The capacity to work puzzle: a qualitative study of physicians’ assessments for patients with common mental disorders

Abstract

BackgroundEntitlement to sickness benefits is a legal process requiring health-related reduced work capacity confirmed by a physician via a sickness certificate. However, there is a knowledge gap concerning physicians’ clinical practice of work capacity assessments for patients with common mental disorders (CMD). Physicians claim more knowledge and skills in how to actually do the assessments. The aim of this study was to explore physicians’ tacit knowledge of performing assessments of capacity to work and the need for sickness absence in patients with depression and anxiety disorders.MethodsWe performed a qualitative study with open-ended interviews and a short video vignette of a physician and a patient with depression as stimuli. Participating physicians (n = 24) were specialized in general practice, occupational health or psychiatry and experienced in treating patients with depression and anxiety. Interviews were audio-recorded and transcribed verbatim. Inductive content analysis was used as the analytical tool.ResultsFive categories were identified. Category 1 identified work capacity assessment as doing a jigsaw puzzle without any master model. The physicians both identified and created the pieces of the puzzle, mainly by facilitating strategies to make the patient a better supplier of essential information. The finished puzzle made up a highly individualized comprehensive picture required for adequate assessment. Categories 2–4 identified the particular essential pieces of information the participants used, relating to the patient’s disorder, capacity in the work place and contextual everyday life. For the sickness absence assessment, apart from decreased work capacity, the physicians also took particulars of the work place into account; e.g. could the work place handle an employee with reduced capacity.ConclusionsPhysicians’ tacit knowledge of assessing work capacity and the need for sickness absence for patients with CMD was identified as doing a jigsaw puzzle. The physicians became identifiers and creators of the pieces of the puzzle using a broad palette of essential information. Our findings contribute to the knowledge gap on clinical assessment and can be used as an educational tool. Because they are based on the professions’ tacit knowledge, acceptance of the model can be expected to be high.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0815-5) contains supplementary material, which is available to authorized users.

Assessing work capacity – reviewing the what and how of physicians’ clinical practice

“…This type of reasoning puts the theory in context, applies it to the specific situation of the individual case. This correlates well with the finding of Bertilsson et al (2018) [45] that in the "work capacity puzzle", the physicians both create and fit the pieces; a process requiring both tacit and explicit knowledge. Similarly, a study comparing work capacity assessments of patients with severe subjective health complaints by physicians in five European countries showed significant differences among physicians but also unexpected similarities, suggesting that "physicians share tacit knowledge regarding sick-leave decision making" for this patient group [51].…”

“…In the updated search, one article was found eligible for inclusion [37]. This large qualitative study explored how physicians assess work capacity in patients with common mental disorders, and their findings support our results.…”

“…In the updated search, one study was identified as meeting the inclusion and quality criteria [37]. As it was identified after completion of the analysis it was not included in the synthesis, but is commented on in the discussion section.…”

Functional Interviewing Was Associated With Improved Agreement Among Expert Psychiatrists in Estimating Claimant Work Capacity: A Secondary Data Analysis of Real-Life Work Disability Evaluations

“…Likewise, we need more studies comparing assessment strategy A versus B, including their precision on prognostic predictions like successful return-to-work. Initiatives are emerging ( 31 , 32 , 40 – 43 ), but they will require support from the insurance medicine community in order to succeed. Consorted efforts could help: researchers who provide methodological skills and experience in conducting studies, professional organisations who contribute content expertise, social insurers who advise about their knowledge needs and help with recruitment of claimants and funding, patient organisations who ensure the integration of the claimant perspective.…”

“…Research on sickness certification reports about general practitioners' reluctance to shift from the description of symptoms and underlying mechanisms towards a functional and work-related perspective (30,31). Lack of training, lack of guidance about work-related health and lack of knowledge about work requirements in today's working world were named as main barriers.…”