Here are my comments:
What is the MMA's stance?
The MMA does not condone the giving of medical chits/certificates (MCs) for just anyone who requests for sick leave. The principle of issuing any MC should be based on the doctor's assessment of the need for the leave to recuperate, which most if not all doctor's do so with care and sympathy.
After careful history and physical examination, a diagnosis is made which is then followed by whether there is need for medications or other treatment plans. This may include sick leave if and when the illness is deemed to have affected the capacity of the ill patient to function productively.
This is particularly important in skill-dependent or fine handicraft or factory work, where errors due to a less than fully attentive physical or mental capacity can lead to possible work disruption, mistakes or even bodily harm from possible injuries.
Doctors usually assess all these factors when a patient requests for sick leave, so most doctors are usually more than sympathetic to oblige--we are after all, always exhorted to be empathetic and caring!
Of course, if a worker/patient keeps recurring with illness and need to go on sick leave, doctors must be extra-vigilant to determine if the patient is malingering or if there was any other problem which lead to their need to stay away from work.
This will obviously be difficult to be assess correctly every time, but the onus is on being fair to the worker who may be genuinely ill and needs a time out for proper recovery. Given the choice of being wrong, most doctors would err on the side in favour of the patient rather than the employer, as is proper in the doctor-patient relationship.
Are there any guidelines that doctors have to follow before issuing MCs?
There really aren't any guidelines to follow. I am unaware if there are any labour guidelines or even medical guidelines as to who truly deserve sick leave, although for major illness there are formulated and agreed upon, time off by medical consensus, for recuperation or recovery with rehabilitation, etc.
E.g. if someone has had heart attack, following hospitalisation the recovery period is at least one month or longer if there are complications. For fractures, these depend on the disability and the work involved, usually months. For coughs and colds, flus, diarrhoea or food poisoning, minor cuts and injuries, these are usually for the one or 2 days, but can be longer if the illness is severe.
There is unfortunately no one patient who comes with the cut and dried one size fit all type of complaint, so it is unfair that doctors have to be blamed if they are more sympathetic than their employers! Some doctors are naturally more stingy on MCs while others more lenient and generous, but this does not mean that either is wrong.
This is just how human beings are. Some of us would work through a bad cold or sprained shoulder or elbow, and refuse to take time off, while another cannot bear the discomfort and opt to rest at home and not work. We each have different thresholds for work and work ethics and commitment.
Similarly, most doctors work on the premise that the patient can understand what he or she needs to recover best, and if someone requests for rest or sick leave, most doctors would not say no, unless this is obviously excessive. Some simply request for time out rather than the MC.
In my own experience as a specialist, my outpatient MCs are extremely few and my patients understand this. Since I commenced private practice some 20 years ago, I have yet to finish 12 of my 20 MC books (of 50 MCs each) which I had printed at the start of my practice! So if a doctor is too generous, then some patients/workers may actually gravitate toward this type of doctor by word of mouth! I guess I am not one of these!
Can doctors detect a genuine patient from a fake?
This can be difficult, because some illness have very little physical signs which can be documented. The very ill most likely need hospitalisation. But consider say someone with a cold, most will have a slight sore throat, runny nose and even low grade fever. But how can you assess whether the muscle or joint aches are true, or whether the headache is real?
We do have to trust the patient when they complain to us of their symptoms. Similarly if a patient says that she or he had been vomiting a few times and had diarrhoea 3-5 times, how do we prove these? unless the patient is so bad that he or she is dehydrated, which then require more urgent treatment.
So it is true that some clever malingering patient can get away with falsely presenting themselves and getting MCs, but the fault is not with the doctor but with the patient or worker.
Can employers & doctors work together to address the problem?
Yes. It would be good if the HR departments of every company keep in close touch with their panel doctors and alert them to the problematic worker who appears to be taking more MCs than is expected. If they can actually show proof that some of these workers have been playing truant by "going to movies", "going fishing" or abusing their sick leaves then these should be alerted to the panel doctors. This would make doctors be more vigilant the next time round.
Errant workers should also be warned by employers, and perhaps the relevant supervisors should find out why their workers or some of these workers are having such poor work ethic and showing such poor commitment--certainly this is not the role for doctors! But we support the move to offer incentives to workers who do not utilise their sick leave allotment, which will encourage worker diligence and commitment--there is nothing like monetary rewards for better work!
Most doctors would have had workers complaining of their work or occupation as boring and unrewarding, so most companies have to find ways to enhance the value and interests of the work or career advancement of their employees.
We support the MTUC president who said that we should respect the workers' and doctors' integrity where possible and give them the benefit of the doubt.
Do you think the issue has affected the image & integrity of the medical profession?
No, I have explained the difficulties of doctors when faced with ill patients or workers who can claim being unwell because there is no magical machine or tests which can find for every occasion, someone truly ill to the point of justifying sick leave or not when 100% well!
But the insinuation of the MEF authorities is not fair or flattering, to themselves, the doctors or the workers in the country. If we truly have the most MCs given for workers around the region, then our working conditions must be so bad or poorly rewarding that many workers find excuses to escape from their work!
Perhaps this is the legacy of our long-standing policy of low wages for so long which has demoralised the attitude of our workers. Paying better salaries and incentive bonuses and demanding more of our workers might help change this attitude of hard work and increased productivity.
