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Nilou FE, Christoffersen NB, Lian OS, Guassora AD, Broholm-Jørgensen M. Conceptualizing negotiation in the clinical encounter - A scoping review using principles from critical interpretive synthesis. PATIENT EDUCATION AND COUNSELING 2024; 121:108134. [PMID: 38199175 DOI: 10.1016/j.pec.2024.108134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/20/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Negotiation as an analytical concept in research about clinical encounters is vague. We aim to provide a conceptual synthesis of key characteristics of the process of negotiation in clinical encounters based on a scoping review. METHODS We conducted a scoping review of relevant literature in Embase, Psych Info, Global Health and SCOPUS. We included 25 studies from 1737 citations reviewed. RESULTS We found that the process of negotiation is socially situated depending on the individual patient and professional, a dynamic element of the interaction that may occur both tacitly and explicitly at all stages of the encounter and is not necessarily tied to a specific health problem. Hence, negotiation is complex and influenced by both social, biomedical, and temporal contexts. CONCLUSIONS We found that negotiation between patient and health professional occurs at all stages of the clinical encounter. Negotiation is influenced by social, temporal, and biomedical contexts that encompass the social meeting between patient and health professional. We suggest that health professionals strive to be attentive to patients' tacit negotiation practices. This will strengthen the recognition of the patients' actual wishes for their course of treatment which can thus guide the health professionals' recommendations and treatment.
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Affiliation(s)
- Freja Ekstrøm Nilou
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Olaug S Lian
- Department of Community Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Ann Dorrit Guassora
- Section and Research Unit of General Practice, University of Copenhagen, Denmark
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Lian OS, Nettleton S, Grange H, Dowrick C. 'My cousin said to me . . .' Patients' use of third-party references to facilitate shared decision-making during naturally occurring primary care consultations. Health (London) 2023:13634593231188489. [PMID: 37519043 DOI: 10.1177/13634593231188489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
In this paper, we explore the ways in which patients invoke third parties to gain decision-making influence in clinical consultations. The patients' role in decision-making processes is often overlooked, and this interactional practice has rarely been systematically studied. Through a contextual narrative exploration of 42 naturally occurring consultations between patients (aged 22-84) and general practitioners (GPs) in England, we seek to fill this gap. By exploring how and why patients invoke third parties during discussions about medical treatments, who they refer to, what kind of knowledge their referents possess, and how GPs respond, our main aim is to capture the functions and implications of this interactional practice in relation to decision-making processes. Patients refer to third parties during decision-making processes in most of the consultations, usually to argue for and against certain treatment options, and the GPs recognise these utterances as pro-and-contra arguments. This enables patients to counter the GPs' professional knowledge through various knowledge-sources and encourage the GPs to target their specific concerns. By attributing arguments to third parties, patients claim decision-making influence without threatening the GPs' authority and expertise, which their disadvantaged epistemic position demands. Thereby, patients become able to negotiate their role and their epistemic position, to influence the agenda-setting, and to take part in the decision-making process, without being directly confrontational. Invoking third parties is a non-confrontational way of proposing and opposing treatment options that might facilitate successful patient participation in decision-making processes, and so limit the risk of patients being wronged in their capacity as knowers.
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Affiliation(s)
| | - Sarah Nettleton
- UiT The Arctic University of Norway, Norway
- University of York, UK
| | - Huw Grange
- UiT The Arctic University of Norway, Norway
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Horppu R, Väänänen A, Kausto J. Evaluation of a guidelines implementation intervention to reduce work disability and sick leaves related to chronic musculoskeletal pain: a theory-informed qualitative study in occupational health care. BMC Musculoskelet Disord 2022; 23:272. [PMID: 35317760 PMCID: PMC8938719 DOI: 10.1186/s12891-022-05234-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Guidelines for pain management and sick leave prescription were formulated and implemented in an occupational health services (OHS) in Finland to reduce work disability and sick leaves related to musculoskeletal pain. We investigated how the guidelines implementation intervention may have produced its effects, how the number of prescribed sick leave days varied before and after the launch of the guidelines, and which factors beyond physician behaviour were seen to influence sick leaves. Methods Seventeen physicians, two occupational physiotherapists and one occupational health care nurse were interviewed. Qualitative content analysis using both inductive and deductive approaches was performed, informed by Behaviour Change Wheel and Theoretical Domains Framework. Employees’ sick leave days related to musculoskeletal disorders in 2015–2019 were drawn from the employer’s register. Results Physicians’ guidelines adherence was facilitated by psychological capability (e.g., having relevant knowledge, remembering to engage in recommended behaviours), reflective motivation (e.g., guidelines-related behaviours regarded as central part of one’s professional role; beliefs in the positive consequences of recommended behaviours to employees and employers), and physical and social opportunities (e.g., adequate physical resources, culture of social support). Some physicians also described barriers to recommended behaviours (e.g., lack of knowledge or non-pharmacological pain treatment tools). The guidelines had served as sources of new knowledge, reminders of recommended practices and means of self-assessment. Considerable declining trend of prescribed sick leave days was detected, especially during the first years after the intervention, levelling off somewhat thereafter. OHS policies and structures were seen to enable professionals’ focusing on preventing pain-related disability and prolonged sick leaves. The decline of sickness absences was also attributed to the municipal client organization’s commitment and the employees’ positive attitudes towards the alternatives to full-time sick leave. Conclusions The guidelines implementation intervention was found successful. The study showed the importance of social and organizational environment supporting physicians’ engagement in recommended practices. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05234-8.
