Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then respectively inform them of your opinion. For some reason, I’ve gotten the impression that clinicians are more likely to be dishonest with inmates than with other patients. I don’t know why. Whatever you do, never lie to an inmate.

4. Maintain appropriate boundaries. While you may briefly mention something about your family or personal life to your long-term patients (depending on your specialty), never do so with offenders. Stick to the task at hand, and don’t answer personal questions. You want a professional, not a personal, relationship with them.

5. Avoid the defensive medicine temptation. Inmates sue doctors at a higher rate than does the rest of the population. Understandably, some physicians will believe they must practice more defensively to protect themselves. Despite such fears, do not order more tests, procedures, or medications for the incarcerated than you would order for other patients. Thorough documentation and caring are, in my opinion, your best defenses in these situations (see #7 below). Remember that your goal is to provide appropriate health care, not placation.

6. Focus on what you can do for them, not on what you cannot do. It’s always better to be positive. If you and the patient are having trouble reaching a mutually agreeable workup or treatment for their complaints, emphasize what you are willing to do to help them and why. Emphasizing the limits you want to set with them will only fuel animosity.

7. Document, document, document. Generally speaking, medical care documentation for inmates does not need to be different than that for non-inmates. However, it is crucial to be extra-thorough if you believe the inmate is in any way disappointed or angry about their medical encounter with you. Document not only your thorough history and physical but also your interpersonal interaction with the inmate, the fact that they were dissatisfied, and then justify your treatment plan as though it is being reviewed in court. If something frivolous is filed against you, it will be much easier for a judge to quickly dismiss before it goes anywhere if you have clearly demonstrated your thoughtfulness in providing care.

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc.

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