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Sickness certification at oncology clinics: perceived problems, support, need for education and reasons for certifying unnecessarily long sickness absences R. BRÄNSTRÖM, PHD, Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, and Department of Public Health Sciences, Karolinska Institutet, Stockholm, B. ARRELÖV, PHD, Stockholm County Council, Stockholm, C. GUSTAVSSON, PHD, Department of Clinical Neuroscience, Divi- sion of Insurance Medicine, Karolinska Institutet, Stockholm, L. KJELDGÅRD, MSC, Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, T. LJUNGQUIST, PHD, Depart- ment of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, G.H. NILSSON, PHD, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet, Stockholm, & K. ALEXANDERSON, PHD, Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden BRÄNSTRÖM R., ARRELÖV B., GUSTAVSSON C., KJELDGÅRD L., LJUNGQUIST T., NILSSON G.H. & ALEXANDERSON K. (2014) European Journal of Cancer Care 23, 89–97 Sickness certification at oncology clinics: perceived problems, support, need for education and reasons for certifying unnecessarily long sickness absences Physicians’ work with sickness certifications is an understudied field. The aims of this study were to gain knowledge of experiences concerning the sickness certification process among physicians working at oncology clinics. In 2008, all physicians working in Sweden (n = 36 898) were sent a questionnaire concerning sick- listing practices. All respondents working at an oncology clinic (n = 428) were included in the current study. Most of the physicians had sickness certification consultations at least weekly (91.3%). More than one fifth (22.3%) reported that they worked at a clinic with a workplace policy regarding the handling of sickness certification and 61.1% reported receiving at least some support in such cases from their immediate manager. Issuing unnecessary long sickness certificates were related to experiencing delicate interactions with patients and to lack of time. To a moderate degree, further competence was requested regarding: different types of compensation in the social insurance system, responsibilities of the Social Insurance Agency and employers, and sickness insurance rules. The large majority of physicians working in oncology reported regularly having consultations involving sickness certification. Overall, they reported few problems, low level of need for more competence regarding sickness certification, and low frequency of issuing sickness absences for longer periods than necessary. Keywords: sick leave, sickness certification, insurance medicine, oncology, cancer, physician. INTRODUCTION Do oncologists find sickness certification consultations problematic? Do they feel a need for more competence regarding such tasks? For the first time, a large-scale nationwide survey regarding work with sickness certifica- tion has been conducted among physicians at oncology clinics in Sweden. Correspondence address: Richard Bränström, Department of Clinical Neu- roscience, Division of Insurance Medicine, Karolinska Institutet, Stock- holm 171 76, Sweden (e-mail: [email protected]). Accepted 22 June 2013 DOI: 10.1111/ecc.12104 European Journal of Cancer Care, 2014, 23, 89–97 Original article © 2013 John Wiley & Sons Ltd

Sickness certification at oncology clinics: perceived problems, support, need for education and reasons for certifying unnecessarily long sickness absences

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Page 1: Sickness certification at oncology clinics: perceived problems, support, need for education and reasons for certifying unnecessarily long sickness absences

Sickness certification at oncology clinics: perceivedproblems, support, need for education and reasons forcertifying unnecessarily long sickness absences

R. BRÄNSTRÖM, PHD, Department of Clinical Neuroscience, Division of Insurance Medicine, KarolinskaInstitutet, Stockholm, and Department of Public Health Sciences, Karolinska Institutet, Stockholm, B. ARRELÖV,PHD, Stockholm County Council, Stockholm, C. GUSTAVSSON, PHD, Department of Clinical Neuroscience, Divi-sion of Insurance Medicine, Karolinska Institutet, Stockholm, L. KJELDGÅRD, MSC, Department of ClinicalNeuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, T. LJUNGQUIST, PHD, Depart-ment of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, G.H. NILSSON,PHD, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institutet,Stockholm, & K. ALEXANDERSON, PHD, Department of Clinical Neuroscience, Division of Insurance Medicine,

Karolinska Institutet, Stockholm, Sweden

BRÄNSTRÖM R., ARRELÖV B., GUSTAVSSON C., KJELDGÅRD L., LJUNGQUIST T., NILSSON G.H. &ALEXANDERSON K. (2014) European Journal of Cancer Care 23, 89–97Sickness certification at oncology clinics: perceived problems, support, need for education and reasons forcertifying unnecessarily long sickness absences

