Correctional medicine

Access to care

Providing health care in this environment requires an understanding and knowledge of governmental, bureaucratic, and paramilitary hierarchies. Many correctional health professionals are employed directly by correctional authorities; however, correctional health care models have evolved into several types. Some jails and prisons contract for-profit companies, academic medical institutions, or public health agencies to provide health services. Contractual health care systems such as these have assumed the administrative structure for health services in prisons and jails. It is often easier to recruit, train, and retain health care professionals under this structure than to employ health care professionals directly by the correctional authority.

PAs generally find correctional employment by working for the legal authority (the sheriff or department of corrections). Using these models, correctional institutions can attract health staff through better compensation, faculty appointments, and continuing education opportunities.

Having professional autonomy and judgment within organized health systems has helped to attract qualified professionals into correctional medicine. Ensuring that inmates have access to health care services is a fundamental responsibility for correctional medical professionals. It means that every inmate, regardless of where he or she is located in the jail or prison, must be able to inform health staff of his or her need to be seen; and when notified, health staff must act in a timely fashion, provide professional clinical judgment, and ensure that ordered care is delivered. Any unreasonable barrier to inmate health services access must be removed.

What makes correctional medicine different from other venues of health care delivery is the long line of legal cases that have established the incarcerated individual’s rights to health care, addressing the responsibilities of custody officials in the health, mental health, and dental treatment of inmates. As a result of these and other court cases, correctional medicine has evolved.

Estelle v. Gamble established the concept of deliberate indifference as the test to determine whether government acted appropriately in the medical care of its inmates. As was clearly articulated, deliberate indifference is demonstrated by prison doctors in their lack of response to the prisoner’s needs or by prison guards in intentionally denying or delaying access to medical care or interfering with the treatment once prescribed. Regardless of how it is evidenced, deliberate indifference to a prisoner’s serious illness or injury constitutes a cause for action.

The government must ensure that adequate medical, mental health, and dental services are provided to the imprisoned. To accomplish this, a responsible health authority (RHA) must be established. The RHA ensures that primary, secondary, and tertiary care is provided for the well-being of the inmate population. The RHA works with custody staff to eliminate barriers that might hamper inmates from receiving these services in a timely manner. For example, one barrier might be where an officer, hostile to inmates, denies an inmate access to the sick call notification system. Training custody and health staff to recognize emerging medical or mental health needs is an important RHA role. Sometimes, there are unreasonable delays in escorting inmates to see health professionals or to get to outside appointments to obtain necessary diagnostic workups. The RHA works to ensure that access-to-care processes are flexible to accommodate inmates’ special health needs, such as chronic illness, serious communicable infections, physical disabilities, pregnancy, fragility, terminal illness, mental illness, potential for suicide, or developmental disability. Such special needs affect housing, work, and program assignments; disciplinary measures; and admissions/transfers to and from institutions. Correctional PAs and custody staff need to adequately communicate these special needs regarding inmates to ensure access to care.

What distinguishes correctional PAs from their civilian community colleagues is that they must be concerned with federal due process. The 8th Amendment to the Constitution prohibits cruel and unusual punishment, and the 14th Amendment ensures the right to due process and full protection under the law. The rights of prisoners cannot be abridged, and those with mental health problems have increased legal protections. Issues such as involuntary hospitalization, transfers from prison to mental hospitals, and involuntary medication and self-harm restrictions are closely scrutinized in mentally ill inmates. Few PAs are prepared to address these thorny legal and ethical access-to-care issues and as a result do not pursue this career track.

Many PA programs offer clinical clerkships in jails, prisons, and juvenile detention centers and can provide PA students with an entrance into correctional medicine; however, in general, PAs are not exposed to the complexities of correctional health care. More PA programs need to become vested in correctional medicine and the disenfranchised populations that are served.

Clinical autonomy

The safety of inmates, staff, and visitors takes priority in a correctional institution. Many decisions that would seem inconsequential in the free world take on great importance in corrections. For example, the choice to issue a pair of crutches for a patient with a nonweight-bearing injury takes on a different perspective when considering the safety precautions required in a jail or prison. As a result, correctional health clinicians face a number of pressures when assessing the health needs of their patients.

