Reputation rehabilitation: Prison medicine

Clanging metal chains and handcuffs can't distract Joachin Okafor, MD, from caring for his patient.

The 44-year-old man has come to Dr. Okafor, complaining of chest pain. He rests on a gurney. An IV is started. Paramedics soon arrive, and Dr. Okafor tells them what medications the man takes.

The patient has a history of heart problems. He has a criminal history, too.

As a prison guard unravels chains attached to handcuffs and shackles the patient's ankles, Dr. Okafor continues to explain the man's condition to paramedics. The guard pulls more chains through the gurney's steel frame, cuffing the ill inmate's hands to his side. As paramedics wheel the man out of the room, he thanks Dr. Okafor, adding, "Have a good day."

This is routine treatment for prisoners at Westville Correctional Facility, a medium-security prison of about 2,800 inmates nestled among corn fields and wide open spaces in northwestern Indiana. Anytime a medical problem requires a trip to a hospital emergency department in town, inmates must be cuffed before leaving. It's also routine for Dr. Okafor to treat the inmates with the same level of compassion he would provide to patients on the outside.

Dr. Okafor practices medicine behind bars because the regular work schedule gives him more time to spend with his wife and four children. There are no HMO hassles, no Medicare issues. He doesn't worry about patients missing follow-up visits. It's a more secure and satisfying job than most outsiders realize, he said.

"If you walk into an emergency room, it's not as safe as here. Somebody can walk in with a gun there," said Dr. Okafor, 43, an internist originally from Nigeria. "[The inmates] know you are here to help them."

Dr. Okafor and physicians like him are changing the profession's impression of correctional facility medicine. Prisons and jails are no longer looked upon as medical wastelands or a refuge for disciplined doctors. Rising prison and jail populations mean increased demand for physicians. Groups such as the National Commission on Correctional Health Care in Chicago have pushed for higher quality of health care through standards on treatment.

Some medical leaders said prison and jail practice is an emerging specialty that has evolved over 30 years and is now gaining respect as a viable job option for physicians.

"Whether or not we call it a specialty, it is one," said Dean Rieger, MD, MPH, medical director for the Indiana Dept. of Correction.

There is no board-certified specialty for prison and jail doctors yet. But Dr. Rieger and other physicians say there should be. About 2 million people are incarcerated in federal or state prisons and local jails -- an increase of more than 500% from 325,400 inmates in 1970. Caring for this growing population is a specialized practice, correctional experts say.

"[Correctional physicians] get a chance to treat illnesses they were trained to treat but don't get to treat because they don't see it as often in the community. So this is a tremendous public health opportunity for them," said NCCHC President Edward Harrison.

Exacerbated health problems

Inmates typically have more health problems than the general population. Many have neglected their health over the years and had limited access to care.

Health problems often are compounded by alcohol and drug abuse. They typically have a physiological age about 10 years older than someone in the general population.

They are nine to 10 times more likely to be infected with hepatitis C and five times more likely to be HIV-positive. They have higher rates of tuberculosis, mental illness and sexually transmitted diseases. And the prison population is growing older.

"If you're interested in a medical practice that has a lot of pathology, this is a good practice," Dr. Rieger said.

On a fall day at the Westville, Ind., prison, Dr. Okafor spends the morning seeing patients with chronic problems. Inmates wait quietly on wooden benches in the hallway until a nurse calls them into an exam room where Dr. Okafor sits at a desk, neatly dressed in an olive-colored suit, brown shoes and gold-toned tie. Patients shuffle in wearing their prison-issue uniform -- tan shirts and pants.

The room has an exam table and patient chair. Bars line the window. Patient charts have names and inmate numbers.

An inmate with hepatitis C says he quit doing drugs. He says he is appealing his case and doesn't plan to be in prison much longer. Dr. Okafor warns him that alcohol will worsen his health and urges him to seek substance abuse treatment.

"I'm concerned about it when you do get out," said Dr. Okafor, an employee of Prison Health Services, which contracts health care for Indiana's inmates.

