I recently published a post asking for readers to submit questions to me that they might have (primarily about my profession). I’ve paraphrased when necessary:

1. “Why do people who truly do have mental issues despise taking their medicine-often times going off of it and landing themselves back into the hospital due their condition? They say they don’t need the medicine-but obviously they do. And those who fake an illness love their medicines and will fight, steal and lie to have these medications.”

A: Most people do not actually want to have a mental illness. For various reasons they resist it and can be in some degree of denial. One aspect of some mental illnesses is also a lack of insight (or varying insight depending on how sick they are). People who fake illnesses for secondary gain (entitlements, attention, etc.) have a large incentive to stay in the illness role to obtain what they seek. The better they play the part, the less likely their cover will be blown.

2. “Do you have any risk management tips? What are some practical things correctional medical and mental health providers can do to minimize lawsuits by inmates?”

A: Excellent questions. And they require answers too lengthy to write here. Therefore I’m going to do a post on risk management issues in the next week or so.

3. One reader recently sent me an e-mail expressing frustration that I do not publish posts on transference issues. Specifically she was interested in material about patients who have romantic feelings toward their psychiatrists.

A: As a male psychiatrist who currently spends much of his professional time treating male inmates and who is not formally practicing psychotherapy, you’re not likely to find articles about patients and psychiatrists having romantic feelings for each other. I’m just one person doing what I do here for free (actually I pay money for my blog; I spend hours each week writing for free). I simply can’t and am not interested in covering everything. Readers interested more in psychotherapy issues with psychiatrists may want to check out Shrink Rap, a psychiatrist blog by 3 psychiatrists (2 females and 1 male). Dinah, one of the psychiatrists there, has a psychotherapy practice and often posts about therapy issues.

4. How could a librarian (presumably in a correctional facility) help inmates to better understand their health conditions?

A: That’s a tough one. I’m vaguely familiar with the library resources that have been available to inmates in the institutions in which I’ve worked–what’s available seems to vary quite a bit from one place to another. Given the less than high school education that many inmates have, I would say that helping them to find books that would be appropriate to their reading levels would be most helpful.

5. “How do you keep from getting frustrated with recalcitrant/dense/reluctant to take your suggestions types, and how do you keep your cool at the times you’d really just like to reach across the table or whatever and shake your patient and say “WHY AREN’T YOU GETTING THIS?!?!!?”

A: I do get frustrated at times. I wouldn’t be human if I didn’t!  But,  I guess that over the years I’ve learned to be more patient with patients, even difficult ones. What helps me is that I see myself as a consultant to my patients. I’m not there to rescue them or save them from themselves. I do my best to establish rapport with them, assess them, educate them, and provide my opinions and recommendations. If they choose to ignore my recommendations, then I document everything and move on. If they change their minds down the road and  want to work with me, then I’ll gladly do it. I don’t take it personally. It’s about them, not about me. As far as patients “getting it,” some people never will. But I believe that establishing a good therapeutic alliance is one of the keys to being able to make a difference. Patients care much less about what you have to say until they know they can trust you.

6.”Particularly in the setting you work in, how do you manage to avoid coming down with, for lack of a better term, secondary PTSD? It’s got to suck to sit and listen to what are undoubtedly some pretty horrible stories for hours on end and I can’t imagine it’s possible not to be affected by what you hear.”

A: Honestly, it’s very draining at times. For me personally, having variety in my schedule (I don’t just work in corrections) is key. I do think I’ve learned to cope with it better over time. However, I’ll have to say that I also think it’s something that some people can naturally do more easily than others. It may sound like an oxymoron to be able to be a sincerely caring person and at the same time realize that you need to do your little part each day to try to help others and then forget about it when you walk out the door, but that’s what I try to do. You can’t save the world. I’ve come across some very caring health care professionals in non-correctional settings who could never survive working in a jail or prison. They would get so emotionally wrapped-up in all the drama and trauma that they would lose their ability to objectively assess their patients. They’d run into boundary issues (they’d become enmeshed) because they’d want to rescue all the unfortunate patients they treated. And that’ s just not healthy for the patients or health care workers. I know that may be difficult for some people to understand, but it’s so true. And these would be the ones, in my opinion, most likely to be traumatized from their work.

