seeking practical advice

[Yidder8]

I am a bit embarrassed to post this, but will try and do so anyway.

I am a male recent graduate from medical school, and will be working soon in primary care. It it will be more of a corporate type practice, (so quite a number of generally healthy working adults).
In my work setting, if you want to take time off for medical reasons, you need to obtain a medical certificate from a doctor.
I have been told that the clinic has a fairly regular stream of female patients seeking medical leave for menstrual symptoms (usually menstrual cramps), and I have been instructed to issue medical chits judiciously (in other words, beware the malingerers).

My query is how can we best assess if menstrual symptoms are genuine in office practice? At a minimum, I would like to ensure that the patient is actually having her period, So my query here is how can we find evidence of menstrual bleeding in practice; specifically, would we expect tampons to be stained with blood at all times, or is it necessary to do a speculum exam. Can bleeding be intermittent, and if so, would it be possible to find tampons not stained with blood and no blood on pelvic examination.

I would give the patient the benefit of the doubt if she complains of menstrual cramps at her 1st consult, and not do any unnecessary examinations or embarrass her. But a problem may arise especially with repeat visitors who may fake symptoms, (especially just before public holidays in order to get a longer holiday) . If the clinic gets a reputation for providing medical leave too easily, (especially to women who are in the intermenstrual phase of the cycle), this may spread among other clients, encouraging them to turn up with fake symptoms, and also making a bit of a mockery of both the clinic and the doctor.

Edit: The practice is also quite big with multiple corporate contracts and satellite clinics, with most providing after-hours clinic services and some 24-hour services. So its not too difficult for a patient to hop from one clinic to another for a medical note. Medical records have not yet been digitised, so we cannot always access records of visits at other clinics, especially after office-hours.
The specific problem we have however is that the practice has contracts with airlines also, i.e. many of these patients are airline crew. The air stewardesses prefer some flights over others, and they sometimes turn up at the clinic just before their flight (usually after-hours and not uncommonly in the middle of the night) to obtain a note. What this also means is that other aircrew placed on standby have to be activated at short notice.

On a spectrum of mild to severe symptoms, most of the patients will probably be at the mild end (but this is also subjective), walking and talking normally. This post is to seek advice on how to make a quick objective assessment at a given point in time (even though a referral may be required in severe cases)

This is a somewhat long post as I have tried to provide some context, but my specific query is shown in red above.
Any advice would be most appreciated. Thank you.

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[bikelady]

To your specific question, I have actually never written a work note or done FMLA for recurrent menstrual symptoms. I do offer treatment for heavy/frequent menstrual bleeding (OCP, DMPA, LNG-IUDs) so the goal of treatment would be to not need to be incapacitated frequently. If someone fails medical treatment, we move on to a hyst (or ablation.) I can see giving a work release for a singular event but not without starting some kind of treatment at the same time - if the patient declines treatment, I would not continue to give FMLA or whatever.

I more frequently encounter somewhat obnoxious pregnancy-related requests to be off work / work fewer hours / etc. They usually say something along the lines of "my manager is fine with it, I just need a note from you." Which always makes me wonder why they need a note at all, since they're the ones making the accomodations. Typically I either phrase these as "Ms. X would like to start working four hour shifts," go ultra-vague and say, "Ms. A is currently pregnant with a due date of XYZ. Please follow your workplace's policies regarding pregnancy-related accomodations" or ask the patient to bring me a letter from HR detailing her workplaces' policy or whatever it is THEY want me to say.

 

[Dr G Oogle]

Agree with above poster. Also anyone with such severe dysmenorrhea they need a work excuse should for sure be offered an evaluation by a gynecologist unless you’re comfortable with that evaluation it’s not always just uterus related, I see many patient with pelvic floor dysfunction that is debilitating and occurs in line with menses, same for Interstitial cystitis and endometriosis often presents with dysmenorrhea but won’t respond to straight forward ovulation suppression.

a simple way of handling this is to assume everyone is telling the truth and refer to a specialist if they keep coming in and requesting time off. If they continue to do this and not go to see the referral just say “ma’am I have recommended specific options for you to receive treatment for your symptoms and cannot continue to write work excuses if you do not follow through with these recommendations...”

 

[Yidder8]

a simple way of handling this is to assume everyone is telling the truth and refer to a specialist if they keep coming in and requesting time off. If they continue to do this and not go to see the referral just say “ma’am I have recommended specific options for you to receive treatment for your symptoms and cannot continue to write work excuses if you do not follow through with these recommendations...”

