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3 GPs' views Case history

Brian Jones is 55 and had a lobectomy for lung cancer six months ago. He appears to be in remission but has seen you for a number of non-specific complaints since he returned to work.

Mr Jones's employer has written to you asking for a report to help them understand his current medical problems, prognosis and ways that they can help

Mr Jones in the workplace.

Brian has made an appointment to see you to discuss his job. He does not want to work any more and would like you to sign him off for six months.

Cancer patient in

rRemission

wants you to

sign him off work

Dr Mabel Aghadiuno

'He might feel he is living on borrowed time and needs to pursue other interests'

I suspect there may be a few hidden agendas here. Brian has been attending for a number of non-specific complaints despite appearing to be in remission. I would have to establish if they are the herald of something more sinister.

Once I am satisfied, I would try to understand what he is trying to say with these complaints. He might be afraid of a recurrence. He might have misconceptions about cancer. He might be finding his job too heavy, being bullied or be unhappy.

He might be depressed. Or he might feel he is living on borrowed time and needs to pursue other interests.

Assuming that Brian has early-stage cancer and that his prognosis is good, I might emphasise that he should have years of health in front of him. I would gently explain that a medical certificate is written on clinical grounds and I cannot state something I consider untrue. But I would reassure him that if he were unfit for work in the future, I would write a medical certificate.

If Brian gives written consent to my writing a medical report I would do so. I would only provide the minimum information the employer needs. I would discuss with Brian what, if anything, he would like his employer to know. I am conscious that this information may be misinterpreted and lay Brian open to being made redundant or dismissed by an unscrupulous employer. I would advise Brian to read the report and make sure that he fully understood its implications.

If he disagreed with any of it, I would modify it in a way that reflected the truth but was still agreeable to him. His interests for me are paramount. Allowing Brian to enter a protracted sick role could be disastrous for his psychological health and a report may help him take stock of his situation and decide what he really wants to do with his life.

Mabel Aghadiuno

is a part-time sessional GP employed by Croydon PCT and

a specialist registrar of the faculty of homoeopathy and practises homoeopathic medicine both

on the NHS and privately

Dr Des Spence

'A sick note is one of our key therapeutic interventions'

This is the classic pincer movement with you in the middle. Where does your duty of care lie ­ with Mr Jones or his employer? There is the MRGP answer but as ever this is PC twaddle. Mr Jones is a young man with a solid tumour with a dreadful prognosis and you must support him to the hilt.

When, and not if, his disease progresses a trusting and supportive relationship with his GP is fundamental to palliative care. Jeopardising this relationship over a stupid sick line will reflect badly on you, the practice and our profession. Just put yourself in his position.

A comprise of offering a sicknote for a number of weeks rather than six months would be sensible. His feelings towards work may change in the next few months.

A gentle exploration of why Mr Jones doesn't want to work would be sensible. Is he struggling to cope, yet needs the money? Does he think his prognosis is so poor that he wants more time with his family? Is he depressed?

Depression is hard to define in palliative situations as it seems almost rational, and the role of antidepressants is highly questionable. A society more accepting of death is the real answer.

A sick line is also one of our key therapeutic interventions and certainly a lot more effective than attending the ministry of poisons for chemotherapy. Doctors frequently give out sicknotes in social situations and I have no problem justifying these.

Old favourites are normally broad, so as to be meaningless ­ the Glasgow classic is 'nervous disability'. We are not the agents of the welfare state nor business. That said my catchphrase is 'Work makes you well'.

With regard to the company's request for a report: discuss it with the patient and ensure he is happy with its content. All companies have a process to deal with sickness so let them get on with it.

Lastly, caring for cancer patients is the

single most important determinate of

your long-term reputation in the local

community.

Des Spence is a GP in Glasgow and a tutor in general practice at the University of Glasgow

Dr Robin Fox

'Mr Jones may be depressed or have other issues'

While I may have many thoughts about why Mr Jones does not want to work, it is vital that I try to explore the reasons with him. He may have misconceptions about his prognosis, be depressed or have other organic, social or psychological issues.

Hopefully these may be addressable and allow him back to work. There may be other advantages (pecuniary, self-esteem) which Mr Jones may or may not have considered.

Many patients who survive a life-threatening condition in their 50s would prefer to enjoy their life, aware that it is full of uncertainty. As the patient's advocate GPs are in a difficult position. In most cases they provide a good medical reason and it is easy to sign the certificate and complete the report.

It is often more difficult with the honest patient who just tells you the truth (that they would prefer not to be working and wish to seek early retirement on medical grounds) and want you to collude with them. If it is clear there is absolutely no reason for them to be off work I would have difficulty completing a medical certificate. I would be honest with the patient and explain this.

In some cases I am not clear whether they are fit for work. In this situation I would probably complete a medical certificate and also inform the patient that I need to complete a RM7 to ask for a second opinion.

The latter two options are really very unpleasant for us as GPs and it is much easier to collude with the patient and protect our name in the town. The Government understandably objects to this but acting as the enforcer of employment as well as the patient's advocate often puts us in an invidious position. Something I wish was sorted out.

Robin Fox is a GP in Bicester, Oxfordshire

Learning checklist

What laws govern reports to employers?

· Access to Medical Reports Act (1988) and Data Protection Act 1988.

· The GP must have the patient's written informed consent. No third-party information must be included.

· The patient can ask to see the report before it is sent. If so, the GP must retain the report until the patient has signed it. After 21 days the report can be sent, even if the patient has not seen it. A copy must be kept for six months.

· The patient can request that a report is not sent, is changed if inaccurate, or that information is withheld. The GP must indicate if this has happened.

· GPs can withhold information if disclosure could harm the patient.

· Practices should have a protocol to prevent delays or inadvertent breaches of the Act, and ensure fees are paid.

Is Mr Jones eligibile for a Med 3?

· Cancer treatment schedules may dictate the period of time off work

· Hospital doctors, not GPs, should provide Med 3s for patients following hospital treatment

· Other complaints should be certificated on their merits

· Repeated requests for Med 3s may indicate an underlying problem

Why might Mr Jones be reluctant to return to work?

· Is he really in remission or does he

feel unwell because his cancer is spreading?

· Does he have another pathology?

· Is he depressed or scared of dying?

· Is he in the middle of a 'work-life balance' epiphany?

· Is he capable of doing his job? Could changes be made?

· Are there other problems at work or at home? Are his employers or

family colluding with or pressurising him?

· Is he in receipt of benefits that would be lost if he returned to work?

What suggestions could you make to help Mr Jones?

· Counselling

· Consult his occupational health or human resources department

· Consult his union or ACAS

· Consult the Department of Work and Pensions about permitted work while claiming benefits

· Try a graded return to work

· Seek advice on taking early retirement on health grounds ­ a medical report from GP would be needed

Melanie Wynne-Jones is a GP in Marple, Cheshire

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