Correctional / prison psychiatry

[Neuro111]

Pgy4 here looking jobs right now. Anyone with correctional or prison ( state or federal) psychiatry experience? Would it suit a new grad?

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[splik]

I think you will find there is huge variability on this depending on where you work. There is a big difference between county jails and state prisons, and difference between privatized prisons and state run prisons. The federal system is its own beast and there are advantages and disadvantages. Some work is more akin to outpatient work, and some more like inpatient work. In addition, prisoners tend to me more stable, chronically mentally ill, while the acuity in jails is often very high. Some correctional jobs are government jobs, whereas others are through private contractors (such as corizon or liberty). Personally, I would avoid working for private correctional contractors if you can (the care is often shadier, and the benefits less good even if the pay is better), but some are better than others (e.g. I might consider working for Liberty but would never work for Corizon).

Geography matters - I would never work in a prison in florida, for instance, nor work in a jail in Oklahoma. The former due to safety concerns, the latter due to standard of care concerns.

Correctional facilities can be total institutions, and the correctional officers as psychopathic as the inmates. What this means for you is: you might have to watch your back. In general correctional facilties are safer than general psychiatric wards or emergency rooms, but this again is highly variable. The only time I was ever assaulted was in a jail (albeit doing a forensic evaluation). I have also received multiple death threats from inmates (though this did not bother me at all, as most of these people will never see the light of day and/or are too dysregulated to actually carry something out that wasn't impulsive).

You may want to try some call shifts or locum work in a facility you are interested in before committing to a specific position. In fact, I would highly recommend this.

 

[NickNaylor]

Our county jail seems like a pretty good gig, depending on what you're looking for. We rotate there as residents; personally, I hated it but the docs there seemed to love it and the pay is quite good considering the work involved.

 

[Neuro111]

@splik Thank you! That was great info! I am mostly interested in California. Hopefully, I will be able to do some shifts there before committing. Thanks, I really appreciate it.

 

[whopper]

Some factors not mentioned.

We all know that working in this type of environment brings about different case scenarios not typically seen in other avenues of psychiatry or it's at least been well documented in textbooks. E.g. if a patient is sentenced to something severe such as life in prison, their suicide rates skyrocket for the next several days. A green psychiatrist not familiar with this type of thing could be in a rude awakening.

But that's not what I'm writing about.

Sometimes the pay in correctional facilities is so great not just cause you're working in a very much less than desirable setting but because the employer wants you to look the other way while the inmates are being given piece of dung care. Hey it's more cost-effective to pay a psychiatrist $400-500K a year for full time work, and if something goes wrong pin it all on him/her vs actually making the real changes needed to give decent healthcare to the inmates that would cost several millions.

Are you willing to do that? E.g. there's a suicidal patient and the facility has nothing the patient needs to get better. E.g. the patient's already been tried on 7 meds and the only med that works is $800/month and the jail or prison refuses to pay for it, or the jail only allows you to spend about 5 minute per patient during the clinic hours. So you complain that the inmates deserve better care and they more or less say, no...why don't you just leave and we'll get someone else.

 

[Sushirolls]

Sometimes the pay in correctional facilities is so great not just cause you're working in a very much less than desirable setting but because the employer wants you to look the other way while the inmates are being given piece of dung care. Hey it's more cost-effective to pay a psychiatrist $400-500K a year for full time work, and if something goes wrong pin it all on him/her vs actually making the real changes needed to give decent healthcare to the inmates that would cost several millions.

Are you willing to do that? E.g. there's a suicidal patient and the facility has nothing the patient needs to get better. E.g. the patient's already been tried on 7 meds and the only med that works is $800/month and the jail or prison refuses to pay for it, or the jail only allows you to spend about 5 minute per patient during the clinic hours. So you complain that the inmates deserve better care and they more or less say, no...why don't you just leave and we'll get someone else.

You know, this also resonates more each day with health systems too but without the the 400-500K salary. Simply saying this is how its going to be, things are understaffed and 'honey badger don't care.' Leave and we'll scoop up the next naive fresh residency grad or ARNP grad to replace you and repeat the cycle.

 

[Ahamis]

I would choose state hospital over prisons in California.

 

[Merely]

Can we or someone sue the hospital for understaffing or not providing the resources patients need? That’s some straight bs

 

[whopper]

In the old HBO series Rome, Julius Caesar's old legion, the 13th, wanted him to give them benefits for their years of service. He didn't want to give them much. So the 13th picked a man to represent them, that man demanded Caesar give more benefits, so he bribed the man.

Caesar then tells the man, when the men want more, it's cost-effective him for him to just bribe the 1 man representing them than to really solve the problem.

