Coming out of residency, I knew I wanted to work in correctional psychiatry. Jails and prisons have among the largest populations of psychiatric patients in the USA [1]. This patient population is the most forgotten and passed over when it comes to the goodwill of society. I was ecstatic when I landed a job doing correctional psychiatry at a medical school. My ultimate goal was to expose and promote correctional psychiatry to medical students. This seemed especially important since there is such a dire need for psychiatrists in correctional systems [2] and there are many unique aspects to practicing in the prison, such as understanding the system, medication formularies, and patient panel management [3]. As I enter my fifth-year practicing and teaching correctional psychiatry, I realize the biggest lessons I pass on to my students are not navigating the system or medication management but, instead, tolerating distress, building empathy, and being with patients in suffering.

My practice in the prison system has been challenging on many fronts. I do telepsychiatry for a prison in rural North Carolina. I see patients both in the general population and restrictive housing. By happenstance, I work at one of the most violent and gang-ridden prisons in North Carolina. The gangs control most parts of prison life, and violence is a normal occurrence at this prison. After a violent event, the inmates go on “lock down,” meaning inmates must stay in their cell for days at a time. Practically speaking, the constant violence and lock downs mean that even my patients in general population spend most of their days locked in a small cell with very little time around other people and even less time outside.

My patients present with chief complaints like anxiety, depression, paranoia, and insomnia. But I hesitate to diagnose my patients with any “disorder.” One patient is having more panic attacks because blood splattered on him yesterday during a stabbing. A patient is feeling more depressed because he watched the correctional officers drag the dead body of his cell neighbor out after an overdose. Another patient is paranoid because a gang put out a hit on him. My patients have insomnia because they are locked in a small cell all day with florescent lights 24 h a day. These psychological responses seem appropriate and even adaptive considering the horrific circumstances of prison life. This reality of prison life leads to interesting and fruitful discussions with students about the purpose and meaning of psychiatric diagnoses.

For many of my patients, medications have little place in their recovery. Unfortunately, there is not a pill for the ongoing exposure to violence and trauma that they experience. I initially thought I would be teaching about the limited formulary, the concern for misuse, and the pharmacology of psychiatric medications in this medication management prison clinic, but these topics have not been where the lessons are for students. My students learn much more about the limitations of psychopharmacology than the use of it. My clinic exposes students to the helplessness that is experienced by many physicians when faced with human suffering. Although there are many advances in our medical abilities, physicians must contend with the limitations of our modern medicines and learn how to still be a source of support and comfort.

Fortunately, psychiatrists are trained in more than just psychopharmacology, as our training requires exposure to various forms of therapy. Through the alphabet soup of therapy, there are common features to all: empathy, understanding, and being with patients in their time of need. I use these skills when working with patients who are chronically stressed in a violent environment for sentences that extend decades. I model demonstrating interest in my patients, learning about their lives and families, and listening to their sadness as they lose more loved ones outside of prison every year. I speak to my students about treating patients with dignity and respect, particularly as the prison environment is de-humanizing in almost every sense. I discuss with my students that being with my patients in their hardship is the best I can do in many cases, which is true not only in correctional psychiatry, but in many areas of medicine where physicians are called to bear witness to human disease and suffering.

I did not predict that the inhumane environment of correctional psychiatry would be an ideal space to focus on the humanity of medicine with medical students. The prison forces discussions of diagnosis and the futility of many medications while emphasizing the important skills of tolerating the distress of your patients, building empathy, and being with patients through adversity. As it turns out, correctional psychiatry is the ideal site to focus on the art of healing.