Physicians who subspecialize in correctional medicine deal with mental illness, drug addiction and all manner of chronic diseases every day. At the same time, they also grapple with feigned ailments intended to secure prescription drugs or a trip to the hospital and opportunity for escape, said John G. Mills, DO, MPH.
“Correctional medicine is [on] the cutting edge of public health,” said Dr. Mills, who described aspects of this emerging field at OMED on Sunday. “It [involves] providing health care to the most underserved segment of our population.”
Approximately 1.5 million people are incarcerated in state and federal prisons in the United States, said Dr. Mills, who is the medical director of Tarrant County Jail in Fort Worth, Texas. And at any given time, roughly 750,000 people are in jail, arrested but not yet convicted of a crime, he noted. Different types of correctional facilities have different health problems, he said.
“Jails are much more of an urgent care arena,” he said, noting that his jail sees 125 to 150 newly arrested individuals every 24 hours, with 40% or so remaining there for less than a week. Those who are jailed don’t have time to prepare for their incarceration, so they often arrive without their medications and without anyone at the correctional facility knowing their medical histories. What’s more, they are frequently intoxicated.
“In a jail, you’re getting diabetics, you’re getting substance abusers, and you’re getting people with heart disease and hypertension right off the street, so you have to restart their medication,” Dr. Mills said, noting that every inmate at Tarrant County who has a significant illness is seen within 24 hours of admission.
Dr. Mills noted that he must be particularly cautious when restarting diabetic patients’ insulin because the jail diet is much more limited in calories than what many diabetics eat on the outside. For example, an inmate’s family physician may have prescribed enough insulin for the patient’s typical 4,000 calorie diet, while those jailed at Tarrant County are restricted to 2,700 calories a day.
“If you keep him on the same dose of insulin, you might kill him,” Dr. Mills said.
Many ethical issues arise in correctional medicine. For instance, physicians are not supposed to assist with body cavity searches. “But if the patient consents to a body cavity search, then it’s not a body cavity search anymore—it’s a medical exam,” Dr. Mills said.
Although Dr. Mills believes that all prisoners deserve quality health care, he doesn’t like to be taken for a fool. “I try to treat all of my patients like patients except when they start behaving like inmates,” he said.
Several times a year, for example, inmates will try to obtain narcotics by lying about their condition or exaggerating their pain. “They’ll say, ‘I’ve got a brain tumor’ or ‘I’ve got this cancer,’ ” and they don’t have anything wrong with them,” Dr. Mills said. “This is breaking federal law.”
When a patient claims to have severe pain, Dr. Mills will observe how he gets out of his chair. “If I see you pull your chair back and stand up in a normal fashion, you probably don’t have severe pain,” he said. Dr. Mills will also ask correctional officers for their observations of an inmate’s probable pain level. Someone seen playing basketball earlier in the day is likely not in a lot of pain, he said.
Many inmates are clever, however. “Some people are very good at being deceptive,” Dr. Mills said. “They are so good at faking seizures that they get taken to the emergency room and watched for two to three days in the hospital.”
But correctional physicians cannot dismiss every seizure as fraudulent. The incidence of seizure in jails and prisons is higher than in the general population because incarcerated individuals are more likely to have sustained head injuries early in their lives, whether from being in a car crash or getting hit in the head with a baseball bat, he said.
As a jail’s medical director, Dr. Mills is responsible for keeping the facility safe, so he can’t always give inmates the benefit of the doubt, he said. He told the audience about an incident that occurred when he worked for a federal prison, which housed an extremely violent inmate who had escaped twice from two different facilities.
The inmate swallowed a handful of pills on an evening when Dr. Mills was at home.
“A young doctor, a resident, covering the jail called me up and said, ‘This guy tried to commit suicide. I’m going to take him to the hospital,’ ” Dr. Mills recalled. “I said, ‘You’re not shipping this guy out.’ “
Dr. Mills directed the resident to call the emergency room and get step-by-step instructions on the procedures to perform to save the inmate’s life.
“Most escapes occur when people are moving outside the fence,” Dr. Mills said, noting that sometimes inmates have fellow gang members waiting for them at the hospital to violently aid in their escape.
Hardened by his nearly 20 years of experience in correctional medicine, Dr. Mills is not opposed to capital punishment like some of his physician friends are. “The death penalty protects correctional workers,” he stressed. “If you have inmates with two or three life sentences, what will keep them from intimidating or physically abusing a nurse or a physician?”
Audience member Donald Cole Smith, DO, who used to work in a county jail, said he connected with Dr. Mills’ talk.
“When you work in correctional medicine, you have to understand that inmates are trying to manipulate you a lot,” said Dr. Smith, an occupational medicine specialist in Phoenix. “You have to do your research and make sure you have the full story and all the information you need before you go ahead and treat the patient.”