Here are the most popular posts from last month based on the number of views:
1. Treating patients who have been convicted of murder
2. A very comprehensive list of medical blogs
3. How to fit many medical blogs into your busy life
4. Five reasons to consider practicing correctional medicine
5. Saying no to patients while maintaining the doctor-patient relationship
Do you have a favorite?
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.
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Saying or hearing “no” in any circumstances involves setting a limit with others or having them set a limit with you. It invariably involves some degree of confrontation. Although learning to say no can be liberating, most people would prefer not to be put in situations where setting limits is necessary.
One of my least favorite but necessary tasks as a physician is saying no to patients.
In the ideal world, doctors wouldn’t have to deny patient requests. Patients would read information only from reliable web sites. Direct-to-consumer marketing of pharmaceuticals would not exist. Patients with addiction histories wouldn’t ask for potentially habit-forming pain and anxiety medications. Doctors would always listen carefully to patients. Doctors would arrive at carefully thought-out formulations of their patients’ problems and then would explain all reasonable treatment options thoroughly. Ultimately patients would then make informed, logical decisions about their health care. Everyone would be happy!
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Here are the top posts from March 2010 based on the number of views:
1. When should psychiatrists discuss their own lives with patients?
2. Can anyone become sadistic if given too much power?
3. Lockup Doc’s interview with a former correctional officer
4. Antisocial personality disorder and psychopathy: What’s the difference?
5. Reducing our temptation to blame the patient
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:
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Like it or not, life is full of them: difficult, demanding, hostile, rude, irritable, aggressive, arrogant, and “manipulative” people. Fortunately most do not have all of those traits! But, in our journey called “life,” we all must interact with people who push our buttons, challenge our patience, and even make us have hateful thoughts that we may shamefully hide from others.
Some of these unpleasant people we may choose to avoid. But, there are many others we cannot: patients, coworkers, and close family members. And, if you provide health care in any setting, but especially in a prison or jail, you already know how the more challenging patients can turn a good day bad, cause your hair to turn gray, and make you seriously consider changing your work setting.
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When I first started working in corrections, I was discussing with a seasoned prison psychologist the unique challenges that all helping professions face in a prison environment.
He told me that prisons have always been staffed by “Nazis and Saints.” He was referring to two diverse groups: one wanting to punish people and the other wanting to help people. Of course he did not mean this literally, but it was a useful metaphor for me when I was new to practicing medicine behind bars.
In reality, the literal truth lies somewhere in the middle. Most security staffs are not “Nazis.” I’ve met many dedicated officers who take their jobs seriously and want to see inmates change their ways for the better. These officers accept me and the role I play and realize that when mentally ill inmates are stable, it benefits everyone. Likewise, there are probably health care professionals who are attracted to correctional work because they want to punish people.
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Reducing health care costs is a daily news topic lately. Correctional health care costs are also very high and continue to rise.
While I believe that we should continue to explore ways to reduce correctional health costs, the obvious but politically unpopular issue that needs to be addressed is the fact that these costs would be much lower in the U.S. if we didn’t have by far the world’s highest rate of incarceration.
This exorbitant and increasing incarceration rate combined with an aging inmate population is going to drive costs steeply higher. The percentage of older inmates (over 50) is expected to rise sharply over the next decade. In fact, according to this post from California Budget Bites:
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It’s probably happened to all health care professionals at some point: Patients, especially those considered “difficult” for some reason, fail to improve despite our best efforts. Eventually we become frustrated enough that we then blame them for their lack of progress.
There are endless possible scenarios where this might occur:
- A depressed patient, who transiently appears to have a personality disorder because of her inadequately treated depression, is not progressing in psychotherapy and has not responded to two different medication trials.
- An elderly man bounces back for readmission to the hospital for a CHF exacerbation. He arrives in the ER with a pack of cigarettes in his shirt pocket.
- A morbidly obese woman continues to have poor control of serum glucose, blood pressure, and lipids despite aggressive pharmacotherapy. Yet the patient has lost no weight despite being counseled for years about the need to do so.
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As correctional health care professionals, there may be times when we are tempted to conduct ourselves in a less than professional manner simply because we can.
We may be able to get away with speaking to our patients rudely, using profanity profusely, or wearing inappropriate clothing. After all, we work in jails and prisons. This culture is far from prim and proper. And, our patients are inmates. Many may tolerate misbehavior from us that patients on the outside would not and should not tolerate.
I’ve previously written about how I’ve found the book, Games Criminals Play, to be an invaluable resource. One key point that I learned is that many inmates, especially those trying to set up and manipulate staff, want to know whether each prison worker is a fellow inmate or “the police.” In other words, do we side with the inmates, or are we professional workers who take our jobs seriously?
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