Prison Medicine 1

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I hate to complain or maybe I hate to be obvious in my complaints. I actually enjoy moaning and groaning to myself and I do a fair bit of that.

Anyway, I had been miserable since Christmas day with nausea that had only remitted when I lay down and stopped any eye movements. I have also had a lot more pain in my left chest requiring more opiates which in themselves cause nausea. I tried upping my dose of Ondansetron (Zofran), an antinausea medicine, but can't tell if it really works. I tried pot 2 days ago but can't tell that it made much difference either and who wants to be stoned and sick?

However, I have another round of Chemo tomorrow and yesterday I couldn't imagine making a three hour car trip, going to the lab, having my Oncology appointment and then being infused for 8 hours followed by a 3 hour trip back. I will take the R.V. Jerry, my next door neighbor, goes with me and can at least drive and let me lie down in the back if need be.

On the day prior to chemo, I am supposed to take massive doses of Dexamethasone (Decadron), a steroid. I cheated and started 12 hours early by taking a dose at dinnertime last night  and my nausea is almost gone. I hadn't eaten for 2 days until last night when I got down some soup. This morning I had a couple of eggs and toast. I don't feel great, but able to do some writing.
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A notice about blog direction. One of the initial goals of the blog was to let my children know who I really was in addition to a contemplation of my history. I began working in prisons in 1987 when my boys  turned 12 and 9. I think they have a good recollection of my life and activities from that point.

Given that I'm not feeling so great, I'm going to free myself from strict chronology. Since 1987, my jobs have been:
1987 -- 1994   Medical Director Eastern Region Maryland Department of Corrections
1994 -- 1997   Residency in Psychiatry University of New Mexico School of Medicine
1997 -- 1998   Attending Psychiatrist Atascadero State Hospital (for criminally insane) California
1998 -- 2002   Psychiatrist, Ely State Prison, Maximum Facility and Death Row, Ely NV
2001 -- 2007   Private Practice of Psychiatry Las Vegas NV
2007 -- 2010   Staff Psychiatrist California Men's Colony (medium security prison) San Luis Obispo CA
2010 -- 2011   Geriatric Psychiatry San Luis Obispo County CA

I'm going to feel free to talk about prison medicine and psychiatry in general after discussing moving from Smith Island and starting my first job in a prison.
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Moving Off of the Island
In June 1987, Brian, my older son, completed the sixth grade in the one-room Ewell school. The following year he would have attended school in Crisfield, a 12 mile trip over open water from the island. The boat ride would have tacked another two hours onto his school day, eliminating opportunities for extra-curricular activities. So, I decided against remaining on the island and began looking to move to the mainland.

I was 44 years-old and had little in the way of savings. The boys were 11 and 9. My sources of income remained a day a week in the emergency room in Crisfield and whatever amount of time I wanted to devote to Island medical work. My living expenses would increase on the mainland because I had been living rent free on the island.

In choosing a place to live, I looked at the few towns within 45 minutes of Crisfield and chose Pocomoke City. The school system had a good reputation and there appeared to be opportunities for private practice within the town itself. I went ahead and made the move over about 30 days. It was laborious. Pack a few boxes. Load them onto a truck. Take them to the dock. Unload them onto a boat. Unload off the boat in Crisfield and put them in the van. Drive the van to the rental house. Cart the boxes from the van to the house. For the larger furniture and remaining boxes, I hired a waterman's boat for an evening after he had finished crab scraping during the day.

I had just begun serious search for more work when the night nurse at the Crisfield hospital encouraged me to apply for the newly advertised job of medical director of the new State Prison being constructed in Westover, Maryland.  She had recently been hired as the Director of Nursing for the facility by Correctional Medical Services (CMS), a private company that had the contract for providing the health care services in the new prison. This company had contracts in several states, but the new Eastern Shore Prison at Westover would be the first work done in Maryland. The company was keen to make a good showing  in hopes of acquiring the contract for the entire state in the upcoming bidding the following year.

