Oof, we have been sick in our house!
We’ve had COVID, run-of-the-mill colds that still make you feel awful, head bumps that bleed like crazy, and a perforated ear drum. I’m humbled by how much the common illnesses of toddlerhood have taken a toll on my family.
It’s hard to feel crappy all the time.
Harder even, in a workaholic culture that gives so little grace to sick people.
(Of course, it’s a million times more challenging for people with chronic illness or disabilities. I heartily acknowledge that we have it comparatively easy.)
The sick day scramble goes something like this:
Afternoon: Sneaking suspicion that our son might be sick. He’s a little cranky, or feels warm to the touch, takes an extra long nap. Or a call from daycare, asking to pick him up because he “projectile vomiting.” (Side note: Why do people describe all vomiting as projectile?)
Evening: He perks up with some ibuprofen. Eats a big dinner. We think we’re in the clear.
Middle of the night: He wakes up crying. Goes back to sleep with some water and more ibuprofen. Somehow, in my sleepy haze, I convince myself he’ll be fine in the morning.
Morning: He wakes up, still cranky and feverish. My spouse and I start the mental gymnastics of how we will care for him.
We go back and forth, juggling who has more important things going on that day: appointments with patients, meetings with clients, big presentations, etc. We rank all of our work responsibilities and the consequences for canceling them. We gauge how much it will inconvenience our colleagues to be gone for the day.
During one of those recent sick days, my husband said to me, “It kind of feels like a loss of dignity, to not have the autonomy to just decide I need to take a day off.”
And we’re the lucky ones. We have paid sick days, flexible jobs that allow (some) remote work, and enough “work capital” to not get fired for needing a day to take care of ourselves and our son. Still, the whole thing feels like an unpleasant calculus: how much am I troubling people at work, versus how sick is my kid, really?
Many of my primary care patients aren’t so fortunate.
One of my least favorite parts of being a primary care doctor is writing “sick notes,” so patients can justify their “medical need” for a day off from work. Requests for sick notes clogs up my schedule, preventing me from seeing patients with real medical issues, and it wastes my patients’ time and energy trying to squeeze in for an appointment. When patients do come in, they cough and sneeze all over everyone in the waiting room
Worst of all, it’s so infantilizing. They have to come groveling to me, hoping I'll adjudicate in their favor and write a note excusing them from work.
I think this is why primary care doctors hate sick notes – and disability evaluations, in the legal sense of the term – so much: it feels like I’m thrust into a role I didn’t sign up for, weighing the supposed veracity of my patients’ symptoms versus their employer’s need for a workforce that shows up, no matter the personal and social costs. It potentially pits me against my patients, the people I’m supposed to be helping, in favor of their employers.
That’s why I almost always write a sick note whenever a patient asks. (Exceptions: teenagers who contact me via the patient portal without their parents’ knowledge, which is a real thing! In general, I recommend kids stay in school unless they’re infectious or really feeling unwell.) But for adults, there’s no benefit to working all the time, and there are very real harms. Need a mental health day, a day to nurse a cold, a day off of work to care for your sick kid? No problem.
In New Jersey, where I work, paid sick days are a legal benefit for most employees. (The glaring exception is independent contractors, who aren’t entitled to any paid sick time.) I don’t have any legal or professional guidelines, as a primary care doctor, about what constitutes a sick day. So I say – most of the time – use ‘em.
But do other primary care doctors agree? My colleagues have a wide range of approaches to the problem of sick notes and short-term disability benefits.
Some have a very, very high standard. They ask their patients to come in for an in-person evaluation, and they’re quite circumspect about who gets the day off work. Others are quite liberal, happily writing a sick note for a concern like “my job causes me stress.”
I was complaining about the “sick note” culture to an ethicist friend of mine, and she brought up several important considerations.
Giving out sick notes must be done fairly. Whatever standard of sickness warrants a day off work, I need to apply it equitably.
If doctors throw up their hands and refuse to weigh in on patients’ medical need for a sick day, somebody else will take over – and it will probably be bureaucrats.
Determining eligibility short-term disability is a complex issue, which I would venture primary care doctors almost universally hate.
All I can say is, I’m glad I don’t have to go crawling to my primary care doc for a sick note every time my son has a fever.