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Doctor's Work Notes and Medical Ethics

I wrote the story below before all of the Wisconsin issues popped up, but the “doctor fraud” scandal segues nicely with the issues in the patient encounter I wrote about.

Kevin, MD had a post yesterday linking to an article in The Atlantic about how physicians in Wisconsin were standing on street corners and writing work excuses for protesting teachers. Videos in the Atlantic article showed the the doctors were writing notes for “stress” based solely on a patient’s history without performing physical examinations. The Atlantic article questions the physicians’ integrity and states that the “profession of medicine has a black eye in this case.”

The author of the Atlantic article is a physician who also writes on health care policy. He calls doctor’s work notes “an employer’s desire to verify through a respected, independent, medically qualified third party the fact of an illness and the true need for convalescence.” I respectfully disagree.

In many of the cases that I see from my practice and those discussed with me regarding other physicians’ private practices, doctor’s work notes have become little more than a legal CYA document for employers and a hoop that employees have to jump through in order to take time off of work.
Can people with a cold go to work? Sure. But if everyone else at work gets sick, then the employer complains to the hospital about why the employee was allowed to return to work. If the employee is given a note not to return to work until symptoms resolve, then the employer complains to the hospital that the doctors are giving the patients too long off of work.
If doctors write for prescription medications for a work injury, or write a patient off of work for more than one day, then employers complain because the care the patient received makes the injury reportable to OSHA.
Employers also put physicians in an ethical bind when they require a doctor’s note for patients who took off time for an illness and are then feeling better and want to go back to work. I can write a note stating that patients are cleared to go back to work, but then patients return and state that the employer needs a doctor to certify that the patients needed to be off of work for the prior “illness” which is now gone and for which the patient never sought medical care.

Commenters to Kevin’s article stated that the doctors were creating inappropriate “legal documents,” were being unethical and were “disgracing the medical profession.”

I think that these statements smack of hypocrisy. Physicians in private practice are monetarily pressured to keep patients happy by doing what the patients want. Hospital based physicians are pressured by the hospitals and by Press Ganey’s patient satisfaction scores to provide sometimes inappropriate care to patients to make the patients happy. In case you had any doubts, refusing to write a note required by a patient’s employer will not make the patients happy. Here’s another example of a patient upset at not getting a 9 month work note from Serenity Now Hospital.

If a physician writes a note off work for a patient because that patient had vomiting “last week” and can’t go back to work without a doctor’s excuse, I don’t think that “legal document” is any less fraudulent than the notes being written on Wisconsin street corners. Yet there is a public outcry in one instance and the other instance is considered “business as usual.”

Just like in medicine, employers are going to get what they pay for. If you require a doctor’s note for an employee to return to work, patients will always be able to find a physician to write them a “note” for work. A work note doesn’t necessarily mean that the employees were really sick. Sometimes it only means that some physicians bow to societal pressures more than others.

The fact that physicians have to be put in that position gives society just as big of a “black eye” as the physicians.




A patient comes into the emergency department with a harsh cough for several days. Little bit of a runny nose. No fever. Might be influenza, might be some other upper respiratory tract virus. Upset over not getting antibiotics. Given some cough medication and discharged.

Then comes the money question: “What about work?”

“What do you mean?”
“Aren’t I contagious?”
“Probably. But you could technically be contagious for another week or two. Do you think you need to stay off of work that long because you have a cough?”

Wrong thing to say.

“I work around people, though.”
“If you cover your mouth when you cough and you wash your hands regularly, you shouldn’t have a problem.”
“I work in a fast food restaurant, so I’m around food that customers will eat.”
“So you can’t avoid coughing on their food? I guess you could wear a mask … you know what, sir … what else is there that you need for me to do for you today?”
“I need a note for work. My boss won’t let me back until I’m not contagious.”
“I can’t predict when you won’t be contagious any more.”
“Before, you said it could be up to two weeks.”
“So you want a note for two weeks off of work because you have a cold?”
“My boss won’t let me work if I’m contagious. What if I get other people sick?”

