Data source: Identifying relevant documents

This study was a systematic scoping review and content analysis of published healthcare professional materials on carceral health. To conduct a systematic search for relevant documents, a member of the study team (N.V.N) first identified a list of 125 professional medical associations that are members of the American Medical Association (AMA) House of Delegates. The AMA House of Delegates is the legislative and policy making body of the AMA; a list of affiliated medical associations is found on the AMA website [36]. An initial search of materials allowed for a review of associations spanning from large (e.g., American College of Physicians) to small (e.g., the American College of Mohs Surgery). As such, prior to the systematic search, two study team members (N.V.N and E.S.D.) reviewed the list of medical associations and excluded those that were unlikely to have any contact with patients who are detained in prisons and jails (e.g., International Society of Hair Restoration Surgery). This complete list of exclusions is reported in S1 Table.

Between July 11, 2023 and August 19, 2023, we reviewed the first 20 results of an Internet search engine (Google), combining the association’s name and a standard list of search terms, which included, “prison,” “incarceration,” “carceral,” “correctional,” “jail,” and “detainee.” If a document was not identified through the search, we repeated the same search process using the association website’s search query, and subsequently inserted the search terms into PubMed. The research team searched for any educational information, clinical guidance, or any other material on carceral healthcare that was endorsed by the medical association. Presence of the medical association’s name in the title or depiction of its seal on the document were considered indicators of official endorsement. If an association updated a document, the original publication date was noted but the most recent version of the document was included for analysis. Because these data were publicly available and there was no involvement of human subjects, institutional review board approval was not required.

Categorization of documents

Two study team members (N.V.N and T.A.N) independently reviewed the associations’ documents, seeking to categorize them by purpose: educational, clinical guidance, logistical guidance, or policy.

We developed inclusion criteria for each category. Sometimes, the document’s purpose was evident from its title (e.g., an “official policy statement” or “clinical guidelines”). When it was not, the two study team members reviewed the contents and deliberated until consensus. The senior author (E.S.D.) participated in deliberation if consensus was not reached.

Descriptive data points, such as publication date, publication dates of initial and revised documents, and authorship (e.g., singular authors, committees) were also recorded during this categorization.

Thematic analysis

We conducted a thematic analysis of the documents. After in-depth reading of 5 documents, two authors (N.V.N and E.S.D) inductively developed an initial codebook of themes addressed [37]. Non-mutually exclusive themes addressed included living conditions in jails and prisons, disparities in incarceration experienced by minoritized racial and ethnic groups, COVID-19 and specific sub-populations such as women, youth, transgender people.

Next, two study team members (N.V.N and T.A.N) independently performed a thematic analysis of all included documents in parallel. The codebook and definitions were refined iteratively during analysis. The final coding analytic framework was applied to all identified documents that were publicly available as of August 19, 2023. REDCap, an electronic data collection and management software, was used to manage these data. The team met weekly to generate consensus; all documents were coded by both analysts. Coding uncertainty was addressed through thorough team deliberation with the senior author (E.S.D.) until consensus was reached. Once the thematic analysis was completed, descriptive statistics were calculated using Excel.

Document categories frequencies

We found that documents appeared to be written with four main objectives: 1) educational materials for healthcare providers, 2) clinical guidance, 3) logistical guidance, and 4) policy advocacy. Several documents accomplished multiple objectives.

Of the 44 documents, 28 (63.6%) contained educational content on incarceration, carceral healthcare, or the health status of people experiencing incarceration. For example, the American College of Obstetricians and Gynecologists (ACOG) provided information on the reproductive needs of people who are incarcerated.

The majority of incarcerated women are parents and are of reproductive age, which has important implications for their reproductive health care needs. Adolescents in these settings also have reproductive health care needs that often are neglected. Additionally, the rapid turnover of incarcerated individuals and unpredictable timing of jail and detention releases can present challenges for health care delivery and continuity of care. – Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals Committee Opinion Number 830 [39].

Twenty-five of the 44 (56.8%) documents contained tailored clinical guidance and recommendations for caring for individuals detained in correctional facilities. These recommendations included taking precautions to protect a patient’s privacy and ensuring that people who are incarcerated receive treatment matching the standard of care within that particular field. For example, the American College of Emergency Physicians (ACEP) included practical guidance about interacting with patients in custody in the emergency department.

Care provided or needed must be unbiased and must not be influenced by officers. If safety is an issue, allow the officer to be in clear view. The healthcare provider should not jeopardize his or her own safety. The shackles and restraints may or may not need to be removed. - Recognizing the Needs of Incarcerated Patients in the Emergency Department [40].

Twenty-seven of the 44 documents (61.4%) included administrative, operational or organizational recommendations for interacting with the carceral system, which we labeled logistical guidance. For instance, the American Academy of Ophthalmology published a document with detailed instructions for seeking reimbursement after caring for patients detained in prisons and jails [41]. Logistical guidance documents also included suggestions for ensuring continuity of care after hospital discharge and navigating the correctional staff hierarchy to identify with a person authorized to make decisions as illustrated by the American Academy of Psychiatry and the Law.