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Affiliation(s)
- Ritva Horppu
- Finnish Institute of Occupational Health, P.O Box 40, 00032, Helsinki, Finland.
| | - Ari Väänänen
- Finnish Institute of Occupational Health, P.O Box 40, 00032, Helsinki, Finland
| | - Johanna Kausto
- Finnish Institute of Occupational Health, P.O Box 40, 00032, Helsinki, Finland
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Serbic D, Evangeli M, Probyn K, Pincus T. Health-related guilt in chronic primary pain: A systematic review of evidence. Br J Health Psychol 2021; 27:67-95. [PMID: 33949061 DOI: 10.1111/bjhp.12529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/01/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Chronic primary pain conditions are characterized by significant functional disability, emotional distress, and diagnostic uncertainty. Health-related guilt associated with coping and living with chronic pain is poorly understood. There had been no attempts to synthesize findings on health-related guilt across studies. Therefore, the aim of this study was to conduct a systemic review of evidence, to enable an understanding of the role of health-related guilt in chronic primary pain, and to provide directions for future research. METHOD A search strategy was developed based on our eligibility criteria. Four databases (PsycINFO, Scopus, PubMed, and Web of Science) were searched for relevant papers from inception to 8 July 2020. Data from 12 qualitative and six quantitative studies were synthesized narratively. RESULTS The review of qualitative studies resulted in three themes, relating to the management of pain, diagnostic uncertainty/legitimizing pain, and how participants' actions or inactions affect others. These findings were integrated with evidence from quantitative studies, which showed that higher levels of guilt were associated with more pain and pain interference, functional impairment, and poorer psychological and social functioning. CONCLUSIONS The findings demonstrate that health-related guilt is an important psychological factor associated with more pain and poorer function in people with chronic primary pain conditions. Future research should examine health-related guilt as a potential mediating/moderating factor leading to more distress and suffering in this population and as a potential target for interventions.
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Affiliation(s)
- Danijela Serbic
- Department of Psychology, Royal Holloway, University of London, Egham, UK
| | - Michael Evangeli
- Department of Psychology, Royal Holloway, University of London, Egham, UK
| | - Katrin Probyn
- Department of Psychology, Royal Holloway, University of London, Egham, UK
| | - Tamar Pincus
- Department of Psychology, Royal Holloway, University of London, Egham, UK
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Lian OS, Nettleton S, Wifstad Å, Dowrick C. Modes of Interaction in Naturally Occurring Medical Encounters With General Practitioners: The "One in a Million" Study. QUALITATIVE HEALTH RESEARCH 2021; 31:1129-1143. [PMID: 33660573 PMCID: PMC8114434 DOI: 10.1177/1049732321993790] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In this article, we qualitatively explore the manner and style in which medical encounters between patients and general practitioners (GPs) are mutually conducted, as exhibited in situ in 10 consultations sourced from the One in a Million: Primary Care Consultations Archive in England. Our main objectives are to identify interactional modes, to develop a classification of these modes, and to uncover how modes emerge and shift both within and between consultations. Deploying an interactional perspective and a thematic and narrative analysis of consultation transcripts, we identified five distinctive interactional modes: question and answer (Q&A) mode, lecture mode, probabilistic mode, competition mode, and narrative mode. Most modes are GP-led. Mode shifts within consultations generally map on to the chronology of the medical encounter. Patient-led narrative modes are initiated by patients themselves, which demonstrates agency. Our classification of modes derives from complete naturally occurring consultations, covering a wide range of symptoms, and may have general applicability.