Physicians’ work with sickness certifications is an understudied field. The aims of this study were to gainknowledge of experiences concerning the sickness certification process among physicians working at oncologyclinics. In 2008, all physicians working in Sweden (n = 36 898) were sent a questionnaire concerning sick-listing practices. All respondents working at an oncology clinic (n = 428) were included in the current study.Most of the physicians had sickness certification consultations at least weekly (91.3%). More than onefifth (22.3%) reported that they worked at a clinic with a workplace policy regarding the handling of sicknesscertification and 61.1% reported receiving at least some support in such cases from their immediate manager.Issuing unnecessary long sickness certificates were related to experiencing delicate interactions with patientsand to lack of time. To a moderate degree, further competence was requested regarding: different types ofcompensation in the social insurance system, responsibilities of the Social Insurance Agency and employers,and sickness insurance rules. The large majority of physicians working in oncology reported regularly havingconsultations involving sickness certification. Overall, they reported few problems, low level of need for morecompetence regarding sickness certification, and low frequency of issuing sickness absences for longer periodsthan necessary.

Keywords: sick leave, sickness certification, insurance medicine, oncology, cancer, physician.

INTRODUCTION

Do oncologists find sickness certification consultationsproblematic? Do they feel a need for more competenceregarding such tasks? For the first time, a large-scalenationwide survey regarding work with sickness certifica-tion has been conducted among physicians at oncologyclinics in Sweden.

Correspondence address: Richard Bränström, Department of Clinical Neu-roscience, Division of Insurance Medicine, Karolinska Institutet, Stock-holm 171 76, Sweden (e-mail: [email protected]).

Accepted 22 June 2013DOI: 10.1111/ecc.12104

European Journal of Cancer Care, 2014, 23, 89–97

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Original article

© 2013 John Wiley & Sons Ltd

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In Sweden, more than 50 000 individuals are diagnosedwith cancer every year, and the overall 10-year survivalrate is between 55% and 60% (The National Board ofHealth and Welfare 2011). Getting a cancer diagnosis iscoupled with many different stressful experiences, bothphysically, socially and emotionally. In addition to theexcessive physical and mental stress caused by the diseaseand its treatment, many patients experience disruption ofordinary life functions and roles, including roles related towork and productivity (Petersson et al. 2011).

A relatively large proportion of those diagnosed withcancer are part of the workforce at the time of diagnosis.In Sweden, approximately 37% of those diagnosed with acancer diagnosis in 2010 were younger than 65 years ofage (The National Board of Health and Welfare 2011).For many in this group, returning to work is an essentialaspect of reintegration into ordinary life functions androles (Petersson et al. 2012). The large majority of cancerpatients working at the time of diagnosis return to workwithin the first 2 years (Roelen et al. 2011b), but thetime and rate of the return to work vary greatly betweencancer types and between countries (Johnsson et al. 2009;Fantoni et al. 2010; Roelen et al. 2011b). In the lastdecade, there have been indications that the rate ofreturn to work after a cancer diagnosis is decreasing andthat the time until return to work is increasing (Roelenet al. 2011a). The differences in rates of and time untilreturn to work might partially be explained by differ-ences in treatment and social insurance systems acrosscountries and over time; however, physicians’ sicknesscertification practices also play a central role in thesick-leave and return-to-work process (Alexanderson &Norlund 2004).

To get sick-leave benefits, a medical certificate issuedby a physician is needed in most countries, in Swedenafter 7 days of sickness absence. The certificates issuedby the physician are important for the decisions made bythe employer and the Social Insurance Agency regardingwhether the patient is entitled to benefits and rehabilita-tion measures (Alexanderson & Norlund 2004; Söderberg& Alexanderson 2005). Physicians’ work with sicknesscertifications is an understudied field, in all medicalspecialties, but especially so in oncology (Wahlström &Alexanderson 2004a). To date, the majority of studieson physicians’ sickness certification practices have beenconducted among general practitioners (Wahlström &Alexanderson 2004a; Wynne-Jones et al. 2010). However,a high frequency of work with sickness certification con-sultations has been reported among oncologists (Lindholmet al. 2010), emphasising the need for further studies inthis group.

Several studies and literature reviews among physiciansin Sweden have shown a need for more knowledge regard-ing sickness certification (Wahlström & Alexanderson2004a; Löfgren et al. 2010) and a number of problems havebeen reported, for example difficulties to assess work capa-city and estimate optimal duration of sick leave (Löfgrenet al. 2007). Recent studies have identified work with sick-ness certification as a psychosocial work environmentalproblem, even among oncologists (Ljungquist et al. 2012,2013). Further knowledge about the specific views, con-cerns and needs of physicians working with cancer patientsand their sickness certification is highly warranted.

