July 16, 2004

Honorable Thelton Henderson
U. S. District Court
450 Golden Gate Ave.
San Francisco, California 94102
Re: Plata v.Schwarzenneger, 2nd report, part 2
Dear Judge Henderson:
This letter is part of our second report.
Credentialing and Physician Qualifications
Based on review of several facilities, there appears to be an emerging pattern of
inadequate and seriously deficient physician quality in CDC facilities. As a backdrop for
this discussion, it is worthwhile to describe the differences in physician practice. After
medical school physicians may do one year of internship and begin practice. Such
rotating internships typically consist of one to two months rotation in each of various
specialties, such as medicine, surgery, etc. Physicians who complete a rotating internship
can legally practice medicine as general practitioners. It is generally at this point that
they acquire a license.
Most physicians do not do rotating internships. Rather, they enter residency programs in
the specialty of medicine that they intend to practice in. Such residencies are typically 3
to 6 years of training with practical and didactic training in the area of specialty. Such
areas of training include Anesthesiology (the practice of giving anesthesia during
surgery), Internal Medicine (the practice of diagnosing and treating medical problems), a
variety of surgical fields, etc. Training in each of these areas is specialized and does not
cross over to include training in other areas. One exception is Family Practice which
consists of several months each of training in Internal Medicine, Obstetrics and
Gynecology and a variety of surgical specialties.
The CDC by practice treats all physicians equally. Requirements for medical licensure in
any state generally only require completion of medical school and internship. CDC only
requires licensure in order to perform in any staff position. The Personnel Board
selection process treats physicians the same as long as they have a license. Thus the only
requirement for hiring is a medical license. There is no further hiring requirement.
However, while the medical needs of the patients in the CDC may be satisfied by general
practitioners with training in only a rotating internship, most services require some
training in general internal medicine. Some positions should be filled by Board Eligible
(completed a training program but without passing a certifying examination) or Board

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Certified (trained and passed a certifying examination) internists. CDC Health Services
Division under Dr. Kanan has recently initiated a process of credentialing physicians that
is comparable to what is done in HMOs and other managed care organizations.
Credentialing considers not only licensure but other qualitative factors such as moral
character, whether a physician is impaired physically or mentally, and the training that a
physician has. However, the current CDC credentialing rules are not selective and it is
extremely difficult to weed out poor quality physicians. In addition, there are no job
description requirements other than licensure. Thus, an incompetent anesthesiologist or a
retired neurosurgeon can be hired to see patients for diabetes and coronary heart disease,
conditions that they have never been trained to treat. This situation exists at all of the
facilities we reviewed to date and results in very poor medical management. In one chart
review, for example, at one of the CDC acute care hospitals a patient who was breathing
fast because of bilateral pneumonia was seen by a retired neurosurgeon who thought the
patient was having an anxiety attack and prescribed anti-anxiety medication and
medication for psychosis when instead he needed intravenous antibiotics and oxygen.
This was a potentially life threatening mistake that was remedied when the patient was
seen by a different physician the next day and admitted to a community hospital.
Credentialing is a process whereby the medical authority or committee of an organized
medical staff in a hospital reviews the training of a physician and approves that physician
to do certain things. These “things” are called privileges. As an example, physicians
may be privileged to do abdominal surgery, facial surgery, read an electrocardiogram,
treat a person with rheumatoid arthritis or diabetes or pulmonary function testing, etc. In
a typical HMO, credentialing is typically performed by a single physician, usually a
Medical Director who has experience and training in evaluating physician quality. In
addition, there are training requirements in order to be on staff. As example, one can’t do
surgery unless one has trained in surgery or see medical patients unless one has training
in Internal Medicine or Family Practice. In the CDC the current policy on Credentialing
(Chapter 9) only requires that each “supervisor” ensures that each employee has the
correct credentials. This basically means only a license. There is no review of whether
the physician has training for the diagnostic and therapeutic endeavors the physician will
be engaged in. In addition, in practice, supervisory staff at facilities does not oversee
credentialing. Credentialing is managed by committees of physicians that are comprised
of all the physicians on staff. This type of arrangement is common in hospital settings.
However, typical rules in hospitals are that Board Certification in a specialty is required
to practice. Thus in a hospital one would never see an Anesthesiologist practicing
Internal Medicine. Yet in the CDC this can and does occur. CDC credentialing-bycommittee by staff physicians results in a review process in which physicians mostly
approve each other and credential each other. Under the current CDC circumstances, this
perpetuates poor physician quality. Physicians without training are approving physicians
for practice in which they are not trained. Self-supervision tends to result in inadequate
oversight over physician quality and in groups of inadequate physicians approving each
other and maintaining a system of poor physician quality. For new hires CDC Central
Office has inserted authority to review all hires, however, re-credentialing of physicians
is performed locally.