Inherent in a correctional institution is the power that security staff wields in deciding what can or cannot be permitted in the institution. Decisions about staff utilization, inmate housing, work assignments, and disciplinary sanctions for both staff and inmates are under the purview of administrative security staff. For example, hiring a PA to work in a jail takes not only the approval of the responsible physician or medical administrator but also that of the jail administrator. The PA must pass a detailed security screening, which, in some jurisdictions, may take several months to complete. The PA must abide by the employment rules directed by the medical authority, but he or she must also abide by the directives of security.

Sometimes there is conflict between security and medical staff over clinical decisions and actions. Custody staff should not, however, interfere with the implementation of clinical decisions. Qualified health professionals should direct clinical decisions and actions regarding all health care provided to their patients. Case in point: the PA orders a knee magnetic resonance imaging (MRI) test for a high security risk inmate. Security staff is reluctant to transfer the inmate to the hospital for the MRI, particularly because he is a dangerous escape risk and policy requires three officers to transport him. The jail administrator refuses to transport the inmate because of the threat to public safety. Most civilian health staff members are not accustomed to such denials of care. In this case the clinical decision should be tempered with cooperation and consultation with administrative security staff. How urgent is the MRI to making a clinical decision? How long has the patient been complaining of his symptoms? Is the denial of care deliberately indifferent to the inmate’s medical need? The answers to these questions influence the course of action that the PA should take. More importantly, the successful correctional PA is one who knows how to negotiate with custody staff to achieve the goals necessary to provide the best possible care for his or her patient.

Clinical autonomy cannot be jeopardized; however, in a correctional institution, diagnostic and therapeutic orders are not issued in a vacuum. Rather they require a coordinated effort among custodial, administrative, and health staff.

To facilitate the implementation of health care orders and decisions, most facilities hold meetings between security and health staff. Through joint monitoring, planning, and problem resolution, the health, correctional, and administrative personnel can facilitate the health care delivery system. Included should be discussions about the barriers to effective treatment and care. For example, evidence-based medicine has shown that disease progression is best controlled when the patient is involved in monitoring his or her disease. Patients with asthma should have peak flow meters, and diabetic patients should have glucometers. Custody policies, however, often prevent such items in the housing units for fear of security breaches. Treating asthma in a correctional environment is problematic because many facilities have inadequate ventilation systems or restrictive keep-on-person medication programs. Restricting opportunities for inmates with diabetes to self-test, self-prepare, and self-administer insulin presents an additional barrier to improving disease control. Administrative problem-solving, corrective actions, timetables for proposed changes, and updates on changes proposed during previous meetings are important strategies for implementing effective patient care.

Quality of care

Correctional PAs have to be knowledgeable in continuous quality improvement (CQI) monitoring. CQI identifies problems; proposes, implements, and monitors corrective action; and studies the effectiveness of corrective actions in addressing problems. This multidisciplinary (i.e., medical, nursing, mental health, substance abuse) structured process examines outcomes, as well as high-risk, high-volume, or problem-prone aspects of care, and ensures that established standards of care are met. CQI committees should assess processes that affect the effectiveness and efficiency of staffing, continuity of care, and the quality of services.

Patient satisfaction

Health care organizations are interested in the quality of care provided to their patients. They are interested in what their patients perceive to be quality. Correctional health systems are no different. Patient satisfaction surveys have been conducted by health care organizations for quite some time now; however, this is a new concept in corrections and is not widely accepted by correctional administrators. After all, correctional institutions are predicated on having individuals who do not want to be there and who are mistrusted by staff. This distrustful environment does not support surveying techniques. Nevertheless, a few correctional institutions have started conducting inmate-patient satisfaction surveys.

Staffing issues

It is difficult to recruit, train, and retain health professionals to work in correctional health care because prisons and jails do not have medical care as their primary mission. Jails and prisons are foreign working environments for most health care professionals. Nevertheless, correctional institutions have a mandate to provide adequate and timely evaluations, treatment, and follow-up care consistent with community standards.

