What would you do? "Doc, can you write me a note?"

August 20, 2004

How would you handle patients who want you to help them get time off from work? We'd like to hear your opinion.

How would you handle patients who want you to help them get time off from work? We'd like to hear your opinion.

I want you to write me an excuse to take a couple of weeks off from work. I'm stressed out and exhausted, and I need a rest."

Jane M. was about 40, though the dark circles under her eyes made her look older. She sat slumped over in a chair with her elbow on the consultation desk while she nervously twisted a strand of her hair. "My work has me so stressed that I have trouble sleeping, and I have headaches and a backache every day," she said.

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Jane had been working as a secretary in a consulting firm downtown and had seen many of her co-workers laid off during the recent economic downturn. Her chart showed several recent visits for headaches and a few prescriptions for a sleep aid. Otherwise, she'd come in regularly for her yearly physicals.

I had her climb up on the exam table and pulled out the blood pressure cuff while I considered her request. "Hmm. 140/85. A little high."

"It used to be really low," she said in a choked voice, looking away while tears started to form in her eyes.

I handed her a Kleenex and said, "Stress can raise your blood pressure. A lot of people don't realize how strong the connection is between the mind and the body. If things aren't right with one of them, then things tend not to go well with the other."

Jane sighed. "I feel like if I just had some time, I could get my head together and things would be all right. You see, I got switched to a new division six months ago. My new boss criticizes everything I do and then calls me onto the carpet for not getting enough done. Yesterday I started crying at my desk and couldn't stop. They made me go home and said I couldn't come back without a doctor's note if I wasn't able to do my work.

"Sometimes when I'm out, I start thinking about the whole thing. I feel my chest getting tight and I feel like I can't breathe. My kids don't want to go to the store with me because they're afraid I'm going to have a heart attack or something. I used to be a really fun mom, but not anymore. I find myself snapping at them over nothing. Sometimes I think about finding a new job, but I have 20 years in with this company, and I don't think I could find anything with the same pay and benefits in this economy.

"Every night I lie awake until 2:00 or 3:00 a.m. and can't sleep because I'm thinking about everything that I have to get done the next day. The only way I can get any sleep is if I take a pill or have half a bottle of wine, and then I can't get up the next morning."

I listened to her heart and lungs, which of course sounded normal. I pondered whether a "few weeks off" would fix what sounded like an intractable life situation.

When patients had started visiting me to ask for help in getting time off from work, I'd wondered who had placed me in this role. It usually turned out to be the patient's boss, who required a doctor's note for a leave of absence, whether paid or unpaid.

Why can't work supervisors and employees just agree that some people need time off to deal with emotional issues? Part of the answer is the Family and Medical Leave Act. Adopted in 1993, the law is supposed to ensure that new mothers, seriously ill patients, and immediate family members who care for them can take a leave of absence for up to 12 weeks without losing their jobs. Although the FMLA does not require that employees be paid for this time off, some companies do pay them.

When physicians fill out an FMLA form, they have to specify a reason for a leave of absence and the expected length of this absence. An internist or a family physician can usually estimate the amount of time needed to recover from a physical ailment such as pneumonia or a heart attack. However, the length of a leave of absence for anxiety, stress, or depression is much harder to determine—especially when the patient says the symptoms are actually brought on by their work environment.

After I first saw a patient with work-related stress, I went to the senior member of our practice to learn what he did in these cases. He said that he would write a letter restating what the patient had told him: "My patient, Mrs. Jane Doe, states that she is stressed and exhausted and cannot work for two weeks." Thus the patient received what she had requested without his having to certify anything. He said that employers had accepted these notes without question.

I liked the idea of not having to estimate how long the patient would be absent, but that didn't help me with the FMLA form. My colleague's approach also didn't address the root cause of the problem: that the person's job or her response to it was making her stressed, anxious, and depressed. Just taking time off wouldn't change that. And for many of my patients, getting a new job was not really an option.

As I wondered what to do about Jane, I recalled the last time I'd written a note for a patient who'd wanted a month off from a stressful job situation. My heart had gone out to her as she'd been sitting beside me crying in my office. After she'd left, however, the forms from her job and her disability insurance company had started arriving. They'd asked for psychiatric diagnoses that I was not qualified to give and wanted to know how long she'd be out from work. Then the human resources department of the patient's company had called to ask about my plan of treatment. "Rest" had not seemed an adequate answer.

A month later, this patient had returned for her release-to-work note and had announced that she was not ready to go back to work. She was just starting to enjoy lunching with friends and reading good books again, and didn't want to ruin her recovery by returning to a stressful environment. When I'd refused to extend her leave of absence, she'd become angry and had left my practice.

Now I was confronted with Jane's similar problem and was wondering whether there wasn't something else I could do to help her. Should I tell her that the best way to deal with her dilemma was to confront it directly by going back to work? Should I write her a generic note restating her complaint? Should I write a more detailed note, explaining that she was going through an episode of depression? Or should I refer her to a mental health professional who could analyze her problems in depth and give her advice on how to cope with them? What would you do?

 

Stephanie Weaver. What would you do? Medical Economics Aug. 20, 2004;81:50.