Category Archives: Practice Management

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

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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)

What Does “Medically Necessary” Mean?

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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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What is the most common mistake made when treating withdrawal?

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What is the most common mistake made when treating withdrawal in a correctional facility?

Consider these two patients:

  • A jail patient booked yesterday is referred to medical because of a history of drinking.  He has a mild hand tremor and “the look” of a heavy drinker. But he says he feels fine and has no complaints. His blood pressure is 158/96 and his heart rate is 94.
  • A newly booked jail patient says that she is going to go through heroin withdrawal.  She is nauseated but still eating and has no gooseflesh or rhinorrhea.  Her heart rate mildly elevated.

In many jails, neither of these patients would be started on treatment for withdrawal at their first visit to medical.  But this would be a mistake!  Both patients should be started on treatment for withdrawal immediately.

The most common mistake made when treating withdrawal in a jail is not to treat the withdrawal at all!

Both of these patients have the potential to slide downhill rapidly.  And in both cases, the potential benefits of starting treatment far, far outweigh any potential liability.

Let’s look at these cases in more detail.

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Beware the Bounce-Back!

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I learned about Bounce-Backs back in my Emergency Medicine days.  A bounce-back is a patient who you saw in the ER and discharged but then returned within 48 hours with the same complaint.  A lot of time is spent in emergency medicine education talking about how to handle bounce-backs.  The basic message is “Beware! You may have missed an important diagnosis the first time!” 

Bounce-backs happen in correctional medicine, too. Bounce-backs can happen in jails, where we often deal with patients we do not know well. But bounce-backs also happen in prisons, when patients we do know well have a new complaint.  Just like in emergency medicine, a bounce-back in a jail or a prison is a patient who comes to the medical clinic with a new complaint, receives a diagnosis and treatment and then re-kites for the same complaint within a couple of days.  Here are a couple of examples. 

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Introducing Sharen Barboza

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I am pleased to be joined on JailMedicine by my colleague Dr. Sharen Barboza! Dr. Barboza has been providing correctional mental health care for more than 20 years. Her complete bio can be found in the About The Authors tab (here). Besides her broad experience, intelligence and common sense, Dr. Barboza is simply the best speaker I have heard at any correctional medicine conference. I am honored to have her as my co-editor at JailMedicine! Jeffrey Keller

Dr. Sharen Barboza

I am truly honored, grateful and humbled to join Dr. Keller on JailMedicine.com.  I think that now, more than any other time in the past, we are all realizing the impact that our mental health has on our ability to function in the world.  For so many of us, we take the “health” part of our “mental health” for granted.  We trust our thoughts to be based in reality; we rely on our emotions to adequately and appropriately meet the moment; and we have confidence in our ability to cope with what comes our way.  Most days. 

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Using a Wrench Instead of a Hammer for Alcohol Withdrawal

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I am seeing a 52-year-old male in my jail medical clinic who was booked yesterday on a felony DUI charge.  He says he drinks “a lot of beer” but denies having a drinking problem.  He is cranky and not really cooperative.  He does not want to be here.  However, the deputies tell me that he did not sleep much last night and did not eat breakfast.  I note that he has a mild hand tremor and a heart rate of 108.  According to the clinical Institute Withdrawal Assessment for Alcohol–revised version (the most common tool used in the United States to assess the severity of alcohol withdrawal since 1989) my patient needs no treatment for alcohol withdrawal.  But this is wrong!  In actuality, my patient is experiencing moderate withdrawal and should be treated immediately and aggressively. 

 Using CIWA is like using a wrench to pound in a nail.  It can be done, but it is not really efficient or accurate.  A different tool (a hammer) could drive the nail much more quickly and effectively. CIWA is simply not the right tool to assess alcohol withdrawal.  We should be using something better.

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ACCP Position Paper on the Funding of Hepatitis C Treatment

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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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You Need a Plan for Corona virus in your Facility

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Unless you’ve been living under a rock, you have been hearing about the threat of a Corona virus pandemic. Every day, the evening news anchor breathlessly gives an update of the number of new cases, the number of new countries affected and the number of new deaths.  You probably already know that this disease was originally found in China.  What you may not know (but you should if you work in corrections) is that Chinese prisons were especially hard hit.  This disease spreads most rapidly where people are enclosed together, like nursing homes, cruise ships and prisons.  If this disease gets a foothold in the United States, correctional institutions are likely to suffer. 

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Oral Testing of Reported Penicillin Allergies?

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Penicillin is miraculous.  It was discovered in 1928 by Alexander Fleming (founding the modern era of antibiotic medicine) and is still the most common antibiotic prescribed in my jails.  The dentist and I use Penicillin VK as our preferred initial agent for dental infections.  I prescribe PCN VK, as well, for strep throats.  I use amoxicillin occasionally for sinus infections and UTIs and even amoxicillin/clavulanate (Augmentin) occasionally. 

Because penicillin is so useful (and inexpensive), I hate to hear the words “I’m allergic to penicillin.” If a patient with a dental infection can’t take penicillin, for example, the dentist commonly prescribes clindamycin, which is expensive, a pain to administer three times a day and has potentially bad side effects.  I have seen more than one patient who developed C. difficile after getting a broad-spectrum antibiotic because of a reported penicillin allergy–probably unnecessarily!

This problem is pretty common since about 10% of the adult population will report a penicillin allergy.  However, research has shown that, when tested, more than 90-95% of patients who state that they have a penicillin allergy really do not. These patients can be harmed by giving them an inferior antibiotic more likely to cause them harm than plain old penicillin.

The test most commonly used to gauge true allergic status is Penicillin Skin Testing (PST). No jail or prison that I know of does skin prick tests.  We also don’t refer patients reporting penicillin allergy to an allergist for testing.  We just groan and prescribe an inferior antibiotic. 

However, this could potentially change based on research published this year on the safety and efficacy of “Direct Challenge” penicillin allergy testing.  Direct challenge means giving a low-risk (this is important) patient an oral dose of whatever penicillin you want to prescribe and observing them for an hour for an allergic reaction. This has been done in studies and has been reported to be safe and effective.

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