I will be meeting a new jail patient with multiple medical problems today in my clinic. I know this much before I even meet him: He will almost certainly be scared, especially if this is the first time he has ever been to jail. He will likely be suspicious of me. He may even be downright hostile. I know this because this is the norm for correctional medicine. I can't be an effective doctor unless I can turn this attitude around.
Consider the situation from my patient's perspective. Prior to seeing me, he was arrested, handcuffed, and driven to jail in a police car. Once at the jail, he was thoroughly searched (spread-eagle against the wall), fingerprinted, and had his "mug shot" taken. His clothes were taken away and he was given old jail clothes (including used underwear). He was placed in a concrete cell. Now he is summoned by a correctional deputy and told (not asked) to go to the medical clinic.
He did not choose me to be his doctor. Though he doesn't know anything about me, he has no choice but to see me for his medical care. Not only did he not choose me; he cannot fire me or see anyone else. He may fear that I am not a competent doctor; otherwise, why would I be practicing in a jail?
This is the attitude that I have to overcome. How to do this is an essential skill for correctional practitioners. And, of course, the single most important encounter is the first one. A negative first impression is hard to overcome -- and I am already starting out at a disadvantage. What I have to do in only a few minutes is convince my patient that I am a legitimate medical doctor and that I care about him. I have learned in many years of doing this that several things are essential.
I must put aside my judgments, emotions, and fears. I will be taking care of people accused of horrific crimes, such as pedophilia, murder, and rape. But I am now their doctor and must do my best to take care of their medical needs. If I feel disgust, I must not show it, nor allow it to interfere with my judgment. Similarly, I will find other inmates frightening, and still others I will genuinely like. I cannot allow these emotions to show in my affect or behavior, either. A basic principle of correctional medicine is fairness. I must treat all patients the same, whether I like them, fear them, or am repelled by them.
I must look like a doctor! If I want this patient to trust my competence and my judgment, I need to look the part. There is a temptation to think, "Hey, it's a jail! I don't need to dress up!" But that is a mistake. If I dress casually in jeans, a T-shirt, and sandals, it will confirm my patient's unconscious suspicion that I am not a "real" doctor. When I worked in the ER, I usually wore scrubs, but since jail inmates commonly wear scrub-like attire, scrubs are out (in my opinion). I usually wear a dress shirt, slacks, and a suit coat. Appearance for a healthcare provider is more important in a jail, not less.
I must be genuine and gentle. It may be that my patient has not heard a kind word since being arrested. Being in jail can be humiliating. New patients will assume that I am also going to be stern. I have to treat the introduction as if I were meeting this person in church, not a jail. If I look the patient in the eye, smile (genuinely), and say "Hi Mr. Smith! I'm Dr. Keller. It is nice to meet you" or "it's good to see you again"; this will go a long way to establishing a working doctor-patient relationship instead of an inmate-jail employee relationship.
I should get close, if possible. If I start out behind my desk (where I was reviewing the patient's chart before they arrived), I need to come out from behind the desk so there is no barrier between me and the patient. Yes, security is important, but I should not act as if I am afraid of my own patient. Besides, since there is always a security officer nearby, the actual risk of violence is less than in the average emergency department.
I need to explain my role. I usually say that my job it to continue their medical care while they are in jail. A common fear of new jail patients is that I am going to take over and ignore what their previous doctor has done. I tell my new patient that I am going to work with their outside doctors. Sometimes, this only entails reviewing old medical records. However, a phone call to their outside practitioner will go a long way in establishing trust with my new patient. I may indeed eventually take over if the patient stays in jail long enough but, hopefully, I will have established a good and trusting doctor-patient relationship by then.
I need to explain how medical care in jails work. There are not a lot of advantages to being in jail generally, but one exception -- a true advantage in most jails -- is how accessible medical care is. Patients with chronic medical problems are generally seen by medical personnel more frequently in a jail than they would on the outside. For example, if they take medications, they will come face to face with a nurse every day. It is easy to frequently check blood pressure, blood sugars, weight, and schedule "How-are-you-doing?" sort of visits. I tell my new patients, "I will be talking to you a lot!"
I need to be patient. Even with a good start, healthy relationships are -- of course! -- not made in a single visit. It typically takes several weeks, many visits, and patience to get patients to consider me to be "my doctor." But it does happen!
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 .