What Makes Correctional Medicine Different?

Correctional Nurse Kim. She can say "No."

I recently read my friend Lorry Schoenley’s excellent article on Correctional Nursing is Different–Research Report which is about the differences between correctional medicine and traditional community medicine. Coincidentally, I also found myself at about the same time hiring a new full-time Physician Assistant with no correctional experience and having to explain how important these differences are.   If you do not recognize and embrace these differences, you can get yourself and your patients into serious trouble.  In this article, I am going to point out some of the important differences between correctional medicine and what I am going to call  “Outside Medicine.”

We Practice the Principle of Fairness

Outside medicine is not fair.  A patient with good health insurance will have a small co-pay for medication prescriptions whereas an uninsured patient will be unable to afford many medications.  The insured patient also will get tests and treatments that  will be refused the uninsured.  There should be no such discrepancy in corrections.

A more subtle but still important example has to do with practice variations.  When I worked in the emergency department, I had a partner who always prescribed antibiotics for sore throats.  I rarely did.  So on those occasions when we were working together, you could come to the ER with a sore throat and if my partner picked up your chart, you would get an antibiotic, whereas if I happened to pick up your chart, you would not get an antibiotic.  That sort of discrepancy does not work well in corrections.  All clinical encounters are discussed back in the dorms.  The inmates will figure out that practitioner A gives out antibiotics (or extra mattresses or cold medication or whatever) and practitioner B does not.  They will preferentially want to see practitioner A and write grievances about practitioner B.  Practitioners within a facility need to get together and set up basic practice standards that everyone adheres to.

Likewise it is not fair to make exceptions to practice standards for favored inmates.  Everyone gets tempted to break policy for an inmate with an exceptionally good story.  But (to use one example) if you give a sleeping aid to one inmate, the Principle of Fairness says that you have to give a sleeping aid to every inmate who asks for it.  If you freeze off a wart on one inmate, you must freeze off warts on every inmate who asks.

Our Patients Do Not Go Home

I came to correctional medicine from the emergency department.  There, we often do not know if patients will follow-up as we advise them to do.  In fact, we often are pretty sure that they will not.  So we emergency physicians develop an attitude that this ER visit is our one and only chance to make a diagnosis.  We will order every test we think we might need because the patient is not coming back; this is our one shot.

Correctional Medicine is much different.  Our patients are not disappearing; they are going down the hall to a different part of the building.  We know that they will keep their follow-up appointments.  In fact, they will probably be checked on frequently in the meantime.  If the patient has prescribed medications, the nursing staff will at least see them face-to-face once or twice a day.  The deputies will be watching them. Our ability to keep track of our patients between visits is very important.  It means that we can and should have relatively less reliance on tests and more reliance on observation and scheduled follow-up.

I call this “The 8 Hour Test” or simply “The Test of Time”  (you can order a 4-hour test, a 24 hour test or any other time period you want depending on the clinical situation). These should be thought of as a formal test.  They tell you how a disease progresses with time. As an example, let’s take a patient with abdominal pain and a so-so exam.  He might have appendicitis, but probably not.  In the ER, since I would worry that he might not come back if I discharge him, I would get a CBC (even though it would likely be worthless) and maybe even an ultrasound or CT.  But in the jail, where he is under observation, I would more likely order an 8-Hour Test.  I know from experience that in 8 hours, he will not be the same; he will either be improved or he will be worse.  So I have him re-checked in medical in 8 hours.  Has his temperature changed?  Is he eating?  Has the pattern of his abdominal pain changed?  I actually will get far more clinically useful information from the 8-hour test than I would have from a CBC at the initial visit.  If he has improved in 8 hours, then I am very sure that he does not have appendicitis.

The bottom line is that we in correctional medicine should take advantage of our ability to follow our patients closely.

We Verify Patient History

In correctional medicine, we must verify patient histories to a much greater extent than is done outside of correctional facilities.  If a patient says that she takes medication X or last saw Doctor Y last week or had surgery two weeks ago, we must verify the stated history.  The nurses in my jails spend a good part of their day verifying patient history in order to get the current med list right and to coordinate care properly with outside physicians.

A patient in one of my jails stated that she had a PAP smear done 6 months ago that was abnormal and she was supposed to follow-up “immediately” with a gynecologist, presumably for a culposcopy.  However, when we tracked down the PAP smear results, they were normal.  Another patient stated that his orthopedist wanted him to wear a neoprene brace on his knee following a knee injury 2 years ago.  However, the orthopedist, when contacted, laughed and told us he does not believe in neoprene braces.  He actually recommended rehabilitation exercises which the patient never did.  A third patient stated that she was currently taking warfarin.  She even brought some in to the jail with her, though it was out of date.  However, when we checked, her internist had discontinued the warfarin 4 months previously.

