Last December Ruth, one of Shannon Trust’s volunteers, caught up with Dr Yousaf to hear about his experiences as a GP, and his thoughts on the importance of reading.
Dr Yousaf, or Dr Y as he is known to his patients and colleagues, has worked as a GP in prisons and with people in Young Offender Institutes, since 2012.
His book, Stitched up – Stories of life and death from a prison doctor, distils his experiences over this time. He takes readers into his less than glamorous consulting rooms, shares crises, ‘code blue’ life threatening emergencies and some of his regular appointments. He deliberately avoids knowing what crime his patients have been accused of, because he doesn’t want this to get in the way of his care - but as he’s worked in all categories of prison it could be anything.
His book is a fascinating and humbling read, with its insight into prison life in general and prison health care in particular, as well as the remarkable people who help those in their care and try to keep them safe.
What drew you to work with patients in prisons?
I value care work on the margins of society, as this is often where need is greatest.
My GP experience began at a practice for homeless people. It was then that I realised what a misconception our stereotypical picture of homeless people is, and how close we all are to becoming homeless.
There’s great overlap between homelessness and prisons. Once you get into one of those negative cycles, things can just keep going wrong unfortunately.
A colleague suggested I might be suited for prison work. So, rather as things can spiral out of control for my patients, professionally speaking I followed that spiral, and went from homelessness to prisons.
Something I strive to do is see the humanity in people – I always see a person as a person and not as their medical condition. So, for example, rather than thinking of someone as a schizophrenic, they’re a person with schizophrenia.
This may sound like semantics, but actually it’s really crucial to see the person you’re caring for as a person. Being in prison, or being homeless, is a dehumanising, brutalising experience so no one’s going to be at their best – and this is when your humanity really shouldn’t be forgotten.
Are you able to describe, briefly, a typical day and some of the challenges you’re likely to face?
If I can come in and log onto my computer that’s a good day, because I feel I’ve got my bearings and can make a start.
But this isn’t always the case! There might be an early emergency that needs managing or colleagues asking for advice, or maybe something’s happened in the night that the medical team need to know about. Or sometimes someone might need to go to hospital urgently, so the prison has to move appointments around to make officers available for an escort. Generally, people who work in health care like to bring order to chaos; we tend to be good at solving puzzles and aren’t easily overwhelmed by the complexity of different things happening at the same time.
In terms of a typical prison GP’s day, there’s a clinic in the morning and a clinic in the afternoon, which is similar to GPs in the community. I think what’s different is that most prisons have a segregation (or care and separation) unit. Depending how big the prison is, this can hold up to 20 patients – we need to do a round there at least 3 times a week, generally Monday, Wednesday and Friday. Some prisons have an in-patient unit (or hospital wing) too, for the patients who are most unwell, so we need to do a ward round there. We may also be asked for input or support at clinics which our nurses and paramedics run.
We have lunchtime meetings – including clinical quality meetings and multi-disciplinary meetings, for example involving psychiatrists, prison staff or the prison drugs team. We also have meds management meetings, to make sure our prescribing is safe. Prison GPs have additional qualifications so they can prescribe certain controlled medications, like methadone, which away from prisons are administered through community drugs teams.
I think the biggest difference currently is that remand prisons can take in between 30 and 50 new people a day. So that’s potentially 50 new patients on a daily basis. At times working in a remand prison can seem like working in a busy A&E department. Some will have come to prison from court without their medications, and some may not know what medications they’re on. Prison pharmacies need to do a significant amount of work with community GPs to try and make sure there’s no break in treatment. Sometimes people don’t see their community GP, men especially, and are only diagnosed with conditions, or get on top of their medication, when they come into prison.
So really it is anything and everything – day to day you’ll see all the conditions that are seen in the community. Lots of chronic diseases. Lots of people with disabilities. And lots of people who get diagnosed with serious illnesses like cancer in prison.
It's very time pressured. You’re always running from one thing to another as there’s always something that needs doing. If there aren’t patients to see, there are letters or tests to sort out. Especially since Covid we’re seeing more patients who have multiple conditions, which in the community would be covered by different teams – for example, a physical illness alongside mental heath issues and substance misuse issues.
But for those of us with that problem solving mentality, it’s very satisfying when you feel you’ve genuinely helped someone.
What made you realise that some (or many) of your patients in prison struggle with reading, or can’t read at all?
I’m passionate about making medicine accessible, and educating my patients about their health, so my usual practice is to give outpatient information leaflets. When I started working in prisons it was quite common for people to say they couldn’t read, and I would have to do drawings to help them understand what was happening to their bodies.
Also access to prison health care is by filling in applications, to see the doctor or dentist or physio. This is a problem if you’re functionally illiterate. You might need to ask another inmate to fill it in for you, which isn’t great if it’s for something really personal. And a lot of the patients see it as a weakness having to ask for help, so this may stop them asking for health care.
You’re generous in the comments you make about Shannon Trust in your book. How, and when, did you become aware of us, and the work we do?
