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Background The purpose of this study is to increase understanding of physicians’ attitudes towards disability pension applicants, and the impact of diagnosis. We hypothesize that physicians are more likely to think that patients with physical illnesses should get a disability pension than those with mental illness or alcohol dependence. Disability pension is an important source of income for those unable to work because of a disability and type of diagnosis should not impact accessing these benefits. Methods We conducted an experiment with a 2 by 3 factorial structure in Sweden. Each physician was randomly assigned one of six patient vignettes, with the same background description but with a different diagnosis. Each vignette had a diagnosis of either depression, alcohol dependence or low back pain, and was about a man or a woman. Logistic regression was used to examine the odds of a physician reporting that a patient should get a disability pension. Effects are reported in terms of odds ratios (ORs). Results 1414 Swedish registered physicians in psychiatry or general practice (24% response rate) completed the survey. Physicians assigned the alcohol dependent vignette had OR 0.45 (95% CI: 0.34 to 0.60) for perceiving that a patient should get a disability pension compared to physicians assigned the low back pain vignette. Physicians assigned the depression vignette had OR 1.89 (95% CI: 1.42 to 2.50) for perceiving that a patient should get a disability pension compared to physicians assigned the low back pain vignette. Conclusion The patient diagnosis was associated with the physicians’ response regarding if the patient should get a disability pension. A physician’s perception is likely to impact a patient’s access to disability pension.

In recent decades, many countries have implemented return-to-work coordinators to combat high rates of sickness absence and insufficient collaboration in the return-to-work process. The coordinators should improve communication and collaboration between stakeholders in the return-to-work process for people on sickness absence. How they perform their daily work remains unexplored, and we know little about to what extent they collaborate and perform other work tasks to support people on sickness absence. This study examines which work models return-to-work coordinators use in primary healthcare, psychiatry and orthopaedics in Sweden. A questionnaire was sent to all 82 coordinators in one region (89% response rate) with questions about the selection of patients, individual patient support, healthcare collaboration, and external collaboration. Random forest classification analysis was used to identify the models. Three work models were identified. In model A, coordinators were more likely to select certain groups of patients, spend more time in telephone than in face-to-face meetings, and collaborate fairly much. In Model B there was less patient selection and much collaboration and face-to-face meetings. Model C involved little patient selection, much telephone contact and very little collaboration. Model A was more common in primary healthcare, model C in orthopaedics, while model B was distributed equally between primary healthcare and psychiatry. The work models correspond differently to the coordinator's assignments of supporting patients and collaborating with healthcare and other stakeholders. The differences lie in how much they actively select patients, how much they collaborate, and with whom. Their different distribution across clinical contexts indicates that organisational demands influence how work models evolve in practice.

Background: Receiving support from a return-to-work (RTW) coordinator (RTWC) may be beneficial for people on long-term sick leave. The aim of this study was to investigate whether the number of contacts with an RTWC and their involvement in designing rehabilitation plans for the patients were associated with perceiving support for RTW, emotional response to the RTWC, and healthcare utilization. Methods: In this cross-sectional study, 274 patients who had recently been in contact with an RTWC in Swedish primary or psychiatric care answered questions regarding their interaction with an RTWC, perceived support for RTW, and emotional response to the RTWC. Results: Having more contact with an RTWC was associated with perceiving more support in the RTW process (adjusted OR 4.14, 95% CI 1.49–11.47). RTWC involvement in designing a rehabilitation plan for the patient was associated with perceiving more support in the RTW process from an RTWC and having a more positive emotional response to the RTWC. Conclusions: From the patient’s perspective, this study indicates that the involvement of an RTWC and receiving a rehabilitation plan that an RTWC has helped to design might be perceived as important in the RTW process.

Objective. Tasks involved in sickness certification constitute potential problems for physicians. The objective in this study was to obtain more detailed knowledge about the problems that general practitioners (GPs) experience in sickness certification cases, specifically regarding reasons for issuing unnecessarily long sick-leave periods. Design. A cross-sectional national questionnaire study. Setting. Primary health care in Sweden. Subjects. The 2516 general practitioners (GPs), below 65 years of age, who had consultations involving sickness certification every week. This makes it the by far largest such study worldwide. The response rate among GPs was 59.9%. Results. Once a week, half of the GPs (54.5%) found it problematic to handle sickness certification, and one-fourth (25.9%) had a patient who wanted to be sickness absent for some reason other than medical work incapacity. Issues rated as problematic by many GPs concerned assessing work capacity, prognosticating the duration of incapacity, handling situations in which the GP and the patient had different opinions on the need for sick leave, and managing the two roles as physician for the patient and medical expert in writing certificates for other authorities. Main reasons for certifying unnecessarily long sick-leave periods were long waiting times in health care and in other organizations, and younger and male GPs more often reported doing this to avoid conflicts with the patient. Conclusion. A majority of the GPs found sickness certification problematic. Most problems were related to professional competence in insurance medicine. Better possibilities to develop, maintain, and practise such professionalism are warranted.