The numbers and types of health care professionals required depend on the size of the facility and the scope of on-site medical, dental, mental health, and substance-abuse services. There is a difference in the functions and responsibilities of jails and prisons. Jails detain individuals who have been accused of a crime and who are waiting adjudication by either a jury or judge. On average, jails will hold detainees for about a year, although in some cases jails will hold individuals a few years past adjudication. The point is that once a conviction and sentence have been rendered, the individual is transferred to a prison. Prisons are long-term holding facilities for individuals who have been convicted and sentenced for their crimes.

Compensation and benefit packages are generally not competitive and are a disincentive for many PAs. The security clearance process is sometimes lengthy and dissuades individuals from staying with the process; they may instead take another job that has been offered. Opposition and pressure from family members is another barrier that a PA may face in taking a correctional health care position. The patient clientele are vastly different from the norm. Many are recalcitrant, ungrateful, argumentative, and even combative. In spite of these drawbacks, correctional PAs find that being at the crossroad of medicine, public health, law, ethics, and criminal justice is challenging and rewarding.

Finding and retaining qualified health professionals to work in jails, prisons, and juvenile detention and confinement facilities are important concerns. To help attract health professionals, some institutions serve as clinical rotation sites for students. Clinical rotations in correctional institutions provide unique and challenging opportunities for students to exercise clinical skills and be considered for future employment. The goal in hiring health professionals is to find professionals who are willing to establish and maintain a therapeutic relationship with inmates. Medical professionals are trained to advocate for quality patient care; however, providing such services in an antitherapeutic environment is difficult.

When these two dynamics collide, conflicts about authority over health services decision making and management may occur. For example, health care professionals hold to a tenet that patients should have control over the health care decisions that affect their lives. In correctional institutions, however, such autonomy may create problems for custody.

An inmate who refuses to take clinically ordered behavior-modifying medications (increasing the likelihood of disruptive behavior) or refuses to submit to a human immunodeficiency virus (HIV) blood test when a staff member has come into contact with the inmate’s blood presents problems for custody. How custody responds in such situations is often not the way medical professionals would solve the problem. The frequent conflicts that may arise between custody and health staff require well-developed, effective communication and problem-solving skills. Health professionals who do not have those skills are often co-opted and seen as an extension of security rather than as medical professionals.

PAs working in a correctional environment need to know that there is a constant balance between public safety and public health. They need to know that their environment is a paramilitary, organizational-based hierarchy and that public safety drives decision making relative to patient services. For example, administering medication to patients at a given time of day during pill call is made more complicated when the facility goes into a lockdown status (where, because of a breach in security, inmates are kept in their cells). The method and manner in which medication is administered may completely change to accommodate the public safety situation.

Clinical performance enhancement

The clinical performance enhancement process evaluates the appropriateness of a health clinician’s services. The PA’s clinical work is reviewed by another professional of at least equal training in the same general discipline, such as a review by the facility’s medical director or chief PA. The purpose of this review is to enhance clinical competency and address areas that need improvement. It is different from an annual performance review or a clinical case conference in that it is a professional practice review focused on the professional’s clinical skills.

Clinical performance enhancement reviews in a correctional environment are no different from any other institutional setting (e.g., the military or hospital). For example, treatment for HIV must follow certain clinical guidelines regardless of setting. Nevertheless, a correctional clinical performance enhancement review has an additional component in the review of one’s clinical judgment by assessing how one’s clinical competency affects public safety. The clinical PA may indeed be effective in managing the health care of uncooperative or even malingering inmates by gaining their trust and respect; however, if the clinical PA receives information from such inmates that public safety might be jeopardized, the clinical PA has a responsibility and duty to report it, even to the point of devaluing patient trust and confidence.