The aims of this study were: to describe experiencesamong physicians’ working at oncology clinics concerningthe sickness certification process, regarding their problemsand need for further competence concerning sickness cer-tification; and to examine the association between experi-ences, perceived problems, need for education and issuingsickness certificates for longer periods than necessary.

METHOD

In the fall of 2008, all physicians living and working inSweden (a total of 36 898) were sent an invitation to par-ticipate in a questionnaire study concerning their sick-listing practices. The questionnaire was to be returned ina prepaid envelope and three reminders were posted tonon-respondents. No compensation for participation wasoffered. A total of 22 349 (60.6%) returned the question-naire. In the current study, the responses from the 348physicians who worked as physicians mainly at oncologyclinics were included. Information regarding currentlyactive physicians as well as age, sex, year of medicaldegree and year of licence as physician (after 2 years ofinternship), and type of specialist qualifications (after atleast 5 more years of residency training) were obtainedfrom the Swedish National Board of Health and Welfare.The study was approved by the Regional Ethical ReviewBoard of Stockholm (No. 2008/795-31).

Measures

In addition to archival information regarding partici-pants’ age, gender and level of medical education, answersto the following questionnaire items were included in theanalyses.

Frequency of sickness certification

The participants were asked to give an estimate of thefrequency by which they had consultations includingaspects of sickness certification (more than 20 times per

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week/6–20 times per week/1–5 times per week/sometimeseach month/a few times a year/never or almost never).

Organisational support

Two questions were asked regarding organisational sup-port in the sickness certification process. The items con-cerned: support from the immediate management at theclinic; and whether the clinic had a policy regarding sick-ness certification aspects.

Frequency of delicate interactions with patients, timerestraints and collaborative efforts

Questions regarding specific situations relating to clinicalwork with sickness certification were asked and the

respondents were to indicate the frequency by which theyhad experienced these situations [more than 10 times perweek (coded as 4)/6–10 times per week (coded as 3)/1–5times per week (coded as 2)/sometimes each month (codedas 1)/a few times a year/never or almost never (coded as0)]. The questions concerned conflicts with patients, lackof time, and collaborative efforts and referrals to otherhealthcare workers or external organisations (see Table 1).The responses relating to each of the three main types ofsituations were summed and divided by number of itemsto give three total measures, that is, delicate interactionswith patients, time restraints, and collaborative effortsand referrals (all sum scores: min = 0; max = 4). In thecurrent study, the Cronbach’s alpha coefficients for thethree summed score were 0.74, 0.85 and 0.69 respectively.

Table 1. Reported frequencies of different situations related to sickness certification among physicians mainly working at oncologyclinics, regularly (at least once a week) handling sickness certification (n = 316)

At leastonce aweek (%)

About oncea month(%)

A few timesa year or lessoften (%)

Frequency of delicate interactions with patientsHow often in your clinical work do you. . .

. . . say no to a patient who asks for a sickness certificate? 1.0 14.9 84.1

. . . have patients who partly or completely say no to a sick leave you suggest? 2.9 13.8 83.3

. . . issue a sickness certificate so that a patient will be eligible for higher benefits thanunemployment or welfare benefits?

0.6 2.2 97.1

. . . have conflicts with patients about sickness certification? 2.6 6.7 90.7

. . . worry that a patient will report you to the medical disciplinary board in connectionwith sickness certification?

0.3 1.3 98.4

. . . feel threatened by a patient in connection with sickness certification? 0.3 0.3 99.4

. . . worry that patients are going to change physician if you don’t issue a sicknesscertificate?

0.3 1.0 98.7

. . . have patients saying they will change physician if you don’t issue a sicknesscertificate

0.3 0.0 99.7

Lack of timeWhen handling sickness certification tasks, how often do you not have enough time. . .

. . . with your patients? 55.4 20.4 24.2

. . . to manage patient-related aspects (e.g. issuing certificates, contacting otherstakeholders, documentation)?

65.3 21.5 13.2

. . . for further education, supervision or reflection? 57.4 15.2 27.4Frequency of collaboration, referrals and supportHow often in your clinical work do you. . .

. . . collaborate with or refer patients to physical or occupational therapists whenhandling cases involving sickness certification?

