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Lecture for year 3 medical students on
December 16, 2014 at the Faculty of Medicine King Fahad Medical City, Riyadh,
Saudi Arabia by Professor Omar Hasan Kasule Sr 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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
THE RESPONSIBILITIES OF EMPLOYERS
·
Employers should recognise 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
recognise 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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
·
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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.
Source: Australian
Medical Association www.ama.au/position-statement/guidelines-medical-practitioners-certificates-certifying-illness-2011
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 Clin Pathol. 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)