Consults to jail/forensics

[nexus73]

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I am starting to put effort into building up more forensic work outside my main job and called the local public defenders office. They were happy to receive my CV and will keep me in mind for forensic evals in the future.

But they also said they really need help on occasion with defendants in jail who seem clearly psychotic and need meds, but the jail medical service is not great, or doesn't seem to know what they're doing, so the defendants just sit and wait, in decompensated psychosis, and would I be able and willing to see those defendants if needed. I would only consider this if my fees were paid by the public defenders office, and would likely charge closer to forensic rates than clinic rates.

I am considering whether this is even feasible to do from a private practice, going into the jail to provide treatment without a contract directly with the jail. If possible, I think setting the boundary of it being a one-time consult, or initial visit and one follow up consult, may help make it clear the jail medical team remains the primary provider and I am not taking over ongoing psychiatric management. If jail medical staff (likely a nurse practitioner) requested a consult, I could evaluate the individual and give treatment recommendations, they would then implement perhaps the setup could work.

I know that once I enter the role of treating doctor, I would not be able to consult in a forensic role for the individual.

Does this seem feasible, or any pitfalls, reasons to absolutely not consider something like this?

 

[splik]

you could do this as a forensic consultation, usually the courts rather than the public defender's office pays. You basically do the evaluation and make recommendations but do not take on a treatment role. Since you aren't contracted with the jail to provide services you couldn't take on a treatment role. Usually they are asking for a diagnostic evaluation, risk assessment, and treatment recommendations. That can sometimes be helpful for mitigation and diversion as well.

being an expert for a public defender's office is usually not very lucrative by the way. The fees are low and there's usually a cap on hours so you don't necessarily get paid for all the hours you do. They usually expect you to do this work at discounted rate, not your full fee (in fact you may be asked to provide your full fee and the discounted rate for which you will be paid). Only high profile cases are usually paid well with a larger number of hours approved. Those cases usually go to more seasoned forensic psychiatrists, sometimes of national renown.

 

[romanticscience]

I contracted with my state to do criminal evals to get forensic experience. As splik mentioned it's usually the less favorable type of work in terms of pay. The rate I'm paid is more than 50% less than my private forensic rate. I do the work because I find it interesting, allows me to be exposed to severe mental illness (in private practice this pathology almost is never encountered), and further's my network. Once, at an AAPL conference, a senior forensic said many get their names out there by working with public defenders. Those PDs go into private practice and "remember" you. I haven't really experienced this yet.

I'm ambivalent about dropping the contract, however, another plus is that it gives me non-patient work (record review and report writing) which allows me to fill in gaps in my private practice schedule (e.g., no-shows or lighter days).

In my state, these evaluations are done through our department of health--office of mental health and substance use. You may be able to get on some type of panel.

 

[whopper]

I'd consider this dangerous liability territory. The problem is this. Jails and prisons are state-owned. So if they get sued the state ultimately pays including things like the rulings against the jail. If you provide treatment outside of contract you are now held liable to standards in the community and without the protection a state-worker would receive.

Treatment in jails and prisons are, for the most part, terrible. So you are now likely going into territory that is lower than standard of care. Someone could argue that because you're in the jail they're the "community" standard and not the outside community but the point is the same. You are now not covered by the state. I would also factor in that as an outside the institution may even try to strategically target you to take the fall for one of it's many very badly handled cases.

 

[PsyDr]

I am aware of this type of practice in high profile criminal cases. The pitfall is always going to be liability. So long as you are tied to the defense team, you have some protection (i.e., the legal team is not going to sue their own agent). Due to their extended nature, appellate cases have better protection.

 

[whopper]

At the jail I worked there was a duration where within a few months several inmates died.

Inmate deaths will be reviewed by auditors, St. Louis County jail director assures advisory board

Preliminary report by CGL Companies finds organizational and communications issues at the Clayton jail.

www.stltoday.com

I was not there when this happened although I'm not surprised at all.

Now imagine doing some work at the jail, providing care, as a non-state employee. Imagine several inmates dying and their deaths had nothing to do with you. Any lawyer will think, "who's connected to this case at all, I MEAN AT ALL, that's not under the state protection for liability?

