Correctional Nurse Kim. She can say "No."

I recently read my friend Lorry Schoenley’s excellent article on Correctional Nursing is Different–Research Report which is about the differences between correctional medicine and traditional community medicine. Coincidentally, I also found myself at about the same time hiring a new full-time Physician Assistant with no correctional experience and having to explain how important these differences are.   If you do not recognize and embrace these differences, you can get yourself and your patients into serious trouble.  In this article, I am going to point out some of the important differences between correctional medicine and what I am going to call  “Outside Medicine.”

We Practice the Principle of Fairness

Outside medicine is not fair.  A patient with good health insurance will have a small co-pay for medication prescriptions whereas an uninsured patient will be unable to afford many medications.  The insured patient also will get tests and treatments that  will be refused the uninsured.  There should be no such discrepancy in corrections.

A more subtle but still important example has to do with practice variations.  When I worked in the emergency department, I had a partner who always prescribed antibiotics for sore throats.  I rarely did.  So on those occasions when we were working together, you could come to the ER with a sore throat and if my partner picked up your chart, you would get an antibiotic, whereas if I happened to pick up your chart, you would not get an antibiotic.  That sort of discrepancy does not work well in corrections.  All clinical encounters are discussed back in the dorms.  The inmates will figure out that practitioner A gives out antibiotics (or extra mattresses or cold medication or whatever) and practitioner B does not.  They will preferentially want to see practitioner A and write grievances about practitioner B.  Practitioners within a facility need to get together and set up basic practice standards that everyone adheres to.

Likewise it is not fair to make exceptions to practice standards for favored inmates.  Everyone gets tempted to break policy for an inmate with an exceptionally good story.  But (to use one example) if you give a sleeping aid to one inmate, the Principle of Fairness says that you have to give a sleeping aid to every inmate who asks for it.  If you freeze off a wart on one inmate, you must freeze off warts on every inmate who asks.

Our Patients Do Not Go Home

I came to correctional medicine from the emergency department.  There, we often do not know if patients will follow-up as we advise them to do.  In fact, we often are pretty sure that they will not.  So we emergency physicians develop an attitude that this ER visit is our one and only chance to make a diagnosis.  We will order every test we think we might need because the patient is not coming back; this is our one shot.

Correctional Medicine is much different.  Our patients are not disappearing; they are going down the hall to a different part of the building.  We know that they will keep their follow-up appointments.  In fact, they will probably be checked on frequently in the meantime.  If the patient has prescribed medications, the nursing staff will at least see them face-to-face once or twice a day.  The deputies will be watching them. Our ability to keep track of our patients between visits is very important.  It means that we can and should have relatively less reliance on tests and more reliance on observation and scheduled follow-up.

I call this “The 8 Hour Test” or simply “The Test of Time”  (you can order a 4-hour test, a 24 hour test or any other time period you want depending on the clinical situation). These should be thought of as a formal test.  They tell you how a disease progresses with time. As an example, let’s take a patient with abdominal pain and a so-so exam.  He might have appendicitis, but probably not.  In the ER, since I would worry that he might not come back if I discharge him, I would get a CBC (even though it would likely be worthless) and maybe even an ultrasound or CT.  But in the jail, where he is under observation, I would more likely order an 8-Hour Test.  I know from experience that in 8 hours, he will not be the same; he will either be improved or he will be worse.  So I have him re-checked in medical in 8 hours.  Has his temperature changed?  Is he eating?  Has the pattern of his abdominal pain changed?  I actually will get far more clinically useful information from the 8-hour test than I would have from a CBC at the initial visit.  If he has improved in 8 hours, then I am very sure that he does not have appendicitis.

The bottom line is that we in correctional medicine should take advantage of our ability to follow our patients closely.

We Verify Patient History

In correctional medicine, we must verify patient histories to a much greater extent than is done outside of correctional facilities.  If a patient says that she takes medication X or last saw Doctor Y last week or had surgery two weeks ago, we must verify the stated history.  The nurses in my jails spend a good part of their day verifying patient history in order to get the current med list right and to coordinate care properly with outside physicians.

A patient in one of my jails stated that she had a PAP smear done 6 months ago that was abnormal and she was supposed to follow-up “immediately” with a gynecologist, presumably for a culposcopy.  However, when we tracked down the PAP smear results, they were normal.  Another patient stated that his orthopedist wanted him to wear a neoprene brace on his knee following a knee injury 2 years ago.  However, the orthopedist, when contacted, laughed and told us he does not believe in neoprene braces.  He actually recommended rehabilitation exercises which the patient never did.  A third patient stated that she was currently taking warfarin.  She even brought some in to the jail with her, though it was out of date.  However, when we checked, her internist had discontinued the warfarin 4 months previously.

We Say “No.”

Outside doctors are not only practicing medicine; they are also running businesses.  Their patients are also customers.  Doctors on the outside must keep their customer/patients happy or the patients will leave.  A physician who is too abrasive or not accommodating enough will find himself without a viable practice.  I have seen several medical practices fail for this reason. Because of this aspect of outside medical practice, outside practitioners generally give patients what they want.  If a patient wants a sleeping pill, she will most likely get a sleeping pill.  If the patient wants the new drug advertised on TV, their doctor will likely prescribe it.

However, in corrections, we find ourselves in a much different practice environment.  Our patients are not customers; they are our patients, period.  Our obligation is to practice good medicine, not necessarily to make them happy.  Consequently, we in correctional medicine say “No.”  A lot.  We have to say “No” in order to do our jobs properly.  We have to say “No” in order to be fair (see principle #1, above).  We have to say “No” in order to maintain the safety and security of our facility; something outside physicians seldom have to consider.

The problem is that medical personnel new to corrections usually have little experience saying “No.” It is a new skill that they have to learn.  There is a right way and a wrong way to say “No” that should be taught to new correctional medical employees (blog post on this subject coming soon!).  However, many of them (more than half, in my experience) cannot master this skill and so fail as correctional providers.

Are there other important differences between correctional medicine and outside medicine that I have not mentioned?  Please comment.