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At the heart of general practice since 1960

When a doctor asks you to bend sicknote rules

Case history

June has been off work for four months, ostensibly with frozen shoulder but really because of an acrimonious dispute with her employers about the allegedly unbearable stress of her work. She has rather grudgingly been seeing the practice physio who feels her shoulder is now as good as it ever will be. Until now June received sicknotes from you with 'shoulder pain' as the diagnosis.

A letter arrives from her employer's occupational health doctor, recommending early retirement on medical grounds for her at the age of 37. Unfortunately, this cannot be arranged for at least another three months 'for administrative reasons'. Would the GP be kind enough to continue certification until then?

You know June is happily painting her new flat and you have seen her playing tennis in the park. When she attends, however, her shoulder appears to be exquisitely tender and she brandishes the occupational health doctor's letter.

Will you go along with the idea of early retirement to let your doubtless hard-pressed occupational health colleague off the hook? Or are you brave enough to decline certification to this healthy patient?

Dr Melanie Wynne-Jones

'Nobody has suggested seeking a specialist opinion'

To call June's shoulder problem incurable and encourage her to give up work at 37 has ramifications beyond a quick get-out from her job.

I would start by trying to have a frank discussion with her about what has happened, how she is feeling, what she expects of her shoulder, whether she is clinically depressed, and whether she is keen to accept medical retirement or has been bullied into it. Has she consulted a union rep or solicitor about the stress; does she need psychological help?

At 37 she may have a surgically remediable problem and deserves a specialist opinion; it is surprising no one has suggested it.

This, of course, may not be what she wants, and I would not be able to inform her employer directly without her consent. I could, however, allude to the referral on her sickness certificate.

Many patients do not like to have stress or depression on their sickness certificates, and where there is co-morbidity, it may be reasonable to omit these diagnoses in the short-term. Where they are the true reason for sickness absence, a symptom description (debility, anxiety) is preferable to writing a false diagnosis.

Writing 'stress' on a Med 3 may alert a good employer to the possibility of bullying or overwork. Are June's employers and occupational health doctor aware of her stress, and if so, why do they want her to retire on physical grounds? Are both sides willing to review the situation?

Caught between my suspicions, the law and my responsibilities to June, I would suggest a referral, and write something like 'intermittent shoulder problem, have referred her for second opinion'.

Dr Abayomi McEwen

'I would sign her off as suffering from stress instead'

It would trouble me to collude with June and her employer's occupational health doctor and it will not help them face the real issues. Being medically retired at such a young age has ramifications for future work, her mental well-being and self-esteem.

I would discuss my dilemma with June and say I know she is undertaking activities that make me believe she is physically well enough to work. Stress is a perfectly legitimate diagnosis to put on a certificate and, assuming I agree with June that the stress of the situation at work is such that she cannot go back, her certificate should say so.

I hope I would be able to negotiate this change of certification with her. This may be made more likely if I still accept she has some pain and

explain somatisation disorder in plain language.

I would encourage her to explore all the

avenues open to her to resolve the dispute at work.

In my letter to her occupational health doctor, who is probably no harder pressed than me, I would outline the history of June's time off work, including the physiotherapist's report. I would omit to mention that I had observed her playing tennis or knew she was painting her flat. I would state my personal view that early retirement would not help.

Part of the role of the occupational health physician is to work with both the 'sick' employee and the employer to try to find a way to get the employee to back to work as fast as possible.

My report should help that process, hence my eagerness to state things from June's viewpoint clearly and dispassionately. Phrases like 'June informs me that she feels...' would feature largely.

Dr Nick Imm

'I may be in for difficult consultations with June'

What on earth is the point of an occupational health doctor who shies away from occupational health issues?

It is common to find a grey area between the overlapping roles of general practitioner and occupational health doctor but I think this is pushing it.

June is involved in a dispute at work and possibly has work-related stress. Clearly, the person best placed to assess her or intervene is the occupational health doctor ­ and this is what they are paid to do.

If a medical report is required then I'll happily supply it. But this is not what is requested.

I'm sure I can't be the only person aware June is off work with 'shoulder pain' yet is actually pretty fit. Playing tennis and redecorating her new flat does little to conceal the fact and I wouldn't be afraid to confront her about this.

There is some obligation for the employer and occupational health doctor to assess her suitability for work and see whether adjustments to her work pattern would help her continue. However, I don't see any evidence of such an assessment being performed.

There is evidence that the longer a person is off work, the less likely it is they will return to the same level of work. Furthermore, I find it hard to believe that it is in June's best interest to be off for months on end without good reason.

I'm uneasy about issuing sicknotes that are basically untrue. My patient is plainly not suffering with a frozen shoulder and does not seem particularly stressed. By agreeing to the request for further certification I would be colluding with my occupational health colleague and the employer, and this is a precedent I certainly would not wish to set.

Perhaps this might be a good time for the occupational health doctor to review their working relationship with this particular employer?

I'd be brave enough to decline further certificates and encourage June to bite the bullet and address her work issues. I appreciate I may be in for many more difficult consultations with June before the situation is resolved.

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