It's that time of year again. If the hay fever has begun, the season of examinations cannot be far behind. And that means that it will soon be time for an urgent doctor's letter to the exam board to plead for special circumstances to be taken into consideration, for more time to submit a dissertation, for permission to resit the exam or repeat the course.
The expansion of the university sector appears to have resulted in the recruitment of vast numbers of students who lack either the motivation or the aptitude for academic work. This means that when exam time comes around, many, pursuing the familiar culture of ‘throwing a sickie’ from the world of work, take refuge in the sick role — or at least seek the respite afforded by the sick note.
I hear from friends and relations who work in higher education that no exam board now takes place without due consideration of a pile of letters from GPs supporting student appeals. The interpretation of the subtly graded degrees of enthusiasm in doctors' support for their patients' appeals has become a highly regarded skill in the senior common room. Students soon learn the importance of ensuring that their doctors' letters include objective disease labels rather than reports of subjective perceptions of illness, (if only they devoted the same energy to their courses!). The result is an annual inflation in the rhetoric of incapacity.
The pursuit of the fetish of assessment at every level of the education system has encouraged a burgeoning demand for medical certification of absence or poor performance from students in further education colleges and schools as well as universities. It will not be long before GPs are being asked to write letters to explain or excuse unsatisfactory results in primary schools SATs and pre-school assessments.
It is ironic that, at a time when GPs' role in certifying sickness in relation to employment or disability benefits has been devalued and restricted, we are expected to take on a wider role in policing the education system. We also seem to have acquired ever-expanding responsibilities in relation to leisure activities and insurance claims. Before people go on holiday they need a ‘complete checkup’, a certificate that they are fit to travel, a list of required medications, and a note indicating that they need a wheelchair in the airport and oxygen in the plane. When plans fall through, they need another note explaining medical grounds for cancellation.
Worship at the gym may have become the secular alternative to going to church, but attendance still requires medical approval. This too necessitates a ‘complete checkup’ and a declaration that physical exercise is not medically contraindicated. When enthusiasm wanes, another note may be required to reclaim registration expenses. Every minor car or playground accident, sports injury or pavement trip, pub brawl or street scuffle requires a detailed medical report, irrespective of the fact that no medical treatment may have been necessary. Patients often come to the surgery some time after incidents of this sort, not because they have injuries that need treatment, but because they have been advised that they should seek the authoritative and documented confirmation of a doctor that this incident took place (even if the doctor has no evidence other than the patient's account).
The diverse forms of appeal for medical certification reflect the breakdown in relations of trust and loss of authority in society. Lecturers cannot rely on their students, teachers do not believe what their pupils, or their pupils' parents, tell them; employers do not trust workers, service providers and service users are at one another's mercy. While politicians and health policy gurus disparage doctors for being paternalistic, others in authority are keen to take advantage of the residual legitimacy of the medical profession to compensate for their own loss of respect. The result is what Michael Power describes as ‘an inflationary spiral’ of mistrust.1
- © British Journal of General Practice, 2008.
