Some Notes for Prison Physicians

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Here are some observations and suggestions for physicians engaged in Correctional Medicine based upon experiences in prisons and psychiatric hospitals for the criminally insane in Maryland, Nevada, and California.

Some General Observations:


1.  It is very expensive to attempt to control the activities of human beings, especially antisocial human beings with energy enough to throw themselves into a battle with health care providers and other authority figures.

2. Inmates have an excellent communication system within the prison and they possess a large fund of knowledge about employees. If prisoners care to know they can easily find out what car you drive, where you live, and how much money you make. They will know who your friends are among other staff.

3. Some of your co-workers in prison have a great need to feel loved and respected and will establish relationships to fulfill those needs with inmates who are wonderful at providing compliments and flattery. Mental health staff are just as vulnerable as other staff and correctional officers. Inmate-staff relationships  include the passing of information about staff.  Last year I was angry at having a prisoner ask me about my upcoming vacation. He wanted to know if I was going any place or just staying home. It meant that some staff member had been blabbing this information and gave an inmate an "opening line" in an attempt to become "familiar" and to break out of something other than a formal relationship.

4. Inmates sometimes work in teams to "set-up" prison staff. Once a staff member violates a regulation,  that if known to the warden would result in dismissal, the inmates can bring pressure upon the worker. Typically the blackmail will take the form of bringing contraband, like money, drugs, and cellphones into the facility.

5. A very good and interesting book on the subject of staff-inmate relationships is Games Criminals Play: How You Can Profit by Knowing Them by Allen and Bosta. I think it is a must read for anyone working in a prison. It was very helpful in orienting me.

6. A prison is a part of the criminal justice system. However, the Criminal Justice System is less about justice and more about convincing.  Given the adversarial system, the inmate quickly separates himself from "his case." It is no longer about responsibility for the murder, but about the ability to "convince," and "plead the case." This is a perfect situation for antisocial persons who refuse to take responsibility for actions. However, something approaching the "truth" is pretty important for making medical decisions.


7. I've mentioned previously that there is often friction between correctional officers and health care staff who may be looked down upon as do-gooders. Many correctional officers have come to their profession after failing to find jobs in other police forces. In California I believe that the only requirement is a high school education. The occupation can be high stress, particularly when working around young, violent offenders in lock-up units. It is easy for health care workers to consider their own roles to trump security concerns and to make decisions that infringe upon the discretion of the correctional officers. Correctional officers are taught from day 1 that the primary purpose of the prison is the maintenance of security. This difference in perspective is a source of irritation for both groups.
Training can go a long way toward smoothing over such differences by allowing each group to grasp the point of view of the other. For example, it frequently occurs that an inmate refuses to leave the cell for a physician to do an evaluation. If a newly hired physician merely tells the correctional officers to remove the patient from the cell and put him in an examination room, things are likely to heat up. Extracting an inmate from a cell is not a trivial exercise. It will require a "use of force." A situation involving such force will result in a number of correctional officers participating in the exercise who will then be spending hours writing a report detailing their activities and observations during the "use of force." 
Rather than merely demanding that the patient be removed, a physician will do better by approaching custody and stating the problem: "I need to see inmate so and so in the examination room. He doesn't want to come, but I really need to see him. How can we accomplish this?" Correctional officers will often have a solution. "Inmate x has a good relationship with C.O. John. Let me see if John can come down here and help us." If John is able to easily persuade the inmate, then a lot of time has been saved. If the inmate continues to refuse, correctional staff have at least had a shot at the problem. The supervisor might discuss the use of gases like pepper spray as opposed to the use of battle gear and shields to enter the cell. Cell extraction is frequently associated with injuries. In many institutions, all cell extractions are recorded both for training and as evidence in the event that claims of injury are made by the inmate. I worked in a prison at the time that cameras were first introduced for this purpose--it makes an incredible difference. Everyone is on their best behavior.

