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Acting by persuasion— values and rhetoric in medical certificates of work incapacity: A qualitative document analysis
  1. Guri Aarseth1,
  2. Bård Natvig1,
  3. Eivind Engebretsen2,
  4. Anne Kveim Lie3
  1. 1 Institute of Health and Society, Department of General Practice, University of Oslo, Oslo, Norway
  2. 2 Institute of Health and Society, Department of Health Sciences, University of Oslo, Oslo, Norway
  3. 3 Institute of Health and Society, Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
  1. Correspondence to Dr Guri Aarseth, Institute of Health and Society, Department of General Practice, University of Oslo, Oslo 0318, Norway; guri.aarseth{at}


When the patient applies for disability benefit in Norway, the general practitioner (GP) is required by the National Insurance Administration (NAV) to confirm that the patient is unfit for work due to disease. Considering the important social role of medical certificates, they have been given surprisingly little attention by the medical critique. They may make essential differences to peoples’ lives, legitimise large social costs and, in addition, the GPs report that issuing certificates can be problematic. This article explores values, attitudes and persuasive language in a selection of medical certificates written by GPs. We direct attention to such texts as significant social actors using a mixed rhetoric including certain values and attitudes. When arguing for granting the patient disability benefit, some GPs emphasised the ‘worthiness’ of the patient by pointing to positive attitudes approved by the national insurance: a will to work and participate, to cooperate and be motivated. Others pointed out the patient’s positive character in terms of universally accepted values, called for the reader’s (the NAV official) sympathy , understanding and helpfulness or appealed to his/her willingness to be realistic and pragmatic and grant disability benefit (DB). The dialogic style varied: some certifiers—although they argued for disability benefit—showed openness to possible opposing or alternative voices by displaying their own uncertainty. Others addressed the reader to share responsibility, demanding or urging for DB. This shifting rhetoric, we believe, mirrors that the GPs see themselves as the patient’s advocate, and that they may find themselves conflicted. We propose further studies within qualitative research to investigate the effect of this rhetoric on the reader, the decision-makers. In addition, to improve the quality and accuracy of these important documents, we suggest that medical schools introduce students to the making of text as a specific skill of medical practice.

  • primary care
  • medical humanities

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  • Contributors GAA and AKL conceived of the project and AKL, BN and GAA elaborated the design of the work. GAA, AKL, EE and BN planned the sample method of the material. GAA collected the raw material. GAA, AKL, BN and EE participated in the collection of empirical data, data analysis and data interpretation. GAA elaborated the draft and GAA, AKL, BN and EE critically analysed and repeatedly revised it. All the authors had full access to the data and all finally approved of the present version to be published. GAA, AKL, BN and EE agree to be accountable for the accuracy and integrity of all parts of the work.

  • Funding The study was funded by the Norwegian Research Fund for General Practice (AMFF) administered by the Norwegian Medical Association

  • Disclaimer The funding body has not taken part in any stage of the study or in writing the manuscript.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval All the patients (anonymised and deidentified to the authors) gave their written consent to using their medical certificates in research and publishing. The project was approved by the Norwegian Data Protection Official for Research, by the Directorate of Labor and Welfare (NAV) and by the Council of Secrecy and Research in the Ministry of Justice and Public Security.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no available data.