Time to Ban Employer Work Note Mandates : Emergency Medicine News

Bivens, Matt MD

Notes push patients to visit EDs just for a piece of paper, putting others at risk

One Christmas Eve many years ago, EMS rolled in with a man in distress. He was small, thin, and middle-aged, and he was obviously in terrible pain, clutching his chest and growling like a cornered animal: "GRRRRRRRRRRR!"

I followed the stretcher to the room. The paramedics had picked him up at home, and he was reporting severe pain, but he had declined an IV and medication and had a normal ECG. I glanced at the 12-lead, and it was indeed stone-cold normal. But the patient looked, well, like he was about to die on me. (Aortic dissection? Atypical cholecystitis? Nutcracker esophagus?)

The patient also looked familiar, and a nurse colleague whispered, "That's Bobby [not his real name] from housekeeping, right?" It was indeed. Bobby was a developmentally delayed man who often cleaned the emergency department floors.

"Hi, Bobby," I began. His face instantly contorted into a terrible grimace. He clutched his chest anew, stiffened, and hiss-growled in agony: "GGGGSSSSSSKKKKKK!"

We all started back in fear. The nurse even cried out, "Oh my god!"

I was just as alarmed. "OK, Bobby, don't worry!" I said, thinking that I needed morphine, the ultrasound machine, and another ECG. "Bobby, we're going to get you some medicine."

Instantly the hiss-growling stopped, the grimace disappeared, his entire affect changed, and he said calmly, "I think I need to stay home from work tomorrow."

Tomorrow being Christmas.

"Uh, OK, well, let's focus on what's going on right now," I said uncertainly, wondering what was in fact going on.

"So, you've been having chest pains?"

"Yes. Chest pain," he replied. He looked completely comfortable. "I think it will get better if I stay home from work tomorrow."

I tried to continue taking a history, but Bobby, almost as if he were impatient with this, suddenly cried out, "GAAAAAAHHHH!"

He smacked his right hand to his chest so hard that the impact was audible. We all jumped in alarm. He squeezed his pectoralis muscle in a claw-like fist and roared in agony. He raised his left hand to the ceiling, fingers spasmed and claw-like, as if he were asking the heavens: "Why is this happening to me?"

I was less in control of this situation with every passing second. To correct that, I started giving doctor orders: "C'mon, let's get an IV in this guy, and I need the ultrasound."

And abruptly Bobby was better. (Takotsubo? What the heck is this?) He declared, "I need to stay home from work tomorrow." Then I belatedly got up to speed: Was this all about a work note?

"Bobby," I said in a tone that mixed annoyance and actual fear. "You know I don't have anything to do with your work schedule, right?"

Instantly his hand thwacked violently at his chest with that same audible slap. His entire body arched, and he let out his loudest roar yet.

For a third time, a roomful of veteran health care providers involuntarily lurched backwards, many of us with our own little cries of fear. This was getting less plausible with each performance, but somehow it was also getting scarier.

"Bobby, stop it, stop it!" I cried. "I'll give you a work note! You don't have to go to work tomorrow!"

And he was better.

"Thank you," he said.

We all just looked at each other.

And then I scanned his chest to prove to myself he didn't have an aortic dissection.

At discharge he walked out briskly, clutching his papers and waving cheerily. I like to think he had a wonderful Christmas, and I honestly don't think it mattered one bit that the floors did not get cleaned in the ED that day.

I have found in the years since then that the occasional ED visit really is just about a work note. When I suspect that, I find it's best just to ask nonjudgmentally and in a tone suggesting I'm just trying to help, "Are you partly here because you need a work note?"

I recently reviewed the literature on excuse notes for work or school, and there really isn't any, at least not for U.S. emergency departments. Our professional societies don't seem to have any positions on this either.

There's more literature from Canada and the United Kingdom. In the United States, we call it a work or a school note. In Canada, it's a sick note, and in the United Kingdom, it's a fit note. (Occup Environ Med. 2018;75[7]:530; https://bit.ly/3TXmTEg.)

One survey of Canadian physicians found that most provide at least one work note per day, usually as part of a medically pointless visit. (J Occup Health. 2021;63[1]:e12195; https://bit.ly/3U76xbC.) Only 13 percent of Canadian emergency physicians charge for a sick note visit, an average of $22.50 (about $16 U.S.). That's mind-boggling to me mainly because I have no autonomy to make any billing decisions whatsoever.

The Canadian Association of Emergency Physicians advocates for a ban on sick note requirements by employers and schools. (CJEM. 2020;22[4]:475; https://bit.ly/3NihS6x.) "Sick notes encourage patients with infectious disease, such as influenza or gastroenteritis, to leave their home and visit their family doctor or the ED purely for a piece of paper, which puts other patients at risk," CAEP said. "The ED includes the sickest and most vulnerable patients—including children, pregnant women, seniors, and immunocompromised patients—and a bureaucratic sick-note demand places their lives at risk unnecessarily."

DR. BIVENS works at emergency departments in Massachusetts, including St. Luke's in New Bedford and Beth Israel Deaconess Medical Center in Boston. He is double-boarded in emergency medicine and addiction medicine. Follow him on Twitter @matt_bivens.

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