Behind bars: the compelling case for academic health centers partnering with correctional facilities

Promoting Interest in Future Correctional Health Care Employment Through a Jail-Based Rotation for Resident Physicians

Recruitment and retention of clinical staff in correctional settings remain a significant challenge. Few physicians learn about the provision of care within carceral institutions, most notably during their initial training programs when career trajectories are typically determined. A rotation for senior family medicine residents was developed in a county jail with an experiential learning curriculum that centers the needs of individuals experiencing incarceration. We investigated whether residents who completed this rotation subsequently worked within correctional medicine or cared for individuals in the community who had been formerly incarcerated. Residents who concluded the rotation between 2014 and 2020 and had since graduated from their training programs (N = 20) were invited to participate in an anonymous survey. Approximately 88% of survey participants reported caring for patients with a history of incarceration since completing the rotation. Nearly 18% reported having worked in a jail or prison after graduation. All respondents reported that they would consider pursuing correctional medicine at some point in their career. Findings from this study suggest that providing a brief but structured clinical rotation for senior medical residents in a jail or prison may encourage graduates to consider working with people involved in the criminal legal system.

The State of Medical Education on Criminal Justice Health: A Systematic Review

BACKGROUND

The justice-involved population faces significant health disparities yet is often overlooked in medical education, resulting in medical providers having limited preparation to serve this community. The objective of this study is to understand the scope and context of medical education in correctional healthcare.

METHODS

Literature was systematically reviewed for curriculum on correctional healthcare aimed at undergraduate or graduate medical learners in U.S. educational institutions. The search strategy was developed with the guidance of a medical research librarian and included five literature databases, which were analyzed by two data analysts. The risk of bias was assessed using the appropriate Critical Appraisal Skills Programme checklists.

RESULTS

Our search identified 49 studies highlighting 95 unique curricula. Curricula were evenly split between the undergraduate (n = 44) and graduate (n = 50) level. The two most represented specialties were psychiatry (n = 43) and general medicine (n = 30). Educational modalities included clinical rotation (n = 48), didactics (n = 14), or a combination (n = 28). Curricula increased knowledge in correctional and specialty-specific medicine and improved attitudes towards justice-involved patients; however, there was no significant effect on plans to work with the justice-involved population. Common themes of curricula included treating justice-involved patients with respect (n = 23), structure and function of the legal system (n = 20), and career recruitment (n = 16).

DISCUSSION

There is limited education on the care of the justice-involved population and most learners are unlikely to experience education on this population during their training despite the extensive and unique health and psycho-social needs of this population. Quality of education remains variable and challenging to assess due to limited outcome data and the low quality of literature; however, our thorough search strategy and standardized approach allow for a complete and accurate representation of the literature.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Registration number CRD42023427470.

Resident Experiences at a Community Hospital Caring for Patients Who Are Incarcerated

There is no standardized curriculum that teaches medical residents to navigate the ethical and logistical complexities of bedside care delivery to patients who are incarcerated. In this article, we describe resident physician bedside experiences at a community teaching hospital caring for patients who are incarcerated. From 2022 to 2023, residents in emergency medicine, general surgery, internal medicine, and obstetrics and gynecology were offered an anonymous survey, self-administered via REDCap software, to explore their experiences caring for this patient population. Of 168 resident physicians, 78 (46.4%) completed the survey. The majority were cisgender women (62.3%), 20 to 30 years old (78.2%), and White (70.5%). Of these residents, 98.7% had cared for a patient who was incarcerated or in custody, yet only 15.4% reported receiving formal education regarding caring for this patient population, and only 24.4% were aware of relevant institutional policies. Qualitative analysis revealed themes including barriers to care, permission and authorization, conditional treatment, inconsistency, and conflict. Resident curricula that target knowledge gaps related to procedure and policy and address ethical concerns at the bedside may improve the clinical learning environment and lead to more consistent, equitable care delivery for patients who are incarcerated.

Infection Prevention and Control in Correctional Settings

Correctional facilities house millions of residents in communities throughout the United States. Such congregate settings are critical for national infection prevention and control (IPC) efforts. Carceral settings can be sites where infectious diseases are detected in patient populations who may not otherwise have access to health care services, and as highlighted by the COVID-19 pandemic, where outbreaks of infectious diseases may result in spread to residents, correctional staff, and the community at large. Correctional IPC, while sharing commonalities with IPC in other settings, is unique programmatically and operationally. In this article, we identify common challenges with correctional IPC program implementation and recommend action steps for advancing correctional IPC as a national public health priority.