Thanks for this advice, this would work in some situations, but please my edit above.

 

[anonperson]

I am a bit embarrassed to post this, but will try and do so anyway.

I am a male recent graduate from medical school, and will be working soon in primary care. It it will be more of a corporate type practice, (so quite a number of working adults).
In my work setting, if you want to take time off for medical reasons, you need to obtain a medical certificate from a doctor.
I have been told that the clinic has a fairly regular stream of female patients seeking medical leave for menstrual symptoms (usually menstrual cramps), and I have been instructed to issue medical chits judiciously (in other words, beware the malingerers).

My query is how can we best assess if menstrual symptoms are genuine in office practice? At a minimum, I would like to ensure that the patient is actually having her period, So my query here is how can we find evidence of menstrual bleeding in practice; specifically, is it possible for tampons to appear completely unstained during the cycle?
And is it at all possible for a female not to be wearing a tampon during the period (in other words, does the absence of a tampon indicate that the patient can't be having her period) [Apologies I know that this is probably a silly question, but I would just like to be sure].

I would give the patient the benefit of the doubt if she complains of menstrual cramps at her 1st consult, and not do any unnecessary examinations or embarrass her. But a problem may arise especially with repeat visitors who may fake symptoms, (especially just before public holidays in order to get a longer holiday) . If the clinic gets a reputation for providing medical leave too easily, (especially to women who are in the intermenstrual phase of the cycle), this may spread among other clients, encouraging them to turn up with fake symptoms, and also making a bit of a mockery of both the clinic and the doctor.

Edit: The practice is also quite big with multiple corporate contracts and satellite clinics, with most providing after-hours clinic services and some 24-hour services. So its not too difficult for a patient to hop from one clinic to another for a medical note. Medical records have not yet been digitised, so we cannot always access records of visits at other clinics, especially after office-hours.
The specific problem we have however is that the practice has contracts with airlines also, i.e. many of these patients are airline crew. The air stewardesses prefer some flights over others, and they sometimes turn up at the clinic just before their flight (usually after-hours and not uncommonly in the middle of the night) to obtain a note. What this also means is that other aircrew placed on standby have to be activated at short notice.

The senior doctor who was showing me around mentioned that aircrew usually call the clinic to find out who is the doctor-on-call before coming in and they do this generally to target the male doctors. She added that it can be difficult to work on board with menstrual cramps so she is generally sympathetic; however she will always check the patient is having menses. I was just wondering how she would do that (but felt a bit shy to ask)

Any advice would be most appreciated. Thank you.

What exactly is the issue?

If you don't want to write a work excuse note then don't do it.

If the pain is that debilitating, then they require treatment whether it's NSAIDs, hormonal treatment etc. If they decline but still want a work note, then use your own judgement on If you want to write the note.

Regarding the last sentence, why don't you ask the senior doctor how she confirms if a patient is on her menses instead of asking random people on a message board to read her mind.

I'm assuming she's doing a pelvic exam and if there is no blood, she doesn't write a note.

 

[Yidder8]

What exactly is the issue?

If this is not clear, it's a bit disappointing, I thought I took the trouble to explain this in some detail. However, I have edited the query to make it a bit more specific (I hope)
If you think these patients are going to turn up distressed & doubled up in debilitating pain, I'm guessing you have not worked in a corporate practice before.
If you find the post annoying, there's really no need to reply.

Anyway, thanks for all the replies thus far

 

[Dr G Oogle]

If you have no way of knowing that a patient is clinic hopping for notes then it’s not really a sure. You’re job is to take care of these patients and if you’ve never seen them before again the right thing to do is to trust the patient. It’s not your job to police them and call around to see if they’ve been to other clinics, that sounds more like a corporate bureaucrat’s job.

 

[anonperson]

If this is not clear, it's a bit disappointing, I thought I took the trouble to explain this in some detail. However, I have edited the query to make it a bit more specific (I hope)
If you think these patients are going to turn up distressed & doubled up in debilitating pain, I'm guessing you have not worked in a corporate practice before.
If you find the post annoying, there's really no need to reply.

Anyway, thanks for all the replies thus far

How did you get through medical school without understanding that pain is subjective. So, yes, you are asking us to read your mind and the patients mind. If you don't think her pain is legitimate, don't write the note. Send her to someone else.

You are not obligated to put people off of work.

