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Introduction

Institutional practitioners are physicians who work for an entity whose interests are sometimes adverse to their patients' interests. The most common institutional practice is occupational medicine, which is reviewed in Chapter 30. This chapter discusses prisons, sports teams, and schools. These represent a continuum, with prisons having the greatest conflict between the institution and the patients, and schools having the least. When physicians practicing in these environments balance their duty to the patient against their duty to the institution and the community, they must not confuse public safety issues with institutional convenience. For example, prison physicians should not drug patients just to keep them quiet but must not hesitate in diagnosing and treating communicable diseases that may spread in the prison setting. School physicians face the same dilemma when requested to recommend Ritalin to quiet an unruly student.

The team and school physicians share the conflict between institutional obligations and the fiduciary duty to the individual patient. This conflict is exacerbated because many patients are unable to make knowing choices of treatment. Often the patients are minors. In others, the coercive atmosphere of team sports makes it difficult for individual athletes to resist the pressure to compete when it is medically contraindicated. School and team physicians must be careful to protect their adult patients' autonomy. When the patient is a minor, the physician may have to intercede to protect the child from the pressure of overly competitive parents and coaches.

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