I’d see someone who was clearly very intelligent, but couldn’t read and had this negative self-talk about being dumb or stupid. So, with colleagues we’d get in contact with Shannon Trust to try and encourage that person to get on a reading programme.
Literacy is something that’s important to me. It was through working with Shannon Trust that I realised how big an issue not being able to read is – not just in prisons, but in society. It was eye-opening to learn how people who struggle to read and write effectively have their voices silenced.
For me, Shannon Trust changes lives one sentence at a time.
Jamie’s story runs like a thread through your book, from his aggressive demands in your early days, to him accepting the role of prison health champion and starting to learn to read with Shannon Trust, and so beginning to write himself – embracing poetry – and then ahead of his release inspiring you to start writing again yourself. This shows a profound change in someone’s thinking about themselves and their future. Is this something you see regularly (maybe not always quite so marked) or was Jamie an exception?
There are thousands of Jamies in prisons. I think what his example teaches is the importance of not giving up on people.
We’re all capable of change and improvement, and not just with reading. It’s never too late to learn different ways of dealing with our frustrations and emotions.
In the introduction to your book, you talk about the intersection between medicine and literature. What benefits do you see for your patients in prison when they can read, and have access to books and other reading material? Is reading and literature something you believe can contribute to rehabilitation?
I believe in the therapeutic power of literature. Words are power, and having your voice heard is a superpower.
I think literature is especially important in prisons, because there’s a lot of frustration and there can be a lot of time when people are locked up.
For instance, in the segregation unit you will often see people reading. If I do my rounds there and see someone with a book, I document this and ask if they’re enjoying it. I might also discuss what they’re reading or make suggestions for other books. This is important because people in prison have stories as well, and their stories need to be shared.
You can quite often feel isolated, especially in prison, and find it difficult to formulate thoughts or name your emotions. So, if an author puts words together in a poignant way that matches your experience, it can feel as if they’re speaking right to you. This is what books do. They can be transformative.
Reading is also a masterclass in empathy. Sometimes people in prisons can lack empathy with others. But the more you read the more empathy you develop, so you start seeing the world through someone else’s eyes, or trying to understand situations from another perspective. This is the magic of books.
I’d like to be able to do a book clinic and be able to prescribe books or poems, to treat people holistically.
How do you maintain (or top up) your reserves of patience and compassion for your patients (and maybe sometimes colleagues too), and make sure the dehumanising environment you’re working in doesn’t get in the way of your commitment to treating everyone as a person?
I’ve seen things I can’t unsee, and had experiences I wish I hadn’t. My name, Shahed, means witness; and I’ve witnessed a lot. With this it’s important to recognise my own humanity; to forgive myself and forgive others.
Before I began working with homeless people and in prisons I was quite thin skinned, and now I’ve got quite a thick skin. I look at the bigger picture.
At the same time, I want to thrive and flourish in my role. One of the ways I do this is with humour, which is often dark humour but it’s my coping mechanism. You do tend to find that people who work in high stress environments have dark humour; it keeps us all going. It’s not at the expense of patients – it’s at the expense of ourselves. We have to be able to laugh at ourselves, not take ourselves too seriously, and not take it to heart when people who come to see you are swearing, insulting you or banging the desk.
It’s also important not to be too hard on yourself, and amongst colleagues to look out for each other. People who choose medical careers tend to be quite meticulous, which is a good thing. But the flip side is that we can be hard on ourselves, focus on things that could have gone better and overlook the things we do well. This can lead to burn out, depression and self-harm.
Do you have a favourite book? If so, what is it and why?
I’m a moody reader, so my favourite books depend on my mood. We had stormy weather in late November and I picked up Wuthering Heights, which I’ve read many, many times. It was one of my favourite books when I was a teenager. But whenever there’s driving rain that book just pops into my mind.
Autumn spooky season is when I read lots of ghost stories. Spring is very different. I have lots of books on my to-be-read pile, and I have some that I keep always to hand.
Probably one of my favourite books is Beloved by Toni Morrison. I love, love, love this book; I think it’s the voice that holds me, the cadence, the melody, the poetry right from the opening sentence. I’ve read everything by Toni Morrison – she’s the GOAT; I absolutely love her.
I make time to read. I’m a writer, so I find the way I process the world is through writing, and reading is part of this. I tend to write between 10pm and 2am every day. I don’t need a lot of sleep so I make sure I write every day, and that’s my time.
Reading is something that’s been really positive in my life and I want others to benefit from it as I have. In male prisons in particular I see people who prioritise going to the gym, and I would love there to be a recognition of the equal importance of a mental gym, which is a library. Reading promotes mental toughness, understanding and empathy. Thinking of reading in this way could help us start tackling the issues we have with men in particular not talking about their health, especially their mental health. Prisons could be the sorts of places to start these processes.
For those who want to learn more about his experiences and working life, Dr Yousaf’s book Stitched up – Stories of life and death from a prison doctor is readily available in print, audiobook and on Kindle. We’re grateful to him for taking the time to talk to Shannon Trust, for his interest in our work, and for encouraging some of his patients to try our programmes.
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