Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 3 of 31 Page ID
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~MDReview
Unhiersity of Southern California Engemann Student Health Center Consultation

Report of Consultation Performed By:
Kimberly Schlichter, MD, FACOG
Sharon Beckwith, CEO, MDReview
Date of Consultation:

The site visit for the consultants took place November 15-16, 2016.

Purpose of Engagement: .
· MDReview was asked by the int~rini co-medical directors, WiUiam Leavitt, MD, and Mildred · .
Wenger, MD, of University of Southern California (Usq Engemann Student Health Center to assist
with the internal investigation concerning Dr. George Tyndall, a staff gynecologist who sees ·
students in the Women's Health Division at the Engemann Student Health Center. The leadership
of the Student Health Center received a report that described certain practices used by Dr. Tyndall
during his examinations of female patients. Dr. Schlichter and Ms. Beckwith were appointed to
an ad hoc committee to review Dr. Tyndall's dinlcal practice and behavior.
Dr. Tyndall came to the Student Health Center in 1989. He has held the position of staff physician
in the Women's Health Division since then. During his time at USC, several complaints have been
made about Dr. Tyndall's behavior and/or practice of medicine. In 2013, Dr. Larry Nelnstein, then
executive director of Student Health, reported to the Office of Equity and Diversity (OED) that
several personnel, as well as a patient, had made allegations related to Dr. Tyndall. Several of
the personnel were interviewed, but a formal investigation was never opened.
· Earlier this year, allegations regarding Dr. Tyndall's behavior were again taken to the OED. This
complaint was initiated by the nursing supervisor. She felt that his comments and conduct
constituted sexual harassment. In the course of the investigation, several other members of the
Nursing Department and two patients also made similar complaints regarding Dr. Tyndall. During
the course of this investigation, Dr. Tyndall was put on administrative leave. Several people have
been interviewed by an investigator for the OED. Dr. Tyndall has also been interviewed twice and
has defended his behavior and medical care verbally and in writing as appropriate. As many of
the issues are related to the appropriateness of his medical care, MDReview was hired to act as
an ad hoc committee to assist with the investigation, induding a determination as to whether Dr.
Tyndall's practices constituted standard of care.
In addition, in relation to the need to fumigate his office white he was on administrative leave,
Dr. Tyndall's office was entered and searched for the source of an infestation. In so doing, a

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locked cabinet was found containing photographs and slides of female genitalia. A separate
Inquiry was started regarding the appropriateness of Dr. Tyndall possessing this material, and Dr.
Tyndall responded. The ad hoc committee was also asked to address this Issue, including Dr.
Tyndall's responses.
This report used information obtained during interviews done over the course of two days with
colleagues and coworkers of Dr. Tyndall, as well as Dr. Tyndall himself; review of 28 medical
records, documents provided by USC regarding the allegations, including Dr. Tyndall's responses,
and documents related to photographs and slides found in Dr. Tyndall's office; and Dr. Tyndall's
explanation regarding his possession of these images.

Background:
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Dr. Tyndall came to the Student Health Center at USC immediately after completlon of a residency
(information not verified by ad hoc committee) In obstetrics and gynecology at Kaiser Foundation
Hospital, Sunset Boulevard. He has stated that he passed the written board exam at the
completion of his residence (information not verified by ad hoc committee). As his work as a staff
physician in Women's Health did not involve performance of gynecologic surgery or obstetrics,
he was not allowed to sit for oral boards for the American Board of Obstetrics and Gynecology, .
and therefore could not become board certified. It is assumed that he has maintained a license
In the state of califomia to practice medicine. His job responsibilities have consisted of caring for
female patients at the Student Health Center. At no point during his employment at the Student
Health Center has Dr. Tyndall had teaching responsibilities of any type or been involved in
university-sanctioned research or any outside research to the knowledge of the a,rrent co-interim
directors of the Student Health Center.
Prior to 2013, complaints regarding Dr. Tyndall's behavior and conduct had been taken to Dr.
Neinstein. These induded Dr. Tyndall interviewing female patients In his office with the door
locked and insisting that medical assistants {MA) remain on the other side of the curtain while he
examined patients. Dr. Neinstein reported that he counseled Dr. Tyndall and that following
counseling, Dr. Tyndall had responded by altering his behavior. Other complaints included Dr.
Tyndall keeping an excessive amount of material, primarily papers but also food wrappers and .
other trash, in his office to the point it was felt to be a safety and hygiene hazard, and he was
. forced to discard of some of the material.

Scope of Engagement:
The ad hoc committee performed an onsite evaluation and series of interviews to obtain a broad
set of opinions regarding Dr. Tyndall's conduct and medical care. It was felt that an onsite
evaluation would allow coworkers and employees to be more willing to express their roncems
without fear of recrimination and to maximize candor and openness. Those interviewed were told
that all efforts would be made to preserve anonymity and ronfidentiality.

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On November 15 and 16, 2016, Dr. Schlichter and Ms. Beckwith Interviewed and/or participated
in discussions with 17 people, induding:
1.
2.
3.
4.

