Frequency and nature of problems associated with sickness certification tasks: A cross-sectional questionnaire study of 5455 physicians

Abstract

Objective. To study the frequency and nature of problems associated with physicians’ sickness certification practices. Design. Cross-sectional questionnaire study. Setting. Stockholm and Östergötland Counties in Sweden. Subjects. Physicians aged ≤64 years, n =7665, response rate 71% (n =5455). Main outcome measures. The frequency of consultations involving sickness certification, the frequency and nature of problems related to sickness certification. Results. A total of 74% (n =4019) of the respondents had consultations including sickness certification at least a few times a year. About half of these physicians had sickness certification cases at least six times a week, and 1 out of 10 (9.4%) had this more than 20 times a week. The items that the highest percentage of physicians rated as very or fairly problematic included: handling conflicts with patients over certification, assessing work ability, estimating optimal length and degree of absence, and managing prolongation of sick leave initially certified by another physician. There were large differences in frequency and nature of problems between different types of clinics/practices. General practitioners had the highest frequency of problems concerning sickness certification while the lowest was found among specialists in internal medicine and surgery. Conclusion. Sickness certification should be recognized as an important task also for physicians other than general practitioners. The physicians experienced problems with numerous tasks related to sickness certification and these varied considerably between types of clinics. The high rate of problems experienced may have consequences for the physicians’ work situation, for patients, and for society.

• Family practice
• healthcare
• insurance medicine
• physicians
• sickness certification
• sick leave

One important part of social insurance systems is the sickness benefit insurance providing benefits to persons who cannot work due to disease. In Sweden as well as in most other Western countries many physicians are required to provide medical documentation on the sickness benefit claimant to the employer and to the social insurance office. This involves different specific work tasks (see Box 1) [1]. Studies have shown that sickness certificates have a substantial impact on social insurance officers’ judgements regarding the right to sickness insurance benefits [2–4] and can be seen as “the core administrative mechanism for a variety of redistributive policies” [[5], p. 4]. Thus, physicians’ sickness certification has a major impact on the life situation of many patients.

Box 1: Physicians’ duties related to sick-listing [1]

To determine whether a patient has a disease or injury according to the existing criteria.

To ascertain whether the disease or injury lowers the patient's functional ability to such an extent that the work ability is impaired.

To consider, together with the patient, the advantages and disadvantages of sick leave.

To decide the degree (full or part time) and duration of sick leave, and also what medical investigations, treatments, or other interventions (such as occupational rehabilitation, work training, workplace visit) will be needed during the sick leave.

To determine whether there is a need for contact with or referrals to other specialists, the social insurance office, occupational health services, the employer, or other parties, and if so, to establish adequate communication with those stakeholders.

To issue a certificate that provides sufficient information for the social insurance officer to decide whether the patient is entitled to sickness benefits and in need of other return-to-work measures.

Despite the importance of physicians’ sickness certification practices, there is very little scientific knowledge in this area. A recent systematic review of all studies of physicians’ sickness certification practices [1] found that study populations were small, ranging from 14 to 607 participants. The main methods of data collection were interviews and questionnaires, often including case vignettes [1]. Many studies were exploratory, qualitative studies. Also, most studies were limited to general practitioners (GPs), and none of them included all relevant clinical specialities. Notwithstanding, the investigations provided limited evidence of two factors: that physicians perceive sickness certification tasks as problematic, and that sickness certificates are often of poor quality [1]. These findings are at a very general level, and more detailed knowledge is needed as a basis for interventions. In Sweden, as in many other countries, measures for improving sickness certification practice have focused primarily on training of GPs.

According to a recent systematic literature review physicians find it problematic to handle sickness certification, and the sickness certificates issued are often of poor quality. However, the frequency and nature of the perceived problems are unknown.

• Sickness certification was surprisingly common in many different clinics/practices. The frequency of reported problems was highest among general practitioners and lowest among physicians working in internal medicine and surgery.

• Physicians primarily reported problems in handling conflicts with patients over sickness certification, assessing levels of work incapacity, estimating optimal length and degree of certification, and managing prolongation of sick leave initially certified by another physician.

