Today’s JailMedicine post was written by Bruce Boynton, MD.  Dr. Boynton has been a Regional Medical Director of the prisons in New Mexico and currently is the Statewide Medical Director in Mississippi.  He wrote this article to help introduce newly hired practitioners to the world of Correctional Medicine.  I think it is excellent!

MD: Hi, I’m Doctor Jones and I’ve just started working here at Riverbend. I’ll be holding my first sick call this afternoon and I understand you’re the officer assigned to the clinic.

CO: It’s good to meet you Doc; welcome to Riverbend.

MD: There is something I’d like to ask you. I have a lot of experience in Family Practice but I’m new to corrections. Is there anything special you think I need to know? I suppose that people are people and medicine is medicine no matter where you go. Isn’t that right?

CO: Well Doc, people are people, but Riverbend ain’t the Mayo Clinic. The first thing you have to understand is that our business is corrections, not medicine. Safety and security always come first. Medical is important, but it’s not the reason we’re here. Once you understand that a lot of our rules and regulations will make sense to you.

MD: Can you give me an example?

CO: Sure; take the rule about contraband. You can’t bring cell phones, cigarettes or sharp objects into a correctional facility. They are a security risk because inmates can use them for bribes, weapons, planning escapes, or some other illegal purpose. You have to sign in and out of the facility, and may be patted down. You have to go through the same drill as the correctional officers.

Your medical routine may be interrupted by a lock-down. It’s not that we are insensitive to the needs of patients and providers. It’s just that security comes first.

There are dozens of such rules and we have to enforce them strictly. Break a rule, even if it seems insignificant to you, and you can be locked out of the facility. The inmates watch us constantly to see if we are keeping the rules. If we don’t keep the rules how can we expect them to?

Because of security concerns we have to work as a team: Docs, nurses, therapists, teachers, correctional officers, everyone. You have to let the correctional officers know about special medical problems, such as contagious disease threats, and we have to let you know what’s going on as well. If communication breaks down the inmates will attempt to play one person off another.

MD: I’ve heard that inmates can be manipulative. Does that cause problems?

CO: Yes; they may yell, scream or sweet talk you to get what they want. But it would be a grave mistake to conclude that because they act badly they should be treated badly. If anything, inmates should be treated with more respect so they will have good examples of how to treat others. Inmates need role models to emulate: professionals who are firm, fair and consistent. Inmates will test you. If you are weak and not ethically grounded they will pick up on your every weakness. Corrections demands a higher standard of conduct, not a lower. Perhaps it requires the best in us to reform the worst.

MD: That’s very valuable information! What else should I know?

CO: It’s important to understand how inmates access medical care. Inmates have a constitutional right to healthcare, specifically, access to care, the right to a professional clinical judgment, and the right to receive the care so ordered. But that doesn’t mean they have the right to any care they want; the right is to necessary and required care. They get the care they need, but not necessarily the care they want.

MD: What about accepting or refusing care? Do we just tell them what to do?

CO: The same rules apply as in the free world. Inmates have a right to care but also have a right to refuse care. They sign a consent form for treatment during the intake process but must again be consented for some medications and procedures. Inmates have the same right under HIPPA as you and I.

MD: How do inmates request care?

CO: When inmates first enter jail or prison they receive an intake screening, designed to detect urgent medical needs such as suicidal ideation, infectious diseases and intoxication. The nurse will determine what medications they are taking. If they have an ongoing medical problem like asthma or diabetes they will be scheduled for chronic disease clinic.

Thereafter, if the inmate wants to see a provider he will submit a request, sometime called a kite or sick call slip. Depending on the nature of the request the inmate will be scheduled to see a nurse or a provider.

MD: OK, now I understand the administrative part, but I suppose the medical care part is the same as on the outside.

CO: Not quite. In correctional facilities you get requests you never hear on the outside. Inmates come to medical to ask you to authorize snacks, lay-ins, housing reassignment, different shoes, lower bunks and extra mattresses.

MD: Why would they ask a provider for such things? They are not a part of medical care.

CO: You’re right; often they are not medically necessary, but these are things they want and that give them status among other inmates. If you give an extra mattress to one inmate, then every inmate will want one. Remember, you must be firm, fair and consistent.

MD: I keep hearing about Utilization Management.

CO: In jails and prisons everyone is concerned with UM. Offsite consults, hospitalizations and unnecessary ER runs are a big deal.

MD: Why is that?

CO: This facility is the inmates’ Medical Home and it is important to provide as much care on-site as possible. Every unnecessary day your patient stays in the hospital costs your company money, costs us money and may even put our lives at risk.

MD: How so?

CO: Because we have to station two correctional officers at the hospital 24 hours a day to guard each and every inmate. That’s a thousand dollars a day that our bosses would rather not pay. The same goes for offsite consults and ER runs. If we’re short staffed we put the safety of the whole facility at risk to escort your patient. There is always the threat that an inmate may try to escape or have someone waiting at the hospital to pass them a weapon or help them escape.

MD: Wow, I hadn’t thought about that. Anything else I should know?

CO: One more thing; you’ve heard that the pen is mightier than the sword?

MD: Yes, of course.

CO: It’s true. That little pen gives you awesome powers.

MD: What do you mean?

CO: Just think about it; when you write a prescription you unleash a chain of events that consumes the time and effort of dozens of people. First there’s the unit clerk or nurse who transcribes the order. Orders are sent to the pharmacy where pharmacists, techs and workers order and package the medication and ship it to our facility. Our nurses have to check in all the meds and administer them in pill lines that can be 300 inmates long. Inmates may cheek or hoard meds to commit suicide, get high or use as prison cash. So you see you do have power, just use it wisely!

MD: Gee thanks, I appreciate your advice.

CO: You bet! Let’s go……Here comes your first patient.