Medical certificates (MCs) are issued by doctors as evidence that their patient is unfit for work for a specified period of time, ensuring paid sick leave for employees covered under the Employment Act.1 Doctors should be mindful of the importance of MCs in protecting both individual patients and public interest, and of the potential ethical pitfalls involved.
This article will discuss the Singapore Medical Council's (SMC) guidelines on the issuance of MCs, as well as the types of medical leave that can be specified in an MC. A second article will follow on the role of MCs in safeguarding public interests in matters of workplace safety and in limiting the spread of contagious disease, as well as the possible need for uncertified medical leave.
SMC ECEG regarding MCs
The SMC Ethical Code and Ethical Guidelines (ECEG) 2016 cautions doctors to consider medical factors when they issue an MC, and to guard against allowing the interests of other stakeholders to affect their actions.2 In particular, doctors may be under pressure to alter the duration of an MC for non-medical reasons, such as requests from employers, financial incentives or workplace benefits for the patient. Patients also often request for MCs to be issued for a slightly longer or shorter duration, which may be granted when medically reasonable.
Doctors should respect confidentiality by writing a diagnosis on the MC only with the patient's consent.2 For the same reason, the MC should be given directly to the patient unless he/she (and not his/ her employer) requests otherwise. For civil servants, consent should be sought before electronic MCs are uploaded to the Government's Medical Billing System from registered clinics.3
The date of issue of the MC and the dates for which the patient is certified unfit for work must be clearly and accurately indicated on the MC.2 If the doctor is reasonably certain that the patient would have been unable to work for a number of days prior to the consultation, the MC may be written to cover those days. However, the date of issue must not be backdated.
MCs should also be personally signed to ensure professional and legal accountability.2 Doctors should not change the details on MCs written by their colleagues, and should instead write a new MC if they feel that there are medical reasons to do so. It is good practice to document in the clinical notes the reasons for such amendments.
In a recent case,4 a doctor was fined $15,000 for activities that included multiple violations of the ECEG's guidelines for writing MCs. The SMC Disciplinary Tribunal also noted that they would have recommended suspension of 36 months, had the doctor been registered at the time of sentencing. These violations included backdating the date of issue on an MC, writing an MC for himself without medical grounds, and attempting to give the impression that the MC was written by another doctor. This case serves as a reminder that the ability to issue MCs is a serious responsibility.
Types of sick leave
A doctor should specify on an MC whether the patient requires hospitalisation leave or outpatient sick leave, based on the patient's medical condition (rather than on request).2 Hospitalisation leave certifies that the patient's illness is severe enough to warrant hospitalisation.5 He does not necessarily have to be hospitalised, however, and may recuperate at home if it is medically safe to do so.
Sometimes, a patient can return to work with certain limitations on the type of activities he can perform, in which case he is certified fit only for "light duties". The ECEG states that it is the doctor's responsibility, because of his/her medical expertise, to ascertain "to the best of [his] ability...that appropriate light duties are in fact available to the patients at their place of work".2 This can present a challenge in practice, as doctors are allowed to rely on their patients' assessment of the availability of light duties.6 Non-governmental organisations concerned with migrant worker rights have, however, suggested that there is a risk that this assessment may be influenced by pressure from employers.7
The Ministry of Manpower (MOM) encourages employers to grant paid sick leave if no option for light duty exists, but does not mandate this.5
As the system evolves, a more detailed document, perhaps resembling the fit note issued by doctors in the UK,8 could be used to specify the type of light duties appropriate for the individual patient. This would allow employers to take greater responsibility for their employees' well-being, instead of allowing the burden to fall solely upon doctors.
Leave for appointments
The question often arises as to whether employees can use MCs to take paid leave to attend a medical appointment. The MOM website addresses this with the statement that an employee is entitled to paid sick leave as long as they are given an MC.5 The doctor is thus at liberty to decide, based on medical factors,2 when this is appropriate.
Alternatively, a "time chit" may be issued as evidence of a patient's attendance at a clinic or hospital. The MOM, however, does not compel employers to accept time chits. This system may disadvantage low-wage workers who are less likely to be granted uncertified time-off, and shift workers who may resort to scheduling clinic appointments on their rest days to avoid losing pay.
When appropriate, and with the patient's consent, it may also be helpful to communicate with employers or to remind patients of their rights under the Employment Act.