Thanks for your questions. I hope some of my answers made sense! Feel free to leave your comments.

Photo by e-magic

Doctors, nurses, and other health care professionals often find themselves in situations where they must speak up for their patients. Typically such patients either do not realize what they need, do not know how to ask for what they need, or they lack the authority to obtain what they need.

The circumstances and challenges of advocating for patients vary significantly depending on the practice setting. I’ve previously written about how practicing in correctional settings presents unique challenges. Essentially the main challenge in any jail or prison, regardless of how “treatment-friendly” it may be, is that a correctional facility exists for the primary mission of security, not treatment.

So, if you’re a health care professional in corrections and you have a patient who needs your voice, how can you go about being an effective advocate?

1. Identify what your patient needs as clearly and concisely as you can. Be mindful of the implications of your request on security staff and on the security of the institution. Consider the potential problems it might create with other inmates wanting the same privilege or exception for themselves. Be realistic, and keep it simple. The more complicated the request is, the less likely that security or administration will be to give approval.

2. Rely as much as possible on facts, data, and the science of your profession to state your case. For example, if you are a psychiatrist or psychologist and strongly believe that your patient needs to be moved away from his current cellmate because he is either a dangerous predator likely to kill or a vulnerable, likely victim, then do not base your concern on how the situation makes you feel. You’ll be more effective if you’re seen as rational and logical. In this particular case, if you can cite results from psychopathy testing or IQ testing to bolster your concern, you will have more credibility. It’s much more difficult to argue with facts and science than with emotion.

3. Choose your battles wisely. If you never find yourself speaking up for your patients, then you may be missing opportunities to help them. After all, many patient needs are not self-evident; nor are they obvious to non-health care professionals. But, if you feel as though your are constantly battling for your patients at every turn, then you may have an unrealistic viewpoint of what can be accomplished in a correctional facility. You’ll be more likely to become cynical, burned out, and you may lose favor with administration and security and be seen as a trouble-maker. And the unfortunate end result is that you will be less helpful to your patients. You’ll have much more credibility if you carefully choose your requests.

4. Think win-win. Even though it may require a concerted effort on your part, you are more likely to work collaboratively with those in power if you think of yourself as being on the same team. Follow the chain of command in your system, and do not undermine those with authority in order to promote your cause. For example, e-mailing the world about your concern in an effort to force others to be accountable may help you win the immediate battle for your patient, but you’re sure to lose the war. Administration and Security may not understand your profession, but if you present yourself as professional, organized, rational, mindful of security concerns, and asking for special accommodations only when necessary, you are more likely to become an effective and respected patient advocate.

Photo by Christiana Care

In the U.S., correctional facilities are required by law to provide inmates with access to medical care. As health care costs have spiraled out of control everywhere, jails and prisons have attempted to develop innovative ways of reducing this hefty financial burden while simultaneously meeting their legal obligation to provide care.

One approach that has gained significant popularity in recent years is to require inmates to pay a small fee, usually less than $10, to gain access to medical care in certain situations. There are arguments both for and against these co-pays. I’ll list just the main points.

Proponents argue that co-pays reduce the abuse of urgent appointments as well as the over-use of routine medical visits for frivolous complaints. They believe that requiring inmates to invest financially in their own care encourages personal responsibility–outside of prison, required co-pays are the norm for most people. Since inmates spend money on toiletries, candy, and chips, co-pay supporters therefore believe that inmates should be able to contribute something toward their medical care.

Those opposed to co-pays point out that most inmates are already indigent, and taking money away from them that they would have used to buy toiletries, postage stamps, and other similar items would be unreasonable. They express concern that requiring payment reduces access to care (and access to care still is very poor in some correctional systems). Inmates may put off seemingly minor health problems that could worsen and ultimately result in an increase in morbidity, mortality, and cost. From an institutional public health standpoint, inmates with infectious diseases may be more likely to go untreated, resulting in the unnecessary spread of illness to staff and to other prisoners.

