Psychiatrists′ work with sickness certification: frequency, experiences and severity of the certification tasks in a national survey in Sweden

Sickness absence due to mental diagnoses has increased in Western countries [1, 2]. Psychiatrists issue a considerable number and an increasing share of the sickness certificates in Western countries [3, 4]. Sickness certification in psychiatric care constitutes an increasing workload, and is particularly complex as it includes a number of new diagnoses for which the criteria are still under discussion [5]. Several new and effective therapies have been introduced with sometimes faster recovery. Increasing teamwork in psychiatric health care may imply that psychiatrists more often are involved as consulting specialists. The possible side effects of being sickness absent with psychiatric diagnoses are more troublesome to handle than in somatic health care [6, 7], and several psychiatrists even experience this to be a work environmental problem [8].

In Sweden, after one week of self-certification, all patients need a medical certificate issued by a physician to be considered for sickness benefits. These certificates have great impact on whether the employer or, after two weeks of sick leave, the Social Insurance Office, decides that the patient fulfils the criteria for benefits or not [9]. Consultations regarding sickness certification involve several different tasks such as; deciding whether the patient has a disease or injury, assessing the patient’s function and work capacity, together with the patient consider advantages and disadvantages of being on sick leave, making a decision about the duration and degree of sick leave, cooperating with others when needed, issuing a certificate, and documenting measures taken [10, 11]. It is also possible that the views on work capacity in mental illness is even less developed than in other health care areas, as are standards for what generally constitute the normal mental and social work demands in different occupations.

Physicians in general consider sick-listing tasks as problematic [12], especially regarding conflicts with patients, assessment of work incapacity, estimation of length and degree of certification, and prolongation of sick-leave initially certified by another physician [10, 13]. One recent study indicated that the odds ratios for finding these tasks problematic were highest in primary health care [10], but that physicians in some other clinical settings, nevertheless, had such consultations more often than GPs and many of them also found these tasks problematic, e.g. in rheumatology, psychiatry, and orthopaedics. Sickness certification is also considered to be an important task for physicians other than general practitioners [13, 14]. The physicians in these studies experienced problems with numerous tasks related to sickness certification and the problems varied considerably between types of clinics. In a study with limited participation of psychiatrists, sick-listing was found to be influenced by the physician's specialty and gender, and physicians were strongly influenced by how patients presented their problems [15]. So far, most studies regarding physicians' sickness-certification practices have targeted primary health care and general practitioners [11, 16]. Psychiatrists have received little attention, resulting in a lack of knowledge about frequency and specific problems in the sickness certification tasks needed to reach optimal professional practice in this field.

The objective of this study was to explore frequencies of problematic issues in the sickness certification tasks and experiences of severity regarding these problematic issues among psychiatrists.

Data from a comprehensive questionnaire (see Additional file 1) about physicians’ sick-listing practices sent to all physicians in Sweden were analysed. The study population receiving this questionnaire comprised all the 36,898 physicians who lived and worked in Sweden in October 2008. The questionnaire was developed based on previous studies, in interaction with clinicians and other researchers, and a pilot study [11, 13, 17]. Information about age, sex, year of medical degree and of registration (after two years of internship), and type of specialist qualifications (after at least five more years of resident training) were obtained mainly from the National Board of Health and Welfare. Three reminders were posted to non-respondents, and the response rate was 60.6%.

The study population consisted of the 1185 physicians who answered the questionnaire and who were specialists in psychiatry (board certified psychiatrists) (20.9% of them also had another speciality). In this study, we restricted the study group to those 723 (61.0%) psychiatrists who were under 65 years of age and were working mainly in psychiatric health care. From among these physicians, we included the 579 physicians (53% women) in the analyses who ‘at least once a week had consultations involving sickness certification’ (Table 1).

Answers to the following types of items were analysed: frequency and severity of problems concerning handling of sickness certifications, access to professional support or expertise, and frequency of issuing certificates for unnecessarily long sick-leave periods. The specific questions (number 6, 8–10, 12–14 and 23 in the questionnaire) and their wording are presented in Table 2 and in Figures 1, 2 and 3.

