Emily Wang tells of trying to treat inmate who had been in solitary confinement
Inmates are unused to care and may have been abused in prison, she says
Few medical professionals have training needed for dealing with incarcerated, she says
Wang: Doctors must be trained to get past stereotypes; patients must learn to deal with doctors
Editor’s Note: Emily Wang is an assistant professor of medicine at Yale University and co-founder of the Transitions Clinic Network. She is a Public Voices Fellow with The Op-Ed Project. The opinions expressed in this commentary are solely those of the author.
I knew immediately that James wasn’t like most of my patients. The first thing I noticed was that he had rearranged the exam room so that he was not sitting with his back to the door. He was twitchy and seemed paranoid. He said he’d felt sick just stepping out of his apartment to come to his appointment. When I tried to examine him, he jumped and batted my hand away. My stethoscope flew off my shoulder.
I was startled, though not particularly surprised. James had just been released from 10 years of solitary confinement, and it was the first time in a decade that he’d been touched by another person. If some other provider had seen him, this visit might have ended differently: with frustration, aggression or even a call to the clinic security. But because I was trained to care for patients with a history of incarceration, I gathered my composure and continued on.
Close to 13 million patients return home from correctional facilities in the U.S. each year, often having been exposed to extreme conditions or even, as was reported in a recent New York Times article about Rikers Island, allegations of abuse at the hands of correctional officers. But rarely if ever are these patients seen by a provider trained to care for their special needs. Only 22 primary care residency programs in the U.S. train physicians in how to care for prisoners or people who have been through the correctional system.
The ignorance of medical professionals has serious consequences for these men and women and the health care system at large, especially as many of these patients stand to gain access to health care through the Affordable Care Act. Whether they use it is a particularly significant issue for the mentally ill, who are overrepresented in the prison population, many of them urgently needing treatment once they’re released and must also manage medications.
Most health care providers don’t know how common incarceration is (one in every 31 adults is in the prison system, according to the Pew Center on the States). They don’t know that being released from a correctional facility puts a person at high risk for being hospitalized or dying, or that prisons even operate their own health care systems.
They don’t know that many of our most powerless patients have their first exposure to health care as adults in prison, that patients in correctional facilities do not inject their own insulin or manage their own medications, may have to get permission from a correctional officer to see a health care provider and can even be punished with solitary confinement for not taking their medications.
Training medical professionals about the correctional health care system alerts them to the unique health risks of prison and how they might help patients prevent future incarcerations. But perhaps even more important, it creates a space to acknowledge that even physicians have a hard time avoiding the prevalent stereotype of criminals – black, dangerous and deserving of incarceration – and this can affect who they treat and how.
As someone who sees only former prisoners in her primary care practice, I know that hearing that someone has a criminal record can bring out our base fears and fantasies of prison life and of those who commits crimes, prejudices often fueled by the media and politicians. As doctors, we like to think we are objective, but we’re just as susceptible to these fantasies as anyone else.
Discrimination based on criminal record is pervasive for people trying to get a job, find housing and secure social services, so why wouldn’t it affect the delivery of health care as well?
This year, my colleagues and I published a study in Health and Justice that found that 42% of individuals released from prison felt discriminated against by individuals working in the health field, based on their criminal record. Some commented that the mere mention of their distant incarceration history in the electronic health record has led to doctors “not wanting to prescribe them prescription pain medications.”
How can we counteract this? Medical providers can start by visiting a prison and by bringing their trainees. For instance, medical residency programs like the University of California, San Francisco’s offer training about the health risks of incarceration, how to ask about a patient’s incarceration history and even help trainees identify their own biases and develop strategies to confront them.
We also must teach patients who have been imprisoned how to talk about their incarceration, to be aware of providers’ biases and to learn how to mention that they’ve been in prison without getting into the specifics of why. Without this, some patients may inadvertently offer details about past criminal activity that their physicians may not be able to overlook or forget.
If we fail to address these issues, the consequences can both affect the people needing treatment and burden an already stretched health care system. Past evidence shows that the experience of discrimination among any population deters patients from seeking primary care when they need it and leads them instead to end up in the emergency department when it is far more expensive to get the treatment they need, and often too late.
For patients released from correctional facilities, it’s not hard to see how a similar outcome might take shape. Our lack of awareness of our own biases as doctors and of the specific needs of the prison population may lead to patients avoiding primary care, mental health treatment or substance abuse treatment and ending up in the emergency departments or, if these issues remain untreated, back in prison.