Assessing Fitness for Work – A vignette study of GPs in Ireland

1. Assessing Fitness for Work – A vignette study of GPs in Ireland Ms Michelle Foley (WIT) Dr Kevan Thorley (UOM) Dr Marie Claire Van Hout (WIT)

2. Background • A systematic review of the literature implies that GPs can find their role as certifiers problematic, and a source of conflict with certification often based on the GPs’ desire to preserve the doctor-patient relationship (5-7). • Non medical factors such as social circumstances and demand for certification rather than fitness for work have been implicated in GPs’ decision making on sickness certification.(8, 9) • GPs’ imply that negotiation with patients and their perceived ability to work present difficulties during the consultation process .(4) • Research suggests that training in occupational medicine is considered inadequate and GPs report that they are often ill-prepared for the task of assessing fitness for work. (9-13)

3. Aim • GPs are required to act as gatekeepers for statutory benefits, thereby further complicating the fitness for work consultation process. • Significant rise in the level of sickness certification in Ireland and currently over 80% of all sickness certificates relate to illness with diagnostic challenges such as psychological problems and musculoskeletal conditions. • Uncertainty in assessment of these condition is thought to influence the way in which a GP will arbitrate in sickness leave (14). • Explore the specific nature of the consultation process related to three areas; information seeking in relation to the patient’s social/family circumstances, information seeking related to workplace history and other information required by the GP to assess the severity of the condition.

4. Method • The study took place between April and June 2011 using an on-line survey tool • Recruitment was facilitated by the ICGP (n=200) • Response rate 31% (n=62) • Ethical approval was granted by the Waterford Institute of Technology, ROI and University of Manchester Research Ethics Committees, UK. • Data was analysed using NVivo version 8

5. Vignettes Vignette (5-8) - Variable type Physical problem (+) Mr X is 41 years old. He has been a machine operator for the past five years. It is a local company that provides components to the medical devices industry. The job involves machine set-up, machining and measuring of component parts. The job also requires some lifting which is assisted using hoist equipment. Variable type (+) = Mr X is married with three children. Mr X partner works as a nurse in the local hospital; this often involves her working at night and at weekends. Variable type (-)= Mr X is single Mr X records show that he is experiencing occasional lower back pain over the past three years, which has lead to the occasional day or two off from work. He has been treated with pain killers on these occasions and you also recommended that he takes regular exercise. Two weeks ago Mr X came to you experiencing a dull ache in his lower back, which he explains has gotten progressively worse over the previous four months. Mr X describes that he is very stiff first thing in the morning. You provide Mr X with a sickness certificate for a period of one week. Mr Walsh went back to work for one week, but he is now back at the surgery complaining of pain when bending down and reaching forward. Variable type (+) =Mr X asks if you can provide another sickness certificate. He feels that an extended period of recovery will help to alleviate some of the symptoms. Variable type (-) =Mr X states that he can't really afford to take more time off from work. Vignette (1-4) - Variable type Psychological problem (+) Mr X is a 38 year old office manager who has been with the company for the last five years. The company is a large multinational company specialising in pharmaceuticals. Mr Flynn supervises a team of ten administrators. The job involves accounts, personnel and general administrative work. There are occasional visits to sister plants but mainly the job is office based. Variable type (+) = Mr X is married with three children. Mr X partner works as a nurse in the local hospital; this often involves her working at night and at weekends. Variable type (-) = Mr X is single Your notes indicate that Mr Flynn is experiencing intermittent low mood and tearfulness over the past two years. This has resulted in Mr X taking occasional days off work. A month ago he came to you and reported that he had experienced persistently low mood and tearfulness. Mr X also indicated that he is having problems with concentration and sleeping. You gave Mr X a sickness certificate for two weeks and prescribed an antidepressant. At the end of the certification period Mr X returned to work for a four week period, but is now back at the surgery and states that the symptoms have ‘gotten worse’ and he is now having anxiety attacks and feels he just can’t cope . Variable type (+) =Mr X asks if you can provide another sickness certificate. He feels that an extended period of recovery will help to alleviate some of the symptoms. Variable type (-) =Mr X states that he can't really afford to take more time off from work.

6. Results • Support structures, relationship health interpersonal and financial circumstance were dominant themes across all vignette versions. • Overall, GPs wanted to know more about the patients social circumstances when presented with a psychological illness. • Information on substance misuse also dominated in questioning of the psychological condition. • Information seeking on patients’ workplace was consistent with known reasons for workplace sickness leave but showed notable differences based on the type of presenting problem. • Physical signs and symptoms were the most frequently requested information needed to access the severity of the condition • Suicidal ideation was most requested to assess the severity of the psychological condition • Accessing evidence in the physical complaint was mostly related to obtaining the results of MRI and X-ray procedures.

7. Discussion • Further insight into the reasons for high rates of psychological related sickness certification. Several studies have shown that certification rates are higher for patients with a psychological problem and the condition seem to generate greater sympathy from GPs (6, 9, 17-20). • Psychological patient’s information seeking was predominantly concerned with workload and to a greater extent with social networks and relationships with employers and fellow employees. Additionally, 15 references were made to the possibility of ‘bullying at work’. Concurs with a recent qualitative study conducted in Ireland in that GPs suggested work place bullying as a common reason for sickness certification (7). • Lack of corroboration with employers and under these arrangements a lack of engagement results in unrealistic expectations in managing their role as certifiers (13, 22)

8. Limitations • Use of Vignettes • Male Patients • Response rate • Results have not been analysed in the context of GPs working experience, gender or additional qualifications, specialism and training.

9. Acknowledgements • Carol White and Dr Claire Collins ICGP • Dr Dolores Liddy, Waterford Healthpark • The GPs who took part. • Professor Aneez Esmail (UOM)

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