Some General Rules for Physicians:

1. It's best to maintain your distance from inmates when you are not in a professional setting. When hailed by inmates as you pass through the yard, you can say "hello" and even mutter something about the Jets-Dolphin score when asked, but I try not to allow an inmate to fall in beside me and begin a conversation about his medical condition or anything else. Rather than walk across the yard with the inmate, I stop and tell him that I can't discuss anyone's medical information in a public place but that I would be happy to continue the discussion at a sick call visit. I wish him a good day and leave him.  When you are passing through a place where there are inmates, you are part of the public theater. Giving an inmate (particularly a healthy one) attention other than a greeting may be seen as reflecting a special relationship with the inmate in question. When you say goodbye to an inmate after stopping his attempts at conversation, don't fall for the hang dog "I'm being disrespected" bullshit. The inmate knows very well what is going on--that others are watching a performance. And he'll also know that you're aware of the game and that you won't give the appearance of having any special relationship. But say hello in reply to every greeting and give respectful nods to all. There is nothing more that is required. With severely mentally ill, this rule can be modified as necessary.

2. Make sure that your medical department is running a clean operation. One needs to be practicing good medicine. If not, the rest is just a scam, isn't it? Is this medical care that you would feel comfortable with for you and your family? If not, you need to look at your ethical compass. 
Sometimes inmates will attempt to prove that your medical department has denied them care by neglecting them or not honoring their request for sick call. Most of the time when an inmate says that he "already put in a sick call slip" for some problem, he will be lying and blaming someone in the system. However, you need to make sure that sick call slips are getting to the medical department in a prompt fashion and that they are being acted upon. 
The inmate is basically powerless when it comes to accessing medical services and needs the assistance of custody or a sick call slip. After several months or a year or two, inmates will have created a report card on you. If you practice as a caring physician, they will know that. If they see what appears to be poor or uncaring medical services, they will develop a poor opinion of your dedication to your profession. If they see you as bowing to every inmate pressure, they will see you as a fool and a soft touch and wonder about your medical abilities to see through what all the inmates know to be a scam.

3. Don't grease the squeaky wheel, but do gather information. The physician must also be a "cross examiner." When an inmate claims a prior medical condition and states that he had a prior schedule for a medical service that was interrupted by prison, those records must be gathered. Inmates claims about medical conditions and other medical problems that will affect conditions of his incarceration must be corroborated. Should the inmate refuse to comply with that reasonable request to obtain the prior medical records, the inmate must be informed that without that information, a decision will have to be made based on the data currently in front of you. By the way, never trust written information provided directly by the inmate. Data about the prior medical history must come from an original source.

4. Practice medicine up to the limits of your capacities, particularly in urgent situations. If there is any way that a medical problem can be managed in the institution, it should be done there. Physicians on call, whenever possible, should be expected to come to the facility to see any patient where transfer is being considered unless it is a life or death emergency. One wants to avoid involving a naive, free-world physician in the care of the correctional patient whenever possible. 
Physicians are trained to take their patient at face value at all times. As prison physicians we know that is a mistake in our special population--a little more evidence is required. Antisocial individuals are less likely to be as concerned with the notion of truth and are more likely than others to exaggerate or lie in order to seek an edge or a special accommodation.

5. Don't Avoid the Difficult Patients. There will be a set of patients who appear weekly on the sick call list. Some of these patients are attempting to "establish a case," creating a paper trail that "proves" that they have a serious medical condition (as indicated by the multiple visits for the same complaints that were not successfully addressed.)  In Maryland, this was much easier to manage than in California. In Maryland, we could admit a patient to the infirmary for a few days to better observe the behaviors. A lot of medical problems seemed to disappear after 24-48 hours never to reappear. Do not put off the frequent attender based only upon your observation that "he's just been seen." He needs to be seen in order to satisfy Estelle v. Gamble. You must demonstrate an ongoing attention to his complaints. Here is a medical suit brought against me and everybody else while in Maryland.

