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Medicine Behind Bars

More new physicians are being drawn to the nation’s prisons by the promise of exciting cases and epidemiological challenges.

The New Physician March 2007
When Lauren Gillory, a third-year at the University of Texas Medical Branch (UTMB), spoke of her internal medicine rotation recently, the conversation veered, almost by default, to the subject of tattoos. Many of her patients are covered with them—human canvases silently seeking expression.


She recalled one patient in particular: 25 years old and emaciated by Crohn’s disease, he had faces drawn on the back of each hand—one with fangs dripping down two of his fingers that revealed themselves when he balled up his fist. He had tattoos on his arms, chest, neck and face. Teardrops were permanently inked on his cheeks. And when he closed his eyes, two smiley faces appeared on his eyelids.


Third-year David Keelen, on the same rotation team with Gillory, was struck by how his ward once filled up with patients whose symptoms seemed exacerbated by the telecast of the World Series. One, a patient with cystic fibrosis, presented with normal O2 stats that did not match up with the level of complaint. It turned out that many of his patients’ “symptoms”—and subsequent inpatient stays—could probably have been resolved by easier access to a television.


The common denominator for Gillory and Keelen’s patients is that they were both wards of the correctional system of the state of Texas, and both were seen at the Texas Department of Criminal Justice (TDCJ) Hospital in Galveston, which includes—besides television sets in every room—a warden, prison guards and numerous security checkpoints. The inpatients, of course, find the hospital more comfortable than their normal environs, but for any trip to the operating or exam room—even for women inmates about to give birth—shackles are required for transport.


GETTING INSIDE


Nationwide, very few medical schools offer rotations in correctional institutions, although several use prisons for elective course work. New York University School of Medicine, for example, has a popular elective in psychiatry at Bellevue Hospital’s prisoners’ ward. But rarely are opportunities in correctional health as accessible as at UTMB, where the state’s prison hospital, built to keep sick prisoners inside the penitentiary walls in as many situations as possible, sits on the medical school campus. This allows students rotations in a setting adequately described by one correctional health administrator as “the nexus between ethical, legal and medical issues.”


At rare times, correctional health might require a physician to preside over a hunger strike. More commonly, he or she might have to decide whether to report a violent guard to the prison warden. And prescribing medicine to a population that is 74 percent drug- or alcohol-dependent presents a constant challenge. Even a relatively benign pharmaceutical like the HIV drug efavarenz (Sustiva), which can cause intense dreaming, has a black-market value in a penitentiary.


Do you recommend an operation, even a critical one, if the healing time exceeds the patient’s maximum sentence? Do you see a patient with a head cold if the warden wants him in solitary confinement for participating in a violent altercation? Or do you protest such a punishment if a patient—no matter what he or she has done—is suffering from serious depression?


The challenges of correctional medicine are ironically felt: The only population guaranteed health care in this country is the same population that society prefers to ignore. As such, conditions in prison clinics can range from state-of-the-art to resembling those found in the developing world, says Scott Chavez, vice president of the National Commission on Correctional Health Care (NCCHC), which sets the standards on prison medical services for 25 percent of the incarcerated population in the United States. “I’ve seen good and bad.”


GOOD BEHAVIOR


One thing holds true: The first time the doors close behind you in a county jail or a state or federal prison, the sound of the steel door clanging shut is hard to forget. Students at UTMB sometimes feel overwhelmed and intimidated the first trip down the long, elevated corridor that connects the so-called “free world” with the prison hospital. But soon they forget the feeling of menace or the prejudices they assumed would cloud their medical judgment.


Patients are patients, no matter that they wear jumpsuits. In fact, prisoners seeking health care tend to be cooperative and polite, according to those interviewed for this article. “They’re like the perfect patients,” Gillory says, referring to prisoners’ tendencies to explain their symptoms cooperatively and to show gratitude for the care they receive. Keelen says he witnessed a patient who had been partially paralyzed for six months wiggle his toes after a medication adjustment reduced the swelling around his spine. By the next morning, the patient insisted on using a bedpan by himself and was refusing help to sit up, hoisting himself up instead by an overhead bar.


