The Cruel Tyranny of Sick Notes

In the midst of this winter’s so-called “tripledemic” of flu, Covid, and RSV, millions of workers will face a dismal dilemma: show up to work sick or spend the day off wrangling the American medical system in all its high co-pay glory. For these workers, there is no third option of simply staying home to rest and recover.

This is no accident. Many of the largest U.S. employers require doctor’s notes, a form of medical documentation intended to prove the legitimacy of an illness. These policies disproportionately impact the 76.1 million American workers paid by the hour: At Amazon, for instance, the typical software engineer might take a week off to recover from a bad cold, but a seasonal warehouse worker returning from the same break would likely need medical documentation to avoid getting fired.

Employers would argue doctor’s notes are about accountability—ensuring workers don’t take the day off to watch Netflix or further extend a long weekend. The focus on worker attendance has only grown worse amid ongoing labor shortages. As managers try to figure out why so many Americans don’t want to work, they cling even more ferociously to the workers they have on staff, not seeming to consider that policies as onerous and condescending as requiring doctor’s notes play a role in driving people away in the first place. This is especially true as American families contend with frequent school closures, the lack of affordable childcare, and health care costs that have grown twice as fast as wages in recent years.

But these policies are inconvenient by design: Pain is the point. By levying tremendous costs against workers for health-related absences, companies hope employees will take sick days only when absolutely necessary. Even in those cases, doctor’s notes often serve as a bureaucratic buffer, allowing corporations to shirk whatever benefits they owe sick or disabled employees.

During nineteenth-century industrialization, many American companies employed on-site physicians. According to historian David Rosner, these doctors served as both medics and human resource managers, in both cases ultimately serving corporate interests. So while on-site physicians healed injured workers, they also identified those deemed too injured to remain productive, helping companies “prune” the workforce over time.

Doctor’s note policies evolved in response to the proliferation of third-party insurance in the 1930s. “The idea was that Blue Cross would be a third party in the negotiation between management and labor over health,” Rosner said. He noted that corporations started with a leg up, since doctors—especially those in smaller company towns—belonged to the same social class as business managers. Doctors and managers often lived in the same neighborhoods, sent their children to the same schools, and participated in the same social clubs. As a result, Rosner said, there was “a natural tendency for [doctors] to be very suspicious of workers’ complaints.”

Over time, management formally incorporated these suspicions into corporate policy. In the 1960s and ’70s, the New York City Transit Authority subjected sick workers to unannounced visits from company doctors tasked with scrutinizing the legitimacy of an illness. The transit authority even hired investigators to follow sick workers throughout the day. Anyone sick for more than two days needed a doctor’s note, and management called doctors to verify notes hadn’t been forged, according to Marc Kagan, a former transit mechanic and union officer. Kagan described the atmosphere of fear during these years, as management routinely fired workers based on subjective charges of chronic absenteeism.

The Transport Workers Union bargained for more lenient policies over the years. Through negotiations in the 1980s, an arbitrator ruled that investigators could only check on sick transit employees during certain hours of the day. Then in 2002, the TWU negotiated to give most transit workers three sick days without doctor’s note requirements. “It’s gotten better for the majority of workers, and that’s primarily a result of the union negotiations,” said Steve Downs, a retired New York City train operator and union officer.

In today’s largely post-union environment—just 10.1 percent of workers were unionized in 2022, a record low—corporations have reclaimed many of these modest gains. Walmart, for example, makes most hourly employees earn up to two days of protected PTO for sick days. Once those are exhausted, workers start losing points: one full point for every shift missed, with three points opening the door to termination. Sick workers can try to avoid this fate by applying for medical leave with a doctor’s note. If it’s granted—and Walmart has a history of denying applications—employees still only receive a fraction of their typical paycheck.

These corporate point systems draw from behavioral economics, treating workers as discrete rational units within a system designed to “nudge” them into more profitable behavior. Amazon has taken this idea to the extreme with its gamified warehouse labor system, which has workers “play” arcade games by completing work-related tasks. When doctor’s notes serve as an input in point systems, access to medical care becomes just another work metric earned or revoked based on productivity.

“While I deem the points just about generous enough for the average person who rarely gets sick, it doesn’t take into account having to miss work because of a sick child, a very real thing for many associates,” a Walmart employee, who asked for anonymity for concern for their job, explained over email.

Points aside, doctor’s note policies still mostly serve as a blunt instrument of corporate control. During December’s holiday travel debacle, Southwest Airlines threatened to fire anyone “alleging illness” if they didn’t bring a doctor’s note upon return—and in case that wasn’t inconvenient enough, the airline stipulated that notes from telehealth visits wouldn’t count. A small business in California fired a worker after her car accident; she showed up to work shortly after the accident, but the managers asked for doctor’s note after doctor’s note, each time alleging insufficient documentation. “They retracted their previous offer of accommodations and sort of forced me to either quit or go on medical leave,” she said. By the time management requested a third doctor’s note, she concluded they just wanted an excuse to force her on medical leave, which reduced her salary in the weeks leading up to her dismissal.

Whatever the supposed justifications of doctor’s notes, it should be clear they have little to do with worker health. Instead, the policies betray a fundamental indifference to health as anything other than a means of unlocking further productivity. This corporate logic relies on the premise of worker fungibility—it’s not so much that workers aren’t trusted to care for their own bodies but that corporations don’t see worker bodies as something worth preserving in the long term. This dynamic was clear during early American industrialization, and it holds true in the contemporary corporate systems that carry only a vague recollection of the hard-fought labor victories of years past.