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Independents' Day

Friend wants sicknote to extend maternity leave

Case history

You are running late towards the end of a busy Friday afternoon surgery. Your next patient is Susan, a 30-year-old family friend who recently had her second baby. She looks relaxed and happy, with a spring in her step. 'My, you are running late today,' she says, 'but don't worry, I'll be quick. I'm only getting about six hours sleep a night with the new baby. I don't really want to go back to work just yet, so if you'll just sign me off for another, say, six weeks ­ just like your partner did with my last baby. ''Postnatal debility'' I think he wrote on the certificate. And if I could have some paracetamol for general aches and pains as well ­ oh, and some multivitamins as a tonic, then I'll be off. How's everyone at home? Anything planned for the weekend?'

She eyes the sicknote pad on your desk, then smiles at you. How do you react?

Dr Claire Cox

'Patients are often adept at concealing depression'

The issue here is what is right versus what is expedient. Our hackles rise when we are confronted with several dubious demands, particularly when a social relationship is being exploited. You either roll over and acquiesce ­ which is particularly tempting when you are running behind ­ or dig your heels in and refuse to help.

I would start off by apologising for running late, empathise with her difficulties and then explore how she was coping.

Of particular relevance is screening for postnatal depression. Though she appears in good form, patients are often adept at concealing depression and she may find it embarrassing to admit these feelings to a friend.

If she wasn't depressed I would explore strategies that might help her cope with her tiredness and return to work, such as seeing the health visitor, her partner sharing 'night duty' and returning to work part-time. If these strategies are rejected, I have to decide which battles are worth fighting, while maintaining our relationship, and where compromise can be reached.

The issue of the paracetamol is of little significance, so I would give her a script without question. I would state there was little evidence that multivitamins were of benefit in well-nourished adults, but ask her in what way she thought they might be helpful. If she still wanted them, I would give a script.

The key issue for me is signing her off sick in the absence of any illness. I would say I didn't feel comfortable signing her off in these circumstances. If she became distressed, my compromise position would be a closed certificate for two weeks to give her time to adjust to her situation and I would offer her a review appointment. I would refuse to be drawn on what my partner may have done during her last pregnancy, stating that we each have to make our own professional decisions.

It is hard to know if the friendship will survive this, but if boundaries aren't made clear, saying 'no' next time may be even more difficult.

Dr Stefan Cembrowicz

'I'd sign her off for a week until I can tell her the tests are fine'

I have to shift the balance of power back to my side of the desk. To mix metaphors, this patient is threatening to get round my defences. The first thing to do is slip into professional doctor mode ­ to banish those memories of her seeing me in the infant paddling pool, or at the school fete after one glass of Chateau Collapso too many.

Earnest, concerned but brief inquiries after her health are a sensible first step. Then perhaps some blood tests (to exclude anaemia) such as thyroid function, FBC, and a viscosity to make sure we aren't brewing up something inflammatory; and a BP check, all done while remaining non-committally detached.

The Edinburgh Postnatal Depression Scale takes a couple of minutes for patients to complete and will reassure me that she isn't concealing any psychopathology. This piece of impressive medical ritual will warn her that she is not on easy ground; perhaps my partner was a pushover, or perhaps he did have a good reason for his sicknote, but she is now dealing with me. My first impression is she wants to play the system; though perhaps behind her over-familiar approach she has some serious concerns. Can I clarify why she doesn't want to go back to work just yet?

Unless I'm turning up obvious problems, giving her a final sicknote for a week hence until the tests come back is reasonable. In this way I am displacing her approach to me on the social front to the medical issue of whether she has an illness that would entitle her to a sicknote.

If she has not got the message and attends again I will be able to pass on the good news that all is well, followed by friendly best wishes to her husband, without any further reference to sicknotes.

Dr Clare Wilkie

'I would make it clear that what my partner wrote is irrelevant'

I can swallow my irritation, write the prescriptions and a sicknote for the next six weeks, engage in some insincere small talk and congratulate myself on completing the consultation in less than two minutes ­ or I can address the issues. The principal issue appears to be Susan's request that the state pay for her extended maternity leave. Lesser issues are her request for medication of questionable value and her rather intrusive tone.

But I must not jump to conclusions. I will ask her how she is coping with the new baby, her older child and her partner if he is around, to see whether she needs more support. I will truthfully say she looks very well and congratulate her on having a baby who lets her sleep for six hours a night, hinting that many new parents are nothing like as fortunate.

If Susan's answers indicate that she is well and not suffering any postnatal depression, I need to ask her directly what the health problem is that would require further time off work. I would make it clear that what my partner wrote in similar circumstances is not relevant now.

If there is no overt health problem I would find it difficult to prolong her maternity leave on the grounds of health. It would of course be tempting, though unforgivably unprofessional, to add that I returned to full-time work when my child was 11 weeks old.

I will need to pass quickly on to her medications. Of course I will prescribe paracetamol, but I will advise her against multivitamins and suggest she ensures her diet is reasonably varied. I will of course be impeccably polite ­ but I'll be keeping my weekend plans to myself.

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