Psychiatrists navigating in the correctional environment need to successfully communicate and interact with staff who operate in a structured chain of command. This chain includes a hierarchy, from line officers to supervising officers, with progressive ranks up to the facility warden or chief administrator. - The American Academy of Psychiatry and the Law Practice Resource for Prescribing in Corrections [42].

Lastly, 30/44 (68.2%) documents highlighted policies, either by advocating for policy change or by simply sharing information on policies, laws, or statutes relevant to the practice of that specialty, or to the welfare of people in prisons and jails more broadly. These included model language for policies at the level of a healthcare institution or recommending members promote policy change at the local, state, or national level. The following example is from the American Academy of Family Physicians (AAFP):

Due to increased incarceration time for many individuals, the AAFP calls for a review and changes to the cash bail system, as it increases the risk of both short- and long-term negative health outcomes, exacerbates socioeconomic disparities, and is racially biased against individuals who are Black, Indigenous, and people of color. - Incarceration and Health: A Family Medicine Perspective (Position Paper) [43].

Among advocacy-oriented policy statements, we further characterized their focus. Some documents addressed multiple topics. Among these: advancing or changing aspects of healthcare for people detained in prisons and jails (26/44; 59.1%), broader calls for reforming the criminal-legal system (17/44; 38.6%), and specific calls for improving correctional living conditions (13/44; 29.5%). S3 Table contains example excerpts from policies addressing these themes.

Common themes

Our thematic analysis of the associations’ official documents revealed several throughlines, irrespective of the document’s intended purpose. These content areas included general overviews of carceral healthcare, characterization of patients experiencing incarceration as medically vulnerable, addressing ethical quandaries that arise in the care of patients who are incarcerated, and highlighting certain subpopulations, such as youths and women. Table 1 presents overall prevalence of themes and Table 2 provides selected excerpts of all content areas that were extrapolated from this analysis.

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Table 1. Specific content areas and special populations.

https://doi.org/10.1371/journal.pone.0330361.t001

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Table 2. Example excerpts from medical association documents by theme.

https://doi.org/10.1371/journal.pone.0330361.t002

Many documents presented overviews of social, economic, and health factors that disproportionately impact incarcerated populations. The American Psychiatric Association called attention to the overrepresentation of minoritized racial and ethnic groups in correctional facilities, stating, “Black Americans are imprisoned at a rate of approximately five times the rate of White Americans, while Hispanic Americans are incarcerated at 1.3 times the rate of White Americans [44].” Another frequently mentioned topic was that people who are incarcerated have a Constitutional right to healthcare. The American Academy of Psychiatry and the Law document presented the legal framework underpinning this right in a practice resource for psychiatrists [42], emphasizing that their carceral status should not interfere with receiving healthcare.

We also discovered documents that included themes that educate clinicians on circumstances arising from their patients’ conditions of confinement. Ten documents included content about the impact of the COVID-19 pandemic in correctional facilities, with some acknowledging the enhanced risk of aggregate living conditions and emphasizing that delays in routine care should be avoided, in spite of the pandemic [45,46]. Other considerations specific to patients’ confinement included ethical concerns in the care of patients who are detained (e.g., shackling) and the incarceration of refugees and migrants. Additionally, many associations separately discussed at-risk subpopulations, including women, youth, older adults, sexual minorities, and transgender people. These documents acknowledged that disparities in numerous marginalized groups are often amplified in carceral settings.

Scarcity of Education and Guidance

We discovered that only 16 out of the 116 specialty association members of the AMA House of Delegates included in the search have published material on the care of individuals who are incarcerated. Topics spanned from educational attainment to socioeconomic status to chronic and acute medical conditions and to substance use and behavioral health disorders. We found that these statements help to establish a foundation for clinicians to understand overarching social and health disparities prevalent in populations involved in the criminal-legal system.

Only 12 out of 116 associations included in the search promulgated documents that contained pragmatic guidance to improve or manage the clinical care of patients experiencing incarceration, with guidance specific to their respective specialties. A scant number of documents offer guidance on delivering healthcare that affirms the human dignity of a patient who is incarcerated or, on a more basic level, how clinicians should interact with correctional staff in a clinical setting. Clinicians already struggle to address surrogate decision-making, in-hospital shackling, and correctional officer hospital presence as they care for patients who are incarcerated [25,28,47,48]. Because few educational or pragmatic guidance documents exist, clinicians are left to their own devices to navigate these often-complex dynamics.

Power of professional medical associations

We found that a small number of associations have published policy documents that advocate for the improvement of the criminal-legal system, correctional living conditions and healthcare of individuals experiencing incarceration. Yet, several associations have taken a significant stance on providing humanity-affirming care. Notably, the American College of Obstetricians and Gynecologists (ACOG) has published on key topics, including opposition to universal shackling, providing clinical guidance for clinicians to treat pregnant and post-partum patients in correctional settings, calls for lawmakers to protect and enhance the quality of healthcare for people who are incarcerated, and advocacy that has catalyzed federal legislative protections for patients who are incarcerated during childbirth [39,49,50].

