I have begun a new blog that is being published on MedPage Today entitled “Doing Time: Healthcare Behind Bars.” The difference between that blog and JailMedicine is the audience. JailMedicine is written for medical professionals already working in a jail or prison (bless us all!). The MedPage Today blog is written for medical professionals who have no idea what Correctional Medicine is all about. The first post of Doing Time follows: Continue reading
You are seeing a newly booked patient in your jail medical clinic. He states he has been in jails before, many times, and is always given a second mattress and an extra pillow because he had surgery on his back many years ago. You note that the patient has not seen a doctor on the outside for many years, that the patient walks and moves normally and that he has a normal neurological examination. You tell the patient that medical does not give out passes for extra mattresses or pillows. The patient angrily erupts in a blaze of obscenities and threatens a lawsuit.
Manipulation happens when a patient wants something that they should not have (like an extra mattress and pillow) and will not accept “NO” for an answer. In my last JailMedicine post, I outlined the strategies patients employ in an attempt to entice or force practitioners to change a No to a Yes. This patient is employing the “threatening” strategy.
Verbal Jiu-Jitsu is the technique of deflecting and defusing manipulative confrontations. Notice that I did not use the word “defeating.” That is because the first and most important rule of Verbal Jiu-Jitsu is to remember that this is not a war or a contest! There should be no “battle of wills” between you and your patient. There is no winner or loser. Instead, you and your patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to avoid any kind of verbal battle. Continue reading
One of the more common complaints that I hear from correctional practitioners (especially new practitioners) is “Manipulative patients are driving me crazy!” To be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. ERs are the epicenter of narcotic drug seeking! But it is true that many of our patients in Corrections are especially skilled in manipulation. They have practiced this skill their whole lives and have become very proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.
Manipulation in a medical encounter occurs when a patient wants something he shouldn’t have and won’t take “No” for an answer. If the patient wants something he should have-no problem! Or If the patient is told “No” and accepts that answer–also no problem!
So manipulation involves these two essential elements:
1. The patient wants something she should not have. This something could be an extra mattress, a special diet, gabapentin, an MRI, a referral off site–anything.
2. The patient does not accept “No” for the answer.
What comes after not accepting “No” for an answer is manipulation. Manipulation is the attempt to coerce the practitioner into changing a “No” into a “Yes.” Manipulation comes in many forms. Continue reading
I remember the first time someone told me that I was “wasting my talents” by working in a jail. At that time, I had no ready witty rebuttal. I love my job and I especially appreciate working with a patient population that is disadvantaged and underserved. Of course, the idea that incarcerated inmates are worthy recipients of medical care is, well–controversial. Inmates are not as politically correct as other medically disadvantaged populations.
As an example, if you were to tell your family and friends that you were going to work with at a medical clinic for the homeless in an inner city, or to provide medical care in a needy third world country, the reaction probably would be something along the lines of “Good for you! I admire your selflessness and dedication!” Yet when you tell these same people instead that you are going to work in a prison, you are much more likely to get this reaction: “What’re ya, nuts? Why would you waste your talents working with them?” I personally have heard the “you’re wasting your talents” line more than once. Continue reading
The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.
Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk.
However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.
The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.
It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution–if we make them available. Continue reading
This post is the final in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons. The previous three differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms and We Can’t Fire Our Patients and They Can’t Fire Us!
The final major difference between correctional medicine and medicine in the outside world is this: Our patients do not go home. We have a captive audience. Literally! Believe it or not, this is a very important medical point.
Back in my previous life as an ER doc, if I asked a patient to come back tomorrow to be rechecked, I knew that few of them would. It was just too much hassle. They had to find a ride back to the ER (especially hard for the homeless or those without cars), they had to endure another prolonged wait in the ER waiting room. And they would be charged big bucks for another ER visit! No wonder so few of my scheduled follow-ups actually returned!
Once I began to practice in a jail clinic, I soon realized that the situation is much different. The patient I see in clinic today will not go home. She will go to her housing dorm down the hall. I know exactly where she will be tomorrow–or in a week. If I want to see her again tomorrow, I can. In fact, I can reliably see her in follow up anytime I want to.
