County Jail as a Novel Site for Obstetrics and Gynecology Resident Education

Exposure to diverse populations is a critical component of resident education, as it promotes the development of physicians who can provide comprehensive care for patients from a variety of backgrounds. Similarly, caring for underserved populations during residency training has been recognized as an important strategy for developing professionalism; engaging with underserved groups encourages physicians to integrate individual patient care with broader public health issues.1 The Accreditation Council for Graduate Medical Education (ACGME) systems-based practice competency includes learning about system issues which influence health inequities. Prior studies have shown that residents feel uncomfortable with their knowledge of the specific issues affecting underserved populations.2–4 

At a time when the US health system is undergoing radical reform, it is more important than ever to train residents to provide care in diverse settings. Prisons and jails serve primarily medically and socioeconomically marginalized populations with poor access to health care before incarceration.5 Jail presents not only a public health opportunity for an underserved population5–7 but also an educational opportunity for residents.

We designed a curriculum consisting of 6 weekly, half-day clinic sessions at the local county jail for first-year obstetrics and gynecology residents. We anticipated that this would provide a varied clinical experience, help residents to develop their communication skills, and encourage them to think broadly about the social context of reproductive health care. We present information from the first year of this rotation.

Beginning in July 2009, all first-year obstetrics and gynecology residents at our institution began rotating through the Women's Health Specialty Clinic at the San Francisco County Jail. This clinic operates as a partnership between San Francisco Jail Health Services and the University of California, San Francisco (UCSF). The weekly clinic was started by a UCSF faculty member (CS) whose salary is supported by the Department of Obstetrics and Gynecology at UCSF. Because the jail is under the purview of the Department of Public Health, resident salary and malpractice insurance is covered through San Francisco General Hospital and the Department of Obstetrics and Gynecology at UCSF. Medications and clinic supplies are covered by Jail Health Services. Additional equipment and supplies, such as a colposcope, intrauterine devices, and subdermal contraceptive implants, were procured through educational grants through UCSF.

For one-half day per week during their 6-week Ambulatory Care rotation, residents see patients at the jail under direct supervision by an obstetrics and gynecology faculty attending physician. Residents gather the patient history and then present to the attending with the patient in the room. Physical examinations, procedures, and counseling are all done with the resident and attending in the room together with the patient.

Currently, one attending physician staffs the clinic. This faculty's training prior to starting the rotation included a Sheriff Department orientation, clinical care and resident education in a county hospital, familiarity with social science literature of health disparities and prisons, and clinical experience working in a jail. We are in the process of formalizing a training guide for other faculty to be able to staff this clinic.

Before the first session, residents receive a copy of the San Francisco Sheriff's Department Guidelines for working in jail. Security clearance is arranged by Jail Health Services. On the first day, the faculty attending provides a detailed orientation, including an overview of incarceration in the United States, correctional health, and the San Francisco County Jail. Rotation objectives, which were designed with the 6 ACGME core competencies in mind8 are reviewed (table 1). A Values Clarification Exercise is conducted with the resident; this is a scenario-based discussion designed to encourage providers to recognize their own implicit judgments involved in challenging patient interactions (provided as online supplemental material). Finally, residents go on a tour of the jail intake facility and the general housing units.

To complement the clinical aspects of the rotation, the residents complete weekly reading assignments which are then discussed with the attending during each clinic session. Some articles describe clinical research with incarcerated women,6,9–21 while others provide anthropological and sociological analyses of incarceration. For the final session, residents write a 1-page reflection essay, processing their experience at the jail.

All residents completed an anonymous online rotation evaluation. To ensure anonymity, responses were reviewed at the end of the year, and no demographic identifiers were collected. This 17-item questionnaire asked residents to report the most and least valuable aspects of the rotation; to describe challenges; to contemplate the applicability to future clinical experiences; to evaluate the didactic portion of the curriculum; to assess their perceptions of safety and supervision; and to suggest rotation improvements. These were all open-ended questions. The responses were manually coded and analyzed in an iterative manner to explore patterns and key themes. The questionnaire also asked residents to rate, on a scale from 1 to 5, to what degree their experience matched the rotation objectives. Information on the number and type of clinical visits and procedures per resident was also collected during this time period. This evaluation study was granted an exemption by the Committee on Human Research at UCSF. At the end of the rotation, residents were evaluated using the online ACGME competency-based evaluation, which is used for all rotations in our residency program.

All 9 first-year residents in our program completed the rotation evaluation. Overall, they identified it as a positive experience and reported that rotation objectives were adequately fulfilled (table 1). Family planning and prenatal care were the most frequent visit types, but residents were exposed to a wide range of gynecologic diagnoses (figure). Residents performed, on average, 4 procedures during each 6-week rotation, including intrauterine contraception and subdermal implant insertions, colposcopies, and endometrial biopsies. More than 1/3 of patient visits were follow-up visits (table 2). In the evaluation, when asked what they would change about the rotation, all residents either reported “nothing” or suggested more exposure to this setting. No residents reported concern for their safety or supervision.

