“We all know what is the optimal way to do it, who shouldn’t get a sick note and how close the follow-up should be, but why don’t we do it? You mention time pressure, so I think sometimes with sick notes, in the short term, it solves a problem there and then, and the patient is satisfied. Conflict, it drains so much energy, it affects the relationship and the trust, so sometimes I think… I think the times I have done something on a poor basis, it has been to preserve the patient’s trust, or because it was an easy solution. Sometimes because I didn’t know better maybe.” – Male GP (#28).
Through the analysis we identified four major themes in the discussions about sickness certifications: (i) patient demand and preference for sick leave, (ii) gatekeeping practices in sickness certification tasks, (iii) conditions limiting gatekeeping, and (iv) perspectives on the gatekeeping role and sickness insurance system.
Patient demand and preference for sick leave
Participants stated that sickness certification is more often requested by patients rather than suggested by the GP. Participants described suggesting sick leave as a treatment for patients’ symptoms as an exception to the rule of patients directly or indirectly asking for such leave.
“It’s very rare that we are the ones suggesting, like, now I think you should be issued a sick note. It’s very rare, so that one can remember those times, I think.” – Female GP, specialist (#24).
Exceptions included patient cases where the GP assessed the patient to be in need of taking a break, to prevent exhaustion or burn-out. In these cases, the patients might have a strong preference against being issued a sick note, in which case GP would convince the patient to accept to be sick-listed.
“I have also become more focused on limiting patients often, especially if it is a burnout issue. They often think they will be back again after two weeks, then I say that no, I don’t think that happens, and just be completely honest about it quite early, that no, you have a long, you actually have a long way to go.” – Male GP, specialist (#17).
Throughout the discussions, participants also described how they felt that some patients would expect being issued a sick note, regardless of the GP’s assessment of the justification or benefit of sick leave. Examples given included encounters with patients expressing “having the right” to a sick note, having “certified themselves” or arrived with “service orders” for certified absence, irrespective of their health condition or work capacity.
“It happens quite often that the patient doesn’t suggest anything at all, but they say they’ve already signed themselves off sick. That it’s already done, they’ve managed it all by themselves. They just need a paper confirming it.” – Male GP, specialist (#12).
Participants frequently referenced the language commonly used in society about certified sickness absence, such as “I have to sick-list myself”. Participants expressed being at the receiving end of a “sickness certification culture” where a “low threshold” for requesting sick leave exists. Many referred to cases from the news where politicians had “taken sick leave” due to causes that appeared to not be health related, and thought that this influenced this culture.
“If you read the newspapers and listen to politicians and so on, there’s that statement, ‘I had to sign myself off sick’, as if one does it by oneself as if it’s not a [medical] assessment.” – Female GP (#20).
Gatekeeping practices in sickness certification
Participants consistently distinguished between patient cases with objective medical symptoms, such as respiratory diseases or a broken leg, versus those with subjective symptoms like anxiety, depression, fatigue, pain and nausea. When the patient had clear medical symptoms, decisions were deemed straightforward, allowing the GPs to rely on their medical expertise to determine the necessity and duration of absence. In contrast, cases reliant on patients’ self-reported symptoms posed challenges and represented the majority of sick leave requests. When discussing sickness certification tasks and challenges, participants most often referred to the latter cases.
Rejection of sick leave requests
When asked about whether and when rejection of patient requests for sick leave happens, participants consistently reported that they rarely reject such requests.
“Rarely. It is rare. One does try to, can have a discussion about it of course, but if there are any patients who are absolutely, completely clear that they are not going to be able to go to work because it is so difficult, then it doesn’t happen so often in my office at least, that I refuse.” – Female GP, specialist (#7).
Many participants expressed a general reluctance towards declining patients’ requests for sick leave. Participants held the view that overruling requests would either not be accepted by the patient, not benefit the patient in terms of their well-being, or not alter the final outcome (sickness absence).
“… there are some [patients] where it is difficult to understand why they are unable to work with minor problems. My experience with trying to pressure them to work anyway is relatively poor. Because they can’t do it, and it ruins the relationship with the patient, and they end up being signed off sick eventually anyway, just with something else.” – Male GP, specialist (#19).
Examples of rejected requests were few, limited to cases the participants deemed non-judicious, i.e. clearly outside the eligibility criteria for sick pay. This could be when the reason for the request was other people’s illness, lack of prioritisation of personal tasks, or work conflicts. Nonetheless, responses to these types of requests still seemed to vary among participants. The quotes below illustrate different responses to patients requesting sick leave due to work conflict.
