ENCORE: The high cost of sick notes
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When a body is discovered 10 miles out to sea, it sparks a mind-blowing police investigation. There's a man living in this address in the name of deceased. He's one of the most wanted men in the world. This isn't really happening. Officers finding large sums of money. It's a tale of murder, skullduggery and international intrigue. So who really is he?

I'm Sam Mullins, and this is Sea of Lies from CBC's Uncover. Available now. This is a CBC Podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. This week's show first ran in January 2024. Since then, more provinces have updated their sick note policies. We'll have more about that at the end of the show. Say you have a cough, sniffles, and a fever, and you take a couple of days off work.

That's what you're supposed to do, by the by. You come back to work, and the first thing your boss says is to get a sick note from your health care provider. That's what happened to Haley Buecher-Dick, who lives in Roland, Manitoba, when she was working at a fast food restaurant back in 2017. When I worked there, you got minimum wage.

And there was no paid sick days. They would really put pressure on and kind of imply that you might get written up if you didn't get it before your shift started. Although often I was like, well, I'm not going to the ER for this. Like, this is ridiculous. But I mean, the walk-in doctors would be understandably annoyed.

And I get it. Like, that's terribly annoying. That's just terribly frustrating. And so I never had to pay anything. But certainly, like, I remember telling myself that if I had if they were going to ask me to pay for anything, I was going to go to my boss and say, hey, so like, when am I getting the money back for for this doctor's note? Because this is a virus. It's embarrassing to go in and know that you're really not supposed to do that.

You see the look on the physician's face when you walk in. You're like, I'm just here for a doctor's note. And they're like, and they're not even really annoyed with you. They're just annoyed with the entire thing. I found it. I found it really. I would say I found it really annoying and I found it very embarrassing to patients and their health care providers don't always see eye to eye. But when it comes to sick notes, they're in lockstep.

Patients hate asking for them, and health care providers would rather not have to provide them. My name is Dr. Gregory Sawisky, and I am a full-scope rural physician in Ponoka, Alberta. I take care of patients basically from cradle to grave. Dr. Sawisky says he doesn't write sick notes on demand. He makes a counteroffer.

When I have a patient that requests a sick note for work, I first ask them, is this needed by your employer or did you just want one? If they say that they absolutely need a sick note that their employer is requesting or demanding one, I tell them that what I can do is provide a note

stating that a sick note is an uninsured health service so that there is a fee involved. And if the employer is requesting it, then that payment is the responsibility of the employer. And I'll put this on a note. And at the end of the note, I will put a little invoice for the cost of the sick note with the caveat that upon receipt of the payment for the sick note from the employer and not from the employee, I will be happy to provide a note.

And I also make it clear on the note that sick notes are a usage of time that's not ideal and that if the patient is truly unwell, they should be at home resting and not sitting in a clinic requesting a note. I have never, ever gotten an employer to pay for the sick note and then to have the note produced. Whether the note itself is

acts as sort of a pseudo sick note because then the employer is aware that the patient actually went to a doctor's office. That may be the case, but I've never had them come back and say that they were willing to pay for it. Some patients don't wish to be caught in the middle and just preserve harmony with their employer. They'll then just pay for it. But I do tell those patients that I'm going to give them a receipt.

I encourage them to file an expense claim as this was a requirement from their employer. And I say, here, you'll be giving a note and here's a receipt. If this is a cost of your business, then you give it to your boss and have them reimburse you.

I find that patients are often a little gleeful with a tongue-in-cheek note like that because they know that they're sick. And they know that asking a sick note is, especially during our current healthcare crunch, a difficult task.

challenge because they know how busy we are. And they're often caught between a bit of a rock and a hard place because their employer is demanding a note. And so when they see that it's going to be put back on the employer, and especially when the cost is going to be put back on the employer, patients I find often have a little bit of a smile on their face and they say they will be happy to give this to their boss and see what their boss says.