Administrators, both physicians and nursing
Colleagues in the Women's Health Division
Nursing staff (RN's and MA's) In the Women's Health Division
Dr. George Tyndall

It should be noted that the majority of those interviewed had worked with Dr; Tyndall for more
than 10 years, and that eight had worked with him for 14 or more years.
In addition, medical records of 28 students were reviewed by Dr. Schlichter; these included
encounters from 2009 through 2016. Eight of these records were of colposcopies only. Reports
related to this review were submitted separately. Information obtained from this clinical review
is included in this report.
Other documents provided to the ad hoc committee included memorandums related to the
complaint made by the nursing supervisor; the inquiry regarding Dr. Tyndall's possession of
images of female genitalia, some of which have student/patient identification information on
them; and a curriculum vitae provided by Dr. Tyndall.

Summary Findings from Interviews:

All Student Health Center personnel who were interviewed, save Dr. Tyndall, expressed a desire
to maintain high standards of care for the student-patients at the Student Health Center. While
some concerns were expressed about possible involvement in legal action, the majority of
interviewees were open and forthcoming and provided detailed information regarding Dr.
Tyndall's conduct and medical care. Based upon these discussions, several consistent themes
became evident:
1. Frustration with prior lack of action on concerns raised regarding Dr. Tyndall
Several people interviewed expressed frustration with the administration of the Student Health
Center. This was related to their feeltng that prior complaints were either Ignored or resulted
in only limited and/or temporary improvement in Dr. Tyndall's behavior. Personnel indicated
they felt It was necessary to take their concerns outside the Student Health Center to be taken
seriously and/or result in any permanent improvement in a situation they felt put patients at
risk and made them very uncomfortable professionally. Several were concerned that the
current investigation would again be fruitless. Multiple people said they had seen Dr. Tyndall's
behavior as worsening significantly in the last few years.
2. Both personnel and patients were frequently upset after their encounters with Dr. Tyndall.
Several interviewees indicated that patients frequently asked to see other providers after
seeing Dr. Tyndall. At times, this seemed to be due to a lack of comfort with Dr. Tyndall's
care that they were either unwilling or unable to express. At other times, it was due to Dr.

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Tyndall's inability to oomplete the needed services In the scheduled time, either because he
was running late or because he took an Inordinate amount of time to perform the scheduled
services. It was also noted that those patients who did indicate a desire not to return to Dr.
Tyndall's care, if they were international students, had better command of the English
language.
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. In addition, several nursing staff said they had reached a point that they preferred not to go
into a patient exam room with Dr. Tyndall because the way he dealt with the patients made ·
them uncomfortable. This induded seeing patients who were in tears, upset, or obviously
offended by Dr: Tyndall's conduct, all of which Dr. Tyndall would be oblivious to, or he would
make oondescending comments to the patients about their disoomfort.
3. Belief that Dr. Tyndall had a preference for a particular patient population
Almost all interviewees commented emphatically that Dr. Tyndall had a dear preference for
the type of patient he saw. These patients were described as International and/or Asian, most
typically non-American Asian, with a lower level of fluency with English. The opinion was that
these patients had a reduced understanding of what they were being told. In addition, Dr.
Tyndall's exams and behavior differed depending on what type of patient he was seeing. If
the patients were young or Asian, they were more likely to have a pelvic exam CX>mpleted, ·
while if they were non-Asian, obese, or older, it was less likely that a pelvic exam would be
deemed necessary (by Dr. Tyndall or the patient). Also, comments made to patients that the
nursing staff were uncomfortable with or felt were inappropriate were more likely to be made
to students for whom English was their second language.
4. Reports of inappropriate, unprofessional, and/or unusual behavior .
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Nursing staff were particularly troubled by what they saw as Inappropriate comments being ·
made to patients. The description of the comments was uniformly similar among multiple
interviewees who indicated this was a concern. Patients were frequently told they had
"flawless skin." During the pelvic exam, Dr. Tyndall would make comments about vaginal
caliber or tightness by saying "you are toned" or "your PC (puboc:occygeus) muscle is tight,"
and ask whether the patients exercised, typically whether they ran or swam. If patients asked
what that meant, he would tell them that running and other forms of exercise led to a tight
PC muscle and that their boyfriend or spouse would be "really happy about it." Or. Tyndall
would comment on the status of the patient's hymen. He would tell patients they had "perky
· breasts" and frequently ask if they had breast implants.
Nursing staff were uncomfortable when Dr. Tyndall asked them to stand beside him while the ·
patient was in lithotomy position to hold a light rather than use the available self-supporting ·
light source. He would then frequently ask them to "look at this" and point out an area of the
. patient's anatomy.
When chaperones were allowed to stand at patients' sides, they were frequently instructed .
not to talk to patients and/or hold patients' hands as a gesture of support during pelvic exams..
Several years ago, Dr. Tyndall refused to allow chaperones into the room during his exams