I have personally observed inmate behavior in systems both with and without co-pays, and I have seen both sides of the issue in action.

In my opinion, some inmates with no personal investment in their own care may tend to behave in an entitled manner, may be less likely to follow treatment recommendations, and may have unrealistic expectations of the medical team. On the other hand, I have seen inmates who are required to pay something for their care put off much needed medical attention simply because they could not afford it.

How have the courts reacted to inmates who have challenged co-pays as being unconstitutional?

According to attorney, Robert P. Vogt:

The general rule appears to be that it is not unconstitutional to charge inmates a co-pay fee for the provision of medical services provided that needed medical services are not denied simply because the inmate cannot pay. This general rule attempts to strike a balance between correctional facility obligations and inmate responsibilities.

Courts have recognized that the constitution ‘guarantees only that inmates receive necessary medical care; it does not guarantee free medical care.’

For jails and prisons considering starting a medical co-pay program, the National Commission on Correctional Health Care (NCCHC) has published a position statement on the issue. In principle, the NCCHC is opposed to co-pays on the grounds that already-scarce correctional health care resources may become less accessible. However, they do list guidelines that should be followed for those wishing to implement a co-pay program.

While on the surface the concept of whether inmates should be charged co-pays for medical care may seem straightforward, the practical aspects of implementing such programs without reducing access to needed care are quite complicated and fraught with numerous ethical and legal issues.

What is your opinion–should inmates be required to pay something for their health care?

Correctional psychiatrists inevitably treat patients who have been convicted of a broad array of crimes. There is a correlation between the security level of the institutions in which one works and the severity of the crimes of the inmates being housed there.

Since I’ve treated inmates of minimum, medium, and maximum custody levels, I’ve had the opportunity to work with people who have been convicted of everything from drug possession to multiple murders.

What’s it like treating patients who have killed other human beings?

First, after one has treated inmates for a while, the crimes that they have committed lose their shock value. It’s neither glamorous nor anything like the interviews of Hannibel Lecter in “The Silence of the Lambs.” However, when working with them, I never forget that because of their past actions, many have the potential to kill again.

While the criminal history of my patients is pertinent to their psychiatric treatment, to me it’s usually just one piece of information that is of varying importance from one case to the next. However, it’s typically not the focus of my treatment of them.

Second, it’s not a simple question to answer, primarily because homicide perpetrators are a very heterogeneous group.

At one extreme are those whose actions have resulted in the accidental death of others, such as those who have caused a fatal motor vehicle accident while intoxicated. At the other extreme would be those who have intentionally committed multiple murders. In the middle would be inmates who may be remorseful for having impulsively killed out of anger, sometimes while under the influence of drugs or alcohol.

While inmates who have killed may be different from each other in many ways, one commonality is that many are serving life sentences and will someday die in prison. This results in a unique treatment situation, even for a prison psychiatrist. How does one help to give a prisoner hope when he’ll never get out of prison?

An article in Psychiatric Times focused on this issue in “Discussing the Meaning of Life with a Lifer.”

The author points out that the rate of mental illness in prison is even more pronounced among lifers (approximately one in four lifers has mental illness).

Consistent with my own observations, he also mentions that some lifers have a “nothing to lose” nihilistic approach to life while others in the same circumstances gradually accept their fates, find meaning in their lives by focusing their efforts on others in positive ways (an outward focus instead of being concerned only about themselves), and ultimately do well.

Not surprisingly, given that they want to better themselves, this latter group typically is the more rewarding for psychiatrists to treat.

I have also learned many life lessons from this cohort as well. One is the great degree to which happiness or life satisfaction is related to the way in which we respond to our circumstances much more than to the circumstances themselves.

It is because of this concept that some prisoners can be “free,” at least in their minds. Likewise, many of us who are not incarcerated may feel imprisoned by our own lives, primarily because of how we process our circumstances. It’s not difficult to understand this concept intellectually, but it is much harder to practice changing how we look at things in our own lives, especially when we face adversity.

