Moonlighting inside the big house

The seizure didn't look authentic to internist and emergency physician Moses Quiñones. For one thing, the patient picked a comfortable spot to collapse. Another tipoff: Quiñones saw the man's eyelids fluttering, and after the episode his saccadic movements weren't sluggish.

Upon getting a consult from a neurologist, who found no evidence of seizures, Quiñones took the patient off medication and denied his request for a single cell in the maximum-security prison. The patient, who had been convicted of plotting to murder his wife, a nurse, first threatened to kill Quiñones, then sued the doctor for not treating his "epilepsy."

Quiñones took the lawsuit in stride, figuring that this one would be dismissed like most of the two dozen suits he's been hit with in 14 years of treating prisoners. The death threat, he reported to the warden.

For five years Quiñones has worked in a prison one day a week, in addition to his regular job as an emergency physician. After the first month "inside," he nearly quit. "I had just given excellent care to an inmate, who proceeded to yell at me," he recalls. "I thought, I'm double-board-certified; I don't need this." An inmate who witnessed the encounter asked if he could give the doctor some advice.

The inmate explained that the patient had bet another inmate two packs of cigarettes that he could convince Quiñones he had back pain so he could get a bottom bunk—a status symbol in prison. "You're treating these guys like adults when they are really just 12-year-olds in adult bodies," said the helpful prisoner. Quiñones decided to change his approach. "I treat my 8-year-old son with a lot of respect, but I don't give him everything he wants," he says. "The same with prisoners. I give them what they need medically, not what they want, no matter how much they pout and posture."

Prisons and jails today attract a wide variety of physicians, many of whom supplement their private practices with corrections work. After 30 years in private practice, family practitioner Melvyn Genraich needed a change of pace. So he works one morning a week at a lockup for juvenile felons in Pyote, TX, making $125 an hour. "It's profitable, and a surprisingly refreshing break from the office routine," says Genraich.

Peoria, IL, oncologist Stephen Cullinan started doing consults on HIV-infected prisoners who had developed malignancies. Three weeks later, he was delivering primary care 20 hours a week in the prison. "In oncology you look at a lot of X-rays and blood smears, and the work can be rather narrow," says Cullinan. "In prison I treat asthma, diabetes, and hypertension, and I got very good at managing HIV."

Inmate pathology is "much more fascinating than anything you see in a private practice," adds orthopedist Todd Wilcox, medical director of a 2,000-inmate "super-jail" in Salt Lake City. "We had a case of leprosy recently, and a case of neurocysticercosis. We also see advanced-stage cancer in homeless people. Often jail or prison is the only place these people get medical care."

FP Catherine Clark is drawn to the multiculturalism of the inmates and the "M*A*S*H mentality" at Prince William County jail in Manassas, VA, where she works one day a week. "This jail also houses immigrants without the proper papers, so we see people from all walks of life, not just criminals," says Clark.

For some physicians, prison work means a chance to participate in cutting-edge medical technology. Emergency physician Oscar Boultinghouse is developing telemedicine capabilities that will eventually connect 80 correctional facilities in Texas, thereby reducing the expense and security risks of transporting prisoners to outside specialists. And in the Salt Lake City super-jail, "we've just implemented one of the most sophisticated electronic medical records on the market," boasts Medical Director Wilcox.

"It's true that some physicians work in prisons and jails because they can't find jobs elsewhere," says FP Roderic Gottula, past president of the Society of Correctional Physicians and former medical director of the Colorado Department of Corrections. "But the good correctional health care professionals are the cream of the crop, with skills above those in private practice."

Timely, decent pay—and no billing

Penal institutions feature another draw that usually doesn't accompany public health work: good pay. "There are 2 million inmates whose health care is paid for," says Joseph Paris, medical director of the Georgia Department of Corrections and president of the Society of Correctional Physicians. "That's nearly 1 percent of all insured patients." And unlike in private practice, physicians who treat prisoners don't have to deal with insurance companies, billing hassles, and nonpayment.

Although some jails and prisons pay a premium for primary care doctors, most are as concerned about health care costs as other segments of industry. Consider that roughly 40 percent of inmate care is managed by private firms, according to Correctional Medical Services, the largest such vendor. And those vendors are often paid on a capitated basis. Physicians then contract directly with the vendors.

Health Professionals, a firm that manages health care in 25 Midwestern correctional facilities, pays part-time physicians $60 to $120 an hour, depending on the amount of call coverage and location of the facility. "There's no overhead in a jail or prison," says internist Norman Johnson, president of the company. "What you earn, you take home. Primary care doctors who work full time in correctional facilities can earn $120,000 to $160,000 a year, plus benefits."