Furthermore, although scientifically inconclusive, the results of some smaller studies have indicated other problematic areas in the sickness certification process: to evaluate work ability, to assess length and degree of sickness absence, and to deal with conflicts with patients [1], [6]. These problems seem to be consistent over time and between different countries; however, larger studies are needed to verify the observations.

The objective was to study physicians’ sickness certification practices with regard to the frequency of consultations involving consideration of sickness certification and frequency and nature of problems experienced related to this task, in general and in different clinics/practices.

Material and methods

Study design

A cross-sectional questionnaire study was conducted.

Study population

The study population comprised 7665 physicians in two counties in southern Sweden, Stockholm (1.9 million inhabitants) and Östergötland (0.4 million), representing 24% of all employed physicians in Sweden [7]. Stockholm County includes the capital city and other urban and rural areas; Östergötland County has two middle-sized cities and large rural areas.

In Stockholm County, the participants included all members of the Swedish Medical Association (SMA) below the age of 65 and registered as working or living in Stockholm in 2004. About 95% of all physicians in Sweden are members of the SMA. The SMA register could not provide information on the physicians’ speciality or worksite; therefore, all physicians were included. The physicians’ home addresses were obtained.

In Östergötland County, the local branch of the SMA did not permit access to the member register. Therefore, information was acquired from the database of the company Pharma Marketing AB, which includes all licensed physicians in Sweden. Of all physicians in Östergötland, the following were excluded: those working in clinics/practices where sickness certification is rare (for example, paediatrics and geriatrics), those over the age of 64, and those working or living abroad or not working as physicians. Addresses that the physicians previously had given to Pharma Marketing were acquired; their home addresses (two-thirds) or work addresses (one-third).

The questionnaire

A comprehensive questionnaire was developed to gather information from physicians concerning their sickness certification practices and need for continued training in this area. The questionnaire was based on results of previous studies [1], [6] and discussions with two reference groups comprising healthcare staff and social insurance office staff. Some 20 researchers and teachers in sickness insurance were asked to comment on preliminary versions of the questionnaire. In June 2004, the questionnaire was tested in a pilot study including 102 randomly sampled physicians in Uppsala County. After a few minor changes to the wording and addition of nine items, 83 close-ended questions were included.

The questionnaire was distributed by mail in October 2004. The physicians’ home addresses were used when available (96%) to avoid interaction with colleagues during completion of the questionnaire. The handling of questionnaires was done by Statistics Sweden to guarantee anonymity of the participants. Two reminders were posted to non-respondents.

The response rate was 71% (see Table I). The mean partial non-response was 2.8% (range 0.6–5.3%). The selection of physicians in Östergötland was more specific with regard to speciality, which is why the proportion of participants who reported having consultations involving sickness certification tasks was higher in Östergötland (91%) than in Stockholm (71%). In the following analysis only the 4019 physicians (74%) who had such consultations at least a few times a year were included. Here questions regarding frequency of having consultations including sickness certification (never, a few times each year, monthly, weekly,>6 times/week,>20 times/week) and problems associated with sickness certification (Box 2) were analysed. Responders were also asked to indicate what type of practice/clinic (out of 11 alternatives) they mainly worked at (see Table IV).

Box 2: Tables III and V are based on the following items, presented in the order of appearance in the questionnaire.

How problematic do you find it… (very problematic/ fairly problematic/ not very problematic/ not problematic):

1. to assess whether a patient's functional capacity is reduced?

2. to assess the degree to which reduced functional capacity limits a patient's work ability?

3. to discuss with patients the advantages and disadvantages of being on sick leave?

4. to fill out sickness certificates to be used by social insurance offices?

5. to suggest a plan of action and/or measures to be taken during sick leave?

6. to manage the two different roles as a patient's physician and medical expert for the social insurance offices and other authorities?

7. to decide whether to authorize prolongation of a sick-leave period that was previously certified by another physician?

8. to ascertain the optimum duration and degree of sickness certification?

9. to handle situations in which you and a patient have different opinions concerning the need for sick leave?

Table I.  Response rate and characteristics of the physicians in the study population.