Challenges of Gender-Affirming Care in Incarcerated Transgender People

Social and health disparities among transgender people may result in increased rates of incarceration, particularly among Black transgender women. The World Professional Association for Transgender Health states that all recommendations for gender-affirming care made in the Standards of Care-8 be applied equally to people living in institutions. Understanding the structural challenges to gender-affirming care in the corrections environment will allow the endocrinologist to navigate the complex correctional health care system. The barriers to gender-affirming care and surgery will be highlighted in this article.

Training on Corrections and Health Within U.S. Academic Health Professions Education: A Scoping Review

Despite the scale, inequity, and consequences of mass incarceration, health care provider knowledge and awareness on correctional health remain limited. Understanding the educational experiences of health professions learners and the studies used to evaluate them can provide useful information about current gaps to guide future curricular improvement. To address this need, we conducted a scoping review of peer-reviewed studies examining United States-based academic health professions educational programs on correctional health. Studies were coded based on study characteristics, learner outcomes, and degree to which they contained elements described in relevant position statements by two professional medical associations. Overall, 27 articles (1975-2021) were included. Learner outcomes were primarily documented at the "reactions" (93%) and "learning" (52%) levels of the Kirkpatrick model (1979), relative to "behaviors" (11%) and "long-term outcomes" (0%). Comparison of curricula to select position statements revealed multiple content gaps in the realms of prevalent conditions requiring expertise (e.g., violence and self-harm); ethical and medical-legal considerations (e.g., privatization of correctional health care); and correctional health care systems, structures, and administration. Taken together, findings highlight gaps in, and opportunities for, correctional health educational programs. Addressing health care workforce training needs is a necessary yet insufficient step to achieving health equity for populations affected by incarceration.

Health Care During Incarceration: A Policy Position Paper From the American College of Physicians

The American College of Physicians (ACP) has a long-standing commitment to improving the health of all Americans and opposes any form of discrimination in the delivery of health care services. ACP is committed to working toward fully understanding and supporting the unique needs of the incarcerated population and eliminating health disparities for these persons. In this position paper, ACP offers recommendations to policymakers and administrators to improve the health and well-being of persons incarcerated in adult correctional facilities.

Proposing Abolition Theory for Carceral Medical Education

Medical schools, like all institutions, are conservative since they seek to maintain and expand on their accomplishments. Stakes are high in carceral medicine given the risks of replicating the inhumane social conditions that exist within prisons and allow prisons to exist. Given the increasing number of partnerships between state and municipal carceral systems with academic medical centers, medical schools must consider which guiding theory they will use to teach carceral medicine. The interdisciplinary theory of prison abolition is best fit for the task of training medical students to think about the long term goals of societal change and public health.

The Importance of Correctional Health Care Curricula in Medical Education

We designed an anonymous survey to identify knowledge gaps regarding correctional medicine and health disparities for justice-affected patients and distributed it to medical students. Fifty-six percent of the 140 students who responded (14% response rate) had some interaction with the criminal justice system and/or a justice-affected person. Most students somewhat agreed to having knowledge of health risks/disparities related to incarceration. Most were unaware of correctional medicine as a subspecialty. A majority felt comfortable providing care to justice-affected patients and on average agree this population should have equal access to health care. There was a statistically significant correlation between students who considered correctional medicine as a career and belief that these patients should have equal health care access, with the importance of including correctional health care in medical education. We agree with the growing body of literature that concludes there is a need for correctional health care curricula in medical education.

Justice for Incarcerated Moms Act of 2021: Reflections and recommendations

In the last five decades, the number of women behind bars in the United States has risen exponentially. It is now estimated that there are nearly 58,000 admissions of pregnant people—disproportionately women of color—to jails and prisons each year. Recognizing the urgency and consequences of mass incarceration on pregnant people, their families, and communities, House Resolution 948: Justice for Incarcerated Moms Act of 2021 was introduced to Congress as a part of the Black Maternal Health Momnibus. The Justice for Incarcerated Moms Act aims to improve health care and promote dignity for incarcerated pregnant and parenting people through an array of policies and oversight. In this article, we review and reflect on the components of this bill within their broader public health and reproductive justice contexts. We close with recommendations for policymakers and professionals committed to promoting equity and justice for pregnant and postpartum incarcerated people.

