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see the benefits of careful return to work, but our efforts to achieve this in the old system were often frustrated, and they still are. Employers often reject fit notes because the suggestions, whilst clinically appropriate, do not fit in with their administrative needs in relation to statutory sick pay – that they must have the employee completely off in order to get the money. It may also cost them more to make the necessary changes, and they cannot be bothered. I feel the government should look at changing the law, to make the acceptance of the doctor’s opinion compulsory, and make it up to the employer to decide whether to make the changes or put the employee off work, but not insist the doctor change their advice. This was the case in New Zealand. There needs to be change in the administrative rules about re-claiming statutory sick pay, etc, for the employer. The article also mentioned hospital doctors giving med3 forms. Many hospitals do not allow their medical staff to give these forms, insisting that only GPs can do this, and must do this even if they have not seen the patient and had no confirmation from the hospital of the cause. This makes us unacceptably reliant on the patient’s verbal communication of how long the consultant supposedly said they are entitled to be off work. Hospitals do not stock


the required stationery, and juniors are given obsolete stationery and no training in how to use it. This will lead to the next generation of GPs having no training, thus making the system fail again. It leaves little scope to work within our competence if we are forced to opine in specialist cases because the consultant specialists refuse or are not enabled to provide fit notes, and we


Too close to home IN THE LEARNING points attached to the Stevens-Johnson case (p23 of Casebook 18(3)), you repeat the wise advice that “it is good practice not to treat people too close to you, either relatives or colleagues”. This of course includes self-treatment, and is in general wise commonsense – until someone interprets the words literally. A few years ago, passing through London on my way to the airport, I began feeling


gout pains in my foot. I have had occasional attacks of gout over the years, fortunately rarely, so I did not bother taking prophylactic treatment but I recognised this pain and knew that it presaged extreme pain over the next few hours. No problem, I thought, I’ll just go to the local pharmacist and buy myself a few indomethacin capsules, that’ll stop it. The young pharmacist was horrified – “Oh no, I can’t give you tablets! It’s unethical for doctors


to treat themselves!” No amount of persuasion, seniority or authority helped. She even rang the Pharmaceutical Council for advice, and their response was the same. By that time I had to rush


for my plane and there was no time to contact my GP or anything else. For those who don’t know, the pain of gout


is about the worst there is. I wouldn’t wish it on anyone. But please, those of you who formulate


official guidance, choose your words carefully. David Freed, Manchester, UK


are not given the necessary information by them. As to patients believing their doctor was not qualified to judge them fit for work, are we talking about patients who would not consider anyone qualified to judge them fit for work, having decided themselves that they don’t want to work, or are we actually talking about patients feeling their doctor has insufficient knowledge of what their work involves? David Church, GP, UK


An unexpected, painful end WE COLLECTIVELY WRITE in response to the outcome of this case (from Casebook 18(2)) against Mr E. It would appear that the patient Mr Q had exemplary treatment while under the care of Mr E. It appears Mr Q sustained a unilateral left-sided undisplaced acetabular fracture without any loose bodies. It also appears that at follow-up clinic,


the fracture had healed radiologically and clinically, with Mr Q walking pain- free and without a limp. We feel that the prognosis that Mr E gave with regards to the development of unilateral hip osteoarthritis, taking into account the fact that the fracture was undisplaced and had healed radiologically and clinically by three months, is correct and is backed by the associated literature. There is a wealth of literature that indicates, particularly in undisplaced acetabular fractures, that the functional outcome and level of pain present at one


year post-fracture would be the residual outcome level, and it is highly unlikely to deteriorate. It would also seem implausible that a unilateral acetabular fracture would cause symmetrical hip joint osteoarthritis bilaterally. Mr Q developed pain in both hips six years after the accident, indicating that the arthritis of both hips is highly unlikely to be related to his undisplaced


acetabular fracture. Mr MJ Barakat, Specialist Registrar, Trauma & Orthopaedics, Southmead Hospital, Bristol, UK Miss J Torres-Grau, Junior Doctor, Trauma & Orthopaedics, Southmead Hospital, Bristol, UK Mr I Packham, Consultant, Trauma & Orthopaedics, Southmead Hospital, Bristol, UK


Casebook and other publications from MPS are also available to download in digital format from our website at:


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OVER TO YOU


UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk


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