As Health Services Manager, Ms. Waterman was not personally in-

volved in Mr. Riley’s medical care beyond responding to some of his
HSRs.
49 Therefore, even if her comments that Mr. Riley had “another th[ing]

coming” and she was “in hot water about” shoes demonstrate frustration,
she was not deliberately indifferent. R.46-1 at 99; R.51-1 at 61.
No. 23-1253                                                    17

of circumstances of the patient’s care. Id. at 728. Moreover,
even if, with the benefit of hindsight, NP McArdle should
have sent forward Mr. Riley’s requests, there is no indication
that her failure to do so constituted deliberate indifference.
She knew he was receiving treatment for his condition and
that he had declined to buy suitable shoes available to him.
She also knew that the specialists understood that prison se-
curity concerns might well preclude Mr. Riley’s procuring the
optimum model of shoe. In the context of the totality of care
provided to Mr. Riley, a rationale jury could not conclude that
NP McArdle’s decision that Mr. Riley should give the shoe
choices available to him a more sustained try amounted to de-
liberate indifference.
   For these reasons, the district court properly concluded
that Ms. Waterman and NP McArdle were not deliberately
indifferent to Mr. Riley’s condition.
                               B.
    Mr. Riley also submits that the district court abused its dis-
cretion in denying his second motion to appoint counsel. He
is correct in stating that we review a district court’s denial of
a request for appointed counsel for abuse of discretion. Pruitt
v. Mote, 

 (7th Cir. 2007) (en banc). Pruitt
makes clear that a court abuses its discretion when “(1) the
record contains no evidence upon which the court could have
rationally based its decision; (2) the decision is based on an
erroneous conclusion of law; (3) the decision is based on
clearly erroneous factual findings; or (4) the decision clearly
appears arbitrary.” 

 (quoting Musser v. Gentiva Health
Servs., 

 (7th Cir. 2004)).
18                                                             No. 23-1253

                                      1.
    We begin by stating the governing principles that are well-
established by statute and case law. First, a federal civil liti-
gant has no right to court-recruited counsel. See Dewitt v. Cori-
zon, Inc., 

 (7th Cir. 2014). But under the fed-
eral in forma pauperis statute, the court may request an attor-
ney for “any person unable to afford counsel.” 

(e)(1). In so doing, the district court must make the fol-
lowing inquiries: “(1) [H]as the indigent plaintiff made a rea-
sonable attempt to obtain counsel or been effectively pre-
cluded from doing so; and if so, (2) given the difficulty of the
case, does the plaintiff appear competent to litigate it him-
self?” Pruitt, 503 F.3d at 654–55. 50 If the district court abused
its discretion in conducting that inquiry, “we will reverse only
upon a showing of prejudice.” 

.
     In determining whether a plaintiff appears competent to
litigate the case without the assistance of counsel, the court
must consider “both the factual and legal complexity of the
plaintiff’s claims and the competence of the plaintiff to litigate
those claims himself,” which are “necessarily intertwined.”
Eagan v. Dempsey, 

 (7th Cir. 2021) (quoting
Pruitt, 

). There are no “fixed criteria” for as-
sessing whether a plaintiff is sufficiently competent to litigate
his case, but “a district court certainly should consider the
plaintiff’s literacy, communication skills, educational level,
litigation experience, intellectual capacity, and psychological

50 To the degree that the district court considered the merits of Mr. Riley’s

case in its consideration of the motion to appoint counsel, see R.64 at 48
(“Whether a lawyer had presented the evidence or the plaintiff presented
it himself, the evidence does not support the plaintiff’s claims.”), it did not
abuse its discretion. See Watts v. Kidman, 

 (7th Cir. 2022).
No. 23-1253                                                  19

history.” 

 Nor are there fixed criteria for evaluating the
complexity of the plaintiff’s claims, but “[s]ome of the circum-
stances that require judicial consideration are the phase of the
litigation, if the prisoner has been transferred between facili-
ties, if the claims involved the state of mind of the defendant
such as those involving deliberate indifference, and if the case
involves complex medical evidence, including expert testi-
mony.” Thomas v. Wardell, 

 (7th Cir. 2020); see
Eagan, 987 F.3d at 682–83.
                               2.
    Keeping in mind the deference we owe the district court,
we now evaluate the denial of Mr. Riley’s request for ap-
pointed counsel. Mr. Riley made reasonable attempts to ob-
tain counsel prior to filing his motion. He contacted at least
four attorneys, all of whom either declined to take his case or
did not reply. Even though Mr. Riley’s correspondence with
one of those attorneys prompted confusion, the district court
was on solid ground in concluding that Mr. Riley’s misunder-
standing with Mr. Story was not, standing alone, a ground for
recruiting counsel. Instead, Mr. Riley could have moved to re-
open discovery or to extend the deadline for his response to
the defendants’ summary judgment motions. Thus, we must
determine whether the district court abused its discretion in
determining that Mr. Riley appeared competent to litigate his
case without the assistance of counsel.
    We first consider the nature of the case. Relatively
straightforward claims of deliberate indifference do not re-
quire appointed counsel. See Perez v. Fenoglio, 