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cir insisted that chaperones stay on the other side of a dividing curtain. Dr. Neinstelri counseled
Dr. Tyndall on this inappropriate behavior in the past, and he ceased, but the MAs Indicated
that they frequently felt Dr. Tyndall preferred chaperones not be in the room with him or
interact with the patient.
. In interviewing Dr. Tyndall, he indicated he was aware that the nursing staff had raised this
issue and seemed perplexed by it. He raised two issues relevant to this. He contended that •
his patients would never need a person to support them or hold their hand as his exams never
caused patient discomfort. He also contended that the patient holding someone's hand
· · interfered with performing an accurate exam.
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While several of the staff described Dr. Tyndall as being nice, several also described his .
making comments to them personally that Involved racial stereotypes. When some of them
told Dr. Tyndall that these comments were not appropriate, he was perplexed and did not ·
understand why they were inappropriate.
Two separate members of the nursing staff said that Dr. Tyndall asked to keep an intrauterine.
device {IUD) that had been removed from a patient. In one case, he asked the patient's
permission. In the other, after the patient had left, he came back into the room and asked .
the MA to clean it and put it in a bag for him.
Multiple people stated that Dr. Tyndall's office was full of papers, trash, and old food wrappers.
They said It caused the office to have a bad odor and they felt It was behavior that would be
considered hoarding. They also commented that his personal hygiene was not good. It was
noted that he would wear an obviously dirty shirt and would smell bad. This latter Issue was
reported by several to be getting worse recently.
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Multiple interviewees also reported that Dr. Tyndall kept some type of rag or doth in his
pocket that he would always use to grasp a door knob to open it, but that he would also use •
this same cloth to wipe his face or blow his nose. He was also said to be unwilling to shake
. hands. {The latter was noted when Dr. Tyndall was interviewed by the ad hoc committee. He .
claimed he did not want to shake hands as he had a cold, although both Interviewers noted
that during the hour that was spent with him, no outward signs of illness were observed.)
5. Poor or questionable medical care
a. Inadequate exams
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· Several people interviewed reported that Dr. Tyndall ·seemed to lead students into saying
they did not want an exam or a part of it. In addition, his breast exams were described
as brief or not thorough. He would comment to patients either prior to doing the breast
exam, when it was still under discussion, or during the exam Itself that they were too
young to get breast cancer.
Dr. Tyndall's answers to questions regarding breast exams during his Interview supported ·
the above statement. He indicated that he felt that if he palpated a breast lump in a young
woman and referred her for evaluation, it would always result in an open biopsy for what

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would be found to be a benign lesion. In addition, he said that he felt a breast exam when
the patient had implants was not useful as the implant was in front of the breast tissue,
which is factually incorrect.
Uniformly, he was described by those interviewed as rarely obtaining a biopsy when a
colposcopy was performed. One interviewee also stated that in cases In which he did do
an endocervical curettage (ECC, a form of biopsy), he would always remove the curette
and say "there's no tissue" and not submit it, but that the patients never reacted with the ·
typical discomfort related to this procedure being performed correctly.
Review of medical records supported the staff's contentions regarding Dr. Tyndall's
performance of colposcopies. Medical records of 13 colposcopies were reviewed. No
biopsies were performed because In all cases, the findings were documented as normal.
In five cases, Dr. Tyndall said he performed an ECC but did not submit the specimen due
to "no tissue obtained."This procedure does not produce grossly visible tissue when done
correctly.
b. Infection control issues
Almost all interviewees either volunteered or confirmed, when asked, that Dr. Tyndall was
never seen to wash his hands, and that in many Instances, he even commented to or
asked a patient if it was OK not to wash his hands and "just wear gloves" as the soap was
"too harsh."
Dr. Tyndall started performing what sounds to be total body checks for skin lesions in the
last several years. He did this after the pelvic exam. He removed the first set of gloves
and donned clean gloves. He turned the patient prone and then separated the buttocks
. to check the anal area. Without changing his gloves, he then went on to examine the
patient's upper torso, neck, and scalp. As described, this is a violation of the standard to
proceed from "dean to dirty" in the course of an exam or procedure.
Several personnel reported that he poorly controlled body fluids that can accumulate on
the speculum or his gloves during the exam, resulting in frequent contamination of
surrounding equipment and his own clothes. In addition, he used the gloved hand that he
has just used to perform a pelvic exam to touch the exam room curtain.
c. · Inappropriate pelvic exam tedmique
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. Dr. Tyndall was described by multiple interviewees of modifying his pelvic exam technique
in the last several years. He is now desaibed uniformly as always beginning his pelvic
exam by asking the patient's permission to insert one gloved lubricated finger, regardless
· of the purpose of the exam, his prior experience examining the patient, or her sexual
experience or history of traumatic exam. He would then remove it and ask the patient's
permission to insert two fingers. It was during this portion of the exam he typically made
comments about the patient being "toned" or having a ''tight PC muscle," frequently
seeming to palpate this tight area while he talked with the patient Typically, a bimanual .
exam was not done at this time. Dr. Tyndall would then perform the speculum exam and
then might, but not always, perform a bimanual exam. At times, the patient would be

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uncomfortable and ask him to stop, which some personnel reported he did not always do, .·
and that if the patient did complain of pain, he would make a condescending comment
that she should not be feeling any discomfort.
(Dr. Tyndall stated during his interview that his patients never experienced any discomfort
during his exams because he thoroughly explained everything to them ahead of time.)
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Ad Hoc Committee Feedback to Dr. Tyndail's Responses to the Initial Complai~t: .