One might think, “So what? What difference can it possibly make on the practice of medicine that our patients do not go home?” The answer is that this fact does indeed have several important consequences for the practice of clinical medicine. I can think of at least four. Continue reading
This post is the third in a series exploring how Correctional Medicine is different than medicine practiced outside of jails and prisons. The previous two differences were The Principle of Fairness and All Clinical Encounters are Discussed Back in the Dorms.
There is a controversy in pediatrics that I have been following recently. Some pediatricians have been dismissing children from their practice if their parents will not allow them to be vaccinated. This practice has been criticized as punishing innocent children for the actions of their parents but the pediatricians defend it by saying they are just trying to protect their other patients from being exposed to pertussis, measles and other transmittable diseases in the waiting room.
This story illustrates an extreme example of something that we all know: that the practice of “firing” patients is commonplace in outside medicine. Many of my jail patients have been dismissed from medical practices, some more than once! Patients can be fired for variety of offenses. Some violate the contracts of their pain clinics. Some are dismissed for simply not following the doctor’s advice—like to get their children vaccinated. Many are no longer welcome when they cannot pay their bills or have lost insurance coverage. (One orthopedist that I know routinely sends a dismissal letter to his patients on their 65th birthday since he refuses to participate in Medicare). Finally, patients can be fired for just being too difficult to deal with. One jail patient in particular I remember screamed drunkenly at his doctor’s secretary to the point that she called the police. He received his official dismissal letter while he was in jail.
Well! Things are different in Correctional Medicine! We can’t fire our patients. Our patients remain our patients no matter what. It doesn’t matter if they violate the terms of a pain contract by, say, diverting medications. It doesn’t matter if they refuse to follow our advice. It doesn’t matter if they are difficult to deal with. Continue reading
On my last post, I began a series discussing how Correctional Medicine is different from medicine in the “outside world.” The first (and arguably the most important difference) is that medicine inside corrections has to be fair, whereas the bigger world of US medicine is not fair.
The second big difference between Correctional Medicine and outside medicine is this: Every clinical encounter in correctional medicine is discussed back in the housing dorm. This does not occur in outside medicine and is critically important to understanding doctor-patient relationships in corrections.
For those not familiar with the housing situation in jails and prisons, most inmates are housed in large housing dorms or pods. Depending on the size of the institution, these can house anywhere from 10 inmates to over a hundred. As you might expect from this situation, inmates spend a lot of time talking with each other, especially since they generally have more free time than your average person in the outside world. Inmates spend a lot of time talking to one another.
So when an inmate returns to the dorm from a visit to the medical clinic, it is natural for the encounter to be discussed. If the encounter was unusual or noteworthy in any way, this quickly becomes known throughout the pod. And since different housing pods also communicate with each other, information about clinical encounters quickly spreads throughout the entire institution. Continue reading
I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.
But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!
This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness. Continue reading
I went to the always excellent NCCHC spring convention in Nashville last month. One of the many outstanding presentations was done by frequent lecturer Deana Johnson. Deana talked about the risks of using the word “malingering.” Her basic message was to be very careful about saying that an inmate is malingering—in fact, perhaps we should never use that word.
I was surprised by the degree of spirited disagreement from several members of the audience. They pointed out that “malingering” has a specific medical meaning and sometimes—even often—it is an appropriate medical diagnosis. They pointed out that malingering is listed as an official diagnosis in DSM-5 and that outside medical agencies, like mental hospitals, use the term malingering. If we can’t say that an inmate who is clearly faking is malingering, what are we supposed to say?
Today in Jail Medicine, I am going to tackle the term malingering. It turns out that there is indeed a correct and proper way to use the term malingering in correctional medical practice—but it is tricky and most often (in my experience) done incorrectly, with resultant bad consequences.
There are three important reasons for this. First, most people have an inaccurate idea of what malingering actually means in a medical sense and so use the term inaccurately. Second, the use of the term “malingering” also carries with it an emotional definition that MUST be taken into account when it is used in a medical document. Finally, use of the term “malingering” has important consequences for patient relations, patient behavior and time management.
The bottom line, in my opinion, is that “malingering” is a term that should very rarely be used in correctional medicine. There are better and more precise ways to convey medical information. But if you do absolutely want to use the term “malingering,” you need to know how to use the term correctly. Continue reading