By Doug Brunk, San Diego Bureau
Dr. Marc F. Stern says he feels safer as an internist working in correctional settings than he did in his previous career working for the Veterans Affairs health system.
In that setting, he said, one patient pulled a machete on him in the emergency department. Another tried to open the emergency department door with a chain saw. Someone else came in with a hand grenade and threatened to pull the pin.
"I've never had any of those experiences in prison," said Dr. Stern, an internist who is health services director of the Washington State Department of Corrections. "Health care professionals in prison are very safe. Historically, they've been even safer than the custody staff, possibly because patients view the health care folks as there to help them. There are isolated incidents in prisons. When additional security is necessary, it's provided."
Working in correctional settings is the best-kept secret for physicians with an interest in public health, he said, because the pathology of inmates is wide ranging and the ability to impact their health and well-being is significant, particularly since 98% of inmates return to civilian life. "They become our kids' boyfriends and girlfriends, and our neighbors," Dr. Stern said. "We have an opportunity to affect their health, their health care behaviors, and … their social behaviors. This is a population that has a high prevalence of diseases like HIV and hepatitis C. So, while we have them in our midst, we have an opportunity to control the disease and teach them low-risk behavior, so when they come back into our communities, they are less likely to spread disease."
He recalled one cantankerous inmate who came to see him in the prison clinic with a chief complaint of back pain, insisting that he undergo an MRI. "To me, that was a reflection of the fact that he was in pain and he didn't understand a lot about the pathophysiology of back problems and how this should be worked up and treated," Dr. Stern said. "He used his limited health literacy to come in and be demanding."
After a brief physical exam, Dr. Stern drew a diagram for the man of what was going on with his back and explained that his problem was not serious but likely to be chronic and that he would not benefit from elaborate testing. He also provided tips to the man as to what he could do to slow the progression and to manage the pain.
"He said, 'thanks for explaining that to me. Now I understand why I don't need an MRI. I understand the disease. I guess I'm just going to have to live with it,' "Dr. Stern recalled. "I was able to convert somebody who was belligerent and drug seeking and treatment seeking into someone who understood the disease, was grateful, and less likely to misuse health care resources in the future … [or] be uncooperative in their health care usage in the future when they return to the community."
He acknowledged challenges to practicing in correctional settings, including a reliance on tight government budgets and a certain level of animosity from the general public for providing health care to prisoners when so many civilians in the United States lack adequate access to health care.
"Unfortunately, their animosity is misdirected, because what we should have is access to health care for all Americans, including those who are underinsured or noninsured outside of prisons," Dr. Stern commented. "What they don't understand is that prisoners have a constitutional right to access to basic health care. That's something the citizens of the United States have said they want through the constitution."
Another challenge is actually providing the hands-on care in correctional settings. "Even when you have the money, it's hard to find health care practitioners who want to work in a prison, so I hope the 'secret' gets out," he said.
Volunteers for the Cause
Dr. John May finds the field of correctional medicine so rewarding that he founded the Florida-based Health Through Walls (www.healththroughwalls.org
"Being conscientious in correctional medicine is one of the most important components of delivering good care," said Dr. May, whose program assists inmates in Haiti, the Dominican Republic, Jamaica, Tanzania, Ghana, and other counties. "By that, I mean following through and trying to understand the issues that a patient presents with are more important than the medicine you might prescribe or the work-up that you may order."
He went on to note that while most physicians take care of individuals who are part of a community, physicians who practice correctional medicine attend to a community of individuals.