One of the issues· raised was Dr. Tyndall's Insistence that the Student Health Center's policy
(stated by Dr. Tyndall) of only requiring a chaperone in the room when a male provider does a
pelvic exam is a violation of "APGO/ACOG standard." Dr. Tyndall stated that "according to
APGO/ACOG, there should always be an assistant/chaperone present during physical exams of
undothed women ... regardless of the gender of the dinidan"; he attached a footnote to this
statement to Obstetrics and Gynecology, 7th edition, Wolters Kluwer/Lippincott, Williams &
Wilkins, 2014. During his interview, he referenced this book as containing the standards of care
by which he practices. This book was not written to establish guidelines but rather is a medical
student textbook. That said, it actually does not state what Dr. Tyndall contends. There is a short
reference to chaperones that states that any request for a chaperone by physician or patient,
regardless of sex, should be accommodated. A better resource for guidelines, Guide/Ines for
Women~ Health care: A Resource Manual, 4th edition, Toe American College of Obstetrics and
Gynecology, 2014, states that a chaperone is not required and at times can be deleterious (page
100).
Dr. Tyndall ~lso contended that his tedinique for performing pelvic exams is "by the book." But
the technique described by all nursing personnel is not by the book. Guidelines for Women~
Health care: A Resource Manual, 4th edition, states that the speculum exam is to be done after
the external inspection, and that if lubricant is used it should be minimized to prevent
contamination of any specimens that should be collected (page 228). That said, there are isolated
. instances in which it may be appropriate to probe the vagina before the speculum exam is done
to check for any obstructions or anatomic abnormalities that may hinder the speculum exam, .
most typically if the patient's history suggests such an issue. But these are isolated instances and
. dearly not present in all of the patients that Dr. Tyndall examines.
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Dr. Tyndall also defended his statements to a patient being "toned" or having a "tight PC muscle"
. as a response to their answer to Question 12 on the Student Health Center health history form.
He stated he does this only under certain circumstances: If the patient checks {reviewer assumes
this means checks in the affirmative) Question 12, and if he also notes a "toned PC musde" during .
the exam. He then educates the patient about Kegel exercises and how they relate to orgasms.
Dr. Tyndall stated that if the patient was not complaining about sexual functioning, no comment
· about vaginal muscles or Kegel exercises would be made. Per documents supplied to the reviewer,
Dr. Tyndall stated that "he cannot remember a single incident where a patient did not check
question 12." Question 12 is actually a four-part question. In fact, upon review of 20 Student .
Health Center health history forms attached to the medical records sent for review, none of the
four parts of Question 12 were ever checked in the affirmative.

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Upon interviewing Dr. Tyndall, he confirmed that he felt there was a connection between Kegel
exercises and orgasms. Dr. Tyndall stated during his interview that he only practiced "evidence- ·
based medicine," but when asked for the source of this belief, he referred to a Reader's Digest
artide he read more than 20 years ago. The belief that there is a connection between doing Kegel
exercises and orgasms is certainly not widely accepted among gynecologists, and the reviewer is
unaware of any scientific literature supporting this connection.

The other defenses Dr. TyndaU gave of doing a digital exploration of the vagina before doing the
· speculum exam was to check to see if the patient would tolerate the speculum exam as she may .
have vaginismus, or because if the "PC muscle is highly toned" and she is not sexually active, he
would give the patient the opportunity to skip having a speculum exam as It might cause pain. If
the patient gave a history suggesting vaginismus, this would be appropriate. But according to
nursing staff, regardless of whether he had examined the patient previously or she gave a history ·
suggestive of vaginismus, the exam was done the same way. The medical records that were
reviewed supported that in many cases, Dr. Tyndall examined patients he had previously
examined himself without difficulty. ACOG standards recommend a pelvic exam, induding .
speculum exam, in patients older than 20 regardless of their sexual history (see Guidelines for
Women~ Health care: A Resource Manual, 4th edition, and the ACOG Committee Opinion Wei/Woman Visit, August 2012, reaffirmed 2016). While these guidelines allow for flexibility depending
on the patient's preferences and history, routinely exploring the vagina before the speculum exam
to determine if the patient might have discomfort is not standard of care or appropriate.
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Dr. Tyndall defended questions he asked patients about whether they ran or exercised based
upon his assessment of their PC muscle as relevant to informing the patient about what he found
during the exam. But this does not in any way explain or defend his questioning of the patient.
And, factually, while many muscle groups may be strengthened by running, the pelvic floor (of
which the PC muscle is a part) may actually be damaged by running because of the repetitive
impact. The only form of exercise that is commonly felt to strengthen the pelvic floor is Kegel
exercises.
Dr. Tyndall's statement that he comments on the status of the patient's hymen to determine if
she is having problems with intercourse contradicts his own contention that he has paid attention
. to her answer to Question 12 on the Student Health Center health history form, which indudes
whether the patient has questions or concerns about sexual functioning. The appearance of the
hymen even after a patient has become sexually active is highly variable, and there is no medical
reason to make an issue of this with the patient unless the patient herself raises questions
regarding it.
• Telling a patient that she has "flawless skin" is not the way It would typically be described from a
medical standpoint. In that case, it would be more appropriate to say, "I don't see any suspicious
areas." This may simply be a poor choice of words on Dr. Tyndall's part, as It sounds more like a
compliment than a medical statement. Complimenting a patient on any aspect of her appearance
may confuse the physician-patient relationship and should be avoided.

