‘It’s horrible. There’s rats in the house. The person from the Department of Housing saw them,’ the patient told me.
‘Oh good. They’re going to call in the pest controllers then,’ I said.
‘No. They need a letter from you.’
‘What?’
‘They need a letter from you telling them to remove the rats.’
I shouldn’t have been surprised. The organisations looking after public housing regularly require letters from a doctor before any changes can be made, stating how the current situation was detrimental to the tenants health. I’d written letters before for people saying that the mould in their house was bad for their respiratory conditions. So, of course, I wrote a letter saying that having rats in the house would be detrimental to this particular person’s health, while struggling to think of anyone whose health might benefit from having rats.
This was the most extreme example I’ve come across, but every agency wants a certificate from a doctor. It’s one of the legitimate social roles we have, providing a sort of expert witness to the community. Importantly, we certify the cause of death, and routinely, we certify that people are off work, sick. We certify that people have disabilities, or that they match their passport photographs.
I can understand how we acquired the role of authority to certify a particular person’s restrictions as being legitimate. I think it’s nice that we are thought of as a profession that’s trusted enough to certify official documents and photos, alongside ministers of religion and lawyers.
At some point, though, this seems to have morphed into being called on to authorise all sorts of actions that you’d expect shouldn’t require a doctor. That rats might be bad for health is only the most extreme of these. I’ve written letters for people stating that their employers needed to adhere to the COVID-19 pandemic public health orders applicable to everyone at the time. I’ve certified that people who, as expected, are clearly well enough to go back to work, are in fact well enough to go back to work. I’ve filled out forms for agencies where nothing has changed, ‘just so we’ve got an up-to-date form on file.’ And such is the level of authority my completed forms have, that I’ve been contacted to change a tick box to indicate the patient has an exacerbation of their condition rather than a permanent condition, otherwise my form will be rejected.
Frustrating as I find these requests for certificates, I don’t refuse to do them. If I did it would be my patients who would lose out. I view most of them as an opportunity to advocate for my patient, and usually my frustration comes out in letters that start ‘I was surprised to be asked to certify that ... ’
Most of my patients have limited control over their lives, and the need for a letter from me is just another way that agencies have of exerting control over the lives of my patients, and an invitation for me to join them. For this reason, provided I am not lying, I will usually try to support the patient in achieving what it is they need, and use the power of my certificates to give power to the patient.
If society is going to give us this power, then we may as well at least use it for good.
- © British Journal of General Practice 2021
