Stop Signing Doctor's Notes to Avoid Being Sued

Historically, pediatricians have had little risk of being named in a malpractice case. Parents tend to like their kids' pediatrician and a doctor's likeability plays a big role in whether a patient sues. When pediatricians are sued, it's mostly for failure to diagnose and for honest, unavoidable professional errors. We've always told ourselves that if we followed common-sense policies and kept clear and complete documentation, we should be able to avoid the nightmare of a malpractice suit.

A recent encounter with a university-bound patient, however, got us worried. After losing a lawsuit in 2008, the National Collegiate Athletic Association (NCAA) set rules requiring sickle cell trait screening for student athletes, even though medical societies, including the American Society of Hematology (ASH) do not recommend it.  In fact, ASH considers sickle cell trait screening bad medical policy since ASH recommends that all athletes receive the same training and preventative care regardless of their sickle cell status. The lawsuit was frivolous.

The NCAA case, and others like it, have led to the sharp increase in form and "doctor note" requests to practices throughout the US. The work for our office and for the families in tracking down a college-bound athlete's newborn screen, when the sickle cell testing was performed, is a total waste of time. These requests are a time-consuming nuisance, and given the fact that the NCAA lost that unfounded suit, we wonder if our signing forms and notes is opening us up to frivolous suits as well.

For example, last month we were asked to ensure in a note to a daycare center that a patient was "not contagious." Occasionally we can do this, say for a rash that is obviously a contact dermatitis, but often we simply cannot make a "not contagious" guarantee. A rash that may be viral or a child with a cold who is contagious might be contagious, on and off, all winter and most of the spring. This is not a reason to keep a child out of daycare. We are stuck between a rock and a hard place since daycare centers can keep parents from work and earning a living. If we don't write the note, the parent can't return to work. But if we write it, and another child happens to catch a similar virus to the one we diagnosed, are we opening ourselves up to a lawsuit? 

Waste-of-time, uncompensated requests from a school, coach, camp, or daycare moves risk, both real and imagined, onto a doctor. We often reply to requests with a simple, "No, thank you." And when our polite refusals are ignored, we write angry articles and send a copy of the text instead of the "note" to the requesting institution.

We link the increase in note requests to helicopter parents. In recent years, there has been a noted increase in research and press coverage, both in the U.S. as well as in the UK, confirming the negative impact of risk-adverse parenting. Studies have shown the negative effect of  of helicopter parents as children transition to adulthood. It turns out that treating our children as fragile, helpless beings turns them into fragile, helpless adults.

As we've written before, we've taken steps to reduce school note writing by setting policies of simply refusing most requests. We've also had success in reaching out directly to local school nurses and superintendents to learn more about their needs and concerns, which has helped all parties involved. And yet, like a bad game of whack-a-mole, the harder we work to keep the requests at bay, the more requests, varied and creative, stream in.

Risk-adverse daycare centers, in addition to having appropriate policies for written orders for prescription and nonprescription medications, also require a physician note for ordinary everyday items including sunscreen, bug spray, and even physician permission to give non-water or non-dairy beverages. When we encounter these ridiculous requests, we question the judgement of the adults who set these draconian policies in the first place. As parents, we wouldn't want these fearful adults to provide care to our child.

A new trend we're seeing at our area's schools is a refusal to accept the words "spine normal" on our standard school form as confirmation that a scoliosis screening was performed. Schools are forcing children to undergo an in-school scoliosis screen, even though one has already been performed in our office. It's important to note that school screening for scoliosis has long been of questionable use anyway, and the U.S. Preventive Services Task Force recently updated its recommendation against universal scoliosis screens as there is no evidence to support it.

Daycare centers, school administrators, and leading public-health groups owe it to our children to set reasonable rules for and, more importantly, against requirements for physician notes and forms. Most importantly, our state and national legislators must pass laws to protect institutions who educate and care for children to shield them from litigious parents who mistakenly think they should shelter their strong, confident children.

(Editor's Note: The U.S. Preventive Services Task Force reached out to say it has previously issued an "I statement," concluding that the current evidence is insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in children and adolescents ages 10 to 18 years. Essentially, this means that the Task Force can not recommend for or against screening - there simply is not enough evidence to come to a conclusion either way.)