Each action plan contained from one up to ten challenges, with a median of three. A total of 178 challenges were reported in the plans. Stated challenges formed seven categories as described below. Five categories of stakeholders responsible to initiate actions were identified: The physician in charge, the concerned Health Care Unit, the Health Care System of the region, the patient and the employer, the Social Insurance Administration and legislation. As shown in Table
there were several stakeholders involved in each challenge category.
Number of challenges stated in the plans by group of stakeholders responsible to initiate action
The group interview data comprised a variety of challenges with sick-listing. These challenges were in agreement with the challenges identified in the action plans. The challenges with sick-listing were connected to generic competences needed to fulfil all seven professional roles as defined by CanMEDS. All challenge categories needed competencies from at least two roles in their handling.
Practitioner patient interaction
This category illustrates the physicians’ perceptions of challenges related to their handling of the individual patient contact. To handle challenges in this category the physician had to integrate competencies as a Professional and as a Communicator. Both action plans and interview data included descriptions of difficulties and frustration to deliver highest quality care with integrity, honesty and compassion when handling situations when the patient’s demand of a medical certificate and the judgement of the physician were in conflict.
"“When the physician and the patient had different opinions regarding the need of sick leave – patients just pass by and seek another colleague to get the certificate”"
Furthermore difficulties were described in the communication with patients and in establishing a therapeutic relationship with patients motivating them to participate in a rehabilitation programme. Physicians experienced that it was more time consuming to motivate a patient to work than to issue a sickness certificate – and they had difficulties to manage this when they had no time in their daily schedule.
"“The patient was supposed to pass out through the door – she stopped and asked for a sick leave certificate. That question could spoil all plans of the day and the working schedule would be delayed. This resulted in that the physician gave up his code of conduct and issued the certificate without further argument”"
It was perceived as difficult to practise medicine ethically consistent with obligations and avoid unnecessary sick-listing, particularly when time was a restriction.
"“…The conflict… the double roles of a physician to both be a person executing public authority duties and (at the same time) be a responsible assisting physician …”"
Interviews statements indicated feelings of loneliness, sleeping difficulties and shame when the physician felt unprofessional in the handling of sick-listing issues.
"“They (the physicians) felt guilty and that they had not done enough…”"
Work capacity assessment
The category illustrates the physicians’ view on difficulties to assess work capacity. To handle the challenges of this category the physician had to use competencies as a Medical expert, Communicator and Scholar. A lot of challenges and ambiguity were stated regarding work capacity assessment in general, its definition, and how it related to the medical history. Physicians expressed a lack of competence in how to access and apply knowledge regarding the demands of the patient’s work place and integrate it with how the patient’s disease/-s could afflict function in general and the patient’s ability to perform his or her work in particular.
"“In patients with psychiatric diagnoses – physicians described challenges with the assessment of work capacity”"
In communication with patients it was perceived difficult to handle a sick-listing discussion with unemployed patients. Further to pose effective questions to patients about their work conditions and disabilities. As a scholar a struggle was to maintain lifelong learning, to be updated and to follow all new regulations instead of continuing with old routines.
"“The older physicians did not oppose (the patients’ will) and had a more comprehensive perspective than younger physicians – they (the younger) had just learnt how it was meant to be done (the regulations)”"
"“…They (the physicians) had a lack of knowledge regarding social insurance formal rules and regulations… “"
Interaction with the Social insurance administration
This category illustrates the physicians’ struggling to establish an efficient interaction with personnel at the Social insurance administration. Challenges in this category were well matched with the competence role as Collaborator but challenges also involved difficulties in the role as a Scholar. Challenges when the Social Insurance Administration (SIA) questioned medical certificates were recurrently discussed. It was perceived challenging to formulate sickness certificates in medically complicated patient cases and subsequently get the SIO to understand the situation. Slow handling by clerks and frequent exchange of clerks at the SIA was also perceived as a challenge.
"“If I wanted to help my patient with work place training, it could take half a year to get permit (by the SIA) to initiate it…”"
Physicians expressed difficulties to keep up with their own life-long learning in social insurance medicine. Furthermore, they struggled with how they could facilitate the learning of the Social Insurance Officers (SIO) in the understanding of medicine.