“If there’s a conflict at the workplace, sometimes it might be appropriate to say that no, this isn’t… there needs to be a dialogue between you and your employer, and it’s not something to be signed off sick for just because you can’t go to work due to disagreements.” – Female GP, specialist (#7).
“Yes, often [work] conflicts. In such cases, it’s a bit more challenging to achieve that agreement. It’s usually wise to initiate sick leave while simultaneously starting the dialogue with occupational health services, the manager, and arranging a dialogue meeting and all that. Occasionally, things resolve themselves, and many times, in my experience, the best solution for the patient is to just find another job and move on from the current one.” – Male GP, specialist (#16).
In the case of other people’s illness or adverse life events, participants expressed more difficulties in rejecting or contesting requests, often due to the patient’s situation evoking empathy from the GP. In these cases, some participants were more adamant to refuse the request, while others scrutinised further for symptoms that could warrant a certified absence.
“If there’s a violation of the rules, so to speak, if someone wants a sick note due to reasons other than their own illness, I have to explain that it’s not possible. But sometimes there’s an accumulation of various unfortunate events which result in patients genuinely… call it a psychological reaction, a stress reaction [that causes them to] not be able to work. But if it’s clearly not because of their own illness, then we have to say no.” – Male GP, specialist (#4).
“In these types of situations [death in the family], I feel like I almost have to put words in their mouth… They do have a lot of symptoms, but you kind of feel like you have to search a bit, ok, do I have any symptoms here, signs of their own illness, then it can be noted as whatever it is, psychological reaction, stress-induced.” – Male GP (#28).
Negotiate grade and duration of sick leave
A common approach when responding to patient requests for sick leave was to engage in “negotiations” with the patient about the grade or duration of the absence spell, to reach a solution that both parties could accept.
“Often, I try to negotiate a graded one, rather short days. They come in expecting two weeks, so I try like, ‘three days?‘. If they want a week at 100%, I say 50% to try and negotiate.” – Female GP (#2).
“Often, it’s a bit like you have to ‘roll with the punches’, so to speak, that you have to try to make a suggestion and then, no, that doesn’t work, no, ok, but maybe we can try something else, and give and take a bit then. Sometimes you have to certify full-term for a period, and then see, ok, but we can certify full-term for two weeks and then come back and look at the plan, that you should prepare yourself a bit to maybe start working a bit.” – Female GP, specialist (#33).
Participants differed in their views on the benefits of graded sick leave. Some actively negotiated a graded sick leave as opposed to full-term leave in almost all cases. Others believed that graded sick leave could result in an unnecessary long-term absence, referring to experiences with absence spells being “dragged out”.
“Where I see we have a significant role is […] engaging in a dialogue with patients about the degree of sick leave. Most patients often come with the impression that they can either work or they can’t, and this applies both when they start the sick leave and also when they are ending it. And the only thing we know that limits sickness absence levels in Norway is graded sick leave; it’s the only thing that science has proven to reduce sickness absence levels.” – Male GP, specialist (#21).
“I increasingly feel that [the gradual return process] often contributes to prolonging the situation. If I think that in this case it’s better to reach the finish line instead of jumping in too early, only to end up having to start over, then I think, yea, that’s what I believe.” – Male GP, specialist (#14).
During negotiations with the patient, participants reported to also try and educate the patient about the social and health related benefits of maintaining their routine and being present at work, regardless of the grade or duration of the sick leave. This included recommending different types of physical or social activities, including maintaining contact with their employer and colleagues. Others reported using language such as “timeout” to signify the expected duration of the absence spell or inform the patient that “at the end of this absence spell, you will not be ill anymore”.
Limiting unnecessary long-term or non-beneficial absence spells
Participants shared the view that full-term absence from work over longer periods might be harmful, in particular to patients with mild mental health problems, medically unexplained physical symptoms, or drug addictions. Participants described how patients in these cases might experience either no improvement or worsened symptoms from being on sick leave.
“Yes, I sometimes think some get worse from being on sick leave.” – Female GP, specialist (#7).
“If they don’t come back, the longer time it takes and…” – Male GP, specialist (#6).
“Yes, it can be harmful. […] With mild mental health issues, I often think that they don’t get better from being on sick leave. But they have to be on sick leave because they can’t handle the job […] so they need the sick note anyway, even if both me and perhaps the patient know that it’s not the best.” – Female GP, specialist (#7).