Later, a prisoner gets his diabetes checked. Dr. Okafor, in typical calm and soothing tone, asks the man to watch his diet. He tells the patient if he doesn't keep the diabetes in check, he could have eye, kidney and circulation problems. "And you don't want any of those," Dr. Okafor said.

Nurses and inmates said Dr. Okafor's concern for his prison patients is genuine. Several inmates believe he's the best doctor the Westville prison has had.

"He's a good doctor, and he cares about his patients. He's not just going through the motions," said inmate Kenny Sevier.

Internist Kelly O'Brien, MD, also practices in the correctional system. She works in the Denver City Jail as a correctional care physician for Denver Health.

Five years ago, Dr. O'Brien left a position as an associate program director in internal medicine. "I was ready to do something different. I didn't want to get into private practice," she said.

She knew someone who was a jail doctor and decided to pursue that option. Today, she works 8 a.m. to 2:30 p.m. and sees three to 16 patients in a typical morning. She said the pay is comparable to other practice situations, and she finds the work challenging and interesting.

"In this position, I do far less paperwork. I don't deal with Medicare. I don't deal with Medicaid," she said. "I've enjoyed the change. The patients, for the most part, have treated me politely and have been grateful for their care."

Evolution of correctional care

There wasn't much in the way of medical care for prison and jail inmates until the early 1970s, medical experts said. At one time, incarcerated doctors provided care to fellow inmates at some facilities. In others, prisoners aided physicians in their work.

But court rulings and organized medicine reformed the system. Federal court decisions in the early 1970s set a constitutional basis for adequate medical care for inmates, according to an article in the July 28 Journal of the American Medical Association.

The U.S. Supreme Court in Estelle v. Gamble affirmed that deliberate indifference to serious medical needs of inmates violated the Eighth Amendment, and by 1981, half of the states were directed to or consented to improve conditions, the JAMA article said.

Meanwhile, the American Public Health Assn. in 1976 issued national health care standards for correctional facilities. The AMA also published health care standards and created a program to accredit jail health care systems. Some medical schools in states such as Texas have been contracted to provide care, and private prison contractors also have helped improve the quality of care, experts said.

"If you look at the quality of medicine in the correctional system now, it's night and day," said Ron Shansky, MD, a correctional health care consultant based in Chicago who worked in prison medicine.

Adding to the higher level of professionalism are groups such as the NCCHC and the Society of Correctional Physicians. The NCCHC credentials doctors through its Certified Correctional Health Professional program and offers a voluntary health services accreditation program. The Society of Correctional Physicians, formed in 1993, provides professional development for correctional physicians and has about 400 members.

Society Executive Director Paula Hancock estimates that 3,000 to 5,000 physicians work full or part time in correctional health care.

"A lot of these [correctional doctors] see this as a calling, and a lot of them see it as a great place to practice," she said.

Internist Jennifer Clarke, MD, MPH, feels lucky to have her job as staff physician for the Rhode Island Dept. of Corrections. When she heard about the job after finishing a fellowship, it sounded like a good adventure. Her parents weren't thrilled about the idea, but she has not been hurt and feels safe.

"I tend not to ask about their crime," Dr. Clarke said of her inmate patients. "Some of the women just volunteer the information to me."

She said it took a few months to adjust to security gates closing behind her. But now she likes the variety her work offers.

"It's a combination of doing a lot of primary care and a lot of urgent care," she said. "It's a huge bonus to know every patient I see I don't have to worry about how they're going to get their medication."

Despite such interest in correctional care, problems remain. An article in the September 1999 Journal of Health Care Finance said health care delivery in correctional settings was not cost-effective and not adequate in quality. The article also said offenders often received care from doctors guilty of crimes or facing ethical problems. A September 2004 report by The Los Angeles Times said one in five California prison doctors had been disciplined by the state or sued for malpractice.

But the bad news hasn't dampened interest. And in some places, pay has improved. For example, prison doctors in Utah made $60,000 to $80,000 annually in 1990. Now they can make up to $150,000 with call.

"We get plenty of applications," said Richard M. Garden, MD, clinical director of the Utah Dept. of Corrections. "There's not that problem of recruitment anymore."