,
20                                                            No. 23-1253

784 (7th Cir. 2015). 51 Because he “received at least some medi-
cal treatment,” Mr. Riley had to show “a substantial depar-
ture from acceptable professional judgment, practice, or
standards.” 52 Questions of proper medical treatment often in-
volve complex medical evidence and require expert testi-
mony. But Mr. Riley’s claim primarily rests on the defend-
ants’ intent, not on complex medical evidence. The primary
question is not whether the specialists were correct to recom-
mend high-top shoes; instead, it is whether Ms. Waterman
and NP McArdle consulted the specialists at all. The record
reveals that they reviewed the specialists’ proposed treat-
ments, most of which were cabined as recommendations.53
Although state-of-mind questions can be difficult for pro se
litigants, see Eagan, 

, here the district court was
entitled to conclude, on the record before it, that this case




51 See also Johnson v. Doughty, 

 (7th Cir. 2006). In Johnson, the

plaintiff alleged that prison officials were deliberately indifferent because
they treated his hernia through non-surgical means. See 

. The
district court did not abuse its discretion by declining to appoint counsel
because the case “was not overly difficult.” 

. We note that John-
son predated Pruitt but is cited favorably in Pruitt. See Pruitt, 503 F.3d at
654–56.
52 Appellant’s Br. 37 (quoting Eagan v. Dempsey, 

 (7th Cir.

2021) (emphasis in original)).
53 When he recommended a “shock absorption shoe” for Mr. Riley, Dr. Ja-

cobs recognized that this type of shoe may not be permissible. R.42-1 at
38. At a later appointment, Dr. Jacobs reiterated that his shoe suggestions
“are simply recommendations.” Id. at 37. And Dr. Smith “recommended”
that Mr. Riley be allowed to purchase non-catalog shoes but noted that
some shoes from the catalog could work for his orthotics. R.38-2 at 45.
No. 23-1253                                                              21

presented no particular difficulties that would have been
ameliorated by the participation of counsel at summary judg-
ment. 54
    We next consider the district court’s estimation of the com-
plexity of the case considering Mr. Riley’s litigation capabili-
ties. See Pruitt, 

. The court addressed this point
and clearly believed that Mr. Riley was sufficiently competent
to litigate the case himself. Indeed, the court gave specific rea-
sons for its conclusion. In its view, Mr. Riley “had no diffi-
culty communicating with the court in writing” and filed a
“clear and straightforward” amended complaint that ade-
quately explained the facts. Riley, 

, at *19. He
also responded to the defendants’ arguments, cited source
documents, and filed hundreds of pages of documents with
the court. Mr. Riley “[was] a better communicator than many
unrepresented plaintiffs,” and did a “very thorough, capable
job of representing himself.” 

 Because Mr. Riley was suffi-
ciently able to litigate his relatively straightforward deliberate
indifference case, the district court did not abuse its discretion
in declining to appoint counsel.
                              Conclusion
    The judgment of the district court is affirmed.
                                                             AFFIRMED


54 Mr. Riley’s contention that his transfer to a new facility warranted the

appointment of counsel is equally unavailing. In Santiago, an inmate’s
transfer should have been considered because he did not know the names
of some of the defendants and witnesses. See Santiago v. Walls, 

 (7th Cir. 2010). In contrast, Mr. Riley knew the identities of both
defendants and was able to obtain declarations from two witnesses. He
also conducted discovery from his new institution.
22                                                  No. 23-1253

   JACKSON-AKIWUMI, Circuit Judge, dissenting in part. I dis-
sent in part because there are facts in the record from which a
jury could find for Shawn Riley on his claim that defendants
were deliberately indifferent to his serious medical needs. Be-
low, I highlight those facts before explaining my differing
analysis of the claim. I conclude with a brief note about Riley’s
motion for appointment of counsel, though I join my col-
leagues’ resolution of this second issue.
                                 I
   There are three sets of facts in this hefty evidentiary record
which, when taken with the factual background recited in the
majority opinion, compel my conclusion that Riley’s case
should have proceeded to a jury trial.
    First is the timing and repetition of the specialists’ recom-
mendations about Riley’s care. As shown below, physicians
made numerous specific recommendations that Riley receive
high-top athletic shoes:
      Date         Specialist         Recommendation

