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Penal Code

Lisa S. Gussak ~

When I see Rosa’s name on my patient list, I smile. I have known her nearly eight years. Under my care, she’s given birth to her last two children, and although she takes the kids to a pediatrician rather than me, we have an uncanny habit of bumping into each other outside the office. I’ve seen her and the kids in the market, at a park and in the hospital lobby, and I have been invited to, but could not attend, a family birthday party.

Today she’s coming in for a routine physical. I last saw her fourteen months ago. She needs a Pap, a follow-up on her sometimes elevated blood pressure, and paperwork documenting her vaccinations so that she can volunteer at her kids’ school.

Three years ago, after the birth of her last child, she developed preeclampsia, with stubborn and difficult-to-control high blood pressure. She went on meds, but hated them and adopted the gym as her primary treatment strategy. She went nearly every day, lost twenty-five pounds in six months and came off her medications.

She’s Dominican, here for many years without papers, and has never risked leaving the US to go visit her family. When her brother in the Dominican Republic was killed, she missed the funeral. Thanks to Skype, most of her family knows her kids. She’s been with the same partner for longer than I’ve known her. She and Edwin have three kids. She has never worked outside of their home, instead focusing on raising the kids while he provides the family’s financial support.

I examine her, do her Pap and fill out the required paperwork for school. Only while filling out the form do I notice the increase in her weight and blood pressure.

“Rosa, have you been checking your blood pressure and weight when you go to the gym?” I ask.

She pauses, then says, “Doctora, I haven’t been to the gym in a long time.” She pauses again, then says, “Money is very tight, because Edwin has been locked up for more than year.”

Shocked, and wanting to make sure I heard her correctly, I repeat in Spanish what she’s just told me.

“Si doctora, esta en prision,” she says.

This is when you sit back down, resisting the urge to check your list to see how many other patients are waiting, and you close the computer.

Over the next fifteen minutes, she tells me that Edwin’s been in prison in Concord for nearly a year on a drug-related charge.

“He has one year left, maybe less,” she says. “I believe he is innocent.”

I say nothing.

“Edwin’s father is helping me out with money when possible, but it’s a struggle,” she goes on. “My gym membership stopped months ago. I’m not working. Even though I’m afraid to drive to Concord, I have friends who help me to get there nearly every week.”

“How are the kids doing?” I ask.

“Only our oldest, Julia, who’s nine, knows the truth about where Daddy is. I’ve only taken her to Concord a few times. Julia has a teacher who helped me find a support group for her, and now she knows other kids at school whose fathers are in prison.”

I nod, and she keeps talking.

“I have no idea how to talk with our younger ones, who are five and three, about their dad, and they aren’t asking.”

“Are you interested in meeting with a counselor?” I ask.

She shakes her head. “I’ve got lots of friends and family to talk with, and they help me a lot.”

I hug her tight before she leaves, clutching a plan for self-care, blood-pressure monitoring and a follow-up visit in two months.

Later that afternoon, putting together my notes in the electronic medical record, I know that I want to add something to Rosa’s problem list to help myself and other caregivers remember this “problem” she is living with and trying to manage.

I plug “PRISON” into the EMR search bar and find the following:

Kitchen in prison as place of occurrence of external cause (Y92.140).
Or if the occurrence happened in the prison dining room (Y92.141) or in the swimming pool (Y92.146), if the prison has one.
Finally if you
have no idea where the occurrence occurred, you can choose unspecified place (Y92.149).

Plugging in the word “INCARCERATED” yields:

Incarcerated avulsion fracture of medial epicondyle of R humerus with nonunion S42.447K

I pause and wonder how a piece of bone normally attached to the upper arm bone can become both fractured and incarcerated (the medical term for being confined or abnormally retained, a condition that prevents healing).

Incarcerated epigastric hernia K43.6.

Images of stomach tissue trapped up in the chest flash before my eyes.

Incarcerated femoral hernia K41.30.

Ditto, but this time in the groin.

…and many more variations. When I use the word “JAIL,” only one option pops up:

Fever, jail A75.0

Increasingly frustrated, I try “INCARCERATED FAMILY” and get no results.

