stop_making_excusesI got a message last week: Patient's mother requests a note so she can bring his lunch to daycare.  They say it is federal law that he eat a healthy diet.

OK.  So I have to write a note saying, "Please allow Jonnie to bring his lunch to school?"  It takes MD after your name to have the authority to say that lunches should be brought?  Apparently so.

It seems the daycare was up in arms because the child's mother packs Cokes and sweets, which makes the other kids want the same.  They begged me to rescind the note.  I told them that, while this was bad parenting, it was not my place to be in the middle of this discussion.  They have the right to kick the child out of daycare if they choose.

It makes me wonder, how do I get in the middle of this kind of thing?  This is not the first time that I have had to write a note like this; I get requests regularly for notes for all sorts of things.

  • My child needs to get up and go to the bathroom during class.  Could you give me a note saying that if he needs to go, it is OK?  I wrote it, but wonder how my medical education was used in making this judgment.  Why wouldn't the teacher just let the kid get up to go?
  • My daughter gets thirsty a lot during class.  Can she get a note saying its OK to get a drink?  I did not write that one.  The child would somehow have license to get up multiple times per class.  Dehydration does not take 45 minutes.  Besides, would my asking for this obligate the teacher to follow it?  Thirst is not a medical condition that I treat
  • Can I get out of PE?  I have kids who hate PE, who want any possible excuse to get out of it.  Personally, I got out of PE for the first two years in high school due to a knee condition I had (this proved to me once and for all that there is a God).  Not liking PE, however, is not a good enough excuse.
  • Jury Duty - Everyone wants to get out of jury duty.  Panic attacks, chronic back pain, migraines, everything seems to be an excuse to get out of it.  I don't usually give exemptions because I think they should do it.  I did (and missed three days of work).  I guess jury duty is the adult equivalent of PE.
  • Airline tickets - There are special occasions where patients require an excuse from a booked flight (surgery, serious illness, etc).
  • Health Club Membership - This is generally more difficult to get out of than anything I have ever seen.  Health clubs are very reluctant to let a contract go, even sometimes with a note from the doctor.  The practice has made me have very negative feelings toward the industry.
  • I was sick last week and missed a couple of days of work, can you give me a note?  No.  I don't write a note for someone I did not see.  When I write a note for someone, I usually just state the fact that I saw them in my office, so please excuse the absence.
  • calvin_hobbes_aristo

No Child Left Behind

sm_excuse The NCLB law has been an incredible boon to both pediatricians and the fake excuse industry.  Why?  Here's what happens:

  1. The schools are not only judged by test scores, but by attendance of students.  Schools can get on the "bad" list if their students miss too many days.  Each student is allowed only five unexcused absences from school.  Notes from parents don't count.
  2. If a child gets sick enough to stay home, the parent is often forced to bring the child to the doctor, even though it is a sickness that they know needs no treatment.  Why?  Doctors are clearly more skilled at saying a child has diarrhea than a parent.  We are experts at it, so we must make the clinical judgment that the child does, in fact, have diarrhea.
  3. Some parents resort to forging notes for multiple absences.  In the past year I have had to discharge families from our practice because of multiple forged excuses.  Do I blame them for wanting to save money?  Not at all.  But forging a doctor's excuse undermines the relationship.

My kids are healthy, so I haven't faced it yet, but I suspect that my note saying they were absent for diarrhea would not be accepted.  I think this is because my judgement of diarrhea is blurred by my close relationship with my child.

Overall, excuses are both a power trip (I can get people out of nearly anything) and a pain in the rear.  I wonder what would happen if physicians started wielding this power as a weapon.  What would happen if, after Medicare cuts, we started writing excuses at such a rate that there would be a major economic down-turn causing staggering inflation and rising interest rates.

That'd show them, wouldn't it?  Then when they asked us to testify in court as to why we did this, we could get one of our colleagues to write us an excuse for that.

Then if they wanted the records showing that the person was in fact sick, we can say that our dog ate it.

It sounds foolproof to me.