ABSTRACT
Background: Prescription of sick leave periods is a common but complex task in general practice in many countries. Objectives: The objective was to identify issues around sickness certification and solutions aimed at improving this process. Methods: Through Medline, Cochrane, and Web of Science bibliographic databases, 56 relevant original articles in English or French were retrieved, focusing on the certification process in general practice. Data was synthesized using a thematic analysis. Results: The various issues identified were difficulties in assessing the need for sick leave and its length, difficulties in the doctor–patient relationship, and difficulties related to healthcare system organization and to the socioeconomic environment. Some possible solutions to these difficulties have been assessed either for validity or effectiveness. In particular, patient functional assessment or cooperation with occupational practitioners could help in adjusting the sick periods. Guidelines or legislative reforms on sickness certification could only potentially improve the filling in of certificates.
Conclusion: Sickness certification represents a procedural as well as a relational, organizational and political challenge. Well-validated tools or procedures to support doctors in this task are lacking. The development of functional assessment and cooperation with occupational practitioners requires appropriate training and education for present and future GPs. Further research is needed to refine these strategies, which should be tailored to each country.
KEY MESSAGE:
Problematic issues in GPs’ sick listing practice are assessment of the need for sick leave, the doctor-patient relationship, healthcare system organization and the socioeconomic environment.
Sick-listing practice might be improved by functional assessment of patients and better cooperation between caregivers.
These strategies should be tailored to each country and scientifically evaluated.
INTRODUCTION
Sickness certification places a major burden on workers, healthcare system, employers and society as a whole. In 2000, in the European Union, 14.5% of employees reported that they had had a sick leave at least one day over the previous 12 months, varying from 6.7% in Greece to 24.0% in Finland (Citation1). There are also variations over time within a given country, as for instance in Sweden, where absence due to sickness varied from 5.5% of the workforce aged 20–64 in 1990 to 2.5% in 1996 (Citation2). These variations can be influenced by different compensation schemes (especially for the first days of illness) across organizations or across countries (Citation3), and by trends in the labour market (sick leave rates usually decrease when unemployment increases) (Citation2). Although not reported in a standardized way, prescription of sick periods is a frequent task in general practice, the certification rate varying from 0.18 to 2.1 per person per year in Norway and the UK (Citation4). In Sweden, 9% of all consultations include a consideration of sick listing, and a certificate is actually issued in 94% of instances (Citation5). In this country, 40% of initial certificates are issued by general practitioners (GPs), the same percentage that is issued by hospital physicians (Citation6).
However, most GPs report difficulties with the sickness certification process, perceived as complex and time- consuming (Citation7). In fact, sick leave may be regarded in a similar way as any drug, i.e. as having effects and side effects; it should be used with the proper dose and duration, and thus should be dealt with in the same way as any other medical prescription (Citation8). For instance, prescribing too little time off work can result in relapse and prolonged sick leave can be a risk factor for prolonged depression (Citation9). Consequently, many GPs hope for changes aimed at reducing their stress and improving fairness for patients, and some of them would like to be relieved of their certification role. Certain GPs would even consider leaving general practice for another medical specialty, to avoid this task (Citation10). Such large dissatisfaction may ultimately lead to GPs’ disinvestment or misuse of the system.
The aim of this study was, therefore, to conduct a systematic review of both the problematic issues faced by GPs when issuing sickness certificates and their possible solutions. To identify specific tools or procedures that might support doctors in this task was a target.
METHODS
Search strategy
Research articles were sought in the Medline, Cochrane, and Web of Science bibliographic databases. For each database, the query covered all the years from its inception, i.e. 1966 for PubMed, 1972 for Cochrane, and 1975 for Web of Science, until December 2011. For instance, the search equation used via the PubMed interface was as follows:
(“sickness certification” [Title/Abstract] OR “sick certification” [Title/Abstract])
AND
(“family practice”[MeSH Terms] OR “primary health care”[MeSH Terms] OR “physicians, family”[MeSH Terms] OR “general practice”[Title/Abstract] OR “general practitioner*”[Title/Abstract])
NOT (“editorial”[PT] OR “letter”[PT]),
where [PT] denotes the type of publication. A total of 146 articles were retrieved from the three databases.
Only articles in English or French language were included. Eleven additional articles were identified from secondary references or expert advice.
