One of the more common complaints that I hear from medical practitioners in jails and prisons (especially new practitioners) is, "These manipulative patients are driving me crazy!" Well, to be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. But it is true that many of our patients in jails are especially skilled in manipulation. They have practiced this skill their whole lives and have become proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation "Verbal Jiu-Jitsu." In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what "manipulation" actually is.
My definition of manipulation is this: in a medical encounter, it's what happens after a patient wants something he shouldn't have -- like a narcotic, a special diet, gabapentin, an MRI, a double mattress -- and won't take "no" for an answer.
Then comes the manipulation, the attempt to coerce the practitioner into changing a "no" into a "yes." Manipulation comes in many forms.
1. Exaggeration. "This is the worst pain in the world!" "I can't stand it any longer!" "I am so much worse now than when I came to prison!" Exaggeration is an attempt to make this a special case, worthy of special consideration compared to other patients.
2. Belittling. "Only crappy doctors work in jails. No wonder you can't understand how to treat my pain. My outside doctor gave me what I need – oxycontin. Now there was a good and kind doctor! You should be ashamed." Belittling goes hand-in-hand with splitting.
3. Splitting. This consists of comparing you to someone else who would give the patient what he wants. The other person is commonly an outside practitioner. But splitting is especially effective when the other practitioner is someone within your own facility. "The other doctor who works at this prison gave an extra mattress to my cellie! And he is not in as much pain as I am!"
4. Threatening. This comes in various forms. First is the threat of physical violence. Inmates can get quite skilled at communicating physical threats without saying a word. A particular hard look of a tight jaw, narrowed eyes, tense muscles, and clenched fists – coming from a muscular guy with facial tattoos – can make anyone feel the hair stand up on the back of their neck, even if there is no way the inmate could/would ever act on the threat. The second type of threats are various forms of complaints. Basically, the inmate is saying, "If you don't give me what I want, I'll make your life miserable." Complaints may start with written grievances (that you have to spend time and effort to answer), but then can quickly escalate to letters written to the ACLU, formal complaints written to your State Board of Medicine, pro se tort claims, even malpractice lawsuits. Everyone who has worked in corrections for a very long has heard these words: "You'll be hearing from my lawyer!"
5. Fawning. Fawning is, of course, the exact opposite of threatening and belittling. "You're the best doctor I have ever met! I tell all the other girls in the pod how great you are!" Many inmates are exceedingly good at fawning because, again, they have practiced their whole lives. A particularly insidious -- and often effective -- variation of fawning is flirting and sexual innuendo. "You always smell so good Dr. Smith. What cologne do you use?" I remember one inmate who told me, "Dr. Keller, you really know how to wear a suit. I worked at a clothing store, so I know."
6. Filibustering. Filibustering is being so relentless in the demand that you finally relent. Filibustering is done in two distinct ways. Method one is this: "I won't leave your office until you give me what I want! I will argue with everything you say." An hour later, the patient is still haranguing you and your clinic schedule (as well as your nerves) are shot. Even more effective is the sequential strategy: "I will be in your clinic every week with the same complaint. Nothing you do (except for what I want) will ever work." After 3, 5, or 10 visits for the same complaint of "intolerable headaches," you might finally give in and write the prescription for gabapentin that the patient wants.
7. The straw-man victim. This is where the manipulator charges you with acting against a protected class rather than based on your clinical findings. "You're only refusing me opioids because of my race/I am transgendered/my religion," etc.
8. Champions. A "champion" is someone who pleads the patient's case from the outside. The champion can be an attorney or an advocacy group, but most commonly is a family member. Champions use all of the manipulative techniques above, such as exaggeration, splitting, and incessant filibustering. Since champions are not incarcerated, they have access to many people whom inmates themselves cannot reach, such as the sheriff, the newspaper, and even the governor!
9. Self-harm. Self-harmers are patients who deliberately harm themselves to force you to do something they want. Examples of self-harmers include patients who cut themselves ("cutters"), patients who insert foreign bodies into their penis or anywhere they don't belong ("inserters"), and diabetics who try to induce severe hypoglycemic or hyperglycemic events in themselves. Self-harmers are often particularly hard to deal with.
Like any other skill, dealing successfully with manipulation requires training, practice, and experience. A good start is to go through this list and have your response prepared and practiced in advance. What would you say if a patient belittles you or accuses you of racial bias?
Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his "true calling" of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at .