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Affiliation(s)
- Olaug S. Lian
- University of Tromsø–The Arctic University of Norway, Tromsø, Norway
| | | | - Åge Wifstad
- University of Tromsø–The Arctic University of Norway, Tromsø, Norway
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Yin Y, Chu X, Han X, Cao Y, Di H, Zhang Y, Zeng X. General practitioner trainees' career perspectives after COVID-19: a qualitative study in China. BMC FAMILY PRACTICE 2021; 22:18. [PMID: 33430776 PMCID: PMC7797889 DOI: 10.1186/s12875-020-01364-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/27/2020] [Indexed: 11/20/2022]
Abstract
Background The coronavirus disease 2019 (COVID-19) has been a worldwide public health emergency that has put great pressure on medical workers and the medical system. General Practitioners (GPs) played an important role in controlling the epidemic, and GP trainees also took an active part in this approach. This study was to explore Chinese GP trainees’ career perspectives after COVID-19. Methods We conducted a qualitative research study which included 12 GP trainees from three teaching hospitals in China. Semi-structured telephone interviews were conducted. Grounded theory and thematic analysis were used to code the data and identify categories and factors. Results Eleven participants chose to continue a GP career after COVID-19, and nearly half of the participants strengthened their determination to dedicate themselves to this career. Only one participant decided to change the career choice because of interest in another specialty. Four main themes influencing GP trainees’ perceptions of career development after COVID-19 emerged from the interviews: changes of GPs’ work content in COVID-19, challenges of being a GP, psychological changes of the career, how to provide better primary care. Although some negative psychological changes existed, most of participants were inspired by role models and medical colleagues. They had more in-depth understanding of GPs’ role and responsibility during COVID-19, and exhibited intensions for self-improvement in career development, especially in public health education and self-protection in preventing infectious diseases. In addition, the wide use of telemedicine provided a new work way for GP trainees. However, challenges, such as increased workloads, low income, lack of resources in primary medical institutions, and distrust of GPs are faced by trainees during the outbreak. Conclusions Overall, no substantial changes were seen in the career choice of GP trainees after COVID-19 outbreak. However, they were inspired and had an in-depth understanding about the GP’s work and responsibility during an epidemic. Owing to the challenges faced by the GPs, measures are needed to improve the GP education and work environment in the training phase. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-020-01364-x.
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Affiliation(s)
- Yue Yin
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China
| | - Xiaotian Chu
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China
| | - Xinxin Han
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China
| | - Yu Cao
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China
| | - Hong Di
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China
| | - Yun Zhang
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China
| | - Xuejun Zeng
- Department of General Practice (General Internal Medicine), Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, 100730, China.
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Cailhol J, Lebon MC, Sherlaw W. Will my patients get their residence permit? A critical analysis of the ethical dilemmas involved in writing medical certificates for residence permits in France. BMC Med Ethics 2020; 21:59. [PMID: 32660550 PMCID: PMC7359478 DOI: 10.1186/s12910-020-00500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND France has long been a country of immigration and in some respects may be seen to have a generous policy with respect to asylum seekers and access to health care for migrants. The French state notably provides healthcare access for undocumented migrants, through state medical aid and since 1998 has had a humanitarian policy for granting temporary residence permits for medical reason (TRPMR) to migrants. Within a context of political debate, reform and tightening immigration control we will examine this latter policy focusing especially on the dilemmas that arise for physicians of migrant patients when they are requested to write medical certificates as part of a TRPMR application. In a 2017 reform the key role of making recommendations on the granting or not of permits was handed over to Ministry of the Interior health inspectors. Recommendations are made after perusal of medical certificates established by the migrant's physician and complementary evidence. MAIN BODY The writing of medical certificates by a physician would seem straightforward. This is far from the case since it raises a number of ethical dilemmas. These occur within a physician-patient relationship embedded within a social contract between the State, the physician and the migrant patient. To clarify the ethical issues arising 3 vignettes based on practice within an infectious disease unit at a large Paris hospital have been developed. The vignettes highlight ethical dilemmas in the care for migrants with tuberculosis (dilemma in defining health and disease), chronic hepatitis (dilemma between beneficence and do not harm), and HIV / AIDS (issue of deservingness). We will go on to reflect on issues of social justice and responsibility for the health of migrants within a globalized world. CONCLUSIONS Criteria for residence permit delivery appear less than clear-cut and are interpreted in a restrictive way. Neither are the consequences of refusing a residence permit taken into account. We call for an empirical transnational ethics study involving countries implementing similar TRPMR policies. We also call for inclusion of lobbying competences into the medical undergraduate curricula, in order to breed future generations of physicians skilled in defending social justice.
