Dealing with sickness certification – a survey of problems and strategies among general practitioners and orthopaedic surgeons

A comprehensive questionnaire, with 83 fixed response questions about perceived problems, proficiency regarding sick-listing together with questions about cooperation with Social Insurance Office and need of training, was used. The questions were based on earlier knowledge from the literature and interviews with physicians.

About 7700 physicians below the age of 65 in two counties in Sweden (Stockholm and Östergötland) were contacted by mail and asked to participate in the study. In the Stockholm County the register of the members of the Swedish Medical Association was used to identify physicians working in Stockholm. Since 95% of all physicians are members of the Swedish Medical Association virtually all physicians were reached. In Östergötland a register used for advertising purposes was used (Pharma Marketing AB) including 100 % of all physicians. The questionnaires including two reminders were managed by Statistics Sweden. The study was approved by the Regional Ethical Review Board in Stockholm.

A total of 5455 physicians (71.2 %), answered the questionnaire [29]. In this study the answers from the following two groups of physicians were analysed; the physicians who handled sick-listing tasks at least a few times per year, were specialists, and worked in a GP office (n = 673) or in an orthopaedic surgery (n = 149), Table 1. In Sweden the specialist training for both GP and OS is about five years.

The questions and response alternatives are listed in respective Table 2, 3, 4, 5. Based on type of questions we have chosen to define them as dealing with personal stressors, personal strategies, roles etcetera, as seen in the tables. Descriptive statistics including estimation of p-values from chi-2 tests were calculated using SPSS. Two logistic regressions were performed for questions dichotomised to binary variables. In Tables 2 and 4 the variables were dichotomised to every week versus less often, in Table 3 to very or rather problematic versus hardly problematic or not problematic, and in Table 5 to yes and partly versus no. In the simple regressions, workplace was used as the independent variable and crude odds ratios (OR) including 95% confidence intervals (CI) were reported. In the multiple regressions, gender and working years were used as independent variables when calculating adjusted ORs for workplace including 95% CI. There were missing values for 25 of a total of 822 physicians regarding working years and no missing values for the other variables. Missing value statistics in the 27 simple regressions were: minimum = 0, median = 5, maximum = 18. The corresponding statistics for the multiple regressions were: minimum = 25, median = 29, maximum = 42. In response to the question on threats in Table 3, only one orthopaedic surgeon reported experiencing threats weekly. There were no other problems with few counts in the cells.

In both groups of specialists, 97% met sick-listing patients every week, Table 2, and a majority experienced problems weekly with sickness certification. At a more detailed level, most physicians experienced problems with "to encounter a patient who wants to be on sick leave for some reason other than work incapacity due to disease or injury". A larger rate of GPs reported personal stressor. Among GPs the most frequent personal strategy used was "to have contacts with social insurance staff...", and for OSs it was "to issue sickness certificates without a personal appointment". All differences between the two groups were statistically significant.

The most common types of clinical problems were "to assess the degree to which reduced functional capacity limits a patient's work ability", "to handle situations in which you and a patient have different opinions about the need for sickness absence", and "to decide whether to authorize prolongations of a period of sick leave that was previously certified by another physician", Table 3. All factors studied except for "to issue sickness certificates to be used by Social Insurance Offices (SIO)" were experienced as significantly more problematic by the GPs than by the OSs. Although the ORs decreased somewhat for most of the questions, the differences did not significantly change when adjusting for gender and working years.

A higher proportion of OSs issued prolonged sick-listings every week more than would have been necessary due to waiting time for investigation and treatment in health care as compared to GPs, Table 4. On the other hand, more GPs prolonged sickness certificates of medical reasons, due to that their patients had to wait for measures to be taken by the SIO or the employer. Furthermore, they had a four times higher OR for issuing certificates when they had not enough access to adequate care or care providers for the patient.

"Support from management regarding handling of sickness certification cases" was experienced by 32% of GPs, and 26% of OSs, while 30% of the former and 55% of the latter had no "common strategy for handling matters related to sickness certification at the clinic", Table 5. The figures did not change much when only considering those who had reported frequent (i.e. every week) problems in handling sickness certification. Nor did the ORs change when adjusting for sex and working years.