 March 24, 2017 Dr. Jacobs      “high top athletic type shoes”

 May 5, 2017       Dr. Jacobs   “athletic type shoe, high-top
                                in nature”

 November 17, Dr. Jacobs        “shoe gear that will allow ad-
 2017                           equate depth to accommo-
                                date orthotic”

 March 23, 2018 Dr. Riley       “I restated on the prison form
                                the diagnoses and recs Dr. Ja-
                                cobs had put down 11/18/17”
No. 23-1253                                                                    23

 April 20, 2018        Dr. Jacobs        “air-ꕕŽȱ Š‘•Ž’Œȱ œ‘˜Žȱ ŽŠ›ȱ
                                         … above 75 dollars patient
                                         would be responsible.”

 July 11, 2018         Dr. Smith         “allow him to purchase his
                                         own personal shoes from an
                                         outside catalog and exceed
                                         the $75 limit as needed. He
                                         needs stability athletic-style
                                         shoes that can accommodate
                                         his orthotics.” 1


    Second is the prison’s policy that required nurses, includ-
ing McArdle, to refer requests for non-vendor footwear to the
Special Needs Committee (SNC). Specifically, prison policy
mandated that “[p]rescribing practitioners shall refer items …
for review of special needs [by the SNC] rather than write or-
ders for specific items.” 2 Regarding shoes, the policy stated
that the Health Service Unit (HSU) had no power to permit
inmates to order shoes from outside the prison’s vendor cata-
log, and the only way to access such shoes was approval from
the SNC. The SNC was comprised of medical and security
staff. When reviewing requests for special items, the SNC con-
sidered the inmate’s medical record, the requested item’s
medical benefit, and the potential effect on the prison’s secu-
rity environment.



    

-1 at 43; R. 42-1 at 42; R. 42-1 at 38; R. 38-2 at 51; R. 42-1 at 37; R.

38-2 at 45.
    

-5 at 2 (emphasis added).
24                                                  No. 23-1253

   Third is Waterman’s stated disregard for the specialists’
recommendations concerning Riley. Waterman told an HSU
nurse not to “make any orders or notes about shoes” because
she was “in hot water about it.”3 Waterman also remarked
that Riley “had another th[ing] coming” if he thought he
would get access to the specialist-recommended footwear.4
                                 II
   With these facts in mind, I turn to the four ways I depart
from my colleagues’ analysis of the deliberate indifference is-
sue.
    The majority opinion concludes that Riley’s claims fail be-
cause Waterman and McArdle “did not ignore the specialists’
recommendations that Mr. Riley be permitted to acquire high-
top shoes[, but] [i]nstead … sought to comply with both DOC
policy and the treatment recommendation by instructing Mr.
Riley to order suitable shoes from the catalog.” Ante, at 15. But
there is evidence from which a jury could conclude that the
defendants intentionally denied Riley shoes and failed to
comply with policy.
    Prison policy required nurses to refer non-vendor shoe re-
quests to the SNC. Nurses were not allowed to take any other
action because the SNC had sole authority to determine
whether shoes were medically necessary and permissible. A
jury considering that the specialists’ recommendations for Ri-
ley were not referred to the SNC despite the mandatory policy
language, along with Waterman’s instructions to the nurses
not to make “any order or notes about shoes,” could conclude

     

-1 at 61.

     4 

.
No. 23-1253                                                   25

that the defendants not only ignored policy but purposely ob-
structed the established review system for non-vendor shoe
requests.
    The majority opinion’s contrary conclusion rests on the
premise that acceptable shoes were available to Riley through
the vendor catalog. But that factual premise is disputed. Ri-
ley’s health service requests, which were submitted to the
HSU, stated that the “high top” shoe he ordered from the cat-
alog was “actually mid[-top],” and did not provide adequate
foot support or accommodate his orthotics. 5 Plus, the final
two specialist recommendations expressly stated that Riley
needed shoes from outside the catalog. Given this factual dis-
pute, I find it impossible to conclude, as my colleagues do,
that the defendants “did not ignore the specialists’ recom-
mendations” and the defendants “sought to comply” with
DOC policy. Ante, at 15.
    Next, the majority reasons that even if McArdle and Wa-
terman disagreed with the specialists’ recommendations,
“disagreements between medical professionals about the
proper course of treatment rarely amount to deliberate indif-
ference.” Ante, at 15. But that deferential consideration only
applies where the medical practitioner is exercising medical
judgment. See McGee v. Adams, 

 (7th Cir. 2013)
(explaining that “[w]hen a medical professional acts in his pro-
fessional capacity,” the professional’s treatment is judged
against a highly deferential substantial departure standard)
(emphasis added)); Pyles v. Fahim, 

 (7th Cir.
2014) (“A medical professional is entitled to deference in treat-
ment decisions …”) (emphasis added)).

