Correctional Medicine Rocks.

Correctional Medicine is a great job! Wait, it’s even better than that—Correctional Medicine rocks!

Nobody told me this when I was in medical school. I had to stumble on this truth on my own and by happenstance.

I am an emergency physician by training and I worked for 25 years in my local emergency department. One day, my county commissioners asked me if I would be willing to provide medical care to the inmates in our local jail. I grumbled and groused. I was not enthusiastic. “But we’re desperate!” they said.

I had no idea what I was getting myself into!

Our local jail had been built in 1912. It was small, hopelessly overcrowded and dungeon-like. It smelled bad. It had no medical clinic; medical care for the incarcerated was not a priority in 1912. In fact, I am sure that I was the first physician who ever walked through those doors to provide medical care to the incarcerated. I had to figure out how to do it. So I took over one cell, propped the door open, and that was my clinic. I examined patients on a folding table with a sheet on it.

But you know what? I loved it! And I never saw that coming!

First of all, I was seeing many of the same patients I saw in the ER. Contrary to what I had expected, these patients weren’t any different than any other patients. They were just as appreciative of getting medical care and just as likely to look me in the eye and say, “Thank you.”

What I found especially rewarding was that a lot of my jail patients were not getting medical care on the outside. They were homeless, or uninsured, or addicted. For many of them, being in jail was the first time as adults that they had ever had easy access to medical care.

I had interactions like this: “Hey Doc! What’s this thing on my arm?” “Well, that’s cancer. We should take care of that.” “You know, a blood pressure of 240/130 is not healthy. Let’s treat that. You’ll feel better.”

Shoot, I was diagnosing diabetes, heart disease, autoimmune disease, you name it. I made far more new diagnoses than I ever had as an ER physician.

I LOVED it.

But my physician friends were confused at my enthusiasm. They asked me, “Why in the world would you want to work in a jail?” They had this preconceived notion of correctional medicine being low-skill. But, of course, it is not! Correctional medicine is challenging and rewarding. They had this prejudice that incarcerated patients are different and sketchy and why are they getting good health care, anyway? But that is not what I found.

Incarcerated people are just people.

Yes, some jail patients are difficult to deal with and some can even be dangerous. But that is not different from my ER patients! What is true and is different from outside medicine is the fact that we can’t fire our patients. They are our patients no matter what. So that guy with a swastika tattooed on his forehead and a confrontational, in-your-face personality? He is my patient.

The ability to develop a healthy doctor-patient relationship with that guy is a skill particularly important to develop in correctional medicine. But I know it can be done; I learned how to do it myself.

The next step in my education about Correctional Medicine occurred when the Idaho DOC sent many prison inmates to be housed in my jails. I began to take care of more chronic medical problems over longer periods of time. I found that I liked being able to follow a patient over time through from diagnosis to treatment to recovery.

Interestingly, that ability to follow patients longitudinally over the long term is being lost on the outside. Medical care in the community has become so specialized that if you are a primary care doc, and your patient has an MI or gets cancer, that patient will often become the cardiologist’s patient or the oncologist’s patient and you might never see them again. Not so in prison medicine. We diagnose, prescribe, and watch our patients respond.

It felt good to get a patient who arrived at the jail in the throes of addiction, at rock bottom, soiling his own pants, and then see him recover and leave the jail six months later looking great and excited about the prospect of living a drug-free life in an outside MOUD program that we set him up with. Yes, he might relapse after release. That’s life and that’s the nature of addiction. But you know what? Not all of them relapse.

I felt good about the diabetic patient who arrived at the jail with an A1c of 13, but who left the jail a year later with an A1c of 6.7, 40 pounds lighter, and proud of what she had accomplished. I felt good about the cancer patient who was diagnosed, treated, and then was in remission.

I loved it. Correctional medicine rocks!

So! I ran into an acquaintance of mine, an anesthesiologist, at a community function. “How are things going in the jail?” he asked. “Great!” I said. “I have a great job!” “You’re lucky,” he said. “I hate my job.” He told me about hassles with coding, billing, reimbursements, fights with hospital administrators, and boredom.

And this was not an unusual occurrence! I’ve had similar conversations with several physician friends. An orthopedic surgeon I know hates his job and wants to retire—but can’t afford to. An internist told me, “Insurance and billing are killing me! I’m forced to spend less and less time with my patients. I can’t afford to give them the time or attention they deserve.” Another internist and a family practitioner I know both gave up their longstanding private practices to become a hospitalists—but they don’t love that job, either. The list goes on and on.

A large percentage of physicians in the outside medical world are unhappy in their work. This is borne out by physician surveys. A third of practicing physicians would not choose a career in medicine if they were offered a do-over. Half would not recommend medicine as a career to their children. Only a third rate their morale as good or excellent.

Yet a switch to correctional medicine is not on any of these physicians’ radar! Just like I once did, outside physicians distrust correctional medicine. They don’t know anything about it, but they don’t like it. But that is the key: They don’t know anything about correctional medicine!

That is partly on us. We in this room know that we have great jobs but we have not done a good enough job spreading the word: If you want to do work that is rewarding and meaningful, working with patients who are socially marginalized and lack ordinary access to medical care, you could go work at a third-world refugee camp. Or you could instead go to work in your local jail or prison!

Consider this fact: incarcerated people cannot go out to find good doctors in their communities on their own. Good doctors—and nurses and administrators—have to choose to go to them. That is us! That is the people in this room!

We correctional professionals need to embrace the fact that we work with a disadvantaged and marginalized population. When a fellow physician says, with one eyebrow raised, “You work in a jail?” we need to say back, “Of course I work in a jail! That’s where the sick people are! Why aren’t you working in a jail?”

Let me close by telling a story. At our local state fair every year, inmates from the nearby women’s prison who are nearing release collect the trash and clean the facilities. They wear bright orange jumpsuits with PWCC in large letters on the back. One year, when I was walking through the fair with my family, I heard a yell from across the fairgrounds: “Hi Dr. Keller! Remember me? I’m doing great!” And I did remember her. I remembered that she was not doing great when she first came to the jail. But she was indeed doing great now, healthy and ready to get out of prison.

That is Correctional Medicine.

You all should be proud of yourselves and your profession. I’m certainly proud of you!