I can’t fire my patients

I remember back in residency there would occasionally be the wild, rude, drug seeking patient that we would have to call security on for threatening the staff when they were told they weren’t getting a bump in their opioid prescription. There were also the patients that would constantly no-show for clinic appointments, were never compliant with any treatment regiment, and when confronted would become verbally abusive. These types of patients had one thing in common. They were fired from clinic. Exiled into the world to find another poor provider never to be allowed in the doors of our clinic again. Conversely, if our patients weren’t happy with our care they could fire us as well, quit the clinic and seek out another provider.

In the correctional environment we are stuck with each other, I can’t fire my patients, and they can’t fire me. It’s like being a doc in some bizarre summer camp, we are all on the same canoe. To illustrate the contrast in this topic between the normal world and the parallel universe that is prison medicine a few recent patient encounters come to mind.

The first was a rather ornery obese older gentleman in a wheelchair. Now, it helps to understand that when I say “ornery” in the context of corrections that is usually pretty bad when everyone is beyond the societal norm of ornery already. I was seeing this guy for pain management and he was getting rather aggressive when I started asking why he was in a wheelchair. I combed through his chart and couldn’t figure it out anywhere. He claimed it was from a back injury (no records) and thought I would end the line of questioning there, and likely this strategy worked for him in the past, but I kept digging and found out he was in his wheelchair well before his back injury. Long story short he was lazy, and at some point along the way figured out that if he could convince someone to give him a wheelchair he could just happily roll his way through his sentence and probably convince medical to keep him on all kinds of pain meds, of course the years he spent immobilized essentially made it so he was to some degree now dependent on his wheelchair. I made him get up and walk around, which he did just fine. Politely as I could I informed him I could not find a medical reason why he needed to continue his pain medication, and I also encouraged him to use his wheelchair less, workout, stretch, etc. He took this news poorly, said some unpleasantries and then I asked him to leave. I got up and opened the door and he wheeled himself out. I returned to my desk and realized about 10 minutes later that a large stack of paperwork was missing which included his medical records. During our encounter he had asked for his records, but it is policy that they have to formally request records through the medical records department. I immediately called the officer on his range and told him that I think he stole a pile of papers. His¬†cell was “shaken down” and of course they found my papers. His response was that I gave them to him and I am the one to blame for getting him in trouble. He then filed a series of complaints on me that went nowhere. I often still see this kind fellow in the waiting room and it is only a matter of time before I’ll have to see him again and pretend like nothing ever happened.

The next case was a guy that I first saw when he was in solitary. When I first saw him it was to discuss the fact that his Wellbutrin due to his attempted diversion of it. Wellbutrin is a highly abused drug in prison. A popular antidepressant in the normal world, but what few people on the outside know, and most inmates know is that when crushed and snorted it has a short methamphetamine like effect. So about a week prior to our visit the nurse was giving him his med on pill line which means he had to take a cup with the medication in it, and be observed taking it and give the cup back. Story goes that he attempted to switch the cup out with another empty one, pretty common strategy actually. The nurse wrote him up, and I discontinued his medication. He had been waiting to see me for about a week at this point. I was half expecting him to come into the clinic room screaming and yelling, but it was quite the opposite. He walked in with a big smile on his face, “hey doc, so good to see you, I’m really looking forward to talking with you”. He then went into a monologue about how everything was just a big misunderstanding, and how he really needed his medication back. I attempted to be nice and empathetic at first by apologizing for the situation, but that I just won’t be able to restart his Wellbutrin, followed by listing a variety of other non-abusive medications to try. This cat and mouse game continued for about another five minutes before I had enough and said “Listen, I want to be clear, you are never getting Wellbutrin again in this institution, I’m happy to discuss other treatment options, but we are done talking about Wellbutrin”. To that his posture shifted he looked at the ground in a moment of contemplation and then looked at me and said squarely “F#%k you punk, F%$k you”, he then got up and walked out with two guards following him. About two weeks later he was released from solitary and I saw him in the normal medical clinic (I have a small satellite medical room in solitary). Our next visit he started out by apologizing and we had a very pleasant ¬†conversation, he admitted to some addictions, we had a big boy talk about him getting some things in his life together and I gladly prescribed a different medication.