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

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.

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?

Inmates study staff and look for clues to answer this question. The more professionally we behave and appear, the less likely we are to become targets for setups. Secondly, conveying a professional image will likely improve our credibility with administration and security staff. It’s difficult enough to provide treatment in a non-treatment setting as it is without us undermining ourselves. Finally, the stigma we all face for working where we do would likely be lessened if we exhibited the same professionalism standards that our colleagues in the community exhibit.

So, how can we improve our professionalism?

First, we should dress appropriately. We shouldn’t be dressing as though we’re getting ready to watch the football game on the family room couch if we’re going to work. Dressing sloppily conveys a lack of attention to detail and a lack of taking our roles seriously. Dressing provocatively says that we may be willing to compromise boundaries.

Several months ago I read an article in Clinical Psychiatry News. It was written by a very experienced psychiatrist who had just started doing some corrections work. He felt sympathetic toward the inmates and began wearing green scrubs to work so that he would be dressed similarly to them. I am sure his intentions were honorable, but I feel strongly that trying to be more like inmates in order to bond with them is a big mistake. By doing so one is more likely to be seen as a sympathetic and easy target. I’ve come to believe that most inmates who are looking for quality health care would much rather receive it from someone who appears successful, polished, and detail-oriented.

Second, we should treat our patients respectfully and use a professional tone and language just as we would if we were working in the community.

There is no denying that treating prisoners can at times be very emotionally exhausting and thankless work. There will undoubtedly be some patients that we frankly don’t like and who behave in very hostile and disrespectful manners toward us. However, we must be certain that we do not lower our professional standards by responding with inappropriate behavior.

Third, we must maintain appropriate boundaries with our patients. This is one area where we need to be even more careful in correctional health care than do our community-practicing colleagues. In corrections, other than discussing our professional credentials, we should not be volunteering personal information or answering personal questions.

But wait, isn’t it more important that we’re caring individuals? Isn’t all of this professionalism talk a bit superficial?

Certainly being caring is one of the most important qualities that we can possess. But, if we lack professionalism, we’re not doing our best. And we’re undermining ourselves. We cannot complain about getting no respect if we do not behave respectably.

However, if we exhibit the above-mentioned traits of professionalism, we’ll likely be more effective at what we do. We’re likely to be more respected by inmates and others, we may feel better about ourselves and what we do, and we’ll be showing the rest of the world that working in correctional health care truly is a worthy and honorable endeavor.

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How many times do we condemn or agree before hearing the other side of a story? How many times do we stand accused of not listening carefully? How many times do we misinterpret or misunderstand a gesture, a word, an intention? Why do we assume that we know so much about other people’s lives even though we clearly do not? And, even if we did, why do we think we know what’s best when it comes to how others should live their lives?

Through our cumulative experiences in life, the figurative spectacles through which we see the world become tainted. We, unlike small children, lose the ability to see all things as they are. Instead, we see things through our tainted lenses and think we know best.

I recently wrote about how I feel judged by others in my role as a correctional psychiatrist. Maybe I just think that being judged is a negative when in fact it’s a positive. It’s a constant reminder to me of how I do not like to be stereotyped or judged. Consequently I am less likely to judge others.

Like most other mortals, I slide back to being judgmental at times. I really don’t intend to do so. In fact, I really want to be completely nonjudgmental. It’s frustrating to keep trying to be a better person yet inevitably falling down.

That’s one interesting twist about practicing medicine in prisons. I have the opportunity to work with people who have behaved very badly. Some of my patients have committed the worst possible crimes against their fellow humans.

What I’m not proud of is that when I see the news stories just after these criminals are caught, I sometimes have the same visceral reactions about them that many other people do. I’m outraged, indignant, angry. How dare these bastards do such things to other people! In the moment, I really want them to pay for what they did!

