Recommendations For Illinois Department Of Corrections Medical System Improvements

These are matters that I would address to improve the Illinois Department Of Corrections medical system. Eliminate disease-specific chronic care clinics. This is a contrivance that hinders good care. Replace with “medical clinics” that address concurrently all chronic problems at every visit. Maximum interval between medical clinic visits to be four months, but can be as often as the physician requests for any given patient. Simplify charts. Too many compartments. We only need two: "Physician notes" and "Lab/X-ray studies." Notes to be filed in chronological order regardless of source or topic. A patient’s medical history evolves chronologically, and that is how physicians should think to assess properly the patient’s history and medical issues. The current charts require the physician to search through about 8 different compartments to find data. Many of the filings are random. For me, personally, this was the biggest obstacle to good medical care. (To some degree, but not entirely, the EMR solves some of the above difficulties.) Institute throughout the system the "Internal Medicine” model of excellence. This means that each patient to receive a good history and physical, necessary but not excessive lab studies, review of past medical records, assessment and definition of all medical issues, continuous re-assessment of medical status by critical thinking. Use the history, physical exam, and review of medical records as the basis for all tests and treatments— for every problem, for every visit. Within reason, try to define/diagnose properly ALL the patient’s medical issues, again using critical thinking and the above principles of internal medicine. Do not intellectually ignore symptoms and findings because these do not appear to be of significant immediate compromise to the patient. In other words, physicians to maintain curiosity at all times and think like physicians. Thinking should not cease just because nothing is to be done. Eliminate bad physicians. We know who they are. Corrections medicine should not be a haven for incompetent physicians. Incarceration itself should be the punishment for the inmates, not bad medical care. In the corrections setting, the mandates are to limit-- and when feasible eliminate/reverse-- pain, deterioration, and loss of function. For those with significant impairments, maintain independence and maximize ability to carry out acts of daily living. May defer what is safely deferrable, but continuously re-examine and re-analyze. Disastrous outcomes should never occur because of neglect or laziness. The “team” approach, as discussed below, will help prevent “disasters." Eliminate as many “forms” as possible. One of the great obstacles to good medical care in the IL DOC is “Poly-FORM-acy.” I counted approximately 30 different forms in each chart. None were good. Only a few were at best mediocre. The rest were awful. The best form is a blank piece of paper. Eliminate “Problem Lists”— one of the many unnecessary forms in the world of polyFORMacy. These lists are always wrong, especially in multiple provider systems. Problems appear that do not exist and many that do exist do not appear. They are impossible to maintain accurately. In the internal medicine model, physicians should list in their progress notes approximately every third visit all the problems of the patient, with proper updates. Emphasize the TEAM approach. Physicians in the DOC are too ISOLATED!! A physician in an institution may go weeks or months before he or she has a substantial interaction with other physician colleagues inside or outside the DOC system. This is very stressful to physicians. It contributes to burnout and lazy care. We need to communicate more often and more easily with each other, to help each other out and to share expertise. Many ways to do this. Have the best physicians in the system make periodic visits to other facilities to conduct consult clinics for the more difficult cases. Improve the “collegial review” process to be more helpful for diagnosis and treatment. Establish a more readily accessible specialty consultants panel. Expand tele-medicine. Encourage other communication formats.

Ensure that all prisons have adequate dental facilities, including proper dental x-ray equipment. One cannot practice dentistry without this. Dental care is extremely important.

More physician input into programs of nutrition and exercise. More group classes on medical topics, especially diabetes and obesity. Introduce yoga and aerobic exercise programs. Consider to eliminate free weights altogether, as these are a frequent cause of injuries. Improve food service to include more fruits and vegetables. Minimize junk food. Encourage vegetarian diets. Teach physicians how to communicate better with outside consultants, and vice versa. Consider to have academic institution(s)— medical school(s) and/or teaching hospital(s)-- take over the entire medical services contract. Do not use a for-profit proprietary out-of-state entity to provide the medical care for IL DOC patients.*** Corrections medicine is an obligation of the State and the medical profession. It is a public health obligation as well. In-state medical institutions should take on these obligations and do so for teaching and humanitarian reasons. Millions of dollars would remain in-state and help the state’s own medical institutions. Overall care would improve. Access to specialty, emergency, and post release follow-up care would all vastly improve. I can discuss this in more detail at another time. *** Note: I, myself, as the Medical Director of the Jacksonville (IL) Correctional Center, was an employee of Wexford Health Sources, which, in my opinion, is probably the most ethical and scientific of all the proprietary corrections medicine companies. I consider almost all the other proprietary companies that provide corrections healthcare to be mercenary. Nevertheless, there is no question in my mind that the administration of medical care in the corrections setting best belongs in the domain of in-state academic medical institutions. Several states have such a system, with excellent outcomes in all aspects.

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