Category Archives: Guideline

Correctional Medicine is Different: We Can’t Fire Our Patients—and They Can’t Fire Us!

This post is the third in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous two differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms.

There is a controversy in pediatrics that I have been following recently. Some pediatricians have been dismissing children from their practice if their parents will not allow them to be vaccinated. This practice has been criticized as punishing innocent children for the actions of their parents but the pediatricians defend it by saying they are just trying to protect their other patients from being exposed to pertussis, measles and other transmittable diseases in the waiting room.

unknown-1This story illustrates an extreme example of something that we all know: that the practice of “firing” patients is commonplace in outside medicine. Many of my jail patients have been dismissed from medical practices, some more than once! Patients can be fired for variety of offenses. Some violate the contracts of their pain clinics. Some are dismissed for simply not following the doctor’s advice—like to get their children vaccinated. Many are no longer welcome when they cannot pay their bills or have lost insurance coverage. (One orthopedist that I know routinely sends a dismissal letter to his patients on their 65th birthday since he refuses to participate in Medicare). Finally, patients can be fired for just being too difficult to deal with. One jail patient in particular I remember screamed drunkenly at his doctor’s secretary to the point that she called the police. He received his official dismissal letter while he was in jail.

Well! Things are different in Correctional Medicine! We can’t fire our patients. Our patients remain our patients no matter what. It doesn’t matter if they violate the terms of a pain contract by, say, diverting medications. It doesn’t matter if they refuse to follow our advice. It doesn’t matter if they are difficult to deal with. Continue reading

Reader Question: How Should We Handle Inmate Requests for their Medical Records?

Dr. Keller, We have recently had inmates requesting copies of their medical records. We have not been releasing those records but we now have a new jail commander that feels we should release those records. Also, what about after an inmate has been released and then requests the information? We’re not sure what to do on this and would appreciate any input you might have. Kathleen

That is a good question, Kathleen! I also frequently have inmates in my jails who request (or demand) copies of all of their medical records. Prisons typically do not have this problem because every state prison system (that I am aware of) already has a detailed policy and procedure on how to deal with inmate requests for medical records. Medical personnel are often not even involved in the procedure. But many jails, like yours, do not have a policy and are commonly confused about their obligations when inmates want copies of medical records.

Does HIPAA give inmates have a legal right to their medical records? What if there is sensitive information in the medical records? What about mental health records? Does it matter if the inmate wants to sue me? Some medical files are huge. Do I have to copy everything? If we have obtained medical records from an outside clinic, do I have to give the inmate those records, as well? How long do I have to respond to their request? Can I charge the inmate for my time and effort? What if the inmate has been released and then requests copies of her medical records?

I have had all of these issues come up in my jails. This is such a frequent occurrence, and is so emotionally charged, that every jail should have a written policy on what to do when an inmate requests copies of his medical records. Believe it or not, it turns out that HIPAA has a section specifically dealing with medical records in corrections. And so, Kathleen, today’s JailMedicine post will review the HIPAA guidelines for corrections, answer all of your questions and make suggestions to help you write a medical record policy for your facility.medicalrecord Continue reading

Game Changer! The New ACA/AHA Cholesterol Guidelines

About a year ago, the American Heart Association released new cholesterol management guidelines. These guidelines changed how we practitioners should deal with cholesterol evaluation and management almost to a revolutionary degree. They are a BIG departure from past thinking. For example, under the old system, we practitioners were supposed to follow cholesterol labs. We were supposed to get LDL levels down below 100. Not anymore! In fact, under the new guidelines, once you have started someone on therapy, you really don’t have to check their cholesterol ever again! Really!

Also, the new guidelines say that there is basically only one therapy for almost all lipid patients: statins. According to the new guidelines, we should get rid of all other lipid therapies. Niacin? Throw it away. Gemfibrozil and fish oil? Get rid of them.

What about triglycerides? The new guidelines say that you should only treat hypertriglyceridemia with medications when the triglyceride level is greater than 1000mg/d. Holy cow, 1000! Where did that come from?

This document is almost revolutionary in its sweeping changes. It makes treating hyperlipidemia so very much easier. In my opinion, all correctional practitioners and nurses involved in chronic care clinics should know the new guidelines. If you have not already done so, you need to re-write your lipid protocol.cholesterol Continue reading