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Review of credentials at several facilities revealed that at one facility a physician trained
in Obstetrics manages the HIV patients, and a neurosurgeon sees patients for Internal
Medicine problems in the ER and in the hospital even though he is not trained, for
example, in reading electrocardiograms, a basic function of emergency medicine and
internal medicine. None of the physicians managing CTC inpatient units at facilities we
reviewed so far had both Board Certification in a primary care field and experience
managing medical patients in an acute care setting outside of training. More importantly,
at one of the facilities we reviewed, 50% of the 8 physicians had either a prior criminal
charge, loss of privileges at community hospitals or had questions of mental health
problems. The CDC had tried to fire one of these physicians but he was re-instated by
the personnel board. At another facility, of the 20 credentialed physicians, 7 have
problems, including mental health disorders, prior alcoholism, or loss of privileges or
license because of substance abuse or incompetence or both. Typically, when a problem
physician is hired by an HMO or other managed care organization, there are monitoring
programs to monitor these types of physicians but such a program does not exist in the
CDC. My understanding is that Dr. Kanan has been the first Medical Director to attempt
to bring increased control over the credentialing process, but she has had a difficult time
with personnel board rulings, the labor union, and a legacy of bad physician hiring
practices and institutional inertia.
In regards to problem physicians, the current CDC credentialing policy does not require a
review, with documentation of an interview with the employee for issues related to
adverse actions. More importantly, physicians are re-credentialed every two years. At
these two year re-credentialing exercises, the re-credentialing is done by a committee of
staff physicians. Thus, for re-application, adverse actions are entered into the reapplication packet and reviewed by the peers of the physician re-applicant, many of
whom have the same sort of problems. At one of the facilities reviewed, the Vice
Chairman of the committee that oversees credentialing is an Obstetrician who had lost his
license for 7 years for incompetence and alcoholism. He is overseeing, in part, the
review of physicians practicing Internal Medicine and Surgery in the hospital. He has no
experience in Internal Medicine yet is deciding which physicians should be recredentialed and what they should be allowed to do. In effect, there is inadequate review
of problem physicians.
Peer review is a periodic review of physician work and review of possible problem cases
to assess the quality of physician work in their field of practice. In fact, at all of the sites
reviewed, there was no meaningful peer review of any sort of physician quality. The one
facility that had a Chief Physician and Surgeon not only did not have peer review, but the
Chief Physician and Surgeon gave unqualified positive recommendations on the recredentialing form (on the matter of quality) to physicians who Experts feel are not
competent. This is compounded by lack of physician leadership. The Chief Physician
and Surgeon position is a leadership position of physicians who are practicing primary
care internal medicine. At the facilities we reviewed prior to this report, only one Chief
Physician and Surgeon position was filled, and this position was filled by a retired
ophthalmologist (a doctor who specialized in ocular disorders). That person was
supervising and supposed to train the other doctors in the field of Internal Medicine, an

