Tips for Issuing Sick Notes in Unclear Cases

Almost every doctor has encountered this situation: A patient requests a sick note, even though, from a medical perspective, there are doubts about their inability to work.

The demand for certificates of incapacity for work presents ethical and legal challenges for doctors. On one hand, doctors aim to respond empathetically to patients and take their complaints seriously. On the other hand, issuing a sick note as a favour contradicts professional ethics and can have legal consequences.

While each case must be assessed individually, doctors rely on fundamental strategies and principles in their daily practice to make informed decisions.

This article is based on a forum discussion from Coliquio, a Medscape Network platform, and presents five key tips to help you avoid issuing questionable sick notes.

Tip 1: Set Clear Boundaries

Many doctors in the forum discussion emphasised the importance of setting clear, personal guidelines. A Coliquio member from psychiatry and psychotherapy noted that “it’s much easier to draw a line right away and not issue a courtesy note than to play along for a while.” Declining a sick note request may be challenging, but it prevents excessive demand in the long term.

Setting boundaries requires careful assessment, which is not always easy to achieve. A member from gynaecology explained, “With some women, you suspect they simply want more time off at the cost of others. But you can’t prove it, and such discussions don’t always lead to the desired outcome.”

A minor suspicion regarding the authenticity of a patient’s complaint is generally insufficient to refuse a sick note (see Tip 4 below for guidance in such cases). However, if doubts are well-founded and can be documented, it is advisable to decline such requests.

Issuing a sick note against the doctor’s professional judgement not only encourages further questionable requests but also carries legal risks.

Tip 2: Take Complaints Seriously

Clear boundaries and experience can help doctors quickly recognise requests for courtesy sick notes. However, doctors should avoid rushing to conclusions.

A general practitioner (GP) shared, “I try to approach these patients empathetically and understand their problems. Sometimes, a sick note is not the right solution, and then there is none. Other times, a sick note is justified, even if it initially seemed like they just wanted a favour.”

In many cases, a thorough diagnosis of work incapacity is not possible in a GP’s office. Symptoms such as nausea, dizziness, non-specific headaches, diarrhoea, vomiting, anxiety, restlessness, bullying, and acute stress reactions cannot be objectively measured.

While a brief physical and mental examination can help rule out red flags, much of the assessment depends on the patient’s self-reported symptoms, which may vary in terms of credibility. The goal is to address complaints responsibly, without being overly accommodating.

“This also includes considering each patient in their individual context. Whether someone is unfit for work also depends on their profession. Therefore, there doesn’t need to be a blanket approach after tooth extractions,” noted a dentist. “After a simple tooth extraction, a manual labourer working in dust and dirt is more likely to receive a sick note than an office worker.”

For mental health conditions, early warning signs should be taken seriously, and a sick note may be warranted even for mild symptoms to prevent further deterioration. This approach may help prevent prolonged work incapacity and hospitalisation, as highlighted by a psychiatrist.

Tip 3: Listen and Educate

Some anecdotes from the forum describe cases where requests for sick notes are so blunt that a refusal is straightforward. For example, one gynaecologist shared: “I have an exam at university tomorrow and have not had time to study. Can’t you give me a sick note?”

However, in most cases, the assessments are more nuanced. Patients often struggle to accurately gauge the severity of their symptoms. In such situations, an explanatory conversation is helpful.

A dentist noted that asking detailed questions, providing reassurance, and alleviating concerns about potential harm from work often helps patients who overestimate their symptoms. These conversations can also shift perspectives.

I ask detailed questions, reassure them, and address their concerns about work being harmful to them. This often changes their perspectives.

“If I feel that a sick note is not absolutely necessary, I take the time to explain what it means for the employer and colleagues when someone is frequently absent. I might issue a 2-day sick note if it’s the end of the week and tell them to get in touch if they’re not better by Monday. I make it clear that I cannot fully assess how sick they feel subjectively or how difficult their work is. This way, patients feel taken seriously and reconsider whether they still need a sick note on Monday,” another GP added.

Tip 4: Keep Periods Short

When work incapacity is uncertain, issuing a sick note for a shorter period rather than a full week can be a practical solution.

An orthopaedic specialist shared their positive experience with this approach: 

“I often ended longer sick notes on a Wednesday or Thursday, so the patient was ‘certified healthy’ again on Thursday or Friday. I then regularly received requests to include the weekend in the sick note — but I never agreed to this and always pointed out that a sick note does not end like a calendar on the weekend. There was some grumbling, but it always worked.”

Shorter sick leave allows for reassessment of the patient’s condition after the initial period of sick leave. This helps distinguish cases in which the initial impression of a non-serious request was inaccurate.

Tip 5: Accept the Grey Area

In many cases, there are no definitive right or wrong answers. Serious complaints should always be thoroughly investigated. When doubts arise regarding the medical necessity of a sick note, discussing the symptoms and working conditions in detail can provide clarity.

If a patient insists that they are unfit for work, it can be difficult for doctors to prove otherwise. This complexity was highlighted by an internist, who commented: “Diarrhoea and episodes of dizziness and weakness — who wants to provide evidence to the contrary? Sick note assessments can be complex and are rarely a topic of casual discussion.”

Additionally, the tight schedules of most practices often leave little time for a systematic investigation of the cause of work incapacity.

Ultimately, doctors must use their best judgement to determine whether a sick note is warranted, considering the medical factors and the patient’s circumstances. Accurate documentation and professional integrity are essential in all cases.

This story was translated from Coliquio using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.