Obstetrical and Gynecological Training in the Correctional Setting: Learning to Care for the Most Vulnerable Patients
Year: 2012
Type: article
Abstract: The United States is in the midst of a 3-decades-long epidemic, characterized by a historic rise in the number of people incarcerated. We now incarcerate a larger proportion of our citizens than any other society has at any other time in history. The driving force behind this trend is the societal attitude toward the medical diseases of addiction and mental illness.1 The “War on Drugs” policy along with the “get tough on crime” attitudes have resulted in more than 2.3 million people behind bars at this time, as well as approximately 10 million people cycling in and out of correctional settings each year.2,3 Most of the individuals behind bars are people of color for whom social challenges, limited education, and poverty are the norm, along with a crushing burden of disease.4Although prisoners are mostly men, women are not excluded from the incarceration epidemic. In fact, the rate of incarceration is increasing faster among women than it is among men.4 Moreover, the prevalence of HIV/AIDS, hepatitis B and C, other blood-borne pathogens and sexually transmitted diseases is higher among female prisoners than it is among male prisoners.5 The burden and severity of addiction likewise is higher among female prisoners.5 This latter trend may be attributable, in part, to a greater reluctance to incarcerate women, thereby selecting for those who may be most severely affected. Although many individuals avoid thinking of prisoners, because they are “out of sight, out of mind,” the fact is that more than 95% of all prisoners eventually return to society.6In this issue of the Journal of Graduate Medical Education Medicine, Sufrin and colleagues7 describe a model 6-week rotation in a local county jail for first-year residents in obstetrics and gynecology that addresses the 6 Accreditation Council for Graduate Medical Education core competencies.8 The clinical rotation was supplemented with a structured, didactic curriculum that included weekly readings discussed in clinic and placed the patient care experience in context. The residents reported that the rotation constituted a positive experience that allowed them to explore the intersection between complex psychosocial issues and health as well as the social determinants of health. The educational rotation was described as an academic and correctional partnership that benefited both organizations.For many reasons, working inside the correctional setting presents a great opportunity for training residents.9 First, prisoners harbor a high burden of disease, especially of the gynecologic variety. Second, those incarcerated feature a tremendous number of comorbid conditions, including addiction and mental illness, which make appropriate medical treatment a challenge in the best of conditions and often impossible in the typical community setting. However, incarceration often affords a respite from the distractions of addiction or the challenging behaviors of uncontrolled mental illness. In the correctional setting, a structure allows for medical intervention and follow-up. Third, incarcerated women cope with a tremendous burden of social issues, including poverty, legal troubles, family issues, and child care and custody issues, all of which can interfere with optimal medical care. As residents are exposed to these challenges, they gain a greater understanding and ability to help their patients address these issues. Fourth, the unique set of challenges that prisoners experience ideally requires a specific awareness to optimally address their needs. Residents can develop and improve this cultural sensitivity during rotations to better serve former prisoners at the point of their reentry to society. This will be especially important as a large proportion of this population becomes eligible for medical coverage through the expansion of Medicaid under the Affordable Care Act.10 Finally, there is a need for a workforce capable of, and confident in, providing care for female prisoners. Exposure during residency may lead some graduates to choose to continue to care for prisoners after the completion of their training.Having residents, medical faculty, students, and others rotate in correctional facilities can also have an effect on the correctional institution and the culture of its staff. Incarceration is a dehumanizing force, one that sets up a power structure that can lead to abuse, conflict, and degradation. However, given interactions with empathetic residents in training, the level of humanity, interpersonal interactions, and quality of care provided tend to improve for all involved (J.D.R. and J.G.C., personal observations during a combined 25 years working behind bars).The county jail rotation described by Sufrin and colleagues7 is exactly the type of program needed not only to facilitate the care of prisoners and the training of young health care workers but also to address the fundamental causes of mass incarceration. This type of program should be expanded to other geographical locations—most academic health centers have correctional facilities within a short drive—as well as to other medical disciplines and a broader range of health care providers. Other critical providers include nursing, dental, and social workers among others. These types of medical educational and care opportunities constitute a silver lining on the dark cloud of the current epidemic of mass incarceration. In addition to capitalizing on these opportunities for training, we should all work to reverse the tide of incarceration that is overwhelming the United States. Having more trained professionals who more fully understand our penal institutions can only help to solve this problem.
Language: English
Subfield: Sociology and Political Science
Field: Social Sciences
Domain: Social Sciences
Open Access status: green
OpenAlex ID: W2145172686