Category Archives: Medical Practice

Manipulation Defined

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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 →

Bad Medicine is Expensive!

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In the last JailMedicine post, I introduced the subject of Utilization Management (UM) in Corrections. To some, Utilization Management has earned the reputation of being too focused on money and not enough focused on patients. But after I had been doing UM for awhile, I had an important insight that changed the way I thought about Utilization Management and (I believe) made my own efforts at UM much more effective.

That key insight is this: That which is expensive in medical practice is bad medicine. The way to control costs in medicine is to reduce or eliminate bad medical practice. Cost containment is simply a happy byproduct of this endeavor. When UM physician advisors work with primary care practitioners, the conversation should center around best medical practice, not money.

It is this simple: Good medicine is cost effective. Bad medicine is expensive. Continue reading →

Controlling Health Care Costs: Utilization Management

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Consider two people standing outside of a grocery store.

Person one is told: “Here is $200.00 for groceries for one month. You may buy any food you wish—but you may not spend more than this $200.00. So, make your purchases wisely. We are going to watch carefully to make sure that you do not exceed $200.00.”

The second person is told: “There is no limit on how much you spend on groceries in the next month. You may spend as much as you wish! And you may come back as often as you like. There are no limits. In fact, no one is even going to pay attention to what you buy!”

Which person do you think is more likely to walk out of the store with the most expensive cut of steak?
Which person is more likely to pay attention to prices and sales?
Which one do you think is more likely to buy food that they will never eat?

This scenario is very like the difference in health care spending within your average state prison system and the medical community at large. Continue reading →

Is this a Medical Refusal–or Manipulation?

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My good friend Al Cichon writes:

Dr. Keller – would you consider a discussion of balancing the autonomy of patient decision-making and the risk to the facility for not providing appropriate care.
Examples
1. Individual is on disability but wants to sign a ‘waiver’ of responsibility so he/she can work
2. Diabetic (NIDDM) individual that wants to refuse diet and be placed on insulin so he/she can eat what ever they wish
3. Individual with a comminuted jaw fracture – cut wires on episode of nausea – now wants regular food despite oral surgeon advising limited jaw movement
Documentation of appropriate exam and advice to the individual is, of course, the foundation of addressing the issue – but do you allow the 100% (physically) disabled person work; allow the diabetic to sign a refusal of the diet & prescribe insulin; give the individual with the broken jaw (who is asking for more hydrocodone) a regular diet?
I believe your expert ability to address these thorny issues will help us all

Thank you for the kind words, Al! The issue you highlight is indeed a thorny one—when a patient wants to refuse strongly recommended medical care. Sometimes these are true refusals, meaning the patient understands the medical intervention being offered and truly does not want it. More often, though, such refusals are a form of manipulation to get something else that the patient wants. I would like to address these two scenarios first and first and then discuss your three specific examples. Continue reading →

Random Thoughts on Alcohol Withdrawal

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I had a lot to learn when I began practicing medicine in county jails. One of the most important of those lessons was how properly to assess and manage alcohol withdrawal. In my previous life as an ER physician, I had seen a few alcohol withdrawal patients and even one or two cases of DTs. I thought I knew what I was doing. Wrong-o! I was first unprepared for the sheer number of alcohol withdrawal patients I would see as a correctional physician. Alcohol withdrawal in jails is simply very common.

But I was also unprepared because much of what I had been taught about alcohol withdrawal was inaccurate or misleading. Nothing teaches like experience! After many years of treating a lot of alcohol withdrawal, I have gained some insights. Continue reading →

Price Check! Are analogue insulins worth their hefty price?

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The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).

Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.

But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen) Continue reading →

Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

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In my last JailMedicine post, I wrote that clonidine is an excellent drug for the treatment of opioid withdrawal. In response, several people have asked about methadone and Suboxone. Why not use one of those drugs instead of clonidine?

The short answer is that both methadone and Suboxone are excellent drugs for the treatment of withdrawal. However, both are much more complicated to use in jails due to DEA legal requirements and a much larger potential for diversion and abuse. If you are using Suboxone or methadone, great! I believe that clonidine is a better choice for most jails. Those interested in using methadone or Suboxone need to be fully aware of the DEA laws surrounding their use. Before you use one of these drugs, you must make sure that you are following the law. I know of two physicians in my hometown who were disciplined by the DEA for prescribing narcotics to treat addiction without registering. The DEA are not kidders!

By the way, Jail practitioners should also be aware that Tramadol has been used successfully to treat withdrawal, as well. Continue reading →

A Better Way to Drain Abscesses: The Berlin Technique

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One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses. Continue reading →

Correctional Medicine is a Great Job! Who Knew?

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I have a confession to make.  Before I knew anything about Correctional Medicine, I had a bad opinion about it.  I’m not proud of this.  I even turned down my first opportunity to get into Correctional Medicine because of my preconceived prejudice. Thank goodness I got a second opportunity, because Correctional Medicine changed my life! Who knew that Correctional Medicine was such a great job and a great career?

Certainly not my colleagues.  Back when I made the mid-life career change to jail medicine, my physician friends asked me, bewildered, “Why in the world would you want to work in a jail?”  Without knowing anything about it, they had a preconceived notion of Correctional Medicine as being low skill and basically without redeeming features.

What a difference 15 years makes! careersprisondoctor Continue reading →

Correctional Medicine Is Different: Our Patients Don’t Go Home!

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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.unknown-1 Continue reading →