Malingering and secondary gain—whether for medications or comfort items—are real issues. “There are people who have real disease, and very significant disease, who may be more interested in getting an extra mattress than in dealing with their A1C of 12.6% or their heart disease,” Dotson says. “Often, patients will come to us with a laundry list of problems they want addressed, and it’s a challenge to figure out what is real and what is not.”
On the other hand, circumstances exist that make a correctional facility an ideal work environment for clinicians. “We do not have a no-show rate,” Judd says, laughing. “And here, we provide a lot of services to people, but we don’t have the pressures of quotas, of having to see a certain number of patients, and we don’t have concerns about billing.”
There are protocols in place to ensure correctional health services providers uphold the standard of care by doing what is “medically necessary” to maintain the patient’s health, but this can, in a sense, be liberating for clinicians. “In a hospital or clinic setting, you might give certain medications or run certain tests when they’re not necessary, because you’re afraid you might get sued,” Floyd said. “In this setting, we follow evidence-based guidelines.” (Note: This does not mean that a clinician in corrections medicine can’t or won’t be sued.)
“I like being able to tell the patient, ‘This is what the protocol is, this is the medication that we have on formulary for it, and this is basically what you are going to get,’” Gruenwald adds. “I like that structure; I like not having to go overboard to please the patient based on what they want.”
Because their patient load is (with apologies) a captive audience and corrections medicine clinicians do not have the same “numbers, numbers, numbers” concerns that their primary care counterparts do, they also have the freedom to focus on what they do best: patient care and education.
“If someone has a really complicated case and you need to spend an hour with that patient, you have that option,” Floyd says. “That doesn’t mean we don’t try and see as many people as possible, but you have the time to do things that you don’t always get to do in a clinic setting.”
“In the DOC, we have the time to do that patient teaching: ‘This is what diabetes is, this is what you need to do about it, and this is why you need to do it,’” Gruenwald adds. “I like treating patients with chronic diseases and seeing them get better and helping them understand their diseases a little more. A lot of them never had that in the community.”