Recent Entries

NSAIDs Essentials of Prescribing for Inflammation

2018-07-11 18:05:45 jeffk2996
In the last JailMedicine post, I discussed the use of NSAIDS for pain. Pain management is probably accounts for 90+% of NSAID prescriptions in primary care. Oftentimes, though, we delude ourselves into thinking that we are also treating inflammation. Usually we are not and that is the subject of today’s post. To show why, we have to delve into the NSAID inflammatory effect. How NSAIDS act to affect the inflammatory response is well known (unlike their pain effect, which is still a mystery). All practitioners should know the basics of how NSAIDS work. This is essential knowledge for rational prescribing.
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NSAIDs. The Essentials of Prescribing for Pain

2018-06-04 11:36:42 jeffk2996
After many years of reviewing prescribing practices of physicians both within correctional systems and outside of the walls, here is something that I strongly believe: Non-Steroidal Anti-inflammatory Drugs (NSAIDS) just may be THE most misunderstood and overprescribed drugs in clinical medicine. It appears to me that, in general, we practitioners overestimate the benefit NSAIDS give. We underestimate the risks NSAIDS carry. And we prescribe NSAIDS in ways that are not evidence based and not in our patients’ best interest.
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The First Principles of Verbal Jiu-Jitsu

2018-04-24 10:00:49 jeffk2996
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.
Posted in: Inmate issuesJail cultureLanguageMedical PracticeUncategorizedTagged in: argumentAverage Wholesale Pricecorrectional medicineevidence based medicineinmatesjail medicinejailsprisonsVerbal Jiu Jitsu Read more... 3 comments

Manipulation Defined

2018-03-17 10:28:23 jeffk2996
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.
Posted in: Inmate issuesJail cultureMedical PracticeUncategorizedTagged in: correctional medicineevidence based medicineinmatesjail medicinejailsmanipulationprisons Read more... 17 comments

Bad Medicine is Expensive!

2018-02-25 20:10:45 jeffk2996
In the last JailMedicine post, I introduced the subject of Utilization Management (UM) in Corrections. To some, Utilization Management has earned the reputation of being too focused on money and not enough focused on patients. But after I had been doing UM for awhile, I had an important insight that changed the way I thought about Utilization Management and (I believe) made my own efforts at UM much more effective. That key insight is this: That which is expensive in medical practice is bad medicine. The way to control costs in medicine is to reduce or eliminate bad medical practice. Cost containment is simply a happy byproduct of this endeavor. When UM physician advisors work with primary care practitioners, the conversation should center around best medical practice, not money. It is this simple: Good medicine is cost effective. Bad medicine is expensive.
Posted in: Medical EconomicsMedical PracticeTagged in: Choosing Wiselycorrectional medicineevidence based medicinejail medicinejailsprisonsUMUtilization Management Read more... 2 comments

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