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.
This does not occur in any meaningful way in the outside world. Back in my Emergency Medicine days, my ER patients did not call up other ER patients when they got home to discuss their experience. General Medicine clinics are the same. The patients in, say, a family practice office, do not communicate with each other outside of the practice. With few exceptions, most do not even know each other.
This strange phenomenon of patients in a medical practice communicating with each other about their experiences is unique to corrections. And it creates a unique dynamic that is critically important to understand if one is going to succeed in correctional medicine.
Inmates Know When You Are Not Being Fair
The principle that “Every Clinical Encounter is Discussed Back In the Dorm” is very closely connected to the “Principle of Fairness.”
In outside medicine, practitioners routinely favor some patients over others. Here are some examples: patient A and patient B call at the same time for an appointment for the same complaint. Patient A is told that the next available appointment is in ten days. Patient B, who is a personal friend of the practitioner, is told “Come tomorrow morning and we’ll work you in.” In another example, two practitioners work in the same office. Doctor X always gives a splint and a Norco prescription to patients with a sprained ankle. Nurse Practitioner Y, on the other hand, never does. If you have a sprained ankle, how you will be treated depends on which doctor you are assigned to. If you present with a sore throat, Doctor X always will give you a prescription for a Z-Pak. Nurse Practitioner Y rarely does; she is more likely to talk to you about viruses.
This can work in outside medicine because these patients never talk to each other. But such discrepancies in practice and behavior do not work in Correctional Medicine because “Every Clinical Encounter is Discussed Back in the Dorm.” Patient A and Patient B will talk to each other. The ankle sprain patients will compare notes. The patient with a sore throat will wonder “Why didn’t I get an antibiotic?”
Correctional practitioners need to keep this principle in mind. Here, for example, is a common scenario from the correctional world. Let’s say an inmate comes to medical clinic and says to a new practitioner: “I have low back pain and I’m not comfortable on these thin mattresses. I want you to authorize a double mattress.” If the practitioner writes the order for the double mattress, this will be discussed back in the dorm (because every clinical encounter is discussed in the dorms)! Within days, that practitioner is going to see many more medical requests for double mattresses from other inmates, who will say: “I have back pain too! I also want a double mattress.” And via the Principle of Fairness, if you give one patient a double mattress based on a complaint of back pain, you are obligated to give every inmate with the same complaint a double mattress if they ask for it. Otherwise, you are treating the first inmate as “special.”
Because of their unique situation, inmates can be quite sensitive to issues of perceived unfairness and special treatment. Anytime a medical practitioner does something for one inmate that they do not do for others, the perception of unfairness manifests itself as complaints, grievances and even lawsuits.
Inmates Discuss Your Professional Demeanor
Every aspect of a professional encounter is fair game to be discussed back in the dorms. If you dress well, like a medical professional, this will be noted and discussed. Other inmates will come to medical confident that they are seeing a true professional.
Alternatively, if you do not look the part of a medical professional (think stained jeans, sandals, poor hygiene), this also will be noticed and discussed. Your patients will arrive with a poor impression already planted in their minds.
Also, inmates know the security rules of the institution very well. If you violate security rules, this will be discussed back in the pods. If you do a special “favor” for an inmate, such as allowing a phone call or giving a gift (example: a piece of candy), every other inmate will learn about this and discuss the implications in detail. Other inmates will invariably ask you to do favors for them, as well.
There are no secrets in a jail or prison! Every encounter with medical personnel is discussed back in the dorms. Correctional practitioners should think about this with every clinical encounter:
“What I do here is going to be discussed back in the dorms. What do I want that discussion to be about?”