Sick Notes

My last post on GANFYD syndrome created some questions about the whole sick note system in Australia, which are perhaps worth exploring.

Let me be absolutely clear – doctors have no problem issuing sick notes when appropriate – such as the patient who presents with a lower respiratory tract infection and, at the time of consult, requests a note as unable to work (or poses a health risk to co-workers). Similarly the patient with a broken limb who may be unable to perform his/her duties. Nor is there a problem with completing notes for WorkCover compensable injury – a prescribed medical certificate with details of illness and proposed treatment/rehabilitation is helpful for both employer and worker to achieve a successful return to duties.

My bottom line? I am perfectly happy to support my patients with a sick note when it is appropriate as part of their consultation. Where possible, I will take into account patient’s circumstances, with reduced fees for healthcare card holders, pensioners etc. medicare rebates will apply to such consultations,

In general, requests for notes for other purposes (overseas travel, insurance paperwork, reports for lawyers, employer’s requesting additional information etc) are private fees – and should be paid by the requesting agency. I see no reason for either the patient, the taxpayer, or the doctor to be out-of-pocket for these matters.

More on Sick Notes

There has been much written recently on whether the while sick note system is even needed – workers have been granted the right to a certain amount of sick leave, and one would hope that could be trusted to self-certify for illness. It certainly makes no sense for patients with self-limiting illness to have to attend a doctor (and spread their germs!) purely to fulfil an administrative requirement of the employer.

Have a listen to Prof Max Kamien as interviewed with the ABC on sick notes, or read Australian Doctor’s commentary, with over half of doctors feeling that sick notes for self-limiting disease are a waste of time and taxpayer’s money. This suggests that over $60 million is wasted each year in Medicare-subsidised consultations purely for the requirement for a sick note – and for no other reason (medical treatment).

Max Kamien Rant

http://kidocs.org/wp-content/uploads/2013/05/Max-Kamien.mp3

The AMA and RACGP have issued guidance on sick notes – which you can access from the links at the bottom of this post. A read of these should alert the doctor to the requirements for

– confidentiality
– accuracy
– veracity

However, there are still a few grey areas. Let’s take an example. A patient attends on Thursday 18/3 with a LRTI since the previous Monday. You examine them, confirm the presence of a LRTI and advise three days of time off work.

They would receive a note along the lines of :

“To whom it may concern.
I write to confirm that I examined PATIENT X on 18/3 and diagnosed them with a medical condition. He/she will be unable to work from 18/3 to 20/3.
Yours sincerely
Dr Y”

There you go – this note confirms their attendance and examination on 18/3, your advice for time off for three days…and as was part of the patient consult for their illness, is Medicare-compensable. It doesn’t specify the reason, other than ‘medical condition’ as the patient has a right to confidentiality.

The following Monday, the patient rings in (or attends) requesting a further note. They feel fine and have returned to work. But their employer now wants “a note to explain why they were ill, to cover the time off from previous Monday and to guarantee that they are fit for work duties.” The patient is bemused as they feel fine.

This is a classic “GANFYD” and raises several issues

– the importance of doctor-patient confidentiality
– the request for a note to cover time off that the doctor cannot confirm
– the request for a determination of ‘fitness for work’
– the fact that the employer requests this information, not the patient…as usual the doctor charges a private fee – but should there be a Medicare rebate?

There is a growing concern about GANFYD syndrome (“get a note from your doctor” syndrome) – the ever-increasing requests from employers/outside agencies for a note. Usually these requests are NOT at the patient’s wish – instead they are requested by organisations who wish to either absolve themselves of responsibility or to fulfil a bureaucratic, not a medical requirement. Max Kamien writes well on this and gave an excellent interview with the ABC.

The doctor may write something along the lines of

“To whom it may concern.
Patient X attended the clinic today at the request of his employer.

I direct you to my previous note confirming sickness from 18/3 to 20/3 due to a medical condition.

Patient X tells me that he/she was unable to work from the previous Monday 15/3 and now feels fit to return to work. I have no reason to doubt his/her veracity.

