Prison medicine during the pandemic [PODCAST]

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“Rumor has it that the SARS-CoV 2 virus was brought into prison via inmates who were on a work-release program.  Allegedly, they boarded a city bus with a driver who was ill.  From there, it crept beyond the work-release camp and wafted over to the general prison population.  The pandemic had reached this impenetrable fortress; a tiny virus with no proper consideration of human incarceration rules.  It had failed to stop at the gatehouse.

Traditionally, due to the nature of prisons and the nature of convicts, infectious illnesses do have a presence in prison systems.  SARS-CoV 2 is no exception.  As the alarms within the prison rose from orange to red, and new hotspots named, the direness increased.

Then, the ebb and flow of prison life ceased and came to a complete halt.

Similarly, in the free world, those who had no convictions or felonies became imprisoned in their homes.  When once, a workday end meant freedom as we left the gatehouse behind, now it only meant further seclusion.  Prison had crept outside the gatehouse.  We left one boiling pot only to enter into another.”

Edna Wong McKinstry is an internal medicine physician.

She shares her story and discusses her KevinMD article, “How to find joy in prison.”

This episode is sponsored by Augmedix: Ambient medical documentation and live clinical support powered by virtual scribes. Did you know that nearly 75 percent of clinicians surveyed in a recent study say they spend over 10 hours per week on paperwork and medical notes?

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Edna Wong McKinstry. She is an internal medicine physician, and she wrote the KevinMD article “How to find joy in prison.” Edna, welcome to the show.

Edna Wong McKinstry: Well, thank you, Kevin, for allowing me to participate in your podcast.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Edna Wong McKinstry: I did the nontraditional route. I actually worked for a little bit in the veterinary field before deciding I wanted to go to medical school, so I joined my cohort, and I was a fair bit older than the rest of them. I also went to school in the Caribbean, so that was another nontraditional route. It was interesting. I wouldn’t say I would repeat it again, but it taught me a lot of lessons, like how to study for an exam when there is no electricity.

And then here I am. I went to residency at the University of Arizona, where I was based for a majority of my adult life, and then I stayed on for three years to work in a clinic there. Then I decided I had a little bit of wanderlust and wanted to travel and see different things, so I actually joined the locums industry, and that has afforded me a lot of good opportunities. So here’s where I am.

Kevin Pho: Tell me a little bit about your practice and the patients you see.

Edna Wong McKinstry: I work mainly, prior to coronavirus hitting, and a lot of practices, a lot of hospitals had declining numbers. I’m actually a hospitalist, so I work mainly in the inpatient acute setting, much like any hospitalist would do. It’s typically a 12-hour day, seven days, seven days off sort of thing, but I get to choose when and where I work. That’s the difference.

Kevin Pho: We’re speaking at the beginning of January now. Tell me what kind of patients you’re seeing and some of the challenges that you’re facing currently.

Edna Wong McKinstry: Oh, good question. So when the coronavirus hit, sort of in March, I saw the writing on the wall, because our numbers were coming down, and as a locum, sort of a fill-in position, we’re the first ones to go. A lot of my contracts actually canceled last minute, so I was pretty much scrambling to see what I could do to pay my mortgage and my student loans. So this opportunity at the prison came up. I was actually recruited through one of the job sites, and I said, “Well, what an interesting sort of job.” I never knew anything like that existed. And I actually don’t regret joining the prison system.

It’s different. It’s a lot of challenges. The patient population, I’d say, would be the Medicaid population. Some offenders, and we do call them offenders, some offenders are white-collar crimes, so they’re a little more well-to-do, but that’s not very common. And the particular challenges would be, you know, medication compliance, diet compliance, a lot of the structural rules and regulations we have to work within. For example, a diabetic who is on insulin can’t just give insulin themselves, because it’s a weapon in jail and prison, so we have to give it to them.