“They size you up quickly, and they won’t respect you if you give them everything,” says Dr. John Barnett, associate chief medical officer and acting regional medical director for privately owned Prison Health Services (PHS) in Virginia, who has spent much of his career in correctional health. “But nor would I let them leave the office without their serious needs taken care of.”


“We, by nature and by training, want to help reduce people from suffering and pain,” says Dr. Sylvia McQueen, Alabama Medical Director for PHS, which operates services in 28 states. It’s not difficult for correctional health-care workers to leave their personal judgments in the parking lot, she says, but protocol is important. “I don’t let [prisoners] call me Sylvia, but I have asked the guards permission to give an inmate a hug, and we’ve cried together many times.”


“Your patients are generally very grateful, because you’re the only person who gives a damn about them as a person,” says Dr. David Thomas, chair of the departments of Surgery and Correctional Medicine at Nova Southeastern University College of Osteopathic Medicine (NSUCOM) in Ft. Lauderdale. “Most everyone else in a correctional setting simply wants them to sit down, shut up, behave and do what they’re told, and has no other interest in them at all other than conforming to the rules,” he asserts.


Thomas, who once served as chief medical officer overseeing more than 85,000 Florida inmates, says that “some of the pathology I saw in…corrections was profoundly more difficult, esoteric and fascinating than at a tertiary care medical center, partly because inmates [often] don’t get medical care [before entering prison]. Secondly, it’s the only environment where you can follow the natural history of the disease.” Indeed, doctors say correctional medicine is a clinical utopia for its wide variety of medical conditions that are rarely seen in a free setting, and because patients, once diagnosed, don’t disappear if they don’t like their doctor.


Another professional challenge for prison physicians is the pervasiveness of chronic disease. HIV/AIDS is five times more prevalent in incarcerated adults than in the U.S. population as a whole. In 1996, almost 500,000 of the nation’s 1.3 to 1.4 million inmates and former inmates in the nation’s jails and prisons were infected with hepatitis B or C, according to an overview of prison health services presented to Congress by the NCCHC. That is a figure that grows, step by step, along with the inmate population as a whole, which is now said to top 2 million.


Their health care, provided by approximately 4,000 physicians across the country, is frequently the stuff of unfortunate press coverage and rarely praised, even as a career in correctional health appears to be growing in prestige and popularity. Two-year fellowship programs combining clinical and administrative course work are now available at UTMB, NSUCOM and the University of Massachusetts Medical School.


The field is growing most quickly among young female physicians. “Women are actually the fastest-growing type of doctor and midlevel [health practitioner] in our system, because the hours are good, the challenges clinically are good…. You can have a life outside of your practice. So here they can get kind of the best of both worlds,” says UTMB’s assistant vice president of Community Health Services Owen Murray, who oversees correctional care programs serving 80 percent of Texas’ incarcerated population. His oversight includes responsibility for 100 prison facilities and the TDCJ Hospital on UTMB’s campus.


“A lot of older folks who got into correction not by choice, but because it was their only opportunity, are gone,” he says. “Now you get a lot of younger, board-certified doctors who do it because they enjoy it and they find it challenging.”


The pay, he adds, is usually competitive, but not always great. Doctors in correctional health, however, don’t need medical liability insurance, nor do they hassle with insurance forms at all. And the hours can be sustainable, in part because prisons have a tendency to reduce on-call assignments, since rowdy behavior is mostly limited to daylight hours. “That takes away some of that anxiety that a lot of good docs have,” Murray says. Paradoxically, the lack of hassles with insurance companies, the steady hours, the monopoly on patients and the interesting work add up to a lifestyle that is less stressful for a physician than many a suburban practice, he adds.


"CALLOUS" SYSTEM?


This is not to say correctional health is worry-free. Doctors working in prisons don’t run out of patients, but they don’t seem to run out of headlines, either. The Los Angeles Times, the New York Times and the Detroit Free Press have all published stories of negligence leading to tragedies in recent months, including the case of Lloyd Byron Martell, whose untreated colon cancer was diagnosed during a one- to four-year stretch in a Michigan prison for driving with a suspended license and fleeing from police who tried to pull him over for a cracked car window.