AHA Dr. Nexus! Shift all blame to this doctor.

Yes! A way out!

But Dr. Nexus is innocent? Oh yeah great. 3 weeks of court, 6 figures of legal work, 5 figures of lost work to prove you were not guilty, yeah! Great for you. I'm so glad you helped out your jail. I'm going to give you a button that says "good person." (Pardon the sarcasm but the lawyer protecting his own people will not give 2 $hits about you).

 

[nexus73]

At the jail I worked there was a duration where within a few months several inmates died.

Inmate deaths will be reviewed by auditors, St. Louis County jail director assures advisory board

Preliminary report by CGL Companies finds organizational and communications issues at the Clayton jail.

www.stltoday.com

I was not there when this happened although I'm not surprised at all.

Now imagine doing some work at the jail, providing care, as a non-state employee. Imagine several inmates dying and their deaths had nothing to do with you. Any lawyer will think, "who's connected to this case at all, I MEAN AT ALL, that's not under the state protection for liability?

AHA Dr. Nexus! Shift all blame to this doctor.

Yes! A way out!

But Dr. Nexus is innocent? Oh yeah great. 3 weeks of court, 6 figures of legal work, 5 figures of lost work to prove you were not guilty, yeah! Great for you. I'm so glad you helped out your jail. I'm going to give you a button that says "good person." (Pardon the sarcasm but the lawyer protecting his own people will not give 2 $hits about you).

It does seem like working for the jail directly is better from a liability standpoint and clear boundaries on doctor-patient relationship. But they have no money which is why they have an np running the medical service, and psychotic people are left to rot waiting for restoration services.

 

[Bartelby]

It's sad the jail is so poorly staffed. Still, what you describe sounds like something I would likely not take. Things to consider:

-Will the jail even allow you to come in and see patients?
-Will the pharmacy fill and dispense your orders?
-As above, no guard against liability.
-How long will it take to drive to the jail, clear security, get brought back to a professional visiting room, get the patient brought back from the pod, and then have the guards collect the patient and escort you out? If seeing only a couple patients it would be hard to make it worth it economically.
-You will need to rely on jail staff to carry out your plan. Can you cultivate good working relationships with them, and will they be competent?

Lots to consider. It's hard to see this working out in a way that is very beneficial to you, though it could be a good public service if you are willing to take on the risk and hassle.

 

[comp1]

I'm one of the least likely to scream liability about every possible interaction. You can always be sued for anything at any time. HOWEVER, this situation is...pretty crazy. Everyone in jail is by definition involved with litigation and also statistically at extremely high risk for things like suicide or other violence. The fact that the public defenders would ask for this is definitely an indictment of our correctional healthcare system, but you personally are not the way to address that. This has to be handled at a systems level. Please say no.

 

[whopper]

It does seem like working for the jail directly is better from a liability standpoint and clear boundaries on doctor-patient relationship. But they have no money which is why they have an np running the medical service, and psychotic people are left to rot waiting for restoration services.

Like
Agree and inmates do deserve better care so I salute anyone wanting to help this situation. Just that I don't want you sacrificed on the altar. As Comp1 wrote-it's a systems problem. For the record, I spent a few hundred hours trying to fix the situation where I was a jail doctor, but each person above me basically in short told me they didn't give a damn. Due to this being a systems problem it needed system's level improvements. E.g. we had psychotic people needing competency evaluations, and the current system had them waiting about 10 months for such an evaluation. I told my university and the county 'd be willing to work extra for free to help make such a system and I was blown off repeatedly even by the university. I've ranted why I left my last job and when I was told by the academic institution, not the jail, "why do you care about these people, they're inmates" that too was a signal I ought to leave that place.

The entire reason why I was willing to make less money was out of a belief that working in academia was a higher calling and the higher calling institution was basically telling me they don't give a damn while also telling me they enjoyed the large sum of money I was bringing in and not letting me get a cut of that money.

