Assessing fitness for work: GPs judgment making

Abstract

Background: The complexity of a fitness for work consultation is well documented. General practitioners (GPs) find that such consultations often create conflict and they feel ill-prepared for the task.

Objectives: We aimed to examine the consultation process in the fitness for work consultation and to report on the response of GPs to two hypothetical consultations of work related sickness absence, one of a psychological and one of a physical nature.

Methods: Three areas of the consultation were examined; social/family circumstances, workplace history and information required assessing the severity of the condition. We used a randomized design using an online questionnaire completed by 62 GPs located in the Republic of Ireland. Analysis was conducted in NVivo 8 qualitative software using thematic and content analysis techniques.

Results: GPs may be expected to collect and consider information relating to social, domestic, financial, lifestyle and workplace factors, including workload, job satisfaction, job strain, work ethic, inter staff relationships and employee support mechanisms. The mode of presentation may trigger specific information seeking in the consultation.

Conclusion: GPs may evaluate fitness for work in a variety of ways depending on medical and non-medical factors. Further research should further examine the factors that may influence the GPs decision to prescribe sickness leave.

Keywords::

• general practice/family medicine
• qualitative designs and methods development of measurement instruments
• psychological problems
• musculoskeletal disorders

KEY MESSAGE:

• GPs show differences in the type of information gathering in the fitness for work consultation based on the presenting illness.

• GPs show differences in the perceived potential stressors at work based on the way patients present their condition.

• GPs recognize that additional support factors are vital to manage effectively illness at work.

INTRODUCTION

There is a large body of research exploring how consultations are approached and handled in primary healthcare (1). Over the past four decades, several models of the consultation have been developed to explain and investigate the consultation process (2). However, research investigating the consultation process in sickness absence certification is limited. The sickness certification consultation presents the opportunity to discuss the illness and its impact on social functioning including work. In many cases of work related absence, doctors can neither confirm nor deny the presence of pathology and the quality of advice given to the patient will depend on the General Practitioners’ (GPs’) knowledge and consultation skills (3,4). There are implications for a patient who is deemed ‘unfit for work’. Longitudinal studies reveal that prolonged spells of work related absenteeism can result once a person starts certified sickness leave. Rates of return to work are reduced after a period of 12 weeks and following a period of six months it is estimated that a person has a 20% chance of returning to work within a five year period.

GPs can find their role as certifiers problematic and a source of conflict. The prescribing of sickness leave is often based on the GPs’ desire to preserve the doctor– patient relationship (5–7). Non medical factors such as social circumstances and demand for certification rather than fitness for work have been implicated in GPs’ decision making on sickness certification (8,9). Difficulties include negotiation with the patient about fitness for work and disagreement between the GP's and patient's perceptions about their ability to work (4). Training in occupational medicine is considered inadequate and GPs report that they are often ill-prepared for the task of assessing fitness for work (9–13).

In Ireland GPs are required to act as gatekeepers for statutory benefits, thereby further complicating the process. Over the past decade there has been a significant rise in the level of sickness certification in Ireland and currently over 80% of all sickness certificates relate to illness with diagnostic challenges such as psychological problems and musculoskeletal conditions. Uncertainty in assessment of these conditions is thought to be one problem for GPs in decision making about sickness certification (14).

We aimed to move away from the area of problematic experience in sickness certification and instead to focus on the process of information seeking in the fitness for work consultation. The aim was to report qualitatively on two hypothetical consultations of work related sickness absence, one of a psychological and one of a physical nature as these conditions represent the highest frequency of certified absence. We wished to explore the specific nature of the consultation process related to three areas; information seeking in relation to the patient's social/family circumstances, information seeking related to workplace history and other information required by the GP to assess the severity of the condition. The study was conducted as a larger exploratory study aiming to explore sickness certification in the Republic of Ireland.

METHODS

General design

The study took place between April and June 2011 using an online survey tool. Ethical approval was granted by the Waterford Institute of Technology, ROI and University of Manchester Research Ethics Committees, UK. Two hundred GPs were e-mailed by random allocation using the Irish College of General Practitioners (ICGP) electronic mailing database. GPs were asked to complete one of eight computerized clinical vignettes. Two additional e-mail reminders were sent to the selected GPs following a two and four week period. Ninety-seven out of 200 GPs agreed to participate, 62/97 completed the survey, leaving a useable rate of 31%. GP consent was obtained electronically and this allowed them to gain access to the vignette.