As discussed above, Dr. Tyndall's contention that a breast exam Is unnecessary if the patient has
implants is simply Incorrect. There is also no risk of rupturing an implant by a dlnical breast exam,
as he stated he was concerned might happen if he examined a patient with breast implants. At
no time would it be appropriate for a physician to comment to a patient that she has "perky

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breasts," a statement Dr. Tyndall denied making but which multiple personnel stated they had
heard him make.
It is impossible to determine if the way in which Dr. Tyndall discussed contraceptive options
unduly emphasized IUDs/Intrauterine systems (IUS). It is certainly appropriate to try to fit the
method of contraception to the patient's needs and habits, and it is well dorumented that long- .
acting reversible contraception methods, including IUDs, IUSs, and Nexplanon, have a lower
failure rate. Or. Tyndall's documentation in his medical records showed a very high level of
concern about contraceptive failure, induding advising a patient to fill a prescription for
emergency contraception before It was needed and carry it with her in a Ziploc bag he provided
. to the patient (a highly atypical and puzzling practice). It is possible that because of his very
strong concern about contraceptive failure that he, without recognizing it himself, unduly
emphasized use of IUDs/IUSs to patients.

Ad Hoc Committee Feedback to Dr. Tyndall's Explanations of His Possession of Images
of Female Genitalia:
• The ad hoc committee was asked to consider the issues and comment upon standard of care
relevant to the discovery in Dr. Tyndall's office of slides and photographs of female genitalia, both
external and cervices. These items were found when the office required fumigation while Dr.
Tyndall was on administrative leave. Of the more than 200 images found, 38 had patient ·
identifying information on them {22 of which were slides of cervices). The remainder were
unlabeled. The photographs lnduded some taken using Polaroid-type film. The Images that
contained identifying information were dated between 1990-1991. There were also receipts for
film development by a commercial processing lab in Rochester, New York (date information was
not provided). It should be noted that neither the images nor the receipts themselves were
reviewed by the ad hoc committee.
Dr. Tyndall stated that he obtained consent to take the photographs, but medical records to
support this contention were not available for those dates. Information provided by other medical
personnel who have been at the Student Health Center for more than 20 years indicated that
there has never been a consent for photography induded on the ·standard forms. At this time,
there does not appear to be any way to determine whether the patient's consent for photography
was obtained.
The use of photography to document findings was somewhat more pervasive in the late 1980s
and early 1990s than it is today. At one time, the use of a specialized camera with a close-up lens
to perform "cervicography" as an adjunct to the Pap smear was promulgated by a company that
would then interpret the photographs. This does not sound consistent with what Dr. Tyndall
described as a camera attached to a colposcope. Due to the magnification on the colposcope, it
is difficult to imagine how anything other than a very small area of the external genitalia could
be photogrcsphed in one frame. Without seeing the images, it could not be detennined whether
the images were likely to have been taken through a colposcope or whether a different type of
camera was used.
Dr. Tyndall's defenses for possessing these photographs were dubious, at best. He stated that he
retained an extra copy of the patients' cervices as a defense in the event the patient later

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developed cervical cancer. But since less than 15% of the images contained any patient
identifying Information, that justification fails to explain the possession of more than 85% of the
images.
· Dr. Tyndall also stated that he used the photographs to educate patients on the findings of his
exams. The problem with that defense is that only the Polaroid images would have been available
immediately for the patient's viewing. It is certainly much more typical to use a mirror to show a
patient a finding if this is needed. He also stated that the patients liked seeing the photographs
and would even make a return appointment solely to see the pictures a~er they were developed.
But again, in light of the very low percentage of the images that had patient identifying
. information, this explanation does not support his possession of the vast majority of the images.
The document provided to MDReview regarding these images stated that they appeared to show ·
abnormalities such as warts and skin lesions, but Dr. Tyndall apparently disputed this. Dr.
Tyndall's ongoing possession of the unidentified Images was not standard of care unless they
were of notable pathology, which·ls contrary to Dr. Tyndall's statement.
The use of photography to record images of the cervix and external genitalia might have had
some benign clinical purpose 25-plus years ago, which Dr. Tyndall no longer recollects, but his
· current defenses are not plausible.

