EVERY RESIDENT SHOULD GO TO JAIL
This article was originally published in the Scope of Practice call to papers for Family Medicine, a journal of The Society of Teachers of Family Medicine
ABSTRACT
Incarceration is a profound structural force shaping the health and lives of those involved. It is such a strong equalizer of social determinants of health that many ethnic, gender, and age disparities of disease in the free world disappear under one common factor — being in jail. Family medicine departments serve at the frontier between the community and the health system. Since our inception fifty years ago as a deliberately counterculture specialty, we have always practiced at odds with an increasingly fragmented and hyperspecialized system. Corrections settings magnify this dilemma. Places like these are exactly where we should be sending our future physicians. If every resident went to jail, our communities would be a little healthier. And a little more just.
EVERY RESIDENT SHOULD GO TO JAIL
The United States criminal justice system represents a critical frontier for health care delivery. Over two percent of our population is behind bars or under close correctional supervision.1 Incarceration is a profound structural force shaping the health and lives of those involved.2 It is such a strong equalizer of social determinants of health that many ethnic, gender, and age disparities of disease in the free world disappear under one common factor — being in jail. Mental illness is twice as prevalent, and chronic and infectious disease burden is up to four times higher among those in in confinement.3 Despite a constitutional right to healthcare for those in state custody (Estelle v. Gamble, 1976), there is no statutory guarantee of health.4
PHILOSOPHY OF FAMILY PRACTICE
At family practice’s doctrinal core is the provision of comprehensive and continuous care to the individual, who themselves are inseparable from the unit of family and community. Since our inception fifty years ago as a deliberately counterculture specialty, we have always practiced at odds with an increasingly fragmented and hyperspecialized system.5 Corrections settings magnify this dilemma. If our Aristotelian inheritance of our art holds that health is a basic and irreducible human good, and the practice of medicine is inherently oriented towards this end, then healthcare in jail is almost certainly counter to the punitive system of justice as it exists today.6 Places like these are exactly where we should be sending our future physicians.
CORE COMPETENCIES
Corrections settings are a crucible for multi-morbid disease burden, health disparity, and soul-searching ethical challenges. Resident training in corrections medicine, whether structured as a discreet elective rotation or a longitudinal experience, is both feasible and aligned with family medicine’s mission and educational objectives. Proficiency in infectious and psychiatric disease, emergency response, substance use and withdrawal, and any and all urgent and office-based procedural skills is prerequisite. Every patient needs the resident to apply their medical knowledge in the context of navigating an often logistically complex, protocol-laden, and resource-limited environment. Every encounter cultivates the resident’s humanistic center while they uphold professional ethical boundaries, balancing patient dignity and autonomy with the constraint of incarceration and facility regulations.
WHERE THE SICK PEOPLE ARE
A mentor once succinctly made the case for training family medicine doctors in settings of greatest need: “You gotta go where the sick people are.” And our communities are only as healthy as our relationships with them. At our program, core faculty and community preceptors, including the jail’s medical director and former medical director, provide structured mentorship and a scaffold for community partnerships.7 In our case, we have a reciprocal relationship with our county custodial center: we send resident and student physicians, they send patients. Each year, our residents visit the largest jail in our state through our Longitudinal Underserved Community Curriculum (LUCC) where they tour the facility from intake to dining hall, meet the medical staff, observe patients in the infirmary, and attend court proceedings. After their morning in jail, residents spend an afternoon immersed in community post-incarceration organizations, ending their journey from rehabilitation to reintegration. The County refers incarcerated patients through the emergency department or by direct admission to our inpatient academic service for a higher level of care than the county corrections center infirmary can provide. Additionally, our core longitudinal clinic serves as a continuity site for medical care from our city and county jails and state prisons. In the second and third year, residents have a four week elective opportunity to work with the medical director and other staff clinicians at County, during which they participate in direct patient care, gain technical competencies in all conceivable office-based procedures, treat addiction and psychiatric comorbidity, and participate in public health and quality improvement efforts, the most recent of which included a hepatitis screening pilot in incarcerated adolescents. A steady pipeline of talented minds between our College of Public Health and our county corrections team has yielded multiple public health initiatives and nationally-presented research, providing more opportunity for residents to participate in projects if they choose.
Logistical concerns, such as scheduling and safety, are surmountable with clear protocols and the regular interface of custodial staff with faculty, resident, and student physicians. Programs without existing correctional partnerships can explore collaborations with local facilities, many of which would likely welcome academic affiliations. Alternatively, if not a categorical rotation in itself, corrections medicine can be integrated into required experiences in special populations or community health. Collaboration with correctional facilities also corresponds with funding priorities for graduate medical education, and can foster institutional support and grants from organizations for public health initiatives and quality improvement. Even in early affiliations where credentialing and resident physician role are still being delineated, the structure of corrections health ecosystems can allow high-fidelity shadowing preceptorships unconstrained by productivity demands or high patient volumes in other health systems, and as such can allow plenty of self-directed learning under attendings who are willing to teach.
PRACTICE AT THE FRONTIER
Family medicine departments serve at the frontier between the community and the health system. This is the interface from which all those C-functions of the primary physician are derived - first contact, critical, continuous, comprehensive, coordinated, patient-centered. Our practice at this interface is our curriculum.8 Within this context, our relationship with our patients, our departments, our community, and with ourselves, is itself the therapeutic means to that healing end. Sending residents where the sick people are reaffirms our commitment to the frontier, reminds us of patients’ structural challenges to health and wellbeing, and emboldens us to make our health system work better for those who need it most. If every resident went to jail, our communities would be a little healthier. And a little more just.
REFERENCES
Prison Policy Initiative. United States profile. Prison Policy Initiative website. https://www.prisonpolicy.org/profiles/US.htm. Accessed May 26, 2025.
Izenberg JM, Morris NP. The freedom cure—structural intervention as medicine. N Engl J Med. 2023;389(5):389-391.
Office of Disease Prevention and Health Promotion. Incarceration. Healthy People 2030 website. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/incarceration. Accessed May 26, 2025.
Estelle v. Gamble, 429 U.S. 97 (1976). https://supreme.justia.com/cases/federal/us/429/97/. Accessed May 26, 2025.
Stephens GG. Family medicine as counterculture. Fam Med. 1989;21(2):103-109.
Baker SH. Aristotle on the nature and politics of medicine. apeiron. 2021;54(4):411-449.
Rottneck F. Every medical student should go to jail. Society of Teachers of Family Medicine website. https://www.stfm.org/publicationsresearch/publications/educationcolumns/2011/july/. Published July 2011. Accessed May 26, 2025.
Neutze D, Hodge B, Steinbacher E, Carter C, Donahue K, Carek P. The practice is the curriculum. Fam Med. 2021;53(7):567-574.