Work Notes (Absentee Excuses and Workers Comp)

[ShakaHoo]

This may be a silly question, but I have spent the majority of my career working in Urgent Care and Occupational Medicine. 
 

At Urgent Care I’d have patients who called out of work sick several days, and were required to have a return to work note. They would come in asking for a note saying please excuse patient from ——— to ———- due to a medical condition and they can return to work. 

Obviously they could have been sun tanning at the beach or on vacation… do you just willingly write the note?  
 

 

In Occupational Medicine there are a small percentage of patients who under no circumstances are receptive to “light duty.”

 “I don’t understand how you can send me to work when I am in pain?”

Do you argue with them, and explain why they are able to work (which usually gets you nowhere) or do you just cave and put them out of work. Often times they will ask to be referred to a specialist… who subsequently puts them out of work anyway. 

I had a patient who was placed out of work by a physiatrist for an “elbow contusion” SIX WEEKS, after I told him he could work light duty. 
 

Sometimes I feel like it’s easier to give the patient what they want, get a 5 star review, and a return customer?  
 

thoughts?

[sas5814]

No. I will give a note from today and, if appropriate, going forward. I have no idea where the patient was 5 days ago.

[Reality Check 2]

The job with workers comp is to say what the patient CAN DO. Then it is up to the employer to accommodate or not. IF the employer cannot find work for them - then the employer sends them home.

States PAY companies to keep people working.

Rarely is anyone completely incapacitated - concussion, yes. New fracture - circumstantial but yes for a few days or until surgeon says what can be done. 

Lumbar pain with foot drop and obvious radiculopathy - expedite the surgical eval and likely off work.

DeQuervain's tenosynovitis - wear a splint, stop repetitive motion - employer might find something for them to do.

Again, provider's job is to diagnose and say what they CAN DO.

Do not be bullied by workers comp patients - stick to the dx and rehab. Push it off on employer to find them something per your well written capacities. 

Assess what a person could SAFELY do based on their injury and limitations.

For Non work comp - NO, no work notes - unless I saw you for the illness. Do not call me on Monday asking for a note for Friday and Monday because your tummy hurt. If I see the patient and assess the condition - then a note might be appropriate. 

As Scott says - it all went to crap when a clinical patient became a customer and Medicine became Burger King.

Follow the science, use logic - live long and prosper.

More caffeine for me - STAT

 

[SedRate]

4 hours ago, ShakaHoo said:

Do you argue with them, and explain why they are able to work (which usually gets you nowhere) or do you just cave and put them out of work

I don't argue. I do have a conversation with them, ask the pt what their job entails and tailor the note including the date I examined them, any time off I think is medically appropriate, and what they're capable of. If they can sit at a desk and type, then I say sedentary duty, specify any restrictions (elevate limb throughout day), and write how many hours with any necessary breaks and for how long. If they need to cut back to part time or have time off to do PT or appointments, I include that. 

4 hours ago, ShakaHoo said:

“I don’t understand how you can send me to work when I am in pain?”

I'm in Ortho so my response may not be as relevant to Occ Med, but I prescribe/counsel appropriate multimodal pain management. If they are in so much pain that they don't think they can work, they need to see a specialist who can further evaluate and write an appropriate script or work note. I only write a note for the current visit and a week in order for them to get an a appt with the specialist. If they backpedal, then I ask what they're capable of and tailor your note.

 

4 hours ago, ShakaHoo said:

Often times they will ask to be referred to a specialist…

I will refer if it is appropriate. If it's because they don't like my answer, that's not a reason to refer, IMO, and I tell them they can most definitely seek a second opinion (on their own).

4 hours ago, ShakaHoo said:

I had a patient who was placed out of work by a physiatrist for an “elbow contusion” SIX WEEKS

That's ridiculous. 

4 hours ago, ShakaHoo said:

Sometimes I feel like it’s easier to give the patient what they want, get a 5 star review, and a return customer?

Probably, but not sure that A. I'd want that return customer, and B. That's appropriate medical care. 

[Reality Check 2]

A work note CAN be written in such terms that there is NO work available but you still said what the patient CAN do.

And - NO - do not cave to get a good Press Ganey - that makes me very upset - no provider should do that - not good medicine - ever. Not ethical at all.

Start a sentence with "Why YES, Your Honor, I did................." and hear how bad it sounds.

[SedRate]

20 minutes ago, Reality Check 2 said:

A work note CAN be written in such terms that there is NO work available but you still said what the patient CAN do.

Yep, exactly. This is how I approach work issues, school notes, etc. I've only had one pt have an issue with it, a firefighter, who broke his leg and had always seen the surgeon. He had tried advancing the pt once which didn't work or whatever so kept him off work since. After several months, he somehow finally got on my schedule. He kept stating there's no work available with those restrictions despite me and the case manager telling him, "I understand, and I still need to write what you are capable of. If they don't have work for you to do that meets that, then that's on your work to figure out and that usually means no work." He wasn't satisfied and wrote a review saying, "PA didn't understand work comp. Dr. So and So does and did a great job." Very frustrating situation to walk into.