5.4 10.9 83.7

. . . collaborate with or refer patients to counsellor and/or psychologists when handlingcases involving sickness certification?

4.9 13.8 81.4

. . . confer with other physicians when handling cases involving sickness certification? 2.3 18.3 79.4

. . . have time alone or with colleagues for supervision/feedback/reflection related tosickness certification issues?

0.3 0.3 99.4

. . . refer/send patients to occupational health services? 0.3 5.0 94.7

. . . or does your healthcare team participate in co-ordination meetings with socialinsurance and/or employers about patients to whom you issue sickness certificates?

0.6 2.3 97.1

. . . or does your care team contact employers in ways other than via the co-ordinationmeetings?

0.3 0.3 99.4

. . . contact social services when handling cases involving sickness certification? 0.0 1.0 99.0

. . . contact the employment offices when handling cases involving sicknesscertification?

0.0 1.0 99.0

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Severity of problems regarding sicknesscertification tasks

A number of specific questions concerned to what extentspecific sickness certification tasks were experiencedas problematic. The wording of each item is presented inFigure 1. Responses were indicated using four responsealternatives [very (coded as 3)/rather (coded as 2)/slightly(coded as 1)/not at all (coded as 0)]. The responses relat-ing to each of the four main types of tasks were summedand divided by number of items to give four total meas-ures, that is, problems with the sickness certificationguidelines, general problems with sickness certifica-tion, problems with assessments and problems withpatient contact (all summed scores: min = 0; max = 3).In the current study, the internal consistencies forthe four summed score were 0.85, 0.82, 0.76 and 0.79respectively.

Reasons for issuing unnecessarily longsickness absences

Twelve questions were asked to assess the frequency bywhich the respondents issued sickness absence for longertimes than necessary due to different circumstances. Theresponse to each question was indicated on a scale with

five alternatives (daily/once a week/once a month/once ayear/never or almost never). The wording of each item ispresented in Figure 2.

Need for more competence

Nineteen items describing potential areas of need for com-petence in insurance medicine. The respondents were toindicate the degree to which they felt the need to increasetheir competence in each of these fields [very high (codedas 3)/rather high (coded as 2)/small (1)/no (coded as 0)].The wording of each item is presented in Figure 3. Theresponses from all items were summed and divided bynumber of items to give a total measure of perceived needfor education (min = 0; max = 3). In the current study, theinternal consistency was 0.95.

Statistical analysis

In addition to descriptive statistics of the participants’responses, a number of logistic regressions were con-ducted to examine potential association between back-ground factors, varying experiences with sicknesscertification, problems and frequency of issuing unneces-sary long sickness absences. Initial univariate logisticregression analyses were used to assess the association

Figure 1. Responses in percentages regarding how problematic, physicians working at oncology clinics (n = 316), thought it was to handledifferent tasks regarding sickness certification (SIA refers to Social Insurance Agency). a69.3% of the respondents had not used theseguidelines. b66.8% of the respondents had not used these guidelines.

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between background variables, work place characteristics,experiences of the sickness certification process and prob-lems relating to sickness certification, followed by multi-variate logistic regression including those variables that

were associated with the outcome variable at the P = 0.05level. All continuous variables were transformed intoZ-scores before being entered into the analyses. All analy-ses were performed using SPSS version 19.

Figure 2. Responses in percentages regarding how often unnecessarily long sickness absences were issued due to different reasons amongphysicians manly working in oncology clinics (n = 316; SIA refers to Social Insurance Authority).

Figure 3. Responses in percentages regarding ratings of reported need for more competence regarding sickness certification amongphysicians manly working in oncology clinics (n = 316; SIA refers to Social Insurance Authority).

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RESULTS

Study sample characteristics

All physicians working at an oncology clinic, a total of 348participants, were initially included. The large majorityof those (n = 316; 91.3%) reported consultations involv-ing consideration of sickness certification at least weekly.This group, consisting of both oncology specialists(58.9%), physicians with other specialist training thanoncology (8.2%) and non-specialists (32.9%), was includedin the subsequent analyses in this study. A majority ofthese were women (57.9%) and the median age was 45.0(range: 25–67).