His case was called a “de facto death penalty,” not only by the Detroit Free Press, but by U.S. District Judge Richard Enslen, who ruled in December 2006 that Michigan’s correctional health-care system was “callous and dysfunctional.” After hearing testimony of another inmate with blood in his urine who had to wait 40 days for tests to be done, and testimony about Timothy Joe Souders, a 21-year-old mentally ill inmate who died of hypothermia and dehydration after spending four days bound and naked in his cell during a heat wave in Jackson, Michigan, Enslen ordered the state to fill immediately
all medical staffing vacancies and authorized a monitoring agency to look after the state’s correctional health program.


The case was hailed a victory by the American Civil Liberties Union, whose National Prison Project brings suits on behalf of inmates for many issues. Medical cases, however, comprise more than one-quarter of the Prison Project’s docket, according to the project’s public policy coordinator Jody Kent. “Certainly, correctional health care would benefit from having young and energetic doctors who are coming out of med school who are interested in doing work in fields that expose you not only to a variety of health issues, but larger societal issues,” she says. “[But] it’s at the point right now where [correctional health] really is a nationwide crisis.”


PRIVATE PRACTICE


Not everyone pushes the sentiment that far, but many point to the privatization of prison health services beginning in 1976 as the start of a shift toward profit-engineered health service contracts, which have eroded the public’s confidence.


The almost-unanimous U.S. Supreme Court decision in 1976’s Gamble v. Estelle declared that inadequate health care in prisons was “cruel and unusual punishment.” It put government-run prison health-care services on notice and paved the way for private, profit-oriented firms, which now oversee 40 percent of the country’s health-care needs for inmates. Its chief flaw, many say, is the mandate of state and county governments to accept contracts from the lowest bidder, creating a propensity to cut back on services. “I’ve seen it work and work very well, but in other places it doesn’t,” Chavez says. “It depends on individuals and the ability to meet the needs of patients and the inmates. But privatization is here to stay. I don’t see it going away, and it has advantages in areas where government can’t provide adequately for the inmates.”


Good doctors, however, can make or break a clinic in any setting, whether inside or outside the bars, and incarceration settings may be too exceptional to make an apples-to-apples comparison anyway. Incarcerated patients are often smokers, and often in the throes of alcohol or drug withdrawal; the population includes “some of the sickest people in the country,” Chavez says.


Besides HIV/AIDS and hepatitis, tuberculosis and sexually transmitted diseases are all overrepresented in prisons, as are major depression, bipolar disorder and various forms of psychosis. One patient Keelen remembers well in the TDCJ Hospital was missing both legs and one arm due to diabetes and the fact that he was prone to self-mutilation. Leprosy was recently diagnosed in a Texas prison, Murray says. And a story in a January 2007 New England Journal of Medicine concluded that within the first two weeks of their release, former inmates were almost 13 times more likely than other populations to die from violence, heart failure, drug overdoses and suicide.


While some doctors might flee, “I got into medicine to serve the underserved,” says Dr. Lynn Sander, who graduated from Boston University School of Medicine in 1975, then moved to Baylor College of Medicine to complete an internal medicine residency with the city’s community health system. Later, a simple job transfer brought Sander into correctional health, which she believes was a natural transition: “Correctional medicine is the best job in the world,” she says.


Barnett, with PHS—a large firm hounded by bad publicity in recent years—is also proud of his long career in correctional health, which started years ago when he volunteered one day a week at a county jail.


During one of his first visits there, he diagnosed a man who had been arrested for DWI the night before as, in fact, a sober diabetic who had gone
into cardiac arrest. The man’s gratitude cemented Barnett’s appreciation for correctional health.



Then there was the woman he arrranged to have sent home to South America, even though she was awaiting trial in the United States on drug charges. She spoke only Spanish and her lawyer, he says, spoke only English; in fact, the two had never met. But Barnett does speak fluent Spanish, and he also recognized that the prisoner’s stomach cancer was certainly beyond hope of recovery. So as her physician, he did the best that he could do. He picked up her file and took it to the local courthouse, where he engineered a quick release for his patient. She then went home, Barnett said, to die surrounded by children and friends.
Anthony C. Hall is a freelance writer in Dryden, New York. Direct comments about this article to tnp@amsa.org.