Every Friday, Dr. Shariar Cohen-Gadol drives 71 miles from his home in West Los Angeles to California State Prison, Los Angeles County, a 262-acre facility in Lancaster that houses more than 5,000 convicted felons, some of whom have rheumatoid arthritis, osteoarthritis, or other rheumatologic disorders. To the California prison system, these inmates need medical care despite their being held in minimum, high-medium, and maximum custody, and Dr. Cohen-Gadol is the physician who provides that care.
Dr. Cohen-Gadol described the overall rheumatologic care provided to California inmates as being better than what some managed care organizations offer. If an inmate with moderate to severe arthritis fails to respond to methotrexate, “I have no problem getting him adalimumab or etanercept,” he said.
“My recommendation may have to be reviewed by the chief medical officer at the institution. But so far, I have been impressed by how prisons have been able to provide [anti-tumor necrosis factor] agents so fast.”
The care he gives the California inmates with rheumatologic disorders is not limited to infusions of biologic agents. Dr. Cohen-Gadol does everything from giving general physical exams to administering intra-articular injections and conducting follow-up visits with those who've started therapy with anti-TNF agents or other medications.
Telemedicine also plays a roll in this care. Dr. Cohen-Gadol uses a telemedicine setup that is located in a dedicated office at the prison and provides him with access via two-way video feed to about 30 other sites in the state operated by the California Department of Corrections and Rehabilitation, a program that he helped launch nearly 2 years ago.
“We may consult with four or five institutions by telemedicine in one day,” said Dr. Cohen-Gadol, a rheumatologist who practices in Thousand Oaks. “I call in and the other health care providers appear on the TV screen. We may evaluate two inmates from one institution, or five follow-ups. I take the history and the nurse at the other end of the connection does the exam.”
He said he was drawn to the work because it broadens his clinical experience without the burden of administrative overhead. His interest in the health issues of prison populations was born during his residency at the University of California, Los Angeles, when he conducted grand rounds on the manifestations of hepatitis C. At the Lancaster facility, at least one-third of inmates are infected with the disease.
“That means that more than 1,200 have chronic hepatitis C,” he said, noting that most of the inmates he treats are in their 30s and 40s. The chronic infection seems to increase the inmates' risk for some markers of rheumatologic disorders. With hepatitis C, many patients “have antibodies for markers of lupus, like [antinuclear antibody], or markers of rheumatoid arthritis, like rheumatoid factor. It creates an enigma for the primary care doctors, so I get the referrals.”
He's seen cases of cryoglobulinemia, Raynaud's disease, exotic rashes, kidney involvement, hives, urticaria, joint pain, myalgia, and polyarthralgia associated with hepatitis C.
“One thing that increases the difficulty of providing rheumatologic care to inmates is the limitation of using certain drugs in patients with hepatitis C infection,” Dr. Cohen-Gadol commented. “A lot of drugs are immunosuppressive and are processed through the liver, like methotrexate. That makes it difficult for a patient with chronic RA. Sometimes we have to use drugs like etanercept or adalimumab because they have worse disease.
“It creates a challenge.”
If an inmate needs an intramuscular injection, the nursing staff can administer it locally. However, for intra-articular or bursa/tendon injections, an on-site physician needs to give it. “This is obviously one of the many shortcomings of telemedicine,” he said.
However, many glitches in his efforts to provide care have nothing to do with flaws of technology. “We are sometimes limited when inmates refuse care, or there are lockdowns, or they are getting paroled, or there are family visits,” Dr. Cohen-Gadol explained. “Let's say you're scheduled to see 20 patients one day. Maybe you'll see 13 or 15 patients instead. It's not perfect.”
As the only rheumatologist consultant for the California's prison system, Dr. Cohen-Gadol endures long waits, sometimes up to 4 months, for certain tests, imaging, and follow-up visits. “Patients may have to be transferred to an academic center for a biopsy.”
He went on to note that the physician-patient relationship in the prison setting is different because “you're dealing with a population you can't fully trust. Many of the patients have a history of polysubstance abuse. A large number have used cocaine, heroin, and crystal methamphetamine. Some of the patients with whom you deal are very manipulative and drug seeking. Others are rude and abusive. Some are brought in wearing shackles because of their past histories. But most of them behave pretty well because they know they need your help.”