Unsanctioned techniques for having sickness certificates accepted: a qualitative exploration and description of the strategies used by Swedish general practitioners

Diagnosing by anticipation: Coordinating patient trajectories within and across social systems

Anticipation is a fundamental aspect of social life and, following Weber, the hallmark of social action-it means trying to take others' responses to our actions into account when acting. In this article, we propose and argue the relevance of anticipation to the sociological study of diagnosis. To that end, we introduce and elaborate on the concept of diagnosing by anticipation. To diagnose by anticipation is to consider diagnoses as cultural objects imbued with meaning, to anticipate how others will respond to their meaning in situ and to adapt the choice of diagnosis to secure a desired outcome. Unlike prognosis, which seeks to predict the development of a disease, diagnosing by anticipation entails seeking to predict the development of a case and the effect of different diagnostic categories on its trajectory. Analytically, diagnosing by anticipation therefore involves a shift in diagnostic footing, from trying to identify what the case is a case of, to trying to identify which diagnosis will yield the desired case trajectory. This shift also implies a stronger focus on the mundane organisational work of operating diagnostic systems and coordinating case trajectories within and across social systems, to the benefit of the sociology of diagnosis.

Resistance and the delivery of healthcare in Australian immigration detention centres

There are few issues that have been as vexing for the Australian healthcare community as the Australian governments policy of mandatory, indefinite, immigration detention. While many concepts have been used to begin to describe the many dilemmas faced by healthcare professionals and their resolution, they are limited, perhaps most fundamentally by the fact that immigration detention is antithetical to health and wellbeing. Furthermore, and while most advice recognises that the abolition of detention is the only option in overcoming these issues, it provides little guidance on how action within detention could contribute to this. Drawing on the work of political theorists and the broader sociological literature, we will introduce and apply a form of action that has not yet been considered for healthcare workers within detention, resistance. We will draw on several examples from the literature to show how everyday resistance could be enacted in healthcare and immigration detention settings. We argue that the concept of resistance has several conceptual and practical advantages over much existing guidance for healthcare workers in these environments, namely that it politicises care and has synergies with other efforts aimed at the abolition of detention. We also offer some reflections on the justifiability of such action, arguing that it is largely consistent with the existing guidance produced by all major healthcare bodies in Australia.

Everyday Resistance in the U.K.'s National Health Service

Resistance is a concept understudied in the context of health and healthcare. This is in part because visible forms of social protest are sometimes understood as incongruent with professional identity, leading healthcare workers to separate their visible actions from their working life. Resistance takes many forms, however, and focusing exclusively on the visible means more subtle forms of everyday resistance are likely to be missed. The overarching aim of this study was to explore how resistance was enacted within the workplace amongst a sample of twelve healthcare workers, based in the United Kingdom; exploring the forms that such action took and how this intersected with health and healthcare. In depth-interviews were conducted and results were analysed utilizing Lilja's framework (2022). Our findings suggest that resistance took a number of forms, from more direct confrontational acts, to those which sought to avoid power or which sought to create alternative or prefigurative practices or norms. These findings speak to the complexities, ambiguities, and contradictions of resistance, as carried out by healthcare workers in the workplace. While many acts had clear political motives, with issues like climate change in mind for example, participants also described how the act of providing care itself could be an act of resistance. While saying something about our participants, this also said something about the healthcare systems in which they worked. These findings also raise a range of normative issues. Perhaps needless to say, there appears to be substantial scope to expand and interrogate our findings and apply the idea of resistance to health and healthcare.

Psychiatrists' Experience of Vocational Rehabilitation for Patients with Mental Illness

The aim of this study was to explore psychiatrists' experience of vocational rehabilitation for patients with mental illness. The study employed a qualitative design to explore psychiatrists' experience of vocational rehabilitation. Ten psychiatrists, five women and five men, 33-62 years of age (median 40), were interviewed. All of them worked with patients at Sahlgrenska University Hospital. The interviews were analyzed using inductive thematic analysis. All participants considered vocational rehabilitation to be of great importance for patients' well-being and health. The results were characterized by two opposite experiences: frustration and agency, these were the two main themes in the analysis. All narratives embraced both experiences, but some reflected more frustration and others more agency. In order for the psychiatrist to master the assignment, there is a need for further training and supervision. The psychiatrist's role, as well as other professional roles within the team, requires clarification, and the support from rehabilitation coordinators and occupational therapists should be enhanced. There is a need for improved cooperation with external actors.

The Doctor as Parent, Partner, Provider… or Comrade? Distribution of Power in Past and Present Models of the Doctor-Patient Relationship

The commonly occurring metaphors and models of the doctor–patient relationship can be divided into three clusters, depending on what distribution of power they represent: in the paternalist cluster, power resides with the physician; in the consumer model, power resides with the patient; in the partnership model, power is distributed equally between doctor and patient. Often, this tripartite division is accepted as an exhaustive typology of doctor–patient relationships. The main objective of this paper is to challenge this idea by introducing a fourth possibility and distribution of power, namely, the distribution in which power resides with neither doctor nor patient. This equality in powerlessness—the hallmark of “the age of bureaucratic parsimony”—is the point of departure for a qualitatively new doctor–patient relationship, which is best described in terms of solidarity between comrades. This paper specifies the characteristics of this specific type of solidarity and illustrates it with a case study of how Swedish doctors and patients interrelate in the sickness certification practice.

