Quick! Name a book that describes the experience of being a medical professional in a jail or prison! . . . Can’t do it, can you? There are lots of books that talk about the life of a lawyer or a doctor in general. There are books about prison inmates and even correctional officers. But, to my knowledge, no one has ever written a book describing the experience of working as a physician in a jail or prison. Maximum Insecurity: A Doctor in the Supermax fills that void. This is a wonderful book, written by Dr. William Wright, about his experiences providing medical care to inmates in the Colorado State Penitentiary maximum-security prison. And not only is this the first memoir I am aware of written about correctional medicine, Maximum Insecurity is also a gem–funny, informative and engrossing. Continue reading
Well, JailMedicine is now over six months old and has been more fun to write and much better received than I had imagined it would be. JailMedicine has had over 30,000 hits! Thank you especially to those of you who have written comments. I have my opinions on certain topics (as you have read) but I realize that smart and accomplished people sometimes disagree with me–and sometimes they are right and I am wrong! We all learn and become more effective clinicians when alternative views are expressed and debated–so please comment!
What can I do to make JailMedicine better? Continue reading
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Those of us who practice medicine in jails frequently (Frequently? Daily!) run into the thorny issue of our relationship to the doctors who care for our patients outside of the jail.
When patients are in our jails, we are responsible for them; they are our patients. But these patients also have doctors outside of the jail that perhaps they have been seeing for years. The inmate considers their outside physician to be their “real” doctor, not us. (Throughout this article, I am going to use the term “doctors” rather than the more generic “practitioners.” I do not mean to slight nurse practitioners or physician assistants. What I say applies to them, as well.)
What brought this topic to mind is a case that occurred in one of my jails recently. A patient came to jail with a prescription pad filled out by his outside physician authorizing him to have a double mattress, an extra blanket and an extra pillow. (There was no note requiring us to feed him pizza every Friday night—he must have forgotten to ask for that.) So I was left in a little dilemma. What should I do about this note? Ignore it? Allow the inmate to have the extra comfort items?
Dealing with inmates’ outside physicians can be tricky, but I have found (mostly through sad experience) that there is definitely a right way and a wrong way to handle these encounters. The right way involves recognizing three important points:
I have a quick ‘n easy solution for those pesky requests for a second mattress that plague all correctional facilities. But before I get to that, though, there are two important points to consider in any discussion about second mattresses in correctional facilities.
First, providing inmates with mattresses, like inmate clothes and toiletries, is the purview and duty of the correctional officers, not the medical staff. What this means is that when an inmate asks for a second mattress, the question being put to us is this: Is there a medical need for this patient to have a second mattress? This is critically important. The inmate would prefer to frame the question differently, something like this: “The correctional officers only issued me one mattress, but you can over-rule them and authorize me to have a second mattress. Will you do me this favor?” This is a totally different question than “Does this patient have a medical need for a second mattress.”
Secondly, having a second mattress is a status symbol inside the correctional community. When an inmate receives a benefit that other inmates do not, he gains status and prestige. Sometimes this motivation is as important for an experienced inmate as is the extra comfort of a second mattress. I believe that if a jail provided two mattresses to every inmate in the facility, there would be requests to medical for three mattresses. (Pretty soon inmate beds would rival “The Princess and the Pea!”) So when we grant inappropriate requests for second mattresses, we are conferring status on the inmate in question. And we are denying status to those who we refuse. This also, in my mind, is important to consider.
So now to the main topic of the day: What constitutes a “medical need” for a second mattress? In my opinion—there are none! Zero. Nada. There is no medical need ever for a second mattress. I challenge anyone to find a reference in any medical literature saying that second mattresses are a treatment for anything. For example, a common reason given by inmates requesting a second mattress is that they have chronic back pain. However, if you pull out any medical textbook that deals with the treatment of chronic back pain, you will not find second mattresses mentioned in any. Go ahead! Look!
