Alemagno, Sonia A. PhD; Wilkinson, Margaret PhD; Levy, Leonard DPM, MPH
The number of persons incarcerated in prisons in the United States has more than doubled in the past ten years, with a dramatic increase in female inmates. These individuals represent a population of primarily uninsured or underinsured persons who have received little primary care and sporadic community-based medical care from emergency rooms and urgent care centers. This lack of medical attention results in a population at high risk for many chronic medical conditions that have been unattended before incarceration. Many prison inmates have histories of violence or abuse (both sexual and physical), substance abuse, and psychiatric disorders, as well as infectious diseases such as sexually transmitted diseases, including HIV. Clearly, this unique setting potentially provides students exposure to a population of patients with a preponderance of medical conditions well beyond the pathology found in most community-based settings, and offers opportunities for patient interaction and charting that are becoming more restrictive in other settings.
In this article, the authors describe the first two years (2000–02) of a pilot medical education program to develop and implement a medicine curriculum for osteopathic medical students that focuses on health care in correctional institutions, including one-month rotations within prison health care settings. The program was carried out at Nova Southeastern University College of Osteopathic Medicine. Students received orientations, directed readings, and prison clinical experience under the direction of board-certified physician preceptors. A total of 53 medical students participated in the first two years of the pilot program.
The prison environment presents unique challenges to medical education. Dolan1 reports that prison health care staff may have educational deficits in several areas, including a lack of knowledge regarding substance abuse and detoxification, responses to medical emergencies, mental health assessments, suicide and deliberate self-harm, and intervention and prevention programs in general. These deficits point to important components to be considered when developing curricula for correctional medicine. Studies further describe the need for curricula related to the complex organization of health care in confined settings. Evans2 describes how prison-based medical settings can be confusing, with considerable debate between custody and prison health care staff regarding whether the needs of certain groups of inmates are health-related or social in nature.
Kaufman et al.3 have described three major values in exposing students to correctional medicine early in their education. First, the exposure of students to the rich pathology provides an inherently worthwhile educational experience. Second, academic medicine can provide a valuable service to the prison community by linking medical staff to academic opportunities for continuing medical education. Third, by exposing students to the challenges and importance of prison medicine, the stigma against such medicine might be overcome, thereby facilitating future recruitment of health care providers for that field.
Clarke et al.4 describe the experience of developing a curriculum to immerse primary care residents in caring for female inmates. The goals of the curriculum were to expose residents to working with patients with multiple psychosocial and substance abuse problems, to provide training in conducting a sensitive gynecologic examination, and to provide exposure to managing common gynecologic problems, including identifying and treating sexually transmitted diseases. The curriculum was further intended to provide residents with the opportunity to counsel patients about HIV prevention. The residents learned to identify, counsel, and refer women who have problems with domestic violence, and those completing the program reported feeling confident in performing a gynecologic examination with minimal discomfort to the patient. The residents also reported positive learning as a result of lectures regarding sexually transmitted diseases, substance abuse treatment and detoxification, domestic violence, sexual abuse, and the interplay between the criminal justice system and health care in general. Fisher et al.5 describe experiences of a plastic surgical teaching service in a women's correctional institution. Patient acceptance of residents was reported to be extremely high. In addition, the curriculum resulted in an enhanced relationship of the residents with nurses due to the great reliance of the surgical team on the nursing staff in the prison for their knowledge of an individual's past behavioral patterns.
The prison context presents unique challenges to health care professionals and trainees.6 Professional dilemmas can occur with exposure to information related to prisoners’ lives, crimes, and despairs. Disclosure can lead to ethical and moral dilemmas when patients impart information about plans for involvement in other or future crimes.7 There is sometimes a need to balance responsibility to society with responsibility to the patient. This is a challenging part of the correctional clinical role.
Other unique aspects of this setting include the difficulty of establishing an adequate history or diagnosis because of language barriers or because of the patient's fear and distrust of authority figures. Difficulties may arise in performing adequate physical assessments because of the presence of physical restraints such as handcuffs or shackles. There may be subtle or serious changes in clinical care resulting from a lack of time with a patient or lack of adherence to care. For example, medications that should be administered four times a day may only be administered twice a day. These clinical complications can be substantial and overwhelming to a clinician in training in a correctional setting.
