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Stressed teacher keeps asking for a sicknote

Three GPs share

their approach to

a clinical problem

Case history

Mrs Peters is a teacher. She was signed off work by your partner two months ago for work-related stress. A locum gave her another sicknote last month. She has come to ask you for a further note, saying she can't face going back because her teaching and administrative workload is too great. She agrees she doesn't seem too bad today, and describes severe situational anxiety rather than depression. She says she will 'fall apart' if she tries to go in to work. The head has told her to stay off because the school risks losing the authorised relief teacher if she comes back too soon.

Dr Claire Wilkie

'She needs to think about her long-term plans in teaching'

This is, sadly, a common situation and most GPs will have highly-stressed or burnt-out teachers among their patients. I wouldn't hesitate to give her a sicknote for three or four weeks. She can't work as she is, and it will take the stress out of the consultation and allow us to address her short- and long-term problems.

We need to think about sources of help. I would ask what support the school have offered her. Have they contemplated external changes to make her job less overwhelming, such as recruiting more teachers or administrative staff? Although I'm sympathetic to the head teacher's staffing problems, they aren't my problems and Mrs Peter's welfare must come first.

I would then offer her support from the practice, including ­ and I will suggest this with enthusiasm ­ referral to our clinical psychologist. This would be, in particular, to deal with her self-esteem and sense of failure. These issues are likely to be important for a professional who sees herself as not being up to the job. I wouldn't advise an anxiolytic or other medication. But Mrs Peters might benefit from ?-blockers later when she does go back to work.

I would encourage her to care for herself while she isn't at work; to rest, exercise, eat well, perhaps to spend more time with her children, to look for support from friends and family.

Mrs Peters needs to think about her long-term plans and ways of avoiding this intolerable degree of stress again. Does she want to go back to teaching full-time, part-time or not at all? I would encourage her to go back even if very briefly, to avoid her feeling later that she left because she couldn't cope. Any decision about changing career should be positive, rather than a decision by default.

Clare Wilkie obtained a degree in classics before taking up medicine ­ she finished the VTS in 1988 and is now a partner in Brixton, south London

I would ask her to see me again in four weeks, to assess her progress and the need for more time off.

Dr Liz Bowen

'I'd check ­ Is there anything else we should delve into?'

Does she really want to do this job? If I felt the same about going to work I would look for another job rather than go to a doctor for a sicknote. Perhaps that's not a financial option for her, or one she is prepared to accept.

I presume that in the last two months she has discussed the situation with her head teacher, and they have looked at ways to alter her workload or work pattern, such as going part-time for a while.

I would try to find out what has triggered this off. Is she young or old? Has she years of successful teaching behind her and is this an acute blip? Or is she new to the job and it's really not for her? Are there any home circumstances that are influencing her anxiety? Is there anything else we should delve into?

I am sure a sicknote in the short-term was the only option to overcome an acute situation. But it feels that now the school have a decent supply teacher they are avoiding a long-term solution. It doesn't sound like the head wants her back! The easy option, and I have to confess it's the one I would go for without hesitation, is to give her another note ­ but just to give her time to sort herself out with a future plan.

If this is something that may improve over time then I would continue to sign her off. Perhaps she needs information about how she can manage her anxiety, or counselling, or a change in her working environment until she is able to return to work.

If there is no obvious long-term solution it would be unreasonable to keep giving her notes just because she can't cope with her job. Perhaps she would need to look into an alternative career.

My gut feeling is that her workload and paperwork are unlikely to decrease. So the choice, as they say, is hers.

Liz Bowen qualified in 1992 and is now a partner in Bangor, north Wales

Dr Patrick Clarke

'We need to negotiate a plan to move things forward'

I feel sympathy for Mrs Peters. She is clearly feeling stressed and burdened by her role at school. The head teacher seems to be supporting her by 'encouraging' her to stay off. But she may not be giving Mrs Peters the help she really needs.

I would find it difficult not to give her another sicknote if she requests it. But to try to solve some of her problems I would want to look into why she is in this situation. She has had two months off and doesn't appear to have made any improvements. We therefore need to negotiate a plan to move things forward.

By agreeing to give her a sicknote at an early stage in the consultation I would hope to gain her trust and confidence. She needs to be reviewed more regularly, so a note for one or two weeks may be more appropriate with further regular reviews. I need to discuss the situations in which she feels anxious and stressed. I would hope to help her find solutions.

I would expect there are a number of other sources of help. Her partner or family may give her support, but because she appears to be having her main problems at school, she needs to work with her head teacher and colleagues to improve her situation and enable her to return to work.

Going back part-time initially may help, as would getting help with some of her administrative duties. Other agencies may also be appropriate, such as counselling, or networks that specifically help teachers.

Finally, I would set a timescale to get her back to work, with a plan or contract if necessary. She will know it isn't in her best interests to remain off work long-term. Other alternatives are medication and psychology, but I would expect to solve this before these more drastic measures are required.

Patrick Clarke completed the VTS in 2002 and is now a partner in Burnham, Buckinghamshire

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