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Affiliation(s)
- Johann Cailhol
- Laboratoire Educations et Pratiques de Santé, Université Paris 13, 74 rue Marcel Cachin, Bobigny, France. .,Infectious diseases unit, Avicenne teaching hospital, APHP, 125 route de Stalingrad, 93000, Bobigny, France. .,Institut Convergences Migrations, Campus Condorcet, Hôtel à projets, 8 cours des Humanités, 93300, Aubervilliers, France.
| | - Marie-Christine Lebon
- Infectious diseases unit, Avicenne teaching hospital, APHP, 125 route de Stalingrad, 93000, Bobigny, France
| | - William Sherlaw
- Laboratoire d'Etudes et de Recherche en Sociologie, Université de Bretagne Occidentale, 20 rue Duquesne, 29200, Brest, France.,Ecole des Hautes Etudes en Santé Publique, 15 avenue du Professeur Léon-Bernard, 35043, Rennes, France
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Dorrington S, Carr E, Stevelink SAM, Dregan A, Whitney D, Durbaba S, Ashworth M, Mykletun A, Broadbent M, Madan I, Hatch S, Hotopf M. Demographic variation in fit note receipt and long-term conditions in south London. Occup Environ Med 2020; 77:418-426. [DOI: 10.1136/oemed-2019-106035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 12/02/2019] [Accepted: 02/14/2020] [Indexed: 11/04/2022]
Abstract
ObjectivesIntroduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.MethodsData were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.ResultsIn a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.ConclusionsFor the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.
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Pain drawings, interpreter support and clinical findings among immigrant patients on sick leave in Swedish primary health care. Prim Health Care Res Dev 2019; 20:e137. [PMID: 31581973 PMCID: PMC6784159 DOI: 10.1017/s1463423619000628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aim: To evaluate the spread of pain and its correlates among immigrant patients on sick leave. Background: Backache, outspread pain and sick-leave questions are problematic to handle primary health care, especially in multicultural settings. Methods: Two hundred and thirty-five patients 20–45 years on paid sick leave (59% women, 93% foreign-born, mostly non-Europeans). Many had little formal education. One-third had professional interpreter support. The patients pointed out on their bodies where they felt pain. This information was transferred on a pain drawing [pain drawing fields (PDFs) 0–18] by a doctor. Major depression and psychosocial stressors were assessed using Diagnostic and Statistical Manual of Mental Disorders. Nociceptive locations for pain were established (pain-sites 0–18). Dependent variable was the number of PDFs. Independent variables were social data, sick leave, interpreter, depression, stress levels and number of pain sites. Calculations were done using descriptive methods and multi-variable linear regression in full models, by gender. Findings: Many patients had depression (51% women versus 32% men). A majority were exposed to psychosocial stressors. Women had more PDFs, in median 5 [inter-quartile ranges (IQR) 4–8] versus men 3 (IQR 2–5), and also more pain sites, in median 3 (IQR 2–5) versus men in median 2 (IQR 1–3). For men, the regression calculations revealed that numbers of PDFs associated only with increasing numbers of pain sites (B 0.871 P < 0.001). For women, this association was weaker (B 0.364, P < 0.001), with significant values also for age (B 0.103) and sick leave > one year (B 0.767, P = 0.010), and a negative predicting value for interpreter support (B −1.198, P < 0.043). To conclude, PDFs associated often with somatic findings but varied much among the women. This implies potential problems regarding cause, function and sick leave questions. However, support by professional interpreters may facilitate a shared understanding with immigrant women having long-standing pain.
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Wainwright E, Looseley A, Mouton R, O'Connor M, Taylor G, Cook TM. Stress, burnout, depression and work satisfaction among
UK
anaesthetic trainees: a qualitative analysis of in‐depth participant interviews in the Satisfaction and Wellbeing in Anaesthetic Training study. Anaesthesia 2019; 74:1240-1251. [DOI: 10.1111/anae.14694] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 01/22/2023]
Affiliation(s)
- E. Wainwright
- Bath Spa University Bath UK
- University of Bath BathUK
| | | | | | - M. O'Connor
- Severn Postgraduate Medical Education Bristol UK
- Swindon and Marlborough NHS Trust Swindon UK
| | | | - T. M. Cook
- Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Bristol Medical School University of Bristol UK
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Singh R, O'Hagan F. "Apping Up": Prospects for Information Technology Innovation in Return to Work Communication. JOURNAL OF OCCUPATIONAL REHABILITATION 2019; 29:104-118. [PMID: 29564677 DOI: 10.1007/s10926-018-9768-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Purpose During return to work (RTW), communication between health care providers and employers largely takes place through standardize paper-based forms. Information technology (IT) platforms may provide advantages in enabling information exchange and decision-making through sharing of guidelines and resources. We investigated stakeholder perspectives on the prospect of IT use for RTW communication in Ontario, Canada. Methods Consistent with the exploratory nature of the questions, qualitative methods were used. Primary data were interviews with health care providers (HCPs), employers, and workers with experience in RTW. The first portion of initial interviews elicited general perspectives and experiences related to RTW communication. Participants were then exposed to a prototype IT communication platform and elicited their feedback. Follow-up interviews with HCP's and EMP's were used to allow further reflection and clarification of data. We used progressive, thematic coding to analyze data. Results 12 HCPs, 7 employers, and 5 workers participated in the study. Five inter-related themes were obtained. Participants expressed no absolute objection to the use of IT for RTW communication but varying degrees of support. Participants revealed how media change depended on a prospective IT innovation's perceived usefulness, fit with current practices, capacity to gain buy-in from other stakeholders, and ability to demonstrate positive performance in actual practice. Conclusions Findings suggest that a transition to an IT-mediated tool for RTW communication is supported in principle; however, major caveats exist in relation to perceived value and fit with stakeholder practice. System support and stakeholder cooperation are likely necessary to adopt the change, yet IT-mediated communication has yet to demonstrate value. To avoid circularity, proof of principal needs to be established through an implementation trial of such technology.