Levity aside, for the patients who need a sick note to keep working, it's no laughing matter. Just ask Boddy Bloodworth, a nurse practitioner who works at Access Winnipeg West Walk-In Connected Care Clinic. My perception and what I have seen is the people where sick notes matter are the working poor. And so therefore, they're the people who...

come in because they need that sick note, right? And then they're then taking time off work or presenting when they could just be at home recovering. So it kind of disproportionately affects like this population that is already disproportionately affected by like everything else. In terms of my experience with it, it's, I don't want to say it's like an unnecessary visit because like it deeply matters for that person because like that person needs money to live. But medically,

They don't need my assessment. Like they themselves are aware what is going on. They themselves are aware that what they need is symptomatic management that they're doing, you know, rest and recovery, which they're doing. And now they're sitting in a clinic room kind of seeing me. And so that then takes up

Those, you know, times that could theoretically be used for people where they're either unsure what's going on or there's kind of other complications that are occurring. Time was when people were sick with a cold or the flu, they just went to work. It was considered virtuous to suck it up. But as Body Bloodworth suggested, there's more to it than that.

In the 1990s, Kerry Cooper, a professor of organizational psychology at the University of Manchester, coined the term presenteeism. It refers to the propensity for workers to come to work when they're sick, in large part because they may face consequences if they stay home. The pandemic was supposed to change that. Public health officers urged people with COVID to stay home so they wouldn't spread the virus to the workplace.

The thing is, it's hard to stay home when you don't have paid sick leave. A situation that affects many workers in low-paying jobs. A 2023 study by Statistics Canada found that between 1995 and 2022, paid sick leave coverage increased moderately. According to the report, in many cases, coverage appears to have risen faster in jobs that traditionally provide relatively little coverage.

But the study also showed that for many frontline workers, people who work at grocery stores, gas stations, child daycare services and nursing homes, paid sick coverage is far from universal. People in those kinds of jobs are typically the ones who need sick notes. One group of workers who have done a 180 on presenteeism are health professionals like me. Recently, I chatted about that with Dr. Kay Dingwell. She's an ER physician in Somerset PEI.

Dingwell's state of well-being became a talking point. I don't know, maybe you're tired, but... Yeah, I'm post-night shift. I only had an hour and a half sleep. You only had an hour and a half sleep? That is, well, maybe you need a sick note. Well, I was sick last week, actually. So I was in eMERGE and very sick last week, so...

I will tell you that among my colleagues, we just have to say we don't have to provide a sick note. They're encouraging us these days as emergency physicians, emergency nurses, other personnel to stay away if we are sick.

and to follow the policy on return to work following COVID. So I'm glad you don't have to ask for a note in your current capacity. No, my department actually is amazingly supportive when someone is sick. And I've been there three years. I love it. It's very collegial. I messaged last week saying, hey, guys, I'm super sick. And one of my colleagues stepped up, took my shifts. And then while she was working my shift, I had to show up.

because of how ill I was. And she just took one look at me and said, I'm taking your shift tomorrow too. And so I ended up being treated in my own department by the doctor covering me. I had a peritonsillar abscess. So I was quite sick. You know, I have that privilege that I can just say I am sick, and I am believed and we figure it out. And everyone should have that.

And you know what? We've done a 180 on that because there was a time when I remember very well when you're supposed to show how tough you were by showing up for work when you were sick. And now we are not doing that at all. That's an amazing change among emergency personnel. Oh, yes. Even while I was in med school and residency. So I finished residency in 2021. And I certainly got the, you know, you really need to show up even if you're really sick.

That was very much part of the culture just a few years ago. So I think COVID did spark some positive shifts in culture, even if it did sort of set our staffing situation on fire. Staffing situation on fire is Kay Dingwell's way of saying that every time a frontline ER physician is sick and can't show up for work, it means another physician must take their place. That's more disruptive than it sounds. In the past six weeks alone, I've been called into work for a sick colleague three times.

We'll be right back.

I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.

