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.Continue reading
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.
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.Continue reading
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.
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.Continue reading
If you are a prison doc, I am about to solve one of your vexing nuisances, so pay attention.Continue reading
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.Continue reading
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.”
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.Continue reading
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:Continue reading