Clinical experiences of sickness certification

In our sample, most physicians reported having sicknesscertification consultations at least six times per week(67.6%). More than one fifth of the respondents (22.3%)reported that they worked at a clinic with a workplacepolicy regarding the handling of sickness certifications ofpatients. However, only about half of these respondents(12.1% of all respondents) reported that the policy waswell established in the organisation. A majority of therespondents (61.1%), reported receiving at least somesupport from their immediate manager at their clinicregarding work with sickness certifications, and 19.3%reported getting extensive support. On a general questionconcerning frequency of experiencing handling sick-ness certification tasks as problematic, about one fifthresponded that they perceived this at least once a week(20.1%). An additional two fifths (39.1%) perceived sick-ness certification as problematic on singular occasionseach month, and the rest of the participants experiencedthis less often.

The participants’ responses to more specific questionsregarding their experience of sickness certification arereported in Table 1. Very few reported having conflictswith patients regarding sickness certification. Much morecommon were experiencing lack of time regarding differentaspects of sickness certification. A majority of the respond-ents experienced this at least weekly. Almost nonereported having supervision or practical support in theirwork with sickness certification, or having contact withsocial services, employers or other stakeholders. About onefifth reported conferring with other physicians at least oncea month when handling sickness certification. About thesame proportion reported that they referred patients toother health professionals such as physical or occupatio-nal therapists (16.3%), and social worker or psychologist(18.7%) when handling sickness certification.

Problems regarding sickness certification tasks

The respondents’ responses regarding different types ofproblems are reported in Figure 1. To assess patients’ func-tion and work capacity were judged as most problematic.General administrative tasks regarding sickness certifica-tion were rated problematic to a certain extent.

Unnecessarily issued sickness certificates

The participants were to indicate the frequency by whichthey issued unnecessarily long sickness absences dueto a number of different reasons (Fig. 2). Over all, abouta fourth (26.8%) of the respondents reported that theyissued unnecessarily long sickness absences at least oncea month, and 5.5% reported doing so at least once a week.The most common reason for issuing unnecessary longsickness absences was waiting times for patient investi-gation or treatment by healthcare services (Table 2).Issuing unnecessary long sickness absences was associ-ated with lack of time and experiencing delicate interac-tions with patients.

Reported need for further competence

Overall, the respondents’ perceived need for further com-petence regarding sickness certification was low (Fig. 3).The areas where most respondents reported need formore competence were: other types of compensation inthe social insurance system, options and responsibilitiesof the Social Insurance Agency, employers’ options andresponsibilities, and sickness insurance rules. To a certaindegree, a need for increased competence about assessingfunctional capacity and work capacity was reported.

DISCUSSION

In this study, we examined oncologists’ work with sick-ness certifications in a nationwide survey. To our knowl-edge, this is the first study with this specific aim. Thelarge majority of physicians working at oncology clinicsreported having consultations regarding sickness certifi-cation at least once a week, and most (67.6%) had suchconsultations at least six times a week. Most physiciansworking in oncology reported that their workplace did nothave a policy regarding the handling of sickness certifica-tion of patients and even in workplaces that had a policy;it was often not well established in the organisation. Nev-ertheless, the majority of physicians working in oncologyreported receiving support in their work with sicknesscertifications from their immediate manager. Although

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the participants reported some degree of problems in han-dling sickness certification tasks, few reported conflictswith patients regarding such aspects. Collaboration withand referrals to other health professionals or other stake-holders involved in the sickness absence process were alsorarely reported.

Overall, the participants reported few situation or cir-cumstances regarding sickness certification as problem-atic. This is in contrast to the reporting from physicians inseveral other clinical settings. Higher rates of experiencedproblems related to sickness certification have beenreported, particularly from physicians working in primaryhealthcare, orthopaedic clinics and psychiatry (Wahlström& Alexanderson 2004b; Wynne-Jones et al. 2010). Themost common problems reported by the physiciansworking in oncology were to assess the patients’ work

capacity and providing a long-term prognosis about futurework capacity. Difficulties in making adequate assess-ment of work capacity have been reported among physi-cians in several previous studies (Cassis et al. 1996;Wahlström & Alexanderson 2004a; Kerstholt et al. 2006;von Knorring et al. 2008; Gerner & Alexanderson 2009;Lindholm et al. 2010). However, the generally low degreeof problems reported among oncologists as comparedwith physicians at other types of clinics, might be aconsequence of the fact that oncologists primarily meetpatients with medically more definable ‘diseases’, as com-pared with physicians working with more symptom-basedillnesses (e.g. psychiatry, primary healthcare, occupa-tional health and pain-related fields) where making judge-ments regarding sickness certifications might be morechallenging.