Love & kisses
Dr Y”

…and then the doctor might struggle to determine whether employer or patient pays for the consult. I see no reason to discount my fee for a professional service (would a lawyer?), but if there was genuine hardship the doctor may be inclined to bulkbill the consult to Medicare…so the taxpayer is effectively paying for the employer’s request for a note. Hardly a good use of the Medicare system, propping up an unnecessary doctors consultation for an essentially bureaucratic matter. Note that pharmacists can issue sick notes (for a fee) – but that no Medicare rebate applies. So unless there is a genuine medical need, I would tend to bill privately and encourage the worker to present the bill to their employer.

Later that day the doctor receives (via his/her receptionist), an angry phone call from the Human Resources manager at the patient’s workplace. They express dissatisfaction that the ‘sick note’ does not explain why the patient was unwell, nor does it cover them as an employer should the worker be unfit for return to work. They demand an explanation of the precise nature of the medical condition and that the doctor provide a statement that the worker is fit for their duties which apparently include maintenance of a sausage-factory production line and “insufflator-hyfrecator cleansing technician”. They also complain that the doctor has suggested that the workplace pay for the previous note.

How do you respond?

Think GANFYD DEFLECTOR (see below)!

 

First up, unless there is signed consent from the patient, the employer has no right to details of the medical condition (it may be blindingly obvious in case of a broken arm or amputation, but this may not dissuade HR). Demand that the employer furnish you with the patient’s written consent. Next they require an assessment of the worker’s fitness to perform his/her duties. We are now firmly in the territory of providing an expert occupational medical opinion. Are you prepared to do this? I always imagine how I would defend myself if the patient came to harm and was being interrogated by a barrister or the Coroner. To be absolutely certain, I might require a full hour long occupational medical examination, a workplace site assessment or perhaps referral to an occupational physician for a specialist opinion. I won;t tell you my hourly rate, but for this sort of private medical one may be guided by a lawyer’s fees for appropriate billing (taking into account training, professional qualifications, admin costs etc)

All this takes time, is taking the Doctor away from core business (being a doctor, seeing sick patients) and is being requested by the employer – who needs to be prepared to pay for it. It is a hell of a lot more than ‘just a note’ and is nothing to do with Medicare.

As always, I would encourage the use of the universal GANFYD deflector letter – originally from the UK, but easily adapted to Australian circumstances. It is included below.

GANFYDS

One should bear in mind that the vast majority of GPs are private practitioners. They charge fees for consults and the patient may be able to claim back a portion of those fees under the Medicare rebate system.

Generally requests for notes or medical reports are NOT a Medicare service, more so when requested by the employer. If there is doubt, or if the employer (or another agency) requests a medical report then be prepared to deploy the GANFYD deflector.

Otherwise you will drown in unnecessary paperwork – and patients who do need to see you will be unable to do so. And keep Medicare out of it, unless there is an underlying medical need for the consult. We are in deficit and health costs are rising – such requests should not be propped up by the taxpayer unless appropriate.

As Prof Max Kamien has pointed out, it’s unlikely anyone REALLY needs these certificates – they are fulfilling a bureaucratic or ‘cover your ass’ need. He reckon’s he’s written over 20,000 bland certificates and only had 2 challenged. Indeed there is an industry in providing fake certificates – such as DoctorsNoteStore.com !

Consider the following examples:

The 16yo school child who misses an exam due to vomiting during class, witnessed by teacher. She sensibly goes home and recovers within a few hours. Three days letter needs to book an urgent appointment as ‘school requires a note’

[Should be able to self-certify. Not needing to see doctor at time of illness. School should be able to act based on student, parent or even teacher’s assessment.]

The worker who was unable to work on a Friday due to a migraine. Presents on the following Tuesday on instructions of employer who ‘want a note so say was unwell on Friday – wouldn’t normally need a note but because was sick on day prior to weekend, employer needs a note”

[worker should be able to self-certify. Doctor unable to determine veracity of illness on Friday when examined 4 days later and now well. Can generate bland note to this effect – but charge privately to employer. Legislation to allow self-certification would be helpful]

The employer who requests a note “stating that worker is fit to return to duty” after a previous injury for a non-work related injury (eg: broken toe).