	Study population	Respondents		Respondents having consultations concerning sickness certification at least a few times a year
	n	n	% of study population	n	% of the respondents
All	7665	5455	71	4019	74
County
Stockholm	6794	4827	71	3446	71
Östergötland	871	628	72	573	91
Sex
Women	3646	2710	74	2007	74
Men	4019	2745	68	2012	73
Educational level
Specialist^1		1381		1046	76
Non-specialist		3995		2947	74
No information		79		26	33
Main workplace
Primary health care		978		954	98
Internal medicine		396		363	92
Psychiatry		394		360	91
Surgery		318		294	93
Gynaecology / Obstetrics		315		282	90
Orthopaedics		200		189	95
Occupational health		124		123	99
Oncology		108		105	97
Rehabilitation care^2		75		58	77
Addiction medicine		47		39	83
Other^3		2368		1230	52
No information		132		22	20
Mean age (years)	48.2	48.3		47.7

¹Information on educational level was not available for the study population.

²Including physicians in social insurance office and insurance company.

³All other types of workplaces.

Statistical analysis

Descriptive statistics including estimated proportions with 95% confidence intervals (CI) were calculated for the group as a whole and for the clinics/practices. Kendall's tau-b was used as a measure of association; this correlation coefficient is appropriate when variables lie on an ordinal scale [8]. The term GP is here used to define all physicians who work in primary healthcare centres.

Results

Altogether, 74% (n = 4019) of the physicians had consultations involving consideration of sickness certification at least a few times a year (Table I). Among those, 24% worked in primary healthcare centres, 9% worked in internal medicine, and 9% worked in psychiatry (see Table IV). About half of the physicians had sickness certification cases at least six times a week, and 1 out of 10 (9.4%) had this > 20 times a week (see Table II).

Table II.  Frequencies of consultations where sickness certification is considered and frequency of problems.

		More than 20 times a week		6–20 times a week		1–5 times a week		About once a month		A few times a year		Never or almost never		All
How often in their daily work did the physicians:	n	%	95% CI	%	95% CI	%	95% CI	%	95% CI	%	95% CI	%	95% CI	%
Have consultations including consideration of sickness certification	4019	9.4	8.5–10.3	41.0	39.5–42.5	34.3	32.8–35.8	9.4	8.5–10.3	5.8	5.1–6.6	–	–	100
Find it problematic to handle sickness certification	3925	0.6	0.3–0.8	5.9	5.2–6.6	26.7	25.3–28.1	30.0	28.6–31.5	21.2	19.9–22.5	15.6	14.5–16.7	100

¹ Physicians who never had these consultations were not included in the analyses.

Almost one-third found sickness certification problematic once a week or more (Table II). There was a moderately strong correlation between the frequencies of consultations considering sickness certification and frequencies of having problems with certification (Kendall's tau-b=0.425, p = 0.0001; n = 3925).

Four items were rated as fairly or very problematic by more than half of the physicians, namely: handling disagreements with patients regarding the need for sickness certification, deciding whether to authorize prolongation of a sick-leave period that was previously certified by another physician, assessing a patients’ work ability, and ascertaining the optimum duration and degree of sick-leave (Table III).

Table III.  Problems in physicians’ sickness certification.

Type of problem^1	n	Very problematic % (95% CI)	Fairly problematic % (95% CI)	Not very problematic % (95% CI)	Not problematic % (95% CI)	All %
i) Handling disagreements with patients	3892	18.2 (17.0–19.4)	42.8 (41.3–44.4)	30.6 (29.2–32.0)	8.4 (7.6–9.3)	100
g) Prolongation of other physician's certificate	3871	15.0 (13.9–16.2)	39.7 (38.1–41.2)	33.8 (32.3–35.3)	11.5 (10.5–12.5)	100
b) Assessing work ability	3908	11.5 (10.5–12.5)	42.1 (40.6–43.7)	35.8 (34.3–37.3)	10.6 (9.6–11.5)	100
h) Assessing duration and degree of absence	3895	10.8 (9.8–11.8)	42.8 (41.2–44.3)	36.8 (35.3–38.3)	9.7 (8.8–10.6)	100
f) Managing two different roles	3879	9.8 (8.9–10.8)	29.2 (27.8–30.6)	41.6 (40.0–43.1)	19.4 (18.2–20.7)	100
e) Suggesting plan of action	3856	7.1 (6.3–7.9)	30.5 (29.1–32.0)	43.6 (42.1–45.2)	18.7 (17.5–19.9)	100
a) Assessing functional capacity	3921	5.7 (4.9–6.4)	30.8 (29.4–32.3)	47.6 (46.1–49.2)	15.9 (14.8–17.1)	100
d) Filling out sickness certificates	3897	5.5 (4.8–6.2)	27.6 (26.2–29.0)	45.7 (44.1–47.2)	21.2 (19.9–22.5)	100
c) Discussing sickness certification with patients	3911	3.0 (2.5–3.5)	26.7 (25.3–28.1)	51.7 (50.1–53.3)	18.6 (17.4–19.8)	100

¹See box 2 for exact phrasing of each item.