Table 2. Factors associated with certifying sickness absences for longer time than necessary among physicians mainly working inoncology clinics having sickness certification consultations at least weekly (n = 316)

n

Certifying unnecessary long sicknessabsences at least monthly

UnadjustedOR (95% CI)

Multivariate†OR (95% CI)

GenderFemale 183 1 –Male 133 1.13 (0.67–1.89) –

Age–34 58 1 –35–44 97 1.05 (0.49–2.25) –45–54 84 1.10 (0.50–2.41) –55–65 67 1.14 (0.50–2.59)65– 10 0.32 (0.04–2.74) –

Oncology specialistNo 130 1 –Yes 186 1.59 (0.93–2.71) –

Frequency of sickness certification consultations1–5 times a week 82 1 1More than 6 times a week 234 0.47 (0.24–0.91)* 0.44 (0.17–1.09)

Workplace policy for handling matters related to sickness certificationNo 278 1 –Yes 38 0.86 (0.37–2.00) –

Support from your immediate managerNo 129 1 –Yes 187 0.88 (0.52–1.47) –

Frequency of the following situations related to sickness certification:Delicate interactions with patients 2.60 (1.86–3.64)*** 1.84 (1.16–2.90)***Lack of time 2.50 (1.76–3.55)*** 1.63 (1.05–2.51)*Collaboration, referrals and support 1.68 (1.29–2.20)*** 1.37 (0.96–1.97)Need for more competence 1.47 (1.10–1.94)** 0.98 (0.63–1.52)

Perceived problems regarding sickness certification:Problems with the sickness certification guidelines 1.10 (0.86–1.40) –General problems with sickness certification 2.08 (1.56–2.78)*** 1.88 (1.13–3.12)Problems with assessments 1.91 (1.44–2.51)*** 1.48 (0.58–3.73)Problems with patient contacts 1.63 (1.25–2.12)*** 0.65 (0.29–1.46)

†The multivariable analysis was performed by simultaneously entering into the model all variables that were significantly associatedwith the dependant variable.Significant at *P < 0.05; **P < 0.01; ***P < 0.001.OR, odds ratio; CI, confidence interval.

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Among the physicians working in oncology, issuingunnecessary long sickness absences was infrequent. Thelikelihood of issuing unnecessary long sickness certifi-cates was higher among those who reported having deli-cate interactions with patients and lack of time. Thesefindings are in line with results from a qualitative studyregarding difficulties experienced by physicians in theirwork with sickness certificates (Gerner & Alexanderson2009).

Although previous research has reported that physiciansrequest more competence and training in how to handlesickness certification (Krohne & Brage 2007; Swartlinget al. 2008; Löfgren et al. 2010) and studies have showninsufficient familiarity among physicians regarding thesocial insurance system (Gerner & Alexanderson 2009;Roope et al. 2009; Walters et al. 2010), the participants inthis study did not report a strong need for more suchcompetence.

The major strengths of this study are the large numberof participants and the fact that all physicians workingin Sweden were included. Other strengths are the manydetailed questions about these tasks. The development ofthe questionnaire was based on several different previousinterview studies (individual and focus groups), question-naires, discussions and literature reviews about physi-cians’ sickness certification practices. Unfortunately, wewere unable to analyses the exact response rate of physi-cians working at oncology clinics, but the overall responserate was 60.6%. As in most surveys, the response ratewas somewhat higher among women and older people

(Lindholm et al. 2010). This study also suffers fromthe limitations associated with self-reports, includingcommon method variance and socially desirable respond-ing. Future studies of the validity of measures regardingphysicians’ experiences and problems with sicknesscertification are warranted. As with any cross-sectionalstudy, the design of the study limits our ability to makeany conclusions regarding causality. Alternative modelsand explanation to our findings cannot be ruled out.

The large majority of physicians working at oncologyclinics reported having consultations concerning sicknesscertification frequently. Overall, the participants reportedfew situation or circumstances regarding sickness certifi-cation that they perceived as problematic. The mostcommon problems reported were to assess the patients’work capacity and providing a long-term prognosis aboutfuture work capacity. The likelihood of issuing unneces-sary long sickness absences was higher among thosereporting having delicate interactions with patients andlack of time.

ACKNOWLEDGEMENTS

This study was financed by AFA Insurance and theSwedish Council for Working Life and Social Research(No.: 2007:1762; 2009:1758).

CONFLICT OF INTEREST STATEMENT

No conflicts of interest exist.

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