Notwithstanding these issues, prison health care experience has been linked to attitudinal change in providers.8 Following exposure to the prison health care environment, nurses have reported more favorable attitudes toward inmates, correctional officers, and the law. These positive outcomes are also reported for graduate medical education programs that have ventured to the prison setting.9
A curriculum committee comprising physician, education, and research faculty developed a pilot program to expose third- and fourth-year medical students to the unique aspects of medicine within prison settings. The intention was to provide a one-on-one experience by having students work with the physician preceptors in prison health care settings. Students conducted history and physical examinations on inmates, observed procedures in clinical and prison hospital settings, and had the opportunity to follow patients through acute episodes. Students were also able to observe and follow patients in specialized hospital settings, including a facility dedicated to the care of HIV/AIDS patients. Students also attended lectures and had the opportunity to work with specialized care in the areas of psychiatry, cardiology, and surgery.
The correctional medicine curriculum provides a unique managed care setting in which to train students. The setting clearly presents the opportunity to provide care to patients with a wide spectrum of diseases, with some inmates in advanced stages of diseases and some receiving medical care for the first time. Students are able to document histories on inmates with extensive problems, including those related to violence and victimization, substance abuse, mental illness, and infectious diseases. Students are challenged in taking histories from individuals who are not generally aware of their family histories.
List 1 summarizes the educational experiences offered to students in the pilot correctional health care program. Major curriculum components include those related to the medical context, chronic disease management, infectious disease, mental health, special populations, and ethical considerations.
The prison health care setting provides students the opportunity to work closely with an extensive support staff, especially correctional nurses. With the development and application of health care standards for accreditation, prisons and jails (which differ from one another in important respects and have different health care requirements) have become unique professional environments. Each is complex and exposes the student to highly structured protocols and documentation requirements.
The prison provides students with a challenging context in which to learn about the dynamics of confidentiality and the patient–practitioner relationship. The setting by nature has restrictions related to patient autonomy and ability to choose between health care providers and directives. Students in this context must learn to work under the observation of security staff, with patients who may not have the option to follow through with usual directives such as exercise or diet programs. The setting allows students to apply concepts of cultural competence in providing care to a very diverse population in terms of race, education, and cultural background.
There is a considerable challenge to gaining the acceptance of faculty, students, and parents/families in implementing a correctional medicine rotation. The prison setting has a stigma in both the general population and the health care system; there are serious misconceptions regarding issues concerning safety and inmate acceptance of medical care. Before the pilot program was implemented, administrators had open meetings to address students’ concerns. Working closely with the prison professionals, the university developed an orientation program that included aspects unique to the correctional setting, including security and safety issues.
Before the new correctional medicine clinical program was begun, students expressed considerable apprehension about their safety. In addition to just not knowing what to expect, they expressed major concerns about being with a population of people who had committed felonies that included all varieties of violent acts. However, in the first two years of the program, no incidents were reported either officially or unofficially. After the first group of students completed the clerkship, these concerns no longer were an issue and there was a waiting list of students who wanted to enter the program.
A prison health care setting is demanding and challenging, even in the absence of trainees. The introduction of medical students to such an environment presents a new dimension to a context that had not traditionally been concerned with medical education. For this pilot program, a major consideration included ensuring the availability of board-certified physicians able to dedicate sufficient time to be preceptors. While a university affiliation may give prison physicians access to continuing medical education, the program also adds a new role and time burden. Therefore, one of the first considerations was how to provide a balance of roles to meet both the health care and educational needs.
Gaining internal support for such a program is essential, including the support of key staff such as nurses and correctional officers. Students entering a prison setting are a security risk that must be taken seriously. Attending to the challenges of the situation, however, led our students to several important outcomes of our pilot program. For example, our experience suggests that if students are exposed early enough in their medical training to the correctional health care setting, it is possible, and likely, that some will select that setting as a professional avenue. With the steady increase in prison inmates, it is clear that there will an ongoing and increasing need for physicians with specialized training in correctional medicine.
We report below the evaluation results of the pilot correctional medicine rotation just described, based on the responses of 33 students. The evaluation focused on three major areas: orientation to the prison health care rotation, advantages and disadvantages to learning, and students’ recommendations for improvement.
Students described a number of aspects that should be included in an orientation to clinical care in a correctional setting, including:
* Introduction to a controlled environment and prison routines
* Ensuring safety and security of students
* Legal and ethical issues related to confidentiality and prisoner rights
* Exposure to infectious diseases
* Role of the health care provider in prison
* Rules and regulations of the facility and health care
* Gaining access to restricted areas
From these responses, it is clear that students have some anxiety regarding the prison context, ones that should be addressed before the rotation.
