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.”
I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain.
Take, for example, a correctional physician that we will call Dr. K who is employed full time a a large urban jail and has had a DEA license for that jail for many years. On the side, she also provides medical services to three other smaller jails, where she does clinics once a week. The question is whether her one DEA license covers her activities at the other jails. Dr. K has always thought that she only needs one DEA license—just like she only needs one Driver’s License—and it will cover all of her activities.
But the real answer is, “No,” Dr. K is not in compliance with DEA regulations.
Today’s post is a repost of an article I wrote previously about Constipation. Concurrent with this article, I have added a Sample Guideline on Constipation to the Guideline Section of JailMedicine (found here).
I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject. We all received “The Talk” (about sex and reproductive health) when we were adolescents. But nobody seems to talk about how to have a proper bowel movement. It is a subject that inevitably causes giggling and uncomfortable laughter. It is not spoken of in polite society. As a result, many people do not understand how their bowels work. I have found this to be a big problem in the jails I work in. Inmates complain of constipation when they are not really constipated. They are bowel-fixated when there is no reason for them to be. Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier.
Today’s post is a repost of an article I wrote previously about Skeletal Muscle Relaxants (SMRs). Concurrent with this article, I have added a Sample Guideline on prescribing Skeletal Muscle Relaxants to the Guideline Section of JailMedicine.
Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”
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.