Words matter. What we write about our patients in our medical notes to a great degree reflects how we feel about them. Our words also mold our future relationship with our patients. One good example cited by Jayshil Patel, MD in a recent JAMA editorial (found here) is the common phrase “the patient was a poor historian.” There may be many reasons why a patient is not able to answer our questions well, such as dementia, delirium or psychosis. In fact, the inability to present a cogent narrative usually is an important symptom of an underlying condition. “Poor historian” does not reflect this fact. To the contrary, “poor historian” implies that the patient is at fault for my poor documentation, not me! “Poor historian” leaves out that there are other ways for me to get a medical history (medical records, talking to family, etc). “Poor historian” also implies that the patient was deliberately not cooperative—even though perhaps I spent maybe two minutes attempting to get a history.
Many other common medical phrases also subtly disparage patients. Two good examples are the words “denies” and “admits” as in: “The patient denies drinking” or “the patient admits to IV heroin use.” The implication of these words is that we are engaged in something akin to a hostile cross examination where I forced the patient to “admit” (against their will) to drinking and I really don’t believe the patient who “denies drug use.” Words guide how we think about our patients, even if on a subconscious basis. When I use these words, I am saying that my patient and I are not on the same team.
In corrections, perhaps the single best example of a word that negatively influences our relationship with our patients is “inmate.”
I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain.
Take, for example, a correctional
physician that we will call Dr. K who is employed full time a a large urban
jail and has had a DEA license for that jail for many years. On the side, she also provides medical
services to three other smaller jails, where she does clinics once a week. The
question is whether her one DEA license covers her activities at the other
jails. Dr. K has always thought that she
only needs one DEA license—just like she only needs one Driver’s License—and it
will cover all of her activities.
But the real answer is, “No,” Dr. K is
not in compliance with DEA regulations.
Today’s post is a repost of an article I wrote previously about Constipation. Concurrent with this article, I have added a Sample Guideline on Constipation to the Guideline Section of JailMedicine (found here).
I have decided after many years of
dealing with complaints of constipation both in the ER and in correctional
facilities that bowel health is the last taboo subject. We all received
“The Talk” (about sex and reproductive health) when we were adolescents.
But nobody seems to talk about how to have a proper bowel movement. It is
a subject that inevitably causes giggling and uncomfortable laughter. It
is not spoken of in polite society. As a result, many people do not
understand how their bowels work. I have found this to be a big problem
in the jails I work in. Inmates complain of constipation when they are
not really constipated. They are bowel-fixated when there is no reason
for them to be. Often, they need education more than they need laxatives.
To this end, I want to discuss several essential factors relating to
understanding and treating constipation that may help make your correctional
medicine practice a little easier.
Today’s post is a repost of an article I wrote previously about Skeletal Muscle Relaxants (SMRs). Concurrent with this article, I have added a Sample Guideline on prescribing Skeletal Muscle Relaxants to the Guideline Section of JailMedicine.
Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”
The recent suicide of Jeffrey Epstein while in custody at a Manhattan
detention facility has focused intense media scrutiny into jail suicide
prevention procedures. Suicide is the biggest cause of death in jails in the
United States—by far. Because of this,
all jails (including the facility where Mr. Epstein was housed) have a suicide
prevention policy. Since the suicide prevention process was an
epic failure at the facility where Mr. Epstein was housed, it might be useful
to discuss how a jail suicide prevention program is supposed to work.
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.
Imagine, if you will, a nurse who is assigned to take care
of 50 patients on a medical floor—by herself. Clearly, this is an impossible
task. There are just too many patients
for one nurse to adequately monitor. But
this nurse gamely does her best. Now let’s
say that there is a bad outcome and an investigation. Even if the understaffing problem is
recognized, it would be easy—and tempting–to scapegoat the nurse, especially
if there was no intention of fixing the staffing problem (“We can’t afford to
hire more nurses!”) Instead, the
scapegoated nurse would be replaced by a new nurse, who, once again, would be
expected to care for 50 patients.
Such were my thoughts when I read this article about the
problems with the medical care for inmates in the Illinois prison system (found
The article says that there have been so many problems with medical care in the
Illinois prison system that a class action lawsuit has successfully forced Illinois
to make sweeping changes to the prison medical system. What is not mentioned in the article is that
similar lawsuits have happened before in other states and will happen
One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic. A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years. Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective. He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids. In addition, Ralph has alcohol abuse issues. The reason he is in jail is a felony DUI charge. Now he is in my medical clinic, looking expectantly at me. How am I going to fix his pain problem?
The answer, of course, is that I am not. I am not that smart. He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem. I’m not going to be able to, either. In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain.
One of my good friends is a die-hard Oakland Raiders fan. Those of you who follow pro football know that Oakland has fallen on hard times recently. They went from being one of the best teams in the league two years ago to one of the worst teams in 2018 with a dismal 4-12 record. As a result, my friend has had to suffer taunts from fans of better teams—like me! He has become despondent.
But it doesn’t have to be this way! The Raiders can quickly and easily turn their season around by using the tried-and-true techniques of medical research. If a pharmaceutical company did 16 clinical trials of their new potential blockbuster, Drug X, they would never let a 4-12 outcome get them down. When published, I guarantee those trial results would look a lot better than 4-12. The Oakland Raiders can use the same techniques to improve their own season record.
Consider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.
Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.
Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell.Continue reading →