When I was an undergraduate, before I switched to pre-med, I was an economics major. Maybe because of that training, when I look at jail medical practices, I tend to look at all of the costs of medical practice, not just the monetary costs. For example, the total cost of providing a medication to a patient in the jail includes the cost of the medication (of course), but it also includes the cost of the various people, like nurses, pharmacists, deputies and practitioners, who spend time creating the prescription. Thinking of costs in this way can change our perspective of what something “costs.”
Consider the case of the man with heartburn. We’ll call him “Jeffrey.” He doesn’t know it, but he is about to go to jail. Before Jeffrey goes to jail, if he wants to purchase something like ranitidine (Zantac) for his heartburn, he would go to a store and buy it. He doesn’t need to see a medical professional. He doesn’t need a prescription. In most places, he doesn’t even need to wait—convenience stores sell ranitidine 24/7. The monetary price Jeffrey will pay for 50 tablets of ranitidine at the store is around $7.00. The cost in terms of time is how long it takes him to run to the store. The total cost in time to the store to provide the ranitidine to Jeffrey is 30 seconds—how long it took the store clerk to ring up the sale.
Now think of the same guy in jail. Jeffrey still has heartburn. Let’s say he still has money—now in his commissary account. He is still willing to buy ranitidine. But ranitidine is not on the jail commissary list. He can buy Ramen noodles or a Snickers bar, but not ranitidine. In order to get ranitidine, he has to put in a “Request for Medical Care” form. What happens now varies from jail to jail and prison to prison. I am going to present a typical jail scenario.
The act of requesting non-emergent medical care costs Jeffrey $10.00. The form is then triaged by a nurse and Jeffrey is scheduled to see a practitioner. Since the clinics are crowded, the appointment is made for five days hence. In the meantime, he continues to have heartburn. On the scheduled day, he comes to the medical clinic. He waits, say, an hour in the waiting area. He then has vitals taken by a nurse. The practitioner, unsurprisingly, orders a prescription of ranitidine from the pharmacy for Jeffrey. The order is sent to the pharmacy and is delivered the next day. It is paid for from the jail medical budget.
- What beneficial effects do we want the drug to have on our patients?
- What harm might the drug cause? How can we maximize benefit while minimizing risk?
- How much does the drug cost? Can we get a better risk/benefit profile from a less expensive drug?
A great place to start using these tools to evaluate appropriate drug use is with the Non-Steroidal Anti-Inflammatory Drugs (NSAIDS). NSAIDS are commonly prescribed drugs, but, in general, we practitioners use them in inappropriate ways. We overestimate the benefit they give. We underestimate the risks they carry. We completely ignore their costs; preferring, it seems, to prescribe expensive NSAIDS which offer no benefits over the cheap stuff.
In this article, I want to summarize the evidence about NSAIDS and suggest a protocol for their use based on that evidence. I say summarize, because the body of research on NSAIDS is very large and I cannot include everything in this short paper. NSAIDS are a very well understood class of medications. Most of the information I include is not controversial. It can be found in most textbooks and review articles. I have included a couple of these at the end of the article.
Let’s start by going over the potential harm that NSAIDS can cause. Most people know that NSAIDS can cause GI complications like ulcers and GI bleeding. The question is—how big of a problem is this? It turns out to be a very big problem, indeed:
- An estimated 16,500 patients die from GI bleeding caused by NSAIDS each year. This is far more people than die of AIDS each year (13,500). In fact, the CDC ranks deaths due to NSAID induced GI bleeding as the 14th leading cause of death in this country.
- Over 100,000 people are hospitalized each year with GI complications caused by NSAID use. Total spending in theUSto treat NSAID complications is greater than 2 billion dollars annually.
- The iatrogenic cost factor of NSAID use is approximately 2. In other words, for every dollar spent on NSAIDS, approximately one more dollar is spent treating NSAID induced complications.
