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.
Why Correctional Medicine is a Great Job
Communication with Incarcerated Patients
Unique Operations in Jails and Prisons
Comfort Items: The Special Problem of Correctional Medicine
Treating Withdrawal—Every Time
Issues of Medical Care in Jails and Prisons
In My Opinion
The Best of Jail Medicine: An Introduction to Correctional Medicine is available now on Amazon.com (here)
It was a holiday weekend in the middle of the night. The booking area of the jail was a big, open, noisy pit with people sitting in plastic chairs, watching TV or on phones and the officers either behind desks or circling the perimeter. It was filling up. A staff member was completing initial mental health screenings in a corner of the open room, up on a platform and behind a computer. She had the electronic health record open to the mental health screening form and she was going through each “yes/no” question, reading from the computer screen and not looking at the recently arrested individual, a young man picked up on a possession charge.
“Are you currently taking any medications for mental health
“Have you ever been hospitalized for mental health
“Are you currently thinking about hurting or killing yourself?” Pause. Swallow. “No.”
“Have you ever been treated for withdrawal from drugs or
She missed it. She missed the pause; she missed the swallow.
When Covid-19 burst onto the scene three months ago, the jail administrators and the medical teams in my jails initiated several common sense practices to reduce the possibility of Covid infiltrating the jails. These included screening and quarantining new inmates before allowing them into the dorms, screening jail employees daily, doing lots of Covid tests and, perhaps most importantly, having deputies wear masks at work. The good news is that, so far, there have been no cases of Covid-19 in any of my jails (knock on wood here).
However, there seems to be growing evidence of “Covid
Fatigue” in my community. When I go out
in public, I am one of the very few still wearing a mask. And this is unfortunately spilling over to
the correctional facilities. I did a
clinic at one of my smaller jails this week and was surprised and dismayed to
see that the deputies were no longer wearing masks. In the meantime, Community Covid cases are
climbing, so the risk of transmitting Covid to the jail is actually greater
than it was, say, a month ago.
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.”
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:
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.
My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different jails.
Today’s Post was written by Rebecca Lubelzyk MD. Rebecca works in the Massachusetts prison system. She is a past president of the American College of Correctional Physicians and the editor of CorrDocs, the official publication of ACCP. This article was originally published in CorrDocs.
I’m on a medical school listserve that publishes writings and academic accomplishments of faculty and students. One week, a mindfulness moment was added to address the stress that physicians feel. The well-intentioned addition brought forth a fairly online virulent discussion about the non-medicine stress that disgruntled physicians feel every day, and how a “mindful moment” will do little to change the extreme performance demands generally imposed upon our profession.
I followed the discussion peripherally but with interest. It was clear all the contributors were dedicated professionals who loved their patients and providing care to them and their families. However, the bitterness towards the insurance/compensation/financial system was prevalent.
How bad it was “out there” became even more apparent when I had a prospective physician shadow me in clinic for a day. I explained how there can be several benefits to correctional medicine (your “no show” rates are essentially nil, patients have their blood pressures and blood sugars checked by a nurse, diets, commissary purchases can be reviewed in detail, etc.) I expressly noted the unique challenges, including the requests for non-medical items or privileges as well as the negative attitudes one encounters when the patient doesn’t want to hear the word “no”.
The physician candidate surprised me, stating that it was the same on the outside. Continue reading →
This article was initially published on MedPageToday,found here.
I remember walking into one of my jails and seeing a patient on the floor of his cell twitching and shaking. “Don’t worry about him,” said the sergeant on duty. “He’s faking it.”
Boy, that spun me up! Nothing will make me more anxious than hearing “he’s faking” or its close cousin, “he’s malingering.” I hate and fear those words. Now, I know that medical personnel, both in my jails and in the emergency departments where I used to work, get upset when they think that they are being deceived or manipulated by a histrionic patient. But charging a patient with “faking it” is almost always a bad and dangerous idea.Continue reading →