A guest column by the American College of Physicians, exclusive to KevinMD.com.

If the old adage “the pen is mightier than the sword” is true, then the doctor’s note is the most powerful weapon around.

When I entered practice over 25 years ago, I wrote notes when people were too sick or injured to work, or to verify that they could return to work. That was it. The patient would come to the office, get evaluated, and go home with a note.

At some point, people started to expect that they could get the note without coming in for a visit, with just a phone call. I could understand some of those requests — after all, who wants to go to the doctor when they’re having a severe case of gastroenteritis — but how could I attest that the patient was ill enough to go to the doctor without the patient going to the doctor?

Why is a doctor’s note needed anyway, especially for brief illnesses resulting in a couple of missed days of work? Having to go to the doctor to get a note would seem to discourage people who are sick from staying home instead of coming to work and spreading their germs to other coworkers and customers.

I suspect it has more to do with employers not believing their employees than their being concerned about their well-being. I can’t judge the bosses too harshly, given some of the requests that I’ve received over the years. One that sticks in my mind is a phone call in my first year of practice for a doctor’s note covering the previous week because the patient had to be out of town for a wedding. (He did not get that note, in case you were wondering.) Then there are the many times patients ask for sick notes for the Friday that just happens to come before a three-day weekend.

“Return to work” doctor’s notes make more sense to me, in that they alert employers to restrictions for the returning employee, and reassure the employer that the employee is free of contagion.

Later in my career, I don’t remember exactly when, the list of reasons for a doctor’s note started to lengthen. Patients asked for doctor’s notes to allow them to wear sneakers to work, to get them parking spots close to their workplace entrances, for apartments near the elevator, to tell landlords that the person next door was keeping them awake, and to excuse them from jury duty because they didn’t want to do it. In some cases, the doctor’s note was the ticket to get something they wanted, in others, a pass to avoid something they didn’t want to do. Some of these requests expected me to verify things I couldn’t verify, such as noisy neighbors.

Why the explosion in indications for doctor’s notes beyond the traditional “Mr. Jones is too sick to work”? Doctors are still trusted highly by society, so their documenting something carries more weight in some circles than an employee’s, tenant’s, or prospective juror’s own words. (Too bad Medicare and the insurance companies don’t feel the same way about us.) I think some of this also stems from the inability, or unwillingness, of people to work a problem out by discussing it and reaching agreement. In other cases, it is an effort to shift accountability to someone else (“I had no choice – she had a doctor’s note.”).

The format of the notes has also changed over the years. An increasing number of entities are not satisfied with a scribbled note on a page off a prescription pad (if one can find a prescription pad in this e-prescribing era). Some require an upgrade from the doctor’s note, a “doctor’s letter” written on letterhead. I suspect that this is because something bigger than a note is needed to cover the body part that the letter is intended to cover. If a doctor’s note is a powerful weapon, as I noted in the first paragraph, then a doctor’s letter must be downright nuclear.

Most frustrating are the times that I provide a doctor’s note and in response receive a form to complete. Why not send the form in the first place or ask for details in the note that would make the form unnecessary? I think that people and agencies that do this believe that we are sitting at our desks all day, like the Maytag repairman, waiting to write the next doctor’s note or fill out the next form.

Sometimes I wonder whether anyone reads these notes and letters. At times, I’ve been tempted to slip in a line or two that would let me know if someone actually did more than look for a signature and file the note. For example, “Because of Mrs. Smith’s severe arthritis, she would be best served by living in an apartment on the ground floor, one with free HBO and high-speed internet.” Or, “Marie has recovered fully from her infection and can return to work without restrictions. Please wear gloves when she hands you this note.”

I always talk myself out of doing so, because if I did write such things, it would only generate a request for clarification — in another doctor’s note.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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