The Sound of Silence

Not a day goes by that we can open the paper without seeing an article concerning the state of affairs in our prison system and some scathing rebuke concerning the state of the medical care in particular. I say, “rebuke” because I am one of those physicians whose medical care is being summarily indicted. A federal judge, the Hon. Thelton Henderson is remanding the Health Care Services Division into the hands of a receiver, candidates for which position are being considered even as I write. The court has approved of a comprehensive program of testing of the physicians’ competence with an eye to weeding out those that are deemed incompetent.

I read these articles with an odd blend of compassion, sadness and indignation. I can look at this situation as an outsider as well as an insider. As I know many of the cases, the articles tell me more about the current state of the public’s awareness of what actually goes on “on the inside” than they do of the actual situations themselves. I’d like to share with you my perspective on the matter:

If you attempt to detach yourself emotionally so as to be objective, several interesting features can be seen. In most all of horrific stories regarding medical care or its absence, there is an element of some unconscionable delay in care, whether it be the failure on the part of personnel to respond to an emergent situation, or the failure for an interminable and indefensible period of time to provide services or medical appliances. This is in contradistinction to the situation that exists outside the prison system, in which some self-evident mishap in treatment ends with a lawsuit.

A parallel feature to that just described is that, in most all cases, it is difficult to isolate out who precisely is responsible. If an inmate dies in a cell, is it the result of neglect on the part of custody, or is it purely the result of medical bungling? You see very little of those situations in which an inmate is given the inappropriate medicine, or in which he dies as a direct result of treatment. Remarkably, you see few cases in which a specific condition was missed or misdiagnosed. In these cases it is fairly easy to ascribe responsibility to one or several people directly responsible.

This is not the usual case in the prison system. This is so because this is basically a closed system, in many respects, and the care involves the participation of a number of people, from the doctor’s accuracy of diagnosis, to the pharmacy’s providing the medication, to the specialists’ contribution, to the custodial responsibility in being alert to medical crises and to the prompt transport of patients, to the timely posting on the patients’ charts of the results of tests or of specialists’ reports and recommendations. If there is a weak link in this chain and if something untoward happens, it is much easier to hold the physician responsible simply because of a conventional and convenient notion that the doctor is “in control.”

In fact, nothing can be further from the truth. We as physicians have nothing to say about those very services upon which we logically depend. In the outside world, “on the street,” as is the term in prison parlance, if a doctor is dissatisfied with the competence or responsiveness of a pharmacy, a medical diagnostic laboratory, a home health care provider, etc., he or she can simply turn to another provider. These various agencies, in turn, aware that they are in a competitive market place, strive to do a good job for their potential and actual customers. In fact, I can only think of two instances in the last five years where due directly to a physician’s incompetence or neglect, an inmate died. Granted, that is two too many, too be sure; but the point remains valid.

There are other factors that contribute to the perception of the inadequacy of medical care. One of these is the unwillingness of the Health Care Services Division to be responsive to our request for help.

The doctors at Corcoran State Prison sent no less than three letters, certified and return receipt, to the Deputy Director in Sacramento, Dr. Rene Kanan, outlining our concerns and –literally—begging for help. Each and every doctor signed them unanimously. What was the result?

Nothing.

To make matters worse, she has not provided for substitute physicians to take the place of those who have left. This aggravates an already critical situation.

Another factor is the adolescent antipathy of one service for another. The Head Nurse and the Chief Medical Assistant are at loggerheads and discourage their respective employees from attending meetings of the other department. Nothing good can come of this as it relates to patient care.

Another factor is the basic antipathy of Custody towards the inmate population.

Regardless of which story of mistreatment of inmates you choose to believe, you can count on the fact that this state of affairs is antipathetic to the mission of the medical department. Think of it this way: Would you leave your child with a baby sitter that had a similar relationship to your child as custody does to the inmate population?

Another factor is found in the epidemiology of the inmate population:

In a fashion more than parallel to that in the outside world, the prison population is getting both older and younger. The youth are mostly gang affiliated and therefore productive of injuries, often life-threatening. The older population is growing in numbers; and the usual diseases are more than compounded in their effect by the generally unhealthy environment physically and socially in prison.

I would like to see relatives of the inmate population as well as interested lay people have an ongoing dialogue with the physicians. When I was the Chief Medical Officer, acting, at Substance Abuse Treatment Facility, I spent—literally—hours conversing with family members and attorneys by phone. This practice in and of itself avoided countless numbers of lawsuits and accusations.

It’s very easy to find criticism of prison doctors. Situations so emotionally charged bring to the surface many people and agencies, each with a political agenda of its own. I am convinced that, with the exception of family members, the specific agendas of these various parties are more important to them than are the individual inmates.

Finally, I’d like to leave you with one simple fact which says it all: In the years I have spent in Department of Corrections, absolutely no one has asked me: “What do you need to do your job?” And, “How can I help you/”

It’s the sound of silence, and it says it all.

(This article was reprinted from The Reporter of Vacaville, California, Aug. 7, 2005 by permission of the editor.)