I refer to Pierre Mallia’s piece in your paper (TMID 15 December) on the area of sickness certification, with broad-reaching negative comments about all company doctors in general, on the basis of his personal experiences.

It is not true that the majority of company doctors give up their professional values for an extra bit of money. This accusation is hurtful, very judgemental and not founded on fact. I have researched the subject using local data, and published on this topic in international medical journals. I have found that the distribution of diagnoses requiring certification by family doctor practices is similar to the distribution of diagnoses reported by company doctors examining sick employees. It is not true that the certification practices of family doctors and company doctors are so different, as implied by the article in question.

The work of many company doctors is such that they have been recognised as specialists in the field of Occupational Medicine. This is a speciality recognised by the Maltese Medical Council, and regulated by the same. Many company doctors work for much, if not most, of the time to improve health and safety at the workplace, introduce policies to prevent health-related illness, monitor sickness to identify and address occupational exposure, screen employees for illness before and during employment, and monitor their rehabilitation after injury or illness.

One cannot ignore these realities, especially due to a minor disagreement between doctors about a simple case of hypertension. In my research, only 2.2% of episodes of hypertension required an administrative intervention, such as a sickness certificate. Thus, Prof. Mallia’s statement that hypertension is incompatible with physical exertion is not supported by data.

Hypertension is not a disease, in the vast majority of cases, but simply a risk factor which may lead to cardiovascular disease in the long-term, in some subjects. European guidelines recommend drug treatment in cases where the risk of major cardiovascular events is more than 20% over 10 years. This is not the case for someone who does not have other risk factors, such as smoking or diabetes. The suggestion that a company doctor’s decision to ask an employee with hypertension to return to work was incorrect, or due to inappropriate influence, seems unsubstantiated by these facts. If one were really to believe that someone who suffers from hypertension cannot work without the risk of a stroke or heart attack, then what about diabetics, who are at even higher risk for such events? What about people who are obese, or smoke, or suffer from high cholesterol levels? If such were to be the case, there would be thousands of people who would need to be laid off from work due to such conditions.

In my experience many people who are genuinely sick appreciate the visit of a company doctor who is prepared to treat them for their illness. The only “coercion” involved is that many companies reserve the right to ask for a certificate from a named doctor. If the employee refuses the examination of that doctor, then consequently that doctor cannot issue a certificate, and the employee would have no valid certificate to present to the company. This system works in the vast majority of cases, and is the norm for many companies in Malta. The alternative is for employees being allowed to visit a number of doctors, at their choice, and present the certificate with the most prescribed sick leave. Is this the system acceptable? What about employees who present a health risk, such as a worker with gastroenteritis who wants to return to work in a dairy or restaurant, but is warned to stay home by the company doctor to avoid spreading disease?

Finally, I am surprised that in the case reported one seemingly did not follow the Medical Council’s ethical guidelines on differences in opinions between doctors. Such differences of opinion should be explained to the patient in the presence of both practitioners. If a difference of opinion persists, then an independent doctor should be appointed to resolve the difference (Medical Council circular 145/93). This process was not followed, or else this was not explained in the article in The Malta Independent. At no point do the Medical Council ethical guidelines recommend the discussion of a doctor’s decision by another in a national newspaper!

Jean Karl Soler

Rabat