I was interviewed at the prison by the regional manager, Philip Nichols, who had worked for the company for many years. He talked as if the job was mine if I wanted it. (Apparently there was not a long line of physicians fighting for the opportunity.) The offer seemed generous. The company paid a very small salary of $7200 per year together with excellent medical benefits. The medical director was responsible for taking call or paying other physicians to provide it. The stipend for this was $60 per day. The salary and the call  worked out to almost $30,000 a year...close to what I had been living on for several years. In addition, there was a contract which would reimburse me $40 per hour for each hour spent within the facility. There were 80 hours a week of available physician time. I could work as much as many of those as I chose and offer the remaining hours to another physician.

When I put all of this together, it looked like about $100K a year and the ability to live in rural Maryand, 5 minutes from the boat ramp on the Pocomoke River, about 30 minutes from Crisfield and about 45 minutes from the Ocean beach on Assateague Island. This was very exciting.

The final hoop in hiring was a face-to-face meeting with the Medical Director of CMS, Larry Levy, M.D. at Graterford Prison in Pennsylvania. It was a long drive, about 4 hours with several stretches of heavy traffic around Wilmington and Philadelphia. I was so worried about the health of my chevy van with its 150,000 miles on the odometer, that I rented a car for the trip.

I had never been in a prison before. I had done some work in jails, but this was different. It looked like a James Cagney movie. There was a concrete wall that seemed about 20 feet high and formed the perimeter. When I walked through the gate, it was disconcerting to see 2 plaques commemorating the lives of two correctional officers who had been killed there in the line of duty.

I had also missed something in translation about the interview there. I believed that I was talking to an administrator for the company, but instead I was being interviewed by Dr. Levy. He was both very smart and very smooth, a combination I had not seen in a physician since my days with the Public Health Service when talking with folks who managed to get grants and contracts from the Federal Government. I was definitely the country cousin talking to the city slicker.

I got the job and started work almost immediately.

Most towns or cities are not keen on having a prison constructed nearby. However, Somerset County was the poorest in Maryland and only too happy to participate in a non-polluting growth industry that guaranteed hundreds of new jobs for the area.

The prison was named Eastern Correctional Institution or ECI. It was located a little south of Princess Anne which is the Somerset county seat. ECI was less than 10 miles from my house in Pocomoke City, a drive of about 15 minutes portal to portal. I started work before the prison accepted its first inmates. This gave me an opportunity to get oriented to some of the culture in the prison.

Eastern Correctional Institution. Built as twin prisons, essentially mirror images with different administrations, East and West.

Somewhere a study had been done about optimal prison size. In deference to that study, rather than build a single prison, ECI was built as two prisons, one the mirror of the other. The only common areas were the infirmary and the Mental Health unit. Generally, these were both accessed through the eastern portion, ECI-East which was completed first. Work was still proceeding on the west ECI-W and would not be finished for 8 to 12 months.

Cleanup was going on throughout the east buildings and grounds in an attempt to find any tools or pieces of metal that had been left on-site by workers and which could be fashioned into "shanks" or knives by inmates. For me, the time before inmates arrived was an opportunity to read as much as possible about prison medical care (there wasn't a great deal) and to concentrate on hiring Physician Assistants who would conduct most of the sick call encounters.

What was apparent in 1987 was that a major reform was under way in American jails and prisons. Just 15 years prior, the American Medical Association (AMA) had surveyed jails and found

• 25% had no medical facilities whatsoever
• 65.5% had first aid as the only medical care available
• 28% had no regular sick call
• 11.5% did not have a physician on call

The National Commission on Correctional Health Care (NCCHC)  was founded in the 1970's by the American Medical Association after surveys of health care provided in prisons demonstrated disorganization and a lack of standards. The NCCHC had developed a set of standards that apply specifically to prisons. Correction Medical Services utilized these standards as their bible in developing prison health care systems. One of my tasks in the few weeks before prisoners arrived was to look at the rules and regulations for prisons in Maryland, to match them up against the NCCHC standards, and to write policies and procedures that would keep the prison (ECI) in conformance with both sets of guidelines.

A Prison Inmate's Right to Health Care
Prisoners are the only persons in the United States who have a "right" to health care as determined by the courts. A nice review of the law in this area is found in an article in the Journal of Correctional Health Care in 2008 by William Rold.

 http://www.realcostofprisons.org/materials/30_years_after_estelle.pdf

The two most significant legal cases are Spicer v. Williamson which establishes the obligation of the prison administration to provide medical services and Estelle v. Gamble which establishes three components of health care that must be accorded the prisoner.

