Physicians sickness certification practices : frequency, problems, and learning

Background: Administration of sickness absence involves many stakeholders, among them physicians, who play a key role in the sickness insurance systems in most western countries. Despite the impact that sickness absence can have on the life situation of the affected individual, physicians have limited training in how to handle sickness certification cases, and very little research has examined the practices of those medical professionals in this context.

Aims: The overall aim of the present research was to gain more detailed knowledge about sickness certification performed by physicians, as a basis for interventions. Study I was conducted to determine the frequency of having consultations concerning sickness certification, and nature of problems experienced in relation to this task by physicians in different clinical settings. Study II explored the problems and characteristics of the daily work with sickness certification, as perceived by board certified specialists working in primary health care or orthopaedics. Study III examined the knowledge and skills that physicians stated they needed in this area.Study IV aimed to ascertain what types of learning situations helped physicians improve their competence in this certification task.

Methods: Two comprehensive questionnaires about sickness certification practices were administered to physicians in 2004 and 2008, respectively. In 2004, 7665 physicians from Stockholm and Östergötland Counties were included; in 2008, all 36898 physicians living and working in Sweden were included. The response rates were 71% and 61%, respectively. Answers from all physicians aged ≤ 64 years who had sickness certification tasks (n = 4019 and n = 14210, respectively) were evaluated using descriptive statistics, correlation analyses, logistic regressions, linear regressions, and analyses of variance.

Results: In 2004, 74% (n = 4019) of the respondents had consultations including sickness certification at least a few times a year, and about half of those had such consultations at least six times a week. The following items were rated as very or fairly problematic by the largest proportion of physicians: handling conflicts with patients about certification, assessing work capacity, estimating optimal length and degree of absence, and managing prolongation of sick leave initially certified by another physician (study I). Many physicians answered that they needed more knowledge and skills in handling sickness certification, for instance regarding assessment of work capacity (44%), the optimal length and degree of absence (50%), and information about aspects of the social insurance system (43 63%). Fewer (20%) reported needing to know more about how to fill out sickness certificates (study III). In 2008, relatively small proportions of the physicians stated that formal learning situations had to a large or fairly large extent contributed to their competence in sickness certification, for example 17% indicated this for undergraduate studies, 37% for internship, and 46% for resident training. However, 65% felt that contacts with colleagues and other health care staff had been beneficial, whereas only one-third (33%) had been helped by training arranged by Social Insurance Office. Between 2004 and 2008, a small but significant increase was noted for all items related to formal learning situations and continuing professional development, while there were no changes regarding informal learning situations such as contacts with colleagues and patients (study IV). In general, the results varied considerably between physicians in different clinical settings. In orthopaedics, 83% handled sickness certification cases ≥ 6 times a week, as compared to 62% in primary health care. However, the rate of problems concerning sickness certification was highest for those in primary care and lowest among those in internal medicine and surgery (study I). Those working in primary health care and psychiatry also had larger needs for knowledge and skills compared to other groups. These differences were still observed after adjusting for sex, years in practice, workplace policy, and support from management (study III). Compared to physicians in orthopaedics, a greater proportion of general practitioners experienced having support from management in the certification task, and more of them indicated that there was a common strategy for handling this duty at their workplaces (study II).

Conclusions: Handling sickness certification was observed to be a very common task among physicians working in many different clinical settings, not only primary health care, which has been the focus of previous studies and interventions. Therefore, this should be recognized as a very common task for most physicians, at least in Sweden. Many aspects of sickness certification were experienced as problematic, but the nature and frequency of the difficulties varied greatly between physicians in different clinics/practices. A majority of the physicians answered that they needed more skills and knowledge in managing this task, and previous learning had occurred primarily in clinical practice, not through formal education. The high rate of problems and the lack of both knowledge and formal education about how to manage sickness certification may have consequences for the physicians work situation, for patients, and for society. Efforts are warranted to educate physicians in sickness certification on both the undergraduate and the postgraduate level, and to provide workplace strategies for improving the prerequisites for handling this task.

Further research should consider sickness certification by physicians in fields other than general practice, such as oncology, surgery, and internal medicine. Studies about how the sickness certification task is learned and what the knowledge acquired actually includes are warranted. For example research about how physicians develop rules of thumb or mindlines in this field, and what they entail.

List of scientific papers

I. Löfgren A, Hagberg J, Arrelöv B, Ponzer S, Alexanderson K (2007). "Frequency and nature of problems associated with sickness certification tasks: a cross-sectional questionnaire study of 5455 physicians." Scand J Prim Health Care 25(3): 178-85
https://pubmed.ncbi.nlm.nih.gov/17846937

II. Arrelöv B, Alexanderson K, Hagberg J, Löfgren A, Nilsson G, Ponzer S (2007). "Dealing with sickness certification - a survey of problems and strategies among general practitioners and orthopaedic surgeons." BMC Public Health 7: 273
https://pubmed.ncbi.nlm.nih.gov/17910746

III. Löfgren A, Hagberg J, Alexanderson K (2010). "What physicians want to learn about sickness certification: analyses of questionnaire data from 4019 physicians." BMC Public Health 10: 61
https://pubmed.ncbi.nlm.nih.gov/20144230

IV. Löfgren A, Silén C, Alexanderson K (2010). "How physicians have learned to handle sickness certification cases." (Submitted)