   

-1 at 24.
26                                                    No. 23-1253

    Here, it is disputed whether McArdle exercised any med-
ical judgment in denying Riley access to the SNC. After Dr.
Jacobs recommended high-top shoes with adequate depth,
McArdle advised Riley “that DOC will not allow him to wear
personal shoes which are different from those available to all
inmates.” 6 Then, six days after Dr. Smith recommended that
Riley be allowed high-top shoes from an outside vendor,
McArdle noted in Riley’s chart that he was not allowed to
purchase outside shoes due to “a security rule, not an HSU
rule.” 7 McArdle’s exclusive reliance on a security rule is not
an application of medical judgment and is therefore not enti-
tled to deference. A jury question remains.
    Elsewhere, the majority determines that the record cannot
support an inference that the defendants persisted in ineffec-
tive treatment. The prison provided Riley with a plethora of
treatments, I agree. But the defendants blocked Riley’s access
to the single treatment that his specialists recommended
again and again: high-top shoes. Our caselaw tells us that a
prison official who “persists in a course of treatment known
to be ineffective” can be found to have been deliberately in-
different. Petties v. Carter, 

 (7th Cir. 2016) (en
banc). And as the majority notes, Dr. Smith told the defend-
ants that “until [Riley] gets the right shoes and inserts, this
pain will not go away and it will continue to get worse.” Ante,
at 10. Riley told the defendants at least a dozen times that he
was in “chronic, debilitating pain” and the care he had been
provided was not helping. 8 Still, the defendants persisted in a

     6 Id. at 28.

     7 Id. at 26.

     8 Id. at 5, 6, 9–16, 18, 19, 21–25.
No. 23-1253                                                  27

course of treatment that did not include the one intervention
that his specialists all agreed would help: athletic shoes high
enough to support his ankles and deep enough to accommo-
date his orthotics. This is sufficient record evidence to create
a material issue of fact for a jury.
    Finally, the majority states that a jury could not conclude
that “the defendants were deliberately indifferent in declin-
ing to elevate Mr. Riley’s shoe requests to the SNC.” Ante, at
16. Deliberate indifference can be inferred where—as we have
here—a prison official refuses to follow existing protocol. Pet-
ties, 836 F.3d at 728. Waterman told an HSU nurse not to
“make any orders or notes about shoes,” despite policy re-
quiring that nurses refer all non-vendor shoe requests to the
SNC. And over the course of sixteen months, McArdle, a
nurse required to refer requests to the SNC rather than judge
them on her own, declined to send the committee any of Ri-
ley’s six specialists’ recommendations. From this refusal to
follow protocol—Waterman’s instructions to ignore policy
and McArdle’s actual ignoring of policy—a jury could con-
clude that the defendants were deliberately indifferent.
    In sum, the record evidence shows six specialist recom-
mendations for high-top shoes, two obstructionist statements
from Waterman, and zero referrals to the SNC. All while Riley
reported, over and over again, “chronic, debilitating pain”
with no relief from other treatment.9 This is sufficient, in my
view, for Riley to argue to a jury that the defendants were de-
liberately indifferent to his serious medical needs.




   9 Id. at 5, 6, 9–16, 18, 19, 21–25.
28                                                    No. 23-1253

                                  III
     On the other issue before us, I agree with my colleagues
that the district court did not abuse its discretion in denying
Riley’s second motion for appointment of counsel. I pause
here only to note that another district court judge could have
easily granted Riley counsel given the following four consid-
erations: (1) the advanced stage of litigation, see Perez v. Feno-
glio, 

 (7th Cir. 2015) (discussing complexities
of litigation past the initial pleading stage); (2) the fact that
Riley had been transferred away from the facility where his
claims arose, see Pennewell v. Parish, 

 (7th Cir.
2019) (“[A] prisoner who is transferred to a facility where the
events underlying his claims did not take place faces addi-
tional hurdles.”); (3) the fact that Riley’s case involved prov-
ing the mental state of his medical providers, see Eagan v.
Dempsey, 

 (7th Cir. 2021) (“We also have
noted the increased complexity in constitutional claims in-
volving the state of mind of the defendant, such as deliberate
indifference.”); and (4) Riley’s loss of access to the legal library
during the COVID-19 pandemic, see 

 (finding plain-
tiff’s transfer to “a facility with few resources and more re-
stricted movement” was relevant to a determination of com-
petency to litigate a case without assistance of counsel). But
we review appointment of counsel decisions deferentially,
and the district court here was within its discretion to deny
Riley counsel.
     For these reasons, I join in part and dissent in part.