[this is a request for an occupational medical assessment. The assessor needs to be fully informed of the worker’s duties and perform an examination directed at their fitness to perform these tasks. Needs will vary eg: desk worker vs deep-sea diver vs professional dancer. A site visit, list of all work duties and a good hour long medical plus a few hours for report/workplace assessment would be required at commensurate rates]

The patient who requires a note from gym/diet agency/sports body stating ‘that is medically fit to undertake task’ eg: parachute jump for charity, crash diet, gym programme, diving

[the agency is essentially asking the doctor to take responsibility for an activity over which they have no control. Two choices – either a quick note (with signed consent) confirming the patient’s past medical history and suggesting that the agency make own assessment of risk…or a full on medical examination targeted to task proposed (preferably by a clinician with experience in the field), privately charged…with same comment that risk remains that of individual and agency]

 

THE UNIVERSAL GAFYD DEFLECTOR

Date:

Dear Sir/Madam

Regarding Name:

Patient Address:

My patient has requested that I send you details of his/her medical history in so far as this is related to employment / workplace needs. I would be grateful if you would confirm your need for this information and complete the details below:

Precise information required (please be specific):

I consent to the above information being given by my GP to my employer.

Patient’s signature:
Print Name :
Date :

Date by which GP response is required (at least 7 days from receipt of your reply to this request):

The employer accepts responsibility for the fee payable for this service depending on requirements. This may require payment for a clinical examination, generation of medical report, specialist consultation & investigation, workplace assessment and administrative fees.

PLEASE NOTE THAT THIS IS NOT A MEDICARE-COMPENSABLE SERVICE AND THAT THE EMPLOYER IS RESPONSIBLE FOR ALL FEES (fee schedule attached)

Signature (employer):

Date :

Please print name and position:

In the event that this information is not required I will assume that the patient themselves can supply you with all necessary details.

Yours faithfully etc

Dr XXXX

 

LINKS

AMA Guidelines for issuing sickness certificates

RACGP – Sickness Certification

The Sick Saga of Sickness Certificates

Pharmacists can issue sick notes

Doctor’s certificates are a sick joke

Should GPs have to write sick notes?

5 thoughts on “Sick Notes”

  1. I love this post! Have had quite a number of head-shaking moments lately as I watch the sick note system deteriorate into a kind of overly bureaucratic madness.

    One was a very reasonable, articulate young man who came to me saying, “I woke up yesterday morning with some diarrhoea and vomiting. I called work and said I couldn’t come in. It turned out to be resolved quickly and I’m fine now. I went to work today and they sent me away, telling me I need a medical certificate and a clearance to return to work.”

    Here he was, completely symptom-free, seeing a doctor as a well man, exempt from work where he could be productively engaging, and there was I having not seen him when he was unwell apparently needing to verify not only his unwellness, but also his fitness to do his job. I really couldn’t believe the insanity! I ended up writing a note to the effect of:

    Dear Employer,

    Mr J presented to me today explaining that he was unwell yesterday and is well today. He advised me that he also explained this to you.

    I have no reason to doubt that he was unwell yesterday, but obviously can no more verify it that you can. In my general medical opinion he is a competent adult and able to make this assessment himself.

    He tells me he is symptom free today. I also have no reason to doubt that. In my limited general examination I fine no obvious signs of illness. This is consistent with that he has said to you and to I.

    I cannot verify his fitness to perform his role at work, but have no reason to doubt his claim that is is not medically unwell.”

    I have also had people come to ED sent home from work because they have a cold, and told by their employer they need to go home, and see a doctor that same day for verification they are unwell. I have explained to them that if their employer has deemed them unfit for work there is no need for me to do so. It is just bizarre.

    That said, I completely 100% agree there is a role for normal medical certificates for illness. It is just the work-place dictates that drive me batty 🙂

    1. You need to use the “Universal GANFYD Deflector” proforma letter – it forces the person requesting the info to take responsibility (and pay) for the service.

      99 times out of a hundred, the request disappears – presumably because the Employer realises he/she CAN accept a patient’s self-certification

  2. ‘Generally requests for notes or medical reports are NOT a Medicare service, more so when requested by the employer’
    I totally agree with the above statement. But, I can find no official document that states this explicitly. Could you provide a reference to this?
    I am keen to stop this unnecessary waste of my time but I work for a large Bulk Billing Practice and trying to introduce a mixed billing pattern will not go down well unless well documented. Help much appreciated!

    1. Medicare rebates only apply for a professional service that is “clinically relevant”
      that is listed in the MBS book
      – “clinically relevant” defined as a service generally
      accepted by medical profession as necessary for the
      appropriate treatment of that pt.
      Peer work, on it’s own, is not medically necessary.

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