Jail Anatomy

[clement]

I’m very uninformed about jail work. I decided to tour one (ok, a really big one) where to this day I still don’t understand what psychiatrists roles are akin to in the various units (apart from the inpatient). Has anyone encountered something like an, “inmate reception center?” I have the impression it’s a medical/psychiatric triage. …What are “typical” jail units and what are psychiatrists’ roles akin to in them (ie similar to inpatient vs outpatient vs er vs consult)?
How do those with very young families handle no cell phones, pat down, and potential lockdown threats? In the one I visited, some snuck phones in and used them in the bathroom.

---

Members don't see this ad.

 

[ObsequiousAplomb]

Reception centers are just what they sound like. People get processed through. Instead of a hospital, think of it more like the military. People come in and are processed through various jails (similar to training camps) en route to their final destination (first billet).

People may be at one prison for the first month before it's decided whether they need the rest of their year / sentence in general population, a medical block, a psychiatric block, etc. people may be sent to a different block at the same prison. They may be sent to several different prisons along the way.

Jails are even higher turnover and throughput because people don't stay in them as long as prisons.

A psychiatrist's role is almost always outpatient level in corrections, just by virtue of the populations. In rare circumstances, there are entire cell blocks or even facilities that are more like state hospital level of care.

 

[clement]

So this is a jail that feels more like state hospital or prison system…with its own inpatient unit, several housing units separately by moderate to severe degrees of illness, a “walk in” clinic, a “psych icu” for those who get severely acute symptomatic (a bit of a respite unit), and an inmate reception area.

As I have little experience with incarcerated populations (save for in ER settings) and am a bit removed from the world of continuous management of SMI.. I figured the reception area was most suitable/straightforward as the role is to essentially triage inmates to one of the other units, get them started on meds if indicated, collaborate with the med clearance process, etc. It was likened to a psych er by my “tour guide.” Main downside is I think 1 psychiatrist on per shift.

However a friend who used to work jails (albeit managed by a toxic private third party company) says the reception area is “the highest liability…” seemingly attributing this to the medical clearance process. Note that this jail actually has a whole barrage of internists including in reception for med clearance and is self insured/overseen by a public sector entity.
The only downside is, I think 1 psychiatrist there at a time. Thoughts?

 

[ObsequiousAplomb]

Your friend is right.

Which has the most burnout:
1. input processing various acuities and seeing EVERYONE for a short time period (the time period where they are least likely to be medicated and most likely to have new people coming in)
2. Cell block of 30 inmates, all so sick that they will be there for the next 20 years no matter what they get treated with?

If you do the processing roles, it's like ER psych, but exclusively this population. The other roles are like state hospitals. Low census, low inertia census.

 

[clement]

Your friend is right.

Which has the most burnout:
1. input processing various acuities and seeing EVERYONE for a short time period (the time period where they are least likely to be medicated and most likely to have new people coming in)
2. Cell block of 30 inmates, all so sick that they will be there for the next 20 years no matter what they get treated with?

If you do the processing roles, it's like ER psych, but exclusively this population. The other roles are like state hospitals. Low census, low inertia census.

Understood re burnout, but liability? Some/many jails are lawsuits ripe for the picking. More so those managed by 3rd party for private profit companies? If it’s a self insured govt entity (ie sue the county or state, not the doctor), does that really help? Technically they can name the doctor but gov entity tries to get the doctor off the case… leveraging the reality that a county/state has more money.

 

[whopper]

There's some very conflicting dynamics with liability.

Malpractice is based on a geographic standard of care treatment. Things in the middle of a rural area are lower quality care vs in the middle of NYC. So the possibly literal million dollar question is does the jail have a differing standard of care? Is it's geographic standard like Vatican City where it is it's own thing? I've never seen anyone answer the question.

Then add to this treatment in a jail is often times poor despite the best efforts of the psychiatrist. Even if you try to do a good job, you might not be able to do so based on various constraints often times outside your power. E.g. the jail may have a limited formulary, what if the PCP in the jail is a piece of crap and you know that PCP isn't doing jack and you can see problems that other doc isn't treating, but it's outside your own speciality, often times complete lack of knowledge regarding the patient's prior history, and there's no easy access to the outside world, plus the social worker who could bridge that gap could suck eggs.

So who's liable? Usually the state covers you, but I've seen cases where the state government told the doc they're covered, but with the first lawsuit pretty much told the doctor they woudn't cover, "you're on your own," and when the doctor protested, the response was "so okay sue us, and you'll win in court 10 years later. We're the state so we can delay the lawsuit for your entire career. You'll end up doing what most do. You'll suck it up, pay for it yourself, and move on cause it'll be a second full-time job fighting us for 10 years."