Doctors that "doctor" sickness certificates: cunning intelligence as an ability and possibly a virtue among Swedish GPs

The relations of power between healthcare-related institutions and the professionals that interact with them are changing. Generally, the institutions are gaining the upper hand. Consequently, the intellectual abilities necessary for professionals to pursue the internal goods of healthcare are changing as well. A concrete case is the struggle over sickness benefits in Sweden, in which the Swedish Social Insurance Agency (SSIA) and physicians are important stakeholders. The SSIA has recently consolidated its power over the sickness certificates that doctors issue for their patients. The result has been a stricter gatekeeping of sickness benefits. In order to combat the inroads made by state institutions into sickness certification, and into the sphere of medical practice, some doctors have developed cunning "techniques" to maximize the chance to have their sickness certificates accepted by the SSIA. This article attempts to demonstrate that cunning intelligence-the ability of the weak to "outsmart" a stronger adversary-plays an important role in the practice of medicine. Cunning intelligence is not merely a defective form of prudence (phronesis), nor is it simply an instance of instrumental reason (techne), but rather an ability that occupies a distinct place among the intellectual abilities generally ascribed to professionals.

Primary care physicians' concerned voices on sickness certification after a period of reorganization. Focus group interviews in Sweden

Objective: This study explored the views of primary health care (PHC) physicians on sickness certification after reforms in 2005 prompted by the Swedish government to increase the quality and decrease the inequalities, and costs of sickness certification.Design: Qualitative design with focus group interviews. Data were analysed using qualitative content analysis.Setting: Urban and rural PHC centres in Region Västra Götaland, Sweden.Subjects: GPs, interns, GP trainees and locums working in PHC centres 2015. Six focus group interviews with 28 physicians were performed.Main outcome measures: Experiences and reflections about the sickness certification system.Results: The latent content was formulated in a theme: 'The physicians perceived the sickness certification process as emotive and a challenge to master with differing demands and expectations from authorities, management and patients'. Sickness certification could be easy in clear-cut situations or difficult when other factors besides the pure medical were ruling the decisions. The physicians' coping strategies for the task included both active measures (cooperation with health care staff and social insurance officers) and passive adaptation (giving in or not caring too much) to the circumstances. Proposals for the future were to transfer lengthy sickness certifications and rehabilitation to specialized teams and increase cooperation with rehabilitation coordinators and social insurance officers.Conclusions: Political decisions on laws and regulations for sickness certification impacted the primary health care making the physicians' work difficult and burdensome. Their views and suggestions should be carefully considered in future organization of primary care. KEY POINTSIn 2005 Swedish government introduced reforms to decrease the inequalities and costs of sickness certification and facilitate the physicians' work. Focus group interviews with Swedish primary care physicians revealed that sickness certification was challenging due to differing demands from authorities, management and patients.Coping strategies for the sick-listing task included both active measures and passive adaptation to the circumstances.A proposal for future better working conditions for physicians was to transfer lengthy sickness certifications and rehabilitation to specialized teams.

The quality of the sickness certificate. A case control study of patients with symptom and disease specific diagnoses in primary health care in Sweden

Objective: To compare information in sickness certificates and rehabilitation activities for patients with symptom diagnoses vs patients with disease specific diagnoses. Design: Retrospective case control study 2013-2014. Setting: Primary health care, Sweden. Subjects. Patients with new onset sickness certificates with symptom diagnoses n = 222, and disease specific diagnoses (controls), n = 222. Main outcome measures: Main parameters assessed were: information about body function and activity limitation in certificates, duration of sick leave, certificate renewals by telephone, diagnostic investigations, health care utilisation, contacts between patients, rehabilitation coordinators, social insurance officers, employers and occurrence of rehabilitation plans. Results: Information about body function and activity limitation was sufficient according to guidelines in half of all certificates, less in patients with symptom diagnoses compared to controls (44% vs. 56%, p = 0.008). Patients with symptom diagnoses had shorter sick leave than controls (116 vs. 151 days p = 0.018) and more certificates issued by telephone (23% vs. 15% p = 0.038). Furthermore, they underwent more diagnostic investigations (32% vs. 18%, p < 0.001) and the year preceding sick leave they had more visits to health care (82% vs. 68%, p < 0.001), but less follow-up (16% vs. 26%, p < 0.008). In both groups contacts related to rehabilitation and with employers were scarce. Conclusion: Certificates with symptom diagnoses compared to disease specific diagnoses could be used as markers for insufficient certificate quality and for patients with higher health care utilisation. Overall, the information in half of the certificates was insufficient and early contacts with employers and rehabilitation activities were in practice missing. KEY POINTS Symptom diagnoses are proposed as markers of sickness certification quality. We investigated this by comparing certificates with and without symptom diagnoses. Certificates with symptom diagnoses lacked information to a higher degree compared to certificates with disease specific diagnoses. Regardless of diagnoses, early contacts between patients, rehabilitation coordinators and social insurance officers were rare and contacts with employers were absent.