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131216L - MEDICAL CERTIFICATES

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Lecture for year 3 medical students on December 16, 2013 at the Faculty of Medicine King Fahad Medical City, Riyadh, Saudi Arabia by Professor Omar Hasan KasuleSr MB ChB(MUK), MPH (Harvard), DrPH (Harvard)


LEARNING OBJECTIVES
·         To familiarize students with the role of the doctor in certifying an illness or disability
·         To explore clinical, social and ethical issues associated with the doctor's responsibility to certify disease or disability in individuals.

KEYWORDS
Certification of disease or disability

AGENDA/CONTENT
·         Reasons for seeking a medical certificate
·         Different forms of certification
·         Documentation issues for certificates related to clinical problems
·         Social/societal/ethical issues associated with issuing medical certificates
·         Legal issues associated with issuing medical certificates

SCENARIOS
Scenario #1:
·         A senior consultant approached you and asked for a medical certification for a 2-day sick leave. He asks to write that he is sick with a serious anxiety disease but the truth is that he wants to take his wife to another town for treatment a mental breakdown due to discovery that she contracted a sexually transmitted disease in her recent travel.
·         What issues are involved in this scenario?
·         How would you deal with this situation?

Scenario #2:
·         A relative asks you to change the death certificate to say that his daughter died from complications of appendicitis because the true cause of the death, an infected induced abortion, would be shameful to the family.
·         What issues are involved in this scenario?
·         How would you deal with this situation?

Scenario #3:
·         You are employed full by the factory as a doctor to treat the worlers and you report to the General Manager
·         A worker comes to see you about his alcohol and drug problem. You treat him and you promise not to reveal his secret to the Manager because he will lose his job
·         The Manager suspecting that the worker had an alcohol and drug problem asks you to give him a report about the patient.
·         What do you do?

Scenario  #4:
·         A worker falls during work and breaks his collar bone. As a company doctor you treat him until he recovers
·         The worker sues the company seeking damages for the work-related injury
·         The General Manager asks you not to release any records to the court because the company will have to pay a big amount of money that will lead to bankruptcy
·         What do you do?

REASONS FOR SEEKING A MEDICAL CERTIFICATE / FORMS OF CERTIFICATION
·         A certificate certifying illness may be issued where a patient's state of health necessitates time away from the work-place, school, or other relevant activities.
·         Another certificate may be required for carer’s leave entitlement.
·         Death
·         Disability and compensation

EXAMPLES OF CERTIFICATES /
·         Certificate of illness for sick leave
·         Certificate of medical fitness
·         US Veteran certificate of disability
·         Certificate of disability
·         US Death Certificate

MAIN ELEMENTS OF A CERTIFICATE
·         Name and address of the medical practitioner issuing the certificate
·         Name of the patient;
·         Date on which the examination took place;
·         Date on which the certificate was issued;
·         Date(s) on which the patient is or was unfit for attendance;
·         Supplementary information
·         A diagnosis if required and if no confidentiality issue arises
·         The certificate should be legible and written so that a non-medical person is able to read and understand it.
·         The certificate should be written on stationery designed specifically for this purpose.
·         Medical practitioners have a responsibility to obtain and note sufficient factual information through history and examination to issue a sickness certificate.



RESPONSIBILITIES OF THE MEDICAL PRACTITIONER …1
·         Medical certificates are legal documents. Medical Practitioners who deliberately issue a false, misleading or inaccurate certificate could face disciplinary action under the Law.
·         Employers may, in reasonable circumstances, seek further information from the medical practitioner who issued a certificate. Before providing any further information to the employer, the medical practitioner should verify the employer’s identity and obtain express consent from the patient before disclosure of the further relevant information to their employer.



RESPONSIBILITIES OF THE MEDICAL PRACTITIONER …2
·         Where an employer contacts the medical practitioner to verify the veracity of a sickness certificate (eg., to determine if it’s fraudulent in any way), the medical practitioner should verify the employer’s identity and confirm the veracity of the certificate. The doctor should not provide any other information about the patient without the patient’s express consent.
·         The doctor may decline to provide a certificate if he or she feels it is inappropriate to do so.


THE RESPONSIBILITIES OF PATIENTS
·         Patients have a responsibility to consult their medical practitioner in a timely manner when requesting a sickness certificate.
·         Patients also have a responsibility to present the reasons for requesting a certificate in a way that enables the doctor to make an accurate assessment of their eligibility for a certificate.
·         At the time the certificate is issued, it is the responsibility of the patient to ensure that the employer's requirements for leave have been met.
·         Patients must not alter the certificate in any way.


THE RESPONSIBILITIES OF EMPLOYERS
·         Employers should recognize the right of their employees to keep details of their medical condition confidential. Employers should not expect to see a diagnosis on the certificate. Employers should also recognize that the certification by the medical practitioner of an employee's unfitness for work is sufficient.
·         The employer has a responsibility to inform the employee of the requirements for sick leave.


DATE OF CERTIFICATE …1
·         Certificates must be dated on the day on which they were written. Under no circumstances can this be breached.
·         There may be medical conditions which enable the medical practitioner to certify that a period of illness occurred prior to the date of examination. Medical practitioners need to give careful consideration to the circumstances before issuing a certificate certifying a period of illness prior to the date of examination, particularly in relation to patients with a minor short illness which is not demonstrable on the day of examination and add supplementary remarks, where appropriate, to explain any discrepancy.


DATE OF CERTIFICATE …2
·         Medical practitioners should be clear that their assessment of the patient is based on the patient’s history and the findings of the examination. The certificate may include information provided by the patient but the medical practitioner’s assessment should be based on illness or injury observed by the medical practitioner or reported by the patient and deemed to be true by the medical practitioner.
·         Medical practitioners should retain a copy of a patient’s sickness certificate.

WHEN A SICKNESS CERTIFICATE SHOULD NOT BE PROVIDED
·         A certificate should not be provided where a doctor believes that there is insufficient evidence of disability.
·         Wherever possible, doctors should avoid issuing sickness certificates to anyone with whom they have a close personal relationship.

CERTIFICATES FOR CARERS’ LEAVE
·         Only the patient’s treating doctor should issue a carer’s certificate. Carer’s certificates should only be issued with the consent of the patient.
·         It is not the treating doctor’s responsibility to determine who may qualify as a carer.

DEATH CERTIFICATE
·         The failure of a physician to immediately certify death may be a crime and a professional misconduct
·         A paramedic may sign a death certificate if the cause of death is obvious and there is no suspicion of criminal intent such as old age and accidents with no chance of survival (eg decapitation)

ACCURACY OF THE CAUSE OF DEATH
·         56% of certificates appropriately completed (J ClinPathol. 2012 Oct;65(10):949-51.)
·         Major errors 38.3%, minor errors 77.6%, mechanism of death listed as cause of death 21.9% (Indian J Public Health. 2009 Jan-Mar;53(1):31-3)
·         underlying cause of death was misdiagnosed in 80.3% of the death reports (J Family Community Med. 2008 Jan;15(1):43-50)