When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.
One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”
Medical clearances are a hugely important and often neglected part of the jail medical process.
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.”
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.
I will be meeting a new jail patient with multiple medical
problems today in my clinic. I know this
much before I even meet him: He will
almost certainly be scared, especially if this is the first time he has ever
been to jail. He will likely be
suspicious of me. He may even be downright hostile. I know this because this is
the norm for correctional medicine. I can’t be an effective doctor unless I can
turn this attitude around.
Consider the situation from my patient’s perspective. Prior to seeing me, he was arrested,
handcuffed and driven to jail in a police car.
Once at the jail, he was thoroughly searched (spread-eagle against the
wall), fingerprinted and had his “mug shot” taken. His clothes were taken away and he was given
old jail clothes (including used underwear).
He was placed in a concrete cell.
Now he is summoned by a correctional deputy and told (not asked) to go
to the medical clinic.
He did not choose me to be his doctor. Though he doesn’t know anything about me, he
has no choice but to see me for his medical care. Not only did he did not
choose me; he cannot fire me or see anyone else. He may fear that I am not a competent doctor;
otherwise why would I be practicing in a jail?
This is the attitude that I have to overcome. How to do this is an essential skill for
correctional practitioners. And, of course, the single most important encounter
is the first one. A negative first impression is hard to overcome–and I am already
starting out at a disadvantage. What I
have to do in only a few minutes is convince my patient that I am a legitimate
medical doctor and that I care about him. I have learned in many years of doing
this that these things are essential:
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.
I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . . Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR
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.
My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different jails.
I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised? If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them? Any ideas would be greatly appreciated!
After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them “pinched” from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as “sleepers” on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily?
If you have any ideas I would greatly appreciate it.
Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. “In-possession” medications are referred to as “KOP,” which stands for “Keep on Person.” I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications: