General practice behind bars

http://www.pulsetoday.co.uk/practice-business/practice-topics/employment/general-practice-behind-bars/1/20000799.article#.UKzyMOTgmAg

Dr Jenny Schaefer is a prison GP. She describes her working week looking after prisoners in Bristol - and reveals how even the hardest of criminals suffers from man-flu…

How long have you been a prison GP?

I started at HMP Bristol in May 2009. It’s an all male, Category B prison built in Victorian times, housing about 600 prisoners.

How did you become a prison GP?

It’s a miracle that I ended up here at all. As a medical student I had a placement with a GP who took me on his rounds in Dartmoor Prison. I can clearly remember walking through the wing, vowing to myself that I would never work in prison, for two main reasons. Firstly I didn’t think I could ever have a sufficiently suspicious mind to consider, as he did, possible secondary gain coming into the differential diagnosis. Secondly, I was a female 23 year-old in an all-male environment. Now I’m older neither of those are such an issue for me!

In May 2009 I approached the GP who was then the provider of GPs to Bristol prison, and he gave me locum work there. Then when I left the detox unit where I was working, in April 2010, it happened to be at the same time as one of the full-time GPs retiring, and I took on a more regular role. I’d been a GP for 20 years by this time, but I’ve always had a portfolio career, spending two years in Namibia, and also, for the past ten years, working in a drug and alcohol detox and in a health service for homeless people. I had adapted my working week to suit my young family, but was in danger of becoming deskilled. My appraiser advised me that I would have to

do some ‘normal’ general practice and, apparently, an all-male prison counted.

There is a rigorous security clearance procedure involving lots of form-filling.

I was required to have the RCGP Certificate in Substance Misuse Part 2. Also, to ease me in, my employer provided written guidelines, mainly related to prescribing.

There is also specific training that the prison itself requires each staff member to undertake. For instance, personal protection, breakaway, key training (there are a lot of locks), ‘challenge it, change it’ (discriminatory/bullying behaviour), ‘safer custody’ (prevention of suicide and self-harm in prisoners) – I particularly enjoyed these training sessions because healthcare staff were learning alongside prison officers whose experience of prison life and prisoners is very different. And also of course computer system training in SystmOne, which is shared by most prisons and allows excellent continuity, as prisoners are forever being transferred from one prison to another and paper drug charts do not always get transferred with them.

Do you work full-time in a prison or alongside another primary care position?

I recently reduced my hours in the prison so that I could take up a salaried position as a GP in the centre of Bristol. I now work two mornings a week in HMP Bristol. There is a full-time GP and three other GPs who work part-time. Between us we provide two GPs in the morning, one GP in the afternoon and a session on Saturday and Sunday, and also one GP for a special two hour session 6-8pm weekdays to welcome in new prisoners who have specific needs to do with substance misuse.

How does primary care in a prison work?

I’m sure all prisons have their own way of working. At HMP Bristol the nursing management oversees a team of frontline nurses who staff the wings. Prisoners will attend the treatment room hatch for medication at set times of day. If they wish to discuss health issues they need to put in an application (an ‘app’) to see someone from Healthcare. Then he is triaged in the nurse’s clinic, and may be added to the GP clinic list if appropriate. I almost always have a nurse with me in the room, for security but also as a witness to the proceedings. I write even more copious notes than I would do in usual general practice, as the client group has a tendency to take advantage of even the slightest lack of clarity. If there are particular concerns about a patient’s risk to staff, a prison officer will stand outside the room.

There is a phlebotomist, a visiting hepatitis C specialist nurse, a visiting dentist, a visiting sexual health consultant and a nurse whose main role is to ensure everyone is immunised against Hep B. We are in the process of devising nurse-led chronic disease clinics.

We also have a large Mental Health team provided by the NHS (Avon and Wiltshire Partnership) for those with severe enduring mental illness, and we work closely with them.

What does a typical day involve?

I lock my phone in the boot of my car. Phones are strictly prohibited. A prisoner who gets hold of a phone will go to great lengths to hide it – I even have to be cautious in prescribing haemorrhoid ointment in case I am just providing a lubricant to allow the phone to be hidden more effectively. I put on my ID card and belt with chain, pass through the double door (like an airlock) and collect my keys from the office. Then I check in at the doctors’ office, to see if there is anything handed over, and if necessary visit the Brunel Unit. Here there might be someone newly returned from hospital, or someone newly received into the prison, with a medical condition or prescription to review. Then I go to the wing, to conduct a clinic of patients already triaged by the nurse. They will generally come to me as they might in general practice, but home visits just mean a walk down the corridor to a patient’s cell. Later, like any other GP,  I will write repeat prescriptions or referrals, look at pathology results or hospital letters, or liaise with colleagues either in the prison or in secondary care.

At any time this might be interrupted by a radio call ‘Code Blue’ (difficulty breathing eg someone found with a ligature round his neck, or someone having a fit) or ‘Code Red’ (where there is blood involved, usually through self-harm). There are big bags of equipment to grab and the healthcare staff run to whichever location the radio has announced.

On Tuesday mornings I take part in the Relapse Clinic, where, with a nurse and a specialised prison officer I see prisoners who have begun to take drugs illicitly since they’ve been in prison, having been detoxed off methadone or buprenorphine during their sentence. We try to motivate them to stop, supported by substitute medication and CARATS workers who run groups and one-to-ones on such subjects as ‘cravings and triggers’, ‘harm reduction’ etc.

The 6-8pm session serves the prisoners who have come from the court that day, and who may not get through the night comfortably due to drug or alcohol withdrawal symptoms. They are assessed and a standard small dose of methadone and/or diazepam prescribed, according to physical findings and urine drug screen. The following day their outside prescription will be confirmed, if they have one, and the dose adjusted accordingly. Chlordiazepoxide and the usual vitamins are given for alcohol detox.

Anything out of the ordinary you’d like to mention?

Self-harm is very common – as part of a personality disorder, as part of dealing with drug withdrawal or bad news, or just out of habit. Suicide is also a very real possibility, for example for someone who has just come back from court with a long sentence. Measures are put in place to support and monitor anyone who is thought to be at risk.

Early on it struck me that the structure of my day revolves around security, and not the consultation. I have to ensure to carry out patient contact within set hours, or they will all be locked away and un-contactable.

Occasionally there will be a radio announcement for a ‘Standstill roll-check’. This means that the prison has been unable to account for all its prisoners, for example as they arrive back from labour (working within the prison eg sorting rubbish for recycling, or assembling bathroom fittings etc). If this happens no one is allowed to go anywhere that involves passing through a locked gate or door until the ‘missing’ prisoners have been found. Clinic comes to an abrupt end, and if the roll-check ends after the official time of ‘lockdown’, then the clinic is not resumed.

If someone is deemed particularly of risk to others or himself he will be housed on the Segregation Unit. On occasion, for instance if he is carrying out a dirty protest and throwing faeces out of the door, I will be unable to open the door or approach the patient to examine him. I have had to diagnose rashes through an observation panel, and assess the severity of a hernia with the patient standing at the far end of the cell with his hands on his head. Thankfully such instances are rare.

On one day a month there is no patient contact at all as there is a staff training day and there are insufficient officers available to ensure security and safety.

Having worked in substance misuse before and being naturally rather paranoid and cynical, I was already used to patients being somewhat economical with the truth. You have to pay more attention to the examination and investigation and rather less to the history, than in usual General Practice. I have learnt that it is completely impossible to tell if someone is telling the truth or lying. People have looked me in the eye and told me things that I subsequently find out are definitely not true. One prisoner told me the technique is to convince yourself that it is true first, then present it to the doctor. It’s a survival technique and I don’t get cross with them, but I do feel sad that they think it’s necessary. Once, a man who had just been received into the prison collapsed unconscious. Through resuscitation he came round sufficiently for me to ask him if he had taken any opiates, or was ‘plugged’ (heroin in a packet pushed into the rectum, at risk of splitting and causing overdose) and he denied it before slipping into unconsciousness again. He came round soon after being injected with naloxone.

I have not yet been threatened with violence, though it has happened to my colleagues. More frequent is the threat that follows my declining to prescribe certain medications; either the threat to self-harm, where I remind them that that will still be their responsibility, not mine, or the threat to complain about me through their solicitor. This threat has been made many times but I haven’t received any such complaints yet.

You have to have a touch of OCD for this job; I obsessively check prescriptions because the consequences of a drug error are so large. The prescription must be completely clear to the dispensing nurses. The pharmacy team is very reliable and knowledgeable and act as a great safety net. Prisoners have been known to accept two doses of something knowing that it is a drug error – they don’t sue, they say thank you!

Do you see yourself working as a prison GP for the rest of your career, or will you return to a more traditional form of general practice?

I really enjoy the work. It combines General Practice with substance misuse and my natural ability to suspect someone’s motives! Plus I feel in some small way I am making life better for men who have found themselves in a very dark place – there is a lot of sadness, guilt and bitterness behind those walls.

 I have already made the step to return to more traditional General Practice, although since my salaried role is in a city centre practice there is a certain overlap with the client group. The pattern of my portfolio career suggests that at some stage I will be moving on, but I have no plans to just yet.

How does your waiting room differ to that of a local GP – in terms of most common complaints, treatments; What kind of patients do you typically see? What are the particular clinical challenges of being a prison GP? What do you find yourself dealing with most frequently?

The patients are all men over the age of 18, so there is no paediatrics, obs and gynae or family planning! There are some elderly patients, often sex offenders, but mainly the prisoners are 18 – 50. Their problems are asthma, chest infections, (almost everybody smokes, roll-ups) hypertension, epilepsy, diabetes, skin infections and infestations, musculoskeletal disorders and of course man flu, just like any other practice. There is a lot of mental illness, as well as insomnia, anxiety and depression. Prisoners are usually anxious whilst on remand on the run-up to their Court date, and also if they are fearful that their partner might be ‘playing away’. I also see a disproportionate amount of sequelae to trauma that was not presented to hospital when it first occurred – eg badly healed broken ankles from someone jumping off a roof whilst running from the police.

Probably the biggest clinical challenge is discerning whether a condition is genuine or not; substance misuse is always on the agenda. Very often a careful clinical examination will reveal nothing wrong at all.  Prisoners may be trying to top up their own opiates, or using medication as ‘currency’ with other prisoners. Gabapentin, pregabalin, tramadol and of course benzos, zopiclone, codeine and co-codamol are much in demand, and as a result I probably err on the side of undertreating pain.  Saying no to their request for analgesia or sleepers is rarely received quietly and has resulted in threatening behaviour, though I have never been physically attacked.

Trips out of the prison are also sought after by the patients. When referring a patient to secondary care I have to request that the patient is not informed of the date or time of the appointment, in case there are friends or family waiting to ‘spring’ him when he arrives at the hospital. This can lead to delays if the prisoner is erroneously sent his appointment by post. Another challenge is that prisoners going to hospital need to be accompanied by two prison officers. This is a drain on human resources, and often I am asked to choose between two or three prisoners who should ideally be going out on the same day. This can lead to delay in diagnosis and treatment.

A further challenge is that Bristol is a ‘local’ prison serving the local Courts, and so prisoners rarely stay here throughout the whole sentence; instead they are transferred to other prisons. Having chaotic people contained for a period is a great opportunity to manage their chronic disease optimally, but often they will not be with us long enough for continuity. In serious cases eg awaiting outpatient investigations, they can be put on ‘medical hold’ which means that they cannot be transferred out until they have had their hospital appointment. This is another privilege which some prisoners like, and so they may feign the particular symptoms they consider would warrant a ‘medical hold’.

 How do people react when you tell them what you do?

A common reaction is ‘aren’t you afraid?’ to which I say no, because generally there are plenty of trained officers around whose job is to deal with any threatening behaviour. And actually most of the prisoners are very respectful, calling me ‘Miss’ constantly and making way if I happen to walk by when they are cleaning the floor or painting the walls. I cannot think of anything that a prisoner might need to say to me in complete confidentiality without a nurse present, so I decline the request, as it is usually just someone wanting to manipulate more medication.

Probably the other main reaction is of distaste for the nature of the client group. My reply is that all of them have had immense rubbish happen to them in the past, childhood sexual abuse, for instance, or beatings from an alcoholic father, and their idea of what’s right and wrong, and their tools for dealing with the unpleasant things of life, have been confused and under-developed. There but for the grace of God go any of us. I have far more patience for the struggling heroin addict than for the patient in more traditional general practice who Googles their symptoms and shows me on their phone the investigations they want before I’ve asked the first question!

Would you recommend it to other GPs?

Yes, in that I enjoy it tremendously. But not to everyone – I think you need to have developed very good boundaries, an ability to say ‘no’ in the face of persuasion. I think experience of, or at least an interest in, patients with substance misuse problems is essential. There’s no point doing it if that is the type of patient you have no patience for!

How is your work funded? Do you operate within a practice or another structure? How do you share the practice workload?

The PCT has contracted Med-co Europe to provide the GP sessions, and Med-copay me as a self-employed locum. Bristol Community Health (our PCT) oversees Healthcare in the prison. The morning GPs share the workload, one is responsible for the substance misuse (detox and rehab) wings and the other for all the other wings. We switch every two months so we don’t either burn out or get deskilled.   In the afternoon and at weekends the one GP is responsible for everything.

Sum up being a prison GP in three words – Fair but firm

Dr Jenny Schaefer is a GP at HMP Bristol 

 

When I’m not on duty I enjoy badminton, amateur dramatics, being a pastor’s wife and spending time with my teenage sons.

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