Selection of articles
After excluding duplicates, each abstract, if available—and otherwise the full article—was reviewed to ascertain its relevance. The selection process, consistent with the PRISMA guidelines (Citation11), is presented in , which includes exclusion criteria used. Review was restricted to research articles focusing on the sickness certification process in general practice. Two authors performed selection of articles separately, and consensus was sought in the event of disagreement. Finally, 56 relevant articles were included in this systematic review.
Figure 1. Flow chart describing the selection of articles to be reviewed.
Data analysis
Data was synthesized using a thematic analysis, which was mainly interpretative for the problematic issues relating to sickness certification and mainly integrative for the possible solutions (Citation12). One author first scrutinized the included articles and classified them according to their prominent or recurrent issues. The other author independently reviewed each article, and in the event of disagreement, the issue was discussed until a consensus was reached. The issues identified were secondarily subsumed based on thematic headings (themes) agreed upon by the authors. The possible solutions to the problematic issues were identified in the articles and classified into four groups of solutions: proposed, implemented, assessed for validity and assessed for effectiveness. For each article included, we systematically extracted the following data: first author, country, year of publication, study design, inclusion criteria, number included, intervention (if any), and results. We evaluated the methodological quality of studies assessing solutions for validity or effectiveness, based on internal validity criteria derived from the US Preventive Services Task Force (Citation13). Specific criteria were used for intervention trials (randomization, blinding, loss to follow-up, intention- to-treat analysis), cohort studies (selection bias, loss to follow-up, confounding factors) and cross-sectional studies (selection bias, confounding factors). In the end, study quality was classified as of good, fair or poor.
RESULTS
Most of the studies (Citation30) originated from the Scandinavian countries, especially Sweden and Norway, 13 from the UK and four from the Netherlands. Twenty-one were based on qualitative research (focus groups, interviews or qualitative textual analyses); 19 had a cross-sectional design; five involved cohort studies; three randomized controlled trials; three before-after studies; one, a controlled intervention trial; and four were reviews.
Various issues identified from the reviewed articles were classified according to 4 main themes, i.e. difficulties (i) in assessing the need for sick leave; (ii) in the doctor-patient relationship; (iii) related to healthcare system organization; and (iv) related to the socioeconomic environment. Themes and issues are presented in , along with possible solutions, which have been proposed by authors; implemented by GPs; or assessed for validity or effectiveness.
Table I. Problematic themes and issues encountered by GPs in issuing sickness certificates, along with possible solutions.
Difficulties in assessing the need for sick leave
Patient assessment, i.e. grading patients’ work disability and its length and degree from a functional perspective, was the most common theme reported (in 32 articles). Patients’ complaints lacking objective clinical evidence, but associated with problems such as pain, fatigue or burnout, were mentioned as being the most difficult to assess.
Training GPs in structured functional assessment based on an ICF-derived checklist, has been shown to improve GPs’ knowledge of patient's workplace and stressors, and increase the rate of partial sick leaves in Norway (Citation22,Citation23). Two pain questionnaires—the SF-36 bodily pain score (Citation14) and the acute low back pain screening questionnaire (ALBPSQ) (Citation15)—showed predictive validity in identifying patients likely to be put on long-term sick-leave. Several authors considered entrusting sickness certification to insurance or occupational physicians (OPs) or to multidisciplinary teams, including psychologists, physiotherapists and physicians. One suggested sickness certification could be entrusted to physiotherapists for musculoskeletal patients, but this has never been assessed for effectiveness (Citation24). This delegation process has only been assessed for work injuries and occupational diseases in Croatia, where entrusting sickness certification management to OPs decreased the frequency and length of sick periods (Citation47).
Difficulties in the doctor–patient relationship
The theme doctor-patient relationship was considered in 21 articles. GPs frequently feel that they fulfil a ‘dual role,’ being both the patient's advocate and a medical expert for the insurance system. They often have conflicts with patients about the need for sick-leave, either when the patient demands a sick leave perceived as irrelevant by the physician or when the patient refuses the sick leave prescription. Some solutions for difficult situations have been suggested, such as using institutional support and getting help from more experienced colleagues, but these proposals have never been assessed. A Swedish study showed an association between having a workplace policy and a reduced risk for physicians to experience sick-listing problems, but causality was not proven and types of policy not defined (Citation25).
