Sick note or fit note? A simple approach to restrictions and limitations
The health benefits of a timely and safe return to work after an injury or illness are well known.[1,2] Community family physicians are in a unique position to facilitate their patients’ recovery, and one way to do this is to use a fit note instead of a sick note.
A sick note usually states: “My patient is not able to work.” Unfortunately, a broad statement of inability to work can be discouraging and may become a barrier to recovery. In contrast, describing retained abilities in a fit note is recovery focused and useful for considering modified duties. It helps the physician speak to medical concepts and allows those with return-to-work expertise to do the rest.
A fit note can be structured around the concepts of risk, capacity, and tolerance. These concepts are reviewed in AMA Guides to the Evaluation of Work Ability and Return to Work, and physicians can formulate them into restrictions and limitations.
A simple approach to thinking about restrictions and limitations can go a long way. We propose the following three-step approach: first, advise on the risk of harm; second, state what you can measure; and third, document retained abilities.
Advise on the risk of harm
First, consider activities that pose a substantive risk of harm to the worker or others. The risk can be of sudden incapacitation, performance decrement, or further injury. Restrictions may be permanent or temporary. Examples are “not able to operate machinery” due to medication side effects or “not able to bear weight” while an unstable fracture heals.
Restrictions are especially important if your patient works in a safety-sensitive or safety-critical occupation such as a driver, pilot, or police officer. The Canadian Medical Association’s Driver’s Guide: Determining Medical Fitness to Operate Motor Vehicles provides a good approach to restrictions for drivers, which could potentially be applied to other workers. Sometimes it is hard to know if there is a risk that should result in a restriction. If your patient is seeing a specialist, they may be able to help. If your patient has a WorkSafeBC claim, you can also reach out to a WorkSafeBC medical advisor.
State what you can measure
Second, consider the patient’s capacity. Is there something your patient cannot do no matter how hard they try? For example, despite good effort, a patient with a frozen shoulder may not be able to fully abduct the shoulder. In this case, an objective limitation might be “not able to reach above shoulder height with the affected arm.”
Document retained abilities
Third, document your patient’s individual tolerance to certain types of tasks or activities. Tolerance varies between people and over time for the same person, reflecting biological, psychological, workplace, and social circumstances. One patient with lumbar degenerative disc disease may be asymptomatic and able to perform all work and recreational activities, while another patient with similar lumbar degenerative disc disease may struggle with household chores.
By communicating retained abilities in a positive way, physicians can facilitate recovery. For example, rather than stating that a person with low back pain is “unable to work as a construction laborer,” the physician might state that the person is “able to perform tasks that do not require repetitive flexion of the lumbar spine or lifting more than 5 kg.” While both statements are true, the latter signals options and hopefulness to both the worker and the employer.
One way to gauge retained abilities is to inquire about nonwork activities such as hobbies, home life, and recreation. For example, being able to watch a movie implies sitting tolerance of 2 hours. Likewise, being able to do dishes or mow the lawn offers useful clues about retained abilities at work. Independence in home and community tasks implies a potential for graduated and modified return to work.
Completing the journey of recovery: Return to work
Matching abilities to available workplace accommodations is the role of a return-to-work coordinator. While physicians are often asked to assume this role in the community, for your WorkSafeBC patients, case managers and return-to-work specialists at WorkSafeBC can take on this role. An ability-focused fit note lays the foundation for appropriate accommodations. If required, you may speak directly with the employer or with WorkSafeBC about return-to-work plans (there are fee codes for this).
Returning to work is a healthy and important step in recovering from a work injury or illness. Worklessness not only affects a person’s livelihood but is also associated with significant health risk.[6,7] Helping patients return to work is an important role for physicians. Tolerance-related limitations may delay return to work. By describing tolerance in a positive, ability-focused fashion, physicians can help promote recovery. A fit note will have more impact than a sick note on your patient’s livelihood and health.
If you have questions, contact a medical advisor at WorkSafeBC via the RACE app or call 604 696-2131 or 1 877 696-2131 toll-free.
—Tung Siu, MD, CCFP, ACBOM
Medical Advisor, Medical Services, WorkSafeBC
—Peter Zeindler, MD, CCFP, FCFP, CCBOM
Medical Advisor, Medical Services, WorkSafeBC
This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.
|This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.|
1. Institute for Work & Health. Workplace-based return-to-work interventions: A systematic review of the quantitative and qualitative literature (full report). 2004. Accessed 20 March 2023. https://iwh.on.ca/scientific-reports/workplace-based-return-to-work-interventions-systematic-review-of-quantitative-and-qualitative-literature-full-report.
2. Organisation for Economic Co-operation and Development. Issues for discussion. Presented at the OECD High-Level Policy Forum on Mental Health and Work, The Hague, Netherlands, 4 March 2015. Accessed 20 March 2023. www.oecd.org/mental-health-and-work-forum/documents/ISSUES-FOR-DISCUSSION.pdf.
3. Talmage JB, Melhorn JB, Hyman M. How to think about work ability and work restrictions: Risk, capacity, and tolerance. In: AMA guides to the evaluation of work ability and return to work. 2nd ed. Chicago: American Medical Association; 2011. pp. 9-21.
4. Canadian Medical Association. Driver’s guide: Determining medical fitness to operate motor vehicles, ed. 9.1. Gloucester, ON: CMA Joule; 2019.
5. WorkSafeBC. Doctors of BC/WorkSafeBC unique fee schedule. 2021. Accessed 3 February 2023. www.worksafebc.com/en/resources/health-care-providers/guides/doctors-worksafebc-fee-schedule.
6. Felhaber T. The risks of worklessness. UBC Faculty of Medicine: This changed my practice (UBC CPD). 20 September 2017. Accessed 3 February 2023. https://thischangedmypractice.com/the-risks-of-worklessness.
7. Waddell G, Burton AK. Is work good for your health and well-being? London, UK: The Stationery Office, 2006. Accessed 20 March 2023. www.gov.uk/government/publications/is-work-good-for-your-health-and-well-being.
8. Canadian Medical Association. The treating physician’s role in helping patients return to work after an illness or injury. Ottawa: CMA, 2013. Accessed 20 March 2023. https://policybase.cma.ca/media/PolicyPDF/PD13-05.pdf.
Tung Siu, MD, CCFP, ACBOM, Peter Zeindler, MD, CCFP, FCFP, CCBOM. Sick note or fit note? A simple approach to restrictions and limitations. BCMJ, Vol. 65, No. 4, May, 2023, Page(s) 139,142 - WorkSafeBC.
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Time is the greatest healer. It is dangerous & unethical for MD's prematurely push injured/disabled workers
back into hazardous industrial workplaces where production, NOT SAFETY, is the Employer priority. MD's
have a supreme ethical oath NOT TO CAUSE HARM to their patients.