[sas5814]

Doing the right thing is always frustrating when there are so many people who take the path of least resistance.

I work with one lazy butt who just does whatever makes the patient happy and gives steroid injection like he is a one man urgent care. I am about to go see another of his patients who didn't get better with the miracle shot.

I have to look myself in the mirror. Working for the VA there are lots of secondary gain issues because we have so many programs that pay for this and that. I keep it on the strait and narrow. If the truth doesn't make the patient happy.... too bad. If the truth doesn't make the employer happy....too bad.

Just as an example we have "aide and attendance" that is supposed to compensate a family member for lost work if the veteran has a health problem that requires the family member to take care of them on a daily basis. Had a guy want it for his wife after he had a mini-diskectomy stating he couldn't fill his own pill box. He was 41. No.....

He insisted I complete the paperwork so I did. Didn't work out the way he planned.

[kettle]

I'm all for writing notes on what people can and cannot do. Old term but workplace hardening comes to mind here. Back to work soon as possible with restrictions then restrictions slowly become less and less until full ability is able to be done. Some states do this some don't, was some research that showed this led to more people returning to the workforce and less long term disability.

Regarding urgent care notes. I often ask what they do for work. Get into a rock and hard place at times. For someone who shouldn't have missed work I will just give a note when they were seen and that they can return immediately. 

[rev ronin]

One of the things I point out on Workman's Comp cases is that the activity prescription form documents limits that apply 24x7.  I had a lady swear she couldn't bend one knee postoperatively. OK, reasonable, fine, we write that, done.  When the state investigator gets video of her repeatedly squatting down with heels-to-butt to get something off a low shelf and standing up without assistance while grocery shopping--clearly a public place--it's on her.

I do often have to do some education with nervous patients who are afraid they are going to get screwed by the system, and I point out that proper documentation protects everyone.

[ventana]

occ health

the employer pays you, not the patient, this is where you responsibility lies.

IF an employee can work light duty that is what you give them.  I hardly ever took someone out of work fully.

As for people not "liking" going to work, to bad. I never argue, I am polite and upbeat and always say they can go to their own Doc if they way

[sk732]

I never give retroactive sick notes - only for the time I saw the person.  I've been burned once before, so no N-O.

When it comes to RTW, the job is to tell the employer what the employee can do safely and for how long - the employer decides if light duty can be accommodated or not.  More often than not people will get their backs up - it's much easier to not work than to go back to work, and the longer it takes for them to get back, the less likely they will.  I also tell people the pain isn't going to magically disappear, especially back stuff and sitting at home doing dinky doo will literally increase the recovery time. People love to push back though...and for people like that, I've seriously considered getting my PI license, getting out of the medicine business per se and setting up a surveillance business for insurance companies that are paying out medical comp for people that, how should I put it, are less than honest about what they're doing/can do, such as picking up over/under the table work that they're allegedly incapable of and double/triple dipping.

[rev ronin]

3 hours ago, sk732 said:

People love to push back though...and for people like that, I've seriously considered getting my PI license, getting out of the medicine business per se and setting up a surveillance business for insurance companies that are paying out medical comp for people that, how should I put it, are less than honest about what they're doing/can do, such as picking up over/under the table work that they're allegedly incapable of and double/triple dipping.

While that's tempting, it's a violation of our role in medicine. We are to work for the patient's best medical interest, no matter who is paying us. So yeah, I try to get people back to work ASAP, but always because it's the best thing for them, not because I don't want anyone profiting off of an injury. It's a subtle distinction, and I despise freeloaders as well, but there is a definite cost to the patient/clinician relationship if we're treating them all like possible fraudsters.

This may seem like splitting hairs, but taking an "I believe you can get back to work, and I'm here to support you through that" approach strikes me as the best approach.  Investigators are out there to do their jobs, I appreciate them, and when they've caught someone, I've never opposed the appropriate consequences. It's just not my job to go looking.  I have occasionally told claim managers of suspicions I could articulate, but I've also been happily proven wrong when the workers went through the process and got back to work.

There's definitely an aspect of coaching/counseling/chaplaincy involved in getting seriously injured folks back to work.  They've been hurt on relational, self-worth, and emotional levels, not just whatever it was that took them out.

[sk732]

I should rephrase or make things clearer - if I were to go around doing surveillance work, it wouldn't be with an active medical license, as like you said, that's not ethical.  It's along the same lines of why I wasn't allowed to apply to the Human Intelligence program as a medic - you hear things from people that you're not supposed to be spreading around or you gain trust in a way a spook shouldn't be able to and are expected to take advantage of that trust.  Having the medical training/experience on the resume gives you some street cred regarding having seen sick/injured people and how they should be able to function/not function.

I'm very up front with people that "Yeah you're recovering, but you need to get up and go to work".  I work on managing expectations that you're going to be having pain regardless and try to normalize it as part of their process.