Difficulties relating to healthcare system organization
Limited communication between GPs and OPs in disability management and lack of support from health authorities were the most frequent issues within the healthcare system. In a Dutch cohort study, when a barrier in return-to-work was present, there was an exchange of information between the GP and the OP less than 50% of the cases (Citation16). In various qualitative studies, GPs have described excessive pressure for productivity as limiting the time available for assessing the need for sick-leave, for filling in the certificate correctly or for motivating the patient to return to work. Furthermore, some GPs reported issuing prolonged certification due to delayed referral, investigation, treatment or social aids. These difficulties can be reinforced by a lack of knowledge in sickness insurance legislation, which GPs often perceive as complex and outside the medical field (Citation35).
Several authors proposed to improve the cooperation between GPs and OPs through initial or continuing medical education. However, in a Swedish study focused on back pain management, no positive effect on disability and length of sick leave was obtained from a specific training course aiming to increase collaboration between GPs and OPs. Although it improved the mutual knowledge of the physicians’ occupations, it changed neither their behaviour nor the patients’ prognoses (Citation62).
In 1995, Sweden undertook a dramatic administrative reform to regulate sickness benefits by excluding nonmedical criteria for sick listing, encouraging partial sick listing and facilitating the rehabilitation process. Two assessments consistently showed that the reform achieved greater accuracy in filling in certificates, but did not reduce sick listing rates (65,66). In 2002, the British Department of Work and Pension issued guidelines, including recommended sick leave lengths for several disorders, but a formal assessment showed that GPs had low awareness (36%) and use (20%) of it (Citation61). A certification form including more options for return to work (adapted work or schedule) may also favour fitness for work advice (Citation60).
Difficulties relating to the socioeconomic environment
Main reported barriers to good certification practice related to the socioeconomic environment were the lack of workstation adaptation by the employer and labour market requirements inadequate for patients’ health, which can favour delayed return to work or repeat sick leave (Citation31). Beyond improving cooperation between GPs and OPs, some authors stressed the need to develop preventively a healthier working environment based on ergonomic principles, but no specific intervention has been assessed or even implemented to date.
DISCUSSION
The main problematic issues identified were difficulties in assessing the need for sick leave, in the doctor-patient relationship, in relation to healthcare system organization and to the socioeconomic environment. A few reviews on the sickness certification process have been published previously. Söderberg and Alexanderson described physicians’ practices and assessed their determinants, mainly from quantitative studies and did not find evidence regarding the possible influence of the healthcare organization (Citation68). A review by Wahlström and Alexanderson found limited evidence that physicians perceive sick-listing certification difficult or problematic and encouraged further research (Citation35). More recently, Wynne-Jones et al. globally focused their analysis on the feelings of GPs, and identified three main themes, namely conflicts, role responsibility and barriers to good practice (Citation53). Though our review overlaps the latter theme, in our framework, the difficulties experienced by GPs include the potential conflicts either occurring with the patient or enclosed in their dual role. This also emphasizes the challenge for GPs to assess the functional and contextual status of the patient, a theme which was not developed in previous reviews. In addition, this review has explored the practical solutions that have been considered internationally for improving the various stakes in the sickness certification process, including some recent studies involving healthcare organization. This review found that the main solutions to improve sick-listing practice would be using tools or procedures for functional assessment of patients and better cooperating between caregivers. Strategies considered for this purpose were to train GPs with guidelines and reform the healthcare system.
Functional assessment
The generic scale used for functional assessment in sickness certification was derived from the International Classification of Functioning, Disability and Health, better known as ICF, published by the World Health Organization in 2001. This classification includes the following domains: body functions (impairments/integrity), body structure (impairments/integrity), activity and participation (limitations/capacity and restrictions/performance) and environmental factors (barriers/facilitators) (Citation69). Any domain can be scored from 0 to 4, which enables follow-up on patients’ conditions and communication between parties (Citation70). Training GPs on functional assessment using a 39-item-ICF-derived checklist improved their knowledge of the patients’ workplace and perceived stressors, and increased the rate of partial sick leave (Citation22,Citation23).
In Norway and in Sweden, where GPs are expected to use functional assessment daily, functional ability was missing from two of three certificates, and the domains documented often reduced to ‘body functions’ (Citation17,Citation71). Nevertheless, professional practice mostly involves ‘activity and participation,’ a domain that should theoretically be referred to in all certificates. Even if physicians are less familiar with including environmental barriers in their clinical assessment (Citation72), this would help them to recognize situations likely to result in long sick leave and then to propose adequate intervention for their patients (Citation73).