Medical Students' Knowledge and Attitudes Regarding Justice-Involved Health

Despite the demonstrated need for sustainable and effective carceral health care, justice-involved medical education curricula are limited, and it's unclear if informal clinical education is sufficient. Investigators aimed to quantify medical student involvement with carceral populations and explore how students' knowledge of and attitudes towards justice-involved patients changed over the course of their training. A survey was designed by the investigators and sent to all current medical students at a single United States medical school. Stata 14.0 was used to compare results between the years of medical school. Differences between groups were tested using linear regression. Most 4th year students reported working in a carceral health setting. An increase in overall knowledge of justice-involved patients was observed as carceral medicine education (p_trend = 0.02), hours worked in a jail (p_trend < 0.01), and substance abuse training (p_trend < 0.01) increased. Overall attitude score increased with the students' reported number of hours working in a jail (p_trend < 0.01) and the amount of substance abuse training (p_trend < 0.01). Finally, we found a trend of increasing knowledge and attitude scores as the year of standing increased (p_trend < 0.01). Our data suggest that most USC medical students work in a carceral setting during medical school. Didactic and experiential learning opportunities correlated with improved knowledge of and attitude toward justice-involved patients, with increases in both metrics increasing as the year in medical school increased. However, senior medical students still scored poorly. These findings underscore the need for a formal curriculum to train our healthcare workforce in health equity for carceral populations.

Qualitative exploration of the medical learner's journey into correctional health care at an academic medical center and its implications for medical education

Correctional systems in several U.S. states have entered into partnerships with academic medical centers (AMCs) to provide healthcare for persons who are incarcerated. One AMC specializing in the care of incarcerated patients is the University of Texas Medical Branch at Galveston (UTMB), which hosts the only dedicated prison hospital in the U.S. and supplies 80% of the medical care for the entire Texas Department of Criminal Justice (TDCJ). Nearly all medical students and residents at UTMB take part in the care of the incarcerated. This research, through qualitative exploration using focus group discussions, sets out to characterize the correctional care learning environment medical trainees enter. Participants outlined an institutional culture of low prioritization and neglect that dominated the learning environment in the prison hospital, resulting in treatment of the incarcerated as second-class patients. Medical learners pointed to delays in care, both within the prison hospital and within the TDCJ system, where diagnostic, laboratory, and medical procedures were delivered to incarcerated patients at a lower priority compared to free-world patients. Medical learners elaborated further on ethical issues that included the moral judgment of those who are incarcerated, bias in clinical decision making, and concerns for patient autonomy. Medical learners were left to grapple with complex challenges like the problem of dual loyalties without opportunities to critically reflect upon what they experienced. This study finds that, without specific vulnerable populations training for both trainees and correctional care faculty to address these institutional dynamics, AMCs risk replicating a system of exploitation and neglect of incarcerated patients and thereby exacerbating health inequities.

"I Just Had No Idea What It Was Like to Be in Prison and What Might Be Helpful": Educator and Learner Views on Clinical Placements in Correctional Health

Phenomenon: Correctional health services can provide quality learning experiences for medical students and graduate medical trainees, including through motivating learners to work with people involved with the justice system, and promoting understanding of the social determinants of health. Approach: We conducted 38 semi-structured interviews to examine the views of learners and educators on how to promote high quality clinical learning in correctional settings, with a focus on the Australian context. Participants included medical students; general practitioners who had undertaken graduate trainee placements; clinical staff involved in teaching and clinical supervision; and graduate program medical educators and university teachers from Australia, New Zealand, and Canada. Data were analyzed thematically. Findings: Clinical placements in correctional settings provided learning about the health of people involved in the justice system, but also beneficial clinical learning for working with a wide range of patients with complex health needs. Valued learnings included managing complex consultations, mental health and substance use disorders, and overcoming anxiety related to interacting with people in prison. Learner concerns included limited patient contact time, apprehension prior to placements, and stress related to experiences during the placements. This apprehension and stress could be mitigated by orientation and debriefing, and by appreciating healthcare professionals in correctional settings as advocates for their patients. Clinical supervision was perceived to be demanding in this context. Independent patient interaction was not usually possible for students and there could be short windows of time in which to provide direct patient care, making pauses for teaching difficult. Insights: Clinical placements in correctional health services provide experiential learning of direct relevance to medical student, and potentially to general practice trainee, curricula which is valuable even when learners do not have particular interest in correctional health. Furthermore, these placements may increase the capacity of the medical workforce to provide skilled care to other underserved populations. High quality learner and clinical supervisor experiences, and program scale and sustainability, require enhanced learning support systems through partnerships between correctional health services and education institutions. Required supports for learners include orientation to security arrangements, debriefing sessions which assist learners to distill their learning and to reflect on challenging experiences, and alternative learning opportunities for when direct patient consultations are not accessible. Supervisor teaching supports include shared teaching approaches in the correctional health clinics and added student support from university-based staff.