Strengths of this study is that physicians working in the two participating counties represent one fifth of all physicians in Sweden, that practically all GPs and OSs in the area were included, and the high response rate (71%). Social Insurance legislation and its administration is the same throughout Sweden as is the sick-listing role of GPs and OSs. The results might, thereby, be considered representative for most Swedish GPs and OSs. A limitation is that the dropout rate could not be related to specialities. This was the first time the questionnaire was used, except for a smaller pilot study. The reliability of the instrument was not tested. Based on how the questionnaire was developed, and on comments from participants, other physicians, as well as researchers in the area, face validity can be claimed. So far, other validity tests have not been made.

A vast majority of both GPs and OSs stated that they found at a weekly basis handling sickness certification matters as problematic. The experience varied widely between the two groups of doctors. However, experience has earlier been shown to vary between different groups of GPs [23]. One important factor explaining why GPs reported more problems than the OSs, might be that the GPs more frequently encountered patients who wanted to be on sick leave for some reason other than work incapacity due to disease or injury. This might in itself also explain why the GPs experienced more conflicts with and threats from their patients. On the other hand, they had more regular contacts with social insurance officers and referred patients somewhat more often to occupational health services, implying that they might be able to get more support in these issues. OSs on the other hand issued more certificates without a personal appointment with the patient.

Better cooperation and more frequent contact between health care and SIO have been suggested as one important solution for sickness absence problems in health care [8]. Despite the fact that more of the GPs reported having regular planned contacts with the SIO, they perceived many more problems than the OSs. The SIO has, thus far, offered educational activities to GPs to a much greater extent than to other physician categories. Perhaps these contacts and educational activities have not been adapted to the problems perceived by the GPs, but have instead made them more aware of problems related to sickness absence certification as compared to the OSs. GPs also seem to have less opportunity to use administrative measures in coping with sickness certifications.

Most of the OSs did not find it problematic to assess the patient's functional capacity, in contrast to the GPs, who found it much more problematic. One reason for this difference might be that the two categories of physicians met different types of patients, and many of the OSs' patients had been referred to them by other physicians (i.e. GPs or occupational health specialists). However, assessing the degree to which reduced functional capacity limited the patient's work ability was one of the most problematic issues for both groups, with more than half of the OSs and 80 % of the GPs perceiving this as problematic. A majority of the GPs also found it problematic to ascertain optimal time and degree of sickness certification. There is, so far, no scientific evidence on the best or optimal sick-listing of patients which makes this a difficult task for many physicians [1]. In order to assess the patient's work ability, the physician also needs information about the patient's work place, and this information is difficult for physicians to obtain and validate [16]. Physicians often fail to contribute information needed by the SIO concerning functional capacity when they issue sickness certificates [1, 30].

Handling situations in which the physician and patient have different opinion about the need for sickness absence and prolongation of sick-leave spells previously certified by another physician were themes reported as problematic by more than half of both groups. Writing the sickness certificates was the only issue not considered to be more problematic by GPs than by OSs. As most GPs recently had had special training from the SIO, one could have anticipated their rates to be even lower.

A higher proportion of OSs than GPs reported issuing prolonged certifications every week due to waiting times in health care for medical examination, investigation, treatment or rehabilitation. GPs on the other hand more frequently issued prolonged certifications when treatment possibilities were lacking (e.g. lack of cognitive behavioural therapists) and when the patient was waiting for measures to be taken by the SIO, the employment office or the employer. These differences are possibly due to the fact that GPs more often need to cooperate with other stakeholders both within and outside the healthcare. GPs are thereby more dependent on others, while OSs might by themselves influence the waiting times influencing there work with patients.

Overall, a higher rate of GPs reported more problems, as well as having support from management and common policies regarding sickness certification; they had more than two times higher odds of having such support and policies. Among the physicians reporting problems every week, the ones working as GPs perceived somewhat less support and fewer reported common policies, but on the other hand somewhat more of the OSs reported support from management. We did not ask the physicians if they experienced the support or the policies as helpful or not, so it is not possible to draw any conclusions about the pro or cons of support or common policies based on the results from this study.

As was shown in this study as in others physicians experience problems related to their sick-listing task. Physicians perceive problems due to where and with what they work. In order to plan for educational activities and interventions in order to improve the management of sickness certification, we need knowledge about experiences of different groups of physicians. This study has helped us to meet the different need of vocational training for GPs and OSs. Further research, with other types of study design, taking into account organisational differences, different patient-mixes, the possibility of referring problematic patients, and other factors that might be of importance is, however, needed to explain the differences in sick-listing issues between physician groups. We also need more studies in order to settle best practice and how to organise health care services appropriately regarding sick-listing, especially regarding patients with ambiguous diagnoses.