The frequency and nature of problems varied substantially between the different clinics. GPs reported significantly higher frequency of problems (Table IV) compared with any of the other groups (95% CI not shown). Also, a significantly higher proportion of GPs (p < 0.0001) found it problematic to assess functional ability, work ability, and handling disagreements (Table V).

Table IV.  Characteristics of the study population by demographic and work related factors.

			Mean age	Mean years of practice	Specialists	Women	Sickness certification ≥6 times/week^4	Problem with sickness certification ≥1 times/week
Main workplace	n	%	years	years	%	%	%	%
All	4019 ^1	100	47.7	17.6	73.8	49.9	50.4	33.2
Orthopaedics	189	4.7	48.1	19.2	79.3	20.1	82.5	53.0
Rehabilitation care^2	58	1.4	51.3	20.3	86.2	50.0	79.3	36.8
Occupational health services	123	3.1	54.9	24.1	93.4	48.8	78.0	41.8
Oncology	105	2.6	44.7	15.0	64.4	63.8	73.3	21.9
Psychiatry	360	9.0	49.0	17.3	76.8	58.1	64.4	40.6
Primary health care	954	23.7	48.1	16.6	70.8	54.8	62.2	60.1
Addiction medicine	39	1.0	52.1	18.4	82.1	51.3	53.8	44.7
Surgery	294	7.3	46.3	17.6	72.1	26.5	52.7	15.5
Gynaecology /Obstetrics	282	7.0	48.1	19.0	77.7	70.6	37.6	24.8
Internal medicine	363	9.0	43.0	13.9	56.7	45.2	33.1	17.2
Other^3	1230	30.6	47.9	18.6	77.1	49.4	34.0	17.1

¹Out of these, 22 did not indicate their main workplace.

²This group also include physicians in social insurance offices/insurance companies (n = 6).

³All other workplaces.

⁴Physicians who have consultations including consideration of sickness certification ≥6 times/week.

Table V.  Proportions of physicians at different clinics that rated four specific tasks of sickness certification as fairly or very problematic.

	Problems related to
		Assessing functional ability	Assessing work ability	Handling disagreements with patients	Filling out sickness certificates
Main workplace	n	% (95% CI)	% (95% CI)	% (95% CI)	% (95% CI)
Primary health care	953	64.5 (61.5–67.5)	81.8 (79.3–84.3)	82.8 (80.4–85.2)	43.4 (40.2–46.6)
Psychiatry	353	40.8 (35.7–45.9)	54.3 (49.1–59.5)	59.0 (53.9–64.1)	28.2 (23.5–32.9)
Internal medicine	360	34.7 (29.8–39.6)	52.9 (47.7–58.1)	64.5 (59.5–69.5)	31.3 (26.5–36.1)
Addiction medicine	39	30.8 (16.3–45.3)	38.5 (23.2–53.8)	46.2 (30.6–61.8)	21.1 (8.1–34.1)
Gynaecology/Obstetrics	281	28.8 (23.5–34.1)	48.9 (43.0–54.8)	63.0 (57.4–68.6)	27.6 (22.4–32.8)
Oncology	105	24.8 (16.5–33.1)	45.7 (36.2–55.2)	54.8 (45.2–64.4)	27.6 (19.0–36.2)
Rehabilitation care^2	58	24.1 (13.1–35.1)	36.2 (23.8–48.6)	61.4 (48.8–74.0)	24.6 (13.4–35.8)
Orthopaedics	189	22.2 (16.3–28.1)	52.7 (45.6–59.8)	58.5 (51.5–65.5)	45.7 (38.6–52.8)
Occupational health services	122	22.1 (14.7–29.5)	32.5 (24.1–40.9)	39.7 (31.0–48.4)	17.4 (10.6–24.2)
Surgery	290	20.0 (15.4–24.6)	36.8 (31.3–42.3)	46.6 (40.9–52.3)	30.6 (25.3–35.9)
Other^1	1154	24.3 (21.8–26.8)	40.4 (37.6–43.2)	49.1 (46.2–52.0)	30.0 (27.3–32.7)

¹All other types of workplaces. ²Including physicians in social insurance office and insurance company.

