Honestly, I Could Not Help Him

My patient had come for a routine doctor visit. He was a well-built, soft-spoken middle-aged man who was always polite, respectful and adhered meticulously to his HIV medication. He complained only if he was in a great deal of pain or discomfort.

As usual, I asked him about his family: three adopted children. Over the years that I had known him, the children had grown to adults and had left home. One had secured a job, the second was in college, and the third had just joined the Marines. We talked about his work; he sorted packages at a warehouse. We chatted about the weather and then turned to his health.

From my nursing assistant's notes, I saw he was doing well. Results from his blood tests, CD4 (specialized immune system cells) counts and HIV viral load (the amount of HIV virus in the blood) looked equally good, and his physical exam was unremarkable.

I had time, so we chatted some more about his family. It was then that he hesitantly said, "Dr. Jain, my youngest son is coming back to town for a couple of days." Then, his eyes averted, he fell silent for a few long seconds. His voice quivered as he continued. "I wanted to spend some time with him. Can you write me a note for work?" His vacation time was all spent -- and he could not afford to take a leave of absence without pay.

Nearly a decade-long doctor-patient relationship had made us friends, and he was asking a small favor -- a favor that would mean a great deal to him but would be simple for me: penning a note on my stationery. He could have pretended to have a sinus infection or an ankle sprain, which could have gotten him a doctor's note for sick leave, but he did not. True to his nature, he was honest and straightforward.

Nearly every week a patient asks me for a doctor's note -- for a day off from work, skipping school, rescheduling a college exam or altering flight tickets. Nearly always, I consider the request, asking patients how many days they need off. If we differ on the number of days, we negotiate. I also have patients who within days of surgery or a hospitalization beg me for a letter to let them get back to work; again, we negotiate.

When it comes to patients' requests to fill out a form for disability, I cringe. The application is elaborate and asks questions such as "Can the patient lift 20 pounds?" as if I am supposed to have weights in my office to evaluate them. I cringe also because there is secondary monetary gain from a disability request. A doctor's signature for disability permits a person to get a monthly check from Supplemental Security Income for nearly $600 a month. On these cases, I am not lenient. However, when I refuse, I believe patients usually find another doctor who will sign their disability papers.

My patient was different. He was looking for two days with his son. I scoured my mind and the chart -- for something, anything, that would justify a note from me and allow him some time off. I asked him more questions. "Do you have any fever, cough, congestion, reaction to the medication?" But he was healthy; no tests were required; no medication needed change. At one level, from my heart, I wanted to give him the sick note just for his honesty.

It is not uncommon for doctors to exaggerate an illness to allow a patient to receive benefits. In one physician survey, 11 percent said they would be willing to misrepresent the patient's conditions to obtain an insurance company's approval for a necessary surgery or procedure.

Similarly, studies show that when patients request prescription medication, physicians are inclined to give it. However, they're not inclined to acquiesce to an unnecessary sick-note demand, according to a survey of doctors in the United Kingdom.

I was in agreement with these doctors. But, in a strange way, I felt guilty for being ethical on this occasion.

My patient had requested a note because his youngest son, who was 19 years old, was coming home for a few days from basic training and heading to fight the war in Iraq at a time when more than 75 American soldiers were dying there each month. My patient wanted to spend a few precious hours with his son.

The encounter reminded me of the different tugs of professional honesty, patient demand and human kindness that many of us face. As a lay person who had known him for a decade, I would have obliged him. As a doctor, I had no basis on which I could certify him as sick.

I gently suggested that he appeal to his employer to give him a couple of days off. My patient nodded, ever the gentleman; he understood and accepted my refusal. ¿

Manoj Jain is an infectious disease physician in Memphis and the medical director for the Tennessee Quality Improvement Organization. Comments:health@washpost.com.