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: Read more... 2 comments
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: Read more... 16 comments
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: Read more... 2 comments
Consider two people standing outside of a grocery store. Person one is told: “Here is $200.00 for groceries for one month. You may buy any food you wish—but you may not spend more than this $200.00. So, make your purchases wisely. We are going to watch carefully to make sure that you do not exceed $200.00.” The second person is told: “There is no limit on how much you spend on groceries in the next month. You may spend as much as you wish! And you may come back as often as you like. There are no limits. In fact, no one is even going to pay attention to what you buy!” Which person do you think is more likely to walk out of the store with the most expensive cut of steak? Which person is more likely to pay attention to prices and sales? Which one do you think is more likely to buy food that they will never eat? This scenario is very like the difference in health care spending within your average state prison system and the medical community at large.Posted in: Medical EconomicsMedical PracticePractice ManagementUncategorizedTagged in: Read more... 5 comments
My good friend Al Cichon writes:Posted in: Inmate issuesLegal mattersMedical PracticeUncategorizedTagged in: Read more... 7 comments
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 allThank 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.