Considerations:
After considering all information provided to and obtained by the ad hoc committee, lndudlng the
interviews and review of patient records, significant concern exists that many of Dr. Tyndall's
practices are not within current standard of care. In addition, he repeatedly exhibits behavior that
is unprofessional, inappropriate, and/or unusual. Of greatest concern are the issues with infection
control and Inadequate or inappropriate breast, pelvic, and colposcopic exams. The issue with Dr.
Tyndall refusing to wash his hands is a serious violation of infection control standards. Guidelines
for Women~ Health Care: A Resource Manual, 4th edition, devotes an entire section to hand
hygiene (pages 147-148). It specifically states that the use of gloves alone is not adequate.
Dr. Tyndall has some unusual and potentially dangerous opinions about breast exams. While he
stated in his records that he discusses the "controversy" regarding breast exam with his patients
and lets them decide whether to have one, his bias against breast exams would make it likely
that the information he provides is similarly biased, and therefore, the patient cannot make a true
informed decision. Dr. Tyndall's reviewed medical records documented that the exam was
"offered" rather than recommended, as It should have been.
His technique for pelvic exam by performing a digital exploration of the vagina before doing the
speculum exam in all patients is not standard of care. While he asked the patient's permission at
the time of the exam, if he told the patient that was how an exam was done, the patient, again,
was not allowed to make a truly informed consent to what could be considered a violation of her
body.
It is simply not plausible that 100 percent of 13 colposcopies done because of Pap smear
abnormalities or the presence of high-risk human papllloma virus would be normal. It also

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 13 of 31 Page ID
#:4528

appeared likely that the ECC was not being performed correctly. Nursing personnel indicated that
when Dr. Tyndall did this procedure, the patients did not react to what is uniformly an
uncomfortable or painful procedure if performed correctly. In addition, Dr. Tyndall made the
unusual decision not to submit the specimen he purportedly obtained because of "no tissue
· obtained"; even when the procedure is done correctly, there ls no grossly visible tissue obtained.
Fortunately, none of the colposcopies that were reviewed were for the more concerning highgrade abnormalities, and therefore, the plan for repeat Pap smear In one year would be
appropriate even if a low-grade lesion were present but was not identified by Dr. Tyndall.
Dr. Tyndall was reported to exhibit several behaviors that would be mnsidered unusual at best,
and inappropriate or unprofessional at worst. As previously discussed, comments made to
patients about "being toned," the status of their hymen, or the appearance of their breasts were
not adequately defended by Dr. Tyndall and were inappropriate and not within standard of care.
To answer a question from a patient about what it means if she has a "tight PC muscle" by saying
to "ask your boyfriend" is demeaning to a woman and highly unprofessional. While he stated that
he performs a pelvic exam in the unusual way discussed above to avoid patient discomfort, he
unrealistically contended that his exams never cause patient dlsromfort and was resistant to
allowing the nursing and MA personnel to provide support and comfort to the patient during the
exam, which is unprofessional.
Some of Dr. Tyndall's behaviors are potentially indicative of underlying psychopathy. These
indude his request to save removed IUDs, his hoarding behavior and poor personal hygiene, as
well as the use of a rag to open doors and refusal to shake hands. While MDRevlew was not
specifically asked to address these behaviors, induding the issues with infection rontrol, the
repetitive description of these very concerning behaviors during the interviews makes them
Impossible to ignore.
Lastly, the ad hoc committee was very roncerned that the bulk of the patients whom Dr. Tyndall
sees are unusually vulnerable. Younger women in general are less familiar with the normal
ronduct of a female exam. Language and cultural barriers would make it even more difficult to
know what to expect during the exam. It would be easy for a healthcare provider to take
advantage of this and perform medically unnecessary exams and make comments that patients
may assume are appropriate. The patient, not recognizing that she has undergone an
Inappropriate exam or that an inappropriate/unprofessional comment has been made, would
make no romplaint regarding the behavior.

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 14 of 31 Page ID
#:4529

Potential Interventions and Remedies

Officials at the student Health Center need to decide whether to maintain Dr. Tyndall's
employment as a Women's Health provider. Based on the ad hoc committee's comprehensive
review, a number of significant concerns exist that would raise serious questions about patient
physical and psychological safety were Dr. Tyndall to return to practice. These indude but are ·
not limited to:
•

Gaps in fund of knowledge, dinlca·I judgment, a~d adherence to current accepted practice .
guidelines regarding women's health.
.
..
• Failure to acknowledge and follow current basic fundamentals of hygiene and Infection
··. control practices.
.. • Applying differing practice patterns based on the age, ethnicity, and appearance of
.
. patients, based on multiple similar reports from staff members.
• Using physical exam techniques that vary from standard accepted practices and could be,
and likely were (based on patient feedback), mnsidered to represent inappropriate .
physical contact with patients that would likely be considered serious boundary violations
by a professional conduct, licensing, or credentialing committee.
· · • Making highly inappropriate comments to patients, particularly those more vulnerable ·
based on young age and language barriers, regarding physical appearance and behaviors ·
that would also constitute significant professional boundary violations.
• · Taking and retaining photographs of patient genitalia without dear Informed consent,
. appropriate patient identification, and safe storage and disposal, and lacking any dear
dinlcal reasons for such images to exist.
• A combination of behaviors, physical hygiene, and · Interpersonal relations that raise
questions about the presence of some underlying physical or mental health condition ·
. affecting his safe practice of medicine.
.

.

. .

-

.

..