When discussing the use of sick leave to treat patients with symptoms like anxiety, depression, fatigue, and pain, many participants stressed that the effectiveness of sick leave varies significantly based on individual cases. They highlighted the difference between acute stress or burnout, long-term fatigue or depression, and anxiety problems. In acute cases, many agreed that full, short-term sick leave could be effective in aiding patients to better manage their lives. In the other cases, several participants advocated the use of partial rather than full-term leave and emphasised being aware of the risks of aggravated symptoms and/or not returning to work.
“If someone has stretched the limit too far and would benefit greatly from two weeks, then that’s completely unproblematic, giving them a little restart. But yes, if there is clear depression, I mean, you feel it and you know that there have been several sick leaves already, then that is different than if it is a kind of one-time occurrence.” – Female GP (#22).
“A large group we often have on follow-up, [are] those with medically unexplained symptoms. And there I think, initially, they are poor candidates for full sick leave, there can be a lot of aggravation [of symptoms] there. I believe making them more passive, that’s not good for them. In those situations where it sometimes, if it results in [sick leave], I try to make it as short as possible.” – Male GP (#28).
Some participants pointed out that determining the underlying health issue and assessing the potential benefits of sick leave, is not always straightforward in these cases.
“I don’t think there’s a clear divide. There are some where it’s depression, and then there are some where it’s overload and tiredness. And then there’s this divide in between where it can flow from one state to the other, and that divide can be difficult when evaluating sick leave. Where I have used the most effort is when I conflict with myself, when I become unsure if my assessments are correct. When I think the patient should not be on sick leave or should not be sick to that degree, but the patient insists that they should, that they need it. When I either say no and get an angry patient, or say yes and go home feeling I have compromised my professionalism.” – Female GP, specialist (#18).
As a strategy to ensure that patients return to work, many participants advocated making a plan for the duration of the absence spell and/or agreeing on a gradual reduction of absence percentages over time. Participants seemed to have somewhat different strategies when it came to the concreteness of the plan and how they arranged the patient follow-up. The quotes below illustrate a defined plan from start to finish, whilst the other a more wait-and-see approach.
“I usually say that there are many numbers between zero and a hundred, […] and then I listen a bit to what they think, and then we find some number that fits, and then I also write a follow-up at some point, hear how it goes and…” – Female GP, specialist (#27).
“It’s essential to provide clear guidance during patient follow-ups. […] By laying out expectations, patients have a clearer understanding of what lies ahead. You can even pre-arrange the sick leave, setting two weeks at 50%, followed by two weeks at 40%, and then another two weeks at 30%. I find this approach works very well; it unfolds seamlessly.” – Female GP (#20).
Several participants shared experiences with patients ending up in long-term absence spells, observing how the threshold of returning to work would increase the longer the duration of the absence. The dialogue below describes how initial short-term leave could lead to longer absences and an increasing reluctance or inability of patients to return to their regular routines or work.
“We don’t get them back.” (#14).
“Yes… Well, you’re right about that. It usually starts with a two-week sick note. Then they come back, things haven’t changed, they don’t feel any better, and after a dialogue, it usually extends to a longer sick note. I’m not sure if it becomes a crutch for the patient or what happens, but something does...” (#16).
“Yes, and then there tends to be some sort of aversion that develops. If you’ve been away for a while, the threshold to return keeps rising. […] I can’t predict when it’s going to happen. But I’ve experienced it a few times where I think, yeah, that wasn’t so smart.” (#14).
Dialogue between participant #14 (Male GP, specialist) and participant #16 (Male GP, specialist).
A few participants described how they, based on similar experiences as those mentioned above, had changed their strategy for patient follow-up after observing patients not feeling better after being on sick leave.
“There are certain strategies and adjustments I’ve adopted over time to potentially reduce the duration of absence spells. Previously, I would schedule a follow-up appointment right before the end of a patient’s sick leave to ensure they were fit to return to work. However, this often resulted in an extension of the sick leave, as patients felt they weren’t ready. Now, I’ve shifted to outlining a comprehensive sick leave plan during the initial meeting […], and schedule a follow-up a few weeks after the sick leave has concluded. This gives the responsibility to the patient to reach out if things aren’t going as planned. I’ve observed that this approach tends to decrease the duration. Excessive monitoring can sometimes inadvertently lead to prolonged sick leaves. […] The barrier to proactively extending sick leave becomes much higher than simply attending a pre-arranged appointment and getting an extension.” – Male GP, specialist (#21).
Regarding patients that were enrolled in work allowance assessments, post 12 months of sickness absence, some participants described how the contact with these patients diminished.