This ended up being another one of those no-win situations. If I say “I’m not giving you a work note for your cough,” then the person goes and gets people sick at work and the business complains to the hospital administration. Don’t roll your eyes, it’s happened before. If I write a note like the patient wants, then I look like a dimwit for giving someone off of work for a cold … and the employer complains to administration because the patient was given an extended absence.

So I wrote the following note:

This patient is suffering from a viral upper respiratory infection. This disease can last for up to several weeks and can be spread from one person to another by direct inhalation of viral particles or by coming into contact with contaminated surfaces, including hands. The spread of disease can be reduced by covering one’s mouth when coughing, by washing hands frequently, and by wearing a mask. You, the employer should consider these factors in deciding whether this patient is able to continue working at your facility.

What would you do?


  1. so ridiculous you have to waste your time dealing with this stuff. Blame the dishonest workers just looking for a reason not to work. They should be happy they have a job.

  2. I don’t give people a work note for a viral infection. Maybe I’m a hard ass, but c’mon.

    I see patients daily who “called in sick” with some trivial illness and then their employer demands a work note. Of course, their primary doctor can’t see them on the same day in the office, so they come to the ER to get a work note. This is the most stupid waste of time and money because the patient wouldn’t have even gone to any doctor in the first place until their stupid boss demanded a note. My always say “Wimpy McFaker was seen in the ED today at 12pm and can return to work now”. Maybe my Press Ganey scores suffer, but at least I can sleep at night.

    OTOH, I will give notes for serious illnessness.

    • And this is why pharmacists should be allowed to write medical certificates. Which, in my area, they are. And the stink the (Australian) AMA kicked up was unbelievable.

    • I think each case must be looked at individually. For example, an RN working in neonatal intensive care has a fever of 101 to 102 for 3 days and sore throat, cough and sinus congestion for 5 days, calls out sick the 3 scheduled days of work that week. The other days she was sick were not work days. Because of calling out sick 3 days she goes to immediate care because it’s a weekend. Has a fever of 101.5 at time of exam. Rapid strep test negative. Doctor says it’s viral, and gives RX for cough/sinus congestion. RN explains to MD she works in NICU and masks are not allowed, persons sick with or without fever not allowed in NICU due to compromised patient population. Asked for note to return to work. MD gives note to return next day ( interesting that MD could know patient would be fever free next day). The RN was not scheduled fir work the next day so the MD wrote note to return the day after next. Now here’s where it gets ridiculous… Because the RN was off for 3 days prior to calling out sick for 3 days and then had 1 more day off after calling out sick and next scheduled work day..,, the employer says they must file for state disability. Omg! The rule is if you call out sick and the time you are off total is more than a week you have to file. It does not matter if you are sick the whole time, how many days you called out sick. The time was regular days off fir 3 days, then called out 3 days, and then had one more day off before next scheduled work day. This is absurd to be made to now pay an MD to fill out disability papers for calling out sick with a virus for 3 days only. The last time this happened my doctor refused to fill the papers out. The RN is now being told to do this again! Not all patients can work when they are sick. Where and who you work with is important. It may seem dumb to some MDs but premature babies can be severely compromised by infections and can even die. Our NICU says if you are needing to wear a mask, you shouldn’t be there. You must be free of fever for 24 hours before entering NICU. Parents and staff have to follow these rules. Once a visitor with cold symptoms and whose children had RSV visited and it spread. Several of babies ended up on vents, Every patient had to be moved out to separate rooms outside of NICU so the unit could be throughly cleaned. More staff required, higher acuities and care. Needless to say this cost quite a bit of money. So please ER MDs stop lumping your patient into a bunch of whimsy, liars, trying to take off work…. Because all employees CANNOT work with colds!

  3. As a small-business-person, notes are sometimes necessary for worker’s comp claims and other insurance issues. If someone consistently calls in sick, asking them to get a note is for verification, and I have no problem accepting the word of a medical professional. In fact, what you wrote in that story would be just fine, and if they create a habit of calling in for sniffles, they can do so elsewhere.

