Lockup Doc

A few months ago I performed an inpatient consultation on a non-incarcerated patient. His psychiatric care was being managed by a neurologist in another community.

I was shocked and disappointed when his family informed me that the neurologist told them that if the patient sought a medical opinion elsewhere, the neurologist would no longer treat the patient.

Even on a bad day I cannot fathom exuding such arrogance and insecurity! Hopefully this doctor’s attitude about second opinions is the exception and not the rule among physicians. However, this situation sparked my curiosity about second opinions.

Throughout my career, I’ve often encouraged my patients to obtain second opinions, either when Read more…

As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.

One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.

Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.

Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate,  prescribing habits.

My prescription style inevitably evolved further when Read more…

Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that  patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then Read more…

(The following is a fictional vignette based on thousands of real patient encounters. Any resemblance to an actual person is purely coincidental.)

The heavy door slammed with an echo he’d never forget. He thought he could trust her, but he had been proven wrong. He should’ve known not to trust anybody in prison. In fact, throughout most of his life he’d known only a few people he ever could trust. Naked, cold, humiliated and feeling as though he had been violated again, “David” now wanted to die more than ever. He didn’t care how; it didn’t matter if it hurt. He just needed to end it all. But, he would soon realize that it would be nearly impossible to do. Nearly ever imaginable method of suicide had been removed from him. He was now “safe” in the eyes of the prison, but he sunk into a deeper depression.

It was David’s first time in prison. He had spent a few days in jail prior to his current age of 22, but it was remarkable that he hadn’t gotten himself into more trouble. His father was a career criminal who had repeatedly emotionally, physically, and sexually abused him as he was growing up. David had grown up far too fast. He had had few boundaries and rules and almost no adult supervision in his younger years. He started smoking cigarettes at age 10, started drinking at 12, and was using marijuana regularly by 13.

Despite having the deck stacked against him, David was Read more…