Handling questionable requests for sick notes

Editor’s note: This article originally ran in the Medical Post in 2007. After sick notes came up recently as an issue in the Doctor Daily newsletter, we—along with Dr. Armstrong—realized everything written in this column almost two decades ago stands up and offers insight for today. “Hey doc, I need a note saying I can’t work. I know the injury isn’t that bad but they want me back at 100% or not at all.”Sound familiar? How does that request make you feel?A problem increasingly prevalent in doctor’s offices is patients asking for the dreaded doctor’s note or back to work slip. I can’t remember ever getting any training as to how to approach these little nuisances, yet they become a completely overwhelming issue. It usually begins with the patient tapping you on the shoulder with the request. You are then supposed to make an educated and insightful decision that will have an impact on the patient, his job, income, mortgage and indeed even the company that has employed him/her. Not bad for 30 seconds of work that you neither expected nor wanted!Doctor’s notes have become a fundamental part of the physician’s daily life and like it or not it can have tremendous financial consequences. Until a better system comes along to deal with patients who are off work because of illness we have to bite our tongues and cooperate as best as possible.Unfortunately for physicians there are some but certainly not all patients who exaggerate their illnesses to avoid work and we must be cognizant if we are to do the right thing for all involved. We do not necessarily have to accommodate patient wants. Should we fall into that trap we can make decisions that are overtly unhealthy, unsafe and just plain unethical. It can also be expensive for insurance companies and provincial workers compensation boards.From the patient’s point of view there are any number of reasons and possible hidden agendas that we have to be aware of as we listen to their wide-eyed requests for that note. We often make the incorrect assumption the patient is always truthful and sincere in their attempt to quickly return to work.Read: Three-quarters of Canadians support legislation to curb sick notes: surveyPatient’s goalsA patient may magnify pain or disability to reduce the workload, extend time off work or optimize shifts so they don’t work weekends or nights. Other secondary gains include easier duties, reduced workloads or avoiding work with certain individuals or supervisors.Some may want to prolong their short-term disability until it becomes long-term disability or avoid child support payments, school issues or using their vacation time.When a job action or layoff is about to take place the number of workers getting “injured” just prior usually goes up.The worker may want to schedule his office appointment during work hours in order to miss but get paid for work. Sometimes a patient may miss a back to work date and on seeing the doctor weeks or even months later ask that the extra time be included in the sick time.Some feel time off is “owed” them by the corporation or they want to get back at the company for some perceived injustice.Substance abuseSubstance abuse can alter perception, motivation or willingness to work or follow medical advice. Passive aggressive behaviour and non-cooperation with treatment regimens is common. They don’t appear for family practice or specialist appointments, don’t have blood tests or other diagnostic procedures done and don’t keep track of the dates that they were injured or they avoid filling out forms that might reflect badly on them or their employer.Most physicians are so busy running their practice that when a request for a doctor’s note comes up, it is seen as an intrusion. Not much thought is given to the implication it may have for the patient, workers compensation and insurance company and consequently the patient benefits. The little thought given to constructing a back to work program is often more directed at getting the patient out of the office.Usually there is no job physical demands analysis (PDA) document accompanying the patient nor is there an awareness of a return to work program in place at the job site which might help the physician to prescribe light duties, modified hours suited to the disability or adjust these variables until full duty is achieved. Insurance or provincial compensation forms can be a means of tracking the course of an injury and disability and less of an inconvenience. These notes are oft times incomplete with respect to time needed for injury resolution duties that are able to be carried out and those that need to be adjusted and when reassessment should occur.=Progressive return to dutiesFunctional ability forms can help clarify or prompt back to work job modification. These forms however are far from perfect in pinpointing exactly what the patient/worker may need to optimally return to his job progressively.Many workplaces or corporations have an employee health and safety committee. It is governed by provincial occupational health and safety acts.Many plants have toxic substances close by and the possibility of exposure through inhalation, skin contact or ingestion exists. Because of this and other health risks such as accidents there may be a nurse on staff to deal with and monitor injuries or exposures. There may also be an occupational physician who has had special training and insight into intricacies of that particular plant and the inherent hazards.Insurance coverageThe corporation may provide provincial insurance coverage, private insurance for non-work-related illness or provide the insurance themselves. Their goal of course is to minimize lost time injuries in any way possible and to assist in the return to work for an injured or ill patient.Should there be an increasing number of workplace injuries payments that companies make to provincial workplace safety and insurance boards increase and there may be a subtle move within the company to discourage the declaration of such accidents and keep the penalty payments down. Indeed some employees have been terminated if they keep getting injured or have taken too long to return to work.Some workplaces will discourage the reporting of work injuries for fear of increasing their lost time injury numbers which raise red flags with the various provincially run workplace safety and insurance boards and increase financial penalties.The company physician will usually have some element of extra training in occupational health and safety and often can offer pragmatic advice about a patient returning to his/her job in some capacity. They should have insight into the physical demands of a particular job and a company’s return to work program and influence with the employees supervisor/manager. The days of just sending an injured worker home for several days or weeks should be far behind us. Unfortunately this isn’t necessarily so.Sometimes a company doctor may have to alter or modify a return to work note from the family doctor to suit the job. He will have the ability to see the worker at his job and observe the work ethic, ergonomics or habits. Contrary to what the employee, thinks any medical information derived at the work site is still confidential. Corporate physicians work on behalf of the employee—after all a healthy worker generally is a productive worker.It is incumbent upon company doctors to do an accurate occupational history of an injury, ensure proper documentation for workers compensation or insurance coverage and in the case of a pre-existing medical condition to minimize the penalty to the plant where the injury took place.He can also help a family doctor become aware of the patient’s game and help reduce any social pressure and FP may feel about giving into an employee’s requests. The social pressure can be high for an FP who has been attending an individual for years and is like an old friend.FP dutiesFor the FP the basic function is, as accurately as possible, to document the chronological sequence of events and any previous history of similar injuries or disability order the appropriate investigations ascertain the functional ability of the patient and when it may change and then prescribe treatment. Asking the employee for a PDA can certainly help determine appropriate restrictions. A follow-up visit if necessary should be arranged and after this documentation or the patient and workplace may be completed. It is up to the workplace and its human resources department to determine what job is suitable given the guidelines set out by the doctor. The doctor is not responsible for the job change. Sometimes the plant doctor and the family doctor can discuss a mutually agreeable course of action for their common patient. The family physician need not get annoyed if another medical person is involved because they can take pressure off him and the ultimate goal is the well-being of the mutual patient.“Hey doc! Can I get a note from you saying that I don’t have to work midnights?"When doctors hear this they are put in yet another awkward position. In fact there aren’t that many conditions that can exclude a worker from midnight shifts. They include:Acute psychiatric illnesses that could be exacerbated by the fatigue and alterations in the diurnal variations that humans experience e.g., schizophrenia, bipolar diseaseUnstable cardiac conditions such as angina or recent myocardial infarction that require intensive investigations and treatmentEpilepsy that is not totally stabilizedComplications during pregnancyBrittle diabetics who experience rapid swings and blood glucose levelsSo a supposedly benign little back to work note can be the tip of a very onerous iceberg. When the physician is as informed as possible before he lifts his pen, a doctor's life becomes a little less complicated when the return of the worker to his job can be expedited.Dr. Ken Armstrong has been a respiratory therapist, family physician and an occupational physician plus hyperbaric doctor. He retired in 2017 and happily globe trots with his wife, scuba gear and underwater camera.

Handling questionable requests for sick notes

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