The fit note he wants — and the one you can't sign

PLAB 2 & PRES 3 · ethics / general practice · medium · 8 minutes

Candidate brief

You are an FY2 doctor in a GP surgery. Mr Kevin Doyle, 41, a warehouse supervisor, attends asking for a fit note. He had a back strain three weeks ago, was given a two-week note by your colleague, and by his own account his back is now "basically fine — 95%". He wants a further four weeks off. When you ask why, he says: "Honestly, doctor? They've put a new manager in and he's making my life hell — performance meetings, watching everything. I just need a month away from the place while I look for something else. You can put the back down again — nobody checks." Please assess the request and manage the consultation.

What examiners look for

A fit note is not a favour, a prescription or a sick-day voucher — it is a signed professional statement that a named person is unfit for work because of a stated condition. Writing "lumbar strain" for a healed back is falsifying a record, and probity failures — not clinical misjudgements — are what end medical careers. The refusal is therefore not personal, and it should never be delivered as if it were. But a good refusal is a fork, not a wall. Nearly every unjustified note request conceals a justified consultation: this man has work-related stress, rising drinking, broken Sunday sleep and a union rep he has never called. The candidate who explores gets the real history; the candidate who polices gets a walk-in-centre anecdote. "I can't sign for the back — now tell me what's actually happening" is the whole skill in one sentence. Hold the honest middle on stress: work-related stress CAN make a person genuinely unfit, and a note saying so is legitimate when the clinical findings support it — assessed on the day, from the patient's actual state, not from the convenience of the narrative. Today's Mr Doyle is functioning and says he is not ill; another week of PIP meetings might change that picture, and his GP door must be open when it does. Certify the patient in front of you, never the story that helps him most. Use the machinery that exists for exactly this: "may be fit for work" with adjustments when someone is partially fit; occupational health; the union; ACAS and Citizens Advice for the employment-law thicket doctors should not improvise in. A doctor who reaches for these has not refused help — they have refused ONE dishonest form of it and offered four honest ones. And document the refusal kindly and completely. The note that was never signed will be judged, if it is judged at all, by the record of why — a record that shows a man listened to, screened, signposted and left with his dignity, and a doctor who would not lie for him but would clearly work for him.

Guideline references

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