“You can often see it with patients who have been sick for a year and then transition to work assessment allowance (AAP).” (#8).
“How rarely they come in?“(#12).
“Yes, then you don’t see them for half a year.” (#8).
“No, haha… And you wonder where in the world they went.” (#12).
Dialogue between #8 (Male GP, specialist) and #12 (Male GP, specialist).
Two participants provided examples where they successfully had prevented patients from becoming dependent on disability benefits.
“She was on the verge of transitioning to disability, and felt it was unfair as she saw many others were on sick leave with fewer complaints than hers, while I was pressing her to return to work. She felt somewhat invalidated and not fully cared for. Eventually, she did return to work and has been working full-time since. Reflecting on her case, had she continued on to disability benefits, her life trajectory might have been very different. Prolonged sick leave can impact individuals’ perceptions of their health, functional capacity, and ability to work if they aren’t given appropriate guidance on managing their sick leave decisions.” – Female GP, specialist (#18).
“These are some of those few uplifting stories that we live for when we take those fights with the patients. Then, for every success story, there are maybe 10 or 15 or more that don’t amount to anything.” – Male GP, specialist (#21).
Conditions limiting gatekeeping
Information asymmetry
Participants consistently described how, in many cases where sick leave is requested, the patient has symptoms that are not readily observable by the GP beyond the patient’s self-report. Participants expressed not being able to contest the patient’s symptom descriptions and feelings of being ill or not able to work.
“It’s not easy to say… how sick the individual is. So if they absolutely do not feel able to work, I find it difficult to argue… Then it’s a bit like ‘yes, but I am sick’, ‘no, you are not sick’. How am I supposed to say no on any level?” – Male GP, specialist (#6).
This information asymmetry was also evident when discussing assessments of the patients’ work ability. Participants stated that they found it difficult to challenge the patient’s description of not being able to work, especially when they lacked sufficient information about the patient’s employment situation and the patient was persistent about their employer’s lack of ability to facilitate.
“So, we are a bit at the mercy of the answers we get then, we can’t call every employer and ask if it’s true that they can’t accommodate, for example. It’s not so rare that people say no.” – Female GP, specialist (#24).
“There are quite a few who say that it’s either 100% sick leave, or 100% work. That they can’t do any other tasks, and that the employer can’t make accommodations, period.” – Female GP, specialist (#25).
“So, you become a bit of a hostage.” – Female GP, specialist (#24).
Risk of conflict with patient and damage to the doctor-patient relationship
Drawing from experience, participants described how contesting patient requests could result in uncomfortable confrontations or conflict. Such conflicts or disagreements led to both the GP and patient being dissatisfied, and several participants admitted that “sometimes it’s easier to write a short sick note than to kind of […] argue”. Some participants also described how the workday would end up feeling unbearable if conflicts with patients occurred regularly.
“I sort of want my everyday life to be pleasant. I’m always trying, like, to meet, if there’s a basis for it, I’ll accommodate the sick note, but sometimes I get so tired if I’m supposed to start arguing with the patient all the time. If you have 2–3 of those in a day, you end up pretty worn out by the end of the day.… I go along with it because I can’t bear it; I get mentally exhausted if I have to fight with the patient every time.” – Female GP (#2).
Participants emphasised how conflict ultimately could damage the doctor-patient relationship, since many patients would end up feeling mistrusted or not taken care of by the GP.
“So you might break the good relationship that has been built up over many years when there’s trust in the doctor and a good collaboration with the patients, then the sick note gets in the way.” – Female GP, specialist (#32).
Time constraints
“Well, often the easiest thing for us is to write a 100% sick leave for four weeks, see ya. There’s no doubt about that.” – Male GP (#31).
“That’s what gives us the least amount of work. But, we don’t do that very often.” – Female GP, specialist (#33).
“No, of course not.” – Male GP (#31).
“We understand that it’s not wise, so we spend time on it, time we don’t really have.” – Female GP, specialist (#33).
When discussing time constraints and use of time on sick leave consultations, participants described how understanding the patient’s underlying problem, discussing the benefits of sick leave, contesting patients’ preferences, and follow-up of patients as the most time-consuming tasks.
“You have 20 minutes, right. The patient has to come into the office, you have to be presented with the issues, you might have to examine, make a plan, document, write a sick note, all in 20 minutes, right. And this probably leads to [more] sick notes and longer spells [than it should be], because you simply need time to do all that. Take dizziness. There are lots of things you need to get done and examined, and then it also depends on getting all the information [from the patient], and that’s difficult in maybe 10 minutes of effective conversation, it takes a bit of time for that to come out. And then maybe there has been an assault that is the cause of everything, right.” – Male GP (#31).
