The stakes of this question are considerable. Large numbers of people with psychiatric illness receive their treatment, such as it is, inside jails and prisons rather than in hospitals or community clinics. Epidemiological work has consistently shown that the prevalence of serious mental illness in correctional settings far exceeds that of the general population, and umbrella reviews have documented heavy burdens of both mental and physical morbidity among imprisoned people. Formerly incarcerated individuals face dramatically elevated risks of death after release, including from suicide and overdose. Yet the physicians best positioned to care for these patients, psychiatrists in particular, remain in short supply within correctional systems, and relatively few medical schools expose their students to carceral medicine in any structured way. National surveys of medical school curricula have found that criminal justice and health is rarely taught, and a 2025 systematic review concluded that education on justice-involved health remains patchy and inconsistent across institutions.

The UNC research team, led by Rachel Hianik, Katelyn Einloth, and Theodore Zarzar of the UNC School of Medicine, together with Paul Mihas of the university’s Odum Institute for Research in Social Sciences, set out to understand what actually happens inside the minds of learners who take the plunge into a carceral clinical environment. Their specific aims were threefold: to identify students’ beliefs before the rotation, to determine whether those beliefs changed as a result of the clinical experience, and to assess whether the elective motivated students to pursue future work in carceral medicine or instead deterred them from it. The researchers gathered deidentified written reflections from 19 medical students who participated in the correctional psychiatry elective between July 2022 and October 2025.

Methodologically, the study followed a well-established inductive qualitative approach. Two independent coders read through the student reflections and constructed a codebook of themes that emerged organically from the text rather than being imposed in advance. The reflections were then systematically coded using ATLAS.ti, a widely used qualitative data analysis software package, version 23.2.1. As coding progressed and new themes surfaced, the codebook itself was revised, and any discrepancies between the two coders were resolved through consensus discussions. This iterative process is designed to minimize the risk that the researchers’ own expectations shaped the findings, and it allowed the team to trace patterns across multiple students’ narratives with a degree of rigor that anecdotal reports cannot match. The study was exempted from Institutional Review Board oversight by the UNC Office of Human Research Ethics, and the authors report no conflicts of interest and no external funding.

The analysis yielded five dominant categories of themes running through the student reflections. The first was preconceived notions, the baggage students carried in before they ever set foot in a prison. The second covered perceptions of the prison environment itself, the physical and institutional atmosphere students encountered. The third concerned perceptions of the people in prisons, that is, how students came to see incarcerated patients as human beings rather than as the caricatures they had imagined. The fourth addressed perceptions of the prison system, the structural and bureaucratic realities of delivering health care behind bars. The fifth captured insights gained, the personal and professional lessons students drew from the experience. Within this framework, one finding stood out with particular force: most students reported that their actual clinical experience simply did not align with what they had expected, especially regarding safety and the perceived aggressiveness of incarcerated people.

That misalignment appears to have been transformative rather than merely surprising. Many students described moments in which clinical interactions humanized incarcerated individuals, collapsing the psychological distance between “patient” and “prisoner” that many had brought with them. At the same time, the reflections were not uniformly rosy. Students frequently recognized the deep shortcomings of the carceral system, from its limitations as a site of care to the moral discomfort of practicing medicine within a coercive institution. The researchers note that students managed to hold both truths simultaneously: an acknowledgment that the system fails its patients in important ways, alongside an appreciation that their own work within it was meaningful and rewarding. This tension echoes earlier writing by study co-author Theodore Zarzar on moral distress, hope, and the carceral experience, and it suggests that the elective does not indoctrinate students into cheerleading for correctional medicine but instead equips them to see the system with clear eyes.

Perhaps the study’s most consequential conclusion concerns how those attitudinal shifts actually occurred. The researchers found that students’ preconceived notions were challenged most powerfully during direct student-patient interactions, not during didactic teaching or observational learning. This carries an important implication for medical education: clinical rotations involving direct patient care may hold unique value compared with lecture-based curricula about carceral health care. The finding aligns with a growing literature on experiential learning and with prior qualitative work, including an Australian study of clinical placements in correctional health in which learners reported having “no idea” what prison was actually like before their placements, and an earlier BMC Medical Education study linking prison health service experiences to social cognitive career choice. It also dovetails with research on the “hidden curriculum” of caring for incarcerated patients, which argues that unexamined attitudes toward this population are transmitted to trainees precisely because structured, reflective exposure is so often absent.

The career implications are equally significant. According to the study’s conclusions, the elective led many students to consider working with incarcerated people in the future. This matters because the pipeline into correctional psychiatry is thin. A 2012 study asked whether exposure during residency training could help address the shortage of psychiatrists in correctional settings, and subsequent surveys of general psychiatry residents have documented wide variability in forensic training. Workforce researchers have also documented persistent misconceptions about working in correctional psychiatry, including exaggerated fears about personal safety, that likely deter candidates who might otherwise find the field rewarding. If a brief medical student elective can measurably loosen those misconceptions before they harden into career decisions, the findings suggest a practical lever for building a workforce capable of serving one of the country’s largest and most neglected psychiatric populations.

The scale of that population lends urgency to the educational problem. The World Prison Population List estimates that more than eleven million people are held in prisons worldwide, with the United States accounting for a disproportionately large share; Bureau of Justice Statistics data indicate that correctional populations in the United States remain in the millions when jails, prisons, probation, and parole are combined. Within US state prisons, systematic reviews have estimated that a substantial fraction of inmates meet criteria for psychiatric illness. The people who cycle through these facilities return to communities, often with untreated or poorly managed conditions, and the transition from carceral to community care is a documented point of catastrophic risk. Physicians who understand this world, because they have seen it firsthand rather than through the distorted lens of popular culture, are therefore not a luxury but a public health necessity.

The UNC study grew out of a correctional psychiatry elective developed with an explicit focus on structural competency, a framework that trains clinicians to recognize how institutional and social forces shape individual health. That design choice may help explain the richness of the reflections the team analyzed: students were not merely shadowing clinicians but were being asked to think critically about the systems surrounding their patients, and then to write reflectively about what they saw and felt. The authors caution, as qualitative researchers do, that their findings derive from a single elective at a single institution with a modest sample of reflective essays, and that the generalizability of the themes to other programs and settings remains to be tested. Quantitative follow-up, tracking whether students who complete such electives actually enter correctional medicine at higher rates, would be a natural next step.

Still, the core message is difficult to ignore. Attitudes that might otherwise persist for an entire career, such as the assumption that incarcerated patients are inherently dangerous, can be revised within the span of an elective through the simple, ancient mechanism of a clinician sitting down with a patient and listening. The study suggests that medical schools seeking to prepare graduates for the realities of American health care should not confine carceral medicine to the lecture hall. It lives or dies, the UNC team’s evidence indicates, in the examination room, where twenty-three-year-old students discover that the person across from them is not a character in a crime drama but a patient, and that treating them can be among the most rewarding experiences of their training. In a field where the patients are numerous, the doctors are few, and the misconceptions run deep, that discovery may be the beginning of everything.