Sick leave Certificates - Pierre mallia - The Times - 1/2/2004

Sick leave certificates
Dr. Pierre Mallia

It has been over a month now since the 'saga' of sick leave certificates had started. It would indeed be a pity to let this issue die down, like many others, without using it as a way forward to dialogue and better things from how they now stand.

I would thank all those who commented on my previous article (The Sunday Times, December 28), especially Professor J.A. Muscat, who supported the conciliatory tone and saw the window of opportunity rather than the drama.

There are some issues that still need further clarification. Both Fiona Galea Debono (The Times, January 1) and Jesmond Bonello (The Times, January 3) saw fit to promote what the profession tried hard to explain. Their conclusions however may leave unanswered questions, "200 doctors issued more than 2,000 certificates each and one particular doctor issued 22 consecutive certificates to the same person for the same condition", and "one particular doctor issued more than 3,500 sickness certificates in eight months". I understand they were simply trying to balance the arguments, nevertheless...

That some doctors issue more than 2,000 certificates is not new to doctors working as company doctors. Some of these see over 30 sick workers every day. That there was an instance where one doctor issued so many consecutive certificates to the same person for the same illness is understandable. The very singularity of this shows it is exceptional rather than the rule, and the fact it was issued for the same illness... well, it would seem to me to be abusive if the illness had to change over that period, especially if the person was waiting to be boarded out.

I reiterate that consecutive certificates are a sign that doctors had faith in the department of social security for understanding the nature of their work. Why make such a transparent mistake?

In no way however does the Malta College of Family Doctors or I condone any abuse by individuals. But indeed, by attacking almost everyone, the social services department could not have defended the abuser better. What better way does the isolated abuser have than to have all his hurt colleagues speaking on his behalf? After all, the honest ones will immediately agree that they are not infallible.

Social Services has access to the appropriate body, which is the Medical Council. If it feels that someone is indeed abusing it can address him or her directly and specifically and if a change in attitude is not seen, then it can refer to this body, which is the only body authorised by law to deal directly with these matters. This step was not done before going public with the figures.

A study published by a council member (Dr Jean Karl Soler) of the Malta College had shown that there is indeed no abuse in sickness in Malta when compared to other countries and indeed fluctuations are reflective of seasonal changes. The correlation with the hunting season is either coincidental or a figment of the imagination. Worse still, it was a speculative conclusion.

After all, when exactly is the hunting season? It seems to me to coincide with change of seasons as well. But again, if Government feels this merits study than maybe it can invest resources to look into this rather than throwing responsibility on a profession. It was also pointed out that 90,000 of the certificates were issued to employees in the private sector and about 80,000 covered public sector. This is a 9:8 ratio, but the ratio of private sector to public sector is far greater, showing that the problem is much greater in the public sector. The problem seems to lie more in management.

But the best certificate came two weeks after my article in a similar article on the British Medical Journal (January 10, p. 328):

"Consider the patient who wants a sickness certificate. He looks fine to you - in fact a lot better than you're feeling. But he says he's sick - most probably with a problem you can't verify. A group from Scotland studied how doctors managed sickness certification and found that most feel uncomfortable. 'I've no discrimination at all,' says one doctor. 'If a patient comes in and says 'I need to be off for two weeks... with a cold,' I'll give him a Med 3 (a sickness certificate), no questions asked.' How can you tell a patient that he doesn't have a headache and should get back to work? It's not only philosophically untenable; it may also destroy the doctor-patient relationship. 'Once a patient didn't come back to me for 10 years because of me refusing her a sick line,' reports another doctor. 'How,' asks a third doctor, 'can we act as policeman, friend, social worker, and all the rest of it? We can't.'

"When asked to sign a certificate you are being asked to be an agent of the state... But it could be worse. You might be asked to examine an elderly and dishevelled man who has just been pulled from a hole in the ground. As you examine him for lice you see you're being filmed. What do you do? Push the camera away? You probably don't if you are an American army doctor examining Saddam Hussein, but both medical ethics and the Geneva Convention suggest you should... (even if) you are an agent of the state.

"Medical systems - and doctors - are measured not by how they manage the grateful patient...but how they care for terrorists, monsters, and the marginal. By demeaning Hussein the Coalition demeaned itself, its cause, and medicine."

Now I am one of the few who support the Coalition in its cause, and do not hesitate to say, am one of the (not few) who still support this government. But by demeaning patients and doctors (who in this case are pushing the camera away) we demeaned medicine and our own government. As one of its candidates may I caution the party paper's editor (In-Nazzjon, December 20) who attacked the ethics of pharmacists, lawyers and, with this issue, doctors, in defending their rights to protect the client as their respective traditions deem best.

Where better to attack a professional than by attacking his ethics? This resounds of days that we would all like to forget. Maybe it would be better to caution the ethics of politicians at all levels. Maybe it is better for us all to sit down and discuss issues before we sprawl our gall over the newspapers for political advantage - itself a breach of ethics - and lose sight of those we serve. Even if you have a right to tell the public how good you are trying to manage their money, there is always a professional way of doing things.

Dr Mallia is a member of the National Bioethics Consultative Committee and is president of the Malta College of Family Doctors. He is author of the book Your Rights as a Patient (PEG, 2002) and The Beginning and End of Life (PEG, 2002). He is also actively involved in politics.

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