Category Archives: Inmate issues

Grievance Responses PLUS Sample Grievance Guideline

Benjamin Franklin once famously quipped “nothing is certain but death and taxes.” However, Franklin did not work in a jail, otherwise he would have said: “Nothing is certain except death, taxes and grievances.”

On the outside, patients do not write grievances—they vote with their feet. If they dislike the medical care they are receiving, they will just go to a different doctor. In a jail, they cannot do this. We have a grievance system in Correctional Medicine because our patients cannot fire us (and we cannot fire them–discussed previously here). If jail patients are unhappy with their medical care, their only recourse is to write a grievance.

Grievances are not necessarily bad things. A medical grievance is sometimes the way by which jail patients alert us to significant problems that we may have not known about or mistakes that we made. I myself have had my butt saved in this manner—more than once! Many grievances are simply about communication errors. We have not yet adequately explained a medical decision to the patient.

Yet jail medical personnel often have a bad attitude about grievances. This is unfortunate, because medical grievances are an important—even essential—part of the jail medical system. I believe that the most important reason for the bad attitude is that people have not been taught how to write a proper grievance response. That, then is the topic of today’s JailMedicine post. Continue reading

Sample Guideline: Bottom Bunk Requests

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policies. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Occasionally, inmates who have been assigned the top bunk of a bunk bed state that they have a medical condition that requires them to be given the bottom bunk instead. Since medical providers must be fair and consistent, it is important to differentiate medical need for a low bunk from requests made for non-medical reasons such as a desire for convenience or as a sign of increased status.

Medical need. Medical need for a low bunk generally falls into one of two categories: Patients who are unable to safely climb onto the top bunk because of physical limitations and patients who have a medical condition that might lead them to fall off of the top bunk and injure themselves.

Patients who are unable to safely climb onto the top bunk because of physical limitations include:

  • Obesity (BMI >30)
  • Advanced age and/or infirmity
  • Late term pregnancy.
  • Permanent physical disabilities, such as amputations, paralysis, or previous strokes.
  • Temporary physical disabilities such as a broken bone or recent surgery.

Patients who have a medical condition that might lead them to fall off of the top bunk include:

  • Seizure disorders which are current and ongoing.
  • Conditions causing vertigo or dizziness, such as Meniere’s disease.
  • Conditions which impair coordination such as cerebral palsy.

Chronic pain syndromes independent of other conditions such as those listed above generally do not constitute a medical need for a bottom bunk assignment.

Patients who have been successfully using a top bunk generally do not have a medical need for a bottom bunk reassignment unless their medical condition has acutely changed, such as with a traumatic injury. Example. A patient has been using a top bunk for three weeks. Now he comes to medical stating that there are several bottom bunks available in his pod. He would like medical to approve a bunk reassignment for him because of an old leg injury. The fact that he has been using a top bunk for three weeks indicates that this patient does not have a legitimate medical need for a bottom bunk.

Nursing Personnel may address routine patient requests for low bed assignments based on this guideline. If nursing personnel are unsure or have questions, they may refer the patient to a medical practitioner.

Documentation. Security personnel assign bunks, not medical personnel. Medical personnel are being asked if a patient has a medical need for a low bunk assignment. Therefore, medical personnel should document the answer to this question only.

Incorrect: “Bottom bunk request is not approved.” Correct: “This patient does not have a medical need for a bottom bunk assignment.”
Incorrect: “Bottom bunk is approved for medical reasons.” (Security staff may elect to place the patient on a single bed, a cot, or a floor “boat” instead of a bottom bunk.)
Correct: “This patient should not be assigned a top bunk for medical reasons.”

If a patient does have a legitimate medical need for a low bunk assignment, consideration should also be paid to the patient’s other housing needs. For example, a low bunk may not actually meet the patient’s needs; the patient may need a hospital bed. Patients who have a medical need for a low bunk assignment may need to be restricted to a bottom tier so that they will not have to climb stairs. Patients who are inmate workers may need work restrictions. If the medical need for a low bunk assignment is temporary (such as a broken arm), the bottom bunk memo should have a time limit.

Sample guidelines can be found under the “Guidelines” tab (above) as they are published. I view these sample guidelines as a group effort! If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments!

The First Principles of Verbal Jiu-Jitsu

You are seeing a newly booked patient in your jail medical clinic. He states he has been in jails before, many times, and is always given a second mattress and an extra pillow because he had surgery on his back many years ago. You note that the patient has not seen a doctor on the outside for many years, that the patient walks and moves normally and that he has a normal neurological examination. You tell the patient that medical does not give out passes for extra mattresses or pillows. The patient angrily erupts in a blaze of obscenities and threatens a lawsuit.

Manipulation happens when a patient wants something that they should not have (like an extra mattress and pillow) and will not accept “NO” for an answer. In my last JailMedicine post, I outlined the strategies patients employ in an attempt to entice or force practitioners to change a No to a Yes. This patient is employing the “threatening” strategy.

Verbal Jiu-Jitsu is the technique of deflecting and defusing manipulative confrontations. Notice that I did not use the word “defeating.” That is because the first and most important rule of Verbal Jiu-Jitsu is to remember that this is not a war or a contest! There should be no “battle of wills” between you and your patient. There is no winner or loser. Instead, you and your patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to avoid any kind of verbal battle. Continue reading

Manipulation Defined

One of the more common complaints that I hear from correctional practitioners (especially new practitioners) is “Manipulative patients are driving me crazy!” To be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. ERs are the epicenter of narcotic drug seeking! But it is true that many of our patients in Corrections are especially skilled in manipulation. They have practiced this skill their whole lives and have become very proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.

