Objectives: To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients. Design: Retrospective cohort study of a sample of prisoners' medical records. Setting: All Belgian prisons (n = 33). Patients: 513 patients over a total of 182 patient years, 3328 gneral practitioner (GP) contacts, 3655 reasons for encounter. Main results: Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (n = 481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention. Conclusion: The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

In order to improve the current state of affairs in the management of clinical reasoning difficulties, a collective paradigm shift is required to alter the perception of residency as an apprenticeship to one of residency as a structured educational programme. Faculty development programmes should be designed in an integrated way so that they not only develop clinical educators' skills, but also modify their beliefs.

The current study shows that GPs working solo have divergent views of group practice. However, they clearly perceive advantages to this type of association (e.g. better quality of life and continuity of care). This study also confirms the high level of stress and tiredness felt by GPs and especially senior practitioners.

The most important recommendation is to understand what the inmates are really seeking in their demands. This information can be used to develop appropriate alternatives in terms of human support and well-being facilities. The therapeutic and security roles of health care workers should be separated, in order to increase the trust that is central to the therapeutic relationship between them and inmates.

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