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The Role Of The Physician Assistant In Correctional Medicine

By: Raymond P. Mooney, PA-C, DFAAPA
Tel: 517-902-1091
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Many States outsource prison healthcare (general medical care, mental health, and dental) to corporations that supply these services. The major companies providing these services are Corizon, Correct Care Solutions, MHM Correctional Services, and Wexford Health Sources among others.

The corporation retained to provide healthcare services to inmates is responsible for hiring the staff to care for the inmate population. The staff can include physicians, Physician Assistants (PAs), advanced nurse practitioners, and staff nurses. These employees are contractual employees and not employees of the state or the department of corrections.

Providing healthcare to the prison population through various corporations is not without significant debate among legislators and prisoner activist groups, including the American Bar Association Criminal Justice Section, the ABA Standards on Treatment of Prisoners, the Equal Justice Initiative, The Sentencing Project, and The Human Rights Watch, to name a few.

The United States has the highest incarceration rate in the world, five to ten times higher than countries like Canada, France, and the United Kingdom.

The national average cost per inmate has been estimated at $6,532.00 a year, not including facility costs.

Although it varies from state to state, all prisons have an infirmary, and some also have an onsite hospital to provide basic care. Blood work, X-rays, and surgeries are done off-site at the local hospital, and specialty consultations occur both on-site and at specialists’ offices.

Physicians, physician assistants, and advanced practice nurses provide all the on-site healthcare to the prisoners. A prisoner who has a medical concern will submit a request to be seen by a healthcare provider or, in the case of mental health problems, by the mental health department.

In the case of Estelle v Gamble, the United States Supreme Court articulated a constitutionally protected right to healthcare in prisons and jails and established what was necessary for an inmate to prove a violation his of his Eighth Amendment rights.

It has been established by the courts that the standard of care of a medical provider in his or her treatment of an inmate must be equal to that offered in the community.

The physician assistant is responsible for performing a complete history and physical examination, developing a differential diagnosis, and ordering appropriate laboratory, radiological, and chemistry studies. The PA will then prescribe treatment and follow up on the progress of the patient and discuss the case with the physician, if necessary or required.

Although the standard of care in the correctional setting is the same as in the local community, it must be remembered that the correctional institution is first and foremost a jail, prison, detention facility, etc. As such, it is custody and administration who are in ultimate control. If a provider wants to transfer a patient to the local emergency room, and the warden or shift captain says no, then the patient will not be permitted to leave. The only alternative for the provider is to document in the medical record the events surrounding the denial, in detail.

Medicine in a correctional institution is the same as the local community but only because it involves caring for the sick. After that, correctional medicine is quite different. You will see diseases in prison that you will never see in a primary care office; your patients are generally sicker as far as their general health and have more comorbid medical conditions. There is an extremely high incidence of obesity, hypertension, COPD, diabetes, renal disease, and coronary artery disease.

Due to underlying character disorders, mental health issues, and personality disorders, the prison population is very noncompliant. This noncompliance only exacerbates their underlying health issues, resulting in a sicker population.

A physician assistant has a significant opportunity to learn a great deal of complicated medicine. However, this requires partnering with a physician who enjoys teaching the art of medicine.

With the numerous medical conditions of the general prison population I would not recommend corrections as a first job for a physician assistant. Any PA interested in correctional medicine should have five years of general practice first.

The extinction of this nation's mental institutions has resulted in our prisons becoming densely populated with the mentally ill. In 2015, it was determined that 56% of state prison inmates, 45% of federal prison inmates, and 64% of the jail population suffered from one form of mental illness or another, and 10% to 35% suffered from severe mental illness.

The primary care provider (PCP) or physician assistant is frequently responsible for mentally ill prisoners. Although inmates are seen regularly by mental health providers, the prison is a fluid environment, and situations and prisoner attitudes can change frequently. The PA must be mindful of each patient’s demeanor, body language, lack of eye contact, and other signs of depression and make a referral to mental health. An emergent referral is indicated if the PA is concerned about possible suicidal or violent prisoner behavior.

Documentation is important in medicine, particularly in corrections. Detailed documentation is vital in the era of the electronic medical record (EMR). Prisoners are transferred on a regular basis, and it is crucial to document this in the EMR to facilitate continuity of care. If the prisons are connected by an EMR, the risks of mixed medications, forgotten follow-ups, etc. can be eliminated if the documentation is there.

The proportion of the prison population over the age of 55 increased by 280% between 1999 and 2016. The total number was approximately 164,000.

The elderly population in prison presents an incredibly unique and challenging demand due to social isolation and the lack of support and care from family and friends. They also have many illnesses that occur at an earlier age because they tend to be healthcare “disadvantaged”. There are inmates with poorly controlled diabetes, poorly controlled seizure disorders, COPD, hypertension, and coronary artery disease, to name a few. An experienced PA interested in internal medicine, chronic care, and geriatrics would find correctional medicine to be professionally rewarding.

Considering that most of us who have entered healthcare as a profession have a concern for others and feelings of empathy instilled in us, we must be mindful of inmates who are manipulative and overly friendly. Never permit yourself to become personally involved with a prisoner or their personal issues. Professionalism and detachment are foremost. Your professional concern is required: your “personal” concern is a significant rule infraction that could end up causing you legal as well as civil complications.

Raymond P. Mooney, PA-C, DFAAPA is a Physician Assistant with 46 years of experience in Family Practice, Emergency Medicine, Urgent Care, and Correctional Medicine as well as over twenty years of experience in reviewing medico-legal cases. He has extensive experience in deposition as well as trial testimony in state as well as federal court. With a diverse background as a Physician Assistant, Mr. Mooney has been providing the legal industry with his expert opinion for over 20 years. He is available to objectively evaluate cases for alleged medical negligence or a deviation in the standard of care on physician assistant practice.

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