CAEP Position Statement – Sick notes for minor illness

EXECUTIVE SUMMARY

INTRODUCTION

Employer- and school-mandated verification of minor illness leads patients to use healthcare resources solely to obtain a “sick note.” This puts unnecessary strain on the patient and the emergency department (ED), and threatens to spread communicable diseases in our community.

The Canadian Association of Emergency Physicians 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.

THE IMPACT OF SICK NOTES ON PATIENTS

The World Health Organization and the Public Health Agency of Canada advise patients with the flu to stay home when sick.^{1, 2} Our patients agree: In a poll conducted on behalf of the Canadian Medical Association, 76% of Canadians believe that people with minor illnesses should recover at home, and 70% believe that we should make it easier for sick people to avoid infecting others.³ These minor illnesses are generally self-limiting, viral illnesses where no medical treatment is required.

However, patients cannot follow this basic healthcare advice if they are required to get a sick note for work or school. Rather than encouraging patients with minor illnesses to recover at home, sick notes create unnecessary healthcare visits that cost the patient time and money. When 1 in 10 Canadians (and up to a third of low-income households) are not able to afford their prescriptions,⁴ the potential added financial burden of a sick note is a further barrier to healthcare. As a consequence, 82% of Canadians would go to work ill rather than get a sick note,³ which undermines patient recovery and threatens public health.

Employers and schools require sick notes in order to verify illness, presumably to deter misuse. But concerns of misuse are likely overblown: According to one study, 45% of workers with paid sick leave did not take even a single paid day off of work in the prior year.⁵ In addition, many patients understandably seek a sick note after they have recovered from their minor illness. In these situations, physicians and nurse practitioners rely on a patient's self-report, making healthcare provider verification of illness an ineffective tool to dissuade misuse.

THE IMPACT OF SICK NOTES ON PUBLIC HEALTH

Sick notes encourage patients with infectious disease, such as influenza or gastroenteritis, to leave their home and visit their family doctor or the ED purely for a piece of paper, which puts other patients at risk. In 2007, Doctors Nova Scotia asked large employers to stop the practice of requiring sick notes (and encouraged physicians to invoice the company for the cost of the note),⁶ and, in 2014, the Ontario Medical Association called on employers to stop requiring sick notes because they drive patients with minor illnesses into waiting rooms and spread infections to more vulnerable patients.⁷ In 2018, the Ontario government followed this medical advice and removed the ability for employers to ask for a sick note for minor illnesses. This decision was recently reversed against the advice of the Canadian Medical Association⁸ and the Ontario Medical Association.⁹

THE IMPACT OF SICK NOTES ON EMERGENCY DEPARTMENTS

The Centers for Disease Control and Prevention specifically advises against using the ED for minor cases of the flu,¹⁰ but that is the unintended consequence of requiring sick notes. While such unnecessary visits by low acuity patients are not the cause of ED overcrowding,¹¹ they are an unnecessary use of healthcare resources at a time of strain and they expose other patients to harm. The ED includes the sickest and most vulnerable patients – including children, pregnant women, seniors, and immunocompromised patients – and a bureaucratic sick-note demand places their lives at risk unnecessarily.