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      ‘Working is out of the question’: a qualitative text analysis of medical certificates of disability

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          Abstract

          Background

          Medical certificates influence the distribution of economic benefits in welfare states; however, the qualitative aspects of these texts remain largely unexplored. The present study is the first systematic investigation done of these texts. Our aim was to investigate how GPs select and mediate information about their patients’ health and how they support their conclusions about illness, functioning and fitness for work in medical certificates.

          Methods

          We performed a textual analysis of thirty-three medical certificates produced by general practitioners (GP) in Norway at the request of the Norwegian Labour and Welfare Administration (NAV).The certificates were subjected to critical reading using the combined analytic methods of narratology and linguistics.

          Results

          Some of the medical information was unclear, ambiguous, and possibly misleading. Evaluations of functioning related to illness were scarce or absent, regardless of diagnosis, and, hence, the basis of working incapacity was unclear. Voices in the text frequently conflated, obscuring the source of speaker. In some documents, the expert’s subtle use of language implied doubts about the claimant’s credibility, but explicit advocacy also occurred. GPs show little insight into their patients’ working lives, but rather than express uncertainty and incompetence, they may resort to making too absolute and too general statements about patients’ working capacity, and fail to report thorough assessments.

          Conclusions

          A number of the texts in our material may not function as sufficient or reliable sources for making decisions regarding social benefits. Certificates as these may be deficient for several reasons, and textual incompetence may be one of them. Physicians in Norway receive no systematic training in professional writing. High-quality medical certificates, we believe, might be economical in the long term: it might increase the efficiency with which NAV processes cases and save costs by eliminating the need for unnecessary and expensive specialist reports. Moreover, correct and coherent medical certificates can strengthen legal protection for claimants. Eventually, reducing advocacy in these documents may contribute to a fairer evaluation of whether claimants are eligible for disability benefits or not. Therefore, we believe that professional writing skills should be validated as an important part of medical practice and should be integrated in medical schools and in further education as a discipline in its own right, preferably involving humanities professors.

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          Most cited references38

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          Language and power

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            'I just want permission to be ill': towards a sociology of medically unexplained symptoms.

            A significant proportion of symptoms are medically unexplained. People experience illness but no pathological basis for the symptoms can be discerned by the medical profession. Living without a clinical diagnosis or medical explanation has consequences for such patients. This paper reports on a small qualitative interview-based study of 18 neurology outpatients in England who live with such medically unexplained symptoms (MUS). The findings broadly concur with those identified in the related literatures on medically unexplained syndromes and unexplained pain: the difficulties of living with uncertainty; dealing with legitimacy; and a resistance to psychological explanations of their suffering. From a thematic analysis of the interview data we identify and elaborate on three related issues, which we refer to as: 'morality'; 'chaos'; and 'ambivalence'. Although this article presents empirical data its aim is primarily conceptual; it integrates the findings of the empirical analysis with the existing literature in order to try to make some sociological sense of the emergent themes by drawing on sociological and cultural analyses of risk and the body. We draw on Bauman's concept of ambivalence to suggest that the very processes associated with more precise 'problem solving' and 'classification' do, in fact, generate even more uncertainty and anxiety. On the one hand, we seek closure and certainty and yet this leaves no means of living with uncertainty. Indeed, society does not readily grant permission to be ill in the absence of disease. We conclude by suggesting that an appreciation of the experience of such embodied doubt articulated by people who live with MUS may have a more general applicability to the analysis of social life under conditions of late modernity.
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              What do GPs feel about sickness certification? A systematic search and narrative review.

              Abstract Objective. To identify GPs' attitudes towards sickness certification. Design. Systematic search and narrative review identifying themes around attitudes towards sickness certification. Results. Eighteen papers were identified for inclusion in the review; these included qualitative, quantitative, and systematic reviews. The papers were predominantly from Scandinavia and the UK. Three themes were identified from the literature: conflict, role responsibility, and barriers to good practice. Conflict was predominantly centred on conflict between GP and patients regarding the need for a certificate, but there was also conflict between all stakeholders. Role responsibility focused on the multiple roles GPs had to fulfil, and barriers to good practice were identified both within and outside the healthcare system. Conclusion. Any potential for changing the certification system needs to focus on reducing the potential for conflict, clarification of the roles of all stakeholders, and improving access to specialist occupational health and rehabilitation services.
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                Author and article information

                Contributors
                + 47 22 85 05 50 , guri.aarseth@medisin.uio.no
                bard.natvig@medisin.uio.no
                eivind.engebretsen@medisin.uio.no
                a.h.k.lie@medisin.uio.no
                Journal
                BMC Fam Pract
                BMC Fam Pract
                BMC Family Practice
                BioMed Central (London )
                1471-2296
                20 April 2017
                20 April 2017
                2017
                : 18
                : 55
                Affiliations
                [1 ]ISNI 0000 0004 1936 8921, GRID grid.5510.1, Department of General Practice, , University of Oslo, Faculty of Medicine, Institute of Health and Society, ; Postboks 1130, Blindern, 0318 OSLO Norway
                [2 ]ISNI 0000 0004 1936 8921, GRID grid.5510.1, Department of Health Science, , University of Oslo, Faculty of Medicine, Institute of Health and Society, ; Postboks 1089, Blindern, 0318 OSLO Norway
                [3 ]ISNI 0000 0004 1936 8921, GRID grid.5510.1, Departement of Community Medicine and Global Health, , University of Oslo, Faculty of Medicine; Institute of Health and Society, ; Postboks 1130, Blindern, 0318 OSLO Norway
                Author information
                http://orcid.org/0000-0002-3159-4636
                Article
                627
                10.1186/s12875-017-0627-z
                5399412
                28427338
                38750bb8-a0b3-4129-98c6-7f4a969e4748
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 21 November 2016
                : 31 March 2017
                Funding
                Funded by: Allmennmedisinsk forskningsfond (The Norwegian Research Fund for General Practice)
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2017

                Medicine
                norway,gp,medical certificates of incapacity for work,document analysis
                Medicine
                norway, gp, medical certificates of incapacity for work, document analysis

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