Advice from the Inside

From the viewpoint of an outsider, correctional medicine seems difficult. Prior to taking up our roles at correctional facilities, we certainly felt that it must be. We shared the same questions: How do you deliver care to a criminal? Do you ask what they’ve done? How do you remain impartial?

The detainees in jails (prior to conviction) and prisons (post-conviction) are the single group guaranteed health care under the U.S. Constitution (see Estelle v. Gamble, 429 US 97). As it is otherwise deemed cruel and unusual punishment to hold an individual against their free will without providing health care, it is the duty of correctional health staff to provide care under the constitutional standard of deliberate indifference. We are bound to provide care in a this environment, rife with the third-party involvement of correctional officers, a significant power structure that unquestionably alters the special relationship between patient and health care provider, and the unfortunate sociopolitical and economic disadvantages of our patient population.

In order to provide the highest quality care for these patients, we must be sensitive to their needs beyond those that would influence their presentation to the health care establishment outside of the barbed wire. A great deal of the difficulty with these patients lies in complete disregard by most of society for their general well-being. Once arrested and particularly once convicted, these people are considered lesser members of society and generally after their release cannot secure jobs, education, employment, or housing without hardship and repeated failure. As detainees, their interaction with health care outside of our facilities, which one would want to believe is otherwise free of bias, is shaded by their uniforms and their cuffs. Our patients are often met with skepticism, not questioned appropriately, bumped to the end of the line, and not given adequate information on their treatment plan or to give informed consent.

Regardless of the crime alleged or indeed committed, our patients not only legally but ethically deserve equal treatment. The desire to ask the questions about the inmate’s non-medical history is understandable, but the answers are irrelevant in the decision to meet the obligations of a health care provider. By recognizing the economic and social forces that contributed to their incarceration, we may be fighting half the battle. Though there certainly are times that one’s trust in the patient’s story comes into question, providers must exercise extreme patience and the ability to imagine some inmates’ motivations for manipulation.

A Case with the Psychologist

Consider Inmate L. One week prior to his arrival, I [AW] received were emails concerning his behavior, including acting disrespectfully towards psychologists, psychiatrists, and officers. He was classified as having Antisocial Personality Disorder and simply being unruly. L arrived up at the facility with 63 staples in his arms, having inflicted knife wounds on himself, and was placed on suicide watch. He had threatened suicide numerous times in what was said to be an effort to remain at the institution that was close to his home. I was on call when he arrived by plane. I entered Receiving and Discharge to see a 280-pound, muscular, dark skinned Black man with four gold teeth. L looked like someone whom no one would want to challenge. His appearance could be called intimidating, and I think it is safe to say that others saw him as just that. L was angry and not pleased to have been forced to leave his last institution. I called his name and asked him to come with me into the small intake room. He complied but did not appear happy about the situation. I had already been informed of what was called his “attempted manipulation” of others and was determined not to be the next victim. I am far from naïve and not often one who is manipulated. I conducted a Suicide Risk Assessment (SRA) as I was charged with doing. L was giving me all the answers to keep him from going to general population. In the first five minutes together, L demonstrated all...