Qualitative exploration of the medical learner\u2019s journey into correctional health care at an academic medical center and its implications for medical education

Ahmar H Hashmi,Nadeem N Tajuddin,Alina M Bennett,Jason E Glenn,Rebecca J Hester

doi:10.1007/s10459-020-09997-4

Abstract

Correctional systems in several U.S. states have entered into partnerships with academic medical centers (AMCs) to provide healthcare for persons who are incarcerated. One AMC specializing in the care of incarcerated patients is the University of Texas Medical Branch at Galveston (UTMB), which hosts the only dedicated prison hospital in the U.S. and supplies 80% of the medical care for the entire Texas Department of Criminal Justice (TDCJ). Nearly all medical students and residents at UTMB take part in the care of the incarcerated. This research, through qualitative exploration using focus group discussions, sets out to characterize the correctional care learning environment medical trainees enter. Participants outlined an institutional culture of low prioritization and neglect that dominated the learning environment in the prison hospital, resulting in treatment of the incarcerated as second-class patients. Medical learners pointed to delays in care, both within the prison hospital and within the TDCJ system, where diagnostic, laboratory, and medical procedures were delivered to incarcerated patients at a lower priority compared to free-world patients. Medical learners elaborated further on ethical issues that included the moral judgment of those who are incarcerated, bias in clinical decision making, and concerns for patient autonomy. Medical learners were left to grapple with complex challenges like the problem of dual loyalties without opportunities to critically reflect upon what they experienced. This study finds that, without specific vulnerable populations training for both trainees and correctional care faculty to address these institutional dynamics, AMCs risk replicating a system of exploitation and neglect of incarcerated patients and thereby exacerbating health inequities.

Highlights

There are a handful of different models for delivering secondary and tertiary healthcare to incarcerated populations (US Department of Justice & National Institute of Corrections 2001), with most correctional healthcare delivered via contracts with private, for-profit companies
In addition to these reasons for academic medical centers (AMCs) involvement in the provision of correctional health care, proponents of academiccorrectional health partnerships claim that correctional care environments provide fertile training grounds for medical graduates and undergraduates
This study documents the lived experience of medical learners in a correctional care environment

Summary

Introduction

Private correctional healthcare companies lack public accountability and governmental oversight and their primary fiduciary responsibility is to shareholders and profit margins, not to the patients (Andrews 2017). AMCs have justified their involvement in correctional care as being uniquely placed to improve population health and address health disparities among those incarcerated (Baillargeon et al 2000, 2004; Bick 2007; Raimer et al 2010). In addition to these reasons for AMC involvement in the provision of correctional health care, proponents of academiccorrectional health partnerships claim that correctional care environments provide fertile training grounds for medical graduates and undergraduates. A 2012 review found 22 U.S academic medical programs that provided highly variable levels of correctional health exposure to medical students and/or residents, ranging from brief rotations to clinical fellowships in correctional health—with little to no mention of ethics or vulnerable populations training included as part of an academic program’s correctional health curriculum (Min et al 2012)

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