The patient, the workplace and the labour market
This category illustrates the physicians’ effort to handle patient cases where it was needed to understand the patient’s medical problem and also his or her workplace, and or the demands at the labour market and how to interact with employers. Physicians used mainly Collaborator and Communicator competences to solve challenges of this category. Workplace related conflicts that resulted in sick-listing were perceived as problematic. To get in contact with the employer was a time consuming process and sometimes without any prospect of success.
"“It was difficult to initiate a dialogue together with the employer and the patient”"
Disability, illiteracy and e.g. language difficulties among immigrants were perceived as challenging in relation to the labour market. It was difficult to motivate patients who had been habituated to be on sick leave to attend rehabilitation programs.
This category illustrates how physicians struggled to find guidance in a structure or standard to handle complicated sick-listing issues. Medical Expert and Health Advocate are obvious roles in relation to this category. As a medical expert, competence to provide effective consultation services with respect to patient care and to legal opinions was challenging. A great ambiguity regarding sickness certification practice in relation to certain diseases was identified. In spite of national normative standards for sick leave lengths for common diagnoses there were several examples in the data illustrating challenges related to insufficient guidance in the sick-listing decision. Two challenging situations mentioned were sick-listing during pregnancy, and how to response to individual patients’ health needs in relation to the disease and its prognosis.
"“ Burn out - especially in women at executive positions on sick leave nothing could be done to help…”"
As a health advocate it was challenging to assess long-term effects of a decision to issue a medical certificate as compared to a refusal. It was unclear to them, which decision would promote the patient’s health in the long run. To identify opportunities to health promotion and to prevent disease of certain diagnoses were difficult. It was also recognised as difficult to distinguish between stress-related problems and depression.
Collaboration and resource allocation within the Healthcare system
This category to illustrates physicians’ dependence of a well functioning collaboration between different departments in the health care network. Competences as both Collaborator and Health advocate were needed in order to handle challenges of this category. The waiting time for medical examination by specialists was perceived as a challenge. Lack of specific competence resources leading to unacceptably long waiting lists was also important challenges e.g. to visit a specialist in neuropsychiatry, a psychologist or the SIO. As a health advocate physicians had difficulties to support routines perceived as a misuse of resources. The general practitioner perceived that it as problematic to continue to handle sick leave issue when a patient was referred to a specialist in secondary care. Furthermore they frequently felt that the information from the specialist was insufficient.
"“Investigation for back pain as an example, if you send a patient for consultation to an orthopaedic specialist – afterwards the patient contacts you to evaluate the need of sick leave, but you have as yet not received the expert opinion from the specialist”"
Leadership and routines at the Healthcare unit
This category illustrates how a dysfunctional leadership and management at the workplace could cause challenges for the physician handling sick-listing issues. Challenges of this category were related to the competence roles as Manager and Collaborator. Several statements were identified tapping different aspects of the organisation at the unit and of ambiguities regarding responsibilities of various professions.
"“It was different depending on leadership, attitude and culture at the workplace – it influenced quality”"
"“Who is responsible for decisions regarding patient care? If the patient sees the social welfare officer assessing that the patient is in need of sick leave for a certain time, then the physician is supposed to use this assessment and effectuate it in a sickness certificate…”"
To collaborate, as a team was difficult if it was an uneven distribution of workload between physicians, a high turnover of physicians, increased workload and deficient local routines and policies regarding sick listing.
"“Some (physicians) had a heavier workload with more patients with socio-economic challenges. It depended a lot on the commission for the out-patient clinic and the population living in the area”"
Physicians also pointed out a lack of time for reflection together with colleagues. The patients’ increased opportunities to choose a specific physician led to challenges in some cases when patients wanted to change physician due to different opinions as regards sick-listing.
"“If the physician did not agree with the patient regarding the need of sick leave the patient changed physician in order to receive a sickness certificate”"
illustrates the multiple connections between the challenge categories, the competence roles and the responsible stakeholders.
Figure 1 Key stakeholders responsible to initiate action to solve different challenge categories when handling sickness certification issues and associated physician competence roles. The complex pattern of challenges perceived by physicians in handling of sickness (more ...)