Response alternatives are presented as numbers and percentages, in terms of either frequency or severity. Some of the items were introduced with the question ‘How often in your clinical work do you …?’ or ‘When handling sickness certification tasks, how often do you …?’ There were six response alternatives from ‘More than 10 times a week’ to ‘Never or almost never’. These were categorized into three groups (Table 2). Other items were introduced with the question ‘How problematic do you generally find it to …?’ with four response alternatives from ‘Very’ to ‘Not at all’ (Figure 1). The third kind of item was introduced with the question ‘How often do you certify unnecessarily long sick-leave periods due to …?’ There were five response alternatives from ‘Every day’ to ‘Never or almost never’ (Figure 3).

The study was approved by the Regional Ethical Review Board of Stockholm.

Regarding the general question as to how often the participants ‘found handling sickness certification consultations problematic’, 11.7% did so at least once a week and 87.3% did so at least a few times per year (Table 2). At least once a week, 4.1% of the psychiatrists had ‘a patient who wanted a sickness certificate for some reason other than work incapacity due to disease or injury’. Furthermore, 3.3% reported ‘having conflicts with patients about sickness certification’ at least once a week, and 85.9% reported having such conflicts at least a few times per year. About 13.0% reported that they at least once a week collaborated with or referred sick-listed patients to a medical social worker and/or psychologist. When handling sickness certification cases, a majority (60.9%) of the psychiatrists reported ‘not having enough time with the patient’, and 76.6% reported ‘not having enough time to manage patient related aspects’ such as contacting other stakeholders, at least once a week.

Regarding the severity of the reported problems, 41.4% responded to the general question about the handling of sickness certification that certification was very or fairly problematic (Figure 1). Issues that rated highest as very or fairly problematic concerned providing a long-term prognosis about the future work capacity (68.5%) and assessment of a patient’s work capacity (57.4%). Also rated high as very or fairly problematic were to assess the optimum duration and degree (part or full time) of sickness absence (49.3%), issuing other types of certificates for the Social Insurance Office (45.9%), and managing the two involved roles; as the patient’s physician and as a medical expert (45.1%).

A majority of the psychiatrists had access in their daily work to members of several different professions (Figure 2). A majority (51.6%) also had extensive or some support regarding sickness certification cases from their immediate manager (Table 3).

At least once a month, more than one third of the psychiatrists certified unnecessarily long sick-leave periods due to waiting times for Social Insurance Office investigations, or for treatments or investigations within the health care and also due to that the patient does not follow recommendations for treatment and rehabilitation (Figure 3).

Psychiatrists’ sickness certification practices were examined in a nationwide survey, which to our knowledge is the first of its kind. A majority (81.0%) had such consultations at least once a week. A large proportion (87.3%) of the psychiatrists experienced sickness certification consultations as problematic at least a few times per year. More than one third certified unnecessarily long sick-leave periods at least once a month due to different types of waiting times.

The experience of severity in these problematic cases varied with response on questions about specific problematic sickness certification issues. The majority found it very or fairly problematic to assess the level of work incapacity and prognosticate the duration of incapacity, had access in their daily work to members of several different professions, and experienced support from immediate management.

Despite considerable differences between countries regarding health care and sickness insurance systems, the problems found in our study are similar to those also reported in other countries [10, 11, 16]. In a British study, Hussey et al. found that the doctor-patient relationship was perceived to be in conflict with the current role of GPs in sickness certification, and that the GPs experienced contradictory demands from other system stakeholders [18]. Wynne-Jones et al. highlighted the main issues in sickness certification faced by GPs in the United Kingdom [16]. Conflicts with patients and other stakeholders, conflicting role responsibilities, and barriers to good practice were recurrent themes. In Norway, Sheel et al. found lack of information, lack of time, and workflow barriers such as poor communication and poor coordination of activities between stakeholders to the three major such barriers [19]. In a qualitative analysis of responses to open-ended questions in a questionnaire completed by physicians in Sweden, similar types of problems were reported, and many respondents lacked support in handling these problems [20].

