American College of Physicians: Internal Medicine — Doctors for Adults ®

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Once the practice of last resort, prison medicine rebuilds its image

From the July/August 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Edward Martin

RALEIGH, N.C.—Disappointed, Norman L. Dean, FACP, shifts his stethoscope, but the tiny, frail woman's chest sounds are still murky, and she flinches when he probes below her sternum. Monday is starting badly.

"I've known her for a year and a half, and she's made a remarkable comeback," he says. While this AIDS patient had responded well to protease inhibitors and other medications, she is now short of breath and complains of abdominal pain. Suspecting pneumocystis pneumonia, Dr. Dean transfers her to an HIV specialist at a nearby university hospital. "This," he says softly after she has left, "is quite a setback."

It is just after 9 a.m. and the sun is climbing above the squat brick building where Dr. Dean is working. The scene could be a community hospital almost anywhere in the country, except for one major difference: Dr. Dean's clinic is ringed by razor wire, and his patients are inmates at the North Carolina Correctional Institution for Women. Another day of health care has begun in one of America's maximum-security prisons.

For many physicians, this is the last place that they would want to work. Besides obvious problems like physical danger and overcrowded prisons, correctional medicine still carries the stigma of second-class medicine. Many see it as the practice of last resort for physicians unable to succeed on the outside.

But for Dr. Dean, one of roughly 4,000 physicians currently practicing correctional medicine, it has substantial rewards. Behind bars, he has found the freedom to practice medicine away from many of the constraints imposed by the world of managed care.

Struggle for reform

Life as a prison doctor is far from glamorous. At the women's prison, Dr. Dean examines patients in a cramped room that doubles as an ophthalmology exam room and has cartons of medical supplies stacked in its corners. Pharmacists and lab technicians crowd into offices intended for half as many occupants. When he hangs his white coat, he shares the hook, on this particular day, with Obinnaya Umesi, MD, an internist who also doubles as the local county jail physician. Nevertheless, he has no complaints.

"When I interviewed for this position, I saw in a single setting the opportunity to practice my subspecialty, see geriatric patients and do primary care," he explains. "Those are all of the things I find really satisfying in medicine and, except possibly in a rural or inner-city practice, I can't imagine anywhere else in medicine today that I could have this great an impact."

Dr. Dean, 60, made the transition to prison medicine relatively late in life. After teaching medicine at Yale University and doing clinical research with prestigious pharmaceutical firms, he joined the North Carolina prison system in 1996.

That year marked the 20th anniversary of a ruling by the U.S. Supreme Court that poor medical care for those behind bars was tantamount to cruel and unusual punishment. It was the beginning of a quest to reform prison care, a formidable task that has progressed in fits and starts.

The explosion in jail and prison populations raises a serious obstacle. According to the National Institute of Corrections, the number of inmates in U.S. prisons rose from less than 1 million in 1990 to 1.6 million in 1997. Experts now believe that figure exceeds 2 million.

Even in states like North Carolina, whose 33,000-inmate system is regarded as among the nation's more progressive, conditions are far from ideal. Dr. Dean works in a 28-bed infirmary in a prison designed to hold 754 women. Currently, the prison holds 1,100 inmates, the result of a growth spurt that has doubled the state's prison population since 1988.

Such circumstances frighten many physicians away. "I'm sure my parents never raised me to be a correctional physician," quips internist Barbara L. Pohlman, MD, the director of North Carolina's $100 million-a-year prison health care system, during an afternoon visit with Dr. Dean. "It's not glamorous and the patients can be horribly difficult. A lot [of physicians] still consider it the poor stepchild of medicine."

In addition, pay for correctional doctors can be a problem. Although North Carolina prison physicians earn $120,000 to $140,000 a year, roughly in line with the $139,000 median of outside internists, nationally they may be the exception. Roderic Gottula, MD, of Denver, president of the Society of Correctional Physicians, notes that poor compensation still plagues the field in many states, making it difficult for prisons to recruit top talent.

Pay issues have contributed to prison medicine's image as a haven for subpar physicians. Although Drs. Gottula, Dean and others adamantly insist that nothing less than community standards should be tolerated in prisons and jails, prison systems in three states—Alabama, Mississippi and Texas—have allowed physicians who have lost their licenses for misconduct to treat inmates. Among those was a Michigan physician who, after pleading no contest to 59 counts of sexually abusing patients, was allowed to practice in Texas prisons.

