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CAMHS won't see you now

Fitness instructor asks for ongoing sick notes

James is a 34-year-old fitness instructor in a local club. His initial presentation six weeks ago was with a minor degree of tendonitis affecting his left arm. When this failed to resolve with a period of rest, he was referred for physiotherapy and is now waiting for this. However, you are wondering why he is not able to go back to work in the meantime and feel reluctant to continue issuing sick notes. Dr Richard Stokell advises.

Why is this a dilemma for you?

This situation causes problems because the doctor has a responsibility to help and support his patient but he also has a duty to certify absence from work. This is more a duty to employers and the state. There may be tension between the two roles.

The other major issue is the preservation of the patient's autonomy. Putting your foot down and sending him back to work takes the responsibility off him. This may generate problems such as him coming back saying 'I told you I wouldn't manage' implying that you sent him back too soon. It may also have an adverse effect on future consultations.

What are the options today?

lTrying to understand why he is taking so long to return to work.

lAllowing him to decide the duration of sickness certification.

lInsisting that this has gone on long enough and providing him with a note to return to work.

Niggling problems that may seem minor to you are very common in general practice presentations. Exploring the patient's feelings in more depth may prove helpful. Asking 'are you very worried about your arm?' may open up a discussion of why he is being so cautious with his injury.

He may fear long-term disability and, being involved on the fitness industry, may have very high expectations of his own fitness levels. In the same way that back-pain sufferers have been proved to prolong their period of disability by fearing they will worsen the injury, he may be waiting for complete resolution of all symptoms before he attempts a return to work.

He may also be unhappy at work or be suffering psychosocial problems unrelated to work. Asking 'how are you filling your time while you're off?' may open up discussion about some of these issues. Unhappiness at work may lead you to involve a careers adviser to consider training options.

Allowing him to decide when to return to work has the advantage of retaining your role as adviser and his autonomy. However, you are entitled to point out the pros and cons of a continuing period of sickness. Questions such as 'how do you see another two weeks off helping you?' and 'are you worried about getting another job if you've had a lot of time off sick?' may encourage him to consider the consequences of a prolonged period of sickness.

He needs to be encouraged to discuss his difficulties with his employer. If he can't perform his usual duties, can his work be changed until he regains full fitness? What are the policies on absence from work? He may not be aware of how long he has before his pay is stopped or cut by 50 per cent. Also, the company is likely to seek an independent medical opinion if things drag on. Another way in which the patient's decision can be influenced is to shorten the period covered by sick notes and review him sooner each time. This may help to persuade him that you expect him to be thinking of a return to work.

It is to be hoped these tactics will avoid the need to use one phrase I have seen in an orthopaedic opinion: 'This fellow is a lead swinger. I have told him to return to work forthwith.'

Key points

lFind out why the patient feels the need to stay off so long

lTry to offer advice about work which is in the patient's best interests

lRetain your role as adviser rather than telling the patient what to do

Richard Stokell is a GP trainer in Birkenhead, Merseyside

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