Medical certification: is it in the patient's best interest?

The paper on ‘work-related sickness absence negotiations: GPs’ qualitative perspectives’1 provided invaluable insight into the feelings and perceptions of GPs who are asked by their patients to provide medical certification regarding absence from work. It highlights the vast differences between GPs concerning the provision of medical certification.

The paper also highlighted that several GPs felt that it would be detrimental to the doctor–patient referral if the medical certificate was not provided.1 However, the question remains ‘if a patient was to ask for a therapy that would not be in their best interests should we as GPs still go ahead and prescribe it?’ For this reason when issuing a medical certificate would it not be wise for the consulting GP to ask themselves ‘am I doing what is in my patient’s best interest?’

Several studies have re-enforced the beneficial effects of work and the adverse effects of prolonged unemployment.2,3 The association of unemployment and an increased Framingham Risk Score, and subsequently, the heightened risk of developing cardiovascular disease has been documented in studies conducted in unemployed men in Poland.4 In addition to the physical illness associated with long-term unemployment, the psychological consequences are also of considerable significance.5

Platt et al established that there was a positive correlation between long-term unemployment and suicide rates among men in Italy during the period of 1977–1987.6 This positive correlation was also supported by a recent study of unemployed men in Japan.7

Although in New Zealand this increase in suicide risk has been attributed to confounding factors,8 one cannot argue the beneficial effects of employment on both physical and psychological health.

Therefore, a healthier population can in turn result in a decrease in surgery visits, hospital admissions, and a reduced strain on limited financial resources with an increase in economic productivity.

Increased sickness absence from work can also result in a greater risk of unemployment.9 The recent changes to the medical certificate have provided GPs with several options as an alternative to ‘you are not fit to work’, helping to ensure patients remains in some form of employment. In addition to this there is evidence to suggest that a graded return to work can increase the probability of the patient gaining and remaining in employment.10

Although the present system of medical certification has many flaws, the realisation that employment has beneficial effects on health have been known for some time and should remain foremost when making a decision regarding time off work.

Perhaps it would be in patients’ and GPs’ best interest if this role was taken away from GPs, thereby minimising the possibility of a conflict of interest and reducing the probability of many a dilemma faced by GPs when issuing medical certificates.

Ultimately, it is the authors’ view that a medical certificate should be seen as any other medicine that is prescribed. Therefore, it should only be issued if it is truly in the patient’s best interests thereby ensuring beneficence and non-maleficence, so that two of the four pillars of medical ethics are respected at all times.

• © British Journal of General Practice, 2010.