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The issue of fraudulent sick certificates is a significant concern for GPs across New Zealand. With the pressures of work and personal commitments, some patients may seek to obtain sick certificates some days or weeks after they have been sick, without contacting the GP at the relevant time or even forge them outright. This not only undermines the integrity of the healthcare profession but also places GPs in difficult ethical and legal situations. This article explores the issue, highlighting the professional obligations of GPs and outlining the appropriate course of action when when made aware that a sick note may be false.
A GP in a busy practice recently encountered an issue involving a forged sick certificate, raising both ethical and professional concerns.
Earlier in the week, a patient attended the practice requesting a sick certificate to cover a period of absence from work three weeks prior. On this occasion, the GP explained that they were not happy to issue a retrospective sick note, as they had neither consulted with the patient during that time nor received any contact from them regarding illness. In New Zealand, doctors are permitted to write retrospective off-work certificates, if they feel it is appropriate, but must document the circumstances of the decision to backdate in the notes and also clearly document what the patient tells you and what is your own clinical assessment of the patient. On this occasion the GP did not feel is was appropriate to write the certificate.
A week later, the GP practice received an email from the patient’s employer, attaching a sick certificate that purported to be from the GP. Upon reviewing the practice records, the GP found no evidence of issuing such a certificate and, in fact, had explicitly refused the request. Recognising the serious nature of the situation, the GP sought guidance on the Medical Protection’s advice line. which has New Zealand-based advisors with expertise in handling such scenarios.
The Medical Protection telephone advisor provided clear advice on how to handle the situation while maintaining professional integrity and patient confidentiality. The key advice included:
You can respond to the employer’s email but only with very limited information. Patient confidentiality with respect to their health information must be upheld, even in the face of a potential forgery, but as is outlined in the Medical Council of New Zealand’s statement on Medical Certification (2023), an employer may contact the doctor to verify whether a medical certificate they received was the same medical certificate the doctor issued to the patient. In that event, it is appropriate for a doctor to verify that they issued that medical certificate to the patient. However, beyond that verification, no further information should be provided without the patient’s consent. So, in this situation, the doctor is permitted to tell the employer, “I did not issue the medical certificate which you have attached to the email you sent me”.
Contact the patient and discuss the matter in a non-accusatory manner. The patient should be given an opportunity to explain the situation. If the patient admits to forging the certificate: • The GP must assess whether the therapeutic relationship has been irreparably damaged. See the Medical Council of New Zealand statement on Ending a doctor-patient relationship, including factors to consider before making this decision. This includes considerations such as the nature of the issue, the patient's history with the practice, and the potential impact on other patients and staff. • Consider whether a formal warning is warranted in line with your practice policy, ensuring that any actions taken are consistent with the policy provisions and ethical guidelines. • The doctor has no obligation to report the matter to the police as fraud, although they would have the discretion to do so, using rule 11(2)(i)(i) of the Health Information Privacy Code, which allows for the release of information, without consent, if it is necessary for the maintenance of law, including the prevention, detection, investigation, prosecution, and punishment of offences. If the patient denies forging the certificate: As above, it is still important in this scenario to consider whether the therapeutic relationship has broken down. However, you must ensure that you bear in mind the fact that the patient has denied forging the certificate and take this into account when considering if any further action is required.
Whilst it is important to acknowledge that advances in technology, especially AI, have made it increasingly difficult for employers to be certain that a sick note isn't forged, GPs can take several proactive measures to minimise the impact when such incidents arise.
Record keeping: Detailed and accurate record-keeping is critical. Every consultation should be properly documented, including notes on any refusals to issue sick notes. By maintaining comprehensive records of the reasons behind clinical decisions, GPs can ensure they have a transparent account of their actions. In the event that a sick note is questioned or suspected of being fraudulent, having clear records can protect the GP from potential legal or ethical issues.
Security features: Explore whether there is an option within your practices software system to create tamper-proof templates. Alternatively, by adopting secure, verifiable formats such as digital signatures or encrypted electronic documents, the integrity of the sick note can be safeguarded against falsification. Consider printing out off-work certificates, signing them and then scanning them to patients, rather than providing the document in an electronic format. While this doesn't eliminate the risk, it could make the process more robust and easier to verify, should any questions arise regarding the validity of the sick certificate.
Awareness of technological advances: Despite all preventative measures, it’s important to acknowledge that we cannot be entirely certain that a sick note won’t be forged, especially in light of the rapid advancements in AI and other technologies. While it is increasingly difficult to detect fakes with complete certainty, GPs should remain vigilant and mindful that these technological developments may enable even more sophisticated forms of forgery.
Addressing suspected forgery: If a forged sick note is brought to a GP's attention, the most appropriate course of action is to follow the steps outlined above and act in line with your professional and ethical obligations. If the GP is unsure about the authenticity of a sick note, you should contact Medical Protection for expert guidance. It is critical to avoid making assumptions, as some cases of suspected forgery may require more investigation before drawing conclusions.
The forging of sick certificates can harm a doctor-patient relationship built on trust and place GPs in challenging professional situations. By adhering to the relevant guidelines set out in the Medical Council of New Zealand statements, maintaining meticulous records, and seeking expert medico-legal advice from Medical Protection when needed, GPs can navigate these tricky situations while upholding patient confidentiality and professional integrity.
