Caring for special populations
BY CINDY BORGMEYER
Stanley Harper, M.D., of Chicago says that even in the early days of his medical training, he never envisioned himself in a traditional private practice. Worrying about overhead or insurance hassles -- it wasn't for him, Harper says. "I just wanted to treat patients -- whether it took 60 hours a week, 80 hours a week or 30 hours a week."
But it wasn't until after Harper had put in some time at the Cook County Hospital Family Practice Residency that all the pieces fell into place.
Landing him, so to speak, in jail.
"When I chose to be a family physician -- actually, when I decided to go to medical school -- I knew I wanted to work in the public health sector," says Harper. "When I finished my residency, there was a new director, a visionary, at Cook County Jail, and they were recruiting. Given the nature of my residency at Cook County Hospital, where we were serving a certain type of client, it happened naturally."
The hospital has a longtime record of caring for the medically indigent, as spelled out in the hospital's current mission statement: "To provide a comprehensive program of quality health care with respect and dignity to the residents of Cook County, regardless of their ability to pay."
Respect and dignity
According to Harper, the same principles apply to caring for patients in a correctional setting.
"You learn to respect them, call them "Mr." or "Mrs." just like in the 'free world,'" he says. "By and large, if you give patients respect, they’ll respect you."
It's a philosophy Harper says has served him well in his career, which has shifted him from the Cook County facility to Joliet Correctional Center in Joliet, Ill., and later to the District of Columbia Central Detention Facility. Now back home in Chicago, he's also worked outside the correctional system. So he knows exactly how health care provided "behind the walls" impacts the health of those outside the facility.
"You see the kinds of medical problems you would see in almost any urban situation," Harper says. In patients with chronic conditions, he says, previous lack of access to health services clearly shows. And the problem isn't restricted to physiological illness. According to a 2003 report by Human Rights Watch, one out of every six prison inmates in the United States has a mental illness -- that's three times the rate for the general population.
Managing inmates' health starts with an intake evaluation, including a history, physical exam and various screening tests. Screenings are done to look for health problems commonly seen in incarcerated patients, as well as for diseases circulating in the community. Often included are a reactive plasma reagin assay for syphilis, X-rays for tuberculosis and a dip stick urinalysis for pregnancy in female inmates, says Harper. "Most jails," he adds, "screen for chlamydia and gonorrhea."
Matter of public health
Health care delivered in correctional settings, Harper points out, is key in protecting the health of the public once inmates are released -- a fact not lost on former U.S. Surgeon General David Satcher, M.D., Ph.D., himself a family physician. Following a study begun during his tenure, the CDC last year issued guidelines for the prevention and control of infections caused by hepatitis viruses in juvenile and adult correctional facilities.
The AAFP also has weighed in on the issue of appropriate care, encouraging correctional facilities to seek accreditation by the National Commission on Correctional Health Care and encouraging health professionals working in these settings to seek NCCHC certification.
Go to http://www.aafp.org/x6839.xml#x6840 to read the Academy's policy on correctional health care. You'll find more information about NCCHC accreditation and certification on the commission's Web site at http://www.ncchc.org/.
Harper says that officers within correctional facilities are trained to recognize potential exacerbations of chronic health problems, such as asthma, and report them to health care staff. In most NCCHC-accredited facilities, inmates sign up for "sick call." In some housing units, sick call may be available every day; in others, once a week.
Usually, nurses perform triage and schedule patients to be seen by the physician.
All in all, Harper says, treating patients in a correctional health care setting
is really no different from working out in the community.
"I've managed thousand of patients behind bars, and when I'm examining a patient, it's basically the same as when I'm examining someone in the free world," he says. "You have the same relationship with the patient as you would anywhere else -- you close the doors for privacy, for example."
Harper's had only one unexpected incident with an incarcerated patient, a man with some psychological problems who was escorted to the medical unit. "I could see that he was not stable, and he lunged," he says. "The officers there restrained him. That was the only time I felt at all uncomfortable. The rest of the time, it's like seeing any other patient at an inner-city community health center."
Gauging impact
"One of the things about working in corrections is when you do make an impact on someone's health status or life, you usually don't know what impact you’ve had," Harper observes.
Of course, there are exceptions to every rule, and this one's no different.
"Every now and then," he says, "I see someone I've cared for, and they remember me." Often, that recognition is little more than a second glance or a brief nod. But when you get it, it sticks with you.
"I remember a dialysis patient I took care of at Joliet," says Harper. "I had gone to renew my license here in Illinois years later and saw him while I was standing in line. He was a very intelligent man -- very articulate -- and we exchanged greetings and talked. He'd done his full sentence, and he was doing OK.
"Occasionally, I've encountered folks and -- very rarely -- they've said 'thanks.' That makes you feel pretty good, not only as a physician but as a person."
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
FP Report is published by the AAFP
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Copyright © 2004 by
American Academy of Family Physicians.