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 989 F.2d 491

NOTICE: Fourth Circuit I.O.P. 36.6 states that citation of unpublished dispositions is disfavored except for establishing res judicata, estoppel, or the law of the case and requires service of copies of cited unpublished dispositions of the Fourth Circuit.
Robert Leon BUCKNER, Plaintiff-Appellant,
v.
WARDEN, EASTERN CORRECTIONAL INSTITUTION; Commissioner of
Correction; William Donald Schaeffer Governor; Lloyd
Gatherum, Medical Department Supervisor; Correctional
Medical Systems, Incorporated, Defendants-Appellees.

No. 92-6228.

United States Court of Appeals,
Fourth Circuit.

Argued: December 4, 1992
Decided: March 9, 1993

Appeal from the United States District Court for the District of Maryland, at Baltimore. Norman P. Ramsey, District Judge. (CA-91-2362-R)

Julie Uebler, Student Counsel, Appellate Litigation Clinical Program, GEORGETOWN UNIVERSITY LAW CENTER, Washington, D.C., for Appellant.

Aron Uri Raskas, KRAMON & GRAHAM, P.A., Baltimore, Maryland, for Medical Appellees.

Audrey J.S. Carrion, Assistant Attorney General, OFFICE OF THE ATTORNEY GENERAL, Baltimore, Maryland, for State Appellees.

Steven H. Goldblatt, Director, David B. Goodhand, Supervising Attorney, Heidi A. Sorensen, Student Counsel, Appellate Litigation Clinical Program, GEORGETOWN UNIVERSITY LAW CENTER, Washington, D.C., for Appellant.

Philip M. Andrews, KRAMON & GRAHAM, P.A., Baltimore, Maryland, for Medical Appellees.

J. Joseph Curran, Jr., Attorney General of Maryland, OFFICE OF THE ATTORNEY GENERAL, Baltimore, Maryland, for State Appellees.

D.Md.

AFFIRMED.

Before WIDENER, HALL, and NIEMEYER, Circuit Judges.

PER CURIAM:

OPINION

Robert Leon Buckner, an inmate at Eastern Correctional Institution (ECI) in Somerset County, Maryland, sued various state officials under 42 U.S.C. § 1983, alleging they had been deliberately indifferent to his medical needs, denying him medical care in violation of the Eighth Amendment. See Estelle v. Gamble, 429 U.S. 97 (1976). In particular he alleged, "I need corrective surgery on my lower lip very bad. The M.D. (Dr. Sohr) here at ECI has said that this [is] 'elective' surgery and that I only want it for cosmetic reasons. On the contrary, the greater portion of my lower lip is missing because of an [automobile] accident in July 1991 and when I eat food falls back out of my mouth and it is hard for me to speak and/or articulate." He seeks injunctive relief to require reconstructive surgery and damages.

On the defendants' motion for summary judgment, the district court entered judgment for them, concluding that Buckner failed to show deliberate indifference to his medical needs. The court pointed out that the record establishes a "high level of involvement" by health care providers and that the action taken by the health care providers was "neither grossly incompetent [n]or inadequate, nor was the treatment provided shocking to the conscience or intolerable to fundamental fairness."

Having reviewed the record carefully, de novo, we conclude that, while Buckner has established satisfactorily a continued need for treatment of a medical condition that existed before he entered prison, he has not demonstrated that the defendants' response was in any sense deliberately indifferent. The record establishes quite the contrary.

As the result of an automobile accident on July 11, 1990, Buckner sustained extensive facial injuries for which he was admitted to Prince George's Hospital Center. When he was discharged two weeks later, he had undergone plastic surgery to repair substantial facial lacerations, including lacerations extending into his lip. No evidence was presented that he sought any further medical treatment, however, until late December after he had been convicted of theft and committed to ECI-a period of some five months.

After he entered into the custody of the Maryland Division of Corrections on December 7, Buckner submitted a sick-call request, on December 11, complaining of back problems and a bad tooth. On sick-call requests of December 13 and December 17, he continued to complain of his back problems. On the December 17 request, however, he also indicated he was having trouble with solid foods because of his facial surgery in July. On each of these sick-call requests, as well as all of the 30 or more that followed in connection with a diversity of complaints, the response by medical authorities was immediate, and in each case they provided some form of treatment.