    • In addition to working in an emergency department, my wife and I run a small business and have employees, too.
      Workers comp and insurance issues are legitimate reasons for a work note.
      If, on the other hand, you want a physician’s note for a worker being “sick,” that note verifies very little other than the fact that the workers can go to a physician and talk the physician into writing a note for them.
      Why do you accept the word of a medical professional you have never met over the employee you have hand-picked to help you run your business?
      If you trust your employees so little that you need to treat them like second graders when they call in “sick,” then you need to reconsider your hiring and retention practices.

      • I encouraged my frequent ill-callers to apply for FMLA benefits for a “serious medical condition” if they were calling in frequently. Rarely were their applications approved. Viruses and such were not approved reasons to be out.

        Believe it or not, going through the progressive discipline process really inspired people to show up. Of my 110 employees, only 5 were absent over the allotted amount (which was pretty strict) of their scheduled hours at any given time on average. Before it started, it wasn’t unusual for people to be calling in 20% of the time.

        Only one person was terminated for absences. We saved a quarter of a million dollars in sick time and overtime usage too the first year this was implemented. It took some time, but it saved everyone time overall.

        A lot of people had multiple children and they’d always call in when one was ill or other such reasons. This “inspired” them to find alternative childcare arrangements for illness and to plan ahead for when this occurred.

        “You’re a professional. Professionals show up to work.”

      • It’s not something I would ask from most of my employees, just the relatively new ones that may or may not be sick. I tend to give people the benefit of the doubt, but when they call in whenever there’s a football game on TV (in one recent case), of course there’s no need to waste a doctor’s time.

      • It’s really unfortunate that people always assume that everyone has family or financial ability to pay in advance for one daycare, and have to pay again for another person to watch your child when they are sick. I am a professional, but unfortunately I do not make enough money to pay two daycare providers (an example: daycare that is paid in advance for the ENTIRE month, is off for a whole week for Christmas. So that means that since I do not have any family or friends to watch my child, I have to pay another person to take over.) I barely make enough money to pay for one, and that is with state assistance. So for you to say this “inspired” them is utterly rediculous. They probably decided that since they had a family unfriendly employer that maybe they will just let that family member who is probably not the best person to watch a kid actually watch their kid because “after all” being able to feed them is a little more important.

        The fact is, most people do have family or friends or financial means to accomodate the many illnesses kids pick up at daycare etc., but not all of us do. I am a single mother (literally). I have no family support at all. I make $3 more than minimum wage (and that’s with one year of college under my belt), and recieve zero child support. So for you to imply that individuals like myself are not professional simply because we are FORCED to stay home is ignorant. The last thing that I ever want to do is call in sick AGAIN. So please take that into consideration the next time you are considering firing an employee in a similar situation.

    • If you tell them the expectations before they’re hired (to be here a certain % of time including “manager discretion”) and they aren’t following that, then you don’t have to bumble around with doctors’ notes. Maybe they wouldn’t want the job and you can move on to other candidates. Maybe they’ll trade all their Sunday shifts with a coworker who doesn’t want to work as many weekdays in advance. You’re just pawning your job off on a doctor, really. Be a good manager and manage the people proactively.

      Where are they going to get a doctor’s note on a Sunday anyway? The ER. What a waste, and your employee should be home resting if they’re truly sick anyway…

  4. I give 1 day for everything. I tell them its the ER policy to only give 1 day and that if they need more than 1 day then they need to see their pmd. Works well and I work overnights so I think its reasonable to stay home the next day if you spent the whole night in the ER. I don’t give notes for a self reported history of illness, I pass that mess on to the PMD.

  5. You’ve got the right approach, Whitecoat — put the ball back in the employers’ court by writing a note that explains the risks.

    They shouldn’t expect fairy-tale reassurance that nothing bad can ever happen to the patient, customers, or fellow employees, just because they enacted a policy of requiring work notes for sick absences.

  6. I just hope you have that note in a template as there is no way one can write that our every single time.

    • I hand wrote it on a prescription pad after getting frustrated. But I like the idea of adding it as a template to the EMR. Thanks.