Over a 10-minute lunch of soy milk and a tuna salad sub, Dr. Dean discusses the problems that continue to plague prison medicine. He can cope with cramped working conditions, asthma patients who smoke and guards who sometimes disregard his patient directives, he says, but not a dual standard.

"There is something seriously wrong if we have people in power who think that someone not to be trusted to practice medicine in society should be allowed to practice in prison," he says. "The people we treat here have made bad choices, but they are still human beings." He leaves his sandwich unfinished.

Old before their time

A typical day for Dr. Dean starts with a 40-minute drive from his home in the university town of Chapel Hill to Raleigh, where he works at both the women's prison and at a separate facility for men. By 8 a.m. he has cleared the gatehouse and heard the electronic doors clanking shut behind him.

For Dr. Dean, working in prison medicine is worlds away from his previous professional lives. He served as chief of pulmonary medicine at a Connecticut hospital for 13 years before moving to North Carolina to work in research for a multinational drug company.

Frequently, however, he found himself recalling the period during the 1980s when he directed respiratory medicine services at a Connecticut veteran's home. "I'd been tempted to stay, because I enjoyed the patient interaction so much," he explains. In 1995 he left his research job and completed a year-long geriatrics fellowship at Duke University.

After joining the prison system, Dr. Dean rediscovered patient contact, but under very different circumstances. At North Carolina's rural McCain unit, his first prison assignment, he cared largely for geriatric inmates and learned that old age comes early in prison.

"Physiologically, most prisoners are 10 years older than they are chronologically," he says, a result of poverty, substance abuse and poor health care. At McCain, he established an asthma intervention clinic that he has since duplicated at the larger men's and women's prisons in Raleigh.

"There was case after case that would appeal to any internist," he recounts. "One was a recalcitrant prisoner in his 20s who was in lockup because of bizarre, aggressive behavior. He had never had access to care on the outside, but he was a textbook picture of Cushing's disease." Dr. Dean's hunch was right on target, and it was later determined that his condition stemmed from a pituitary tumor.

As Dr. Dean looks over a patient chart, a nurse announces that a new prisoner, a safekeeper—the term guards use for prisoners awaiting trial—has arrived. On his way to see the patient, Dr. Dean strides quickly down the corridor. "Always walk fast," he says with a laugh. "You're constantly approached by inmates who want to know why they haven't been seen, or if you can give them something for this or that."

Working as a prison doctor, Dr. Dean explains, hones certain reflexes: Never leave keys unguarded, and never enter an elevator or closed space without a guard. "In the women's prison you feel pretty comfortable," he says. "But the atmosphere in male prisons is more threatening. They try to provoke the male nurses into losing control."

Ultimate contradiction

Much about working in a prison defies jailhouse stereotypes. While many outsiders might assume that physical assaults are common, correctional physicians are rarely attacked. And while AIDS among inmates gets widespread attention from the media, infection rates vary widely among prison populations. In North Carolina, for example, fewer than 2% of inmates are HIV positive. In New York and some other prison systems, on the other hand, 30% of all prisoners are HIV positive.

Much of what Dr. Dean does encounter enters the realm of the surreal. Near the infirmary's two-bed dialysis unit, Dr. Dean passes an open door of interlaced steel rods, painted light brown. Inside lies a blue, plastic mattress, flat on the floor and covered with stained, rumpled sheets. A steel commode and sink with rounded edges is built into a corner of the otherwise empty room. This is suicide watch. Last night the patient swallowed razor blades.

Across a barren quad where two crows peck at dropped food scraps is North Carolina's death row for women. Dr. Dean treats its six inmates, including Blanche Taylor Moore, convicted of poisoning two husbands, a boyfriend and her parents with arsenic-laced potato soup and peanut butter pies. She was the subject of a television movie, "The Black Widow."

At North Carolina's Central Prison, the men's facility where Dr. Dean also works, the 84-bed hospital, which includes a small operating suite and five dialysis beds, is located a stone's throw from death row, where 183 men await their fate. Several are kept alive by renal dialysis while waiting to die by lethal injection.

For Dr. Dean, death row is the ultimate contradiction of prison medicine. "It might seem crazy," he says while awaiting a patient. "But that is just one of the many ways the ambivalence and contradictions of society are reflected in here."