Buckner complained about pain in connection with his facial injuries for the first time on December 19, 1990. He was provided with pain medication and advised to engage in facial exercises. A few days later Buckner was examined, in connection with his facial injury, by Dr. Eric Sohr, who referred him to an oral surgeon, Dr. D. B. Rae. Dr. Rae suggested a mandible labial frenectomy to give Buckner better flexibility with his lower lip. The operation was actually performed on March 13, 1991, and a week later, when Buckner was seen during his post-operative examination, Dr. Rae noted that the surgery "looked great." Buckner apparently agreed, reporting having been "very pleased with the result." Thereafter, on numerous occasions Buckner complained about facial pain and on each occasion was provided with a prescription for pain medicine. To assist Buckner in eating at a slower pace, he was offered a "feed in option," which he refused.

Approximately two months later Buckner insisted that he needed a further operation, leading to an administrative complaint and the complaint filed in the district court. In response to his request for further surgery, both Dr. Sohr and Dr. Rae, who are not shown to have had any bias or ill will toward Buckner, gave their opinion that Buckner's facial condition "should not interfere with eating and speaking" and that further "surgery for this problem [was] unnecessary and purely for cosmetic reasons." They nevertheless continued to treat Buckner's pain with medicine and to see him on a regular basis. Buckner's administrative appeal was denied by the Maryland Commissioner of Correction based on the opinion that no"corrective lip surgery is required."

Buckner makes no assertion that he was not given prompt treatment, but only that he was denied a further operation on his lip. He disagrees with the opinion of two doctors that further corrective surgery would be only for cosmetic reasons. Regardless of whether there might be another doctor who might agree with Buckner on this point, this is not a record on which a claim for deliberate indifference by the state officials is shown to any degree. While it is indeed unfortunate that Buckner continues to suffer pain and defacement from his automobile accident injuries, under the circumstances presented, we believe that the defendants met their constitutionally-established obligations to Buckner. See Russell v. Sheffer, 528 F.2d 318, 319 (4th Cir. 1975). We therefore affirm the judgment of the district court.

AFFIRMED

This is reasonably standard type of inmate suit. There was no evidence of any medical care for this problem in the five months prior to his incarceration. Once incarcerated he becomes focused on getting plastic surgery to his mouth, although his first sick call slips are for back and dental pain. (In fairness to the inmate, he may have experienced increased scarring and skin contractures during the first few months after surgery. So the appearance of complaints at 5 months would not be particularly unusual.) He was seen by the Physician Assistant in sick call and by me a few days later. Our prison was fortunate in having a contract with an oral surgeon who was able to see Buckner within the facility and to perform a frenulectomy. Even more importantly, the surgeon's experience and comfort with his findings allowed him to stand up to the inmates' continued complaints and lawsuits.

Notice also that Georgetown University has used the inmate's lawsuit as an opportunity to give their students experience suing the neighboring government officials in Maryland.

Although he claimed he couldn't eat in the short amount of time provided at the dining hall, he refused an opportunity to take meals at a slower pace and there was no evidence that he lost weight. In the free world, the inmate would be warmly received by a plastic surgeon provided the patient was willing to accept the need to pay. I'm not sure whether Medical Assistance (Medicaid) would have paid for this surgery had the patient qualified. Facial scars are relatively common in prison. This patient was the squeaky wheel. His complaints were never ignored. He was seen promptly. However, we could not have provided this inmate with his surgery without, in all fairness, being willing to provide cosmetic surgery to any other inmate who desired it.

From the above, case we can determine what the judge needed to see in order for us to have met our constitutional mandate. 