Hussey et al. also found that there appeared to be a deliberate misuse of the system by the physicians, that is, GPs, possibly due in part to their problems in handling related conflicts [18]. This is in line with our findings that unnecessarily long sick-leave periods were sometimes issued by the psychiatrists in order to avoid conflicts with patients.

None of the international studies we found has focused on psychiatrists. The studies show similar general problems in the sickness certification task as in the Swedish ones. Hence, the similarities might be the same studying a specialist group as psychiatrists. We look forward to more international studies in this research field.

In our study, only a few of the psychiatrists met a patient at least once a week who wanted to be on sick leave for some reason other than work incapacity due to disease or injury. Even fewer, 1.4% at least once a week said no to a patient who asked for a sick note. This might be due to having developed strategies for handling such requests so that the patient refrained from explicitly asking for a sickness certificate. Nevertheless, at least once a month almost one out of ten issued unnecessarily long sick-leaves to avoid conflicts with patients. This is in line with Englund’s findings that physicians more often issued sickness certificates for patients who actually demanded them than for those who did not do so [15]. Another study, however, found that the physician’s decision to offer a sickness certificate was not influenced by the patient’s demand [21]. Both these studies were based on case vignettes and it is likely that different wording in case vignettes, as well as in questionnaires, could affect the results. There are also findings showing that physicians sometimes act in a way that is contradictory to their own beliefs when actually issuing sickness certificates [22]. On the other hand, almost once a month half of them had patients who refused sick leave that was suggested by the physicians. With reference to the studies we have found it seems to be difficult to generalize our results regarding psychiatrists’ problems in sickness certification tasks to other specialist groups.

A third of the psychiatrists stated that they issued sickness certificates at least once a month for unnecessarily long periods due to waiting times for Social Insurance Office investigations, or for treatments or investigations within health care. Engblom et al. found that ongoing long-term sick-listing cases were perceived as problematic by GPs, and that some of the most commonly reported rehabilitation measures were referrals to psychotherapy and/or physiotherapy, and the prescribing of antidepressants [23]. This could reflect that even though patients have access to rehabilitation, the case remains problematic from the physician’s point of view. Again, the situation may also differ between psychiatrists and GPs, not merely regarding type of medical problems but also severity of psychiatric disorders of patients.

The main strengths of the study are the large number of participants, the fact that all of the psychiatrists in an entire country were included, the relatively high response rate compared to other studies of this type, and the many and detailed questions about different aspects of sickness certification. Nevertheless, the dropout is also a limitation; 41% of the physicians who had specialised in psychiatry did not respond. Also, as in any questionnaire study the results can be a matter of discussion regarding how the participants have interpreted the questions. For instance, their understanding of concepts like ‘problem’ or ‘conflict’ might differ, and reported frequencies do not necessarily correspond to what actually is experienced or done in practice. We were careful not to ask questions about opinions and attitudes, as these are even more difficult to interpret and are seldom associated with actual behaviour such as in sickness certification situations [24, 25]. However, we believe that our results are good estimates of the type and severity of problems concerning sickness certification experienced by psychiatrists in psychiatric health care.

Sickness certification needs to be considered as an important task for physicians, with implications for specialist training, continuous education, as well as future inter-professional collaboration in sickness certification. More emphasis on the prerequisites and possibilities for psychiatrists to gain, maintain, and optimally exercise professional competence in insurance medicine, in the context in which they work, is warranted. To gain further knowledge concerning psychiatrists’ sickness certification in clinical practice and concerning how the problems are perceived and handled, observational studies are an option.

Problems related to sickness certification were frequent and were considered severe among psychiatrists, both in general and regarding specific tasks. The majority found it problematic to assess the level and duration of work incapacity, had access to members of several different professions, and experienced support from immediate management. More than one third frequently certified unnecessarily long sick-leave periods due to different types of waiting times.

The findings have implications for different kinds of organisational and managerial support and training in sickness certification issues, like guidance to assess the level and duration of work incapacity, more of co-operation inter-professional and with stakeholders regarding sickness certification tasks.