Responses to the open-ended questions coalesced around several themes: the unique setting, clinical knowledge gained, learning systems issues, the volume and pace of the clinic, continuity of care, and teaching opportunities. When asked “what did you like about this rotation,” all nine residents commented on the unique population and setting. One resident qualified this by appreciating the opportunity to work beyond the comfort zone of the hospital, while another enjoyed “the intersection of clinical care and examining socio-political structures that affect the women's life.” Four residents positively noted the breadth of clinical exposure to “bread and butter obstetrics and gynecology.” Because clinic flow at the jail relies on deputies, the pace is sometimes unpredictable, occasionally with up to 45 minutes between patients. Some residents appreciated those moments as opportunities for clinical teaching and discussion of broader social issues affecting this population. Others found this downtime frustrating.

Follow-up with patients in jail was reported by many residents as a strength of the rotation. On the other hand, residents reported challenges with ensuring continuity of care once women were released. Residents noted some tensions between societal forces and priorities of medical care. For instance, one resident experienced “struggling with my feelings about what would be best for the patient and society, and with respect for patient autonomy.” The nuances of challenging patient interactions were also evident in comments like “I wanted to advocate for my patients and get them the care they needed, but I also didn't want to be taken advantage of.” This resident was referring to the experience of patients requesting pain medications or special privileges.

Regarding the longer-term effects of the rotation, residents identified an improvement in their communication skills and approach to counseling which they would use outside of the jail. Because the public teaching hospital where our residents train serves a similarly disadvantaged population, residents explained that they were now more aware of the socio-political issues facing marginalized women both in and out of jail. This context meant for one resident that “[I will] treat every patient equally regardless of their socioeconomic status, race, or criminal status.”

The residents' final reflective essays expanded on many of the themes from the evaluations; residents processed their experiences by considering the larger context of their patients' lives and the impact on their self-perception as physicians. One resident wrote that medical care gave women some control over their lives even in a jail setting where they have little (Box 1). Another resident commented on the sense of empowerment which she gained as a developing physician, helping this vulnerable population (Box 2). For a third resident, having time to hear incarcerated patients' stories helped her to remember that all patients have stories (Box 3). Overall, the end-of-rotation essays provided residents an opportunity to reflect on their professional development in this unique setting.

Providing care to women in jail is a novel way to introduce obstetrics and gynecology residents to key aspects of health disparities and vulnerable populations, as well as to routine reproductive health diagnoses. Residents reported having had a positive experience, stemming predominantly from the psychosocial aspects of working in this setting. Through patient care and structured discussions, residents gained an understanding of how race, socioeconomic status, and other social determinants of health contribute to health disparities. With the breadth of clinical opportunities, professionalism development, and practicing medicine within a larger institution, this rotation meets all of the ACGME core competencies. The unique institutional structure of a jail especially highlights systems-based competencies. Because of the positive feedback, the rotation is still an integrated part of our residency. Future directions include a systematic assessment of resident attainment of the core competencies.

This report is the first description of a rotation for obstetrics and gynecology residents caring for incarcerated women. Although a prior study reported that 11% of obstetrics and gynecology programs offer opportunities to work in a correctional setting, none had a comprehensive, integrated curriculum for all residents.22 The educational benefits of exposing medical students to prison health care have been described, with similar emphasis on systems-based learning, breadth of clinical diagnoses, and development of interpersonal skills.23,24 In addition, an Internal Medicine program and Plastic Surgery program reported that a prison health rotation was a useful clinical and preventive health training experience.25 

Although the patient volume in this clinic is low, the time was used for detailed reflection on challenging patient interactions. Residents received immediate feedback on their counseling style and procedural skills. Residents cultivated skills in this rotation that will extend beyond their experiences at the jail. Continuity was present in patient care on site at the jail, and some women were also able to follow-up in residents' continuity clinics after release. In addition to the clinical training, the structured didactic curriculum allowed residents to maintain their critical reading and writing skills while learning about broader social aspects of health care delivery for vulnerable populations. Many patient interactions challenged residents to consider ethical issues of patient autonomy, beneficence, and allocation of resources. To minimize the risk of overreporting the positive nature of this experience, the evaluations were anonymous and not read until all residents had completed the rotation. Challenges of the rotation included integrating a clinical teaching model into a correctional setting and ensuring continuity with patients upon release.

Since the 1976 Supreme Court case Estelle v. Gamble, prisoners have had a constitutional right to medical care.26 Nonetheless, variability exists in the scope of therapeutic and preventive health care services. A partnership such as the one we developed between an academic medical center and a correctional facility can bring additional services that benefit patients, trainees, and even correctional facilities. There is also potential to inspire residents to care for this population in their future careers. A rotation like this can also help residents from other specialties such as Internal Medicine and Family Medicine gain women's health experience.

A rotation for obstetrics and gynecology residents in a correctional setting offers valuable opportunities for clinical and professional development. As residents must learn to work in an increasingly complex world of health inequalities, training residents in a prison or jail is a multifaceted way to benefit both patients and trainees.