I am amazed that around the region, many of the workers are now working very hard and staying late at offices and factories (S Korea, Indonesia, Vietnam, even Philippines which I have visited recently this year). In contrast, the work attitude of some of our local workers are severely wanting by comparison to those elsewhere. Perhaps, getting better skilled and better quality workers can decrease such work absenteeism or poor work commitment.
Have you been to our shopping malls recently, where clusters of workers simply mill around chatting, and who know next to nothing about the products being sold, and who grudgingly help only when pressed upon!!? There seems to be so little pride in their work, sadly.
Are you aware of cases where doctors give out MCs freely & the percentage who do so in the profession?
There are some, but very few which have been proven and therefore action taken, definitely less than 1 in a 500 (we have around 7,500 GPs). If any doctor is found to be "selling" MCs or abusing his/her privilege, then action can be taken via the MMC (Malaysian Medical Council) through formal complaints.
Over the many many years the MMC have acted on less than 20 or so doctors who have flaunted these rules of selling pre-signed MCs on request rather than after a full medical examination. But as you can see, this is really a very small part of the problem, over the millions of doctor-patient encounters yearly!
Dr David KL Quek
MCs in Malaysia among highest in the region, says MEF
By LIM AI LEE email@example.com Sunday December 5, 2010
PETALING JAYA: Employers are incurring over RM1bil losses annually because of workers who feign illness to get sick leave, according to the Malaysian Employers Federation (MEF).
“Malingering or faking sickness to obtain medical certificates (MCs) has become a rampant practice in the country. The MCs rate in the country is now among the highest in the region,” said MEF executive director Shamsuddin Bardan.
“Some employees will take MCs to go fishing, watch a movie, attend a wedding kenduri or send the kids to school. They will even ask their colleagues to tell their bosses they are on MC if they do not turn up for work the next day.”
The MEF, which has just completed its survey on workplace productivity for 2010, is expected to release its report next week.
Shamsuddin told Sunday Star that in Malaysia, about 4% of lost man-days or working days are attributed to MCs alone.
While acknowledging there were genuine sick cases, he said the number of deceptive cases was high, with some malingerers exhausting the maximum 22 days sick leave allowed in a year.
“Malingerers usually follow a pattern - they will take MCs just before or right after a weekend or public holiday. Companies are keeping a close watch on these employees and once there is sufficient proof of abuse, they will be dismissed,” Shamsuddin warned.
Under the Employment Act 1955, an employee who has served at least five years with the same company is allowed up to 22 days sick leave annually which employers feel are “too high” and could give rise to abuse. The number of days do not include the 60 days entitlement for hospitalisation.
Malingerers, he added, were putting a financial strain on employers who had to pay 250% more for each man-day lost when a worker went on sick leave.
Given the 4% loss due to MCs, a company with 1,000 workers stood to lose 9,120 man-days a year.
Shamsuddin added that some companies, which offered incentives for staff with good attendance found they were able to reduce the man-days loss due to MCs from 4% to 0.01%.
However, the majority of employers did not see the point of offering such incentives as they were already paying their staff to work.
MTUC president Syed Shahir Syed Mohamud said they wanted to get a clearer picture from the MEF, adding that it was unfair for employers to claim that most workers on MCs were pretending to be sick.
“This is tantamount to questioning the integrity of doctors who issued the MCs to the workers,” he added.
He also disagreed with MEF’s call to the Government to reduce sick leave from the maximum 22 days, saying there were cases where employees were seriously ill or had met with accidents and needed time to recuperate before reporting back to work.
Doctors caught in the middle over sick leave
MEDICAL DOCTOR, KUALA Lumpur. The Star, Thursday December 9, 2010
YOUR reports and letters regarding the abuse of sick certificates, and the loss of productivity, needs to be looked at a little more critically.
What most people do not realise is that it is often difficult for doctors to decide to give or not to give MCs.
Most patients who want an MC have complaints such as a stiff neck, backache, diarrhoea, abdominal colic or inability to sleep the previous night because of migraine.
These complaints are difficult to verify by any doctor. I have seen doctors uselessly arguing with patients because they do not want to be blamed for issuing too many MCs.
The point to note is that there are no clear-cut physical signs when patients come with such complaints.
The sick certificate the doctor has to sign also does not make sense. He is supposed to sign a piece of paper saying he “has seen and examined this person and found him to be unfit for work for xxx days”.
There is no way a doctor can honestly sign such a certificate based on the above complaints. Yet not to give an MC when genuinely required is also unfair.
I would suggest a way out for both doctor and employees.
The individual seeking an MC should fill out an application in duplicate containing his complaint and how many days he thinks he would be unfit for work. This form should state if he needs any medication or investigation.
Most patients do not, but it does not mean they do not have genuine complaints.
The doctor then interviews the patient and approves or does not approve his request. One copy is retained with the doctor while the other is to be sent by the patient to his employer. The traditional sick certificate should be abolished for these kind of cases.
My advice to doctors is to be generous with such applications provided this format is followed.
If the employee takes too much sick leave, it is up to the employer to send him before a Medical Board to assess his fitness to continue working. This is provided by law.
It is about time doctors are protected from insinuations by employers and the public.