So those are the challenges. And sometimes they don’t show up for their medicines, they don’t want the diet we give them. So it’s one of those, having to work with rules and regulations that impede care, but it’s necessary, if you know what I mean, for population safety within the prison population. And so that’s where I am right now.

Kevin Pho: So with your background as an internal medicine hospitalist, was it difficult for you to transition to the prison population?

Edna Wong McKinstry: It wasn’t a smooth transition. I thought a lot of the things that were done in the prison system were dictated not by boots-on-the-ground physicians, like the ones you see or you hear about working, like myself. They’re dictated at the state level, because a lot of it has to do with funding and money and all of that stuff. So there are a lot of protocols, not dissimilar to the hospitals’ protocols, that sometimes make sense and don’t make sense, but there’s not much you can do about it. You just have to work. You have to be a little bit MacGyver-ish and work, being creative on how to get the care that is needed. Sometimes it’s not always possible, and we don’t live in the perfect world.

So the challenge was, it’s also a little more slow-paced than what I was used to. And I joined the prison system when the pandemic hit. It was June when I first started, and everything had shut down. There was no prison movement. There were no prisoners; they couldn’t come to clinic. You know, we’re the primary care physicians in the prison populations. Just like in the outside world, nobody could go to see their primary care physician. We didn’t have telehealth, so it was challenging. And it did morph over the months. We ended up having to go to the prisoners, so full gown-up and all that.

So that slower pace, where I sat in front of my computer and kind of looked a little lost, was hard to adjust to, and I’m sort of a go-go sort of person. So that was the biggest challenge. Conforming to the rules and regulations was also another challenge.

Kevin Pho: Now, did you have any training prior to making the transition, or did you just have to learn everything on the fly?

Edna Wong McKinstry: Yep, learn everything on the fly, which, you know, I mean, I’m good at that. I’ve been in the locums industry for like five years now, so anything they throw at you, you have to roll with the punches. You’re not there to change anything. You’re there to fill in a spot. I’ve decided that I fit very well as a cog in the wheel, even though sometimes it’s hard to see yourself as a physician as a cog in the wheel, but that’s the reality of it. So you have to roll with the punches.

Kevin Pho: Yeah. So let’s talk about your KevinMD article, “How to find joy in prison.” Now, for those who didn’t read that article, can you just walk my audience through it and maybe share the story of why you decided to write it?

Edna Wong McKinstry: Sure. It’s a funny thing. I was actually answering an ad for GoodRx as a medical writer. You know, I have an English background. I was in the arts before I joined medicine, and I’d always written poetry, creative writing, but then medical school had happened, and I lost all of that, quite sadly. And I was trying to regain this purpose, marrying the science and the arts in my background, so I was actually looking for different avenues of creativity. I chanced upon this GoodRx advertisement, and I’m pretty sure 500 million people answered this. Needless to say, I wasn’t chosen, but I’m like, “What am I going to do with this article? It’s kind of OK. It’s kind of interesting.”

So part of the article was: Educate us about aspirin. And I didn’t tell you about my time in Texas. I was actually faculty, teaching internal medicine residents there. I’ve done a lot of newspaper, sort of teach-the-lay-people kind of articles, so I did that article for that. And then the second part of the requirement was: Write an article. At that time, there was a lot of physician burnout, you know, COVID and all that, so they were wanting to write, like, a pep sort of article: How do I motivate people?

And so this prison thing came into my brain. I said, “You know, it’s kind of like prison.” Lockdown is, you know, I mean, it’s a little different, but it’s sort of similar. So I wrote this article basically to answer that ad, about how there is a life, and you can make a life, even though you’re imprisoned, metaphorically or physically. So that’s how that article came into being, because I really felt like a prisoner. You know, the isolation was very real, so I can understand somewhat what the inmates were going through.

Kevin Pho: Sure. And when you wrote the article, what kind of response did you get?

Edna Wong McKinstry: I think people sort of liked it. There were several comments that said the prisoner’s life is not really like the life that I painted, but that’s just my perspective. And someone else said, “You paint a Martha Stewart-like picture of prison life when it’s not actually that way.” I’m like, “OK, it’s just my take on things.”