One student wrote:
At first I was scared, and I did not know what to expect. The whole place was huge and very institutional-looking. I was not sure whether to make eye contact with the prisoners. Everything was new. Even the simplest things like eating lunch or finding medical supplies involved a totally new experience. I was glad that we got a manual and an orientation or I would have been totally lost. After only two days, I was not afraid any more and I realized that the prisoners were very happy to have us there and treated us with total respect.
Students were asked to rate their achieved learning in seven conceptual areas, comparing the correctional medicine experience to other clinical rotations experienced. These results are presented in Table 1 and indicate that the students had very positive reactions to learning aspects of the correctional medicine experience, especially in the areas of clinical decision making, management of the chronically ill, and infectious diseases.
A student reflecting on aspects of chronic disease management within the prison wrote:
I was surprised at the complexity of managing patients with serious chronic illnesses. Many inmates have asthma, diabetes, and other illnesses that require very detailed systems of health care. The managed care aspects within the prison are overwhelming. Still, I was able to develop a relationship with patients and see them sometimes on a daily basis. I saw an HIV patient in a special unit almost daily. Since I was used to being in a hospital with residents, this setting allowed me to feel more autonomous and to interact directly with the physician faculty on specialized cases.
As a part of a correctional medicine program, students are able to focus on issues that are unique to the setting. Unique aspects include mandated intake examinations, sick call, hospital secure units, legal considerations, and ethical dilemmas related to confidentiality.
Another student wrote:
Maintaining confidentiality in a prison setting must be a huge issue. You can interpret health care status from things like an inmate's movements or a pattern of scheduled visits. It is a real challenge to make sure that no one overhears the encounter. Health care providers are really careful not to discuss cases in front of other patients. The whole experience made me think a lot more about confidentiality within all of the settings I work in.
Students were asked to comment on the advantages and disadvantages of completing a rotation in correctional medicine. The advantages reported by students primarily relate to exposure to a varied and extensive pathology, along with the opportunity to provide care in a nontraditional clinical environment. Students perceived unique challenges to a patient's ability to be compliant. In addition, students expressed positive reactions to being exposed to many specialties in a single rotation.
One student commented on the overall experience:
This rotation had lots of hands-on experiences. I got to focus on patient care and on special aspects like how to make diagnoses of rare illnesses, managing mentally ill patients, what to do about patients who refuse care, and how to deal with a very extensive health care system. I also got to learn from nurses in a way that I had never been able to. There is a real health care team here.
Disadvantages related to the experience included feeling isolated because of the remote location of the prison, a lack of organization to the schedule, having to deal with many changes on a daily basis, and spending time watching care rather than performing clinical tasks.
The pilot project evaluation reveals that students had a positive initial experience. Although there may be considerable challenges to the university, to the correctional system, and to the student, initial feedback indicates that the prison context presents medical education opportunities to students that might not be accessible in other environments. From our experience, critical consideration in implementing such a program include the orientation of students to this new clinical environment and working with prison-based faculty to develop the curriculum around special topics such as chronic disease management, infectious diseases, and the unique aspects of the patient–provider relationship in the prison context.
Conducting education and training programs for medical students in correctional institutions also has the added advantage of bringing the academic health center to the physicians who are working in this environment; they are essentially cut off from the medical education community. Furthermore, the addition of medical students to health care units in correctional institutions may serve as a stimulus to the physicians who supervise them in these unique settings, a form of reciprocity that may prompt those physicians to acquire new knowledge and skills.
Given the increasing prison population in the United States, the constitutional requirement to provide medical care to inmates, and a demand for career-oriented correctional physicians, the educational program we have described takes a step in the right direction. Currently, the program is in its second year and flourishing, with an average of 72 students rotating through the correctional setting each year. It is likely that this experience will lead students to new perspectives related to the rights of patients, the management of chronic diseases, and the delivery of ethical health care. Given the initial positive reaction of almost all students, this program may encourage some of those who participate in it to practice correctional medicine as a career. This advantage, though yet to be determined, may be the program's lasting contribution.
The authors gratefully acknowledge the administrators and physicians of the Florida Department of Corrections Health Services Division for their vision, dedication and participation in establishing this innovative medical training program.