As was found in this review, physicians felt it difficult to assess patients’ work disability when they present with functional complaints, like fatigue and pain. An additional difficulty can be encountered with patients belonging to specific ethnic groups, who can express pain differently (Citation74). Even though they feel manipulated, some GPs often see maintaining their relationship with their patient as more important than conforming to guidelines (Citation58). In any case, denying a request for sickness certificate can be difficult in practice (Citation75,Citation59). A functional scale that is easy for patients to understand would improve their agreement with doctor's medical assessments of their (dis)ability to work, allowing practitioners to reconcile his dual role—acting as the patient's advocate or medical expert—which threatens patient–doctor relationship. Apart from the perceived lack of knowledge on patients’ work situation, some GPs none the less believe that the issue of the function is connected with patients’ subjective experience (Citation17).
Before educating GPs on the use of functional assessment in this context, such an important model deserves better scientific underpinning and evaluation (Citation76).
Cooperation between parties
The different cooperation strategies proposed or assessed involved occupational physicians, physiotherapists, employers and patients themselves. Apart from patients with work injuries and occupational diseases, delegation to or collaboration with OPs did not prove to be effective. Even if this would be impossible to implement in practice for each sick leave, better collaboration could be encouraged, at least in problematic cases. However, even if most GPs wish to work more closely with OPs, they question their dependency on employers (Citation77). Conversely, some occupational physicians feel that patient management by the GP can delay the return to work (Citation57). Better mutual knowledge and trust are, therefore, needed to reinforce this cooperation.
According to some American authors, without OPs, GPs’ communication with employers on diagnosis, prognosis and ability to work may help to adapt the workstation and to reduce mistrust between worker and employer (Citation78). In certain countries, GPs can even directly act as company doctors (Citation79). However, GPs are usually cautious in communicating with employers, except maybe if there is an organizational strategy explicitly designed for that purpose (Citation80).
GPs failure to communicate with social insurance officers for difficult cases can delay the initiation of return to work measures (Citation2). However, social insurance officers sometimes feel unsure about how to handle their contacts with GPs, and would accept physicians’ recommendations instead of making their own judgments about granting sickness benefits (Citation81). More research is therefore needed to develop strategies facilitating interaction between GPs and social insurance officers.
Guidelines
Written guidelines about sickness certification, concentrated on medical documentation, only improved the administrative procedure but had no impact on sick leave rates (Citation67). In the UK, in 2002, the Department of Work and Pensions issued guidelines on sickness certification, but GPs have demonstrated low levels of awareness and use of these guidelines (Citation61). As well, for patients having occupational low back pain, Canadian GPs frequently do not comply with evidence-based guidelines recommending the continuation of usual activities (Citation82).
Guidelines without training are obviously ineffective. The study focusing on British guidelines showed that only 37% of the interviewed GPs had training on sickness certification, 4.1 hours on average (Citation61). The sickness certification process may be facilitated by integrating it into GPs’ computer systems (Citation61). Beyond changes in physicians’ certification practices, it may also prove useful to inform patients better. In Australia, for example, a strategy based on television broadcast of messages on back pain prevention reduced sick periods related to this complaint (Citation83).
Regulations
In Sweden, a reform involving requirements for more information on two different certificate forms, for short- and long-term sick leave and prescription of more partial sick leave, became effective in 1995. Although certificates are now filled in more exhaustively, it did not reduce sick listing rates, in part because partial sick-leave might be inappropriate for certain job requirements (Citation65,Citation66).
In Denmark, since 2008, the current ‘Doctor's note on incapacity’ has been replaced by an ‘opportunity statement’, for which we did not find a published evaluation (Citation84). In the same way, in 2010, the UK government introduced a redesigned statement of fitness for work (‘fit note’), which replaced the ‘sick note’ used previously. The doctor can now indicate that although patients are not fit for their normal work, they could work if the job is suitably modified (phased return to work; altered hours; amended duties; workplace adaptation) (Citation85). Preliminary assessment of the ‘fit note’ procedure shows an impact over one year, with employees taking an average of 5.0 days of sick leave in 2010 compared with 6.7 days in 2007 (Citation86).
