I'll need a sick leave certificate too, doc...

What prevents doctors from applying best clinical practice when issuing certificates for sick leave?

Take Home Messages:

Although Swedish general practitioners sought to issue fewer sick leave certificates, a range of barriers both within and outside the healthcare system prevented them from following their preferred clinical practice.

Barriers associated with the healthcare system included the doctor’s own competence in making complex clinical judgments and dealing with patient demands, the performance of other healthcare professionals and deficiencies within the healthcare system itself.

Barriers outside the healthcare system included general attitudes to sick leave absences and benefits, the labour market, patients’ social circumstances; and the performance of and collaboration between rehabilitation service providers.

A better understanding of these barriers provides the basis for interventions to implement change. A key starting point may be to equip general practitioners with the skills and competencies required to deal with the complex and demanding clinical situations that they encounter when assessing the need for sick leave certification. Improving the community’s understanding of the negative health consequences of sickness absence may influence the situation.

Why the research matters:

Issuing sick leave certificates is a common task for doctors in general practice and is a key factor in the level of sick leave absences from work. Increases in sick leave absenteeism has resulted in scrutiny of doctor practices in issuing sick leave certificates.

What the research involved:

The Swedish government has implemented several programs aimed at developing standard practices for sick leave certification. These initiatives include educating doctors through short courses and issuing guidelines for the duration of sick leave for different diagnoses.

To further the understanding of sick leave certification by doctors, researchers from Uppsala University and the Karolinski Institute interviewed 19 Swedish general practitioners to identify factors that prevented them from issuing sick leave certificates according to preferred clinical practice. The general practitioners were recruited from 17 primary healthcare centres and were interviewed regarding:

Their experiences of issuing sick leave certificates;
Their experience of issuing sick leave certificates in specific situations;
Their preferred practice when issuing certificates; and
The barriers that prevent them from issuing certificates according to their preferred practice.

Summary of research findings:

The researchers found that all of the general practitioners interviewed wanted to issue fewer sick leave certificates but experienced barriers to doing so. The factors that prevented them from following their preferred clinical practice when issuing sick leave certificates were either related to the healthcare system or were outside the healthcare system. The barriers associated with each of these categories are summarised in the following table.

Barriers to optimal practice by Swedish general practitioners when issuing sick leave certificates

Factors within the healthcare system

Doctor skills and competencies, including:

Difficulties in assessing the patient’s signs and symptoms (especially when they do not correlate), work capacity and optimal duration of sick leave;
Difficulties in estimating the risks that sick-leave might pose for the patient; and
Difficulties in resisting patient demands

Other healthcare professionals:

Issuing sick leave certificates, with patient expectations the situation will continue; and
Discouraging patients from returning to work

Healthcare system deficiencies, including:

Constraints on doctor’s time;
Long waiting times to access healthcare providers or rehabilitation programs;
Lack of continuity of care due to high turnover rates among doctors; and
Suboptimal computer support

Factors outside the healthcare system

Societal attitudes to sick leave absenteeism, including:

Perception of sick leave as an acceptable solution to non-medical problems; and
Perception of entitlement to benefits in difficult situations

Labour market issues, including:

Few jobs available for unskilled, older or less able workers; and
Increasing work demands

Patient circumstances

Social problems; and
Family situation

Social insurance regulations, including:

Difficulties in completing sick leave certification forms; and
Poor access to rehabilitation programs among patients without permanent employment

Issues with other stakeholders, including:

Poor collaboration between rehabilitation providers, including employers, insurers, unemployment agencies and social welfare agencies;
Difficulties in accessing and lack of responsiveness of social insurance agencies;
Difficulties in accessing employers, their lack of understanding and refusal to redesign jobs;
Poorly functioning occupational health services; and
Pressure from unemployment and social welfare agencies to issue sick leave certificates to solve administrative problems

Original research:

Barriers to good sickness certification – an interview study with Swedish general practitioners.
Swartling MS, Alexanderson KAE, Wahlström RA.
Scand J Public Health 2008; 36: 408-414.

Link to PubMed abstract