Medical associations have historically advocated on behalf of marginalized populations. For example, the AMA has issued numerous policy statements in support of healthcare for sexual minorities and transgender patients [51–53]. The AMA, American Academy of Neurology, and the American Psychiatric Association have published position and policy statements advocating for equitable healthcare for patients with physical and intellectual disabilities [54–56]. Likewise, the American Academy of Pediatrics has published clinical guidance on the care coordination of pediatric patients with intellectual disabilities [57]. Medical associations could play a pivotal role in filling this void for patients experiencing incarceration, as they have with other disenfranchised patient groups.

Professional medical associations have also long influenced health practice and policy in the U.S. For example, the AMA secured a Center for Medicare and Medicaid rule to minimize prior authorization decisions, and has strongly advocated for affordable, over-the-counter naloxone [58,59]. Official documents issued by medical associations reflect the values and mission of the organization and can create a standard for members to follow. Furthermore, policy position statements can influence the creation of policy at the organizational (e.g., association, hospital system), local, state, or even federal levels.

Medical associations can influence treatment of individuals involved with the criminal legal system in both positive and negative ways, even outside of clinical settings, as illustrated by the story of “excited delirium.” “Excited delirium” has been listed as a cause of death in multiple police-involved fatalities, despite a lack of consensus on diagnostic criteria or clear pathophysiologic explanation for how delirium caused death. “Excited delirium” was formally endorsed by the American College of Emergency Physicians (ACEP) in 2009, in a document entitled, “White Paper Report on Excited Delirium Syndrome” [60]. It has since been shown to have been disproportionately diagnosed among people from minoritized racial and ethnic groups who are forcibly subdued by law enforcement [61]. In 2020 and 2021, respectively, the American Psychiatry Association (APA) and the AMA both formally opposed the diagnosis [62,63]. ACEP revisited the issue in 2021 by reporting recent research on the condition and in 2023, voted to officially derecognize “excited delirium” as a diagnosis, citing the term’s social harms [64,65].

Given that only 16 medical associations have attempted to advance dignified healthcare for people in jails and prisons, all medical associations should examine and acknowledge their potential impact on the health of people experiencing incarceration, either through action (published documents, advocacy) or inaction. Furthermore, they can catalyze a call to action for members to deliver compassionate medical care, policymakers to create policies that respect the dignity and rights of people experiencing incarceration, and correctional systems to collaborate with non-correctional healthcare workers to improve the health and healthcare of individuals involved in the criminal-legal system [66].

What’s Next?

While physicians and other health professionals are ethically obligated to provide care to patients experiencing incarceration that mirrors the patient-centered care they deliver to all patients, they often lack knowledge requisite to protect this patient populations’ rights and interests. Physicians recognize these training deficits and desire additional resources, acknowledging that these knowledge gaps are negatively impacting the care of an already disenfranchised population [67].

An important way to enhance clinician knowledge on carceral healthcare beyond medical association statements is through partnerships between academic medical centers and correctional facilities to provide learners with hands-on experience and knowledge of best practices. Several medical schools have collaborated with state and local correctional systems to develop such experiences, such as the University of Connecticut and University of Massachusetts Medical School [68]; yet, there are very few programs across the U.S. that facilitate this partnership [68]. Moreover, these programs only target clinicians-in-training and not practicing clinicians, failing to address education needs within the current clinician workforce.

Professional medical associations can empower clinicians to provide outstanding care to patients experiencing incarceration, standardize clinical practice guidelines, and even influence correctional and health policy. From our analysis, most documents were published after 2012, reflecting the medical community’s growing attention to mass incarceration over the past decade. Medical associations published 12 documents in 2020 alone, perhaps responding to racial disparities in COVID-19 deaths and the increased media spotlight on police violence and mass incarceration during the expansion of the Black Lives Matter Movement. This increase in attention may have influenced medical associations to promulgate statements and guidance to confront social injustices. However, medical associations should publish proactively rather than reactively. Furthermore, only 13.8% of AMA House of Delegates member organizations included in this analysis have issued guidance on this often-overlooked population. The remaining medical associations should consider developing materials about incarceration and health, narrowing the knowledge gap for healthcare providers. In turn, clinician-leaders can be better-informed as they provide bedside care or advocate for practice or policy change on behalf of future patients.

Limitations and future directions

Our study has several limitations. We relied on publicly available statements accessible through the association websites and through PubMed. Additional relevant documents could also be available only to medical association members, or may not be indexed by the search engines in this study. Statements varied in level of detail from brief, broad statements to nuanced, specialty-specific content. In addition, we were unable to evaluate whether healthcare professionals are referencing existing guidance and, when it is present, how often they influence clinical care. Future efforts should include needs assessments with clinicians from specialties commonly interfacing with patients who are incarcerated to gauge their knowledge gaps, so that societies can provide helpful and specific resources to educate and empower their respective workforces.