The language of work disability. A study of medical certificates written by Norwegian general practitioners

Abstract

Background: About 10% of the Norwegian population between 18 and 67 years of age receive disability insurance. Norwegian general practitioners (GPs) are required to act as experts in matters relating to disability insurance and rehabilitation benefits. From 2012 to 2017, GPs provided almost 98% of all medical certificates of work incapacity for the Norwegian Labour and Welfare Administration (NAV) (personal e-mail report from the Administration of Health Economy, HELFO). Accordingly, we must assume that GPs have a strong influence on the distribution of welfare benefits in society. Several surveys and interviews have drawn attention to GPs’ experience as experts on behalf of their own patients, and studies of NAV officials’ assessments of medical certificates have been conducted. However, we have very little direct knowledge of the content and quality of these medical certificates. This thesis is based on document analysis of 33 medical certificates related to work incapacity. Aims: First, to investigate how the certifiers present and describe the patient as a person and participant in the social security scheme. Second, how they, in their texts, explain illness and how it relates to reduced function and work capacity. Third, to explore the values and attitudes that GPs emphasise in the certifiers’ texts and what kinds of rhetorical strategies they use when addressing their readers. Methods: Qualitative document analysis using methods of linguistics, literary criticism, and narratology.Purpose: To provide direct knowledge about a selection of medical certificates of work incapacity written by GPs. Main results: In the certificates, the focus is on symptoms and disease and to a lesser degree on the patient as a person. The patient is frequently not discernible as a person in the text, but is predominantly described as a passive carrier of symptoms. Their ability to act is described as low or non-existent, and they are passive objects for the actions of other anonymous actors. In contrast, the symptoms are emphasised as independent and strong actors. The patient’s experience with illness is sometimes reported, but the GP’s perspective is usually doctor-oriented rather than patient-oriented. The medical information is partly unclear/inadequate, sometimes ambiguous, and sometimes inconsistent. The reason for the patient’s work incapacity is unclear in most of the texts. In some medical certificates, a subtle use of language insinuates doubt about the patient’s credibility or real work ability. Detailed assessments of the patient’s working conditions or work ability are rarely reported. The texts use a variety of persuasive strategies. Some emphasise the patient’s positive character and attitude, which we take to mean that the patient “deserves” disability benefit or is a worthy applicant. Others appeal to the reader’s compassion, understanding, and helpfulness and to the reader’s willingness to be realistic or pragmatic and to grant disability payment. The voices in the texts construct authority primarily by marking their subjective stance or, more objectively, by speaking with “the voice of the profession”. All of the medical certificates in our sample, directly or indirectly, support the patient’s disability benefit. The texts can be seen as the “place” where two conflicting considerations meet – on the one hand, there is the physician’s deeply rooted, professionally based patient loyalty, and on the other hand is the physician acting as the gatekeeper who is supposed to ensure that nobody other than the worthy needy are supported by society. It is likely that the often negative experiences of physicians in dealing with this role can be expressed in the form of vague, incomplete, or normative texts.