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Becoming a Physician Associate had been a lifelong dream. After entering the Air Force at age 18 and attending the initial medical technician training program, my military career led me from ward work to a clinic far from the main base. The rest of my 21 years in the service was spent in the emergency room and on independent duty (working with one other technician or alone providing care for assigned personnel) but my career would ultimately lead me to correctional medicine.
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After preparatory training of senior ER technicians (originally called ‘Clinical Assistants’), the physicians were prepared for the first PA students, from an early class, who came to our base. The physicians set up semi-formal classes, an upgraded in-service, and established a fairly loose set of ‘protocols’. Clinical Assistants were guided by physicians through patient encounters and when each demonstrated a grasp of the diagnostic process, that situation and its corollaries could be managed independently.
ER technicians were responsible for patient intake and at a brief history and exam. They would present to the physician on duty. ER techs also provided emergency care at the level of an EMT Intermediate including suturing, casting, starting IVs, wound/ burn care, and administering medications. At that point, my only goal was to become a PA. Never did it occur to me, however, that correctional health was in my future.
From Military Medicine to Correctional Health
While later working in the ER as a PA after retiring from the Air Force, the company that employed me asked if it would be possible for me to ‘fill in’ at a couple of jail clinics that they supported. Being a collaborative person, I said, “of course.” This company later withdrew from the jails and I was asked by a jail administrator (also retired Air Force) if something could be done. From there, my career in correctional health seemed to take on a life of its own. Within five years, I formed a small company and provided medical services for five county jails. We ultimately grew to cover jails in 10 counties.
While health care in jail is different in some ways, sick is sick. Similar to a general practice in the community, correctional health PAs perform physicals, take sick call, and manage emergent issues. The frequency of sick call depends on the size of the jail. A small jail (1-49 beds) may only require sick call once a week. A medium jail (50-249 beds) will require staff trained in nursing, mental health, and substance abuse.
Sick call here will last multiple days. Large jails (300-999 beds) require all of the above and may have a full-time medical provider. Large jails may also have in-house obstetrical, dental, and specialty clinics. Then there are mega jails like the LA County jail in California. This mega jail has thousands of beds and has the distinction of supporting the largest inpatient mental health hospital in the US.
Jail vs Prison
Correctional health care also differs between jail and prison. A city or county operates a jail and a majority of the incarcerated are pre-trial or in for probation violation. The average length of stay is often 14 days or less. The state or federal government operates prisons and the incarcerated are all convicted. The length of stay in prison is measured in years.
County jails are all individual with the exception of a few multi-county facilities. There are state standards but their application is varied. State and Federal facilities are usually part of a unified system with a coherent set of standards and guidelines.
The Basics of Correctional Healthcare
Treatment of offenders with a diagnosed issue is nearly the same as in any situation. There are some differences though. The first guiding principles in any correctional facility are safety and security which can be an overriding concern. While medical personnel may work in the jail they are not employees of the jail. So, with limited exceptions, healthcare personnel require an escort by a correction officer at all times.
The guiding principle for health care is ‘Medically Necessary’. Convenience, cosmetics, and curiosity are not considerations. Medical services are designed to provide treatment for those offenders whose’ illness, condition, or injury is deemed medically necessary by correctional facility health care staff. Treatment of a condition is medically necessary when after clinical assessment the patient is diagnosed with a condition manifesting symptoms or signs of sufficient severity that the absence of the considered therapy could reasonably be expected to result, during their current incarceration, in one or more of the following:
- Placing the patient’s (or other individuals’) health or life or serious jeopardy; or
- Increasing (or producing) permanent impairment of bodily function; or
- Continuing or accelerated deterioration or loss of bodily function.
Another important consideration, particularly for chronic conditions, is maintaining continuity of care upon release. Many offenders have no primary care provider or insurance. It is critical to prescribe medications that are affordable and to educate on self-treatment and preventive health care. Making a connection with free clinics and medication support programs is also important.
