The State Board of Medicine in my home state recently sent out a bulletin about the practice of “friendly prescribing” to people who the practitioner has not examined. For example, a friend might call me and say something like “I have a sore throat. Will you call me in a prescription for antibiotics?” I’m sure that almost everyone who has practiced medicine has received such phone calls! The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.
In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.
When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.
One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”
Medical clearances are a hugely important and often neglected part of the jail medical process.
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.
I will be meeting a new jail patient with multiple medical
problems today in my clinic. I know this
much before I even meet him: He will
almost certainly be scared, especially if this is the first time he has ever
been to jail. He will likely be
suspicious of me. He may even be downright hostile. I know this because this is
the norm for correctional medicine. I can’t be an effective doctor unless I can
turn this attitude around.
Consider the situation from my patient’s perspective. Prior to seeing me, he was arrested,
handcuffed and driven to jail in a police car.
Once at the jail, he was thoroughly searched (spread-eagle against the
wall), fingerprinted and had his “mug shot” taken. His clothes were taken away and he was given
old jail clothes (including used underwear).
He was placed in a concrete cell.
Now he is summoned by a correctional deputy and told (not asked) to go
to the medical clinic.
He did not choose me to be his doctor. Though he doesn’t know anything about me, he
has no choice but to see me for his medical care. Not only did he did not
choose me; he cannot fire me or see anyone else. He may fear that I am not a competent doctor;
otherwise why would I be practicing in a jail?
This is the attitude that I have to overcome. How to do this is an essential skill for
correctional practitioners. And, of course, the single most important encounter
is the first one. A negative first impression is hard to overcome–and I am already
starting out at a disadvantage. What I
have to do in only a few minutes is convince my patient that I am a legitimate
medical doctor and that I care about him. I have learned in many years of doing
this that these things are essential:
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.
I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . . Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR