Acting by persuasion— values and rhetoric in medical certificates of work incapacity: A qualitative document analysis

Abstract

When the patient applies for disability benefit in Norway, the general practitioner (GP) is required by the National Insurance Administration (NAV) to confirm that the patient is unfit for work due to disease. Considering the important social role of medical certificates, they have been given surprisingly little attention by the medical critique. They may make essential differences to peoples' lives, legitimise large social costs and, in addition, the GPs report that issuing certificates can be problematic. This article explores values, attitudes and persuasive language in a selection of medical certificates written by GPs. We direct attention to such texts as significant social actors using a mixed rhetoric including certain values and attitudes. When arguing for granting the patient disability benefit, some GPs emphasised the 'worthiness' of the patient by pointing to positive attitudes approved by the national insurance: a will to work and participate, to cooperate and be motivated. Others pointed out the patient's positive character in terms of universally accepted values, called for the reader's (the NAV official) sympathy , understanding and helpfulness or appealed to his/her willingness to be realistic and pragmatic and grant disability benefit (DB). The dialogic style varied: some certifiers-although they argued for disability benefit-showed openness to possible opposing or alternative voices by displaying their own uncertainty. Others addressed the reader to share responsibility, demanding or urging for DB. This shifting rhetoric, we believe, mirrors that the GPs see themselves as the patient's advocate, and that they may find themselves conflicted. We propose further studies within qualitative research to investigate the effect of this rhetoric on the reader, the decision-makers. In addition, to improve the quality and accuracy of these important documents, we suggest that medical schools introduce students to the making of text as a specific skill of medical practice.

Cross‐sectoral frontline delivery of welfare‐to‐work services for young adults with complex problems in Norway

“…Håvold et al (2018) also note that compared to frontline welfare workers, the medical profession ranks high in the occupational hierarchy, with more education and a strong professional organisation. This is reflected in the strong position ‘objective’ medical assessment has in the social insurance system, although GPs may often find it hard to live up to these expectations (Aarseth et al, 2019; Krohne & Brage, 2008). We find few stories, however, about NAV frontline workers actively educating GPs on activation and an ‘asset‐based’ ideology of health, as found by Håvold et al (2018).…”

“…The GPs on the other hand, particularly when faced with mentally ill patients, or patients with musculoskeletal complaints, who have little or no work experience, feel ill equipped in making qualified professional judgements about individuals' work ability (Krohne & Brage, 2008). The inherent conflict between the medical ethos of being the patient's advocate and making professional judgements under great uncertainty, seem to result in various rhetoric strategies in medical certificates, ranging from emphasising the patient's 'worthiness' or positive character, like their willingness to work; making pleas for sympathy and understanding; to displaying professional uncertainties and doubts (Aarseth et al, 2019). Håvold et al (2018) also note that compared to frontline welfare workers, the medical profession ranks high in the occupational hierarchy, with more education and a strong professional organisation.…”

Estranged relations: coercion and care in narratives of supported decision-making in mental healthcare

“…23. Guri Aarseth et al (2019), “Acting by Persuasion— Values and Rhetoric in Medical Certificates of Work Incapacity: A Qualitative Document Analysis,” Medical Humanities 45: 60–6; Hande Güzel (2018), “Pain as Performance: Re-Virginisation in Turkey,” Medical Humanities 44, no. 2: 89–95.…”

Kaleidoscope

“…This is perhaps amplified in psychiatry, where we aspire to parity of esteem and yet many of us have at times just scribbled ‘stress’ upon a sick note to minimise stigma or awkward questions. Aarseth et al 5 label such certificates ‘social actors’ as they produce change (including releasing critical public resources and funds), and report on an analysis of sick notes written by general practitioners in Norway, exploring values, attitudes and language. Interestingly, in the evaluated sample, arguments based on factual medical information and effects on functioning were not to the fore.…”