Spicer v. Williamson
Of course a right for one person involves obligations for others. If a prison inmate has a right to medical care, who has the obligation to pay for it? This was decided in 1926 in the case Spicer v.Williamson. The facts of the case are that Mr. Peter Camel, an armed robber (and no relation to Joe Camel), had shot a deputy sheriff in his attempt to flee from the crime scene. Camel was then seriously wounded in the return fire. The sheriff, Mr. Williamson, attempted to obtain medical care for Camel locally but was directed by a local physician to a surgeon, Dr. Spicer, of Goldsboro in a neighboring county.

Spicer performed the surgery and sent Sheriff Williamson a bill for his services. Williamson passed the bill on to the board of commissioners for Duplin County. The board refused to pay and claimed that they had not approved the use of medical care in another county and had not authorized the expenses incurred for the medical treatment. Spicer, Williamson, and the Board of Commissioners all obtained lawyers and took the case to the Supreme Court of North Carolina which found that

• Sheriff Williamson had the duty to arrange needed medical care for Mr. Camel
• Dr. Spicer was entitled to payment for his services to the Mr. Camel
• Duplin County was responsible for payment to Dr. Spicer

The bottom line is that this case established that the incarcerating authority has the duty to both arrange for medical care and to pay for that care.

Estelle v. Gamble and the Appearance of the Eight Amendment
Estelle v. Gamble is the linchpin for current attempts by prison inmates and their attorneys to affect their medical treatment in U.S. prisons. The eighth amendment simply states:


Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.

This is where the Republicans would complain about judicial activists. It is pretty clear to me that the intent of the cruel and unusual had to do with punishments and torture. However, a couple of hundred years later, it is frequently utilized by inmates to intimidate medical professionals who have failed to meet the entitled expectations for a particular kind of medical care. That's the bad side of it--it has encouraged lawsuits against health care providers based on the constitution rather than on malpractice. This takes the case to Federal courts and bypasses the state system.

This doesn't mean that I disagree with the bottom line dictated by the decision--just that I'm amazed at the pathway by which it was attained.

The facts in Estelle v. Gamble are that Estelle was injured while doing farm work in a Texas prison. He sued claiming that he was denied a work excuse and was punished for failing to go to work. (I wonder if his whole case would have gone away if he had been given a lay-in as he first requested. The following material about the implications of the case is paraphrased from William Rold's article from the Journal of Correctional Health Care in 2008. The URL is  http://www.realcostofprisons.org/materials/30_years_after_estelle.pdf )

 Estelle lost the suit, but in its decision the courts more clearly defined a prisoner's rights to health care:

1. Access to health care
2. The prison's obligation to provide medical attention ordered by medical authority
3. The right to an assessment by a medical professional

Access 

All institutions, of whatever size, must have the capacity to cope with emergencies and to provide for sick call. Access to specialists and to inpatient hospital treatment, where warranted by the patient’s condition, is also guaranteed by the Eighth Amendment

Provide Services Medically Ordered

Once a health care professional orders treatment for a serious condition, the courts will protect, as a matter of constitutional law, the patient’s right to receive that treatment without undue delay.  (There is a group of greedy physicians practicing medicine out there who see the state prisons as deep pockets and are very quick to order a variety of treatments that they would not be ordering for Medicaid patients seeking their services. It's really important for medical directors to be able to identify these physicians and avoid them at all costs because they immediately create the potential for lawsuits by their recommendations...see the order for Valium before court under Joseph A below.)

The Right to a Professional Judgment

The adjudication of constitutional claims is not the business of second guessing health care professionals. In enforcing the right to a professional medical judgment, the courts will not determine which of two equally efficacious treatment modalities should be chosen. Rather, the courts seek to “ensure that decisions concerning the nature and timing of medical care are made by medical personnel, using equipment designed for medical use, in locations conducive to medical functions, and for reasons that are purely medical.”

The Security Cost of Care Outside of Prison

During the first few weeks of my job as medical director of the prison, I met with the administrator of the Crisfield hospital to determine the hospital's interest in providing services to the prison. They clearly wished to do so. I was already on staff and had hospital privileges. I would be able to admit patients to the hospital and to utilize the emergency room as necessary for procedures, such as lumbar punctures for suspected meningitis.

