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Most family doctors asked by patients to provide a sick note for their employers agree, a new Israeli study has found.

The research study, led by Dr. Aya Biderman of the Department of Family Medicine at Ben-Gurion University of the Negev, and carried out within the family doctors' research network, collected data on sick notes issued in 47 clinics treating some 60,000 patients. Of the 918 patients who reported to have asked for a sick note, 560 received one and 358 did not. "There are contradictory reasons for writing out a sick note," Biderman said, "but the main reason appears to be the patient's request."

The study was published in this week's issue of the Israel Medical Association's journal, Harefua. On questioning those patients who scheduled an appointment specifically to secure sick leave, it was found that 99.2 percent received the sick note. Of the patients who visited the physician for treatment, only 63.8 percent received a sick note.

Twenty-five percent of physicians also told the researchers of other reasons, apart from medical ones, for writing a sick note. Of those, 81 percent said the primary reason was the patient's own request, followed by two percent who noted psychological problems, two percent who specified medical issues experienced by other family members, two percent who said the patient was trying to conceal pregnancy from an employer, two percent who described the reason as a need to secure a sick note for a court hearing, and one percent who gave a further variety of reasons, such as a holiday season or the patient approaching retirement.

An average sick note in Israel, the study found, covers 5.5 working days, but half the patients only secured notes for three working days or less. Women were found to be requesting sick notes more often than men, a trend confirmed by similar studies in Sweden and the United Kingdom. The researchers argued this could be explained by women's high employment rate in Israel, and by mothers taking out sick notes for themselves to tend to their sick children. Israeli law allows mothers up to six sick days a year to treat their children. Men, however, obtained on the average longer sick leaves than women.

The age group that secured most sick leaves, at 48.4 percent, were young people under the age of 39, followed by those aged 40 to 49 (26.7 percent ), and older than 50 (24.9 percent ). Older workers received longer sick leaves than younger ones, the study found.

Hired employees were found to take out more sick leaves than self-employed ones, but no divergence was found between manual laborers and office workers.

"Although the system sees family practitioners as gatekeepers on sick notes, they basically give patients whatever they ask for," Dr. Biderman said. "We didn't find doctors who just give out sick notes to everyone, but when deliberating between the employee and the workplace, the patient comes first for the physician."

The sick note policy in Israel is currently being reviewed by the Family Doctors Association. According to the relevant law, which dates back to 1976, a worker is requested to present a sick note from the first day of his illness, even though he begins receiving partial sick pay only from the second day on. In Sweden, by comparison, a sick note is requested only from the seventh day on. The researchers said changing the law to request a sick note only from third day on would reduce visits to physicians and lighten their workload.

Two weeks ago, the Israel Medical Association hosted a meeting between family physicians and industrialists, also in a bid to review sick-note policy. The industrialists requested that physicians write an accurate medical diagnosis on every note, but the physicians objected due to medical confidentiality. The doctors, on their part, asked to be absolved from writing out sick notes for only a few days, but this request was rejected by the industrialists.

"There are no medical instruments to decide clearly when to give or not give a sick note, and it all depends on the patient's motivation," the chairman of the Family Doctors Association, Professor Shlomo Vinker, said. "If a patient comes in without fever but insists he had fever back at home, he'll get a sick note. We can't be policemen and gatekeepers for the employers, and we'll strive to change the existing system so as not to force every worker to get a sick note for an absence of just one day."