Practice dilemma - Emotional blackmail for a sickness certificate

The Dilemma - A man comes to see you in clinic requesting a sick note for swine flu. He states he had the illness two weeks ago and has since recovered. Mr Jones says he did not contact the surgery as he did not want to bother you and that if he does not get the certificate he will be fired and would then be unable to support his young family. How do you manage the situation?

Talk to the patient about his sick leave and document this in his files
Talk to the patient about his sick leave and document this in his files

A GP's response - Dr Louise Warburton is a GP in Telford, Shropshire
The issue of medical certificates for swine flu has caused problems in the area where I work. GPs were overloaded with requests for sick notes from patients with flu. Patients are currently able to self-certify if they are absent from work for less than seven days, to reduce GP workload.

In such circumstances, it would be easy for a patient to try to 'play the system' and get a sick note without too much investigation by the overworked primary care team.

If I was taking a particularly dim view of this scenario, I would think this patient was trying to get a sick note to cover a holiday or unauthorised absence from work.

His comments about losing his job do support this view; surely he would have contacted the surgery as soon as his illness developed if he was that worried about his job.

However, as we are acting as the patient's advocate, we should always give them the benefit of the doubt.

I would discuss the nature of the patient's 'swine flu' with him. It is usually easy to tell if patients are lying or embroidering the truth when speaking to them directly. This gives the message that he cannot expect a sick note without a proper discussion with a doctor.

I would also check his medical records to see if he had many absences from work or other dubious requests for sick notes.

With this information I would decide whether or not to issue the sick note. In the vast majority of cases, I would issue the note as there is no real way of proving if he has been ill or not.

Certainly, in the current swine flu situation, patients are being advised to stay away from work and therefore we have to be more lenient.

I would document this situation thoroughly in his records for future reference.

A medico-legal view - Dr Marika Davies is a medico-legal adviser at the Medical Protection Society
First of all you should establish how long Mr Jones was off work for, because he is able to selfcertify for periods of sick leave of up to seven days.

For absences from work for more than seven days, his employer is likely to ask for a sick certificate. You can only issue a medical statement (Med 3) if you have examined the patient on the day or day before the certificate is issued and have advised them not to work.

A Med 5 may be issued for a backdated period but only if you examined the patient at the start of the backdated period, or have a report issued by another doctor less than four weeks ago. Neither of these apply in this case.

Advising Mr Jones that you cannot issue a certificate is likely to be difficult and it is important to ensure you have explained the reasons why you are unable to issue a certificate, rather than just refusing.

Mr Jones is clearly anxious about his employment, and the situation will need to be handled carefully.

In response to the swine flu pandemic, emergency plans are being considered to extend the period of self-certification beyond seven days. These plans will only be enacted if absolutely necessary and for a limited period of time.

A patient's opinion - Elizabeth Brain is a member of the RCGP patient partnership group
You should begin by subtly testing his veracity in a friendly and concerned manner. It seems suspicious that he did not bother to contact you despite being so fearful for his job.

You might enquire why his employer might be quick to fire him. You might wonder if he has a history of laziness and that this is another example. Could there be family reasons or personal difficulties that might cause him to lie on this occasion?

Asking him if he minded you corroborating this with someone could be fruitless and might harm his relationship with you.

Depending on how long you have you known him, and whether there has been any history of retrospective requests before, you might be prepared to give him the benefit of the doubt.

If this is the case you should explain that you will accept his request on this occasion, and give him a sick note, but emphasise that, in future, he should always contact the surgery at the onset of any illness that is likely to require a sick note.

You should add that you will not be able to give him the benefit of the doubt in future because you have to protect your professional integrity. Your conclusion and action should be added to his medical records. It would be wise to alert practice colleagues in case he repeats this tactic.

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