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Affiliation(s)
- Ripdaman Singh
- Department of Psychology, Trent University, 1600 West Bank Dr., Peterborough, ON, K9J 7B8, Canada
| | - Fergal O'Hagan
- Department of Psychology, Trent University, 1600 West Bank Dr., Peterborough, ON, K9J 7B8, Canada.
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12
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Weerdesteijn KHN, Schaafsma FG, van der Beek AJ, Merkus SL, Maeland S, Hoedeman R, Lissenberg-Witte BI, Werner EL, Anema JR. Sick leave assessments of workers with subjective health complaints: a cross-sectional study on differences among physicians working in occupational health care. Disabil Rehabil 2019; 42:967-974. [PMID: 30688122 DOI: 10.1080/09638288.2018.1513085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aims: To obtain more insight into differences in sick leave assessments of workers with subjective health complaints, we studied sick leave assessments among Dutch occupational and insurance physicians, and explored possible determinants for these differences.Methods: A cross-sectional study was conducted among 50 occupational and 43 insurance physicians in the Netherlands. They all assessed sick leave (complete, partial or no) of nine video case vignettes of workers with subjective health complaints and gave their opinion on the complaints, sick leave and health status. Data were analyzed via a multinomial regression approach, using generalized estimating equations in SPSS.Results: Compared to occupational physicians, complete sick leave was less likely to be assessed by insurance physicians (odds ratio 0.74, 95% confidence interval 0.56-0.97). For occupational physicians, psychological diagnoses, private issues and reduced work ability had more influence on the outcome of the sick leave assessment than for insurance physicians.Conclusion: There are differences in sick leave assessments for workers with subjective health complaints between physicians working in the same occupational health system; insurance physicians are stricter in assessing complete sick leave than occupational physicians. These differences may be explained by differences in roles, tasks and perspectives of the physician in occupational health care.Implications for Rehabilitation Sick leave assessments of workers with subjective health complaints. • The current study showed that there are differences between occupational physicians and insurance physicians in sick leave assessments for workers with subjective health complaints. • These differences may be based on different perspectives, roles and tasks of physicians. • Physicians working in the rehabilitation and occupational health system should be more aware of the impact of these differences on their assessments and advices. • Better communication and collaboration between physicians, and more insight into and clarification of the perspectives may result in more agreement between physicians' sick leave assessment and advice towards workers.
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Affiliation(s)
- Kristel H N Weerdesteijn
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.,Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands.,Department of Social Medical Affairs, The Dutch Social Security Institute: the Institute for Employee Benefits Schemes, Amsterdam, the Netherlands
| | - Frederieke G Schaafsma
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.,Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Allard J van der Beek
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.,Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Suzanne L Merkus
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.,Department of Uni Research Health, Uni Research, Bergen, Norway
| | - Silje Maeland
- Department of Uni Research Health, Uni Research, Bergen, Norway
| | - Rob Hoedeman
- Department of Science, ArboNed Occupational Health Services, Utrecht, the Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Erik L Werner
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Johannes R Anema
- Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.,Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
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Dorrington S, Roberts E, Mykletun A, Hatch S, Madan I, Hotopf M. Systematic review of fit note use for workers in the UK. Occup Environ Med 2018; 75:530-539. [PMID: 29735750 DOI: 10.1136/oemed-2017-104730] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/23/2018] [Accepted: 03/09/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The fit note, introduced in England, Wales and Scotland in 2010, was designed to change radically the sickness certification process from advising individuals on their inability to work to advising them on what they could do if work could be adapted. Our review aimed to evaluate the following: (1) Is the 'maybe fit' for work option being selected for patients? (2) Are work solutions being recommended? (3) Has the fit note increased return to work? (4) Has the fit note reduced the length of sickness absence? We considered the way in which outcomes vary according to patient demographics including type of health problem. METHODS Studies were identified by a systematic search. We included all studies of any design conducted in the UK with working age adults, aged 16 or over, from 1 April 2010 to 1 Nov 2017. Risk of bias was assessed using a modified Newcastle-Ottawa Scale. RESULTS Thirteen papers representing seven studies met inclusion criteria. In the largest study, 'maybe fit' for work was recommended in 6.5% of fit notes delivered by general practitioners (GP; n=361 801) between April 2016 and March 2017. 'Maybe fit' recommendations were made in 8.5%-10% of fit notes received by primary care patients in employment, and in 10%-32% of patients seen by GPs trained in the Diploma in Occupational Medicine. 'Maybe fit' was recommended more for women, those with higher socioeconomic status, and for physical, as opposed to psychiatric disorders. The majority of fit notes with the 'maybe fit' option selected included work solutions. There was inconclusive evidence to suggest that the introduction of the fit note has reduced sickness absence among patients in employment. CONCLUSIONS Fit notes represent a major shift in public policy. Our review suggests that they have been incompletely researched and not implemented as intended.
