Balance needed to ensure stricter rules on MCs do not exclude genuine patients, doctors say

SINGAPORE - Several times in the last decade, Sandra (not her real name) took extreme measures to convince doctors that she was ill and needed a medical certificate (MC).

“Some years ago, I dripped red-tinted prayer oil in my eyes to make it look like I had sore eyes.

“The doctor diagnosed me with conjunctivitis and gave me three days of MC,” said the 34-year-old customer service officer, pointing out that “these days, it is easier to use telemedicine services to get an MC without leaving home or needing to do anything extreme to look sick”.

However, she does not consider herself a malingerer. Rather, she feels she needs to take regular breaks because work is too stressful, and the 14 days of annual leave and 14 days of medical leave that she is entitled to are not enough.

While there may be some black sheep, five doctors and two telemedicine providers who spoke to The Straits Times said that most of their patients are genuinely ill. They said they prefer to err on the side of caution, so they do not deny patients treatment or medical leave, even if there is a chance they are pretending to be ill to escape work or school.

Dr Dana Elliott Srither, founder of telehealth platform Rexmed.io, said that when it comes to giving MCs, doctors rely on their clinical judgment and experience.

In making a decision, there has to be a balance, because patients should not be denied sick leave where warranted, he stressed.

“There are possibilities that patients use common symptoms like a headache and diarrhoea as a proxy for mental health issues like anxiety, which is a common illness in the population.”

There has been much discussion among members of the public and those in the profession following news of the

Ministry of Health’s (MOH) proposal to tighten rules on issuing MCs

to prevent doctors from dishing them out excessively or improperly.

In a circular in April addressing medical practitioners, MOH voiced concern over too many people hiding behind MCs to avoid a day at school or work.

Calling it “malingering and abusing medical leave privileges”, the ministry highlighted an allegation that MCs were given to specific patients repeatedly without referring them for physical consultation or further assessment to confirm if they were really unwell.

Under the Employment Act, employers are required to recognise MCs issued by registered doctors and dentists. According to the Singapore Medical Council’s code of ethics and guidelines, MCs should be issued to patients only on proper medical grounds.

The increasing popularity of online doctor services could make it more difficult for doctors to tell real from fake.

General practitioner (GP) Mohamed Baisal noted that “the absence of a physical consultation” could result in “limited accuracy in diagnosing and managing illnesses”.

Stricter rules in issuing MCs would help to ensure procedural fairness is observed, the GP from Shifa Clinic and Surgery added.

But Dr Baisal, who occasionally provides telemedicine consultations, stressed: “It is our job to treat every patient… without prejudice.”

He added: “We do not deny patients the medical treatments they deserve, including sick leave.”

Telehealth service provider WhiteCoat said it supports MOH’s move to tighten rules, which would “uphold trust levels in the medical profession regardless of the mode of practice”.

The platform said it has already been practising the strict policy of including the doctor’s name, signature and MC registration number on MCs since it started business in 2018.

In order to prevent employees from malingering, some employers offer alternatives such as mental wellness days and sick leave without the need for producing MCs.

The Public Service Division (PSD) – one of the largest employers in Singapore with 145,000 officers – said that since 2013, officers may take up to two days of sick leave in a year without producing an MC.

While some people are concerned that clamping down on MCs will make it tougher to secure one even if it is genuinely needed, Ms Grace Loh, psychotherapist and executive coach at Grace Psycap, believes that tightened rules could contribute to better patient care.

“Stricter MC issuance protocols can help in establishing a more honest and open communication between patients and healthcare providers,” she said.

The patient would be more likely to have a thorough clinical evaluation, which is critical for identifying both physical and psychological ailments that might be contributing to the patient’s health complaints, she noted.

Those who make a habit of faking illness to get an MC may not get away scot-free, either.

“Many companies monitor and observe trends of attendance,” said Mr Jasper Toh, principal consultant at human resources company Impact Best.

“If certain employees (display) a trend in taking MCs, such as before or after a long weekend, companies can start to inquire.”

Mr Toh added that employees who frequently take medical leave could be considered problematic if their work performance is affected, colleagues are influenced to also constantly take medical leave, or staff morale is affected.

The company could start an internal inquiry based on possible misconduct or malingering.

“That is if the employer is able to prove that the employee has been dishonest in getting these MCs, but employers shouldn’t jump to conclusions just based on the number of MCs that have been taken,” Mr Toh said.

Referring to online consults, Mr Ian Lim, a partner at TSMP Law, said: “If it is something that the doctor genuinely can’t assess or make sense of, the doctor may want to call the patient to come in to be examined.”

Mr Lim, who heads his company’s employment and labour team, added that if that is just a one-off incident, the doctor can give the patient the benefit of the doubt.

“But if the patient keeps coming back with repeated trends… the doctor should be on guard.”