At prisons and jails that don't use a private health care vendor, physicians bid directly to the county or state for the job. FP Kennard McNichols, who worked two to three hours a week for 20 years at the Whatcom County Jail in Bellingham, WA, negotiated his hourly rate and employment terms. "Since there's a shortage of physicians willing to do this type of work, you can bargain to determine your pay and hours," he says. "For example, I told the jail that I was only willing to take call during the time I was in my office, which was more expensive for the jail, but an important boundary for me. The work can be financially rewarding if you negotiate well."

While prison medical practice brings freedom from billing and dealing with families, there's no escape from paperwork and utilization review. "We're capitated, so we function like the biggest HMO in Texas," says Medical Director William E. Gonzalez of Texas Tech in Lubbock. (In Texas, two medical schools provide most of the correctional health care in the state.) "We have the same rules as HMOs, such as formularies and prior-approval for referrals.

Family practitioner Melvyn Genraich finds the limited formulary frustrating when he's prescribing drugs for the juvenile felons he treats in Texas. "We have some wonderful drugs to treat acne, but they're expensive," he explains. "So I have to stick to the old-line drugs that aren't as effective." Genraich doesn't find the paperwork and charting onerous, but he says the pace is "pretty intense. I see about 30 kids in a morning."

The frequent presence of the nursing supervisor when Catherine Clark sees patients at the Prince William County jail reminds the doctor of the need to contain costs. "All it takes is one extra HIV patient per month to throw off the budget," says Clark. "I've had to stand my ground to practice good medicine."

Some limits on behind-bars medical care have nothing to do with budgets. As a prison doctor, Quiñones routinely denies patient requests for, say, foam mattresses, which can be burned to create a smokescreen. An inmate can use A&D ointment to lubricate himself and his cell floor to evade the clutches of corrections officers. A brace can be made into a knife. And complaints of foot problems are often little more than bids to get brandname shoes. "In prison, shoes are like cars," explains Quiñones. "If you get special shoes from the doctor, it's as if you're driving a Mercedes." Quiñones has had an easier time parrying footwear requests since he began wearing his own prison-issue shoes to work.

Quiñones' most satisfying moments as a prison physician come when inmates accept his concern as genuine. "These patients are at a crossroads in their lives, and I feel I can help them make better choices," he says. "That's meaningful to me."

Yes, it's a little scary

Quiñones once received 10 stitches in his forehead after he was struck by an intoxicated prisoner who had concocted his own liquor from fruit juice and sugar. The prisoner was angry that he had to be isolated because he was showing signs of active TB. He then sued Quiñones, alleging that the doctor—despite lying unconscious in a pool of blood—had etched a swastika in his back.

For internist Grant Deger, who treats inmates at Whatcom County Jail, the most pulse-quickening part of his day is walking into the jail and having numerous doors clank shut behind him. "People will be screaming in their cells or vomiting as they withdraw from drugs," he says. "It feels like you're walking through Dante's Inferno."

That aside, personal safety isn't much of a worry, insist the physicians who work in correctional facilities. "You always have a guard standing over your shoulder," says emergency physician Andrew Reese of Creative Health Resources, a company that manages inmate health care in nine Virginia jails. "I feel much safer in a jail than in an emergency room, where people come in on drugs and alcohol, and they can be violent. In jail they're sober."

More threatening than bodily harm are the lawsuits. "One prisoner quietly laid down his attorney's card next to me before I treated him," says FP Catherine Clark. "I'm always afraid of lawsuits." Prisoners generally don't sue for medical malpractice. "The rate of medical malpractice in prisons is far below anything outside," says Joseph Paris of the Georgia Department of Corrections. "We have one or two malpractice suits a year for 43,000 inmates."

Inmates do, however, frequently sue physicians for violating their civil rights by denying care. The lawsuits are easy to file, but most eventually are dismissed. "The standard for these lawsuits is deliberate indifference," explains Reese. "To win a suit for violating a prisoner's right to medical care, the inmate must prove that the doctor intentionally did nothing to try to help him." It's a much more difficult burden of proof than demonstrating that the doctor violated the community standard of care in a malpractice action. Most prisons indemnify physicians if they're sued in a civil rights action.

Like many health care facilities on the outside, "some institutions try to get away with not having licensed nurses because it saves money," says Wilcox. "You have to make sure that the nurses aren't providing inappropriate care under your name. It's similar to working at a substandard hospital."

But the most important piece of advice, say prison doctors, is to treat an inmate as you would any patient. "You have to accept humanity as it comes," says Deger. "I shake inmates' hands, welcome them to sit down, and listen to them. My attitude is that jail is their punishment, not bad health care. I do my best to help them, and I'm glad to do it."