Prison Health Opportunities for Medical Students and Residents

Prison Health Opportunities for Medical Students and Residents Heather Filek Amanda Degenhardt Alvin Keng Ruth Elwood Martin John Koehn. FMF 2013

Health Advocacy “Physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction. ” - RUDOLF VIRCHOW

Health Advocate Role Definition: As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations. Frank et al, Can. MEDs, 2005.

Incarceration in Canada • Approx 54, 498 individuals in custody • Higher prevalence of mental illness and substance use disorders • First Nations over represented Stats Canada; 2010/11.

Go directly to jail…

Objectives 1. Review Can. MEDS competencies that prison health educational opportunities can foster. 2. Understand the opportunities available for medical students and residents. 3. Network with others who are interested in prison health education.

History of the Prison Health Project Amanda Degenhardt University of British Columbia MSI 4. FMF 2013

Hx of Prison Health Program • 2 nd year of medicine—CSLO • Started 5 years ago • Initiative to present inmates with information on health and infectious diseases • Unique and marginalized population. • Groups of two to deliver 1 hr presentation • Audience: ~12 -15 inmates • Locations: Fraser Regional Corrections Centre(FRCC), North Fraser Pre-trial Centre (NFPC), and Alouette Correctional Centre for Women (ACCW)

Locations Green = Federal Yellow = Provincial Red = Forensic Psychiatric Hospital Blue = Youth Custody

Hx of Prison Health Program • The prison population has unique health needs: – – Mental illness Poverty Addictions Infectious diseases • Restricted access – limited knowledge of the health and human rights concerns of prisoners • Developing student deliverables • Over the years project development progressed: – BC Corrections relationship – Module Content – Memorandum of Understanding (MOU) to formalize students’ relationship with BC Corrections – Expansion into the Juvenile institutions

Modules Developed • • Navigating the Health Care System Mental Health Basic Hygiene Women’s Health Infectious Disease Health & Your Child Sexual Health

Challenges with Presentations • More examples pertinent with the prison population • Mental health had basic science – kept it more “big” picture • Careful that photos aren’t “triggers” or too extreme as this illicit disruptions • Remove medical jargon

Pilot Project • Adapt and deliver youth targeted health modules (basic hygiene, sexual health, navigating the health care system) to juvenile inmates at the Burnaby Youth Custody Services Centre • More relaxed atmosphere • More time spent on Q&A • Health Jeopardy

Following pilot • Well received and felt this could be an independent CSLO – Safe Relationships (Harassment, Abuse, Neglect and Positive Role Models) – Sexual Identity – Mental Health (Body Image, Self-Esteem and Bullying) – Mental Health (Depression, Anxiety, Bipolar, Psychosis, Suicide) – Addictions (Drugs, Alcohol and Smoking) – Nutrition and Exercise – Dental Health – Sleep and Growth – Body Modification (Tattoos, Piercings) – Risky Behaviour, Accidental Injury and Prevention

Personal Experience • Youth – a lot of food for thought – How do we stop them from entering into the juvenile system? Once in, how do we stop the cycle? – What is my role as a member of the community and as a health care professional • Can. Meds – Communicator • Listen effectively to elucidate concerns and address them • Nonverbasl cues • Safe environment to talk – confidentiality and rapport – Advocate • Community resources – Medical Expert • Explain and provide information to both child and parents to better understand the issue they have come in with

Personal Experience • Incarcerated individuals are marginalized population that is unheard – Not allowed dental floss (potential weapon) – No access to dental care • Lack of awareness of health care rights – Fear or discomfort sharing personal information – When it’s appropriate to see a doctor – What a good patient-physician relationship looks like • Acted as a health advocate – health promotion and disease prevention

Future Effect on my Medical School Experience • 3 rd year of clerkship was in an integrated community clerkship • Weekly family practice office managed transition houses therefore some patients were previously incarcerated • Allowed me to be open and accepting of the patients • Cohesive relationship to address their needs which include acute and longstanding issues

Prison Health Project 2012/13 Alvin Keng University of British Columbia MSI 3. FMF 2013

Prison Health Project in 2012 -13 • Inherited the project from medical students of prior year • UBC Medicine Year 2: Doctors, Patients and Society (DPAS) course - Community Service Learning Option (CSLO) • Team of 7 students in 2012 -13

Locations • Essential Skills to Success – Fraser Regional Corrections Centre – North Fraser Pre-Trial Centre – Alouette Correctional Center for Women – Surrey Pre-Trial Services Centre • Burnaby Youth Custody Services Centre

Existing Modules • • Navigating the Health Care System Mental Health Basic Hygiene Women’s Health Infectious Disease Health & Your Child Sexual Health (at Burnaby Youth Custody Services Centre)

Navigating the Health Care System • Explained the health care system in BC with a focus on a community POV • Sample topics: how to find a family doctor, MSP, Pharmacare, how to get the most from a doctor’s appointment

Mental Health • Discussed common mental disorders and how to stay healthy mentally • Sample topics: depression, bipolar disorder, anxiety disorders, substance abuse, recognizing suicide risk, staying mentally health in prison and in the community

Women’s Health • Discussed different areas of women’s health pertinent to incarcerated females • Sample topics: STIs, breast cancer, the well woman exam, contraception

