Physician's Role in Correctional Medicine

 
Physicians have a complicated role in correctional health care.  It is “primary care” at a high and extensive level.  Physicians in corrections have a captive audience of patients, literally and figuratively, that need a wide variety of medical care. Incarcerated individuals enter and stay in your practice with every possible medical condition. Many of these patients may have had little or no prior medical, dental or mental health care, other than emergency room visits. The correctional physician must be prepared for this population. Many of these patients may have current or past substance abuse issues. Many of these patients may have poor coping skills and even a mind-set to defy authority. 
 
It goes without saying that the correctional doctor has a tremendous role in the provision of medical care. However, that role often goes far beyond seeing patients and giving care. Not only must the correctional physician manage health care, they may also have a significant administrative role in direct health care, in the system of health care, and in health care policy, procedures, and standards. A physician working in corrections must be aware of and balance interests of good solid medical practice, medical board requirements, court findings,  the safety and security of the facility, the individuals in the facility, and the community, all while working in an environment not specifically created for the purpose of health care. A physician may have to take on multiple roles beyond direct one-on-one patient care while working in a correctional facility. Although many of these roles have similar practice experiences outside of corrections they can become co-occurring roles for a physician in corrections.
 
 
 
MEDICAL PRACTICE ROLES
 
 
Primary Care: The correctional physician must be able to provide extensive primary care covering all the aspects of primary care. This includes:  internal medicine, dermatology, preventive care, basic orthopedics, minor in-office procedures, emergencies, urgent needs, routine patient appointments, episodic recurrent care, chronic care, and end of life care. They may be expected to manage other medical areas such as mental health, such as suicidality and forced medication; as well as dental issues, such as severe dental pain, facial trauma or infections if a psychiatrist or dentist is not available.      
 
Emergencies and Urgencies: The correctional physician must have the ability to handle medical urgencies and emergencies, e.g. chest pain and acute asthma, trauma, fractures. Withdrawal and overdose medical issues occur in correctional medicine with regularity, and it is important for all physicians to be competent in these areas. The correctional physician may be the only medical professional available in urgent situations.
 
After-hours Care: The physician goes home, but the patients stay.  Often the only medical staff on site “after-hours” is a nurse, and it is not uncommon for only custody staff to be present. The physician should have plans for management for both primary care, minor and major medical situations that occur after the staff have left.
 
Chronic Care: A correctional physician should be familiar with chronic care programs which follow national medical guidelines.  This could include not only frequent conditions such as diabetes, hypertension, cardiovascular disease, and chronic pulmonary conditions but also less frequent conditions in community primary care such as sickle cell, TB and HIV.
 
Off-site consults, tests, and procedures: The doc may be expected to oversee the consultation process ensuring appropriate appointments are made, reviewing reports recommendations, coordinating care, and seeing to it the necessary and appropriate follow-up is completed. Complex and conditions less commonly seen in community primary care also occur and are frequently not only diagnosed by the correctional physician but also followed in consult with a specialist.  In correctional practice it is not uncommon for a specialist to consult on a patient, and the ongoing care done within the correctional facility. This may include conditions such as:  moderate and severe CHF, COPD, ASCVD, inflammatory bowel disease, severe diabetic complications, chronic liver disease, malignancies and other serious medical conditions.
 
End of Life Care: The physician may be managing terminal patients which involves hospice palliative care, at the facility or off-site, and may be responsible to initiate and manage advanced directives and DNR’s.
 
Public Health: A physician in a correctional facility will in many ways be acting as the Public Health Department for the facility They would be responsible for infection control advice and  practice, outbreak evaluation and management, advice or implementation of congregate living health directives and health issues e.g. vaccinations and preventive and environmental health initiatives.
 
Management and Administration Issues: Beyond direct patient care a physician in corrections may play an integral role in the overall health and health system of a facility. Custody/security owns and runs the institution. However the physicians have the highest level of medical understanding and information and will need to work with them in order to have safe and smoothly running processes. A physician working in corrections must be aware of and balance interests of; good solid medical practice, medical supervision, implementation of process, medical board rules, the safety and security of the facility, the individuals in the facility, and the community. A few examples of medical-custody coordination are:

• Timely access to medical
• Timely treatments and
• Medical training and supervision.

 

Resource balancing is a reality in medicine, but more obvious in corrections. The physician must be involved so that good medical practice can continue. The following are examples:
 

• Medication diversion and abuse. The physician will be working with the health care staff and security staff to minimize this,
• Education of medical & custody staff as well as inmates, both individually & in groups,
• Creation of, or at least review, input on health policies, procedures, and protocols, such as segregation protocols,
• Quality assurance and continuous quality improvement studies and processes,
• Death reviews,
• Oversee inmates with special needs, which may require special accommodations and again working with custody and other medical disciplines. Examples are:

• Individual with physical or mental handicaps
• Restrictions of Transportation
• Geriatric patients
• Juvenile patients in adult facilities
• Patients with assistive devices
• Patients with severe mental illness and
• End of Life planning

 
The tasks and responsibilities of a correctional physician entail far more than the medical care trained for in school or post-graduate training. The correctional physician must also be ready, willing and able to manage them.
 
Medical –Legal – Political:
The physician will be involved in medical-legal situations. Examples are: hunger strikes, sexual abuse, isolation, transgender, compassionate release pleas, elderly release pleas and long term involuntary psychotropic medications. Legal threats and law suits are a way of life among the correctional population. The providers must become familiar and comfortable with this and maintain the practice of good medicine.  They will need to work with risk management, collaborate with attorneys, and deal with court orders.