 

[nexus73]

you could do this as a forensic consultation, usually the courts rather than the public defender's office pays. You basically do the evaluation and make recommendations but do not take on a treatment role. Since you aren't contracted with the jail to provide services you couldn't take on a treatment role. Usually they are asking for a diagnostic evaluation, risk assessment, and treatment recommendations. That can sometimes be helpful for mitigation and diversion as well.

being an expert for a public defender's office is usually not very lucrative by the way. The fees are low and there's usually a cap on hours so you don't necessarily get paid for all the hours you do. They usually expect you to do this work at discounted rate, not your full fee (in fact you may be asked to provide your full fee and the discounted rate for which you will be paid). Only high profile cases are usually paid well with a larger number of hours approved. Those cases usually go to more seasoned forensic psychiatrists, sometimes of national renown.

Since I won't be hiring on at the jail, the bolded section looks like the only reasonable approach, if anything is to be done at all. Would this require the PD to ask the court to pay for an evaluation with treatment recommendations?

thanks for everyone's thoughts

 

[Candidate2017]

I am starting to put effort into building up more forensic work outside my main job and called the local public defenders office. They were happy to receive my CV and will keep me in mind for forensic evals in the future.

But they also said they really need help on occasion with defendants in jail who seem clearly psychotic and need meds, but the jail medical service is not great, or doesn't seem to know what they're doing, so the defendants just sit and wait, in decompensated psychosis, and would I be able and willing to see those defendants if needed. I would only consider this if my fees were paid by the public defenders office, and would likely charge closer to forensic rates than clinic rates.

The road to hell is paved with good intentions. There seems to be some confusion on the public defender's part. The defender's office and jail are two separate entities. A public defender should not ask a psychiatrist retained for forensics/legal purposes to treat their CLIENT as a PATIENT.
The public defender's job is to provide legal representation to their CLIENT, including obtaining a forensics eval if needed. The jail's job is to provide custodial care, including obtaining Constitutionally obligated PATIENT care if needed, in theory. Two separate entities. One has a legal role, the other has a medical role. The psychiatrist can't serve both roles.

If the public defender is upset about the sorry state of jail care, the defender should be arguing for the client's release so they can be properly treated, rather than using the forensics doctor as an ad hoc treating physician.

These issues are separate from the fact that jails suck at providing care, if you were interested performing the medical role and working for the jail rather than the public defender. In reality, RNs are lazy, formularies are limited, labs are whenever, discharge plan is whatever, guards could care less about your plan and can refuse your requests including bringing the patient to your appointment.

 

[whopper]

There's an institution. It's mismanaged. As a result people are suffering. Is it your responsibility to fix that institution? Isn't it their own responsibility?

e.g. say Amazon isn't giving their employees enough pay. Is it your responsibility then to tip Amazon workers more while Amazon is profiting heavily? So what if you decided to insert yourself and give Amazon workers some of your money? Oh yeah I'm sure Amazon will love it. They don't have to take responsibility.

IMHO the best solution is a systems-fix. That doesn't mean you turn a blind eye. That does mean that you vote, inform the public, contact people in the state to encourage better healthcare for inmates. Work with the APA to fix this issue. Will that likely lead to an improvement? No. But seriously the root problem here is the system, not your lack of good intentions, and if you try to help by offering treatment you're putting yourself in extreme risk.

 

[Bartelby]

There's an institution. It's mismanaged. As a result people are suffering. Is it your responsibility to fix that institution? Isn't it their own responsibility?

e.g. say Amazon isn't giving their employees enough pay. Is it your responsibility then to tip Amazon workers more while Amazon is profiting heavily? So what if you decided to insert yourself and give Amazon workers some of your money? Oh yeah I'm sure Amazon will love it. They don't have to take responsibility.

IMHO the best solution is a systems-fix. That doesn't mean you turn a blind eye. That does mean that you vote, inform the public, contact people in the state to encourage better healthcare for inmates. Work with the APA to fix this issue. Will that likely lead to an improvement? No. But seriously the root problem here is the system, not your lack of good intentions, and if you try to help by offering treatment you're putting yourself in extreme risk.

Excellent point. After having held a leadership role myself I couldn't agree more. It's easy to let others (or yourself) guilt you into owning a problem that goes way beyond you.