Manipulation in a medical encounter occurs when a patient wants something he shouldn’t have and won’t take “No” for an answer. If the patient wants something he should have-no problem! Or If the patient is told “No” and accepts that answer–also no problem!

So manipulation involves these two essential elements:

1. The patient wants something she should not have. This something could be an extra mattress, a special diet, gabapentin, an MRI, a referral off site–anything.

2. The patient does not accept “No” for the answer.

What comes after not accepting “No” for an answer is manipulation. Manipulation is the attempt to coerce the practitioner into changing a “No” into a “Yes.” Manipulation comes in many forms. Continue reading

Is this a Medical Refusal–or Manipulation?

My good friend Al Cichon writes:

Dr. Keller – would you consider a discussion of balancing the autonomy of patient decision-making and the risk to the facility for not providing appropriate care.
Examples
1. Individual is on disability but wants to sign a ‘waiver’ of responsibility so he/she can work
2. Diabetic (NIDDM) individual that wants to refuse diet and be placed on insulin so he/she can eat what ever they wish
3. Individual with a comminuted jaw fracture – cut wires on episode of nausea – now wants regular food despite oral surgeon advising limited jaw movement
Documentation of appropriate exam and advice to the individual is, of course, the foundation of addressing the issue – but do you allow the 100% (physically) disabled person work; allow the diabetic to sign a refusal of the diet & prescribe insulin; give the individual with the broken jaw (who is asking for more hydrocodone) a regular diet?
I believe your expert ability to address these thorny issues will help us all

Thank you for the kind words, Al! The issue you highlight is indeed a thorny one—when a patient wants to refuse strongly recommended medical care. Sometimes these are true refusals, meaning the patient understands the medical intervention being offered and truly does not want it. More often, though, such refusals are a form of manipulation to get something else that the patient wants. I would like to address these two scenarios first and first and then discuss your three specific examples. Continue reading

Inmates cannot go out to find good doctors in the community. Good doctors have to choose to go to them!

I remember the first time someone told me that I was “wasting my talents” by working in a jail. At that time, I had no ready witty rebuttal. I love my job and I especially appreciate working with a patient population that is disadvantaged and underserved. Of course, the idea that incarcerated inmates are worthy recipients of medical care is, well–controversial. Inmates are not as politically correct as other medically disadvantaged populations.

As an example, if you were to tell your family and friends that you were going to work with at a medical clinic for the homeless in an inner city, or to provide medical care in a needy third world country, the reaction probably would be something along the lines of “Good for you! I admire your selflessness and dedication!” Yet when you tell these same people instead that you are going to work in a prison, you are much more likely to get this reaction: “What’re ya, nuts? Why would you waste your talents working with them?” I personally have heard the “you’re wasting your talents” line more than once. Continue reading

Medications at High Risk for Diversion and Abuse In Correctional Facilities

The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.

Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk.

However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.

The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.

It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution–if we make them available. Continue reading

Correctional Medicine Is Different: Our Patients Don’t Go Home!

This post is the final in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons.  The previous three differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms and We Can’t Fire Our Patients and They Can’t Fire Us!

The final major difference between correctional medicine and medicine in the outside world is this: Our patients do not go home. We have a captive audience. Literally! Believe it or not, this is a very important medical point.

Back in my previous life as an ER doc, if I asked a patient to come back tomorrow to be rechecked, I knew that few of them would. It was just too much hassle. They had to find a ride back to the ER (especially hard for the homeless or those without cars), they had to endure another prolonged wait in the ER waiting room. And they would be charged big bucks for another ER visit! No wonder so few of my scheduled follow-ups actually returned!

Once I began to practice in a jail clinic, I soon realized that the situation is much different. The patient I see in clinic today will not go home. She will go to her housing dorm down the hall. I know exactly where she will be tomorrow–or in a week. If I want to see her again tomorrow, I can. In fact, I can reliably see her in follow up anytime I want to.

One might think, “So what? What difference can it possibly make on the practice of medicine that our patients do not go home?” The answer is that this fact does indeed have several important consequences for the practice of clinical medicine. I can think of at least four.unknown-1 Continue reading

Correctional Medicine is Different: All Clinical Encounters are Discussed in the Dorm

On my last post, I began a series discussing how Correctional Medicine is different from medicine in the “outside world.”  The first (and arguably the most important difference) is that medicine inside corrections has to be fair, whereas the bigger world of US medicine is not fair.

The second big difference between Correctional Medicine and outside medicine is this:  Every clinical encounter in correctional medicine is discussed back in the housing dorm.  This does not occur in outside medicine and is critically important to understanding doctor-patient relationships in corrections.

For those not familiar with the housing situation in jails and prisons, most inmates are housed in large housing dorms or pods.  Depending on the size of the institution, these can house anywhere from 10 inmates to over a hundred.  As you might expect from this situation, inmates spend a lot of time talking with each other, especially since they generally have more free time than your average person in the outside world.  Inmates spend a lot of time talking to one another.

So when an inmate returns to the dorm from a visit to the medical clinic, it is natural for the encounter to be discussed.  If the encounter was unusual or noteworthy in any way, this quickly becomes known throughout the pod.  And since different housing pods also communicate with each other, information about clinical encounters quickly spreads throughout the entire institution.Dorm 1 Continue reading

Correctional Medicine: The Principle of Fairness

I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.

But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!

This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Unknown-1 Continue reading