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Affiliation(s)
- Sarah Dorrington
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Emmert Roberts
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Arnstein Mykletun
- Department of Mental Health and Suicide, Norwegian Institute of Public Health, Oslo, Norway.,Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway.,Research Unit, Directorate of Labour and Welfare, Oslo, Norway.,Centre for Research and Education in Forensic Psychiatry and Psychology, Haukeland University Hospital, Bergen, Norway.,Department of Community Medicine, University of Tromsø, Tromsø, Norway
| | - Stephani Hatch
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ira Madan
- Department of Occupational Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
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Ng DCC, Lew YJ, Koh EYL, Nguyen VH, Wong HB, James L, Tan NC. Sickness certification in Singapore’s public primary healthcare system: A cross-sectional analysis. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817741661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: Sickness absenteeism has been rising in Singapore with sickness certification commonly performed by primary care physicians. The Primary Care Survey 2014 reported increased primary care demand driven by a rapidly ageing population and the prevalence of chronic disease. This article aims to determine the magnitude of outpatient sickness certification in all the polyclinics in Singapore and identify the demographic characteristics and factors influencing the taking of sick leave by the local multi-ethnic Asian patients. Design: A one-week, cross-sectional survey using computer-assisted interviews with age-stratified, systematically sampled patients was conducted at all 18 polyclinics in 2014. Sick leave data was then extracted from each polyclinic’s administrative system. Data was analysed with logistic regression to determine statistically significant factors. Results: The sickness certification rate was 22.6% during the study period with a weighted average duration of 1.42 days. Sickness certification was most associated with the younger age group (17–20 years; adjusted odd ratio (AOR) = 9.51), an acute condition (AOR = 24.8) and those living in 1–2 room public housing (AOR = 4.72). Among employees, those working in manufacturing industries had the most association with sickness certification while the finance and insurance industry had the least. An acute upper respiratory tract infection was the most frequent diagnosis for those who obtained medical certificates (38.7%). Conclusion: A medical certificate was issued in almost one-quarter of consultations in Singapore polyclinics. Sickness certification was predominated by short-term absence for acute conditions. Characterisation of sickness absenteeism among employees serves as a benchmark for future studies. Mitigation measures were discussed while exclusion of private primary care clinics probably led to an underestimation of the magnitude of sickness certification.
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Affiliation(s)
| | - Yii Jen Lew
- National Healthcare Group Polyclinics, Singapore
| | | | | | | | | | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore
- Duke NUS Medical School, Singapore
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15
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Mandal R, Dyrstad K. Explaining variations in general practitioners’ experiences of doing medically based assessments of work ability in disability benefit claims. A survey-based analysis. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1368614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Roland Mandal
- Department of Health Research, SINTEF Technology and Society, Pb 4760 Sluppen, 7465 Trondheim, Norway
| | - Karin Dyrstad
- Department of Health Research, SINTEF Technology and Society, Pb 4760 Sluppen, 7465 Trondheim, Norway
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16
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Wainwright E, Fox F, Breffni T, Taylor G, O’Connor M. Coming back from the edge: a qualitative study of a professional support unit for junior doctors. BMC MEDICAL EDUCATION 2017; 17:142. [PMID: 28835270 PMCID: PMC5569516 DOI: 10.1186/s12909-017-0978-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 08/13/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND It is known that many trainee doctors around the world experience work satisfaction but also considerable work stress in the training period. Such stress seems to be linked to multiple factors including workload, level of support and growing cultural inculcation into unwillingness to show any personal or professional weakness. In the United Kingdom, junior doctors are qualified medical practitioners who have gained a degree in Medicine and are now working while training to become a specialist (consultant) or a general practitioner. The period of medical training can be particularly stressful