On the other hand, treating the more nihilistic, hopeless patients can result in a psychiatrist feeling helpless and ineffective. Nevertheless, many of these patients still need our help even if the percentage who may benefit from our interventions is small.

If you’ve worked with inmates, what have your experiences been?

Photo by remuz

I’ve previously written about the many challenges of practicing medicine in correctional settings. But if there are so many cons (pun intended), why should anyone consider such a career?

Well, there are many benefits to it as well. If you are a psychiatrist or primary care physician and are either looking for a change or just starting your career, you may want to consider correctional medicine.

Although I’ve done correctional work for quite a few years, my experience has been limited to one geographical area of the country. I contacted correctional healthcare recruiter, Vikkie Schill, from MHM Services, Inc., to help me to convey accurate information about this topic. I want to take this opportunity to thank her for her input. I have no relationship either with Ms. Schill or with MHM Services, Inc.

Here are my top 5 reasons to consider a career in correctional medicine:

1. The patients: Believe it or not, I enjoy working with inmates. Most of my prison patients are polite and genuinely appreciative of my efforts to help them. Sure, if you work in corrections you’ll have to deal with some drug-seeking behavior or other attempts to get you to provide special privileges, but these situations comprise a small minority of patient interactions.

The patient population also is quite diverse. Physicians can expect to see the full array of psychiatric and medical problems. You’ll need all of your professional skills to treat inmates, and you’ll also be treating an underserved population.

2. The hassle factor: Would you like to do what you were trained to do and focus on practicing medicine instead of dealing with other administrative, insurance, regulatory and business hassles? In corrections you can.

Yes, you’ll have to work within a formulary, but in most cases it should be one formulary and not several. You won’t be dealing with prior authorizations, denied claims, billing, collections, coding, paying for overhead, hiring staff, or (in most cases) purchasing your own malpractice insurance. You won’t have to phone-in prescriptions or return phone calls to patients, either. (Inmates communicate with their doctors by submitting written request slips. You will have to spend some time replying to those, but this a more efficient process than playing phone tag with patients.)

3. Getting paid: You will earn a salary or hourly wage. If you cannot see a patient because he refuses to meet with you or because security procedures interfere with your appointment schedule, you still will get paid.

Vikkie Schill informed me that in her company, which provides health care services for many correctional systems, physician salaries vary from state to state. In most cases they are comparable, and in certain cases higher, than in other practice settings. She also mentioned that for early career psychiatrists, MHM Services’ starting salaries tend to be more competitive than those of private practice or hospital settings.

4. Patients’ access to treatment: It is frustrating to treat seriously ill patients in the community and for various reasons have them not follow through with appointments or take needed medication. Since inmates do have a constitutional right to health care and reside in the structured setting of prison, these challenges are much reduced. Most patients do come to their medical/psychiatric appointments. Their medications are paid for, and adherence to prescribed medications is logged.

5. The structure and flexibility: The highly structured nature of prisons makes providing health care there more structured and predictable as well. Have you ever had the experience of having a waiting room full of patients (who have busy schedules, too) while you’re running way behind, the phone is ringing endlessly, and some emergency is happening? I have too. I’ve worked in that type of environment in the community. You will certainly be busy practicing correctional medicine, but you probably won’t find yourself multitasking as much. If there is an emergency, you will be more likely to be able to focus on it. Everything else can wait. If routine patients need to be rescheduled, it’s not a problem.

Many physician positions in corrections offer flexible work arrangements and hours. You can work part-time or full-time. (In my opinion, combining part-time corrections work with part-time non-corrections work is the best way to achieve more professional balance and reduce one’s risk of burnout.) Depending on where you work, you may have little to no on-call responsibilities. Typically there are no weekend hours. And, you probably won’t even be allowed to work on holidays.

So, are you curious about working in corrections? It’s not for everybody, but for some doctors, it’s a great option. Do you wonder if you’d be suited to correctional work? I previously wrote an article about the ideal traits of a correctional psychiatrist that may give you some ideas.

If you already practice medicine in corrections, please feel free to share your experiences and opinions.