"JAMA Medical News & Perspectives - October 28, 1998

Critics Denounce Staffing Jails and Prisons With Physicians Convicted of Misconduct

In an effort to provide health care in their burgeoning jails and prisons, some states are hiring physicians who have been convicted of crimes or have lost their medical license because of professional misconduct. Some states are even issuing medical licenses that restrict the disciplined physician's practice to prisoners. That policy is not just bad for the incarcerated, say correctional health leaders and other critics, it is bad for correctional medicine and it's bad for society.

In one case, a psychiatrist who twice lost his medical license for sexual misconduct, first in Michigan and then Oklahoma, was issued licenses in Alabama and Mississippi. "Although sufficient grounds exist to deny [the psychiatrist] licensure," the Mississippi State Board of Medical Licensure wrote in its order, "the evidence presented, along with Applicant's testimony and demeanor, indicate that Applicant could serve a useful purpose as a practitioner in the State of Mississippi limited to the correctional system." That physician now heads mental health services for Alabama's state prisons (see preceding article).

Another example is Robert A. Komer, DO, whose medical licenses were revoked in six of seven states after he pleaded no contest to 59 counts of sexually abusing patients and other offenses from about 1982 through 1988. In June 1990, Michigan's Board of Osteopathic Medicine and Surgery found him guilty of sexually abusing six psychiatric patients, four of whom he first drugged with amytal sodium. One of the patients was so upset following treatment that she slashed her wrists in a suicide attempt. Another became dependent on the physician's attention and attempted suicide several times "in order to be hospitalized and have more contact with Komer," the board found.

After Michigan revoked Komer's license, Arkansas, California, Florida, Iowa, Missouri, and Ohio did the same. Texas, however, did not. In January 1991, the Texas Board of Medical Examiners placed Komer on probation for 3 years, during which he had to undergo psychiatric treatment and to notify the board in the event he left employment with the Texas Department of Mental Health and Mental Retardation, where he was assigned to the Department of Corrections.

Komer, who now works part time at the Ferguson Unit of the Texas Department of Corrections in Midway, declined to comment.

"No Lesser Standards"

"It is unethical and inhumane to say that a physician isn't trustworthy or good enough to treat people in the community, but that he or she is good enough to care for inmates of correctional facilities or mental hospitals," said Sidney M. Wolfe, MD, director of Public Citizen's Health Research Group, Washington, DC. The practice is "reckless and dangerous," he said

"If physicians who have been disciplined for past misconduct are congregating in correctional settings, it should be a concern to the medical regulatory community," said Dale L. Austin, deputy executive vice president for the Federation of State Medical Boards, in Dallas-Fort Worth. "However, it may be appropriate on certain occasions for a medical board to limit a physician's practice to a specific setting to prevent a repeat of past misconduct and to assure that the public is protected," Austin said. For example, it may be appropriate for a board to limit the practice of a physician who was disciplined for sexual misconduct involving female patients to an all-male inmate population. "Such restrictions, however must be used very cautiously," he said. "I would hope that no board views health care in correctional settings as requiring lesser standards than is required for the general public."

However, inmates, especially those with serious mental illness, are vulnerable to exploitation, Wolfe said. Because prisoners are widely perceived as manipulative, complaining, and dishonest, their complaints of mistreatment are often discounted. In addition, inmates may reasonably fear that complaining about sexual or other abuse from a member of the correctional health care staff could mean that they won't get timely medical care when needed, he added.

"While errant physicians as well as inmates can reform, the recidivism rate for sexual offenders is too high to risk the health and welfare of patients by recycling physicians who may offend again," Wolfe said. "Because prisoners are powerless and vulnerable to exploitation, we need to be careful not to place them under the care of health professionals who have a history of victimizing patients."

In justifying the practice of providing correctional health care jobs for physicians who were found guilty of crimes or professional misconduct, some licensing boards and departments of corrections point to the difficulty in meeting the rapidly increasing demand for correctional health care providers.

