All physicians engaged in clinical practice face the problem of certifying that a patient was legitimately absent from work because of an acute illness or injury. Most employees who are covered by the Americans with Disabilities Act (ADA) because of long-term disabilities have periods of acute illness. Acute problems are not covered by the ADA. The same medical standards for work fitness apply to disabled employees covered by the ADA as to other employees. It is not certain, however, whether the ADA’s limitations on information to be provided to employers prevents the employer from inquiring into the cause of a disabled employee’s absence.

Return-to-work evaluations fall into two classes, depending on whether the employee is seeking to avoid returning or wishes to return to work. Situations in which the patient wishes to return to work pose fewer ethical problems because the patient and the employer generally have the same interest. Nevertheless, the physician must still determine the employee’s medical fitness to return to prevent possible injuries to the employee and potential legal liability for the physician. Except for company-employed occupational medicine physicians, the decision about return to work will usually involve both the physician and the employer. The physician can describe the medical limitations on the worker, but without special knowledge (of OSHA rules, the nature of certain jobs, etc.), he or she cannot decide that a patient can do the job adequately and safely. When evaluating patients’ ability to return to work, the environment in which they work must be given careful consideration. A painter with a broken leg may be able to paint walls while wearing a cast but could not work on scaffolding high above the ground. Cardiac patients who want to go back to work may tell their physicians that they sit at a desk or walk around slowly for the entire workday. What the physician may not know is that the patient works in an area of the plant with an ambient temperature of 120 degrees. On the other hand, the section foreman is not likely to be able to judge how much weight a postoperative patient may lift without danger. These questions should be worked out cooperatively among the worker, the employer, and the physician.

Physicians should be cautious about accepting the patient’s evaluation of the work environment. Patients may not know company policies on limited work or the availability of special positions for temporarily disabled employees. Private physicians should get their patients’ permission to talk to their supervisors for an accurate description of the work available for the patient and the environmental conditions under which the work is to be done. In many cases, the only way to determine if patients are fit to return to work is to allow them to try, but with instructions to both the patient and the supervisor to watch for signs of fatigue or reoccurrence of the medical problem.

The important thing for the physician to remember is that the medical decision is what limitations the worker has. Statements such as “able to return to work” or “light duty only” are not appropriate. The physician should provide explicit limitations such as “no reaching overhead, no lifting greater that ten pounds, and no exposure to extremes of heat.” With this information, the employer is the one to decide if there is a job for this worker that fits the restrictions. Ultimately, it is the employer who must consider the information available and decide whether to allow the employee back in the workplace.