Discussion

The majority of the physicians (85%) issued sickness certificates once a week or more, and about one-third found this task problematic at least once a week. The most problematic issues in sickness certification included handling situations in which the physician and patient have a different opinion concerning the need for sick leave. The frequency of problems was highest for GPs and orthopaedics and lowest for physicians in internal medicine and surgery.

Methodological considerations

This is by far the largest study of the sickness certification practices of physicians and the response rate was high compared with other similar studies. Results from smaller previous studies have been tested here in a large population with an instrument that displays high face validity. No other study has focused on frequency of problems and certification, or included all relevant types of clinics/practices. In fact, we can conclude that even more clinics should be included in this type of study. Our participants could indicate 1 out of 11 specified clinics (chosen by the authors because of their presumed high rate of sick listing). However, the results showed that even in the group “other”, many physicians had high rates of sickness certification cases. A limitation, as in all questionnaire studies, is that all data are self-reported and thus can be affected by recall bias – which could vary between, for example, different clinics.

Although the respondents were recruited in only two counties, the results can probably be generalized to the whole country, since the study population represents 24% of the employed physicians in Sweden. Previous studies have shown that the nature of sickness certification problems seems to be consistent between countries and between different time periods [1].

Sickness certification tasks are very common

To have consultations including sickness certification was very common in the daily work of the physicians (see Table II). This has been found in previous research too, even though different measures have been used. For example, Harding et al. [9] found that GPs in England gave their patients advice on welfare rights in 15% of their consultations. In three other studies [10–12] sickness certification was considered in 9–21% of the primary healthcare consultations. In another investigation [13] 40% of GP patients in Germany were sickness certified, and in a Swedish study 23% of GP patients received a sickness certificate [14]. In his study on GPs, Garraway [15] concluded that the physicians spent four hours per week on the administration of sickness certification.

Physicians find sickness certification problematic

This is to our knowledge the first study of the frequency of problems related to sickness certification experienced by physicians; previous studies on this specific subject have been qualitative. Our results indicate that physicians with many sick-listing cases experienced problems more often (see Table IV). This correlation appeared on both the individual and the group level, and was confirmed by the moderately strong measure of association.

Many respondents found it problematic to assess work ability as well as length and degree of sickness certification (see Table III). This has also been found in earlier studies [6], [16]. Few physicians reported having problems with filling out the certificates, which is interesting considering earlier studies showing that sickness certificates are often of poor quality [17], [18].

Nature and frequency of problems vary between different groups

Previous research has shown that GPs are responsible for a large proportion of sickness certification, measured as a percentage of all certificates issued [18], [19]. The frequency of sickness certification, from the perspective of the physician, was in our study found to be higher in other groups (see Table IV).

GPs reported significantly more problems than all other groups while physicians in occupational health services reported fewer problems despite a very high frequency of such consultations (see Table IV). The differences between clinics in amount of problems may be explained by factors not addressed in this study, such as differences in patient groups, support from colleagues, presence of guidelines, time for cooperation with other stakeholders etc. [20–22].

Implications for further research

Our results raise questions concerning the extensive problems experienced by GPs in handling sickness certification, and further studies are needed to understand and improve this situation. Moreover, additional research should be performed on the questionnaire in order to validate this tool.

Conclusions

Sickness certification should be recognized as an important task for many physicians, not just for GPs. The physicians in this study experienced problems with numerous tasks related to sickness certification, although the pattern varied considerably between clinics/practices. The high level of problems may have consequences for the physicians’ work situation, for patients, and for society.

Acknowledgements

Financial support was provided by grants from Stockholm and Östergötland County Councils, the National Social Insurance Board, the Social Insurance Offices in Östergötland and Stockholm, the Swedish Ministry of Health and Social Affairs, and the Swedish Council for Working Life and Social Research.

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