Strengths and limitations
This review might not be perfectly exhaustive because of limitations in the indexing of articles on this subject in bibliographic databases (Citation38). Maybe studies published in languages other than English or French are overlooked. The review was focused on the doctors’ perspective and did not fully explore the specific perspectives of the patients or of the other parties involved (especially OPs, employers, insurance officers), as well as epidemiological or economic stakes of sick-listing prescriptions. This represents a limitation, justified by the pragmatic approach of the study, aimed at supporting GPs in their sick-listing task and ultimately at improving patients’ management.
Legislation on sickness absence varies considerably from one country to another, with different countries enforcing different periods available for sickness- certification, i.e. the length of sickness absence before a sickness certificate is required. For instance, in the UK and Sweden, sickness certification is needed only after five days, whereas there is no self-certification period in Malta (Citation79,Citation87). In addition, GPs are not at all involved in the certification process in the Netherlands (Citation79).
Despite the extensive medical and economic consequences of sickness absence, there has been very little research, and published studies usually fall short of basic scientific standards, especially with few randomized intervention studies (Citation2).
Conclusion
Sickness certification represents a procedural as well as a relational, organizational and political challenge. Well-validated tools or procedures to support doctors in this task are lacking. The development of functional assessment and cooperation with occupational physicians requires appropriate education and training for present and future GPs’. Further research is needed to refine these strategies.
ACKNOWLEDGEMENTS
The authors thank Professors Alain Bergeret and Yves Matillon for their review of the manuscript.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES
- Gimeno D, Benavides FG, Benach J, Amick BC. Distribution of sickness absence in the European Union countries. Occup Environ Med. 2004;61:867–9.
- Alexanderson K, Norlund A. Swedish council on technology assessment in health care (SBU). Chapter 12. Future need for research. Scand J Public Health Suppl. 2004;63:256–8.
- Edwards P, Greasley K. Absence from work. Dublin, Ireland: European foundation for the improvement of living and working conditions; 2011. Available at http://www.eurofound.europa.eu/docs/ewco/tn0911039s/tn0911039s.pdf (accessed 27 April 2012).
- Wynne-Jones G, Mallen C, Welsh V, Dunn K. Rates of sickness certification in European primary care: A systematic review. Eur J Gen Pract. 2009;14:1–10.
- Englund, Svärdsudd L. Sick-listing habits among general practitioners in a Swedish county. Scand J Prim Health Care2000;18:81–6.
- Arrelöv B, Borgquist L, Ljungberg D, Svärdsudd K. Do GPs sick-list patients to a lesser extent than other physician categories?A population-based study. Fam Pract. 2001;18:393–8.
- Lindholm C, Arrelöv B, Nilsson G, Löfgren A, Hinas E, Skånér Y, et al.Sickness-certification practice in different clinical settings; a survey of all physicians in a country. BMC Public Health2010; 10:752.
- Norrmén G, Svärdsudd K, Andersson D. Impact of physician- related factors on sickness certification in primary health care. Scand J Prim Health Care2006;24:104–9.
- Brenninkmeijer V, Houtman I, Blonk R. Depressed and absent from work: Predicting prolonged depressive symptomatology among employees. Occup Medicine (Lond)2008;58:295–301.
- Gerner U, Alexanderson KK. Issuing sickness certificates: A difficult task for physicians: A qualitative analysis of written statements in a Swedish survey. Scand J Public Health2009;37:57–63.
- Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: Explanation and elaboration. Br Med J. 2009;339:b2700.
- Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesizing qualitative and quantitative evidence: A review of possible methods. J Health Serv Res Policy2005;10:45–53.
- Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al.Current methods of the US Preventive Services Task Force. A review of the process. Am J Prev Med. 2001;20:S21–35.
- Atroshi I, Andersson IH, Gummesson C, Leden I, Odenbring S, Ornstein E. Primary care patients with musculoskeletal pain. Value of health-status and sense-of-coherence measures in predicting long-term work disability. Scand J Rheumatol. 2002;31:239–44.
- Vos CJ, Verhagen AP, Koes BW. The ability of the acute low back pain screening questionnaire to predict sick leave in patients with acute neck pain. J Manipulative Physiol Ther. 2009;32:178–83.
