A Call for Patient Advocacy (by Jeffrey E. Keller MD)

Being incarcerated in a jail or prison sucks.  Almost by definition, incarcerated inmates are disadvantaged.  They no longer have free choice about where they live, what they eat, what they can purchase, what work they can do or how much they can earn.  One thing that incarcerated inmates do have access to is medical care.  And those of us who provide that care are justifiably proud of our efforts on behalf of our patients.

Sometimes, though, we can get trapped in our own little world of the medical department and forget the other aspects of inmate life that we don’t see every day, like where they sleep, what food they eat and how they spend their time.  We may think that those aspects of inmate life have nothing to do with our medical mission, or at least that we have no say in how the rest of the prison or jail facility is run. However, many of these other aspects of inmate life affect the medical well-being of our patients.  

An obvious example is food.  On the outside, doctors emphasize the importance of eating a healthy diet.  It is important, patients are told, to eat lots of fresh vegetables and fruit and to limit consumption of white carbohydrates and meat fat.  “Don’t buy junk food, like sweets and chips!” outside patients are told, “Instead snack on healthy foods like nuts and fruit.”  But incarcerated inmates often have no choice in what they are given to eat at meals and there are no healthy options (none!) offered on many commissaries.

I have found in my years of practice in jails that the quality of food provided to inmates at meals varies greatly from jail to jail.  Some jails do pretty well at providing truly heart-healthy, balanced meals that actually include real vegetables and fruits.  On the other hand, jails that pursue “low-cost at all-cost” food service companies, not so much.  In addition, what is actually on the tray given to an inmate may not resemble the “diet plan” that was shown to jail administrators. 

Similarly, jail commissaries rarely offer any heart-healthy choices.  The justification from the commissary companies is always an economic one: “Those don’t sell well.”  Ramen noodles and candy evidently sell very well, just like they do in the free world.

However, since crappy diets and crappy commissary choices impact the health of our patients, we correctional physicians have the right and even the obligation to advocate on behalf of our patients. When a knowledgeable diabetic patient tells me that the diabetic diet actually has more carbs per meal than the regular diet, I, as her doctor, have the obligation to investigate.  It is not that hard to walk down to the kitchen, talk to the responsible sergeant and kitchen supervisor and see if the story is correct.  In my experience, it often is!

Similarly, if the commissary lacks any heart healthy options, I have the right and even the obligation to advocate on behalf of my patients.  It is not heard to schedule a meeting with responsible sergeant and the representative of the commissary company.

In my experience, these advocacy meetings often work, especially if you are persistent.  If the commissary provider has to look you in the eye every month when they make their jail visit, eventually, they will make appropriate changes.  Same with the food service provider. 

It is possible to do this without being obnoxious or overbearing.  Just persistent in advocacy for the health of our patients, who cannot do this for themselves. Such advocacy actually works to improve the health of our patients.  Our job does not stop at the doors of the medical department.

As always, what I have written here is my opinion. I could be wrong! I would like to hear your opinion. Please post in Comments!

This article was originally published in CorrDocs, the publication of the American College of Correctional Physicians, (here)

5 thoughts on “A Call for Patient Advocacy (by Jeffrey E. Keller MD)

  1. I just started working in a medium security prison as a nurse practitioner. It’s been my experience, as a mid-level, that lower income folks, the “medicaid population,” very frequently have a low vitamin D level – I’ve seen patients with vitamin Ds of 7, 15, 18 = easily, often, predictably, vs. the folks who are better off financially/socially/demographically, so my prediction is that the inmates at my institution would, if I checked them, have fantastically poor vitamin D levels. Paired with what Dr. Keller is saying, I think it’s a good bet that there’s little point in testing for vitamin D levels in inmates, but better to simply, as a matter of course, supplement. The benefit to checking is to gauge dosage – probably a lot of inmates actually need the high dose ergocalciferol; but what do we lose by just giving everyone 1,000 IU daily?

  2. Great article – thanks!

    I appreciate NP Roderer’s comment regarding Vitamin D – some good ‘food’ for thought. I supplement Vitamin D myself, and advise most of my private patients to do the same. Why not Vitamin D for the inmates? Time/cost burden of more medication administration? Worth the effort for a jail setting (shorter average length of stay)? Hmm… something to consider. Thoughts from others?

  3. For several years as a new-to-corrections-NP I was checking serum Vit D levels for newly arrived inmates with anx/dep. Over 4 years, I could count on one hand the number of patients with normal Vit D levels. 95%+ were low with a large percent at VERY low levels, <15 for example. I also advocate for the inmates' freedom to exercise, I've worked in some jails where admin prohibits exercise outside of rec time–both medical and mental health are harder to treat in these jails where inmates are prohibited from body-weight exercise. A few months of calisthenics, strength training, and comradery really seem to be therapeutic.

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