Sickness certification when experienced as problematic by physicians

Sammanfattning: Background and aim: Physicians play an essential role in the sickness absence process, and many of them experience related tasks as problematic. The overall aim of this thesis was to improve the understanding of sickness certification experienced as problematic by physicians in general practice and occupational health services, and to gain more knowledge about the frequency and severity of those problems. Materials and methods: Four studies were conducted, two of which were based on written cases reports, one on discussions of those reports, and one on questionnaire data. Courses intended to improve sickness certification practices for physicians in general practice and occupational health services were held in different parts of Sweden. Before taking part in such a course, the physicians were to send in a case report describing one of their own problematic sickness certification cases. During the courses, these cases were considered in group discussions. In the first study, dilemmas experienced by the physicians regarding their problematic cases were identified. The research material that was analysed consisted of some 100 documented names of dilemmas obtained from five courses, and the analytical method used was a descriptive one-step categorisation. In the second study, the main characteristics of 195 written case reports from nine courses were discerned by analysis using a stepwise descriptive categorisation and quantification. In the third study, 44 case reports were analysed with a narrative approach with elements from both thematic and structural analysis. In the fourth study, the material consisted of answers to a questionnaire that had been sent to all physicians in Sweden. The analyses included responses from 2,516 specialists in general practice regarding the frequency and severity of problems in sickness certification, and the frequency of approving unnecessarily long sick-leave periods for different reasons. Results: Eight categories of dilemmas experienced by general practitioners were identified. Examples of these were “not the doctors’ pigeon” (when the patients’ problem was perceived as not being medical in nature), “diagnosis as disguise” (when there was a discrepancy between how the patient described the problems and what the physician apprehended), and “harmed by sick listing” (when the physician perceived that the main problem was the iatrogenic adverse effects of sick leave per se). In the analyses of the written case reports about problematic sickness certification, information on the following was often provided: age and sex, family situation, occupation, stressful life events, and medical investigations and treatments. Two thirds of the patients had been on sick leave for more than a year. It was found that the most common type of cases concerned women, who were employed in non-qualified nursing occupations and were on sick leave due to psychiatric diagnoses. Furthermore, the most common measures taken by the physician were referrals to a psychotherapist and/or physiotherapist, and prescribing antidepressants. In their written case reports, physicians described clearly different ways to relate to the problems they faced, and five “types of message” were identified. A common feature of the case reports was a striving for neutrality, and that the patients’ stories tended to be interpreted within a traditional biomedical frame. The physicians’ personal and emotional involvement and their relations with the patient were visible to varying extents. Overall, the responses were about having problems as such, rather than the specific features of the problems. According to the national survey about frequency and severity of problems, general practitioners considered assessments of work capacity to be very or fairly problematic. Other problems reported in this context were related to the following: handling situations in which the physician and the patient had different opinions about the need for sick leave, and managing the dual roles as both treating physician and medical expert when writing certificates to be used by the social insurance office. At least once a month, a majority of the physicians issued sickness certificates for longer periods than they deemed necessary, often due to waiting times in health care and in other organisations. Younger and male specialists more often reported doing this in order to avoid conflicts with the patients. Conclusions: The tasks involved in sickness certification challenge the physicians’ professionalism in certain ways, and several related problems are reported to be both frequent and severe. Cases perceived as problematic have several characteristics in common. Some of the problems were more closely related to consultations and typical situations in which the physician had difficulties in acting in accordance with his or her sense of what was the right thing to do, primarily due to conflicting demands or loyalties.