- Anema JR, Jettinghoff K, Houtman I, Schoemaker CG, Buijs PC, van den Berg R. Medical care of employees long-term sick listed due to mental health problems: A cohort study to describe and compare the care of the occupational physician and the general practitioner. J Occup Rehabil. 2006;16:41–52.
- Krohne K, Brage S. New rules meet established sickness certification practice: A focus-group study on the introduction of functional assessments in Norwegian primary care. Scand J Prim Health Care2007;25:172–7.
- Haldorsen EM, Brage S, Johannesen TS, Tellnes G, Ursin H. Musculoskeletal pain: concepts of disease, illness, and sickness certification in health professionals in Norway. Scand J Rheumatol. 1996;25:224–32.
- Mayhew HE, Nordlung D. Absenteeism certification: The physician's role. J Fam Pract. 1988;26:651–5.
- Nilsen S, Werner EL, Maeland S, Eriksen HR, Magnussen LH. Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints. Scand J Prim Health Care2011;29:7–12.
- Krohne K, Brage S. How GPs in Norway conceptualise functional ability: a focus group study. Br J Gen Pract. 2008;58:850–5.
- Østerås N, Gulbrandsen P, Benth JS, Hofoss D, Brage S. Implementing structured functional assessments in general practice for persons with long-term sick leave: A cluster randomised controlled trial. BMC Fam Pract. 2009;10:31.
- Østerås N, Gulbrandsen P, Kann IC, Brage S. Structured functional assessments in general practice increased the use of part-time sick leave: A cluster randomised controlled trial. Scand J Public Health2010;38:192–9.
- Holdsworth LK, Webstera VS, McFadyena AK and The Scottish Physiotherapy Self-Referral Study Group. Physiotherapists’ and general practitioners’ views of self-referral and physiotherapy scope of practice: Results from a national trial. Physiotherapy2008;94:236–43.
- Swartling MS, Hagberg J, Alexanderson K, Wahlström RA. Sick-listing as a psychosocial work problem: A survey of 3997 Swedish physicians. J Occup Rehabil. 2007;17:398–408.
- Timpka T., Hensing G., Alexanderson K. Dilemmas in sickness certification among Swedish physicians. Eur J Public Health1994; 5:215–9.
- Swartling MS, Alexanderson KAE, Wahlstrom RA. Barriers to good sickness certification—an interview study with Swedish general practitioners. Scand J Public Health2008;36:408–14.
- Brage S, Håland Haldorsen H, Håland Haldorsen, Håland Haldorsen GS, Håland Haldorsen EM, Johannesen TS, et al.The use of case histories to explore concepts of disease, illness and sickness certification. Fam Pract. 1995;12:75–83.
- Brage S, Bentsen BG, Bjerkedal T, Nygård JF, Tellnes G. ICPC as a standard classification in Norway. Fam Pract. 1996;13:391–6.
- Coole C, Watson PJ, Drummond A. Work problems due to low back pain: What do GPs do?A questionnaire survey. Fam Pract. 2010;27:31–7.
- Tellnes G, Bruusgaard D, Sandvik L. Occupational factors in sickness certification. Scand J Prim Health Care1990;8:37–44.
- Arrelöv B, Alexanderson K, Hagberg J, Löfgren A, Nilsson G, Ponzer S. Dealing with sickness certification: A survey of problems and strategies among general practitioners and orthopaedic surgeons. BMC Public Health2007;7:273.
- Löfgren A, Hagberg J, Alexanderson K. What physicians want to learn about sickness certification: Analyses of questionnaire data from 4019 physicians. BMC Public Health2010;10:61.
- Engblom M, Nilsson G, Arrelöv B, Löfgren A, Skånér Y, Lindholm C, et al.Frequency and severity of problems that general practitioners experience regarding sickness certification. Scand J Prim Health Care2011;29:227–33.
- Wahlström R, Alexanderson K. Swedish council on technology assessment in health care (SBU). Chapter 11. Physicians’ sick-listing practices. Scand J Public Health Suppl. 2004;63:222–55.
- Von Knorring M, Sundberg L, Löfgren A, Alexanderson K. Problems in sickness certification of patients: A qualitative study on views of 26 physicians in Sweden. Scand J Prim Health Care2008;26:22–8.
- Engblom, Alexanderson, Englund M. When physicians get stuck in sick-listing consultations: A qualitative study of categories of sick-listing dilemmas. Work2010;35:137–42.