Did the above really happen? Happened to a friend of mine. The people in the state then asked me to take over his job when he decided to leave that toxic job. I said no. I was already planning on leaving the place, but that event just reinforced this was the correct decision.

From my own experience most jail psychiatrists are horrendous. Of course there are exceptions. Some are forensic professors who've incorporated the jail into their department's program, but this is rare. Then there's these for-profit organizations where the top doctor puts naive doctors into the role of working in piece of crap facilities, where the facility is willing to pay $400,000+/year, but this scumbag (or genius depending on how you look at it) pays this naive doctor $200K/year and takes in the rest into his own pocket where he pretty much just puts in about 2-3 hours a week into that job, making the naive doctor do a lot of hard work. I can name you organizations that operate this, but not on the forum for obvious reasons. I know of an organization that has several doctors working in that organization, and the head doc takes in a very unfair fraction, while these docs have no idea that this guy is raking in millions while they work their tail off.

 

[clement]

There's some very conflicting dynamics with liability.

Malpractice is based on a geographic standard of care treatment. Things in the middle of a rural area are lower quality care vs in the middle of NYC. So the possibly literal million dollar question is does the jail have a differing standard of care? Is it's geographic standard like Vatican City where it is it's own thing? I've never seen anyone answer the question.

Then add to this treatment in a jail is often times poor despite the best efforts of the psychiatrist. Even if you try to do a good job, you might not be able to do so based on various constraints often times outside your power. E.g. the jail may have a limited formulary, what if the PCP in the jail is a piece of crap and you know that PCP isn't doing jack and you can see problems that other doc isn't treating, but it's outside your own speciality, often times complete lack of knowledge regarding the patient's prior history, and there's no easy access to the outside world, plus the social worker who could bridge that gap could suck eggs.

So who's liable? Usually the state covers you, but I've seen cases where the state government told the doc they're covered, but with the first lawsuit pretty much told the doctor they woudn't cover, "you're on your own," and when the doctor protested, the response was "so okay sue us, and you'll win in court 10 years later. We're the state so we can delay the lawsuit for your entire career. You'll end up doing what most do. You'll suck it up, pay for it yourself, and move on cause it'll be a second full-time job fighting us for 10 years."

Did the above really happen? Happened to a friend of mine. The people in the state then asked me to take over his job when he decided to leave that toxic job. I said no. I was already planning on leaving the place, but that event just reinforced this was the correct decision.

From my own experience most jail psychiatrists are horrendous. Of course there are exceptions. Some are forensic professors who've incorporated the jail into their department's program, but this is rare. Then there's these for-profit organizations where the top doctor puts naive doctors into the role of working in piece of crap facilities, where the facility is willing to pay $400,000+/year, but this scumbag (or genius depending on how you look at it) pays this naive doctor $200K/year and takes in the rest into his own pocket where he pretty much just puts in about 2-3 hours a week into that job, making the naive doctor do a lot of hard work. I can name you organizations that operate this, but not on the forum for obvious reasons. I know of an organization that has several doctors working in that organization, and the head doc takes in a very unfair fraction, while these docs have no idea that this guy is raking in millions while they work their tail off.

A very, very pertinent point about public sector entities leveraging the fact that a) many attorneys won’t even touch cases involving a public entity, b) these cases take forever and a day while sucking juror tax dollars, c) courts favoring protection of a public entity’s sovereignty.

To your point about cruddy jail docs (in line with their “alcoholic locums cohorts?” This according to a locums company I once worked for)…The jail I’m looking at seems to attract diehard SMI and geeked out neuroscience academic defectors of the MD PhD variety along with some forensic academic stock. My issue is I don’t geek out on SMI or neuroscience in that context and most of my relevant experience is of the ER variety (making the jail reception area tempting).

So this is a public sector gig with no third party for profit running it. However…Verry interestingly, the bad press they’ve gotten about poor conditions (thanks, CNN) created handsome pay differentials in a post mass shrink exodus era…and… a strong urge to prevent any further bad press (they will settle cases with physician jail employees-even though this public sector employer almost never settles employment matters for $). Frankly my biggest gripe is having very young children and not being able to bring a cell phone in, pat down rumors, and the supposedly rare risk of lockdown.

 

[ObsequiousAplomb]

Well, aside from going virtual, there's no way to avoid going through jail security twice a day. Unless you're willing to smuggle contraband into a correctional setting, your children won't be able to reach you during the day.

