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)

The Best of Jail Medicine: An Introduction to Correctional Medicine has been published!

Those of us who have practiced medicine in jails and prisons (correctional medicine) know this is a great job! We often see patients who have never had easy access to medical care. As a result, we get to diagnose and treat a larger variety of medical diseases than most medical professionals. We get to see the striking improvements our patients make due to our interventions. Since correctional medicine is largely free from traditional government/private insurance, we are freed from ICD-9 codes, diagnostic-related-groups (DRGs), and billing. We work with a disadvantaged and underserved population that appreciates our efforts and are grateful to have us. Our work is emotionally rewarding!

But it is also true that correctional medicine is different in important ways from medical practice “on the outside.” For example, we cannot fire our patients and they cannot fire us. Because of this, we must learn “verbal jiujitsu” skills to effectively communicate without animosity. We also must be scrupulously fair with our patients in a way that simply does not happen on the outside. And, of course, we must practice in a loud, hectic concrete and plexiglass building with TSA style security checks. These differences can be enough to overwhelm some medical newcomers with sensory overload.

The Best of Jail Medicine: An Introduction to Correctional Medicine consists of 47 articles from the popular Jail Medicine blog that discuss must-know aspects of practicing medicine in a jail or prison.  Each section contains several articles highlighting a different essential aspect of correctional medicine.

  1. Why Correctional Medicine is a Great Job
  2. Communication with Incarcerated Patients
  3. Unique Operations in Jails and Prisons
  4. Comfort Items: The Special Problem of Correctional Medicine
  5. Treating Withdrawal—Every Time
  6. Issues of Medical Care in Jails and Prisons
  7. Difficult Patients
  8. In My Opinion

The Best of Jail Medicine: An Introduction to Correctional Medicine is available now on Amazon.com (here)

Doing It for Attention

In response to my previous post, I received a number of comments and feedback which included assertions that individuals who engage in repetitive self-injury in correctional settings are “doing it for attention.”  That got me thinking.  And the more thinking I did, the more I realized that these statements are likely true.  But, not necessarily in the way one would think.  Let me explain.

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Restraints and Self-Injury

A few weeks ago, I received a request from a psychiatry resident working at a state prison about the use of restraints with patients who engage in severe self-injury.  He was looking for guidance on the use of physical restraints with this population in prison.  He noted that his role of ordering and monitoring patients in restraints caused him to feel more like a provider for the facility, rather than for the patient.  I shared with him with the best resources I know – Resource Document on the Use of Restraint and Seclusion in Correctional Mental Health Care (http://jaapl.org/content/35/4/417) as well as Dr. Applebaum’s commentary on the same (http://jaapl.org/content/jaapl/35/4/431.full.pdf). As I sat down to write this, I intended to discuss the rules and regulations surrounding restraint (e.g., Center for Medicare and Medicaid Services (CMS) 42 CFR § 482.13) but I stopped myself.

The inquiry was not about regulations and requirements for the use of restraints.  The question was about patient care. 

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What Does “Medically Necessary” Mean?

Let’s say one of my jail patients has a moderate-sized inguinal hernia.  I want to schedule surgery to have the hernia fixed, but to do so, I have to get authorization.  This is not unusual.  Just like the outside, before I can do medical procedures or order non-formulary drugs, I must get the approval of the entity that will pay the bill.  By contract, my jails house inmates from a variety of jurisdictions, such as the Federal Marshals, ICE, the State Department of Corrections and other counties.  This process of “Utilization Management” is very similar to getting pre-authorization from an insurance company or Medicaid in the free world, probably because Corrections simply copied the outside pre-authorization process.

Having done this process hundreds of times over the years, both in the free world and in Correctional Medicine, I am struck by a phrase that keeps coming up: “medically necessary.”  When authorization for a procedure is denied, the reason often given is that it is “not medically necessary.”  I then have to argue that what I am requesting is, indeed, medically necessary.  The problem is that there are many possible definitions of “medically necessary,” and I believe many disagreements arise because two parties understand “medical necessity” differently.

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Suicide – Don’t Be Afraid to Ask

It’s September, which is National Suicide Prevention Awareness Month.  Let’s start with awareness. According to the Centers for Disease Control, rates of death by suicide have increased in this country by 35% from 1999 to 2018.  More specifically, the rate has increased by 2% every year from 2006 to 2018.  The overall rate of death by suicide in 2018 was 14.2 people per 100,000.  For men, the rate is higher than the rate for women, with a suicide rate of 22.8 per 100,000 for men and 6.2 per 100,000 for women.  The rate for women, however, increased by 55% between 1999 and 2018.

According to the most recent data released by the Bureau of Justice Statistics, the rate of death by suicide in state prisons was 21 per 100,000 up from 14 per 100,000 in 2001.  In federal prisons the rate in 2016 was 12 per 100, 000 down from 13 per 100,000 in 2001.  In local jails, the rate of death by suicide in 2016 was 46 per 100,000 down from 48 per 100,000 in 2000.

These rates tell us despite our efforts in training, education and suicide prevention within our jails and prisons, people are still choosing to take their own lives.

Suicide is the intentional ending of one’s own life. Think about that.  Just sit and think about the fact that thousands of individual human beings, every year, decide that the life they have should end.  Many of these individuals experienced emotional and cognitive distress beyond what they believed they could handle and saw death as the best possible choice in the moment.  They likely felt alone, isolated, trapped and hopeless.  Like there was nowhere to turn. We can change that.

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ACCP Position Paper on the Funding of Hepatitis C Treatment

I recently published the official position paper of the American College of Correctional Physicians (ACCP) on the treatment of Hepatitis C in incarcerated patients (found here). However, some state legislatures (and others who which authorize funds for inmate medical care), have been reluctant to fully fund Hepatitis C treatment. Because of this, ACCP has formally approved the following Position Paper to encourage full funding of HepC treatment among incarcerated inmates.

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When Should Medical Clearance Be Done? PLUS Sample Guideline!

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.

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Words Matter. “Inmate” or “Patient?”

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.”

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