You know, I wanted to figure out a way of stress relief, because I’m sure I wasn’t the only one going through a lot of, you know, when it first hit, to be a responsible physician, you’re like, “I have to read up on all this.” It kept changing. It was changing second by second. I just couldn’t keep up with all that literature, and at the end of the day, I either go crazy or I find an outlet. And so the article was based on my personal experience as a physician walking through the pandemic and trying to be responsible in knowing what to advise my patients, what to advise my family.

And in the end, it didn’t work out very well, because what I found out was, you know, regular lay media sends out the information quicker than science can catch up on, and we’re always the bad guy, right? And it’s not always the case, because they don’t particularly understand how rigorous the scientific method is, and how we have to fact-check and check back and all that, and we couldn’t do it in an epidemic situation. So the article led to me realizing that everybody needs an outlet. Everybody needs to pause for a little bit, and it’s just mental health. I don’t know, it was either that or something drastic needed to happen, and I didn’t want to quit medicine at that time, because that would be the drastic measure.

Kevin Pho: Yeah. So I want to go back and talk about your experience working with the prison population. Can you describe how the pandemic has affected the prison population in terms of operations?

Edna Wong McKinstry: And I’m going to be very general, because I’m pretty sure I’m bound by some gag order at the state level. So generally speaking, their operations had changed. It used to be they would freely come to clinic. It’s just like how you would go to your primary care physician. You know, they have a complaint, “My foot hurts, my head hurts,” whatever, they come to clinic, and they get seen. You know, people who work in prison, there’s no personal relationship. You can’t pick a physician, because that leads to, you know, prisoners can get what they want if they see one particular person.

So their operations changed, where now they had to be accompanied by a prison. They don’t like themselves to be called guards, so they’re prison officers. We couldn’t move prisoners out for their mammograms, their chemotherapy, for example, or testing that the prison system couldn’t achieve themselves. The prison where I work is actually pretty self-contained. It’s really fantastic. I never realized that it existed this way, and I’m pretty sure there are other prison systems in the country. So we have our own MRI machine, we have a CT scanner, we have mammography, we have the testing capabilities. It’s just like any clinic: phlebotomy, and then they send out to a reference lab. But we have a lot of things available to us to treat and manage chronic conditions and acute conditions in the prison population.

Which, you know, as a resident, I never. This is the comment I kept making: I wish I knew. I wish residents could go through just one day in the life of a prison doctor, and all the challenges that they face, because there are so many challenges, not just medical, but medical-legal, more so than a regular physician would in a private practice. A person is complaining about anything, anything.

So the operations changed, and so I don’t know that that amounted to delayed care, because within the structure of prison health, there are already sort of layers of delay. Like, you have to get approval. You want to send someone out, you have to get approval, and it’s approval for everything. So it’s almost triple-layer worse than insurance, like private insurance, you know. And this is something that we can’t get away from. It’s population health in a nutshell, because you’re given resources, and there are limited resources, and they’re limited resources. And they’re not marginalized, I wouldn’t say that word, but they are inmates, and they have broken the law, you know.

So the resources are there, but they’re limited, so we have to make good use of the resources that we have, and that’s why there are so many layers of, you know, “Mom, can I do this?” You know, “Dad, can I do this?” You have to ask for a lot of permission. So the pandemic sort of made it a little more complicated, because they can’t go out for their treatments. It means that it gets delayed, and then there’s another set of rescheduling, etc., etc. So it’s just the way it is. It’s not anything good or bad. It’s just, you know, working within the confines of what you have.

Kevin Pho: And in general, in prisons, how do things like quarantine work? If someone got exposed to COVID or someone was diagnosed with COVID, you know, talk about what quarantine was like, what contact tracing was like, and how rigorous was that in prison?