Also, stop with the corporate practice BS. A lot of practices are hospital owned nowadays anyways. Doesn't change what you are asking.

 

[bikelady]

I tend to write for work *accomodations,* not a release to be off work entirely. So get specific about what they might need to function on their shifts - bathroom breaks x15min q2h, ok to keep ibuprofen/tylenol at their work area, place to sit down, etc. Do they need an extra carryon bag for their supplies/extra undies/etc? Basically approach the issue as assuming they WANT to go to work, what do they need to make that happen?

But agree with above, not your job to be the PTO Police. If they are clinic hopping, that's their manager's problem. Trust the patient.

 

[bikelady]

My query is how can we best assess if menstrual symptoms are genuine in office practice? At a minimum, I would like to ensure that the patient is actually having her period, So my query here is how can we find evidence of menstrual bleeding in practice; specifically, would we expect tampons to be stained with blood at all times, or is it necessary to do a speculum exam. Can bleeding be intermittent, and if so, would it be possible to find tampons not stained with blood and no blood on pelvic examination.

Specifically re: intermittent bleeding. Yes. Someone with regular heavy cycles will know they are due to start shark week on a specific day - they might not be bleeding heavily at the moment they come in to the office saying they will need to be off work. But in that situation I would offer to initiate treatment- let's place an IUD now and write for Provera so you can work through your next period.

A pelvic exam isn't embarrassing, it's a standard part of the workup. Even if she's not bleeding, if you find a fibroid up to her umbilicus on the bimanual exam you'd refer her for surgery. Easy peasy.

 

[Yidder8]

How did you get through medical school without understanding that pain is subjective.

You managed to get through medical school without understanding that pain is subjective right?
So it should be possible for other people to do likewise

 

[Yidder8]

Specifically re: intermittent bleeding. Yes. Someone with regular heavy cycles will know they are due to start shark week on a specific day - they might not be bleeding heavily at the moment they come in to the office saying they will need to be off work. But in that situation I would offer to initiate treatment- let's place an IUD now and write for Provera so you can work through your next period.

A pelvic exam isn't embarrassing, it's a standard part of the workup. Even if she's not bleeding, if you find a fibroid up to her umbilicus on the bimanual exam you'd refer her for surgery. Easy peasy.

This is helpful, many thanks.

 

[anonperson]

You managed to get through medical school without understanding that pain is subjective right?
So it should be possible for other people to do likewise

I learned early on that pain is subjective so I'm not sure why you are just repeating my question.

Regardless, my point still stands. The decision to write a work excuse note is your call regardless of presence of menses.

 

[Yidder8]

Regardless, my point still stands. The decision to write a work excuse note is your call regardless of presence of menses.

When you dilute your message with unnecessary comments & silly, rhetorical questions, it becomes difficult to figure out what your point is.
See bikelady's response for an example of a direct, helpful response to a straightforward question.

"The decision to write a work excuse note is your call..." You're just stating the obvious here. There is no dispute as to whose call it is. This has no relevance to the query in the initial post (in red).

 

[objleakT]

This may be an unpopular opinion but if a woman comes into the office stating she is having debilitating cramps and needs time off work or other obligations for it, just give her the time off and then do your job and work to find a reason why she’s having debilitating pain. I’m not entirely sure why it matters if there’s proof that she’s bleeding on exam. Menstrual cramping can be debilitating both before and after presence of blood.

 

[Yidder8]

This may be an unpopular opinion but if a woman comes into the office stating she is having debilitating cramps and needs time off work or other obligations for it, just give her the time off and then do your job and work to find a reason why she’s having debilitating pain. I’m not entirely sure why it matters if there’s proof that she’s bleeding on exam. Menstrual cramping can be debilitating both before and after presence of blood.

Yes, that is what I would do as a general rule, say in a solo neighbourhood practice. There is no great 'judgement' involved here.
But the problem arises due to the peculiar nature of the practice (see part in green). While its a good tenet to follow to always trust your patient, the reality is that a sizeable proportion of attendees who complain of menstrual cramps will not be having symptoms, and may not even be anywhere near their period, but just would like a medical note to avoid a particular flight, and be re-deployed to a more desirable flight a day or so later.

My problem/query really is more of a practical one, whether there is some objective assessment that can be done to demonstrate that one is not handing out notes too easily.

[Menstrual cramping can be debilitating both before and after presence of blood. This is useful information, thanks.]