You're listening to White Coat Blackheart. This week, we're talking about the workers who need to get sick notes from health care providers or risk getting disciplined or even fired from their jobs. Some of them ask for sick notes from ER physicians like Dr. Kay Dingwell and me. In 2020, CAPE, that's the Canadian Association of Emergency Physicians, put out a position statement on sick notes for minor illnesses. It says that CAPE, of which I'm a member,

quote, advocates for a ban on sick note requirements by employers and schools via federal or provincial legislation and encourages patients with minor illnesses to stay at home and recover if they do not feel they require acute medical assessment. Dr. Kay Dingwell, the ER physician we heard from earlier, endorses the CAPE position. Recently, she posted this on X, quote, the public health system is not your HR, that's human resources, police.

Your tweet sounded like fighting words. What made you want to post that? So it came from an element of frustration I've had for many years. So well before I was in medicine, because I came into medicine later, I had to go to the emergency department at midnight for a work note or I would have been fired. And I have maintained a degree of frustration with employers requiring those notes ever since.

At the early days of the pandemic, the Canadian Association of Emergency Physicians issued a policy statement on the issuance of work notes. And since I've been at my department since 2021, they've had a policy that they don't give work notes for minor illness. And so I had been seeing with the uptick in viral respiratory illness, people coming in specifically for a note. These weren't patients who were concerned about their symptoms and wanting assessment. These were patients coming in

My boss is requiring me to get a note to take time off work because I have a fever and a cough. These patients don't want to be there. They don't want to wait 8, 10, 12 hours to see me. They want to be home recovering and they don't want to be in my waiting room coughing on sick elderly patients. So I wrote up a thread and targeted at employers who that's

the target audience. These employees are stuck between a rock and a hard place. They don't have say into what their employers want. But I really want employers to be aware that this really isn't an appropriate use of the health care resources that we have. Without directly quoting, because I don't ever give specific patient information, but they'll say things along the lines of, I'm not allowed to take any days off without a doctor's note, or I have to have a doctor's note to take time off, or my boss is going to want a note.

Those sorts of things. So it's often that this may be the barrier between them being able to take time off without potentially facing disciplinary action at work or potentially the loss of their jobs. And we do actually have a little printed handout that sort of explains the department's views and references the CAPE, Canadian Association of Emergency Physicians Policy.

We do provide a note if they wish stating that they were seen there. It just says, you know, it's one of their patient stickers and that they were seen in the department. But it is something that they'll be informed of at triage as well.

And yet they're still asking, so they know there's a sign they're still asking. So they must really need some documentation. Yeah, and I mentioned before I've been in that position where I've been stuck and you need that job and you need to not be facing discipline at work for having a normal human experience like a viral illness. And so, you know, we always have, as we do in all things, a shared decision-making discussion with the patients, but we also need them to know that

This is something that should be, if they feel safe to do so, fed back to their employer. This is not the role of the health system to police employee attendance.

So how often are you being asked to write sick notes these days? Every day. Every day? Yeah, every shift, I should say. In spite of the sign? Yes. Do you see people from particular industries looking for a sick note? No, I find typically it is more precarious hourly employment. We may see it many times with our temporary foreign workers who may have more precarious employment and their attendance is very tightly managed by their employers. And so...

that's typically where I would see the requests coming from.

Are they coming in just for the note or are they saying that they're sick? Because in my experience, often the request for the note comes after everything else. Are they just coming in and saying, I need a note or are they coming in and saying they're ill? It's hard to give a proportion as to how many, but I'd certainly say a fair number do come in and say, I really just need a note. Like, I know I'm sick, but there are certainly a fairly large percentage of

where it's, you know, I have these symptoms, I'm concerned about, oh, hey, dog, can I get a note? And perhaps their main goal incoming was to get the note. And sometimes I'll just ask just from a place of curiosity, say, hey, I have a bit of an interest in this area. Was your primary reason coming in to get the note? And often they'll say yes. And I just say, you know, I'm not judging. I'm just

curious about it because I kind of follow this we have a bit of a discussion but I'm always trying very carefully to make sure that I know that they know that I'm not blaming them because I don't want someone who is worried about their symptoms not to come in because the patient declares the emergency right if they're worried about their symptoms I want them to come get assessed I don't want them to feel like them also wanting a note is a is a reason they shouldn't come in

But a lot of the time when I ask them and they know it's a cold and they know that they've already tested positive for COVID at home, but they're not super sick, that they don't have any interventions that they're seeking. And so those patients, yeah, sometimes I'll just ask out of curiosity, just say, hey, I kind of follow this. It's an area I care about.