Some would say that it is healthy or “realistic” to have such a reaction. While I agree that it would be unhealthy to be indifferent to violent crimes, there is a definite difference between, on the one hand, disapproving of the actions of criminals and wanting to see them brought to justice, and, on the other hand, allowing the fact that others have committed crimes to result in one exuding hatred toward others. Fighting hatred with hatred never works. As Gandhi said, “An eye for an eye makes the whole world blind.”

A selfish benefit of the work I do is that I am presented with endless opportunities to judge others. If I gave in to this temptation, I would not be able to provide good psychiatric care. I am therefore nearly forced to be nonjudgmental. I like being in this situation. It is like having a personal growth program built in to my weekly schedule!

I have worked hard at this, though, and once I am meeting one-on-one with a patient, (nearly) all judgment is gone. I focus on what I am there to do, and I see the patient as another human being in need of assistance. I am far from doing it perfectly, but regardless of the person’s past, I treat him respectfully and try to see him as he is in the present moment.

Ironically, by writing this post on being nonjudgmental, others will judge me. Without knowing me, they will jump to conclusions. I will let them. My ultimate goal is not to be better than anyone else but to be better than I used to be. I have a long way to go, but I don’t plan to give up. Judging another says nothing about the person being judged. It simply says that the one doing the judging has a need to judge others.

Photo credit

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I used to have a more “normal” job.

Early in my career I worked in a large medical center and hospital and rotated through a call schedule. I got called into the ER regularly. I covered the inpatient unit and performed consultations on the medical and surgical units. I did all of the typical work tasks associated with a traditional practice.

Then I left it all.

I started working half-time in correctional psychiatry. I have worked in various other less traditional settings to fill the other half of my schedule over the years, but most of it has been spent working with people with developmental disabilities.

My work life is very, very different from what it was. I like many aspects of it now, and I’ll write more about that some other time. But, I have mixed feelings about having a job that is, well…weird.

Psychiatrists face a great deal of prejudice and stigma regardless of practice setting. Just go to a party and tell people you don’t know that you’re a psychiatrist, and you’ll understand what I mean.

Add to being a psychiatrist the fact that one practices in prisons, and the stigma and lack of respect issues intensify.

For example, in a 2008 survey by the American Correctional Association that was designed to identify the barriers to the recruitment and retention of educators and various health professions, 83% of respondents indicated that “lack of occupational prestige” was a top reason that retaining psychiatrists in corrections was difficult.

On the one hand, some people are quite curious about my field. I believe that this interest stems from a genuine curiosity that many have about prisons. They are forbidden places, extraterrestrial worlds into which most people never enter. In fact, wanting to give others a glimpse into this exciting yet disturbing domain was one of the original reasons that I started this blog.

Unfortunately, for every person interested in or fascinated by my unusual career choice, there are many more who have a negative reaction.

It’s not uncommonly a socially awkward pause followed by a forced smile and a disingenuous, “Oh, that must be interesting” comment. Simultaneously their body language screams, “Quick exit!”

I believe that more people assume that correctional psychiatrists either must be very strange for choosing such a line of work, or else they assume that we’re incompetent wannabe doctors not capable of having “real” practices.

I’ve been told several times over the years by nurses that I “seem so normal” compared to some of the other psychiatrists with whom they’ve worked. I guess I am supposed to feel flattered by such comments, but it is annoying always to be in an uphill battle against stigma and normalcy. The most recent comment I heard from a nurse, and I believe she’s said this to me at least twice, is that every time she hears the country song, “God is great, beer is good, people are crazy,” she thinks of me. Gee, thanks. Just how I want to be remembered!

I don’t dwell on these negative reactions about correctional psychiatry, and on most days they don’t bother me. I do what I do because I really do like it, and that’s what matters. I also do it by choice and am free to leave it at any time. There are even advantages to having a job that is less popular.

But, I’d be lying if I didn’t admit that, especially on a bad day, a part of me still finds it frustrating and somewhat depressing to have spent 9 years in medical school, residency, and fellowship so that I can have a position that I like and believe to be important yet is undervalued, stigmatized, and is thought of by many as, well…weird.

Photo: Tim Pearce, Los Gatos