Ethics · Advanced · Ethics

Fitness to Work After Minor Injury

Practise this PLAB 2 ethics station on Ankle Sprain. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in an urgent care centre. A 42-year-old man, Josef Fischer, comes to see you with a minor ankle injury sustained in a workplace accident. He is requesting a sick note for one week even though the injury appears relatively mild. Please take a history, examine the patient, and discuss the appropriateness of the sick note request.

Background notes: PMH: Occasional back pain from desk work

What this station tests

  • Fit note assessment: 'may be fit for work with adjustments' versus 'unfit for work'
  • Ankle sprain in a sedentary worker does not prevent desk-based work
  • Exploring the real reason: workplace stress, relationship issues, or other factors behind the sick note request
  • Reasonable adjustments: working from home, avoiding stairs, reduced standing
  • Maintaining the therapeutic relationship while declining an inappropriate request

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

A patient requesting a sick note for a minor injury that does not prevent office work tests the candidate's ability to assess fitness honestly while maintaining the therapeutic relationship. Mr Fischer is 42, office worker, with a minor ankle sprain, requesting 2 weeks off work. Open with: 'Mr Fischer, tell me about the ankle and how it is affecting your ability to work.'

Core approach

Assess the injury objectively. Minor ankle sprain: no fracture, no significant swelling, can weight-bear with mild discomfort. He is an office-based data analyst (sedentary work). The injury does not prevent him from sitting at a desk and using a computer.

Explore his motivation. He may have workplace stress, a difficult relationship with his manager, or personal issues he is not disclosing. The sick note request may be a proxy for a different problem. Ask: 'Is there anything else going on at work that is making it difficult to go in?' This often reveals the real reason.

Explain the fit note system. 'The fit note is not about whether you feel like going to work. It is about whether you are medically able to do your job. With a desk-based role, a minor ankle sprain does not prevent you from working. However, I can recommend adjustments such as working from home or avoiding stairs.'

Closing and safety netting

If the ankle genuinely does not prevent office work: issue a fit note stating 'may be fit for work' with adjustments (working from home, avoiding stairs, reduced standing). Do not issue an 'unfit for work' note for a minor injury in a sedentary worker. If he has underlying workplace stress: address this separately with appropriate support.

Maintain the relationship: 'I understand you are uncomfortable, and I want to help. But issuing a sick note that does not reflect your medical situation would not be appropriate. Let me help you find the right solution.' Safety net: 'If the ankle worsens or you develop new symptoms, come back.' Follow-up: workplace stress support if relevant.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Primary focus)

Scores well: Injury assessed objectively. Occupational demands understood (sedentary). Underlying motivation explored. Workplace stress screened.

Costs marks: Not assessing injury. Not considering occupational demands. Not exploring motivation.

Domain 2 (Primary focus)

Scores well: 'May be fit with adjustments' note issued. Adjustments specified. Not issuing inappropriate 'unfit' note. Workplace stress addressed if present.

Costs marks: Issuing 'unfit' inappropriately. No adjustments offered.

Domain 3 (Primary focus)

Scores well: Maintaining relationship while declining. Explaining fit note system. Exploring underlying concerns. Not being judgmental.

Costs marks: Being confrontational. Dismissive. Judgmental. Damaging the relationship.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Issuing 'unfit for work' for a minor injury in a sedentary worker: this is not medically justified
  2. Not exploring the underlying reason: the sick note request may be a proxy for workplace stress
  3. Being confrontational: he may feel judged, so the refusal must be handled with care

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

What is the right way to handle the ankle sprain scenario in this station?

A patient requesting a sick note for a minor injury that does not prevent office work tests the candidate's ability to assess fitness honestly while maintaining the therapeutic relationship. Mr Fischer is 42, office worker, with a minor ankle sprain, requesting 2 weeks off work. Open with: 'Mr Fischer, tell me about the ankle and how it is affecting your ability to work.'

Where are marks won and lost in this ankle sprain station?

Examiners reward: Injury assessed objectively. Occupational demands understood (sedentary). Underlying motivation explored. Workplace stress screened. Candidates are penalised for: Not assessing injury. Not considering occupational demands. Not exploring motivation.

Where do candidates most often go wrong in this station?

Issuing 'unfit for work' for a minor injury in a sedentary worker: this is not medically justified.

Can I do well in this station without real-world experience of ankle sprain?

This station rewards process over personal experience. The skill being assessed: Ankle sprain in a sedentary worker does not prevent desk-based work. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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