Staff and inmate safety

In January 2004, a 15-day hostage standoff between Arizona corrections officials and two inmates captivated the nation’s attention. The hostage standoff ended peacefully through a negotiated surrender of inmates and the release of a female officer. This event perpetuates the public perception that jails and prisons are dangerous places. Although that is true, it is important to remember that events such as this are not an everyday occurrence. Correctional institutions work to ensure staff safety through strict policies and procedures and by ongoing training of staff. Staff and public safety are compromised when lapses in training or procedures occur. For example, once in Sacramento, California, a deputy U.S. marshal placed his weapon under the front seat of his vehicle before entering the jail to pick up a prisoner. When he returned with the prisoner, he forgot to retrieve the weapon. It subsequently slid back where the prisoner was sitting. The prisoner, handcuffed with his hands in front, grabbed the weapon, ordered the deputy to pull over, and escaped. As this case reminds us, it is in the best interest of public safety to ensure that the health and well-being of staff are protected. When staff members forget or fail to abide by policy and procedure, harm can occur.

Risk and harm reduction create a working environment in which staff feel safe in doing their work. There is no central repository for the collection of hazardous duty incidents incurred by correctional health professionals. There are no studies on inmate assaults on health staff, although anecdotally, staff members report that assaults on health staff rarely occur.

In 2001, Human Rights Watch released No Escape, a descriptive report on male prisoner-on-prisoner sexual abuse in the United States that outlined first-hand accounts of prisoner rape and sexual assault stories from 200 prisoners in 37 states. This report reviewed the conditions that contributed to prisoner rape, including the rapid expansion of the incarcerated population during the prior 20 years; the increasing government decisions to privatize its prisons and jails; and the dismantling of prisoners’ legal rights through the Prison Litigation Reform Act of 1996 (an act that made prisoner lawsuits regarding conditions of confinement and deliberate indifference more difficult). As a result of the shocking claims made in No Escape, Congress passed the Prison Rape Elimination Act of 2003 (PREA). PREA requires “the gathering of national statistics about the problem; the development of guidelines for states about how to address prisoner rape; the creation of a review panel to hold annual hearings; and the provision of grants to states to combat the problem.” PREA is the first U.S. federal law passed that deals with assaults on prisoners and aims to improve correctional institutions’ safety.

Infection control

Correctional facilities generally have an exposure control plan that describes the staff actions to be taken to eliminate or minimize exposures to pathogens. In closed environments such as prisons and jails it is important that health professionals maintain standard hygiene practices and precautions. They need to be aware of infection control matters and should receive orientation and annual updates to infection control policies and procedures. Facilities also have needlestick prevention programs that include the use of self-capping needles and functional sharps disposal containers.

Many correctional institutions have infection control committees that establish and maintain the exposure control plan; monitor communicable disease among inmates and staff; ensure prompt treatment for inmates and staff with infectious disease; ensure staff receive appropriate training and maintain procedures; ensure that personal protective equipment is available and used; and meet reporting requirements, laws, and regulations issued by local, state, and federal authorities. Well-publicized outbreaks of the novel coronavirus SARS-CoV-2 in jail and prison settings demonstrate the need for infection control measures in these settings and highlight the challenges associated with developing effective protocols. In fact, at the time of this writing, measures to control of the spread of coronavirus disease 2019 (COVID-19) in correctional settings are still evolving.

Community-acquired methicillin-resistant staphylococcus aureus

A major problem occurring in many jails and prisons today is the increasing rate of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Jails and prisons foster environments in which contagions such as S. aureus and CA-MRSA can be transmitted from one person to another.

CA-MRSA infections are generally mild, self-limiting, minor skin infections that appear as pustules or boils. Inmates often complain of “spider bites,” and correctional staff too often dismiss their claims. Education is necessary for both groups so that health staff can intervene and begin treatment.

Other confounding issues complicate the matter of containing CA-MRSA outbreaks in correctional institutions. They include comorbidities of substance abuse and mental illness, distrust of authority figures, reluctance to cooperate with health care staff, and resistance to rules of hygienic practice. These issues can complicate the ability to adequately ensure self-cleanliness. Before their incarceration, many inmates were either homeless or came from home environments that did not have adequate sanitation or did not stress personal hygiene. The hygienic practices of frequent hand washing with soap and water, avoidance of picking lesions, daily showers, and limitation of the number of personal items shared with other inmates should be emphasized to all inmates.