Vignette construction

Vignettes were constructed to present typical scenarios of patients attending the GP's surgery. The medical conditions chosen represented those most frequently resulting in sickness absence as described by the Department of Social Protection (Ireland) and THOR—GP (UK) (15,16). Two scenarios were prepared, one of a male with a psychological problem and the other of a male with a physical problem. Variables were manipulated to include the presence or absence of a social problem and the request from or reluctance of the patient to be certified to explore the influence of these variables in the information seeking. The result was eight hypothetical scenarios, four of a psychological nature and four of a physical nature. Each scenario was reviewed to check for validity and relevance of the vignette to clinical practice using pre determined criteria. Reviewers included a psychologist, a GP trainer, three occupationally trained GPs, five GPs working in primary healthcare, and two faculty members of an Academic Institution. The final vignettes were agreed and organized into three principal sections: work and family history, nature of the condition and treatment plan, and the current reason for a visit to the surgery. Boxes 1 and 2 illustrate the vignette versions used in the study.

Box 1. Showing the psychological vignette version.

Vignette (1–4) variable type psychological problem (PSY+)

Mr X is a 38-year-old office manager who has been with the company for the last five years. The company is a large multinational company specializing in pharmaceuticals. Mr Flynn supervises a team of ten administrators. The job involves accounts, personnel and general administrative work. There are occasional visits to sister plants, but mainly the job is office-based.

Variable type (+) = Mr X is married with three children. Mr X partner works as a nurse in the local hospital; this often involves her working at night, and at weekends.

Variable type (−) = Mr X is single

Your notes indicate that Mr Flynn is experiencing intermittent low mood and tearfulness over the past two years. This has resulted in Mr X taking occasional days off work. A month ago he came to you and reported that he had experienced persistently low mood and tearfulness. Mr X also indicated that he is having problems with concentration and sleeping. You gave Mr X a sickness certificate for two weeks and prescribed an antidepressant.

At the end of the certification period Mr X returned to work for a four week period, but is now back at the surgery and states that the symptoms have ‘gotten worse’ and he is now having anxiety attacks and feels he just cannot cope.

Variable type (+) = Mr X asks if you can provide another sickness certificate. He feels that an extended period of recovery will help to alleviate some of the symptoms.

Variable type (−) = Mr X states that he cannot really afford to take more time off from work.

Box 2. Showing the physical vignette version.

Vignette (5–8)—variable type physical problem (PHY+)

Mr X is 41 years old. He has been a machine operator for the past five years. It is a local company that provides components to the medical devices industry. The job involves machine set-up, machining and measuring of component parts. The job also requires some lifting, which is assisted using hoist equipment.

Variable type (+) = Mr X is married with three children. Mr X partner works as a nurse in the local hospital; this often involves her working at night and at weekends.

Variable type (−) = Mr X is single

Mr X records show that he is experiencing occasional lower back pain over the past three years, which has lead to the occasional day or two off from work. He has been treated with pain killers on these occasions and you also recommended that he takes regular exercise. Two weeks ago Mr X came to you experiencing a dull ache in his lower back, which he explains has gotten progressively worse over the previous four months. Mr X describes that he is very stiff first thing in the morning.

You provide Mr X with a sickness certificate for a period of one week. Mr Walsh went back to work for one week, but he is now back at the surgery complaining of pain when bending down and reaching forward.

Variable type (+) = Mr X asks if you can provide another sickness certificate. He feels that an extended period of recovery will help to alleviate some of the symptoms.

Variable type (−) = Mr X states that he cannot really afford to take more time off from work.

Questions

After reading the scenarios, participants were asked to enter their typical responses to three open-ended questions relating to the specific fitness for work consultation:

1. What specific information would you search for related to the patient's social/family circumstances?

2. What specific information would you search for in the patient history related to the workplace?

3. What additional information would you require to assess the severity of the condition?

Data analysis

GP entered brief responses to each of the questions (maximum of 200 words). Each of the responses was downloaded and entered in NVivo 8 qualitative software for thematic and content analysis. The first level of coding was conducted by reading through the qualitative data chronologically and generating broad participant driven categories. These categories were discussed between the first and second author and subsequently grouped by theme. Themes were discussed between all authors, and this strategy led to the identification of the several sub-categories of information seeking. References made by the participants to each of the sub categories were noted. The total number of references in each sub-category was then counted and presented as a frequency (Table 1).

Table 1. Showing the main thematic categories and references made for each vignette version.