We Say “No.”

Outside doctors are not only practicing medicine; they are also running businesses.  Their patients are also customers.  Doctors on the outside must keep their customer/patients happy or the patients will leave.  A physician who is too abrasive or not accommodating enough will find himself without a viable practice.  I have seen several medical practices fail for this reason. Because of this aspect of outside medical practice, outside practitioners generally give patients what they want.  If a patient wants a sleeping pill, she will most likely get a sleeping pill.  If the patient wants the new drug advertised on TV, their doctor will likely prescribe it.

However, in corrections, we find ourselves in a much different practice environment.  Our patients are not customers; they are our patients, period.  Our obligation is to practice good medicine, not necessarily to make them happy.  Consequently, we in correctional medicine say “No.”  A lot.  We have to say “No” in order to do our jobs properly.  We have to say “No” in order to be fair (see principle #1, above).  We have to say “No” in order to maintain the safety and security of our facility; something outside physicians seldom have to consider.

The problem is that medical personnel new to corrections usually have little experience saying “No.” It is a new skill that they have to learn.  There is a right way and a wrong way to say “No” that should be taught to new correctional medical employees (blog post on this subject coming soon!).  However, many of them (more than half, in my experience) cannot master this skill and so fail as correctional providers.

Are there other important differences between correctional medicine and outside medicine that I have not mentioned?  Please comment.

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11 thoughts on “What Makes Correctional Medicine Different?

  1. Mardi Millar RN

    The way you say “NO” is very important. At our juvenile facility we have found the juveniles as well as staff respond much better to a qualified “no” as opposed to a flat out “no”. Take the extra time to explain why you are saying “no”, what your observations are that made you come to that conclusion, and what your policies and pocedures/guidelines/nursing protocols are that relate to your negative answer. Taking a few minutes up front can eliminate grievances and further discussion at a later date. Remember to document so those coming on shift after you know what you said. Also stick to your “no.” If the symptoms or conditions do not change, the answer is still “no.”

    Reply
    1. Jeffrey Keller Post author

      Thanks Mardi! It does make a difference if you explain the rational for saying “No.” Otherwise, the inmate perceives that it is a personal issue; you are saying “No” because you don’t like them.

      Reply
  2. Leslie Robertson

    I really like the client vs. patient approach. While we’ve all discussed it, I’ve never quite heard it put so succinctly. I would think that viewing the person as a patient rather than a client can be a very freeing concept. It allows the practitioner to practice pure medicine rather than business.

    Reply
  3. Jeff Frey PA-C

    I just started working in correctional medicine. I have 15 years of “outside” medical experience. During my years of “outside” experience, I would often say “no” to my “clients” because they wanted the newest, priciest mediciation, treatment (etc), when cheaper alternatives were just as good. My intent was to keep costs down but still provide appropriate treatment. However, I became frustarted when my supervising physician would cave and give the patient what they wanted. Bottomline: I can say NO with the best of ’em.
    With all that said, do you have any books to recommend that would be appropriate for a newbie in the field

    Reply
    1. Jeffrey Keller Post author

      Well, Jeff, I am unaware of any good clinical reference geared towards correctional practitioners. That is partly what I am trying to do with this blog. Who else in the medical world has to deal with “second mattress” requests, for example? Clinical Practice in Correctional Medicine by Michael Puisis is geared more towards overview and administration than actual clinical practice. I recommend that all of my mid-levels read one (or more) of the three good books written about manipulation–the so-called “inmate games.” These are “Game Over! Strategies for Redirecting Inmate Deception,” “The Art of the Con: Avoiding Offender Manipulation,” or “Games Criminal Play and How You Can Profit by Knowing Them.” Other than that, I have no recommendations.

      Reply
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  5. Aldo Torrente

    I am new to correctional medicine.
    Currently I have several patients with genital warts.
    In my facility there are three alternatives:
    podophyline, verruca freeze, and trichloroacetic acid.
    In all cases, the provider ONLY can apply the topical treatment.
    What is the protocol to treat genital warts?
    What is the most effective method?

    Regards,

    Aldo Torrente, PA-C.

    Reply
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  7. john ekman

    there is a big difference in the mentality of the inmate patient and the civilian consumer. if the consumer is not satisfied, he or she will usually just seek out another provider, however, if the inmate is dissatisfied (and scheduled to be released soon), he or she may seek you out and make your life miserable. as stated above, it is not that you say “no”, but rather how you say it.

    Reply
    1. Jeffrey Keller MD Post author

      Thanks for the comment John. Yes, if possible, you do not want to fight with an inmate over medical matters. Saying “No” is an art, and if you do it right, the inmate is happy (or at least not unhappy) OR if they are angry, it is not at you!

      Reply

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