As a psychiatrist who has turned down correctional roles and whose father worked in correctional psychiatry for 30 years, I can say that if these things sorry you then I recommend you find a different job that doesn't have those drawbacks. The pay isn't worth it unless you're desperate for the money or are drawn to the population for other reasons.

 

[clement]

Well, aside from going virtual, there's no way to avoid going through jail security twice a day. Unless you're willing to smuggle contraband into a correctional setting, your children won't be able to reach you during the day.

As a psychiatrist who has turned down correctional roles and whose father worked in correctional psychiatry for 30 years, I can say that if these things sorry you then I recommend you find a different job that doesn't have those drawbacks. The pay isn't worth it unless you're desperate for the money or are drawn to the population for other reasons.

Well…On the tour they did point out the one bathroom that’s frequently occupied…That or exit the building at lunch and breaks, if you can actually take them. Supervising psychiatrists get to keep their phones at least. And if one is really desperate, the kids can have a jail landline or supervisor’s number.

All of this said, rumor has it that the work is “easy” compared to a county outpatient clinic. I did meet a psychiatrist working the reception area for 30 years FWW. Whether that speaks to burnout or undesirable conditions…A common rumor I hear about corrections is that female physicians are subject to jail chivalry culture but that male physicians get their eyes gauged out or jaws cracked.

 

[PsyDr]

Jail: Where the cops take you after arrest, but before you’re convicted. If you are sentenced for less than a year, you serve out your time in jail. The jailers handle suicide threats…very slowly. The formulary is highly restricted, because people will do anything to get high (e.g., snorting bupropion, crushing remeron and mixing with koolaid for an analog of “lean”). People will malinger in hilarious ways, including telling people they are intellectually disabled. Some of the violence is incredibly horrific. Lots of maintenance for established diagnoses.

Prison: where you go after you’re convicted. Limited formulary. Guards handle suicidal threats. Prisons can have therapists, but not always. Some places reportedly make providers train with a weapon.

The smell sticks to you, because the building is much more sealed and cleaned than a hospital.

They will freak out about you having normal things like a dollar bill, pen, or metal buttons on your blazer.

In extremely secure locations, I’ve had pat downs that are almost more invasive than a physical exam.

 

[annoyedpsychiatrist]

When I did prison psychiatry for the outpatient clinic, standard of care was so low it was amazing. It was all paper charts, and I could never read what the last note said half the time, or it was confusing to understand, or it just had no information basically. They have limited medicaitons. Some people are actually pretty nice and fairly reasonable. What makes it easier is that you dont give out stimulants and benzos. Everyone asks for cogentin/benadryl/seroquel. Then the people giving the meds didnt always document administration so you have no idea who actually got the meds. Eventually the prison fired the attendings and replaced with telehealth midlevels.

The no show rate was really high, which is funny, because they are forced to be there. People would just not come and refuse to leave their cell, so like 20-30% no show rate at least.

I would never work in a male prison again just because some of the people scared the hell out of me. Working at a female prison I would be somewhat less anxious about, due to less risk of violence, although im sure still some scary people there.

 

[comp1]

Correctional psychiatry was such a mixed bag for me. I only did it in residency, but I could see the challenges and the benefits. The pay is very good, but your own autonomy is sooo limited. It wasn't the formulary. There isn't good evidence for most newer drugs being superior. I just really felt like I was a consultant to the guards/deputies and they would follow my recs or not. I REALLY didn't like the entry and exit processes which lead to almost a 20 minute increase in my "commute" both ways. You also couldn't have your cell phone. This was jail, so the people were very sick. They were also just now becoming aware of major horrible life changes, so they were absolutely massive suicide risks. We had people literally throw themselves from a second floor onto a cement floor. Pretty much all staff including residents were subpoenaed regularly to testify. It wasn't usually malpractice, but instead as fact (unpaid) witnesses to behavior in the jail. However, for an educational service, the personality, mood and psychotic disorders were extremely frank. There was never subtlety or a lack of clarity. It was an excellent place to do a psychiatry clerkship or residency rotation. I just can't quite imagine it as a career.

 

[clement]

When I did prison psychiatry for the outpatient clinic, standard of care was so low it was amazing. It was all paper charts, and I could never read what the last note said half the time, or it was confusing to understand, or it just had no information basically. They have limited medicaitons. Some people are actually pretty nice and fairly reasonable. What makes it easier is that you dont give out stimulants and benzos. Everyone asks for cogentin/benadryl/seroquel. Then the people giving the meds didnt always document administration so you have no idea who actually got the meds. Eventually the prison fired the attendings and replaced with telehealth midlevels.