And you care about it in part because of your personal experience. Can you say something about that? Yeah. So as I mentioned, I came into medicine later. I already had kids. And there was one time I was sick with a stomach bug when I was four months pregnant with my now 13-year-old. And I went in to emerge the first day and was seen at the hospital just down the road here.

And it was midnight. So I was working a shift in the middle of the night. And I got a note and I was covered. But then I was still sick a few days later and went into work.

And I was so dehydrated from having gastroenteritis that I passed out on my coworkers. So, yeah, it wasn't a great situation. And so I have maintained a bit of a vendetta against work notes ever since. What was the experience like asking for the note? Did you find somebody like you when you asked for the note? Yeah, I found someone who was fairly sympathetic, especially because I was quite pregnant at the time. Yeah.

And I felt awful. I just wanted to be home in bed getting some fluids. And I don't think patients who feel unwell...

but know that they don't require intervention, really want to be doing that either. I was fortunate to encounter someone, actually, he's now a colleague who was quite kind and managed me at that time. But it's, you know, no one should feel like they have to just sit and emerge when they don't need to. And instead of being home and getting their home management, that makes them feel better.

So what do you think is behind the request for the note? I mean, it's a documentation of something, but what does it symbolize to you? Well, it's not really a documentation of anything besides a request. I'm not doing any tests on these patients to prove that they're sick. If they tell me they're sick, I believe them. And I'm not going to go do a viral swab or anything like that. I'm doing a test that doesn't change my management, right? So if they tell me they have typical viral symptoms, I'm just going to believe them.

And so I'm not verifying anything in any way. What these notes serve as is a barrier set up by the employer to the employee using any sick time for this person to try and make it so difficult for them to stay home that they come to work even when they're sick.

And that's how these notes are often used. When I posted my thread, I had a couple people who are employers say things like, well, I have this employee who always takes off every Monday, you know, and says they're sick. What am I supposed to do about that? And I said, well, you know, that's an employee-employer issue. That's an issue of discipline in the workplace if you think your employee is lying to you. That is not a problem for the health system to solve.

It's not our role or expertise to act as police for human resources. That's not the role. I'm there to provide medical care. And it's not appropriate for employers to put employees in the physician where they feel like they have to access medical care that they don't feel they need.

And so it's really, I think these notes are just serving as a barrier. They're not documenting anything. They're not proving anything besides that this person waited however many hours in my waiting room. So it really, the only possibility is that these are trying to be used as a barrier to keep people from calling off sick.

So what do you actually do with these requests when you get them? So it depends. All things in medicine are shared decision making, right? We have to focus on the needs of the patient. They're the person whose care is important. I do have a discussion with them and I explain we have a departmental policy. We do not provide work notes.

I offer them the note that we have, which is that they have been seen. It's a bit of a different situation if I'm, say, seeing someone and they are have just been in a major MVC and I am recommending motor vehicle collision. Yeah. So if I'm saying you need to not go to work tomorrow, that's one thing versus someone coming in and saying, hey, I have a cold. I don't want to go to work.

So I do have a discussion with them. I find most people, when I explain the position, that we're trying to ensure that people know that our department doesn't give these notes. They are often very understanding and don't push the issue. But where I work, I'd say...

30% of the patients I see don't have any access to primary care. We have nearly no walk-in clinics and even Maple, so the online, the virtual health platform that the province uses as an unaffiliated care program often can't see people, so they're timing out. So I'm getting patients who have already tried everything and they have exhausted their

potential avenues of appropriately requesting one of these and they've got no choices left. So sometimes you just give in? Yeah. And with the understanding, I don't want to set up a scenario where I'm going to have a lineup out my door on my next shift. No, but it's a truism of emergency medicine that it takes 10 seconds to write the note and 10 minutes to explain why you're not going to write the note. Practicing good medicine always takes more time.

