Physicians' practices in sickness certification for common mental disorders - assessment of work capacity and communication with the patient's workplace

Sammanfattning: Physicians are key stakeholders in the sickness certification process. The first aim of this thesis was to examine physicians’ sickness certification practices from two perspectives: the assessment of work capacity and contacts with patients’ employers. A second aim was to develop and evaluate a tool with the purpose to facilitate such assessments and contacts in the sick leave process of primary healthcare patients with common mental disorders (CMD). Methods: In a systematic literature review, results from twelve qualitative studies about physicians’ clinical practices when assessing work capacity were synthesized. To explore general practitioners (GPs) contacts with sick-listed patients’ employers, answers from 4228 GPs’ responding to a nationwide questionnaire about sickness certification practices were analysed. The tool, a communication facilitator, was developed inductively based on data from six qualitative studies about work capacity and CMD, and was used in a pragmatic trial in primary healthcare. Effects of using the tool on length of sick leave was evaluated using sickness absence register data for participants in the pragmatic trial (n=56). User perceptions were explored qualitatively in individual interviews (n=13). Results: Study I showed that when physicians assess work capacity, they use both medical and non-medical skills and resources to collect and interpret information about the medical condition as well as other aspects concerning the patient and his/her context. Their main source of information was the patient, while contacts with employers were rare. Study II demonstrated that about four of ten Swedish GPs had direct or indirect contacts with patients’ employers. The strongest association with having such contacts was shown for regular collaboration with a rehabilitation coordinator. Other factors of importance for having and being satisfied with one’s employer contacts were finding employer contacts important, collaborating with other health professionals and having organizational resources such as a joint sickness certification policy and managerial support. Study III showed that the communication facilitator, the Capacity Note, had the potential to improve communication about work and health between GPs, patients and employers, but any effects on length of sick leave could not be demonstrated in study IV. Conclusions: The assessment of work capacity is a complex task where a multitude of aspects are considered by the physician. Providing physicians with resources such as time, insurance medical training and methods to assess the workplace could improve the assessment. Having appropriate organizational resources is also of importance for GPs’ contacts with patients’ employers. The communication facilitator seemed to be acceptable to users and relevant for its purpose but could not be fully evaluated due to a limited sample size in the pragmatic trial. A larger trial will be necessary to test if it can affect sickness absence in patients with CMD.