When I give it my last shot with FAMILY MEMBER IN PRISON, my EMR asks in bright blue caps if I mean “FAMILY MEMBER IMPRISONMENT,” below which I’m offered:

Imprisonment of family member Z63.32

After many years of caring for underserved patients, I’ve learned of the enormous toll that incarceration imposes on patients and their families. The financial, social and educational costs to families often affect many generations. Mass incarceration is a public-health crisis in our country, overwhelmingly impacting men and women of color. We imprison more of our own citizens than any other country in the world.

So why is it so hard to find any acknowledgment of this cost in our modern system of medical-care documentation? And why is “FAMILY MEMBER IMPRISONMENT ” a Z code? As many doctors know, and as even my EMR reminds me: “Z codes may not be reimbursed if used as a primary code.”

Why should we as a society care more about the complications associated with incarcerated tissues and bones than about those associated with incarcerated people–the members of our own society we lock up and confine in such extraordinary numbers? And why should we as a society pay doctors more to care for tissues and bones than to care for people and families who are dealing with real-life imprisonment and its impact?

I add “FAMILY MEMBER IMPRISONMENT” to Rosa’s problem list, but not as a primary diagnosis. I want to be sure my health center will get paid for the care we are providing Rosa and her family.

I know that she, Edwin and their kids will suffer the cost for a long time. I need to be sure that we’ll be around to continue caring for all of them as they struggle through life’s challenges, forever changed.


About the author:

Lisa S. Gussak is an associate professor in the department of family medicine and community health at the University of Massachusetts School of Medicine, in Worcester. She loves teaching and mentoring medical students and residents. Her essays have been published in Family Medicine and Families, Systems, & Health. She enjoys photography and has had her work presented in Pulse, Streams of Consciousness and community art shows. “Increasingly I have turned to writing to help document and process the beauty and challenges of caring for patients. This visit with a cherished patient captured so much that is wrong with our healthcare system that I felt compelled to write it down to keep it in my head and close to my heart.”

Story editor:

Diane Guernsey


6 thoughts on “Penal Code”

  1. It has been decades since George Engel M.D. wrote about BioPsychoSocial Medicine (many have revised it to include BioPsychoSocialSpiritual Medicine).
    Pure biomedical care is outdated, but it does enable insurance companies, the government, bigpharm, and others to rule the roost and ignore patients.

  2. Warren Holleman

    Excellent story on an important topic that we don’t talk about nearly enough: mass incarceration as not only a societal sin but also as a health risk factor. In my view, the EMR simply reflects the values and priorities of the health care system, which in turn reflects the values and priorities of our society. Your story also shows other risk factors we often overlook: being an immigrant, being a woman, being a parent… I loved your story–thank you for sharing it with us.

  3. A sad story by an outstanding doctor.

    Her empathy & concern for her
    patient’s whole life is impressive.

    I don’t see this as a tale about
    what’s wrong with electronic
    medical records.

    Rather, it’s story about how Ame, medicine, as taught in most of our medical schools, assumes that healthcare is only about addressing purely medical issues.

    Our med school education ignores the wider social
    context that, often, has a much larger impact on a person’s heath.

    I was impresssed that the child’s teacher had hooked the child up with others who had fathers in

    I realize that most doctors don’t have the time to do this themselves,

    But I wish med schools would teach them to build up a network of “referrals’–not just to specialists but to exc. social
    workers, teachers & psychologit who coudl help their patients.

  4. your essay was excellent. it hit a nerve…. my pediatric office is relatively new to EFR (electronic fucking record!). recently i had to figure out how to document “father in jail” in the social history, and realized there was no box to check. this is a major deficiency, not just in our EFR but in our bureaucratic thinking and the priorities of corporate medicine. clearly this needs to be addressed on many levels. thank you for writing this essay. i hope someone in power in the world of ICD, CPT, DSM, EFR and all the other alphabetical triplets reads it and gets motivated to change things.

    1. The software will only be as good as the product manager’s awareness of health care requirements and how they prioritize enhancements. That is the “prison” you medical doctors must operate in. Maybe we should back to spreadsheets and paper – they were so much more flexible.

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