It was critically important to be able to do routine postoperative care at the prison infirmary which was staffed with RNs 24 hours a day. The prison infirmary was a 15 minute ambulance ride from the hospital.

I was very surprised when I learned that when care was provided to a prisoner at an outside hospital, two correctional officers were required to be with the patient at all times.


Consider the security costs for a week of hospitalization--over and above the hospital's charges. 

• Three shifts a day 
• 2 officers on each shift, for seven days is 42 8 hour shifts per week
• This is 326 hours a week
• If COs make $25/hour, this works out to $8400 to provide the security for a single inmate for 1 week.

Getting patients back from hospitals in a timely fashion was exceedingly important.

We also established a working relationship with William Gill, M.D., to provide surgical services at the prison on an "as-needed" basis. He lived 5 minutes away and could round on complicated patients as necessary at the prison. For each day that he was able to see the inmate in the prison infirmary rather thatn the hospital, the institution saved more than $1000 in security costs.

Some Negative Attitudes Among Taxpayers 

It is common in crime movies and shows to allude to homosexual rape waiting for a suspect after conviction. I think it is horrible that anyone be raped but especially when under the "protection" of the prison warden. The prisoner gives up liberty and pursuit of happiness in prison but shouldn't be forced to give up life or made to fear for life and limb. That was not in the prison sentence.

Most inmates, I think the figure is 97%, will eventually be paroled and be living among us again. What is the ability of the paroled inmate to engage in meaningful work? Rehabilitation attempts have been abandoned in many states. I don't know the science, but is there evidence that all forms of rehabilitation do not work?

Some General Issues Among Workers In Prisons that Challenge Health Care Provision

Correctional Officers and Health Care Workers have to cooperate in order to render health care to inmates. The major impediment to that cooperation is the frequently impolite behavior within each group.

Correctional Officers are generally well-paid when measured against the educational level required for employment. However, there is a long history of a "good old boys" attitude that ignores bad behavior among their members and a view of health care workers as "bleeding heart" "do gooders" who are too ready to provide medical care that is not as readily available in the community. There is also some resentment about the more generous salaries paid to the better educated health care workers.

Health Care Workers tend to forget the dangers posed by the criminal and are more likely to blow off security principles that represent the bible for Correctional Staff. This is probably perceived as dismissive by Correctional Staff and unappreciative of the provision of personal safety for the health care workers.

It is my impression that things have changed quite a bit in more than 20 years. Correctional officers are better trained and there is less harassment of inmates and other staff. I'd say that the great majority of correctional officers are aware that their attitude can either contribute to the stress level or diminish it. Boorish behavior by prison staff increases the risk for everyone, not just the employee who is meting it out. Resentments smolder and accumulate and may lead to violence hours or days later.

The Inmate's Situation

Generally prisons are overcrowded with 2 men placed in a cell intended for a single man. A typical cell has a double bunk bed, a stainless steel toilet and sink combination, perhaps a table but more likely a travel chest that is used to store belongings and the top used to write on. Often, there is no chair in the cell  and one sits on the commode as a chair or on the bunk. One must get used to someone defecating less than 8 feet away. I found it amazing that in such cramped quarters, there is not more violence.

If you take the point of view of the inmate with respect health care needs, he is dependent upon the tier officer to respond to his yell for medical assistance. There has to be a correctional officer on the tier to hear this. Then the officer has to try to sort out the problem and make a decision about whether or not to call the medical department.

If the inmate has a problem that is not emergent, he is generally expected to complete a request for a sick call visit. He  has a box on the tier where this request can be dropped (to enable him to retain privacy from correctional staff). Then this request has to be picked up by the medical department and evaluated by (hopefully) an R.N. or a medical technician who may schedule a sick call visit for the inmate or decide that the problem is more urgent and should be seen the same day.

Some General Issues Among Inmates that Challenge Effective Health Care Provision

Physicians, in particular psychiatrists, are trained to take a patient's story at face value. It is quite simple, at least in California, to utilize the mental health system as a way of avoiding hard-time. Psychiatric diagnoses are primarily dependent upon what the patient says. There is vibrant communication system among inmates that identifies "stories that work" and weak providers who will not stand up to pressures brought by inmates.