for some UK junior doctors, in common with their counterparts in other countries. UK Postgraduate Medical Deaneries provide support for those who need it via Professional Support Units (PSUs); however little is known about the perceptions and experiences of the doctors who access and utilise this support. This study aimed to generate qualitative insight into how the (PSU) provided by one UK Deanery is experienced by the trainees who accessed it. We aimed to investigate whether such experience intersects with the progressive socialisation of trainee doctors into the notion that doctors do not get ill. METHODS Through in-depth telephone interviews with eight female junior doctors, we explored the benefits and problems associated with using a PSU with reference to the formation of trainee doctors' professional identities, and conducted a thematic analysis. RESULTS Themes identified illustrate the process of accepting, accessing and benefiting from PSU support. These are: Medical identity intact (it will never happen to me); Denial of disrupted medical identity; Being on the edge: accepting help; Role of PSU in 'recovery' process; Repaired identity / coming back from the edge; Different ways to be a doctor. The gendered sample occurred simply as it was females who responded to study invitations. Whilst we present some related aspects (such as "manning up" as part of keeping going), analyses of this small sample showed that medical identity as a doctor in training was more salient than a gendered experience of help seeking in this study. CONCLUSIONS This study highlights the initial reluctance of female junior doctors to seek help from the PSU, as acknowledging their own difficulties spoiled their identity as a competent doctor. However, once engaged with the PSU, the findings exemplify its role in repairing medical identity, by offering different and acceptable ways to be a doctor. We interpret these findings within Goffman's theoretical framework of stigma conferring a spoiled identity on recipients, and how this may then be repaired. Reducing the stigma attached to initial help-seeking among junior doctors is crucial to increase ease of access to the PSU and to improve the experiences of doctors who encounter challenges during their training.
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Affiliation(s)
- Elaine Wainwright
- Psychology Department, Bath Spa University, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | - Fiona Fox
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - Tailte Breffni
- Severn Postgraduate Medical Education (Deanery), Bristol, UK
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17
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Merkus SL, Hoedeman R, Mæland S, Weerdesteijn KHN, Schaafsma FG, Jourdain M, Canevet JP, Rat C, Anema JR, Werner EL. Are there patient-related factors that influence sickness certification in patients with severe subjective health complaints? A cross-sectional exploratory study from different European countries. BMJ Open 2017; 7:e015025. [PMID: 28733298 PMCID: PMC5642667 DOI: 10.1136/bmjopen-2016-015025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To develop hypotheses about whether there are patient-related factors that influence physicians' decision-making that can explain why some patients with severe subjective health complaints (SHCs) are more likely to be granted sick leave than others. DESIGN Exploratory cross-sectional. SETTING Assessments of patient-related factors after watching nine authentic video recordings of patients with severe SHC from a Norwegian general practice. Our previous study showed that three of these nine patients were less likely than the remaining six patients to be granted sick leave by physicians from five European countries. PARTICIPANTS In total, 10 assessors from Norway, the Netherlands and France. OUTCOMES The direction in which the assessments may contribute towards the decision to grant a sickness certificate (increasing or decreasing the likelihood of granting sick leave). RESULTS Physicians consider a wide variety of patient-related factors when assessing sickness certification. The overall assessment of these factors may provide an indication of whether a patient is more likely or less likely to be granted sick leave. Additionally, some single questions (notable functional limitations in the consultation, visible suffering, a clear purpose for sick leave and psychiatric comorbidity) may indicate differences between the two patient groups. CONCLUSIONS Next to the overall assessment, no notable effect of the complaints on functioning and suffering, a lack of a clear purpose for sick leave and the absence of psychiatric comorbidity may be factors that could help guide the decision to grant sick leave. These hypotheses should be tested and validated in representative samples of professionals involved in sickness certification. This may help to understand the tacit knowledge we believe physicians have when assessing work capacity of patients with severe SHC.
