Clinical Practice in Correctional Medicine
Editorial Reviews
From The New England Journal of Medicine ® March 25, 1999 The Massachusetts Medical Society. All rights reserved.
Not long after I started working at the prison in Walpole, Massachusetts, a patient came to my office during sick call and breezily announced that he had just swallowed 37 Tylenol tablets. He declined ipecac, stating almost as an afterthought, "Oh yeah, and I swallowed a razor." After we had administered acetylcysteine, a blood test failed to detect acetaminophen, but a radiograph showed the presence of a razor blade in his epigastrium and also a nail clipper, apparently in his rectum. A day or two later, the patient reported difficulty urinating, and my examination verified his claim that the nail clipper was not in his rectum, as the radiograph had suggested, but deep in his urethra. He demanded to be sent to an outside hospital but, once there, refused to have it removed. Several days later, back in the prison and confined to an empty cell in the infirmary, wearing a paper johnny, restricted to finger foods, and on 15-minute checks, he managed to partly severe his Achilles tendon with the feculent razor blade he had just passed. The mental health consultants noted repeatedly in their assessment, "No major mental illness. Manipulative behavior."
Doctors with little experience working in prisons may blithely (or boldly) assert that medical care of the incarcerated patient should simply be held to the standards of the larger community. What point, then, could there be in the publication of a textbook on "correctional medicine"? Those who have spent more time working in prisons, however, know that Harrison's Principles of Internal Medicine can seem rather beside the point in a penal setting and that, despite all one's formal training, medical care frequently becomes a rather improvisational affair. This first textbook of correctional medicine attempts to step into the fray and provide some guidance to clinical staff trying to practice medicine in institutions designed for punishment.
There is no shortage of medical problems in prison. Prisoners have chronic diseases such as hypertension, asthma, and diabetes. Seizures, both real and feigned, are not infrequent. Infection with the human immunodeficiency virus (HIV) is a common cause of morbidity and mortality. Screening for tuberculosis is critical. Incarceration seriously complicates pregnancy and postpartum management. Jails and prisons have, sadly, become the de facto custodial institutions for many persons with severe psychiatric disorders. These topics are competently and concisely addressed. The chapters on the epidemiology and management of HIV infection, in particular, are excellent overviews for the nonspecialist. In addition, Shuter and Bellin have contributed an authoritative chapter on the management of tuberculosis in the correctional facility, based in part on their rich experience at Riker's Island.
Of course, what is unique about Correctional Medicine is not the medical conditions discussed but the setting. A good textbook of correctional medicine should also serve as a kind of traveler's guide to local customs and habits. Indeed, most of the chapters in this book are devoted to issues specific to prison, including the interaction between correctional staff and health care providers, medical ethics in a correctional setting, sick-call triage, suicide prevention, special legal considerations, and care at the end of life. There is much useful information in these chapters, such as the excellent discussion of compassionate release, but also much that is repetitious and self-evident.
Important topics not usually covered by conventional textbooks, and unfortunately missing from this book as well, include the management of ingested or inserted foreign bodies, hunger strikes, and malingering. Notably absent from the otherwise excellent section on infectious disease is a chapter on the controversies surrounding the diagnosis and treatment of chronic viral hepatitis in prisons. Self-inflicted injury is dealt with in a too-brief, although highly nuanced, aside in Weisman's chapter on outpatient mental health problems in prisons. Not surprisingly, there is no mention of very common psychiatric problems, such as depression and adjustment disorders, except as they may be related to suicide -- an omission that reflects the neglect of these problems in the maelstrom of more urgent demands in prisons. Though managed care has had an even more profound effect (for good and ill) on health care in correctional facilities than on health care in society at large, the book provides no critical assessment of this trend.
The book opens with a well-written chapter on the history of correctional medicine. Perhaps the highest praise for the editors and contributors is that the very appearance of this book marks a watershed in the history of correctional care. Largely written by and for clinicians who are often isolated from, and perhaps stigmatized by, the academic medical community and who work without the usual academic support, this book is an achievement that signals an emerging clinical identity. It provides a foundation that I hope will be built on and refined in future editions.
Reviewed by David Kent, M.D.
Book Info
New Mexico State Prison System, Albuquerque. Text for clinicians and clinical staff on how to practice medicine in a correctional environment. Halftone illustrations.
Clinical Practice in Correctional Medicine,Michael Puisis,C.V. Mosby,0815127049,Health Care Issues,Health Services,Health Services For Special Classes,Internal Medicine,Medical,Medical care,Penology,Prisoners,Prisons,Social Science,Sociology,Treatment Of Offenders,United States,Clinical & Internal Medicine,Crime & criminology,General practice
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