Contesting patient claims or discussing the benefits of sickness absence were described as the most time-consuming. Some expressed a certain resignation as regards their ability to convince patients that sickness absence was not warranted or beneficial.
“I used to reject sick notes much more in the past. I questioned them much more when patients came and asked for a sick note. I realised that I’m not getting anywhere; I spend five times as long on that consultation, without gaining much, most of the time. There might be a few instances where we come to a mutual agreement. But when I experience that immense pressure in daily life, I feel that’s a battle I just don’t have the energy to fight.” – Female GP, specialist (#10).
Some participants acknowledged that time constraints could lead to insufficient monitoring of patients on sick leave, potentially resulting in extended absences that are not beneficial in the long term.
“I also think that much of the blame can lie in both that we are pressed for time, so I don’t have time to follow them up the way I perhaps would have done to quickly reverse a difficult trend. And then there are long waiting lists. If there are mild to moderate issues, right, you think maybe they could get quickly back to work if they had a therapeutic conversation alternative that addressed that interest, but they don’t. In these cases I think sick leave becomes harmful because they are kind of in a waiting zone, where they are too sick to be in a 100% job and they actually feel they get worse because they are more isolated and they have fewer of these other safety measures, and I unfortunately am a bit too busy at work to be able to take them in and adequately follow them up.” – Female GP, specialist (#9).
Perspectives on the gatekeeping role and sickness insurance system
Several participants conveyed mixed feelings or dissatisfaction with their role as certifiers of sick leave. The dissatisfaction seemed to be primarily related to the GPs’ lack of knowledge about workplace facilitation options, combined with potential conflict risks associated with contesting requests for sickness absence.
“I really think that the sick leave system has become a bit of a pain to manage, because, as one says, no matter how you twist and turn it, I can describe function from here to kingdom come and hell, but it doesn’t change the fact that the patient goes to work and then the manager says, ‘I don’t want you here because you’re not 100%, you’re not functioning as you should,’ and then the patient is left standing there. And then there’s a conflict between the two of us that really doesn’t need to be there.” – Female GP, specialist (#9).
Many participants held the view that sickness absence is primarily a case between employers and employees.
“I kind of think that sick leave is more, I’m not saying that we shouldn’t issue sick notes, but I believe that sick leave is primarily a matter between the employee and employer. Then I’ve been set to be, say, the scapegoat. If I were to have it my way, I would want the sick leave to be a matter between the employer and the worker, and that I was more of a consultant who could have an opinion about the burden of symptoms for the patient.” – Female GP, specialist (#27).
In many sessions, the participants pointed to the employers’ role and responsibilities in facilitation and reintegrating employees on sick leave.
“I think that the employer could have been more involved many times. I believe that much of the problem is the reintegration and discussion of function, the possibility for work adjustments.” – Male GP, specialist (#16).
“Adjustments, yes.” – Female GP, specialist (#15).
“That much more should happen there than in my doctor’s office, I must say. A lot can happen without us doctors being present.” – Male GP, specialist (#16).
When asked about whether it was the GP or the patient that had the decisive power regarding whether to certify sick leave, participants differed in their views. Some held the view that they were “at the end of the day” the ones with the decisive power, others that the decision was a compromise between patient and doctor, and others again described that in practice is the patient who decides whether or not to be sick-listed.
“I believe if you asked the patients, they’d say it’s the doctor’s decision. They probably prefer someone else determining their sick leave status. But they come in with an opinion on needing sick leave, so, often, we just follow their lead. We don’t really have the means to thoroughly investigate and challenge their claims.” – Female GP, specialist (#33).
The conversation below illustrates the varying perceptions of control and responsibility doctors feel regarding their decisive role in sick-listing decisions, highlighting the tension between perceived authority, collaborative patient care, and professional integrity.
“At the end of the day, we are the ones deciding” – Female GP, specialist (#7).
“I often believe, at least for me, it’s an illusion that I control everything entirely… It feels more like a mutual discussion where both parties come to an agreement. I don’t feel like I decide it all by myself.” – Male GP, specialist (#8).
“Maybe it’s just an illusion, thinking we have control. But I often feel extremely uncomfortable if I issue a sick note that I can’t fully stand behind. That discomfort is immeasurable to me. If I felt I didn’t have control over it, I wouldn’t be comfortable being a doctor.” – Female GP, specialist (#9).