I suspect that almost every physician in theUnited Stateswould agree that antibiotics are over-prescribed. Unfortunately, since the total number of antibiotic prescriptions in theUnited Statesgiven to people with “cold” has been estimated at 44 million per year, it would seem that most physicians have not actually decreased their own prescribing habits. I can see how this would be the case. Physicians are stuck in the inertia of “I have always done it this way.” Also, “my patients expect an antibiotic when they come in and they won’t be happy if I don’t prescribe one.” Finally, “The antibiotic can’t hurt and it might help!” Multiply each incident of an unneeded prescription by, oh, a few million, and it adds up.
Of course, inappropriate antibiotic use can and does hurt. It hurts every patient who has an adverse effect from inappropriate antibiotic prescriptions, stuff like diarrhea, yeast infections, nausea or an allergic reaction. It hurts the community by breeding antibiotic resistant bugs. And it hurts because inappropriate antibiotic use is expensive! 40 billion dollars a year expensive! How much of that money is being wasted at your facility?
One of the neatest things that I have discovered about the evidence-based medicine movement is that using evidence-based principles almost always saves money. There is no better example of this than in the area of antibiotic use.
Three years ago, the Centers of Disease Control published evidence-based guidelines for the appropriate use of antibiotics for upper respiratory infections. The guidelines were developed by a panel of experts which included representatives from infectious disease, family practice, emergency medicine, internal medicine and from the CDC itself. The panel used evidence-based principles to review the huge amount of literature on these subjects. In the end, they came up with guidelines entitled “Principles of Appropriate Antibiotic Use for Acute Respiratory Tract Infections in Adults.” The finished guidelines can be found in the March 20, 2001edition of the Annals of Internal Medicine or online at www.cdc.gov/ncidod/dbmd/antibioticresisance/. The final report included pharyngitis (which I reviewed in the last issue of CorrectCare), acute bronchits, and rhinosinusitis.
I have practiced medicine for over 18 years and have gotten a lot of CMEs over that time. The lectures I have enjoyed the most have tended to be those exposing the myths of modern medical practice. You probably know the ones that I mean. These are the lectures comparing some common medical practice with the literature only to find that the practice doesn’t work—belief in its efficacy is a myth. In fact, just prior to its lamentable demise, The Western Journal of Medicine had a regular series devoted to debunking medical myths.
Myth-busting like this is part of the overall movement toward evidence-based medicine. In a nutshell, evidence-based medicine states we should compare all of the stuff we do as doctors with the scientific evidence of its effectiveness. When we do that, we will find there is a solid base in the evidence for only some of the things we do. Some of our practices have inadequate support in research—nobody really knows whether they are truly effective or not. And some of what we do is flat out contradicted by the evidence. Every year, important research emerges that should make us change the way we practice medicine. However, we too often do not change.
We all know doctors who seem frozen in time; practicing medicine the way it was taught to them in medical school and residency. We ask ourselves, “Why is he still doing THAT?” However, that doctor is most of us. If we critically compare many of our habits with the medical literature, we will invariably find that we ourselves have habits we should abandon.
In fact, failure to change practice based on new findings has been identified by many sources as a major problem with modern medicine. There is a gap, sometimes of many years, between what is known and what is practiced. Over the years, some information in medicine’s knowledge base is verified, and some is refuted. Whenever a new “fact” has been added to the overall medical knowledge base through good and repeated research, it usually takes many years until that knowledge is incorporated into most physicians’ practice.
Even a casual review of medical textbooks and the literature will demonstrate several well-demonstrated medical facts that are not widely practiced by US physicians. One area getting a lot of press is the overuse of antibiotics. We doctors still commonly prescribe antibiotics (and often very expensive antibiotics) for viral illnesses such as pharyngitis, bronchitis and sinusitis despite the enormous amount of literature condemning the practice.