Dr. Dean does not participate in prisoner executions and says that he would refuse if asked. His position is supported by medical groups like the College, who say that participation by physicians in the execution of prisoners is unethical. (For more on the College's position, see www.acponline.org/ethics/index.html.)

Reversals of fortune

While Dr. Dean acknowledges the surreal aspects of working in a prison, he is quick to point out that correctional medicine also offers satisfactions that managed care has stripped from many community practices. The result is some strange reversals of fortune for physician and patient.

His salary is "more than enough to have a pleasant life on," and his predictable workday—8 to 5 and home by 6—would be the envy of many community practitioners. And, despite the challenge of dealing with "patients from hell," as he refers to incorrigibles, the effort is worthwhile for Dr. Dean because many of his patients would receive no care at all outside. "They come from impoverished backgrounds, and some have never seen a doctor before."

After lunch, Dr. Dean walks along a sidewalk outside the infirmary at the women's prison. Inmates in blue, hooded sweatshirts loll in doorways along the sidewalk or sit on bare, concrete benches. Without insurance forms or preapprovals, examinations are detailed and may exceed 30 minutes. He has time to talk to patients.

"Got good news since I saw you last." Helen Perry, 34, convicted of food stamp fraud, says brightly as she leans back in an examination chair. "Got my GED and finished a course to become a home aide."

Sitting at a small table, Dr. Dean makes a note in the woman's chart. "Still smoking?" he asks. Flustered, she laughs. "I cut back to a pack every two days," she says. "I used to smoke half a pack a day." Dr. Dean smiles at her math.

The absence of pressure from managed care has also allowed Dr. Dean to practice his subspecialty, pulmonology. Eighteen months after starting his asthma intervention program here and at the men's prison, Dr. Dean sees more than 200 inmates who maintain diaries logging triggers—commonly airborne fibers, dust or cleaning-fluid fumes—that set off attacks. They note the effectiveness of various medicines such as the pirbuterol inhaler, Maxair, which he prescribes.

"You can see the changes in their health, and have an opportunity to build bonds and trust," he says. "You find that can really make a significant difference in your ability to deliver care."

Bobbi Brossoit, 19, his next patient, is a gangly teenager who sports long thermal underwear beneath her prison skirt. She blows into the flow meter and shows improvement since her last visit. Dr. Dean counts her as a success; she has maintained her diary well. He also treated her sister, Tonya Brossoit, 21, who has recently been released. "Has your sister written you since she got out?" "Yes sir. Twice." "Good," he replies. "Good."

Dr. Dean enjoys the give and take, but he is not naive. He has learned the work details that inmates try to avoid by using a medical excuse. The younger Ms. Brossoit blamed her asthma flare-up on dust from a hated assignment, picking up cigarette butts. "You almost have to become a detective," says Dr. Dean. "Skills you need to get by here don't necessarily include honesty."

Uncertain future

It is near the end of the day, and across the quad from the infirmary, a line of inmates stretches outside and around the brick dining hall. The day fried chicken is served is the highlight of an inmate's week. Weary, Dr. Dean makes some final notes in his charts after the last patient has gone.

For him and his peers in correctional medicine, the challenge to emerge from an unsavory past into an uncertain future is still formidable. Besides overcrowding, there is also the threat of managed care and privatized, for-profit prison systems. While they promise to save tax money by caring for prisoners—particularly geriatric inmates—more efficiently, critics worry corners will be cut and care will suffer.

Some changes are already on the way. Commercial health plans are beginning to replace the staff-physician model in hundreds of systems nationwide, and North Carolina has test contracts with managed care companies in two of its 84 prisons. Two other prison units are operated entirely by private corporations.

Despite setbacks, however, recruiting prison doctors may actually be getting easier due to changes managed care is bringing to community medicine. In St. Louis, Bob Manche, manager of physician services of Correctional Medical Services Inc., a private company that manages 200 correctional health facilities in 28 states, cites the example of highly regarded physicians like Dr. Dean.

"I've been doing this for 18 years, and in the beginning it was nearly impossible to find qualified doctors," he explains. "Now, a lot are making less money under managed care and have a lot more restrictions." His company has 500 correctional physicians under contract.

Dr. Dean takes such developments in stride. "I don't walk around with a sign, 'I work in correctional medicine,'" he says. "A lot in academia still have trouble understanding it, and even well-intentioned people don't realize that the inmates in here are not that much different from the people on the outside."

Edward Martin is a freelance writer in Charlotte, N.C.

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