"It's like heaven over there": medicine as discipline and the production of the carceral body

BACKGROUND

Correctional systems in several U.S. states have entered into partnerships with Academic Medical Centers (AMCs) to provide healthcare for people who are incarcerated. This project was initiated to better understand medical trainee perspectives on training and providing healthcare services to prison populations at one AMC specializing in the care of incarcerated patients: The University of Texas Medical Branch at Galveston (UTMB). We set out to characterize the attitudes and perceptions of medical trainees from the start of their training until the final year of Internal Medicine residency. Our goal was to analyze medical trainee perspectives on caring for incarcerated patients and to determine what specialized education and training is needed, if any, for the provision of ethical and appropriate healthcare to incarcerated patients.

RESULTS

We found that medical trainees grapple with being beneficiaries of a state and institutional power structure that exploits the neglected health of incarcerated patients for the benefit of medical education and research. The benefits include the training opportunities afforded by the advanced pathologies suffered by persons who are incarcerated, an institutional culture that generally allowed students more freedom to practice their skills on incarcerated patients as compared to free-world patients, and an easy compliance of incarcerated patients likely conditioned by their neglect. Most trainees failed to recognize the extreme power differential between provider and patient that facilitates such freedom.

CONCLUSIONS

Using a critical prison studies/Foucauldian theoretical framework, we identified how the provision/withholding of healthcare to and from persons who are incarcerated plays a major role in disciplining incarcerated bodies into becoming compliant medical patients and research subjects, complacent with and even grateful for delayed care, delivered sometimes below the standard best practices. Specialized vulnerable-population training is sorely needed for both medical trainees and attending physicians in order to not further contribute to this exploitation of incarcerated patients.

Corrections for Academic Medicine: The Importance of Using Person-First Language for Individuals Who Have Experienced Incarceration

This Invited Commentary addresses the use of labels and their impact on people involved in the criminal justice system. There are 2.2 million adults incarcerated in the United States and close to 6.6 million under correctional supervision on any day. Many of these people experience health inequalities and inadequate health care both in and out of correctional facilities. These numbers are reason enough to raise alarm among health care providers and criminal justice researchers about the need to conceptualize better ways to administer health care for these individuals. Using terms like "convict," "prisoner," "parolee," and "offender" to describe these individuals increases the stigma that they already face. The authors propose that employing person-first language for justice-involved individuals would help to reduce the stigma they face during incarceration and after they are released. Coordinated, dignified, and multidisciplinary care is essential for this population given the high rates of morbidity and mortality they experience both in and out of custody and the many barriers that impede their successful integration with families and communities. Academic medicine can begin to address the mistrust that formerly incarcerated individuals often have toward the health care system by using the humanizing labels recommended in this Invited Commentary.

Leveraging the U.S. Criminal Justice System to Access Women for HIV Interventions

The criminal justice (CJ) system can be leveraged to access women for HIV prevention and treatment programs. Research is lacking on effective implementation strategies tailored to the specific needs of CJ-involved women. We conducted a scoping review of published studies in English from the United States that described HIV interventions, involved women or girls, and used the CJ system as an access point for sampling or intervention delivery. We identified 350 studies and synthesized data from 42 unique interventions, based in closed (n = 26), community (n = 7), or multiple/other CJ settings (n = 9). A minority of reviewed programs incorporated women-specific content or conducted gender-stratified analyses. CJ systems are comprised of diverse access points, each with unique strengths and challenges for implementing HIV treatment and prevention programs for women. Further study is warranted to develop women-specific and trauma-informed content and evaluate program effectiveness.

Inmate Health Care Provided in an Emergency Department

The United States has the highest rate of incarceration in the world. Many correctional facilities have outsourced the medical care for this population that often presents with complex health issues. This study evaluates the reasons that inmates present to an emergency department (ED) and compares them to the general population ED visits. The most common presenting complaints were trauma (16.8%), abdominal pain (13.5%), chest pain (9.0%), and self-injury (8.7%). These presenting complaints differed significantly from those of the general population (abdominal pain [8.1%] and chest pain [5.2%]). Inmate-patients seen in the ED presented with a significantly higher frequency of trauma, 16.8% versus approximately 1.5%.

Perioperative Care of Prisoners: Providing Safe Care

Correctional nurses are trained to care for prisoners in a controlled security environment; however, when a convict is transferred to a noncorrectional health care facility, the nurses there are often unfamiliar with custody requirements or how to safely care for these patients. The care of prisoners outside of prison has not been adequately investigated, and a gap exists between research and nursing education and practice. Nurses rarely have to consider how providing care for a prisoner in custody affects their practice, the potential dissonance between routine nursing care and the requirements to maintain security, or that care of prisoners in unsecured clinical areas places the nurse and other personnel at risk for physical assault or prisoner escape. Educating perioperative nurses in the care of prisoners in a public hospital environment is important for the provision of safe care and prevention of physical and emotional repercussions to personnel.