According to the US Justice Department's Bureau of Justice Statistics, the nation's jail and prison population has more than tripled since 1980. In 1997, an estimated 1.7 million men and women were behind bars on any given day. Each week the nation has to add 1000 more prison beds to keep up with the exploding prisoner population. That this population has pressing health care needs is well documented—the prevalence of HIV infection, hepatitis, tuberculosis, and other communicable diseases, serious psychiatric illnesses, and tobacco, alcohol, and other drug addictions is much higher in jails and prisons than in the general population. As the mounting number of federal and state lawsuits suggests, inadequate medical staffing in many correctional facilities is compromising the health and safety of inmates and leads to expensive litigation that's paid for by the public.

Difficulty Recruiting Physicians

While it's true that correctional facilities nationwide are having difficulty recruiting physicians, this doesn't justify hiring those who are not qualified to practice in the community, said Edward Harrison, president of the National Commission on Correctional Health Care (NCCHC), Chicago, the nation's leading correctional health services accrediting agency.

"There have been vast improvements in correctional health in recent years, in both professionalism and the quality of care delivered in correctional facilities," he said. "This sounds like a step backwards. The commission has a standard that requires state licensing for physicians and other medical professionals. The commission strongly believes that the community's standard for professional conduct and competency should apply equally to the correctional setting."

Roderic Gottula, MD, president of the Society of Correctional Physicians and assistant professor in the Department of Family Medicine, University of Colorado Health Sciences Center, Denver, said the society's board "is unanimously opposed to the practice of granting medical licenses restricted to practice in corrections. Doing so is detrimental to the welfare of inmates and the practice of correctional medicine."

The American Medical Association's Council on Ethical and Judicial Affairs does not have a policy on this issue.

A recent editorial in Lancet summarized the case against holding physicians in correctional settings to anything other than general community standards: "The principle that prisoners are entitled to the same level of health care as that provided in the wider community is accepted in enlightened societies and prison systems. Failure to achieve such equity could not only damage the patient but also put society at risk" (Lancet. 1998;351:1371).

Any dispoproportionate staffing of jails and prisons with physicians who have trouble getting work elsewhere also makes it more difficult to recruit qualified candidates, said Ron Honberg, JD, director of legal affairs for the National Association for the Mentally Ill, Arlington, Va. "Creating separate standards for prisoners sends a terrible message," he said. "How can you recruit more good people in a field that many look down upon as full of misfits, reprobates, and otherwise unhireables?"

Most Return to Society

According to E. Fuller Torrey, MD, executive director of the Stanley Foundation Research Programs, Bethesda, Md, and an expert on the treatment of severe mental illness, the quality of physicians providing health care in the correctional setting is "biphasic."

Based on conversations with wardens and others on his many visits to jails and prisons in 15 states during the last decade, said Torrey, along with reading about those cases of incompetence that make the news, he concludes that, "There are many dedicated and caring men and women working in correctional health, but there is also a strongly disproportionate percentage of incompetent physicians for whom correctional facilities are the place of last resort to practice.

"The use of special licensing arrangements that allow physicians who cannot be licensed to treat the public to treat sick and mentally ill inmates in prisons or jails is a scandal," he said. "It is a scandal that is being tolerated because we don't care what happens to these people. And we don't seem to care that much what happens after they're released."

According to Torrey, approximately 10% of inmates have a serious mental illness, yet there are few links between the correctional system and the health and psychiatric care systems in the community. The vast majority of men and women in jails and prisons do not remain behind bars. Last year, 12 million incarcerated men and women were returned to society. There is a great national commitment to punish offenders, he said, but very little commitment to make sure that offenders don't leave prison in worse shape than when they enter.

—by Andrew A. Skolnick

Research for this article was supported in part by a Rosalynn Carter Fellowship in Mental Health Journalism.

(JAMA. 1998;280:1391-1392)