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 (). Family planning and prenatal care were the most frequent visit types, but residents were exposed to a wide range of gynecologic diagnoses (). 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 (). 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.
Number and Type of Visits, Jail Women's Health Specialty Clinic, July 2009–June 2010
Number of patient visits, Jail Women's Health Specialty Clinic, July 2009 to June 2010
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.
Box 1 Resident Reflection Essay Excerpt 1
The patient seemed to delight in the concept of choice [of contraception], that she somehow maintained some sense of autonomy, despite having it taken away in all other aspects of her life—what she wore, what she ate, where she slept, when she could go home. It is in those moments that I am able to appreciate a glimmer of hope, the promise of change that flashes in their eyes.
Box 2 Resident Reflection Essay Excerpt 2
In all honesty, it was dream clinic—I was interacting with young women who are traditionally disempowered and marginalized in society….I felt empowered by the work I did at the county jail. I felt, as a physician, I was helping women who had very constrained choices create more choices for themselves. The work we did in that small exam room in the jail made me believe that I could help make their lives outside the jail somewhat less complicated….
Box 3 Resident Reflection Essay Excerpt 3
The women we meet and see in any clinic only bring with them a small piece of the tapestry that forms their life. For Ms. JH, I was lucky to have been able to see the context behind the [prior] months of her life. As a young clinician, I will aim to continue to see my patients as more than the 15 minute slot they have been given in clinic, and consider the social context and story that paints her life.