With respect to psychiatric diagnoses, many inmates complain of depression and anxiety. A certain amount of sadness and anxiety is to be expected when dealing with prison time.

Joseph A

This was an inmate at ECI who had been found guilty of terrorist threats. In addition to his current prison term he was involved in another lawsuit. At the previous prison, his physicians prescribed Valium for him to take before he went to court. Our facility was based upon a dictum that "every inmate is equal," and "what is done for one inmate should be done for all." Absent a severe mental illness, it did not seem reasonable to provide "comfort medications" to inmates going to court. Besides, knowing inmates, some would blame provided medication, such as Valium, for memory lapses and an inability to think. Under such accusations, it would be very difficult to medically defend a policy of medicating.  We stopped the Valium and dealt with his multiple complaints and threats of lawsuits.

There is a riddle among people who work in prison. "How do you know when an inmate is lying?" The answer is "When he is moving his lips." 


Unfortunately, in dealing inmates for 15 years, I would have to say that there is a lot of truth in this. I've come up with my own way of looking at the phenomenon. As a child I lied any chance I got until ?how old? and told my share of lies to teen-age girls.

I am not sure how I would try to survive in prison. Low down on my list of a "moral crime" would be a lie to a health care provider to get something that I felt I needed, like a single cell, a bottom bunk, a cotton blanket, special shoes, a cane, a special diet, night-time snacks, etc. As a physician I look at the behavior as partially survival and don't take offense at the stories. However, you can't run a prison if everyone is an exception. There have to be criteria for exceptions.

This was the essence of most of my work as a medical director in Maryland--in addition to the usual obligations of the physician, I had to establish that there were verifiable data that collaborated the inmate's story. If the data was lacking, my job was to refuse the request in a compassionate fashion. If the inmate wanted to appeal, I informed him about the mechanism for doing so.

Special Problems In California

I've only worked in Calfornia prisons for about 3 years and in forensic hospitals for another 3 years in the State. It is the largest system in the country. Both the mental health hospital system and the prison system have been put under Federal managers in the past decade. Both somatic and mental health care policies and procedures are driven by law suits and lawyers' concerns. However, lawyers who are involved in the oversight are making big bucks and have a vested interest in continuing to find fault with the care.

In my mind's eye I look at the Old Man and the Sea an analogy for the California Prison Health Care System. In the old man and the sea, a fisherman catches an enormous fish and attaches it to his small boat and begins the laborious process of getting the boat home. He runs into sharks who are constantly tearing apart the catch. When he final reaches his port, the flesh of the fish is gone and the fisherman is left with a large skeleton. I imagine the sharks to be lawyers for the class action suits and the mechanisms put in place that are particularly expensive and have not been demonstrated scientifically to be effective. The fish is the California Prison Health Care Budget.

California has built a number of prisons that are in the Central Valley, far from population centers and from available medical specialties and far from places where prison staff might want to live.

California is confronting some of its problems, envisioning a prison hospital that will provide a more uniform level of service quality and reduce the security costs associated with transport for care. Hower, the California authorities recently decided to go with a "an automated" medical record system that will increasingly irritate users. Rather than having access to paper records that left quite a bit to be desired, a "paperless system" has been developed and provides merely an adobe image of the pages of various types of documents. However, the selected categories of the tabulations in the new record do not distinguish between various subtypes of documents and this makes it very difficult for professionals to find the materials that they need in real time. Have you ever gone to the library and used the fax archives of old newspapers and magazines? That is the closest analogy that I can think of to this highly touted automated system that has been implemented.


One can readily see that the search problems will increase as the size of the individual patient records within the system increases. (I know that I'm no longer an expert on implementation of modern distributed computer systems, but I cut my teeth on user interface problems in the 70's and 80's and I've developed commercial software. Clearly this system was designed by folks who did not construct a mock up using a few large medical record and observing professionals attempting to put the mock ups to use.) A consulting firm that had hands on experience with automated systems  looked at the California Health Care System record system plans a couple of years ago and specifically recommended that such a system not be implemented.

As usual, California seems bent on doing things its own way.

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Most of this post has provided background information of a general nature. The next post will be attempt to weave more first-person experiences into the narrative.

Happy New Year.