Should the officials at Engemann Student Health Center decide to try to remedlate these concern~
and create a pathway for Dr. Tyndall's safe return to practice, the ad hoc committee has induded
some potential interventions and remedies that could be instituted to further evaluate and
remediate Dr. Tyndall's current practice and limit risk to patients. Options indude the following:
1. Contemporaneous proctoring of all exams and patient interactions by a board-certified

obstetrician-gynecologist with experience in the student health setting. This would allow
a shoulder-to-shoulder evaluation of current clinical skills, exam techniques, and
interactions with patients. Staff who currently have concerns about inappropriate exams
and behavior are likely to see this as the most definitive intervention that would show that
their voices have been heard by leadership and administration. This is a costly and laborIntensive intervention that would require the collegial cooperation of Dr. Tyndall.
2. Dr. Tyndall rould agree to undergo a full and comprehensive physical, medical, and ·
psychological evaluation, based on concerns about his practice patterns, personal hygiene,
infection control concerns, and interactions with patients. The ad hoc committee was not
equipped to diagnose physical or psychological conditions that could be affecting Dr.
Tyndall's clinical practice. However, issues such as undiagnosed psychiatric conditions are
often a major contributing factor in similar situations. Entities such as califomia Public
Protection & Public Health, Inc., offer a comprehensive evaluation to look for both physical

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 15 of 31 Page ID
#:4530

and or psychological/psychiatric concerns that may lead to some degree of physician
impairment or decreased performance capabilities (please see Appendix B for a list of
potential programs). Dr. Tyndall would have to agree to undergo such a comprehensive
evaluation as well as be willing to share all results, uncensored, with leadership at the
Student Health Center.
3. Dr. Tyndall could undergo a comprehensive evaluation of his dinical capabilities, induding
fund of knowledge, adequacy of training, exam techniques, and decision-making, to
determine whether there are gaps in his overall approach to patient care. There are a
number of national organizations, such as the Center for Personalized Education for
Physicians in Colorado or the Physician Assessment and Clinical Education Program in
California, that have the capacity to perform this kind of evaluation (please see Appendix
B for a list of potential programs). Once again, Dr. Tyndall would have to agree to undergo
such a comprehensive evaluation and be willing to spend the time and resources
necessary to have such an evaluation completed.

While items 2 and 3 both can be costly and time-a:msumlng, they can also help identify possible
underlylng issues affecting the physician's current practice. From previous experience with
comprehensive physician evaluation programs required by leadership, the cost of such evaluations
is often shared between the physician and the facility.

&·· 11116

Nov 30, 2016

Kimberly Schlichter, MD

Shall?n Bl&K,WiH,
Sl\aron Beekwilh {Nov 30. 2016)

Sharon Beckwith, CEO, MDReview

Nov 30, 2016

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 16 of 31 Page ID
#:4531

Appendix A:
The following are a few verbatim quotes from the interviews of nursing and other medical
personnel. These quotes stand out as they reflect behaviors exhibited or statements made by Dr.
Tyndall that were repeatedly stated to be of concern and were highly troubling to those who
observed them:
• Described as a hoarder. Office is very undean.
• Never washes hands.
• Uses a rag In his pocket to open doors.
• Rarely does biopsy during colposcopy.
• Prefers Asian and/or international patients.
• · One finger and then two fingers.
• "Flawless skin."
• "At your age you won't have breast cancer."
• "You are very toned."
• "Are you a runner?"
• "Ask your boyfriend."
. • "Your husband will be happy."

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 17 of 31 Page ID
#:4532

Appendix B:
Below are referral details for organizations that are able to provide recommended comprehensive
medical knowledge/sklll and mental health/fitness for duty evaluations.
1. The Center for Personalized Education for Physicians (CPEP). http://www.cpepdoc.org/

a. Competence Assessment
This in-depth evaluation is tailored to the participant's specialty and practice and provides
detailed information about dinical competence In the areas of medical knowledge, dinlcal
decision-making, interpersonal communication skills, dOQ.Jmentation skills, and practice
systems, while also identifying areas of educational need. The a>mponents of an
assessment vary and are dependent upon a participant's specialty and scope of practice
and may indude structured clinical interviews, multiple-choice examinations, technical
skills simulations, cognitive function screening, review of health information, simulated
patient encounters, documentation review and evaluation, electrocardiogram
Interpretation, fetal monitor strip interpretation, and a radiology documentation exercise.
Toe competence assessment generally takes place over a two-day period. The fee for the
assessment and report compilation is $8,995 to $11,995 depending on specialty.
b. Assessment Report Compilation
The medical director or associate medical director has primary responsibility for collecting
assessment data, interpreting performance results, and preparing a detailed report of the
assessment findings. Reports are generally produced within eight weeks of the
assessment.
•
•
·•
••

Assessment performance data is reviewed and interpreted by specialty-matched
physicians, neuropsychologists, and communication consultants.
Educational recommendations as part of a formal education Intervention are induded
based on the participant's performance.
Participant's performance on the cognitive function screen Is commented upon.
Observed behaviors or health concerns that could impact ability to practice are noted.

c. Educational Intervention
Based on the assessment findings; a highly personalized educational plan is developed
from a broad range of learning resources and is measured through patient case review as
well as ongoing progress and compliance monitoring. Every effort is made to take
advantage of educational resources within the physician's home and practice area. As a .
result, licensed physicians can maintain normal clinical practice activities while
participating in the process. The components of the educational intervention may indude
a supervised practice experience with a preceptor, professional reading and self-study,
· specialty field updates and continuing medical education courses, and documentation and
communication courses. The duration of an educational intervention averages between
· six and 12 months, and the fee ranges from $1,900 to $2,200, depending on specialty,
with a monthly monitoring fee of $725-$925 for the duration of the plan.