  7. I used to be “the bosslady” and we didn’t accept work notes at all. You could be absent a certain % of your scheduled shifts for any reason (not including approved leaves like FMLA which is another cornucopia of fraud–Off 3 times a month for “migraines”? Please.) and anything after that, you were disciplined. It really kept people from calling in for “non-illness” reasons like “want another day off for vacation”.

    I like your letter, but is that letter a “HIPAA violation?”

    • That’s the way it should be. You shouldn’t need an excuse to miss work. If you’re absent more than the predetermined number of times, you’re disciplined, then terminated.

      No HIPAA violation with the note.
      First, there’s an exception for disclosing PHI to employers (45 CFR 164.512(b)(v)).
      Second, the note is being given to the patient, not to the employer. The patient can give the note to whomever he/she pleases. HIPAA laws don’t apply to disclosures made by the patients.

  8. I like Whitecoats approach but prefer to give a letter that states things they can do. “Patient feels great but may be contagious. Can do heavy manual labor by themselves”. I especially like to do this when malingering patients are trying to create a paperwork trail to scam disability benefits. Doesn’t do much for the PG scores but I figure I’ll take the hit for the good of Social Security.

  9. Thank you for writing about this!! I have long been thinking about how stupid work notes are, how much wasted ED visits for work and school notes exist, and how we are expected to predict contagiousness. This begs the question..

    Why can’t we just get rid of work notes in the ED? What if employers knew that people would not get work notes, would they still say to employees go get a work note?

    Has anyone’s ED got rid of work notes? How about just the dischrge instructions saying you were seen and thats it?
    Do they give work notes in other countries?

  10. “Do they give work notes in other countries?”

    In Mexico, the Seguro Social (socialized medicine) pays disability for people who are diagnosed unable to work. The equivalent of a doctor’s note there is serious paperwork involving real money from the government. The note goes to the employer basically saying “the employee is disabled for this period”, relieving the employer from having to pay the employee (and protecting the employee from getting fired).

  11. WC, the doc gets the benefit of the doubt for writing “sick notes” in NY State. However, the excused is considered therefore that doc’s patient and, as such, needs a chart with the history and physical recorded for the ailment necessitating that note. Failure to keep “adequate” medical records in NY State constitutes professional misconduct. If the WI docs who wrote these phony notes did not keep a similar record, these docs might be liable for charges of professional misconduct if the WI rules are similar to NY’s.

  12. To give a slightly different perspective:
    I am one of the poor saps that has to have a note to be paid for my sick time.

    If I am out for more than one day in a row, I have to have a physician’s note. Whether or not I actually needed to be seen.

    Trust me, I don’t like having to pay my copay and pester my doctor for a note any more than he likes taking the time from patients that are waiting for him to write it.

    • My point is that an employer forcing you to obtain a physician’s note to go back to work is a waste of resources, needless expense to you, and really serves no legitimate purpose.
      Want a day off? I don’t care if you’re going to a hockey game or laying in bed. You help my business get better, I’ll bend over backwards to help you. Missing too much work doesn’t do either of us any good. Do it too often and you’re done. End of story. If you miss that much work, you need to re-evaluate your motives in life. I have a business to run.

  13. This Wisconsin stuff makes me sick.
    Lawmakers are elected and paid to be at their job, and vote. Fleeing the state because you aren’t gonna get your way is overgrown kindergarden stuff. That’s sort of the point of voting – majority rules. And doctors helping this with this really turns my stomach – I expect such things from politicians, would have hoped doctors were one cut above.
    Similar for the teachers – argue, protest, strike – do whatever (legal) thing you want. But doctors lying for them, so they can get paid public tax $$$ for “sick time” makes my blood boil a bit also.

    • I heard on a news show that Abe Lincoln, when a senator and being locked into the room to require a vote, jumped out the window and ran to avoid it. They didn’t say what it was about.

