Work Notes

Patients come to the ER for work notes, and I wish they would just be honest upfront about it rather than concoct complaints and then slip in a comment about a work note. It’s frustrating to do all the song and dance about some potential problem they have that they often have difficulty describing. Their answers to my line of questioning about symptoms sometimes don’t make sense, and I’m left scratching my head, sometimes worried there is really something sinister going on. In reality, they are only halfway paying attention because the goal is the work note, nothing more.

I saw a patient with a painful callus. (Surprising that she noticed, since the smell of marijuana in the ER indicated there was enough around that she shouldn’t have noticed her foot pain.) As I was leaving the bedside, she asked, “Can I have a work note for today?” Seems suspicious, right? Her callus did look a little painful, although it was certainly not an emergency. It didn’t happen in a day and wasn’t going to heal in a day, but apparently she’ll be able to work tomorrow. Maybe she’ll be tougher by tomorrow.

If you are an employer, please never send a patient to me or most any other doctor for a work note. If there are legitimate concerns about returning to work due to an injury, the patient needs to see an occupational medicine doctor. They are the ones who typically make determinations about long-term work and do evaluations for that type of thing.

When it comes to infectious diseases—and I mean pretty much all of them—don’t send your employee to the ER for a work note. Influenza, COVID, URIs, influenza-like illness (ILI), which is basically all the viruses that cause the same symptoms that we don’t have a test for… pink eye, sore throats, coughs, pneumonia… you name it… doesn’t need a work note.

You can do one of two things regarding employees who may be ill at work: tell them to practice good hygiene, e.g., washing hands and wearing gloves or stay home. Maybe they actually need a mask to cover a cough for a short time. Masks can stop big particles and otherwise aim your cough or sneeze down so gravity can help keep it away from others. Simply put, cover your mouth when coughing or cough on the floor. I’m not a fan of coughing into my hand or my sleeve. I aim germs at the ground, so if I’m standing or sitting, I lean over as far as possible toward the ground.

I am aware there is likely no science to back this up. I’m aware the germs can still be floating in the air. I’m also aware that most people don’t use hand sanitizer or wash their hands after every time they cough. They might when they hack up that occasional surprise chunk of snot, but they are not doing it consistently with every cough or sneeze. The ground seems to me to be the next best thing.

And for sure at this point, stop pretending there was actual science around COVID masks and distancing. That was not science. That was based on fear, control, and supply chains.

So, if you’re sick or injured and you want to work, that’s between you and your employer. I can’t magically predict how much work you can do. Clearly, not everyone has the same work capacity, even if technically in the same role at a particular job.

Work takes effort in addition to being capable, and I can’t control how much effort you put in at work. I can’t control how much pain you can tolerate. Sure, a broken bone probably needs some accommodations. Being post-op might need some time off. But then again, I’ve been at work two days after knee surgery and didn’t need a note, accommodations, or any special adjustments. Everyone is different.

I gave up long ago trying to be the arbiter of whether someone actually needed a day off work. We had a mentality at the place where I trained and spent most of my career that’s probably like most ERs. It was established under the long-standing second chair of our EM program. Faculty were always to show up to the ER for their shift. Either you worked, or you were sick enough to check in as a patient. There was no middle ground. My colleagues and I have worked plenty of shifts when we were significantly sicker than many of the patients we were seeing.

So, if you ask me for a work note, sure, have a work note. I generally don’t write for more than a couple of days off, but who really cares? It does me no good to argue someone should go back to work. It does me no good to tell you to suck it up. I can’t make anyone do anything.

Putting doctors in the middle of this discussion is pointless. It’s again assuming we have some special training to manage all the complex human factors that go along with an injury or illness and your ability to function. It’s assuming we are all-knowing about what will take place in the future regarding you, your work, your injury, your recovery, your mindset.

I don’t know any of those things. Just like the lack of training in medical school or residency about saunas and hot tubs, this is the same. Unless you are an occupational medicine doctor or a PCP who also does this regularly, this is not in your wheelhouse.

Take sprains and strains as an example: an ankle sprain, a twisted knee, some mild back pain, shoulder pain—these are all common things in the ER that employers require a work note for. Or the employer wants a specific recommendation about how much the patient can lift, move, walk, or stand. Some employers are able to make accommodations for injured employees; some obviously cannot because the job demands that they be 100% functional. If you work in a warehouse, maybe you’re on your feet lifting packages all day, but maybe if you sprain your ankle, they will let you drive the forklift. I don’t know your employer-employee contract, and I don’t know the details of your job. There is no science to back up exactly how long someone can stand with a sprained ankle if they are wearing a protective boot or splint. Would it be better if you can keep your leg elevated? Yes. Does that mean it has to be elevated for the entire 8-hour workday? No.

There are essentially infinite possibilities based on your injury, your motivation, and your employer’s accommodations. Don’t expect an ER doctor to be able to give you a precise answer to something with so many possibilities and combinations.

If you can, go to work. Don’t come to me to get out of work. If you want to skip work, don’t bring me into your deceit.

For employers who have employees that want to come back to work, let them. If you want to know how long something is contagious after it’s diagnosed or treated, Google it. Good luck! Hard science is lacking. Your best bet is to take some reasonable measures to avoid spreading an infection. But if you have employees who want to work, by all means, let them!