The no show rate was really high, which is funny, because they are forced to be there. People would just not come and refuse to leave their cell, so like 20-30% no show rate at least.

I would never work in a male prison again just because some of the people scared the hell out of me. Working at a female prison I would be somewhat less anxious about, due to less risk of violence, although im sure still some scary people there.

When I was a pgy3 I toured a prison and one of their “selling points” was not having to “deal with female prisoners.” With that, was the the implication of hormones, hysteria, self injury, violence. As though testosterone and aspd alone are attracting points in male prisons assuming cisgender inmates etc.

 

[ObsequiousAplomb]

When I was a pgy3 I toured a prison and one of their “selling points” was not having to “deal with female prisoners.” With that, was the the implication of hormones, hysteria, self injury, violence. As though testosterone and aspd alone are attracting points in male prisons assuming cisgender inmates etc.

having worked in both settings, I would prefer the male inmates.

 

[annoyedpsychiatrist]

interesting perspectives, I would be more worried about getting assaulted from the male ones

 

[comp1]

Sure, it's possible to get assaulted, but I think it's a lot more likely you will be in a general inpatient psych unit or particularly a state mental hospital than a prison or jail. (And for all settings, it's a heck of a lot more likely the nurse will be than you will be.) Correctional settings as opposed to therapeutic settings, tend to have easier and more readily accessible containment if you're even seeing patients outside of their cells.

 

[jbomba]

Ill say this given I do jail work. All of my colleagues are pretty top notch people. One is forensically fellowship trained, the others have many years experience and appear very competent. They write good, detailed notes. The formulary is large - its the same formulary one might see in the average community psychiatric hospital. The PCPs also seem caring, they communicate well, we often bounce questions off each other. The jail psychiatrists have monthly case conferences where we discuss cases and/or issues in care. It feels academic at times. Perhaps this is an anomaly, but the jail I am does not at all seem like its filled with bad doctors and horrific conditions. Hell, even the police officers who staff the jail are generally professional, courteous, and have a good working relationship with the doctors. I have no complaints. It also pays obscenely well which helps.

 

[whopper]

So this is a public sector gig with no third party for profit running it. However…Verry interestingly, the bad press they’ve gotten about poor conditions (thanks, CNN) created handsome pay differentials in a post mass shrink exodus era…and… a strong urge to prevent any further bad press (they will settle cases with physician jail employees-even though this public sector employer almost never settles employment matters for $). Frankly my biggest gripe is having very young children and not being able to bring a cell phone in, pat down rumors, and the supposedly rare risk of lockdown.

If there's no 3rd party in between you and direct pay I'd worry about liability coverage-real liability coverage. Will they really protect you when the crap hits the fan? If they will, you actually like working at the jail, and it pays well, then I'd work at the jail.

A lot of factors depend on the locality. In Cincinnati, the mental health coverage in the jail was quite good, there was a closeby forensic psych hospital, there were local hospitals that took inmates in if they were physically ill. Those where competency for trial was in question were seen within hours to only days.

Compared to St. Louis, the coverage was bad, the closeby forensic facility didn't see the defendants for possibly months, those whose comptency were in question weren't seen for at least 6 months while they sat unmedicated jail while refusing meds for severe mental illness.

 

[Indiana_Jane]

having worked in both settings, I would prefer the male inmates.

Same.

 

[clement]

If there's no 3rd party in between you and direct pay I'd worry about liability coverage-real liability coverage. Will they really protect you when the crap hits the fan? If they will, you actually like working at the jail, and it pays well, then I'd work at the jail.

A lot of factors depend on the locality. In Cincinnati, the mental health coverage in the jail was quite good, there was a closeby forensic psych hospital, there were local hospitals that took inmates in if they were physically ill. Those where competency for trial was in question were seen within hours to only days.

Compared to St. Louis, the coverage was bad, the closeby forensic facility didn't see the defendants for possibly months, those whose comptency were in question weren't seen for at least 6 months while they sat unmedicated jail while refusing meds for severe mental illness.

No third party. The county runs the jail and it is a behemoth of a jail. Possibly the mother of all jails. Feels like a state hospital but is not. For all I know, it’s a self insured county offering occurrence based coverage and according to their physician union.. the county negotiates to get doctors removed off the case if they are named. It’s an immensely largely funded public entity- which I assume makes such a proposition appealing to the party that’s suing. Can’t get much out of the scrappy doctor with a $1/2M in student loans.