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 18 of 31 Page ID
#:4533

. 2. Physician Health Program for California {CPPPH). http://www.cppph.org/
a. Program Overview
.

. .

-

..

.

.

CPPPH is dedicated to the establishment of an ideal physician health program in California.
Toe program is designed to encourage and assist all organizations, institutions, and
entitles where physicians practice or affiliate in their efforts to maintain the health of their
physician population. Its. services are available to assist the citizens of califomla, the
regulatory board, associations, hospitals, dinics, and individual physicians. califomia's
ideal physician health program (PHP) identifies, provides, or supports dinically based
health services for physicians with physical, mental health, or addiction issues, which, if
• undetected or not appropriately treated and monitored, could compromise the physician's
ability to practice medicine safely.
b. Program Components
A well-designed PHP will include:
• Education throughout the medical community
• · Orientation to the role and function of physician health committees
.
• Consultation to physician health committees and all with the responsibility for
physician health, public safety, and the maintenance of quality-of-care advocacy for
activities that promote wellness
• Activities designed to support case-finding intervention evaluation, both initial ·
assessment and continuing evaluation as needed, including evaluation for the
resumption of patient care responsibilities
• · Design of treatment and monitoring plan referral to initial treatment ·
• Referral to ongoing treatment monitoring, case management, and quality assurance
activities
c. Policies and procedures for the operation of the PHP
.

.

Once a PHP is established, it will provide consistency and coritiriuity In approaching and
managing physician health across the state. Referrals into the program are accepted from
all sources. Eligibility for the program is designed for persons with substance use, mental
health disorders, or physical illness when a cllnical evaluation determines that the
· condition can be monitored and treated with the resources available to the program. The
length of time a person is required to be in the program is in the range of three to five
. years, based on the severity of illness and clinical recommendation.
· The program does not report information about a participant to any person or organization
· other than the referring person or entity, unless there has been failure to comply with the
- agreement and It was determined that the physician was a danger to the public. The
organization will assign the resources necessary for appropriate quality assurance
activities.

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 19 of 31 Page ID
#:4534

3. Colorado Physician Health Program (CPHP). http://cphp.org/welcome
a. Evaluation
CPHP evaluates any health issue including medical, psychiatric, emotional problems, or
situational stresses. A dient is provided a clinician and psychiatrist who will manage the
case during the course of involvement with CPHP. The initial intake evaluation by CPHP
will take approximately 2.5 hours.
Components of a CPHP evaluation include:
•
•
•

An electronic questionnaire (indusive of health history)
A full psychiatric assessment by a medical director
Execution of materials such as releases and confidentiality agreements

b. Assessment
CPHP assessments take place over time, typically 30 to 45 days but potentially up to 90
days if an extended evaluation is warranted, and may involve multiple phone interviews
with collateral sources, other data collection such as laboratory or further medical testing,
gathering any additional collateral information, appointments with CPHP, and/or referrals
for outside evaluation or testing.
Evaluation and assessment fees vary but are generally about $3,600.
c. Treatment Referral and Monitoring
Treatment referrals and monitoring with CPHP may indude:
• Referral for further evaluation or treatment
• Regular monitoring appointments with CPHP
• Urine drug screen monitoring
• Case management services
• _Reports generated to various entities
• Family services
_ Useful points pertaining to treatment referral and monitoring:
CPHP does not provide treatment It does provide treatment referrals, with an elite
cadre of highly qualified professionals in the community who specialize in working with
_medical professionals.
• CPHP also refers to spedaliZed national programs if a condition requires treatment not
available locally.
• CPHP may monitor an Individual for several months to several years, depending on
-the particular clinical aspects.
•

 Case 2:18-cv-04258-SVW-GJS Document 143-14 Filed 05/23/19 Page 20 of 31 Page ID
#:4535

•

CPHP may collect ongoing collateral data gathered from treatment providers, family
members, and/or workplaces, If the CPHP dient approves the requisite release to do
so within CPHP's confidentiality guidelines.

4. Other Programs
a. University of califomia San Diego PACE Program offers a two-phase physician competence
assessment program. When inquiring, any referring organization should seek information
· about phase 1 and phase 2 of this program. http:l/www.paceprogram.ucsd.edu/
b. University of Florida CARES Program offers competence assessment and remedial
education services. http: //floridacares. med.ufl .edu/

c.

Professional Renewal Center in Kansas offers individualized, comprehensive assessment
programs depending upon the need. It provides a thorough, in-depth, total health
. evaluation. http://www.prckansas.org/

This document has been etectranlcally slgned. Audit trail available an request

/