Prisons are allowed to give poor care. This has been argued in the SCOTUS with the SCOTUS even upholding that prison inmates aren't entitled to decent care, in fact even saying their care should be less than that usually offered in the community. The minimum standard allowed in prisons is set by the SCOTUS to "deliberate indifference" is unacceptable. That's it. It specifically states that the standard of care allowed in prisons is that and not that based on the average or reasonable treatment from most doctors in the community. So if a guy is bleeding to death in the jail and all a doc does is put some bandages on him and say "I care" that could be enough for the prison to be given acceptable care by government standards.

Jails aren't supposed to do the above (and remember in jails you're only there awaiting trial or are there for a misdemeanor, not a felony crime), but often times get away with it or are forced into providing bad care because the local government controls the funding and frankly the welfare of those in jails aren't a big concern for local politicians and usually if anything get points from voters for treating people in jail badly.

So lets say you are an evil a-hole doctor willing to look the other way cause $500K a year is much better than $200K a year. Well guess what? If someone has a bad outcome and sues, you think the evil local government that already was knowingly providing bad services is going to protect you or will they throw you like an offering mentioning that it was all your fault why the inmate committed suicide while in your jail or prison and you were the guy who was supposed to save him. Think about it.

It's been years since I left my last place of employment that I will not mention on this post although if you look thoroughly on my prior posts you'll find it. The above was a critical reason why I left it. The university I was a last a part of wasn't trying to fix the above problem, but was completely willing to take the money I was generating for them despite my insistence we force the local jail to make improvements. (It wasn't U of Cincinnati, it was the placed I worked after U of C. U of C never would've done anything like that).

Even to an evil doctor who isn't worthy of the MD, it's not a good idea to be a prison or jail doctor. Sooner or later a bad outcome will happen.

 

[Merely]

In the old HBO series Rome, Julius Caesar's old legion, the 13th, wanted him to give them benefits for their years of service. He didn't want to give them much. So the 13th picked a man to represent them, that man demanded Caesar give more benefits, so he bribed the man.

Caesar then tells the man, when the men want more, it's cost-effective him for him to just bribe the 1 man representing them than to really solve the problem.

Prisons are allowed to give poor care. This has been argued in the SCOTUS with the SCOTUS even upholding that prison inmates aren't entitled to decent care, in fact even saying their care should be less than that usually offered in the community. The minimum standard allowed in prisons is set by the SCOTUS to "deliberate indifference" is unacceptable. That's it. It specifically states that the standard of care allowed in prisons is that and not that based on the average or reasonable treatment from most doctors in the community. So if a guy is bleeding to death in the jail and all a doc does is put some bandages on him and say "I care" that could be enough for the prison to be given acceptable care by government standards.

Jails aren't supposed to do the above (and remember in jails you're only there awaiting trial or are there for a misdemeanor, not a felony crime), but often times get away with it or are forced into providing bad care because the local government controls the funding and frankly the welfare of those in jails aren't a big concern for local politicians and usually if anything get points from voters for treating people in jail badly.

So lets say you are an evil a-hole doctor willing to look the other way cause $500K a year is much better than $200K a year. Well guess what? If someone has a bad outcome and sues, you think the evil local government that already was knowingly providing bad services is going to protect you or will they throw you like an offering mentioning that it was all your fault why the inmate committed suicide while in your jail or prison and you were the guy who was supposed to save him. Think about it.

It's been years since I left my last place of employment that I will not mention on this post although if you look thoroughly on my prior posts you'll find it. The above was a critical reason why I left it. The university I was a last a part of wasn't trying to fix the above problem, but was completely willing to take the money I was generating for them despite my insistence we force the local jail to make improvements. (It wasn't U of Cincinnati, it was the placed I worked after U of C. U of C never would've done anything like that).

I’m talking about community and for profit hospitals not prisons

 

[whopper]

Someone could sue, but also remember "standard of care" is often times set by the local community standards. If the local community standards is already low it might be impossible to win in court.

An exception to this is some local courts have reset "standard of care" into a what a "reasonable provider" would give and not the community standard. E.g. let's say the APA or AMA say to give reason care x, y, and z must be performed. So even if most of the doctors in the community aren't doing it, the local community standard can't be used as a defense.

But that depends on the local courts. Courts either use the local geographic community as the standard or the reasonable/national standard as one.

 

[Merely]

Someone could sue, but also remember "standard of care" is often times set by the local community standards. If the local community standards is already low it might be impossible to win in court.

An exception to this is some local courts have reset "standard of care" into a what a "reasonable provider" would give and not the community standard. E.g. let's say the APA or AMA say to give reason care x, y, and z must be performed. So even if most of the doctors in the community aren't doing it, the local community standard can't be used as a defense.

But that depends on the local courts. Courts either use the local geographic community as the standard or the reasonable/national standard as one.

If the hospital is understaffed by definition there is a deviation from standard of care right?

 

[whopper]

Again depends.

A hospital could be big enough to be considered the community standard. I did my residency in Atlantic City NJ in the Atlanticare Hospital system. They pretty much were the community standard cause they had the most amount of providers in the area.

If this hospital is one of several, and all the others provide more and better care than it's likely they're below the community standard.