Background and aim: Physicians play an essential role in the sickness absence process, and many of them experience related tasks as problematic. The overall aim of this thesis was to improve the understanding of sickness certification experienced as problematic by physicians in general practice and occupational health services, and to gain more knowledge about the frequency and severity of those problems. Materials and methods: Four studies were conducted, two of which were based on written cases reports, one on discussions of those reports, and one on questionnaire data. Courses intended to improve sickness certification practices for physicians in general practice and occupational health services were held in different parts of Sweden. Before taking part in such a course, the physicians were to send in a case report describing one of their own problematic sickness certification cases. During the courses, these cases were considered in group discussions. In the first study, dilemmas experienced by the physicians regarding their problematic cases were identified. The research material that was analysed consisted of some 100 documented names of dilemmas obtained from five courses, and the analytical method used was a descriptive one-step categorisation. In the second study, the main characteristics of 195 written case reports from nine courses were discerned by analysis using a stepwise descriptive categorisation and quantification. In the third study, 44 case reports were analysed with a narrative approach with elements from both thematic and structural analysis. In the fourth study, the material consisted of answers to a questionnaire that had been sent to all physicians in Sweden. The analyses included responses from 2,516 specialists in general practice regarding the frequency and severity of problems in sickness certification, and the frequency of approving unnecessarily long sick-leave periods for different reasons.Results: Eight categories of dilemmas experienced by general practitioners were identified. Examples of these were “not the doctors’ pigeon” (when the patients’ problem was perceived as not being medical in nature), “diagnosis as disguise” (when there was a discrepancy between how the patient described the problems and what the physician apprehended), and “harmed by sick listing” (when the physician perceived that the main problem was the iatrogenic adverse effects of sick leave per se). In the analyses of the written case reports about problematic sickness certification, information on the following was often provided: age and sex, family situation, occupation, stressful life events, and medical investigations and treatments. Two thirds of the patients had been on sick leave for more than a year. It was found that the most common type of cases concerned women, who were employed in non-qualified nursing occupations and were on sick leave due to psychiatric diagnoses. Furthermore, the most common measures taken by the physician were referrals to a psychotherapist and/or physiotherapist, and prescribing antidepressants. In their written case reports, physicians described clearly different ways to relate to the problems they faced, and five “types of message” were identified. A common feature of the case reports was a striving for neutrality, and that the patients’ stories tended to be interpreted within a traditional biomedical frame.

A key feature of risk analysis is that risk assessment and risk management should be functionally separated. However, the usefulness of a risk assessment may be limited if the output is not designed to help with risk management decisions. The COMRISK project investigated the communication between risk assessors and risk managers. The overall goal of the project was to identify current practices and challenges in communication between risk assessors and risk managers during the risk analysis process, and thus increase and improve the understanding and the quality of the communication between them. Specific actions to achieve this aim included reviewing of historical food safety cases, analysing risk assessment requests, identifying communication guiding documents, including legislation and agreements, conducting semi‐structured interviews with risk assessors and risk managers, and identifying tools for facilitating the communication between risk assessors and risk managers. It was concluded that the usefulness of a risk assessment is strongly dependent on well‐defined and mutually recognised risk questions and that scarce or poor communication between risk assessors and risk managers is one of the major reasons when an output from risk assessment fails to support risk management. The communication between risk assessors and risk managers preceding the onset of the risk assessment, when the risk assessment requests with its risk questions are defined, is especially identified as one of the critical points to ensure a risk assessment that is fit for purpose. However, difficulties in understanding were also reported for the communication between risk assessors and risk managers during and after the risk assessment. Lack of communication is seldom a result of formal constraints or agreements nor can it be explained by a wish of the risk assessors or risk managers. Instead, perceived constraints or traditions appear to be possible underlying factors leading to scarce or poor communication between risk assessors and risk managers. It is essential that both risk assessors and risk managers acknowledge the crucial importance of communication between them while at the same time respect their different roles in a risk analysis.According to respondents, the best solution to facilitate the framing of the risk assessment questions isan open dialogue between risk assessors and risk managers to agree on the goal of the assessment and to build trust. Further, the interviewresults indicate that a formal systematic process may facilitate communication during the risk analysis. Where there is uncertainty, e.g due to data gaps or issues related to the methodology and models, it should be acknowledged and described properly by risk assessors to risk managers. Training of risk assessors and risk managers may improve the possibility of a timely and fit‐for‐purpose output.Such a training should give a deeper insight in the risk management process, give a better understanding of the risk managers role, and especially raise the awareness of the importance of the communication between risk assessors and risk managers.To improve the risk analysis process, it is also important that the risk assessor gets feedback regarding how risk assessments have met the needs of the risk managers.The present study also found that aspects of risk communication studied in this project are not extensively discussed in the guidance documents for risk analysis. More research is needed to identify the barriers for a fit for purpose communication.