White Coats, Orange Jumpsuits: Treating Prisoners

Under the Eighth Amendment to the U.S. Constitution, which prohibits cruel and unusual punishment, U.S. prisons are required to provide healthcare to their inmates; the fastest growing prison population in the United States is the elderly (defined as being over 55 years of age). Between 1999 and 2007, the number of elderly prisoners in U.S. prisons leaped 82% to approximately 90, 000 inmates.

The statistics are sobering. In federal, state and local jails, 38% of inmates, 43% of inmates and 39% of inmates, respectively, have a chronic medical condition and most of those are such problems as diabetes, HIV or heart disease. (data from the U.S. Bureau of Justice Statistics). But, mirroring the society at large, orthopedic conditions are becoming an increasingly prevalent public healthcare problem because inmate populations are aging.

Dan Thompson, the President of Beaumont Bone and Joint Institute, is a traumatologist who has treated approximately 1, 000 inmates. How is treating an inmate population different from treating a non-inmate population? Dr. Thompson notes,

While many people would have sort of a gut level fear about working with this population, I can honestly say that I have never had a prisoner be overtly aggressive with me. In fact, most prison patients are more cooperative than the general public because a trip to see the doctor is a bit of a treat. It is an opportunity to leave the prison for a couple of hours…and they know that if they become difficult then they will not have that opportunity again. The prisoners I have treated are genuinely appreciative, especially if they think that there are few people at the correctional facility who have much concern for them.

For Dr. Thompson, the sight of someone in an orange jumpsuit is not only familiar, but rather welcome. “I have taken care of prisoners since day one of my training in medical school. In those years I worked at a maximum security prison hospital; whereas many of my colleagues have VA experience, I had prison experience. That was my residency as well.”

Dr. David Teuscher, an orthopedist and partner at the Beaumont Bone and Joint Institute in Beaumont, Texas, has worked with incarcerated individuals for the past 20 years. He notes, “There has been an increase in the number of local prisons built in our area over the last couple of decades. In fact, Jefferson County is unique in that it has so many correctional facilities, including county, state, federal, and youth institutions. Despite an existing contract between the state, the prisons, and the University of Texas Medical Branch at Galveston, and because of policy changes emanating from recent hurricanes, there was still a need for folks to be seen for orthopedic conditions on an expeditious basis. Since we were being asked frequently to evaluate and treat prisoners, our staff set up a system whereby the nursing staff at several local corrections facilities could routinely access our clinic.”

But the inmate patient X doesn’t just walk in the door and say “I’m here for Dr. Teuscher.” “Our process is that when we receive a call from the nursing supervisor at a correctional facility, we then route that person through our workers compensation secretary who handles the initial paperwork, including verification of coverage. On the day of patient X’s appointment our clinical coordinator checks the list of inmate patients who must be treated with a little extra protocol. In the event that the patient is a more serious offender, the correctional personnel will remain with him or her in the vehicle and then when called, proceed through a backdoor entrance to the facility. The nursing staff understands that these patients need to go directly to an exam room as opposed to the waiting room. This is largely an issue of making sure that the other patients feel safe. The prisons handle security well, and never send an inmate to our clinic without two security personnel…we have never had an issue with security.”

Credit for this can also be given to the practice itself. “We have all of the understandings worked out in advance. If someone needs X-rays, our clinical coordinator will walk the administrative paperwork through the system. And if an inmate requires surgery, there will be a guard in sterile scrubs in the OR and one in the hallway. Again, all of this must be run in a way that makes your staff, other patients and their family comfortable.”

At times, doctors can do a preliminary assessment of a prisoner’s arm or leg from blocks or even miles away. “Thanks to telemedicine, we can work remotely with the facility’s nursing personnel to evaluate the acuity of the injury. Then from there I must make a determination whether or not this is an offsite situation, meaning that the person should head to the ER. This is a very useful process; a doctor in a remote location can watch a nurse do a basic exam of the injury and say, for example, ‘Yes, we need an X-ray.’ Much of orthopedics is touching and feeling, so while telemedicine is a bit of an adjustment, if you watch closely and ask the appropriate questions, then it can be done well.”

Then there are the questions you want to avoid, à la, “What are you in for?” “I do not inquire about the reason for the patient’s incarceration. Many times, though, they bring up the subject. While I often hear, ‘But I didn’t do it, ’ I just maintain the attitude that they are eventually going to be released from the facility and that perhaps they can rebuild their lives.”

In the event that someone does want to talk about their crime, if I have a good rapport with them I may ask why they did it. The most popular answer is, ‘Stupidity.’ In the end, though, I’m not here to be the judge or jury; as for the inmates, they want to know that they’ll be treated fairly. For anyone interested in working with incarcerated individuals, I would say, ‘Don’t be thrown off by their unique circumstances. They are more like everyone else than they are different.’

While patients “on the outside” might show up at Dr. Teuscher’s office because they took a spill from a motorcycle, those who arrive with guards most commonly have been involved in physical altercations or have sports injuries. “I see a lot of hand injuries because someone has punched a wall—or someone else. Then there are the knee and other injuries that occur while the person is playing sports.”

Echoing Dr. Teuscher, Dr. Thompson says, “Because these prisoners often get into fights, I see a lot of hand and wrist injuries. The athletic injuries I see are because they play a rough style of basketball and handball, which often results in ankle fractures, distal tibia fractures, ACL tears, and rotator cuff injuries.”

There is basic medical care, says Dr. Teuscher, but there is no free ride for old wounds. “There is a misperception that once people go to prison they have extensive medical care and in essence get all of the ‘work’ done that they neglected to do ‘on the outside’…and that it is all paid for by taxpayers’ dollars. Instead, the basic question to be answered when someone is incarcerated is, ‘Does this person need XYZ treatment?’”

And whatever reasonable treatment an inmate needs that is related to a current injury, he or she will receive. Dr. Thompson: “By law prisons must have arrangements with a practice to do a comprehensive orthopedic exam. And if, for example, someone needs a shoulder specialist, he or she will have one. Prisoners do have the right to sue if they are denied appropriate care. As for the reliability of the prison system as a payor, it is excellent.”

Treatment is always a partnership, no matter if the patient is on Main Street or in Central Lockup. “The most difficult part for me, ” states Dr. Thompson “is that what I know is a necessary part of treatment, i.e., postoperative rehabilitation orders, tends to turn into suggestions once these patients return to prison. If, for example, you have done a complex hand reconstruction, then you must consider what access this patient will have to therapy. In a federal penitentiary they will have better access to rehabilitation services, but not at most state and local facilities. In all my years of working with prisoners, however, I have never seen a prisoner leave the facility to engage in physical therapy…it’s just too much manpower and too much of a security risk.”

Scheduling can also require some adjustments, says Dr. Thompson. “At times I have had inmate patients booked for surgery, but they don’t show up until several weeks later. This may be because there has been a lockdown at the prison, for example, or because that particular inmate was involved in some type of altercation. On top of that, there is there a chance that while you are waiting for their surgery date to arrive they are transferred to another facility (and may fall through the cracks).”

If you are entertaining the possibility of working with prisoners, says Dr. Thompson, the main thing is to ensure that your staff and patients feel safe. “You’re going to have prisoners coming into office buildings, so all of those logistics must be worked out in detail. It may be unsettling for your average patient to see an inmate coming in with shackles surrounded by two big guys with guns and bullet proof vests. Despite what may appear visually intimidating, however, again, I have never felt threatened by incarcerated patients.”