“Just Have Your Doctor Write A Letter…”

Once, a long time ago, when I was in third grade at Oglesby School some minor illness kept me at home watching afternoon TV. When I returned, a well meaning classmate asked “You got your note?” I’m certain beads of sweat appeared on my forehead. “What note?”

“Your note-for-being-absent.” He said it fast, like it was one word. “You got no note they send a truant officer to your house.”

I’d heard about truant officers, police who caught you playing hooky while you did something evil, like going to a Sox game on a Tuesday. Truant officers, I knew, looked like Nazi Joseph Goebbels, whose picture I’d seen in Life Magazine. Goebbels could put you in that most dreaded of institutions–reform school!

All because I didn’t bring my note.

I was on the verge of tears by the time I entered Miss Delaney’s classroom. She sweetly asked  “Bring your note? No? Just bring it tomorrow. Your Mom or Dad can write one, saying you were at home sick.” That was it. No Goebbels. No Audy Home for me.

I swore I’d never ever be note-less again

And yes, all through school until 8th grade I dutifully brought my excuse notes. But at the beginning of my last year in grammar school, I handed an excuse note to Miss Kostakes, a no-nonsense Greek woman with pitch-black hair and huge earrings.

“What’s this? A note? You’re giving me a note? David, you’re in 8th grade. Next year high school, then college, then I don’t know what. You’re finished with notes to the teacher.” And she handed it back.

She was right. For the rest of my education, if I didn’t get to class I might be marked absent, but grades became more dependent on the quality of your work and less on showing up. I wish my patients had it so lucky.

A PhD candidate at the University of Chicago who’d been out with the flu recently sent me a frantic email saying her professor wouldn’t let her back in class without a doctor’s note. “But you’re 30 years old, you’re a PhD candidate!”

She apologized, saying “It does sound ridiculous, doesn’t it?”

I write doctor notes for teachers to give to principals, for principals to give to their district supervisors, for floor nurses to give to head nurses, for associate administrators to give to whoever is one notch above them, and for minimum-wage food service and retail workers to give to their shift bosses.

Not surprisingly, I’ve never written a note for anyone in senior management.

What I don’t understand is why it seems everyone’s been thrust back into third grade. Maybe it’s just to remind employees how lowly they actually are in the scheme of things, mere messengers of the gods while physicians and shift supervisors become the authority figures.

Letters, we write letters

You should know that doctor offices generate far more than notes covering absences with the flu. In the past few weeks alone I’ve written letters to…

• Get someone excused from jury duty.
• Refund an airline ticket.
• Permit a cat in an otherwise cat-free condominium.
• Break a lease on an apartment riddled with black mold.
• Ask for some additional time on SAT exams.
• Request a supportive chair at work (these are called workplace accommodation letters and it’s astonishing how architects/designers create environments/select furniture that make workers ill or give them backaches).
• Help a woman get permission to turn off a fluorescent office light that triggered her migraines and be approved to use a desk lamp instead.

One man with airplane phobia needed a letter so he could take a train to a company meeting in New York. Another needed a private hotel room for the company’s annual business meeting because since childhood he’d been unable to sleep with someone else in the room.

Even more letters are generated by the changes in healthcare economics. Patients discover that once-covered benefits are a thing of the past. Pharmacists tell patients: “You need to ask your doctor to write a letter explaining why you need brand-name Ambien instead of generic zolpidem.” Or “Why, now that you’re 65, you still need your Adderall for ADD.” Or why you need a twice monthly massage for fibromyalgia.

Have your doctor write a letter explaining “Why you need…”  “Why you…”  “Why…”

Disability letters a study in corporate nastiness

Applying for disability falls into a category of its own. The gauntlet of red tape that an ill patient must run in order to receive disability benefits, even when she’s been paying the premiums herself, is brutal. The collective attitude on the part of disability insurance employees is a study in corporate nastiness (and they usually sign their letters anonymously, as in “Debbie C, Benefits”).

More than one patient has told me she burst into tears trying to explain her pain to someone who sincerely believed she was just ripping off her employer.