Repeating what I said above, standard of care is either set by local community standards or by reasonable standards that are not bound by local geographic treatment standards. It depends on what the local law says is the law in that area.

 

[Sushirolls]

If the hospital is understaffed by definition there is a deviation from standard of care right?

If you want real change these are more likely the solutions:
Don't work for these entities.
Get elected to some state legislative body or congress and push for change. Things like ending "certificate of need laws", ending CMS strangle hold on what can be paid/performed in an Ambulatory surgery center. ECT is not on the approved list...

 

[Neuro111]

@whopper Thanks so much for the info!

 

[nexus73]

If you want real change these are more likely the solutions:
Don't work for these entities.
Get elected to some state legislative body or congress and push for change. Things like ending "certificate of need laws", ending CMS strangle hold on what can be paid/performed in an Ambulatory surgery center. ECT is not on the approved list...

Agreed. The only time I’ve seen things change at my institution is in the wake of a doctor leaving and the hospital having to at least temporarily make changes in response to the departure. For example, doctor leaves because inpatient workload is too demanding (which doctors had been saying for the last 12 months). Well now the hospital has to respond because it’s no longer just lip service, someone actually left because of the heavy workload.

 

[EatSleepForensics]

Someone could sue, but also remember "standard of care" is often times set by the local community standards. If the local community standards is already low it might be impossible to win in court.

An exception to this is some local courts have reset "standard of care" into a what a "reasonable provider" would give and not the community standard. E.g. let's say the APA or AMA say to give reason care x, y, and z must be performed. So even if most of the doctors in the community aren't doing it, the local community standard can't be used as a defense.

But that depends on the local courts. Courts either use the local geographic community as the standard or the reasonable/national standard as one.

The idea of local community standard of care is increasingly obsolete. The reasonably prudent practitioner standard is the norm now.

 

[Merely]

The idea of local community standard of care is increasingly obsolete. The reasonably prudent practitioner standard is the norm now.

Does standard of care not apply to a hospital? Shouldn’t hospital execs who understaff us and provide not enough nurses, social workers, etc be held liable for bad outcomes ?

 

[EatSleepForensics]

Does standard of care not apply to a hospital? Shouldn’t hospital execs who understaff us and provide not enough nurses, social workers, etc be held liable for bad outcomes ?

Oh don't get my wrong - I feel your pain. And if it's any consolation, they are always included. I can't think of the last claim I saw related to alleged malpractice occurring within an institution where vicarious liability wasn't raised. The hospital/institution itself is usually named as a defendant; I've seen cases where specific other doctors, nurses and administrators were named.

 

[Sushirolls]

Does standard of care not apply to a hospital? Shouldn’t hospital execs who understaff us and provide not enough nurses, social workers, etc be held liable for bad outcomes ?

Hospitals historically are shell corporations. Merely a ship, and physicians are steering it, manning the oars, the rudder, etc.
What's changed is the concept of the health system, the "non-profit" corporation that runs several hospitals and in their quest to standardize things, in principle a good intentioned idea, they do more harm by eroding away physician autonomy, and preferencing the controllable widgets known as mid-levels.

This is unlikely to yield any real results by barking up the admin tree. They also conviently keep the clauses in our contracts that say we have autonomy in all our clinical decision making, despite making pages of policies that say otherwise and if you go against the hospital policy (or paper tiger medical group) policies (or simply not know X policy exists) you will be fired, or pointed at in any lawsuits for not adhering to the policies when lawyer crawl out of the shadows.

Policies don't protect you. Similar to an HR department they protect 'the man' the hospital, corporate medical group, etc.

Thus, another reason for physicians to reverse the trends of employment with large medical group entities, take back our profession and return to small independent medical groups or solo practice.

 

[Merovinge]

Hospitals historically are shell corporations. Merely a ship, and physicians are steering it, manning the oars, the rudder, etc.
What's changed is the concept of the health system, the "non-profit" corporation that runs several hospitals and in their quest to standardize things, in principle a good intentioned idea, they do more harm by eroding away physician autonomy, and preferencing the controllable widgets known as mid-levels.

This is unlikely to yield any real results by barking up the admin tree. They also conviently keep the clauses in our contracts that say we have autonomy in all our clinical decision making, despite making pages of policies that say otherwise and if you go against the hospital policy (or paper tiger medical group) policies (or simply not know X policy exists) you will be fired, or pointed at in any lawsuits for not adhering to the policies when lawyer crawl out of the shadows.

Policies don't protect you. Similar to an HR department they protect 'the man' the hospital, corporate medical group, etc.

Thus, another reason for physicians to reverse the trends of employment with large medical group entities, take back our profession and return to small independent medical groups or solo practice.

I wish this was just a conspiracy theory of someone with a very different world view then me. But then I see it happen on a daily basis... Thought I would always be an employed physician but a few years out of fellowship I find myself just trying to learn as much as possible about running a solo practice.