When patients are behind bars: New specialty challenges physicians
On the first day David Thomas, MD, JD, practiced in a prison, one of the inmates climbed a large tree on the prison grounds and refused to come down. Dr. Thomas was surprised that he was called to work with correctional officers to coax the inmate down from the tree.
“It’s not the kind of thing you perceive a physician either doing or being responsible for, but it turned out that in a correctional environment, it was,” he says.
Dr. Thomas realized then—back in 1994—that medicine in the correctional system involved a distinct environment and patient population. Correctional physicians are expected to handle a range of difficult entities such as infectious diseases, comorbidities and substance abuse, he says.
Years later, while a professor at the Nova Southeastern University College of Osteopathic Medicine (NSU-COM) in Fort Lauderdale, Fla., he would set out with the school’s dean, Anthony J. Silvagni, DO, PharmD, to designate correctional medicine as its own specialty, much as emergency physicians did with their practice niche in the 1970s. Last year, the pair achieved their goal when the AOA approved correctional medicine as a new specialty. Dr. Thomas is now chairman of NSU-COM’s division of correctional medicine.
The approval was the culmination of a six-year process that started when Dr. Thomas and Dr. Silvagni began working on the curriculum for a correctional medicine fellowship. Two recipients would spend two years working at seven institutions throughout Florida and nearby states. They would learn about prisons, which house inmates long term, and jails, which hold them temporarily, and understand the differences between private and public institutions.
Corrections by the numbers
The increase in the state and federal U.S. prison population from 1996 to 2011.
The increase in the population of local jails in the U.S. from 1996 to 2011.
U.S. adults spent time in a state or federal prison or a local jail in 2011.
Source: Bureau of Justice Statistics.
‘Extremes of diseases’
In 2009, the first recipients started the fellowship, the first in the nation to focus on correctional medicine. Today it remains the only one, though physicians and corrections professionals in Texas, Oklahoma and Florida are now working on starting their own NSU-COM-inspired correctional medicine fellowships.
Phyllis Anderson, DO, was one of the first physicians to complete the fellowship. She started it in 2009 with correctional experience—she was the medical director of a county jail in New Jersey—but she says the fellowship was eye-opening because Florida has such a large prison population.
“The fellowship made me a better doctor,” says Dr. Anderson, who is now a designated health authority for the Florida Department of Juvenile Justice. “One of the advantages of correctional medicine is that I get to see things that I’ve only read about and learned out of a textbook—things that my colleagues will never see, such as extrapulmonary tuberculosis.”
Physicians who practice correctional medicine are often highly skilled in treating infectious diseases such as HIV, Dr. Thomas says.
“It is not unusual for the best specialists in HIV care to be correctional physicians,” he says. “If someone goes to a primary care physician who sees that the patient has HIV, most likely the patient will be referred to an infectious disease doctor. And yet the average correctional physician will handle HIV and hepatitis C with alacrity.”
A Florida Department of Corrections study led by Dr. Thomas in 1999 found that more than two-thirds of inmates had their first significant interaction with health care in a corrections setting.
“Prisoners are profoundly medically underserved,” he says. “You generally see extremes of diseases.”
“It is not unusual for the best specialists in HIV care to be correctional physicians.” Dr. Thomas
When a physician is a patient’s first source of continuous health care, the physician-patient relationship will often be more intimate, Dr. Silvagni says. He also notes that in a correctional institution, the physician is one of the few authority figures in an inmate’s life who isn’t there to monitor his or her behavior.
“Most people are there to keep the prisoners in order, to make sure they follow the rules, to make sure they do their jobs,” he says. “The physician is there to improve their health and improve the quality of their life. So this unique relationship develops.”
However, many physicians and medical students are not aware of the special skills correctional medicine requires, Dr. Thomas says.
“Thirty to 40 years ago, corrections was the last refuge of the barely practicing physician,” he says. “It is now a very sophisticated environment where you take care of heavy-duty diseases. But the reputation has not caught up with what the physicians are doing and have to do. The fellowship and the specialty recognition will improve the overall reputation of the profession.”
Dr. Anderson agrees.
“A lot of people will think, ‘Oh, you’re just a jail doctor,’ like you’re some kind of deficient physician,” she says. “But the people I’ve worked with have been some of the finest physicians ever. You have to sharpen your tools in order to think about all the things that are possible with the incarcerated population. You’re thinking more broadly to expand your differential diagnosis.”
As a medical student and resident, Dr. Anderson didn’t realize correctional medicine was a career option. She would see prisoners come into the emergency room and thought that was how they always received medical care. Students today should be aware of the abundant opportunities in correctional medicine and know how fulfilling the work is, she says, noting that many positions in correctional medicine offer loan repayment.
“There are always going to be prisons and jails in America, and they’re in every state,” she says. “So the opportunity for employment is there. And it’s very rewarding as a physician to see the fruits of your labor—to see an uncontrolled diabetic improve in benchmarks and medical outcomes because you did teaching, and you were able to give the diet and medication that the patient needed. It’s rewarding to not have to cut off toes and legs and send people to dialysis because you’ve made an intervention. That’s why we want to be doctors. We want to help people. Well, these are the people that need our help the most.”