• he has not demonstrated that the defendants' response was in any sense deliberately indifferent. The record establishes quite the contrary.
• On each of these sick-call requests, as well as all of the 30 or more that followed in connection with a diversity of complaints, the response by medical authorities was immediate, and in each case they provided some form of treatment.
• Thereafter, on numerous occasions Buckner complained about facial pain and on each occasion was provided with a prescription for pain medicine. To assist Buckner in eating at a slower pace, he was offered a "feed in option," which he refused.
• While it is indeed unfortunate that Buckner continues to suffer pain and defacement from his automobile accident injuries, under the circumstances presented, we believe that the defendants met their constitutionally-established obligations to Buckner

6. Establish Formal Clinics for Frequent Attenders and Difficult Patients
Some of the more difficult patients are those who manage to "split staff" into the good guys and the bad guys. The more needy the staff, the more likely you will find staff who enjoy being the good guy. They are likely to go easier on the patient, to provide more medication, more likely to give lay-ins, and to petition other staff for special accommodations for the patient in question.
The "splitting" inmate can identify those fault lines that exist between staff members and wiggle into them and increase the distance in the split. The more extreme examples of such patients are likely to be so-called "borderline personality disorders." It is hard to imagine more miserable people. They do not have a firmly founded sense of self. Their emotions can bounce around wildly and they often show self-destructive behaviors including cutting on themselves and head-banging. They may attach tightly to a staff member and will hurt themselves if they perceive the care-giver as abandoning him.
Borderline patients thrive on cracks between staff--divide and conquer I think it is. While staff is divided it will be hard to establish boundaries for the patient because the staff is unable to bring themselves to a place as a group where the boundaries can be defined. When viewing a staff that has recently become more dysfunctional, look for a borderline personality disorder patient. In the most severe cases,  the pathology cannot be readily "contained" or "held" by a single person. It will definitely take a village. In order to defeat treatment, the borderline patient will be working to destroy the cohesion necessary for the group to enforce the "no fly zone."
When you identify a difficult patient in the medical department, you are likely to find that the same individual is having problems dealing with custody staff and with his boss at work or his teacher at school. When such a patient is complaining about the inadequacy of care, it is often useful to assemble everyone involved in care, including mental health and custody when appropriate, physicians, nurses, and administration for medical. With all the disciplines there, the inmate is asked to explain the nature of his complaint and his proposal for solving the problem. Following that presentation, a free ranging discussion can follow. The medical department can provide information that has been culled from the previous visits and explain the current status quo and treatment plan.
A group approach provides multiple witnesses who can refute the borderline patient's own perception of the sequence of events and the boundaries of the treatment plan. Everyone is on the same page. It is less possible for the patient to make unchallenged claims about the treatment plan.

7. If you do your job correctly you will be sued. While it is hard for inmates to get much traction in malpractice suits, it is very easy for them to file lawsuits complaining about a violation of their constitutional rights against cruel and unusual punishment. In seven years in Maryland, I believe that I was sued more than 10 times. In four years in Nevada I was sued twice, both times by patients with severe mental illnesses. If you have practiced reasonable medical care, you will win your lawsuits if you can demonstrate consistent and reasonable responses to the inmate's complaints. One of the problems with being sued, is that you will be carrying this history around for the rest of your life. You will be notifying every state board and hospital where you apply for licensing or privileges in the future. This is one of the down sides of prison medicine.

8. Be quick to admit mistakes.  Inmates are probably better at detecting deception than any other population. The medical department will make mistakes. Look at the high medication error rates in free world hospitals and nursing homes. There will be frequent errors in prison as well. Most of them will be Medication Errors. Few will be of serious consequence--but they must be admitted and documented. As a part of the documentation, there should be a chronology that indicates that the information about the error has been passed back up the chain of command. 


As a medical director in Maryland, I took it upon myself to have a visit with inmates who had experienced a medication error. I handled it in a formal manner. "Mr. Smith I called you up here today to let you know that we are aware that an error occurred in your medical care. (dialog with patient about the nature of the error and the possible effect and what you are doing to try to make sure that it doesn't happen again.) "
Then I would continue. "Mr. Smith, I wish to apologize on behalf of the medical department. Would you like me to put it in writing and send it to you, or can I just give it to you directly? "
Mostly they would accept an immediate verbal apology.
"Mr. Smith, on behalf of the entire medical department, I want to apologize for the error that we made. We will do everything in our power to make sure that it does not happen again."


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