Infectious Diseases • Reviewed common infectious diseases, modes of transmission, prevention & treatment • Not presented in 2012 -13 • Sample topics: HBV, HCV, HIV, Scabies, Lice, TB

Health & Your Child • Discussed healthy pregnancies, young child development, and healthy lifestyles • Sample topics: when to see a doctor during pregnancy, nutrition and healthy living tips, dangers of cigarettes, alcohol, drugs in pregnancy, child nutrition

Sexual Health • Developed for youth to discuss common STIs, and prevention, prevention! • Sample topics: Gonorrhea, chlamydia, HPV, herpes, HIV, contraception, prevention

New Modules for 2012 -13 • Self Care • Substance Abuse • Men’s Health

Self Care • Discussed self-care and its relationship to health • Rationale: Rehashed basic hygiene module to include nutrition and sleep hygiene • Sample topics: nutrition, preventable communicable diseases, exercise, sleep hygiene, stress relief

Substance Abuse • Reviewed common substances of abuse and their impact on health • Rationale: Identified as a gap by our community partner • Sample topics: Sleeping medications, anabolic steroids, acetaminophen, cocaine, etc.

Men’s Health • Discussed major health issues affecting men, • Rationale: Identified as a major gap and area of interest • Sample topics: “The Big 5”, testicular disease, prostate disease, the importance of screening, sexual dysfunction • Men’s Health Initiative of BC

Lessons for the Future • Inmates have unique needs and restrictions • Connection to the outside community • Engaging inmates in their health • Measurable impact • Prison is a unique community with nuances difficult to understand for an outsider

Students’ experience of prison health education during medical school Heather Filek University of British Columbia MSI 4 Filek H et al. Med Teach. 2013 Nov; 35(11): 938 -43 FMF 2013

Purpose • Social responsibility is a core component of medical education 1– how are students learning to be socially responsible? • Can. MEDS competencies: – Health Advocate, Communicator, Collaborator • Purpose of the study: to explore the impact of pre-clinical prison health education on medical students 1 Faulkner, L. , Mc. Curdy, R. (2000) Teaching medical students social responsibility: the right thing to do. Academic Medicine, 75(4): 346 - 350

Methods • Students and residents who participated in the DPAS 420 CSLO Prison Project as 2 nd year medical students. Recruitment via invitation email; convenience sampling • 10 in-depth interviews • Each interview audio-recorded and transcribed verbatim • Analysis via interpretive description, a method to “capture themes and patterns within subjective perceptions 2” • UBC Behavioural Research Ethics Board certificate of approval was obtained 2 Thorne, 68 -70 S. (2000). Data analysis in qualitative research. Evidence Based Nursing, 3,

Findings Four main themes were identified as the major impacts of being exposed to the prison population during medical school training

Theme #1 Exposure to incarcerated populations increases students’ insight into issues that diverse marginalized sub-populations encounter “the value of having prison health as part of medical school would be that it exposes you to more or less every marginalized population you could imagine. It’s the immigrants, it’s women, it’s homelessness, it’s aboriginal, it’s drug addicted…”

Theme #2 Positive interactions with the incarcerated individuals enhances relationship building • Received warm welcome from incarcerated individuals • Positive relationships between inmates and future HCP “We got really good feedback from the inmates themselves…that positive interaction was something we’d hoped to foster. ”

Theme #3 Collaboration reinforces teamwork skills • • BC Corrections Prison wardens & guards Health Care in correctional facilities UBC faculty “It’s just like the hospital where things function a lot more smoothly when everyone from the team gets along. And respects one another. ”

Theme #4 Community placements garner important learning opportunities within the medical school curriculum “It’s experiences I can tie back to when I come into contact with patients who have been through the prison system. ” “It’s not something you can learn in a textbook…. it’s only through interacting with the people that you can break down the stereotypes that you have and feel more comfortable interacting with that population. ”

Conclusion of study Findings = Can. MEDS competencies (Health Advocate, Communicator, Collaborator) Our findings demonstrated that pre-clinical exposure to incarcerated individuals and prison health education provided a unique setting for medical students to develop an increased sense of social responsibility and accountability.

“So I think I developed a sense of compassion for a group of people that I didn’t previously understand as well. Hopefully that makes me a better physician for that. ”

Opportunities abound! 1. 2. 3. 4. New Prison Health Advocacy Elective Regional shadowing opportunities Health promotion projects Research . FMF 2013

Prison Health Advocacy Elective • 4 -week elective rotation through UBC • Emphasis on the health advocate role • Embedded cultural competency certification • Multi-site options

Shadowing • Representative prison physicians on SIFP committee from every region of Canada – Kingston, ONT – St. John’s, NFLD – St. Albert, SASK – Vancouver, BC

Health Promotion • Established projects in BC • Support for distributed initiatives through the Collaborating Centre for Prison Health and Education

Research and Policy • Working groups established to contribute to position papers on issues: • • Segregation Access to effective addiction treatment

A National Conversation • Physicians working in prisons have a unique skill set • Learners have potential to contribute a great deal • Well positioned to advocate for change

Thanks! • Questions • Comment • Share contacts • Ben: prison. elective@familymed. ubc. ca