When it’s time for work, Catherine R. Judd, MS, PA-C, goes to jail. Marybeth Floyd, FNP, BC, heads to prison, and so do Kim Dotson, PA-C, and Linda Gruenwald, ARNP. These clinicians are among the many who work in a correctional facility, providing health care to an incarcerated population—many of whom might not have readily accessed such services “outside.”
While correctional facilities vary in their set-up and security level, most practitioners agree that working in these settings has given them opportunities they would not have had in primary care.
“Our patients present very unique challenges, but working in this environment has made me a stronger clinician,” says Dotson, who has worked for the Washington Department of Corrections at Airway Heights Correction Center for seven years. “I see things in prison that I could go a whole career and never see outside that population.”
READY FOR ANYTHING
Much like the general population, the inmate population in the United States has a significant amount of chronic illness—everything from hypertension, hyperlipidemia, diabetes, and hypothyroidism, to HIV and hepatitis C. There are patients with renal insufficiency and kidney disease that requires dialysis. There are mental and behavioral health issues, gastroenterology complaints, and dermatologic disorders.
“What is unique about corrections is that if you were in the community as a family practice clinician, you would see things and then refer the patient to a specialist,” says Gruenwald, who has spent 10 years with the Oregon Department of Corrections at the Two Rivers Correctional Institution. “But in the DOC, you really get the opportunity to learn about these complicated disease processes, because you are expected to care for that patient.”
The available services vary by location, but most correctional facilities have what would be considered an outpatient clinic and an infirmary. The latter often functions in a nursing-home or assisted-living capacity, in addition to housing patients who require more acute care, such as IV antibiotics or wound care. Airway Heights Correction Center has a lab and x-ray services on site, although specimens are sent off-site for processing and films for radiologist review. At Two Rivers Correctional Institution, dental and optical services are available, as well as dialysis. The Dallas County Jail, where Judd has worked for eight years, also has a dialysis unit and a full-time obstetrician-gynecologist to provide women’s health care.
Judd herself works in mental health services, which provides care to about 1,500 inmates out of the approximate total population of 7,000. Her unit manages patients who, if they were in the community instead of in jail, might be hospitalized for major depression and/or suicidal tendencies, as well as persons with (possibly untreated) schizophrenia, bipolar disorder, and other psychiatric disorders.
“For many of the patients who come here, we are their only access to medication. We may be the only door that will open to them for mental health care, because if they come to jail, they’re going to receive care,” she says. “I would say the same for the medically ill—for many of the women, the only time they’re going to get a Pap smear or a pelvic exam is when they come to jail and get their Ob-Gyn services here.”
The volume of patients and the lack of access to care in the community (whether through circumstance or choice) results in a variety of ailments for correctional medicine clinicians to identify and address. “You get to see so much more pathology, things that when they teach you in school, they say, ‘Well, we’ll tell you about this, but you’ll never see it,” says Floyd, who is a Regional NP in Arkansas with Corizon Health, an organization that specializes in medical staffing for correctional facilities. “I see those things.”
Some of the more unusual diagnoses include Fournier’s syndrome and Henoch-Schönlein purpura. A patient with the latter condition was taken to an emergency department with gastrointestinal bleeding, at which time it was discovered that the disease had already started to damage his kidneys. When he was stabilized, he had to return to prison. In such cases, the medical/nursing staff on site needs to understand how to manage the condition.
“When that patient comes back to our facility, we have to do that follow-up care,” Gruenwald points out. “We have to determine how to monitor him, what medications he’s going to need—with the help of a specialist, of course.
“But when it comes right down to it, you are still the primary care provider and so you have to have some type of knowledge about the diagnosis and treatment.”
Obviously, one of the biggest issues in corrections medicine is safety and security. This is one area where, regardless of the specifics of a facility, the general “rules” are universal.
“There are certain things you learn through years of working with this population,” Gruenwald says. “It just becomes second nature—you never get yourself in a position where you can be pinned into a corner.”
Dotson, for one, has her exam room set up so that she is always positioned between the patient and the door. “You just have a heightened awareness with the patients, with your surroundings, with who is walking by in the hall,” she says.
Another commonality among correctional health services is that the exam room doors stay open in most instances. “If you have to do, say, a rectal exam, you will have another member of the medical staff come in and you’ll close the door,” Floyd says. If the patient is from a maximum-security unit, a security officer will remain in the room, although efforts are made to provide the patient as much privacy as possible.
At the Dallas County Jail, security officers are present when medical staff see patients in the housing area. If lengthy history-taking interviews are required, they can be conducted in the visitation booths where attorneys typically meet with clients, as these are designed with safety and privacy in mind.
“Many times, we will say we feel safer seeing our clinic patients here in the jail than we would if we were out in the community or over at Parkland [Health and Hospital System] in the emergency department,” Judd says.
While most corrections medicine clinicians share that sentiment, it doesn’t mean that safety concerns never cross their minds. “There are times as a clinician when you have to get right in there and listen to lung sounds,” Dotson says. “Could the patient take my stethoscope and wring my neck with it? Sure he could!”
To work in a prison, you have to be on guard without letting safety concerns compromise patient care. “You can’t just blindly trust people,” Dotson says. “I don’t think I’m paranoid; I’m just cautious.”
Providing care to an incarcerated population often means working around security limitations. For example, in some facilities, the hours when clinicians can see patients may be dictated by the rest of the prison schedule—when inmates are required to be at meals or in the place designated for daily counts. Many corrections clinics will limit the number of patients who can be in the waiting area at a time, with a security officer as a “gatekeeper.” For patients who require transfer to an outside facility, this can be scheduled, but the exact details may be withheld for security reasons.
THE TRIALS AND LIBERATIONS
Caring for an incarcerated population may raise an ethical dilemma for some. While inmates’ right to health care is guaranteed under the Eighth Amendment, how do clinicians manage to overlook the crimes for which their patients have been convicted?
“That’s one of the things I’m careful about—I see them as patients,” Floyd says. “I make it a practice that I don’t ask, and I don’t look to see what they’ve done. I don’t want that to potentially influence me.”
“I’m not going to lie; it’s a challenge,” Gruenwald admits. “But I’m not here to judge—they’ve already been judged.”
“The bottom line is, I’m a health care practitioner, and this is what I do,” Dotson says. “If I find that I am unable to be objective, I have to pass those difficult patients on. Now, someday, if those patients start becoming too many, maybe it will be time for me to move on.”
For Judd, working in a jail as opposed to a prison means that she encounters people who have been arrested and are waiting for the court system to deal with their charges. “It quickly became apparent to me that so many of the mentally ill people who are in jail wouldn’t be here if we had better mental health services in the community,” she says. “They wouldn’t be in jail for criminal trespassing or theft, for stealing food because they didn’t have any money to buy it or for burglary of a vehicle because they were looking for a place to sleep.”
Working specifically with the mentally ill population highlights challenges that are echoed elsewhere in the corrections system. “One of our biggest challenges is sorting out those who need medication and will benefit from it from those who are just manipulating the system and possibly drug-seeking,” Judd says.
Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”
On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”
There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)
“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”
Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.
“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”
“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”