- Engblom, Alexanderson K., Rudebeck M. Characteristics of sick-listing cases that physicians consider problematic—analyses of written case reports. Scand J Prim Health Care2009;27:250–5.
- Tellnes G. Sickness certification in general practice: a review. Fam Pract. 1989;6:58–65.
- Stigmar K, Grahn B, Ekdahl C. Work ability—experiences and perceptions among physicians. Disabil Rehabil. 2010;32:1780–9.
- Coole C, Watson PJ, Drummond A. Staying at work with back pain: Patients’ experiences of work-related help received from GPs and other clinicians. A qualitative study. BMC Musculoskelet Disord. 2010;11:190.
- Cohen D, Marfell N, Webb K, Robling M, Aylward M. Managing long-term worklessness in primary care: A focus group study. Occup Med (Lond). 2010;60:121–6.
- O’Brien K, Cadbury N, Rollnick S, Wood F. Sickness certification in the general practice consultation: The patients’ perspective, a qualitative study. Fam Pract. 2008;25:20–6.
- Löfgren A, Hagberg J, Arrelöv B, Ponzer S, Alexanderson K. Frequency and nature of problems associated with sickness certification tasks: A cross-sectional questionnaire study of 5455 physicians. Scand J Prim Health Care2007;25:178–85.
- Bollag U, Rajeswaran A, Ruffieux C, Burnand B. Sickness certification in primary care—the physician's role. Swiss Med Wkly. 2007;137:341–6.
- Søgaard HJ, Bech P. The effect on length of sickness absence by recognition of undetected psychiatric disorder in long-term sickness absence. A randomized controlled trial. Scand J Public Health2009;37:864–71.
- Lalić H. Occupational medicine in taking over work injuries from family practice: A one-year follow-up. Coll Antropol. 2009;33:939–43.
- Breen A, Austin H, Campion-Smith C, Carr E, Mann E.‘You feel so hopeless’: A qualitative study of GP management of acute back pain. Eur J Pain2007;11:21–9.
- Gulbrandsen P, Hofoss D, Nylenna M, Saltyte-Benth J, Aasland OG. General practitioners’ relationship to sickness certification. Scand J Prim Health Care2007;25:20–6.
- Money A, Hussey L, Thorley K, Turner S, Agius R. Work-related sickness absence negotiations: GPs’ qualitative perspectives. Br J Gen Pract. 2010;60:721–8.
- Cohen DA, Aylward M, Rollnick S. Inside the fitness for work consultation: A qualitative study. Occup Med (Lond). 2009;59: 347–52.
- Wrapson W, Mewse AJ. Does the doctor or the patient control sick leave certification? A qualitative study interpreting patients’ interview dialogue. Fam Pract. 2011;28:202–9.
- Wynne-Jones G, Mallen CD, Main CJ, Dunn KM. What do GPs feel about sickness certification? A systematic search and narrative review. Scand J Prim Health Care2010;28:67–75.
- Swartling M, Peterson S, Wahlström R. Views on sick-listing practice among Swedish General Practitioners—a phenomenographic study. BMC Fam Pract. 2007;8:44.
- Hussey S, Hoddinott P, Wilson P, Dowell J, Barbour R. Sickness certification system in the United Kingdom: Qualitative study of views of general practitioners in Scotland. Br Med J. 2004;328:88.
- Engblom M, Alexanderson K, Rudebeck CE. Physicians’ messages in problematic sickness certification: A narrative analysis of case reports. BMC Fam Pract. 2011;12:18.
- Anema JR, Van Der Giezen AM, Buijs PC, Van Mechelen W. Ineffective disability management by doctors is an obstacle for return-to-work: A cohort study on low back pain patients sicklisted for 3–4 months. Occup Environ Med. 2002;59:729–33.
- Campbell A, Ogden J. Why do doctors issue sick notes? An experimental questionnaire study in primary care. Fam Pract. 2006;23:125–30.
- Wynne-Jones G, Mallen CD, Main CJ, Dunn KM. Sickness certification and the GP: What really happens in practice?Fam Pract. 2010;27:344–50.
- Sallis A, Birkin R, Munir F. Working towards a ‘fit note’: An experimental vignette survey of GPs. Br J Gen Pract. 2010;60: 245–50.
- Roope R, Parker G, Turner S. General practitioners’ use of sickness certificates. Occup Med (Lond). 2009;59:580–5.