	PSY	PSY	PSY	PSY	PHY	PHY	PHY	PHY
Vignette version	+++	++−	+−+	+−−	+++	++−	+−+	+−−
Frequency (f)	n = 7	n = 9	n = 8	n = 7	n = 5	n = 7	n = 7	n = 12
Question 1
Information seeking related to thepatients social/family circumstances
Thematic category	(f)	(f)	(f)	(f)	(f)	(f)	(f)	(f)
Interpersonal stress	4	3	2	2	2	3	1	3
Support structure	5	7	6	3	0	6	1	3
(Spouse, family, childcare, friends)
Relationship health	4	6	5	1	2	1	1	2
Financial situation	1	3	1	5	1	2	3	2
Substance misuse	1	4	4	3	0	1	1	4
Family history of illness	0	1	1	3	1	0	1	0
Social Isolation/living conditions	0	0	5	2	0	0	1	4
Physical activity and other interests	0	3	4	1	1	0	0	4
Question 2
Information seeking in patient’s history related to the workplace
Thematic category	(f)	(f)	(f)	(f)	(f)	(f)	(f)	(f)
Work-related stress	1	2	3	2	1	0	0	0
Work load	1	5	5	3	0	2	0	1
Bullying at work	4	3	5	3	2	0	1	0
Inter staff relationships and employee supports	4	5	3	3	1	0	1	4
Working tasks	4	2	3	0	4	5	3	8
Working conditions	0	2	3	5	2	6	2	10
Job satisfaction	2	0	0	0	2	0	1	1
Job security	2	0	2	1	1	0	1	1
Question 3
Additional information required to assess severity of patient's condition
Thematic category	(f)	(f)	(f)	(f)	(f)	(f)	(f)	(f)
Suicidal ideation	1	6	4	6	0	0	0	0
Physical and psychological signs and symptoms (mood, sleep appetite changes)	3	5	6	3	2	4	3	9
Physical medical evidence (X-ray, MRI, etc.)	0	0	0	0	2	3	5	8
Consultants report	1	1	0	0	0	0	2	0
Family history	3	2	3	0	0	1	0	2
Medication history	2	1	0	0	0	2	1	2

RESULTS

Social circumstances and psychological problems

Socio-demographic information of participating GPs is presented in Table 2. Support structures, relationship health, interpersonal and financial circumstance were dominant themes across all vignette versions. Overall, GPs wanted to know more about the patients social circumstances when presented with a psychological problem. The mode of presentation may trigger specific information seeking during the consultation process. The presence of a psychological problem prompted greater inquiry into family support structures, the presence or absence of problems in the patient's relationships, and financial worries when compared to a patient having a physical problem. Having a psychological problem was associated with increased concern from the GP about addiction and substance misuse. The presence of adverse social circumstances did not appear to impact greatly on the information seeking process; however, social isolation and poor living conditions were mentioned in the case of the single patient and were given greater importance by the GP when the patient had a psychological condition. The GPs’ concern about suicide appeared more marked when the patient was reluctant to take additional time off from work.

Table 2. Socio-demographic data of participating GPs.

n = 62	Frequency (f)	% respondents
Age
25–30 years	1	1.6
31–40 years	23	37.1
41–50 years	17	27.4
Older than 50 years	21	33.9
Gender
Male	25	40.3
Female	37	59.7
Undergraduate medical training
Ireland	59	94.2
UK	2	3.2
Other EU	1	1.6
GP training
Ireland	51	82.2
UK	9	14.5
Other EU	1	1.6
USA	1	1.6
Postgraduate training in occupation medicine
Yes	3	4.8
No	59	95.2

Workplace

Information seeking on patients’ workplace was consistent with known reasons for workplace sickness leave, but there were differences based on the type of presenting problem. Taking the history of the workplace included working conditions, workload, work ethic, job satisfaction, job security, and inter-staff relationships and employee support mechanisms. GPs considered the working tasks of patients more often when presented with the physical condition and seemed to engage in more detailed inquiry when the patient was reluctant to take additional time off from work; whereas in the case of the patient with the psychological problem GPs were more concerned with workload and social networks and relationships with employers and fellow employees.

Medical aspects

Additional information needed to assess the severity of the condition was largely associated with clinical diagnostics and included medical assessments, medical history, medication and results from previous diagnostic examinations. Corroborating medical evidence required to assess the severity of the condition was evident for the patient with a physical problem (X-ray, MRI, etc.) but not sought for the patient with the psychological problem (i.e. psychiatric assessment, psychiatrist report, etc). Suicidal ideation was most frequently requested to assess the severity of the psychological condition while assessing evidence in the physical complaint was mostly related to obtaining the results of MRI and X-ray procedures.

