The case against clinicians ‘prescribing’ time off work (and what to do instead)

At the Family Medicine Forum (FMF) in Vancouver last week, two WorkSafeBC doctors got lots of questions from a packed room for a panel titled: “I need a note for work, doc!”At core, Drs. Brian Ng and Celina Dunn made an argument that physicians when faced with patients asking for off-work notes should focus on outlining restrictions and abilities rather than just prescribing “one week off work” or some such.Case example: Back pain in a construction workerPatient profile: A 50-year-old male construction worker with a history of chronic low back pain. Recent exacerbation has led to difficulty lifting and prolonged standing.Dx: chronic non-specific low back painQuestion posed to physician/NP: Can this patient return to work?Approach: What is your role? What is your advice?After some group discussion about the above case example, Dr. Ng noted that the College of Physicians and Surgeons of British Columbia (CPSBC) provides context. “The college here in B.C. states that if you do not have accurate information about their work duties, you should not be commenting on . . . whether they can go back to work or what they can do at work if you don’t know.” The reasoning being the patient may say “my job is lifting heavy things” but the company may have light duties for them for a period that doesn’t involve that. “I think,” Dr. Ng continued, “to prescribe a week off work for something would contravene those guidelines because you don’t (have) accurate information without having spoken to the employer or without a note saying these are the work duties, to properly actually prescribe time off work.”“So I would not prescribe time off work for this person in this 10 minute office visit. I would do probably what that group (a suggestion from a table) has done and tell them these are the subjective limitations.” Document those, he recommended, and encourage further discussion with the employer.Tons of questionsBut there were lots of questions from doctors and during table discussions, highlighting just how complicated this role for clinicians is. One audience member said she felt this had not been a part of training. The range of situations doctors face with patients mean there may be situations where it is appropriate to prescribe time off work. “We’re not telling you, you can’t say it—but we are suggesting you avoid saying it,” Dr. Dunn said.Poll: Do you give patients sick notes as part of practice management when you are only hearing from them after they have recovered?‘Gatekeeper’ challenges and the dual roleThe challenges facing doctors as “gatekeepers” of workplace absence and return-to-work (RTW) processes are immense. Indeed, the role of physicians as intermediaries in workplace absences, particularly in writing sick notes or assessing work capacity, can lead to tension. Adding to this complexity, the CanMEDS framework emphasizes health advocacy, which can be interpreted differently by patients, employers and healthcare providers alike.In occupational medicine, physicians often juggle difficult dual roles: healthcare providers and sometimes RTW coordinators. As a slide and discussion during the panel noted: As a healthcare provider, you determine: Is there a medical condition? (if there is a risk to someone if they are participating in something.) And you are looking at prescribing restrictions—and describing limitations and abilities.On the RTW co-ordinator side, you look at matching retained abilities to available work and avoiding restrictive activities. As Dr. Dunn said, this dual role can be challenging: “So, you’re working in this parallel world—doing diagnosis and treatment while also evaluating risk, ability and activity with a return-to-work perspective. Whoever is handling return-to-work coordination, whether it’s the patient speaking with their employer or you communicating directly with an employer or an insurance agency, it’s really their job to understand the specific demands. You’ve outlined the framework: ‘they mustn’t do this, they may have difficulty with that, and they’re able to do this.’”Of course, as Dr. Dunn noted: Your patient can suffer if they say it's medical, but you say it's a human resources issue and you don't want to engage. Objective and subjective limitations in RTW assessmentsDr. Ng emphasized the importance of differentiating between objective limitations—activities a patient objectively cannot perform no matter how hard they try—and subjective limitations—activities the patient reports they cannot do or prefer not to do (commonly due to pain or fatigue). In cases of subjective limitations, Dr. Ng advises to simply make them clear in the note. “The tolerance aspect is the most common issue people report—they’ll say they have pain or feel too tired. You can’t measure or verify this, so just make it clear in your note as a subjective limitation, like, ‘Patient reports they can’t lift more than 20 pounds.’ That’s about the best you can do. Physicians should then leave the final decisions on accommodations and job suitability to employers. That’s about the best you can do, but it’s important to specify what they report they can and can’t do.”In all, Dr. Ng summarized saying after “gathering this information, assess their residual abilities and describe that in your note. Then let the employer determine what duties align with those abilities. I usually tell patients that I can’t give them two weeks off, but I can document what they report they can and cannot do. If they say there are no light duties available, I can’t verify that—only the employer can. Most of the time, the patient leaves satisfied, or at least they don’t argue, which is what we want to avoid.”WorkSafeBC recommends that physicians present restrictions and abilities in a structured manner that allows employers to match patient capabilities with suitable work. This approach minimizes unnecessary time off and reduces the risk of chronic work disability.Indeed, as we know: Work is a social determinant of health. Dr. Dunn argued when we look at the broader benefits of employment, which include improved income, a sense of purpose and mental and physical well-being, the value of work is crystal clear. Indeed, after six months off, statistics show a worker’s chance of returning to work falls below 50%.Physician and employer communication: navigating confidentialityDr. Dunn said clear communication about work restrictions does not require disclosing specific medical details. “You don’t have to share all the medical details. You don't have to give them the diagnosis but give them enough information so they can accommodate your patient,” she said, referencing standards from the CPSBC.“If they have a frozen shoulder, you might avoid commenting directly on that and instead specify they can’t raise their arm beyond 20 degrees,” said Dr. Ng.Case example: Stress leave in a teacher (Stress without a mental health diagnosis)Patient Profile: A 35-year-old high school teacher presents with low mood and anxiety symptoms, which they attribute to work-related stress and interactions with a difficult supervisor. Patient requests note for off work for two weeks.Dx: No psychiatric diagnosisApproach: How do you approach the patient request? What is your advice?One physician audience member tilted her head. “It is so hard when they say they can’t do anything.”Dr. Dunn made two points two address:Have you talked to HR?What is going to change over two weeks?Another physician in the audience said to think about: “Is there a specific trigger or something? If (the physician) gives them time off, what’s gonna happen over those next couple weeks that’s going to change the situation? Because if nothing is going to change when the patient goes back then you’re just digging the hole of chronic disability. One of our colleagues sometimes likes to say, ‘well I wouldn’t tell people to take a two-week break from their marriage!’” (That got laughs from the audience.)Practice standards: clear and factual reportingThe CPSBC practice standards for medical certificates stress that statements must be “truthful and based upon objective clinical information.” Physicians should avoid speculative language or patient-provided self-diagnoses. When issuing retrospective certificates, it is essential to indicate if the patient was not seen during the stated period.Dr. Ng said: “Short term sick notes, like a retrospective diagnosis, may be provided or retrospective opinion may be provided—that this is what the patient says. (We get a) patient coming in saying, ‘I got a cold last week. I couldn’t work. My employer needs a note.’ What I would just say there is: patient reports that they had a cold last week and was not able to go to work but I did not see the patient.”

The case against clinicians ‘prescribing’ time off work (and what to do instead)

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