Joshua Russell, MD, MSc, FCUCM, FACEP
Who among us has worked a single urgent care (UC) shift without at least one patient making a humble request for a sick note to take back to work? “Can I have a work note?” It’s a simple ask. In fact, apart from medication refills, work note visits rank among the most welcomed presentations for many overworked clinicians, offering a much-needed mental reprieve and a chance to finally catch up with charting. However, while the path of least resistance (ie, providing the note without asking too many questions) may seem harmless, it’s worth exploring the knock-on consequences of our frequent complicity in the utilization of urgent care as a “work-note factory.”
As urgent care clinicians, we have many responsibilities. We root out disease when present and offer reassurance when it’s not. We alleviate the symptoms of the ill and then move on to the next patient. And we do this many, many times a day—all while also trying to keep up with our charting and various inboxes. There’s often not even time enough for a lunch break. So while it may require little effort to produce notes for employers on demand, it’s equally understandable for frustration to arise when patients present with a singular focus on walking out with a note to give to their supervisor.
This frustration, furthermore, can be exacerbated by the common tendency of patients to be less than forthcoming with their motivations until the conclusion of the visit. Over the 12 years I’ve practiced in emergency departments (ED) and UC centers, I’ve seen countless patients present for benign and often vague complaints. Sometimes the patients get a workup, sometimes they don’t. But not infrequently it’s only at the very end of the encounter when the patient will divulge, usually as a feigned afterthought, that the all-important note was the true reason for their visit. “Can I have a work note?” There are those words again.
Underlying Motivation
Of late, I have begun paying closer attention to this phenomenon and find myself wondering why these patients are so compelled to seek out this documentation. What’s the underlying motivation here? And, most notably, why is this even a thing?
Let me provide a few examples of the broader categories of work-note-seeking behavior that may sound familiar:
- The Retroactive Work Note: “I missed work several days ago, but I’m all better. I need a note saying I was sick.”
- The Day Off Request: “I have a headache and/or nausea and/or diarrhea, and I can’t go to work today.”
- The Sick Duty Work Note: “I have a sick family member at home, and I need to take care of them.”
- The Anti-Work Note: “I was sick or injured, and I need a note saying that I’m allowed to return to work.”
Each of these scenarios represents a relatively common occurrence, and yet all are slightly different situations. The unifying theme, however, is that we are being asked to be arbiters of the legitimacy of work absences or fitness to return to work. This is a job few of us are trained for and even fewer of us willingly agreed to.
In certain instances, there are clear guidelines that we can look to when faced with such requests. COVID-19 is a perfect example. The Centers for Disease Control and Prevention (CDC) has offered guidance regarding timing of isolation and masking since early in the pandemic.[i]
However, outside of these cases, we are left to our own judgment. And again, few of us have much specific training to guide our determinations, much less the time to probe sufficiently to determine which requests frankly may be inappropriate. Am I the only one who recognizes the absurdity of this? I understand that employers need to hold their workers accountable and prevent excess absences, but have we looked at the toll this expectation takes on the patients or our healthcare system?
Everyone’s Doing It
A colleague recently polled various emergency medicine (EM) and UC social media groups. These polls confirmed my suspicion regarding the universality of this experience. With more than 500 total respondents, 76% of EM clinicians stated that they provide a work note at least once per shift. And 78% of UC clinicians said that they do the same one or more times per day.
Healthcare is obviously a business and a big business at that—$4.1 trillion per year to be exact. From a strategic standpoint, these patients are low-hanging fruit that have very simple expectations, and their “care” generates millions of dollars in annual revenue. Imagine the healthcare costs this group of patients might represent annually in urgent care alone.
13,000 urgent cares
365 days/year
2 patients/day (conservative estimate)
9.49 million visits
That’s nearly 10 million UC visits explicitly for work notes. If the average UC visit charge for such a visit is $100—again a conservative estimate—then this represents about $950 million in healthcare spending for work-note-driven visits in UC alone.
As with the examples above, these visits are not always driven out of medical necessity or even patient concern. The next logical question becomes whether illness- and injury-related absences are a medical problem or an employer problem. I argue it is the latter.
Additional Costs
Some employers want to have a deterrent to prevent unnecessary and excessive work absences. Other employers might have liability concerns and need documentation of employee illness and/or fitness. Fair enough. But busy medical professionals and truly ill patients who need timely access to care are compromised when healthcare providers’ bandwidth is consumed by these millions of visits explicitly for work notes.
Turns out the legislation regarding this practice isn’t very straightforward. Employers generally seem to have the right to ask for a medical provider’s note if a patient misses three or more consecutive days of work. Depending on the state, they might ask for a note for any missed work.[i] But what about a note for missing one or two days? This is situation we are faced with most often. Do patients in these circumstances actually “require” a note, or is this just an employer’s way of disincentivizing absences?
Not only does this quest for documentation involve use of the patient’s time, it also has potential childcare and transportation implications. And of course, there’s always the matter of the bill. For uninsured patients, the cost of obtaining a note to avoid jeopardizing their job only compounds the cost of the lost wages for the time they missed.
For patients with coverage, their insurance carriers aren’t likely to be very happy about this situation either. For that matter, taxpayers should take objection as well, knowing that many of the patients subject to such employer requirements have publicly funded health insurance because they have lower-income, blue collar, or service industry jobs. It’s pretty rare for a lawyer or accountant to ask me for a work note. This highlights the inherent inequities furthered by these policies.
Let’s also examine the effect on other parts of the healthcare system. Already overwhelmed, EDs routinely have wait times measured in hours, pushing these patients increasingly to UC centers. Patients presenting for work notes may expose other patients and clinicians to the flu or other contagious illnesses, occupy healthcare workers’ time, undergo unnecessary testing, and add to the already rampant epidemic of excessive paperwork.
The Madness of Work-Note Seeking
There is relatively easy revenue for UC organizations in welcoming—or at least not discouraging—work-note-seeking patients, and employers can easily enact mandates demanding such documentation as they bear little of the burden of their impact. However, the employees that find themselves subject to such policies are in an unenviable position, and we as clinicians are dragged into the scene as unwitting and largely unwilling participants.
The solution to this dilemma may not be obvious or simple, but if we don’t speak up about the madness of work-note seeking, the trend is unlikely to abate anytime soon. There has to be a better way. A more rational system must be achievable without excessive losses for employers or healthcare systems, while not penalizing those most affected by the status quo: patients and clinicians. I am open to any suggestions. Send an email with your thoughts to [email protected].
References
[i] Centers for Disease Control and Prevention Website. COVID Guidelines. Accessed September 22, 2023. https://www.cdc.gov/coronavirus/2019-ncov/your-health/isolation.html
[ii] Indeed.com Website. Doctor’s Note for Work: What It Is and When You Need One. Accessed September 22, 2023. https://www.indeed.com/career-advice/career-development/doctors-note-for-work
