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,[3] 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,[4] 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).[5]

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.[8] 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.

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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.

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.

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.

6.    Felhaber T. The risks of worklessness. UBC Faculty of Medicine: This changed my practice (UBC CPD). 20 September 2017. Accessed 3 February 2023.

7.    Waddell G, Burton AK. Is work good for your health and well-being? London, UK: The Stationery Office, 2006. Accessed 20 March 2023.

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.

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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david bradshaw says: reply

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.

david bradshaw says: reply

No ethical MD should be using the highly inappropriate terminology & ideology, of "WORKLESSNESS" when referring to
injured disabled human beings. "Worklessness" carries the extremely disturbing, highly disrespectful intended connotion of "Worthlessness". This is alarming and unacceptable conduct for any medical practitioner to be using & publishing.

Nancy McFadden says: reply

I am not interested in writing either a fit note or sick note. I will complete the required Work Safe documentation, but nothing beyond that. Unfortunately many businesses require lengthy forms or a note beyond the Worksafe document, which adds to the already considerable admin burden family physicians face, is not covered, and patients are required to pay for additional form/letter completion. This requirement beyond Worksafe documentation should be abolished.

Nick Fisher says: reply

It is somewhat disappointing to see the article by Drs Siu and Zeindler (BCMJ, vol. 65, No. 4, May 2023, Pages 139,142 WorkSafeBC) on the subject of sick notes versus fit notes. Although well intentioned, I fear it fails to address the deeper issue: that a return to work plan or ‘fit note’ should be a collaborative product of employer and employee, and should avoid primary care input altogether. Many of the recommendations for approaching fitness capacity require no medical knowledge (I.e. asking if someone can watch a whole movie) and could be facilitated by an employer or HR manager. In a time when we have a crisis in primary care, we should be aiming to empower employers to manage these basic approaches themselves and utilising physicians only when there is a requirement for specialist input, and in those cases a referral to an OM physician should be considered. We most certainly should be avoiding the ‘path of least resistance’ of dumping this work on primary care.

Marjan Charkhsaz says: reply

I need to get more information regarding fitness note- information how to accurately fill out wcb forms
And preferably meeting with wcb physician advisor in my office

Paul Winston MD... says: reply

What appears to be two physicians that have most likely opted out of Canada's Medicare system and MSP, advising family physicians and specialists on how not to write a sick note. In the midst of a crisis in primary care and growing specialist wait lists, these two doctors want you to see patients with the sole purpose of paperwork. Physicians have no training in work evaluation. From the orthopedic surgeon to family physician to physiatrist, we are not capable of doing appropriate assessments in the office. Asking patients to see their doctor for non-clinical care is an affront to the dire crisis we are in. It is our job to care for our patients. WorkSafe BC frequently ignores our advice. We hear from patients of their struggles. Case managers are hard to contact for the patient and the physician. WorkSafe BC is a well-funded agency. They must employ their own experts to establish capacity and return to work. Physicians have little respect for the bureaucracy of WorkSafe BC. They know that they will frequently not be paid for the appointments and forms, or spent an inordinate amount of time tracking it down. (1)

Every physician is working flat out to provide clinical care. These two physicians would be better suited to provide the patient assessments or provide clinicians trained to so.

Finally, there are increasing complaints being placed to the CPSBC by patients that are denied WorkSafe BC claims, when WorkSafe BC denies the patient's claim despite physician advocacy on their behalf. I know of multiple instances. WorkSafe BC offers no support for either party in this circumstance.

We are in a health care crisis. WorkSafe BC is asking for non-evidenced-based evaluations from untrained clinicians. As physicians our goal is to treat and advocate for our patients, not seeing them for WorkSafe BC-mandated non-clinical visits.

1. May 4, 2017 — Winston Untangling WorkSafeBC billing procedures. Issue: BCMJ, vol. 59, No. 4, May 2017, Pages 216-217

Lisa Greaves says: reply

As an employer disability manager who has facilitated RTW plans for several years, I find that I get better information from physiotherapists than doctors. Physiotherapists are injury recovery specialists and they have more time with their patients to do a functional assessment, which is ultimately what helps me collaborate with the injured employee to identify safe and suitable work activities.
This is in no way intended to discredit or disparage physicians; I have tremendous respect for doctors, and I think that asking them to do functional assessments is not the best practice. Their waiting rooms are full and they are under tight time constraints with patients. It's about identifying the appropriate practitioner for what we are asking.

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