Why physicians are lousy gatekeepers: Sicklisting decisions when patients have private information on symptoms

Carlsen, Benedicte; Lind, Jo Thori; Nyborg, Karine

doi:10.1002/hec.4019

Cited by 7 publications

(4 citation statements)

References 42 publications

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“…This study is in line with previous qualitative studies on GPs’ gatekeeping decisions in sickness absence certifications, in particular the limited gatekeeping due to information asymmetry and risk of conflict with patients [ 25 , 26 , 29 , 30 , 33 , 35 ]. For several of these studies, data was collected 15–20 years ago [ 26 , 29 , 33 ].…”

Section: Discussionsupporting

confidence: 90%

“…Studies show substantial variation in GPs’ gatekeeping strictness, affecting both sickness absence incidence and duration [ 11 , 21 – 24 ]. Qualitative studies have shown that decisions about sickness certifications are particularly challenged when patients have subjective (unobservable) symptoms [ 25 – 29 ]. Studies also point to fear of conflict and damage to the doctor-patient relationship [ 27 , 30 , 31 ], patient’s ability to evoke empathy [ 30 ], physicians’ communication skills [ 32 ], and competition for patients [ 33 ] as factors contributing to GPs’ decision-making.…”

Section: Introductionmentioning

confidence: 99%

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The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

Hoff,

Kraft,

Moe

et al. 2024

BMC Public Health

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Background General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. Methods Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke’s thematic analysis approach. Results Our results indicate that GPs’ sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs’ opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs’ available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. Conclusion Our study suggests that GPs’ decisions about sickness certification is largely driven by patient preferences. The GPs’ gatekeeping function is limited to negotiations about grade and duration of absence spells.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

Hoff,

Kraft,

Moe

et al. 2024

BMC Public Health

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“…In addition, it is not obvious that doctors will act as gatekeepers to welfare benefits. Many physicians consider themselves as their patients' advocate; requests for sick leave certificates might then be difficult to deny (Svärdsudd and Englund 2000;Carlsen et al 2020;Markussen et al 2013). Their own economic interests may also weaken the role of general physicians (GPs) as gatekeepers, as they may lose patients if they decline requests for a sickness absence certificate.…”

Section: Demand For Health-related Work Absencementioning

confidence: 99%

Skipping the doctor: evidence from a case with extended self-certification of paid sick leave

Ferman¹,

Torsvik

Vaage

2021

J Popul Econ

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This paper examines the impact of a policy reform in a municipality in Norway that extended to workers the right to self-certify sickness absence from work. After the reform, workers were no longer obliged to obtain a certificate from a physician to receive sickness benefits. They could call in sick directly to their line leader and had to engage in a counselling program organized by the employer. To estimate the effect of this reform, we contrast the change in sickness absence among employees who were granted the extended right to self-certify absence with absence among employees who had to obtain a physician’s certificate to be entitled to sickness benefits. We use both a standard difference-in-differences method and the synthetic control method to estimate the effect of the reform. We can rule out large positive effects on absence after the reform, with strong evidence that the policy change actually resulted in a reduction in absence for female workers.

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“…Such tasks are complex and difficult for the GPs [ 3 , 7–9 ], especially when it is challenging to set an accurate diagnosis [ 10 , 11 ] or the patients’ complaints lack objective clinical evidence [ 4 , 10 ]. In these cases, many GPs feel obligated to trust their patients’ unverifiable symptoms [ 12 ]. Consequently, GPs are increasingly experiencing a role conflict between satisfying the interest of their patients and the doctor-patient relationship on one side [ 13 ] and on the other side acting as society’s gate keepers with the obligation to ration access to health care and welfare benefits [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

Suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. A mixed method study of GPs’ experiences

Breivik,

Kristiansen,

Zanaboni

et al. 2023

Scandinavian Journal of Primary Health Care

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Objective To explore Norwegian GPs’ experiences with and perceived suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. Design We used a mixed methods research design. An online survey with 301 respondents was combined with qualitative interviews with ten GPs. Setting Norwegian general practice. Results Most GPs agreed it was difficult to assess a patient’s ability to work without physical attendance for a first-time certification in remote consultations. However, extending a certification was considered less problematic. If physical examinations were required, the GPs would ask the patient to come to the office. The most suitable diagnoses for remote certification were respiratory infections and COVID-19-related diagnoses, as well as known chronic and long-term diseases. The GPs emphasized the importance of knowing both the patient and the medical problem. The GP-patient relationship could be affected by remote consultations, and there were mixed views on the impact. Many GPs found it easier to deny a request for a sickness certification in remote consultations. The GPs expressed concern about the societal costs and an increased number of certifications if remote consultations were too easily accessible. The study was conducted during the COVID-19 pandemic, and the findings should be interpreted in that context. Conclusions Our study shows that issuing sickness certifications in remote consultations were viewed to be suitable for COVID-19 related problems, for patients the GP has met before, for the follow-up of known medical problems, and the extension of sickness certifications. Not meeting the patient face-to-face may affect the GP-patient relationship as well as make the GPs’ dual role more challenging.

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Why physicians are lousy gatekeepers: Sicklisting decisions when patients have private information on symptoms

Cited by 7 publications

References 42 publications

The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

Skipping the doctor: evidence from a case with extended self-certification of paid sick leave

Suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. A mixed method study of GPs’ experiences

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