Strengths of Correctional Medicine
A great strength of correctional medicine is that any necessary care is always provided. Utilization review is accomplished collaboratively. Often, with the appropriate information, corrections, and health care provide a unified front limiting manipulation by offenders. The correctional environment, in some ways, comes close to a single-payer system often using Medicaid rates. If a treatment or test is determined necessary then it happens. In some ways military and correctional medicine are similar but there is one major difference in guiding principles: Military = mission; corrections = security.
Another benefit of my Air Force training was the concurrent administrative experience. Courses in clinical improvement were often followed by training that improved or provided administrative skills. After my retirement from the Air Force, I enrolled in a Master of Public Administration program. Those skills were indispensable in forming practice guidelines and facility health policy.
Deficiencies in Jail Medicine
One unfortunate feature of correctional medicine is that security can be intrusive. Though not officially approved, correctional officers offer spontaneous medical opinions; administration can require actions that are not driven by the benefit of the patient.
Another serious issue is inadequate mental health services for the number of offenders with severe mental illness problems. An area of significant disturbance may occur when different health service agencies have overlapping areas of responsibility. For example, one agency may provide mental health services, and another, general medical services.
Patient-Provider relations and the need for compassionate care are similar to those in the community. It is always important to remember that being incarcerated is the punishment. Facility staff is not there to punish the offender but rather to provide necessities and foster a different approach to life. The only part of an offender’s criminal history you will know is substance abuse as it affects prescribing. There is a fine balance between compassion and manipulation.
I never really felt physically ‘threatened’ in any meaningful way. The officers are protective and react quickly as offenders can be difficult when told “no”. There is also a real issue when the offenders are unhappy, however. There are multiple avenues to file a complaint: the facility, the Department of Corrections, the professional board, the Human Rights Commission, the court, etc. Experience has shown that good, well-documented care resolves almost all of these matters.
Tales from the Block
There are many nonmedical reasons that offenders seek treatment. Status (being able to wear sneakers instead of jail shoes), getting an extra mattress, special foods, bacitracin (rather than spending commissary money on chapstick), a trip out to the hospital, etc. They can also be operating from a different value set. A few examples:
- One young man claimed to need 2 – 3 units of insulin for his diabetes but he was actually skin-popping the insulin to get high from the drop in glucose.
- A middle-aged man demanded special supplements to control his diabetes as prescribed medications “were not enough”. He didn’t think multiple chocolate eclairs were an issue.
- Another young man could not seem to gain control of his glucose levels. Nurses ultimately discovered he was spraying the Lantus on the floor.
Why I Ended Up in Jail
It could be that the structure of the environment was attractive to a retired military person but that was not my primary motivation. A strong motivator was noting that most of the care provided seemed to be done only as an afterthought. Some provided care as well-intended community service, some for financial reasons though none appeared to consider correctional medicine as a full-time profession. Of note, the American Osteopathic Association has designated Correctional Medicine as a subspecialty of Family Medicine.
Providing care in a correctional facility obliges an approach that is consistently firm but fair. Diagnostic and clinical assessment skills are critical. Physical assessment skills are essential as is the ability to explain to corrections why certain treatments are necessary or not. There are times when providing good care has required starting from the beginning and approaching the offender as if he or she was a new patient. Other important skills include medication reconciliation (develop a verification procedure), detoxification (screen, assess, treat, and monitor) and documentation, documentation, documentation!
Working in correctional medicine can be most rewarding. This population is the least supported and suffers the most limitations in access to health care. I cannot say that this type of work is without some of the same frustrations and challenges found in any other area of healthcare. I would definitely recommend it to a PA with good diagnostic skills and a firm sense of cautious confidence.
For further information and good reading, I suggest:
- Jailhouse Doc: A Doctor in the County Jail by William Wright
- The Best of Jail Medicine by Jeffrey Keller
- State & Federal Standards
- NCCHC & ACA Standards