  14. I don’t agree with giving blantantly fake notes but everyone is making such a big deal about it in WI. Happy Hospitalist seems to be about to have convulsions with anger and a fear that the whole medical community is going down the toilet. Of course the whole idea of work notes is dumb – and I like what Nurse K’s place used to do. The only exception would be for something very specific – like the ability to return to work preparing food if you have an open hand wound, or the ability to go back to work as a police officer and use his or her gun after an hand injury. Just needing a work note for some stupid upper respiratory illness is dumb. But I wind up having to do it all the time in the ER. Whatever, it’s just for a day or two.

  15. Hey Whitecoat can I get a work note? I’m heading to Wisconsin to join the protest…

  16. It really does seem wrong for the docs to be doing that. So transparent too.

    Ridiculous that an employee needs a note for simple illnesses that may require them to stay home, but after a day or 2 they can return to work. A waste of time for all involved and not fair to cause the employee to have to also pay a copay or higher fee to be seen unnecessarily by a doctor ..never mind ED charges.

    I agree, it is a good policy for those that call out all the time and would probably deter some of that… but not fair to take up physician time.

    But, if a company provides an allotted amount of sick days, the person should not be penalized for using them if they need to and if you have sick days ..then why need a note to return?

    I don’t know if our hospital had a work note policy. Except for extended absence, but then I think you use your days and then disability for surgical/maternity, etc)

    As far as the employee prone to calling out, I wonder if time banks in which vacation and sick days are lumped together encourage people not to call out? Much nicer to have vacation than sick day. :) And then of course some people don’t even have benefits.

    OH ..WC!

    That interaction you had with your patient wanting a note for an upper respiratory infection would be priceless if converted into one of those online cartoons you can create.

    Throckmorton had one on his site sometime ago and it was doctor vs patient requesting Oxycontin for Fibromyalgia. They seem like human robots with their halting monotone voices and stilted gestures.

    You can create your own cartoons using various characters.

    If you put that conversation into one of these ..it would be hilarious! Ohhh ..do it! Do it! Do it …PLEASE! :)

    If not, I can still imagine it with only reading your words.

    Anyway, here is a link to to one of these cartoons- about an ED doc vs patient faking seizure:

    Ha ha! Imagining the cartoon voices, I just reread your patient interaction again and it fits perfectly! :)

  17. If the visit is for a BS reason. I always write the same thing…” John Smith was seen at (time/date) treated and released to resume previously established responsibilities without any restrictions whatsoever…”

  18. It always seems ridiculous to me that comfortable white collar jobs like mine don’t require doctor’s notes but jobs where the employer frankly does not have as much invested in the employee can be draconian.

    Some time ago I had a fairly major injury and doctor’s orders were no work, no driving for 4 weeks. Of course I worked at home as soon as I was able so the actual lost time less (and I was also obviously still physically impaired when I returned to the office), but I was never asked to produce a note.

  19. Just for the record, I hate being home sick. Daytime TV is just awful, and I get terribly bored. I do everything I can not to stay home sick: I exercise, I eat my veggies, I stay warm. But sometimes I have to stay home and get “rest and plenty of liquids”.

    I have only been asked for a work note if my sick leave exceeds 5 days per year, which is an average in America.

    • Right now i am in bed sick as a dog. I have lost three days worth of wages, and need to now pay thiry dollars for a doctors note and feel even worse today then ever. I am not ready to go back to work, but feel the pressure of losing my job. I am not someone who plays hookie, and have enough symptoms to take the rest of the week off. Cold, flu, smashing headache, dizzy, exhausted you name it. Not sure what i will tell my doctor, but if you all saw me in person you would hope to god i would not re enter the retirement community in which i work until i am at least looking like a human again. Any advice on what to say to my doctor to take a few more days to rest?

  20. The person(s)requesting the “doctor’s note” should pay the doctor’s fee. (The employer)
    It is unethical in my opinion to bill the health insurance for a legal document required by the employer.
    If the doctor does not do “legal” work, the patient should be referred to a lawyer. (Of course, to be paid by the person requesting the note.)
    Any person cannot get through life without a note from their doctor: birth cert./death cert/ and everything in-between.
    There ought to be a law!
    I sympathize with doctors so busy they cannot have time to treat the sick people.

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