My good friend Al Cichon in Maine writes:
Dr. Keller,
What are your thoughts regarding disrespect?
As health care providers we are trained to be tolerant when patients are less than pleasant – excusing their behavior as a result of their illness / injury. Certainly there are occasions when this is appropriate. However, that tolerance can be abused in the correctional setting.
Inmates may be in pain or other discomfort and express themselves in a colorful manner with a variety of the seven words made famous by George Carlin. However, the spiteful, intentional, disrespectful and aggressively vulgar disparaging commentary of some individuals is clearly not the same thing – no matter the context. That is not OK just because it is Jail/Prison either.
In my best behavior, I will pass on the language associated with illness/ injury; address the over frequent use of bad language by inmates during clinic; and terminate visits of those who are grossly inappropriate.
Corrections staff is a wholly different kettle of fish. I personally believe that it is not appropriate. The officers (by their behavior) should set some example of expectation – people will rise to the bar of behavior that is set.
Thanks for the question Al! I agree with you. I do not like to hear swearing from inmates or staff. Along with you, I also think it is disrespectful. I understand that inmates swear chronically and habitually. However, jail staff should have better communication skills than this. When staff swear, it coarsens the overall functioning of the jail. Swearing by staff leads to a decline in the professionalism of the staff and of the discipline of the inmates (I think so anyway).
I can’t stop inmates from swearing in the dorms but I do not have to tolerate swearing in front of me or my staff. If I do tolerate swearing by inmates, even if it is habitual, this also hurts the overall discipline and functioning of the jail medical clinic. It certainly gets on my nerves and thereby diverts my attention from my job! Besides, even if their swearing is habitual, inmates know that they shouldn’t swear in certain social settings. They can control their tongues when they are around their kids or their mothers, for example!
So swearing is not allowed in my medical clinic. This is my unwritten policy:
If I am in clinic with an inmate, and the inmate swears out of habit (like “I hurt my **** back”), then I ask him (or her) not to swear. I actually say “Please don’t swear in front of me.” Most of the time, the inmate will apologize and watch their mouth. However, if they swear again, I then warn them: “Don’t swear! If you do it again, that will be the end of the clinic visit.” Very rarely, the inmate then swears for a third time. And after two warnings, I am pretty sure that the swearing at this point is deliberate. So I then tell the inmate that this clinic visit is over but I will be happy to see them another day–if they don’t swear!
This two warning system is for habitual swearing that is not directed at me. Swearing directed at me or my staff, as in “You are a ******,” is a different matter. Foul language directed at me personally gets no warning. The clinic visit ends right then, and usually I write the inmate up for discipline, since this is a violation of jail rules. The deputies don’t tolerate swearing directed at them! Once again, I make sure that the inmate knows that I am willing to see them again in medical clinic (on another day) if they behave. But the next time I see that inmate, I have a deputy standing right by.
Overall, this has worked well for me. In all the time I’ve been doing correctional medicine, I have only run across one inmate who told me that I had no right to criticize his speech and that he would say **** anytime he wanted. But he also understood that if he did say ****, I would not see him–except maybe in an emergency.
I think that this policy about acceptable language is part of the overall Safety and Security of the Facility. And the Safety and Security of the Facility is more important than any one inmate’s non-emergency medical visit.
As a medical investigator, I hear all manners of language. I also use a “three stike” rule in my encounters. I will ask the offender to please refrain from swearing, the first time. I will advise them strongly to stop swearing the second, and if there is a third, I simply end the dialogue, knowing effective communication cannot be established due to their unwillingness to speak in an appropriate manner.
However, there are some people who honestly do not know there is an alternative word to use to conve their thoughts and this is when I try to give them an appropriate word when I reiterate their thoughts back to them. This is usually met with acceptance and the offender remains receptive to the communication dialogue we have established.
Well put, Sandra. There are indeed some people who are vocabulary challenged and who can be successfully taught! Thank you.
Thank you for the clear procedure presented. This will help when there is resistance to respect in the clinic whether it is an inmate or an LVN. Unofficially I have been following this policy but have not been writing the inmate/patient up. I tell them I will see them when we can communicate better and they are able to talk calmly (after asking them not to swear a couple of times). I agree that the medical and custody staff need to model the correct behavior to the inmates. I will write up an inmate for manipulation “if you don’t order xyz, (usually MRI) then I will break my other xyz (fill in the body part) “.
One important aspect of written discipline for swearing at someone and/or calling someone a foul name is that whatever response is given in those instances, it should be consistent for everyone–deputies as well as medical staff. If an inmate invariably gets written up for calling a deputy a foul name, they should get the identical response for calling medical staff the same name. I personally don’t think that it should be a lesser offense to curse at medical personnel. Perhaps this would be a good topic for a joint meeting between security and medical–what will our response be to these incidents? Which words, threats etc should trigger a write up and which do not?
The process you describe is just right.
It would also apply to other comments – disrespect, disparaging, etc.
My favorite – your not even a doctor! While true is not helpful to either the patient or me.
Most facilities have some policy that identifies unacceptable behavior which includes disrespect of staff (that includes us) and a ‘write up’ is always available.
I’m sensitive to the fragility of the provider – patient relationship in jail. So, I avoid directly filing a ‘write up’ – preferring that the correction staff take that step. It is a double edged sword – appearing ineffective in a disciplinary manner vs having the inmate be upset at the officer. A good cause could be made for both sides of that issue.
I think all correctional providers have run into a variation of “You’re not a Doctor.” Even though I am a doctor, I’ve heard variations like: “You’re not MY doctor” or “You’re not a spine specialist” (or whatever other specialty the inmate thinks will “trump” my training). I’ve even heard “If you were any good, you wouldn’t be practicing in a jail.” All of these are attempts at manipulation, with specific goals. One goal of this type of lashing out is to provoke us and make us upset–which is an emotional state that the inmate can use to manipulate further. The appropriate response (and I’m sure you do this already) is “robotic” and non-emotional. I may feel angry or even hurt and insulted inside, but I should not let the inmate see that in my face or actions.
You are right that it is preferable for the detention staff to actually write the disciplinary write-up rather that we ourselves.
I usually don’t pay much attention to use of “casual profanity” as it is usually a part of how the inmates communicate. If it seems deliberate, that’s another matter and I do the same as outlined in the prior comments. Profanity aimed at me personally is reason to terminate the visit immediately. Likewise any hint of a threat is cause for visit termination and writeup.
All these comments are consistent with how I handle this fortunately uncommon (<5%) occurrence spectrum in the outpatient correctional setting. However, when charting the clinic encourter where the clinic visit is terminated by me due to patient noncompliance or inappropriate behavior, I always document the elective (rather than emergent) nature of the clinical encounter. Emergent patient visits are rarely terminated by me for any reason.
I handle this much in the same way. I have a no cursing sign posted in the waiting area which is very effective. The officers reinforce the policy many times before I have to say anything. Many of the repeat offenders that are familiar with my no swearing policy often warn the newer inmates when they hear them cursing in medical. If the inmates continue to curse after warned several times, the officer will escort them out of medical and lockdown time may occur. Having full support of the custody staff is very helpful also.