Challenges and Rewards of Life as a German Prison Doctor

Ensuring adequate medical care must be guaranteed even within prison walls. The working conditions for the 500 or so prison doctors in Germany are unexpectedly favourable, and not only in terms of remuneration. Prison medicine offers an ideal opportunity for doctors who like to work independently and are able to deal with challenging patients. 
We explored this topic in a conversation with Marc Lehmann, the head of the medical service in Berlin’s penal system.
The interview was conducted by Horst Gross, a specialist in anaesthesiology and intensive care medicine. 
Prison medicine sounds restrictive. What is the reality? 
Lehmann: Let’s dispel a common misconception first. Prison inmates are not second-class patients. In Germany, every prisoner is entitled to medical care equivalent to standard health insurance benefits. Therapies and examinations occur within the penal institution or the prison hospital whenever possible. If external measures are required, or if admission to a clinic becomes necessary, we facilitate it. While this proves personnel-intensive due to the need for supervision, the cost falls on the justice system, not health insurance. This simplifies many things: there is no budgeting by the Association of Statutory Health Insurance Physicians, so no recourse and no diagnosis-related group-controlled occupancy, and significantly less bureaucracy – although taxpayers’ money has to be handled responsibly.
Can you provide an example? 
Lehmann: This is evident, particularly in the case of hepatitis C. A significant percentage of inmates are afflicted by this condition. Although the treatment is widely recognised as highly effective, it comes with a significant cost. Nevertheless, we provide this treatment for all affected individuals who are in custody for a sufficient period of time. This aligns with our rehabilitation concept, aiming to contribute to the eradication of the pathogen as much as possible. Cost coverage is not a concern for us.
What qualifications are necessary for prison medicine? 
Lehmann: Theoretically, the licence to practise medicine is sufficient, as there is no specialist or additional training specifically for prison medicine. However, in practice, this alone doesn’t take you far. We expect our doctors to be specialists in fields that cover a broad spectrum of medical care. General medicine fits well here. Additionally, internal medicine or surgery, with a broad knowledge base, are also welcomed.
So, without being a specialist, one has no chance? 
Lehmann: Not necessarily. Opportunities exist in prison hospitals, many of which have partial authorisation, such as for internal medicine. Working in prisons can be an interesting addition to specialist training. Prison hospitals are well-equipped in terms of apparatus. This also provides exposure to clinical cases that are otherwise rare.
What diseases are prominent in prison medicine? 
Lehmann: We encounter advanced disease presentations resulting from limited contact with medicine. Where else would you witness conditions like miliary tuberculosis or encrusted scabies during your training? Additionally, there are various psychiatric disorders, such as chronic, untreated psychoses.
What about the problem of addiction? 
Lehmann: Over 40% of inmates have a relevant substance-related problem. This primarily involves alcohol, opioids, benzodiazepines, and increasingly crack cocaine, often leading to multiple dependencies. The challenge is to identify those affected promptly and establish a treatment alliance. Addiction problems are also concealed due to the fear of repercussions in custody.
What challenges exist with substitution therapy? 
Lehmann: We follow the relevant guidelines for substituting opioids, and if necessary, it could be a permanent measure. Other substances are administered on a temporary basis as part of detoxification, usually following a drug test. Although this is voluntary, it’s necessary to prevent deception. This ensures that our interventions are genuinely indicated.
Which drug is currently causing the most problems in prison medicine? 
Lehmann: Our challenging issue is pregabalin. It’s prescribed too casually on an outpatient basis. Addicts often seek prescriptions under false pretences when they can no longer access benzodiazepines. During withdrawal, we observe highly agitated and aggressive patients, with courses sometimes more dramatic than other detoxifications. This danger is inadequately recognised among outpatient colleagues.
Many medical practices are currently experiencing great frustration. The keywords are cost pressure and bureaucracy. Could prison medicine be an alternative? 
Lehmann: An experienced general practitioner aligns well with the profile we are looking for. We provide the additional qualifications needed for prison medicine, such as addiction medicine. The shortage of staff has substantially increased salary levels. While you can’t match the financial aspect of a private practice, this is offset by a regular 42-hour week. If your goal is to practise impactful medicine, you’re in the right place with us. Free from economic constraints, you can dedicate as much time to patients as needed.
What personal qualifications are essential for this role? 
Lehmann: The psychological and ethical burden in prison medicine should not be underestimated. We often deal with individuals who have committed serious crimes and have to maintain a high degree of professional detachment. At the same time, we are confronted with severe mental illnesses and the suffering associated with them. Striking a balance between prioritising the patient’s well-being and navigating the realities of prison life is a constant challenge. This requires a certain level of personal maturity. On the flip side, as a prison doctor, you have a genuine opportunity to make a positive difference in individual destinies.
Marc Lehmann is the medical director and head of the medical service in the Berlin prison system. 
This story was translated from Coliquio using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. 
 
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