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area in which he had no training or experience. At the other facilities where there is no
Chief Physician and Surgeon, physicians monitor themselves. Chief Physician and
Surgeon positions are not desirable because a staff physician typically makes more
money than a Chief Physician and has fewer headaches. Thus, when mistakes are made
by staff physicians there is no supervisory physician with experience who can correct or
amend mistakes. Therefore, untrained physicians who make mistakes will continue to
make them because there is no one to identify and correct their mistakes. Experts
recommend that a peer review policy be developed. Peer review, under current
circumstances, should be performed by a physician trained in primary care internal
medicine who has supervisory authority either at the facility or in Central Office. Peer
review should be structured and geared toward primary care medicine and should also
include problem cases that typically could have been prevented by appropriate primary
care management. Such sentinel event cases are exemplified by the Agency for Health
Care Research and Quality (AHRQ) Preventive Quality Indicators. Such review should
be included in QMAT scoring. Peer review should become part of the physician’s file
and repeated adverse scoring should be grounds for increased supervision or discipline
including termination.
Regarding new appointments, Central Office is to be notified by facilities for any
physician applicant if there is a National Practitioner Data Bank report or if there is a
status report on their license. However, by policy, individual facilities may still approve
that physician with the approval of the Deputy Director of Central Office. Because the
Deputy Director is a lay person, Experts deem this policy flawed. The final authority on
hiring and firing physicians should be a physician. As well, there are other matters that
must be considered in hiring and retaining physicians including moral conduct, past
criminal behavior, misconduct with patients, and incompetence. Current policy and job
descriptions for the personnel board are inadequate in this regard. There does not appear
to be effective and practical review and action on impaired or incompetent physicians or
physicians with moral or other personal conduct problems. Finally, because of Title 22,
CTC Bylaws proscribe credentialing. It may be that CDC is of the opinion that Bylaws
can not be modified. Experts are not certain that bylaws of CTCs can not be modified to
include a managed care type credentialing process. In any case, Experts believe that the
job performance requirements for hiring should be modified so that physicians have
training in the area in which they are practicing. This is especially important because the
CDC has a collective bargaining agreement with the physicians union and disciplining
poor quality physicians is harder than it is in other health care sectors. Ideally, CDC
could have separate credentialing for CDC physicians outside the scope of CTC rules and
regulations. CTC credentialing could remain as is, but staff credentialing requirements of
the CDC, above and beyond CTC requirements would include a more thorough Central
Office review. This should be done by management in a fair and equitable manner.
Experts also recommend that physicians covering CTC units have Board Certification or
Eligibility in a primary care medicine field (Internal Medicine or Family Practice)
preferably with experience in managing hospital patients. In a separate vein credentialing
should include a requirement that DEA licensure be required of all CDC physicians.

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Current CDC practice is to treat all physicians equally and make assignments based on
concerns other than training, experience and ability. This is bad practice. For example,
at one facility, the physician in charge of the CTC is a retired surgeon. He is treating
patients with complex internal medicine problems and does not do a good job. The
CMO, who is trained in internal medicine, writes all of the discharge notes because the
surgeon is not competent to do so. However the CMO does not see the patients and this
practice results in bad management and causes patient harm. At another facility, a
neurosurgeon saw a seriously ill patient with internal medicine problems that resulted in
life-threatening problems. At a third facility, an incompetent retired cardiothoracic
surgeon manages complex internal medicine patients and makes serious life-threatening
mistakes on a continual basis. QMAT training for these physicians is very difficult
because they have no knowledge base or training upon which to improve. The check-box
format of answering questions makes it easy to cover up bad care and may give an
impression of knowledgeable care where none exists. As an example, a poorly trained
physician at one of the facilities who did not know how steroid inhaler medication was to
be prescribed or used by the patient was checking the box that he educated the patient in
how to use the medication. This same incompetent physician is managing most of the
sickest patients at that facility. QMAT has a physician trainer who is a pathologist. He is
a good person. However, he has no training in internal medicine. Can he be expected to
train some of the physicians described above in proper diagnostic and therapeutic
decision making? Experts therefore, under the existing circumstances, recommend that
physicians be assigned based on abilities. Physicians should be graded by skills, training
and ability. Those with the greatest ability in the area of their expertise, and best training
and skills should see the sickest patients. The sickest patients should be determined by an
acuity ranking that is devised mutually by Experts and CDC hierarchy.
Finally, the Central Office has inherited a legacy of autonomous functioning by
individual CDC facilities who independently manage their physician staff. Greater
authority should be vested in the Central Office to manage physician practice and
credentialing. This will permit for standardization of policies on credentialing, peer
review, discipline procedures, job descriptions and assignments that do not now seem to
be in place.
Summary of Recommendations
1. Establish a peer review process that is performed by a supervisory physician
trained in Internal Medicine
2. Use Agency for Health Care Research and Quality (AHRQ) Prevention Quality
Indicators as a sentinel event monitoring system to track care. Reviews of these
sentinel events should be performed by supervisory physicians trained in Internal
Medicine.
3. The Central Office Medical Director or equivalent should have final approval on
all physician credentialing and hiring.
4. Modify the job description of physicians to improve physician selection.
5. Correctional Treatment Center (CTC) physicians should be required to have
Board Eligibility in either Internal Medicine or Family Practice.

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6. Require DEA licensure of all physicians except CMO or those doing only
administrative work.
7. Assign physicians by ability and training.
8. Reinforce the supervisory authority of the Central Office Medical Director or lead
physician.

Sincerely for the Experts,

Michael Puisis, D. O.
Joe Goldenson, M.D.
Madie LaMarre CNP

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