Edna Wong McKinstry: They tried to be rigorous. The issue was, you know, it’s such a confined space, right? So obviously the prisoners get to go out into the community for testing. They do go to their neurology visits, whatever, cardiology visits, so that’s one avenue where they potentially can catch the virus. The other avenue is us, you know, all those who work in the prison, me included, staff, the cleaning staff, the prison officers. They transition back and forth, and they can bring COVID in too. And the other part was that we’re sort of an intake center. We process a lot of the inmates, and so that’s another avenue. So inmates, just from jail, or they just were arraigned, they come in through the system and they get processed.

In the beginning, I think there was a hesitancy, I wouldn’t say reluctance, just because of the limited amount of information we had available about testing, and the testing was not readily available. Remember the good old, I mean, it’s been already almost a year, less than a year, but if you remember, we were trying to scramble about our supply source: Where are we going to get it? So testing wasn’t widely done in the prison system because of that limitation, and it morphed throughout the time of the pandemic.

It did change to where my superiors had actually advocated for mass testing. They weren’t. It makes sense: Why can’t we just test everybody, and then we take the positives, we sequester them, you know? And eventually, you know, like I said, layers of complexity, eventually months rolled around, and then it came into being where now they mass tested. So if you came in through intake, meaning you’re a fresh new prisoner, and you test positive, you get sequestered for the 14-day quarantine as an intake, as a brand-new prisoner. If you are in the prison system already, and we tested and you’re positive, you get sequestered too. They go into a separate housing unit, where they’re in cells like you see on TV. I don’t know, I can’t comment much about the contact tracing. It’s above and beyond my pay grade, and I think I’m on a need-to-know basis at this point.

Kevin Pho: We’re talking to Edna Wong McKinstry. She’s an internal medicine physician, and she wrote the KevinMD article “How to find joy in prison.” And for those physicians who are interested in prison medicine, what kind of tips and advice can you share with them?

Edna Wong McKinstry: Keep an open mind. Try not to be as rigid as you were in practice on the outside. And just like anything, you have to accept what is there, change what you can, and know that change doesn’t happen overnight. And if you really want to make a commitment, don’t do it like me and join, like, a locums, where you have no voice whatsoever. You know, be a full-time person, and you can change it from within, slowly.

There’s actually a whole population of prison doctors, and unfortunately they get a very bad reputation, and I actually don’t know why, because I think these physicians, and I have to include the nurse practitioners and the PAs that work within the prison health system, for the most part, they do what they need to do to get things done in the right way, if you wouldn’t mind me using that word. But there are so many limitations.

I actually got interested in prison medicine because in one of my locums in Missouri, I worked very closely with a prison doctor who sent his prisoners, well, we were the teaching hospital, so we took in the inmates, and he was phenomenal. He knew the prisoners, you know. And I said, “I’m sure he’s not the only one.” So keep an open mind, and know that, don’t be harsh as the physician accepting the prisoners from the facilities, because know that there are challenges that sometimes are more medical-legal than anything else. So we send people out for chest pain. We send people out for a lot of things, because sometimes we cannot manage them legally and medically within our system, and that’s why we do it. If something were to happen, it’s going to be an ACLU case, and you can imagine down the road what it is.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Edna Wong McKinstry: Find an outlet. I think that was the important message I learned throughout this whole pandemic, was to find an outlet. And I think we forget our little past selves, you know, and that we need to rediscover. Like, I rediscovered my creativity. I used to, I hate baking. Oh, I mean, baking was too much. It was just, you know, I’d rather cook, because cooking, you can put stuff in and you can make it right, but baking, if you mess up, you mess up. You have to throw the batch away. But if you find an outlet, you can still be creative, and your mind can accept a lot of stuff that’s around you, a lot of things that are happening. I mean, it seems simplistic, but it worked for me. Just find an outlet.

Kevin Pho: Thank you so much for sharing your time and insight, and thanks again for being on the show.

Edna Wong McKinstry: Thank you.

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