We all have heard about the emergence of resistant bacteria as a consequence of our national over-prescription of antibiotics. We don’t so often hear of another downside to prescribing unneeded antibiotics—it is expensive. In fact, most evidence-based medicine principles are like that—if you adopt them, you will save money. What could be better than that? We provide better medical care to our patients, and save money to boot!
One great example is evidence-based treatment of pharyngitis, the infamous “sore throat.” It seems like this is one of the single most studied topics in medicine. There have been literally hundreds of articles published on this topic. Fortunately, the Centers for Disease Control (CDC) in Atlantahave published an excellent review article along with their recommendations that can serve as a basis for your jail’s “Sore Throat Protocol.” It was published in the March 20, 2001edition of the Annals of Internal Medicine, along with similar guidelines for the treatment of sinusitis and bronchitis. It can also be found online at www.cdc.gov/ncidod/dbmd/antibioticresistance/.
In their article, the CDC makes the point that only around 10% of cases of sore throat are caused by Group A Beta Hemolytic Streptococcus (the so-called “strep throat”). Almost all of the remaining 90% of cases are viral in origin. Despite this, 75% of adults who present to a doctor with a sore throat will be prescribed antibiotics! What is the rate of antibiotic prescriptions for sore throat at your facility? It would be well worth the effort to pull the last 100 charts where the chief complaint was “sore throat,” and see how many of these patients received antibiotics.
The CDC recommends instead that antibiotics be limited to those patients who are most likely to have strep throat based on four easily evaluated clinical findings:
(1) tonsillar exudates; (2) tender anterior cervical lymph nodes; (3) fever; and (4) absence of cough.
You then use these four criteria to determine who gets antibiotics in one of the following ways:
1. If the patient has 0, 1, or 2 of the criteria, no antibiotics should be prescribed. If a patient has 3 or 4 criteria, then antibiotic treatment may be used. I prefer this strategy at my jail because it does not require the use of rapid strep screens, which cost $5.00 to $10.00 each.
2. If you prefer to use the rapid strep test, the CDC recommends no treatment for patients with 0 or 1 criterion, and rapid strep testing for those with 2, 3 or 4 criteria. You then treat those where the rapid strep test comes back positive.
The CDC recommends throat cultures NOT be routinely performed. This is important because many lab facilities routinely follow up all rapid strep screens, whether positive or negative, with a $60.00 culture. Throat cultures should be reserved for special circumstances, such as tracking epidemic outbreaks of streptococcal disease, or if there is a suspicion of another bacterial pathogen, such as gonococcus
Finally, the antibiotic preferred by the CDC for the treatment of strep throat is plain penicillin. Not amoxicillin. Not Keflex. Definitely not Augmentin! If the patient is penicillin allergic, erythromycin should be used in its place. This point is important enough to say again: do not use expensive, broad-spectrum antibiotics to treat routine strep throat.
These guidelines do not apply to complicated patients, such as immunocompromised patients, or those with other significant medical problems, such COPD or a history of rheumatic fever. The guidelines also assume the practitioner will carefully exclude other serious throat disorders, such as peritonsillar abscesses or epiglottitis. Still, at my jail, the guidelines apply to over 95% of the patients who present to our medical clinic with sore throat.
Here is how these guidelines apply to a typical case. A healthy 35-year-old male presents to the jail medical clinic with a sore throat. His temperature is 97.6F. He has large red tonsils but no exudate. He has 2+ tender anterior lymphadenopathy. He has been coughing frequently. Physical exam shows no evidence of abscess or other complications. This patient has only one of the CDC’s four clinical criteria. According to the CDC guidelines, he should not have a rapid strep screen performed nor a prescription for antibiotics. Instead, he would be treated symptomatically with acetaminophen, increased fluids and rest.
I would like to encourage everyone to read the original CDC report. It is concise, well written, and authoritative. The four basic clinical criteria are easy to incorporate into a clinical decision model or a flow chart for your facility. I believe that if your facility adopts these guidelines, the quality and consistency of your medical care for sore throat will improve and your medical costs will fall.