Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints

Objectives

To explore GPs’ considerations in decision-making regarding sick-listing of patients suffering from SHC.

Design

Qualitative analysis of data from nine focus-group interviews.

Setting

Three cities in different regions of Norway.

Participants

A total of 48 GPs (31 men, 17 women; aged 32–65) participated. The GPs were recruited when invited to a course dealing with diagnostic practice and assessment of sickness certificates related to patients with composite SHCs.

Results

Decisions on sick-listing patients with SHCs were regarded as a very challenging task. Trust in the patient''s own story and self-judgement was deemed crucial, but many GPs missed hard evidence of illness and loss of function. Several factors that might influence decision-making were identified: the patients’ ability to present their story to evoke sympathy, the GP''s prior knowledge of the patient, and the GPs’ own experience as a patient and their tendency to avoid conflicts. The approach to the task of sick-listing differed from patient-led cooperation to resistant confrontation.

Conclusion and implications

Issuing sickness certification in patients with composite health complaints is considered challenging and burdensome. It is seen as mainly patient-driven, and the decisions vary according to GPs’ attitudes, beliefs, and personalities. Guiding the GPs to a more focused awareness of the decision process should be considered.Key Words: Education, family practice, primary health care, sickness certification, sick-listing, subjective health complaints, work incapacityAlthough we have some knowledge concerning GPs’ practices on sick-listing in general, less is known about how GPs make their assessments regarding sick-listing in the more complex cases of patients with subjective health complaints (SHCs).

• Decisions on sick-listing patients with SHCs are considered by GPs as a demanding and challenging task and are seen as mainly patient-driven.
• Handling of the sick leave decisions varies greatly, according to GPs’ attitudes, beliefs, and personalities.
• Focused awareness of the decision process through more specific education and training among students and GPs should be considered.

Subjective health complaints (SHCs) account for a great proportion of the encounters in general practice [1,2], and include conditions like musculoskeletal pain, tiredness, fibromyalgia, gastrointestinal complaints, depression, and anxiety [3–9]. SHCs are characterized by a plurality of symptoms and often a lack of objective findings or specific pathology to fully explain the complaints [7,10–12]. Lack of objective findings makes assessment difficult and leaves room for great variation in assessment of these patients, including the decision on whether to grant sick leave.A sickness certificate may be granted in Norway if a reduction in work capacity is due to disease or injury [13,14]. Some 79% of the total number of sickness certificates are issued by general practitioners (GPs) [13]. This assessment is often difficult and complex, and many physicians are uncomfortable carrying out these duties [15], being caught in the crossfire between the patients’ demands for sick-listing and society''s pressure to act more restrictively [15,16]. Knorring and her collaborators [17] report that many GPs expressed fatigue, despair, and lack of pride in their work concerning sick-listing. GPs find it particularly challenging to deal with issues of sick-listing when the decision is solely based on the patient''s own report of complaints [17,18].The GP''s age, sex, and whether the GP is a specialist or not, and also how the patients present their problem are factors found to influence decisions regarding sick-listing [19,20,22]. Norrmen et al. [21] found that the strongest predictors for granting sickness certification were agreement between patients’ and GPs’ assessment of reduced work capacity. When the patient''s complaints were judged to be non-somatic, the risk of being sick-listed also increased. However, there is scarce knowledge concerning how physicians actually make their assessment, especially in the more complex cases. The aim of this study was to explore what considerations are made by GPs when they decide whether patients with SHCs are eligible for sick-listing.