In this large survey, nearly all the participating GPs had sickness absence consultations at least once a week. However, 95% of the GPs in Norway had six or more such consultations every week compared to 44% in Sweden. A large majority of the GPs in both countries experienced sickness certification generally as very or fairly problematic. Indeed, a majority of the GPs found most of the examined aspects of sickness absence consultations problematic.
Some of the aspects of sickness certification were experienced as problematic for more of the GPs in Sweden than GPs in Norway. This included discussing the advantages and disadvantages of being sickness absent and to issue a prolongation of a sick-leave period initiated by another physician. Ten percent of the Norwegian GPs and 28% of the Swedish GPs reported encountering patients each week that requested sick leave for reasons other than disease or injury.
GPs in Norway worried more often than Swedish GPs that patients would go to another physician if they did not issue a certificate. A significantly larger proportion of GPs in Norway also found it problematic to handle situations in which they and their patient disagreed on the need for sick leave.
Strengths and limitations
To our knowledge, this is the so far largest study comparing GPs' experiences of sickness certification. Furthermore, this is the first survey study in which a large number of physicians in two countries have been asked several identical questions on sickness certification experiences. Three main strengths of this study are thus the size of the study groups, that GPs from two countries were included, and the many similar questions. The questions used in the studies were subject to discussion among researchers and in pilot-studies in both countries. In addition an effort were made making the two study materials from Sweden and Norway match each other as far as possible (regarding the GPs level of education, and the gender and age distribution). In Sweden, the study population comprised all physicians in the country, and in Norway a representative sample of physicians were invited to participate. A further strength is that the same questions were used in a previous study in 2004 in Sweden [10], and the questions had been thoroughly evaluated in both countries, undergoing revisions based on feedback from researchers and physicians. The response rates were acceptable, 60.6% in Sweden and 66.5% in Norway.
A possible limitation is the fact that the surveys in Sweden and Norway were somewhat different. In Sweden all questions were related to sickness certification while the scope of the Norwegian survey was more comprehensive, including questions on other topics, e.g. the work environment of physicians. This might have lead to differences in the participants, e.g. have lead to those GPs with special interest in sickness certification aspects choose to answer in Sweden but not in Norway.
One general limitation of survey studies is that informants might interpret questions in different ways and that they, regarding frequencies, provide only self-reported information, which may differ from actual practice [28]. Respondents in survey studies also have a general tendency to give positive answers to questions [29, 30], for example understating the frequency of problems they encounter. However, we have no reason to believe that GPs in either country would be more accurate or have less recall bias.
Problems experienced by GPs
This study confirms results from several studies, that sickness certification is experienced as problematic by physicians, especially by GPs [1, 4, 2, 5–7, 9–11, 13, 16, 17, 31]. The study also shows that there are differences between countries regarding GPs' experiences of sickness certification.
The two roles
GPs have two roles in sickness certification, one as a treating physician and the other as a medical expert providing accurate medical information to the social insurance services. In the present study, more than 50% of the GPs in both countries felt that managing these two roles was problematic. This agrees with other studies [10, 12–15, 17, 32, 33]. Clearly, this calls for interventions and support regarding both training and health care management [1, 34, 35].
Non-medical reasons
The qualification requirements for sickness benefit--reduced work capacity due to injury or disease--are the same in both countries. However, three times as many GPs in the Swedish sample--28% versus 10%--each week encountered patients that wanted to be on sick leave for a non-medical reason. Moreover, GPs in Sweden generally experienced sickness certification tasks as more problematic than did their colleagues in Norway. One possible explanation for these differences is that GPs in Norway often see patients at an earlier stage in the sickness absence process, as half of the working population need a sickness certificate already after three days of self-certification--most sick-leave spells do not last more than a week. Another possible explanation is that patients at risk for sick leave differ to some extent between the two countries. A larger proportion of the population in Sweden is eligible for sickness benefits, meaning that expectations of sickness certification might differ. GPs in Sweden and Norway might also differ in how they define the concept of disease. Many Norwegian GPs tend to define conditions such as grief or illness of a spouse as a disease [12]. Nevertheless, the proportion of GPs in both countries that regularly declined to issue sickness certificates to patients was very similar (10-15%).
Conflicts with patients
Actually, one out of ten GPs in both countries experienced conflicts with patients about sickness certification as often as every week. Previous studies have found that conflicts with patients and other stakeholders are a common problem for physicians [3], and some GPs experience the task of sickness certification as so problematic that it was deemed a working environment issue [11]. The proportion of GPs in this study experiencing frequent conflicts with patients could be regarded as high, viewed in the perspective of the GPs' working environment. This may affect GPs in different ways and warrants interventions. Previous studies have indicated that physicians ask for support and more knowledge and skills in sickness certification [12, 34].
Concern that patients will change GP
GPs in both countries worried that patents would go to another physician if denied a sickness certificate. However, a significantly higher proportion of Norwegian GPs were concerned about this: 18% versus 7% in Sweden. In Norway, GPs are partly reimbursed according to the number of patients on their list. This may explain that a higher proportion of Norwegian GPs worried that patients will go to, and possibly permanently switch to, another GP if they do not receive a certificate. Thus, economic incentives in the Norwegian system may influence GPs' sickness certification practices. Previous studies have found that Norwegian GPs experience rationing decisions as difficult, especially when related to economic incentives [36, 37]. This might also be relevant in sickness certification.
Problematic experiences and certificates issued by GPs
Previous studies have found that GPs in Sweden issue 40% of all sickness certificates in the country, compared to 70-80% in Norway [38, 39]. The remaining certificates are issued by hospital physicians, occupational health physicians, private specialist clinics, and out-of-hours services The stricter referral system in Norway might be one reason for this difference. The economic incentives in the Norwegian system may also influence Norwegian GPs to have more frequent consultations with their patients, including patients who are certified sick. Closer follow-up and knowledge of each patient might facilitate the negotiations between physician and patient regarding sickness absence and thereby explain why Norwegian GPs apparently experience sickness absence consultations as less problematic than their Swedish colleagues.