- Faber E, Bierma-Zeinstra SMA, Burdorf A, Nauta AP, Hulshof CTJ, Overzier PM, et al.In a controlled trial training general practitioners and occupational physicians to collaborate did not influence sick leave of patients with low back pain. J Clin Epidemiol. 2005;58:75–82.
- Ford FM, Ford J, Dowrick C. Welfare to work: The role of general practice. Br J Gen Pract. 2000;50:497–500.
- Löfgren A, Silén C, Alexanderson K. How physicians have learned to handle sickness-certification cases. Scand J Public Health2011;39:245–54.
- Arrelöv B, Borgquist L, Ljungberg D, Svärdsudd K. The influence of change of legislation concerning sickness absence on physicians’ performance as certifiers. A population-based study. Health Policy2003;63:259–68.
- Englund L, Tibblin G, Svärdsudd K. Effects on physicians’ sick-listing practice of an administrative reform narrowing sick-listing benefits. Scand J Prim Health Care2000;18:215–9.
- Kersnik J. Management of sickness absence: A quality improvement study from Slovenia. Qual Health Care1999;8: 262–9.
- Söderberg E, Alexanderson K. Sickness certification practices of physicians: A review of the literature. Scand J Public Health2003;31:460–74.
- World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: WHO; 2008.
- Jette AM, Norweg A, Haley SM. Achieving meaningful measurements of ICF concepts. Disabil Rehabil. 2008;30:963–9.
- Nilsing E, Söderberg E, Normelli H, Oberg B. Description of functioning in sickness certificates. Scand J Public Health2011;39: 508–16.
- Kellou N, Frappé P, Barral C, Letrilliart L. Prescription des arrêts de travail en médecine générale? Description des critères fonctionnels et contextuels. Exercer2010;92:68–74.
- Dünner S, Decrey H, Burnand B, Pécoud A. Sickness certification in primary care. Soz Praventivmed. 2001;46:389–95.
- Plesh O, Adams SH, Gansky SA. Racial/ethnic and gender prevalences in reported common pains in a national sample. J Orofac Pain2011;25:25–31.
- Himmel W, Sandholzer H, Kochen M. Sickness certification in general practice. Eur J Gen Pract. 1995;1:161–6.
- Verbeek J, van Dijk F. Assessing the ability to work. Br Med J. 2008;336:519–20.
- Buijs P, van Amstel R, van Dijk F. Dutch occupational physicians and general practitioners wish to improve cooperation. Occup Environ Med. 1999;56:709–13.
- Merrill RN, Pransky G, Hathaway J, Scott D. Illness and the workplace: A study of physicians and employers. J Fam Pract. 1990; 31:55–8.
- Soler JK, Okkes IM. Sick leave certification: An unwelcome administrative burden for the family doctor? The role of sickness certification in Maltese family practice. Eur J Gen Pract. 2004;10:50–5.
- Russell Brown JB, Stewart MG. Managing injured workers: Family physicians’ experiences. Can Fam Physician2005;51:78–9.
- Soderberg E, Alexanderson K. Gatekeepers in sickness insurance: A systematic review of the literature on practices of social insurance officers. Health Soc Care Community2005;13:211–23.
- Guzman J, Yassi A, Cooper JE, Khokhar J. Return to work after occupational injury. Family physicians’ perspectives on soft-tissue injuries. Can Fam Physician2002;48:1912–9.
- Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. Br Med J. 2001;322:1516–20.
- Jørgensen C. Tripartite agreement on reducing sickness absence. Dublin, Ireland: European foundation for the improvement of living and workin conditions; 2009. Available at http://www.eurofound.europa.eu/eiro/2008/10/articles/dk0810021i.htm (accessed 27 April 2012).
- Coggon D, Palmer KT. Assessing fitness for work and writing a ‘fit note’. Br Med J. 2010;341:c6305.
- Khan S. Sickness absence continues on downward trend—EEF/Westfield Health survey. Sheffield, South Yorkshire, UK: West field Health; 2011. Available at http://www.westfieldhealth.com/news/stories/article079.aspx (accessed 27 April 2012).
- Osterkamp R. Work lost due to illness—an international comparison, Munich, Germany: CESifo; 2010. Available at http://www.cesifo-group.de/portal/pls/portal/docs/1/1207803.PDF (accessed 27 April 2012).