So it just takes time to explain and educate. And yeah, it's, you know, same as with a lot of antibiotic prescribing, although I'm a big stickler for this, but it is a lot easier to just write the note instead of explaining why you're doing a delayed script and giving the education around that and

it's often easier to do that sort of thing. But we always have to be mindful of the downstream consequences of our actions, which is that we can perpetuate employers doing this and putting their employees in those untenable positions, which is something I don't feel they should be stuck with.

They deserve to just be able to say, hey boss, I'm sick, and be treated like an adult human being with the judgment to make that call. So what else do you think the medical community could or should be doing to stop the demand for sick notes? I would love to see us advocating in an organized manner for paid sick days. I think if we can get people feeling like they have the right to stay home when they are ill, we may see fewer outbreaks of illness in impoverished

in employment settings, because certainly when we talk about, for instance, long-term care settings, a lot of the time illness is brought in that results in outbreak by employees who are showing up for work. That happened during COVID, certainly. Absolutely. Or where we see in crowded factory settings, as an example, where you'll have an outbreak of gastroenteritis amongst the employees, right? And then you end up with half your workforce off sick. If the first

sick person felt like they could take a day or two to just get better, then perhaps we wouldn't be seeing so much in the way of clustered illness like that. And I think that's a lesson we should take from COVID, that it is reasonable for sick people to stay home. And I wish that we had more in the way of

legislative change to require that employers cover a certain amount of sick days within reason to facilitate this. And it should be required that for minor illness, they not be able to request a sick note.

I can understand lots of businesses have struggled in recent years, and particularly small business, which is very common here on PEI. There are many small family-owned businesses. They struggle, and employee attendance is a major concern for them. But at the same time, we have to balance reasonableness and the rights of individuals when it comes to these sorts of concerns.

So we can talk about advocating for change, but meanwhile, the system is what it is. So people listening to this conversation may be wondering, what do I do if my employer needs a sick note? What do you say to them? So they got to work within what they've got, right? They can't

put themselves at risk, set themselves on fire to keep others warm if they don't feel they can. But if they are, say, in a position where they feel like they have a good enough relationship with their employer to advocate or maybe provide that CAPE handout that I give them and say, you know, have you guys considered changing this policy? People having access to sick days,

is good for people. There's been plenty of research done in this that when employees are facilitated and taking appropriate sick days, you see less illness and less call out. So it does actually end up being good for business. And so people who feel they could have an educational role with their employer would be great.

people who are listening who aren't affected by this, but may be in positions to help change things for other businesses. I would love if they maybe had a look at the policy statement, as well as some of the research on the benefits of offering sick time. Dr. Kay Dingwell, thank you so much for speaking with us. Always happy to. I hope you have a wonderful day. It was a pleasure.

Since this episode originally aired, there's been a push across the country to eliminate sick notes for minor illnesses. The Canadian Medical Association and doctors in several provinces are calling on provincial politicians to change sick note policies. Dr. Kay Dingwell, who we heard in the show, made the case in the PEI legislature for a bill that would eliminate sick note requirements. But the bill was voted down. Other provinces have made changes, though.

Ontario and Quebec have followed in Nova Scotia's footsteps by allowing workers to take up to three days without a sick note. Newfoundland and Labrador and Saskatchewan politicians have also proposed laws that would limit when employers can request sick notes. And BC, Quebec and PEI have passed legislation compelling employers to pay for sick leave, a development that's good for workers and for the system.

That's our show this week. Our email address is whitecoat at cbc.ca. If you like this episode, please give us a rating and review wherever you listen. White Coat Black Art was produced this week by Stephanie Dubois with help from Jennifer Warren and Samir Chhabra. Our digital producer is Ruby Buiza, and our digital writer this week is Jonathan Orr. Our senior producer is Colleen Ross. That's medicine from my side of the gurney. I'm Brian Goldman. See you next week. For more CBC Podcasts, go to cbc.ca slash podcasts.