The letters from disability insurance companies are apparently intended to threaten the patient’s relationship with her doctor. The insurer asks variations of the following: “Please have your doctor give us a narrative report of your history, copies of diagnostic tests, and summary reports from other physicians. In the letter, have him describe all your treatments to date and your response to them. In addition, using the description of your workplace duties (enclosed), please have your doctor complete the enclosed three-page questionnaire summarizing your specific disabilities or lack thereof.”

These questionnaires are insanely specific. “Can she perform a pushing maneuver with her right hand of 0 pounds, 5 pounds, 10 pounds, 15 pounds, up to one hour a day? Two hours, five hours, eight hours? With a five-minute break every hour, 10 minutes, 15 minutes?”

If my patient can push 15 pounds for eight hours with a five-minute break then whoever’s requesting this better be nervous if he runs into the applicant in a dark alley. I try to explain to patients that the reason for these letters attempting to block disability or prevent them from getting a medication that’s worked for years is a combination of simple corporate greed and fear of job loss from the thousands of insurance employee underlings.

The health insurance company doesn’t want to spend the money on your brand-name sleep meds. “If you don’t like generic zolpidem (which costs about $10 a month) and prefer branded Ambien ($250 a month), buy it yourself. We’ll read your doc’s letter about this, but you don’t have a prayer.

Nobody reads these letters

Throughout 2014 I found myself writing more letters and filling out more forms than I’d ever done in my professional career. I regularly received e-mail from patients that began “I need a letter addressed to my….” often combined with “I’m attaching the form they want completed.”

I do appreciate that these letters are important and don’t want your bladder infection to be the cause of your unemployment. But understand it’s merely the physical piece of paper in your file they’re seeking. Nobody actually reads these letters.

Nobody except me and you.

I know this from numerous conversations with supervisors of all stripes in which they’ll ask me a question whose answer is the opening sentence of my letter. They respond with silence or “Oh, I guess I didn’t see that.”

Insurance companies rarely read them either. Once, when I had to write a seemingly endless series of letters over time to an insurance company justifying a particular lab test, I began inserting a random sentence from James Joyce’s Finnegan’s Wake into a random paragraph in my response. We never received one query asking about “But Noodynaady’s actual ingrate tootle is of come into the garner mauve and thy nice are stores of morning and buy me a bunch of iodines.”

Dr E’s Time-Wasting Reduction Act

I’ve decided to inaugurate 2015 with what I call the “Edelberg Time-Wasting Reduction Act” and here it is:

If you need a letter of any kind, write it yourself. If you can write a shopping list, believe me you can write a doctor’s note. Write it as if you’re me writing the letter about you, the patient. Keep it simple and don’t include every tiny thing you’re feeling. Be discreet and, please, no pleading. Get the dates of your illness correct.

Once you complete your first draft, send it to me as an attachment. I’ll read it, edit it for errors, translate it into doctor-speak as needed, transfer it to my letterhead, and mail or email it back to you. If you prefer, pick up a crisp hard copy at our front desk.

When you have a form to fill out, follow these steps:

1. Make a duplicate of the form.
2. Fill in the duplicate as completely as you possibly can, including measurements (like weight and height) when required, estimates of your capabilities, and when you think you can return to part-time or full-time work.
3. On the original, complete the patient portion only. Send both copies to me.
4. But first make copies of your work and keep them in a file folder. Many insurance companies require updated reports and if nothing has changed, in the future you can always obliterate the old date with white correction fluid, insert the current date, and re-copy it.

I’ll check your forms for accuracy and complete the original using your information (as well as mine).

Why are we doing this? Physicians today are so swamped with time-wasting activities that they’re beginning to leave the profession as quickly as they can afford to. The new electronic medical records (EMRs) actually add a full hour to every physician’s workday.

As a bonus, if I incompletely filled out an EMR it’s reflected in a reduced reimbursement from insurers, kind of like the truant officer catching you out all over again.

Now it’s time for you guys to pitch in and waste some time yourself. Your doctors thank you in advance!

Be well,
David Edelberg, MD