DISCUSSION

We highlight the complexity of information GPs may be required to collect and process during a typical fitness for work consultation. Such information includes social, domestic, financial, and lifestyle factors; workplace problems, including workload, job satisfaction, job strain, work ethic, inter staff relationships employee support mechanisms; and medical factors including the results of previous investigations.

Reasons for psychological related sickness certification

Findings in this study may provide further insight into the reasons for high rates of psychological related sickness certification. Several studies have shown that certification rates are higher for patients presenting with psychological problems, and the condition seems to generate greater sympathy from GPs (6,9,17–20). There is little evidence to support the therapeutic role of abstaining from work for those with mental health problems (21,22). However, patients have reported that stress and depression have a high impact on the ability to work, and thus empathic concern may be driven by a switch in viewpoint from the GPs own personal perspective to the perspective of the patient (23). Equally the GP may take the view that working with a psychological condition could add additional pressure to the concept of being ‘well’ (24).

The workplace: stress or protection?

The information GPs sought during the consultation in the present study was similar to that identified in the literature as contributing to sickness absence in the workplace (25). There appears to be greater enquiry into the working situation when the patient is reluctant to take time from work and this may be based on the GP perceived risk of presenteeism (attending work when sick) (26). While certain characteristics of the working environment can contribute to sickness absence, the responses in the current study suggest differences in the perceived potential stressors at work. GPs in the current study recognize support factors considered vital to manage effectively illness at work (27,28). However, they may underestimate the role of social supports as a protective factor against psychological stress even for those with physically demanding jobs (29). Fifteen references were made to the possibility of ‘bullying at work’ a finding, which concurs with those of a recent qualitative study conducted in Ireland suggesting that work place bullying is a common reason for sickness certification (7). This suggests that GPs may medicalize such problems even when they are not necessarily medical (30).

Occupational healthcare?

Corroborating evidence from the employer or an occupational physician was not considered by the GPs in the current study and this finding may reflect the disconnection of employers and occupational health from primary healthcare. There is some evidence from other studies to suggest that GPs rarely engage with employers on work related issues and under these arrangements a lack of engagement results in unrealistic expectations in managing their role as certifiers (13,31). It also appears that GPs may be more confident in certifying for psychological problems and require ‘hard evidence’ to a greater extent in cases of a physical nature. This may be related to increased awareness and training of GPs in psychological medicine.

Strengths and limitations

Although concerns have been raised in relation to the use of vignettes in research they may be useful in measuring aspects of clinical practice, especially in conducting comparative analysis or where ethical issues present in practice (32,33). We took care to construct vignettes to take account of various clinical scenarios relating to typical fitness for work consultations. However, they present hypothetical situations and may not necessarily reflect what a doctor would actually explore in a real fitness for work consultation with a patient (34). Furthermore, the questions did not allow the doctor to explore patient responses, which would further guide the consultation process. Yet, these vignettes could be utilized in further comparative GP studies on sickness certification.

We restricted the vignettes to male patients to minimize the number of vignette versions; future research can delineate any gender issues that could arise. Patients’ gender is an important variable in predicting sickness absence and women are shown to have higher rates of certification compared to men (15,35,36). Possible explanation is the use of sickness certification for extenuating circumstances such as caring for sick children (7,37,38).

The response rate of this study is low at 31%, and no information is available to compare the respondents to the non-respondents, although GPs represented in this study are reflective of gender proportions and age profiles of GPs working in Ireland. Results have not been analysed in the context of GPs working experience, gender or additional qualifications, specialism and training. However, research on sickness certification in Ireland is limited, and this study highlights the multiplicity of factors for consideration in a case of work related illness.

Conclusion

We highlight various roles that GPs may be required to undertake in relation to sickness certification including the potential conflicting role as a patient advocate. The GP must often balance the patient's needs and expectations with their perceived probability of risk should the patient attend or abstain from work. The most important finding is the variation in information seeking based on the type of illness presentation. GPs may be focused on the organizational factors in the workplace rather than the working tasks of patients particularly in cases that present of a psychological nature. While training and education for GPs may increase awareness and understanding of work related sickness absence, failure to recognize the complexity of the problems that occur when consulting on sickness absence may result in lack of preparation of newly qualified GPs for this task. Further research into sickness certification and work related absence in Ireland may benefit both doctors and patients.

ACKNOWLEDGEMENTS

The authors acknowledge the contribution of Ms. Carol White on the administration of the survey.

ETHICAL APPROVAL

Waterford Institute of Technology and the University of Manchester Research Ethics Committees.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.