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Affiliation(s)
- Suzanne L Merkus
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Rob Hoedeman
- Department of Science, ArboNed Occupational Health Services, Utrecht, The Netherlands
| | - Silje Mæland
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway
| | - Kristel H N Weerdesteijn
- Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Frederieke G Schaafsma
- Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Maud Jourdain
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Jean-Paul Canevet
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Cédric Rat
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Johannes R Anema
- Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Erik L Werner
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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18
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Werner EL, Merkus SL, Mæland S, Jourdain M, Schaafsma F, Canevet JP, Weerdesteijn KHN, Rat C, Anema JR. Physicians' assessments of work capacity in patients with severe subjective health complaints: a cross-sectional study on differences between five European countries. BMJ Open 2016; 6:e011316. [PMID: 27417198 PMCID: PMC4947783 DOI: 10.1136/bmjopen-2016-011316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES A comparison of appraisals made by general practitioners (GPs) in France and occupational physicians (OPs) and insurance physicians (IPs) in the Netherlands with those made by Scandinavian GPs on work capacity in patients with severe subjective health complaints (SHCs). SETTING GPs in France and OPs/IPs in the Netherlands gathered to watch nine authentic video recordings from a Norwegian general practice. PARTICIPANTS 46 GPs in France and 93 OPs/IPs in the Netherlands were invited to a 1-day course on SHC. OUTCOMES Recommendation of sick leave (full or partial) or no sick leave for each of the patients. RESULTS Compared with Norwegian GPs, sick leave was less likely to be granted by Swedish GPs (OR 0.51, 95% CI 0.30 to 0.86) and by Dutch OPs/IPs (OR 0.53, 95% CI 0.37 to 0.78). The differences between Swedish and Norwegian GPs were maintained in the adjusted analyses (OR 0.43, 95% CI 0.23 to 0.79). This was also true for the differences between Dutch and Norwegian physicians (OR 0.55, 95% CI 0.36 to 0.86). Overall, compared with the GPs, the Dutch OPs/IPs were less likely to grant sick leave (OR 0.60, 95% CI 0.45 to 0.87). CONCLUSIONS Swedish GPs and Dutch OPs/IPs were less likely to grant sick leave to patients with severe SHC compared with GPs from Norway, while GPs from Denmark and France were just as likely to grant sick leave as the Norwegian GPs. We suggest that these findings may be due to the guidelines on sick-listing and on patients with severe SHC which exist in Sweden and the Netherlands, respectively. Differences in the working conditions, relationships with patients and training of specialists in occupational medicine may also have affected the results. However, a pattern was observed in which of the patients the physicians in all countries thought should be sick-listed, suggesting that the physicians share tacit knowledge regarding sick leave decision-making in patients with severe SHC.
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Affiliation(s)
- Erik L Werner
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
| | - Suzanne L Merkus
- Department of Public and Occupational Health, the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Uni Research Health, Bergen, Norway
| | - Silje Mæland
- Uni Research Health, Bergen, Norway
- Department of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway
| | - Maud Jourdain
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Frederieke Schaafsma
- Department of Public and Occupational Health, the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
| | - Jean Paul Canevet
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Kristel H N Weerdesteijn
- Department of Public and Occupational Health, the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
- Department of Social Medical Affairs, UWV, Dutch Social Security Agency, Amsterdam, The Netherlands
| | - Cédric Rat
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Johannes R Anema
- Department of Public and Occupational Health, the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Research Center for Insurance Medicine, AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands
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Hussey L, Money A, Gittins M, Agius R. Has the fit note reduced general practice sickness certification rates? Occup Med (Lond) 2015; 65:182-9. [PMID: 25740915 DOI: 10.1093/occmed/kqu207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In 2010, the fit note replaced the sick note to help focus on what people are capable of doing, rather than signing patients 'off sick'. AIMS To compare proportions of work-related ill-health issued with sickness certification pre- and post-fit note introduction and assess sickness absence trends. METHODS General practitioners (GPs) report data on work-related ill-health and sickness absence via The Health and Occupation Research network in General Practice. The proportion of cases issued with sickness certification 4 years before and 3 years after the fit note introduction were compared. Changes in certification incidence rate ratios were measured over time. RESULTS Participating GPs reported 5517 cases of work-related ill-health. Pre-fit note introduction 50% of cases were certified sick. There was no change in the proportion of cases certified sick in the first year post-fit note, despite 13% of cases classified as 'maybe fit'. However, in the second year, the proportion of cases certified sick had reduced significantly (41%) and a larger proportion (19%) was advised on workplace adjustments. In the third year post-introduction, there was a slight rise in the proportion of cases certified sick; therefore, although there was a fall of 2% per annum in certification rates, this was not significant. CONCLUSIONS In the first year post-fit note introduction, modifications to work were recommended for people who would previously have been declared fit. Trends analyses showed a slight decrease in the certification rate, possibly indicating GPs will become more practised in advising on workplace adjustments.
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Affiliation(s)
- L Hussey
- Centre for Occupational and Environmental Health, Centre for Epidemiology, Institute of Population Health, The University of Manchester, Manchester M13 9PL, UK,
| | - A Money
- Centre for Occupational and Environmental Health, Centre for Epidemiology, Institute of Population Health, The University of Manchester, Manchester M13 9PL, UK
| | - M Gittins
- Centre for Biostatistics, Institute of Population Health, The University of Manchester, Manchester M13 9PL, UK
| | - R Agius
- Centre for Occupational and Environmental Health, Centre for Epidemiology, Institute of Population Health, The University of Manchester, Manchester M13 9PL, UK
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