Other significant risk factors that have been found include prison occupation, male gender, comorbidities, prior skin infection, and previous antibiotic use. Resistance to antibiotic therapy has added to this problem. Commonly, inmates have not sought regular and consistent health care from one primary care provider. Too often when they obtained medical services before incarceration, inmates went to emergency departments and public health community clinics. This episodic approach to their health care without consistent or organized management complicates the individual’s resistance to antibiotic therapy.

Another problem that complicates matters is that many inmates, by nature, distrust authority and rules. When an outbreak occurs in a jail or prison, inmates are quick to blame jail administrators and health staff for the problem and not take responsibility for themselves. This distrust of authority creates a barrier to improving jail and prison conditions and eliminating the transmission of CA-MRSA.

Tuberculosis

Tuberculosis (TB) in correctional facilities has been a continuous problem affecting the health status of communities at large. Over the last several years, the incidence of TB has been declining; in 2017 the incidence in the general population was 2.8 cases per 100,000 persons. The proportion of TB cases in the U.S. attributable to non-U.S. born persons, however, has increased. Although a similar trend has been observed in correctional facilities, the incidence of TB among incarcerated individuals is substantially higher overall than in the general population.

The control of TB in correctional facilities is a multifaceted problem with no easy answers. Correctional institutions have policies on staff surveillance; however, it is difficult to maintain mandatory and periodic screening of correctional staff members. Between 2001 and 2004, the Florida Department of Corrections had one HIV-infected correctional staff member who was nonadherent with TB treatment and infected five correctional staff members over two and a half years. Four of the five cases were caused by an identical TB strain, indicating a probable common source.

Correctional institutions may have poor ventilation and a transient population, which further complicates the control of TB. As a result, contact tracing is extremely difficult. In 2002, Kansas had a case in which a TB-infected inmate was transferred to three jails and one prison. During the process he came into contact with more than 800 individuals and was positively linked, via identical-band restriction fragment length polymorphism (RFLP), to two inmates with active TB (cellmates in two different locations). In contact tracing, 318 of the 800 inmates were identified and 256 were tested. Among 196 who had no previously documented tuberculin skin test (TST), 41 (21%) had a positive TST during the investigation screening.

Latent tuberculosis infection (LTBI), a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without evidence of clinically manifested active TB, is higher among prison inmates than in the general population. Inmates with latent TB should be assessed and treated and receive appropriate education prerelease. It is estimated that 500,000 inmates with LTBI are released nationwide every year.

Screening for TB infection is a top priority for most jails and prisons and involves administering tuberculin skin tests, performing a chest radiograph if positive, and referring positive cases for treatment. Nevertheless, TB outbreaks do occur in jails and prisons because many inmates do not complete their LTBI treatment.

In addition to screening tests, many facilities have TB coordinators who monitor the screening and treatment of TB among inmates. Among highly trained correctional health staff, the U.S. Public Health Service officers provide care to the majority of foreign-born inmates in the custody of federal prisons and in Immigration and Customs Enforcement (ICE) by actively surveying, treating, and monitoring TB-related concerns.

The high prevalence of TB in jails and prisons suggests that correctional PAs are at the forefront of this public health battle, which requires surveillance, detection, and treatment.

Hepatitis

Corrections populations have high rates of hepatitis C. Estimates indicate that 12% to 39% of all Americans with hepatitis C have spent some time incarcerated. This clear and present public health threat requires consistent policies and programming. With the emergence of new treatments for hepatitis C that result in greater than 90% cure rates, the screening, monitoring, and treating of incarcerated individuals is imperative for public health. Correctional PAs are poised to address the full spectrum of hepatitis C cases, including ones that involve coinfection with hepatitis B or HIV and ones found to have more than one hepatitis C genotype. One treatment consideration is to administer vaccines to prevent other infections, including hepatitis A and B.