Validity must be discussed

I have some concerns about the article “Unsanctioned techniques for having sickness certificates accepted: a qualitative exploration and description of the strategies used by Swedish general practitioners” written by Mani Shutzberg [1]. At first the informants are described as GP:s in Sweden. I believe that Dr Shutzberg have a mix of GP, GP-trainee and interns in the study. It is impossible to be a GP in Sweden, at 29 of age and only have 0.5 years of experience from primary care. The experience of a physician is of most importance in how a physician handle different problems. The second concern is about that the study only have one author. How is it possible to triangulate the result? He has some supervisors, but he doesn’t let us know who they are. In a qualitative study are the context were the study is conducted of most interest. The third concern is the interview guide were the informants are asked in the first question “Which aspects of the sickness certification process do you find most difficult? Examples?” This makes this study biased as a qualitative exploring study from the beginning. By saying “most difficult” he influences the informants to describe a certain part of their work with sick leave certifications. Maybe can this be used in a quantitative study but not in a qualitative. The fourth concern is about the DFA-chain. Dr Shutzberg writs that the DFA-chain is introduced in 2009, this is wrong, it was introduced already in 2005. He doesn’t describe how the WHO classification ICF (International classification of functioning) are linked to the DFA-chain [2]. It seems that he doesn’t know. This is a qualitative study were the author doesn’t know the most fundamental theories about how the Swedish sick leave certificate are constructed. In his references ICF is described [3]. Has he read the references? The result from the interviews must be compared to the theory of ICF. He doesn’t mention activity limitations. He uses the word work ability in the discussion instead of activity limitations. In the Swedish certificate activity limitations must be described, not work ability. It is possible that both the physicians in the study and the author don’t know what the Social insurance officer are expecting in the certificates. If this is the fact, then the result shows their lacking skills in how to formulate a sickness certificate and the result are a description of mental defends. If they don’t know how to formulate a sickness certificate out of Swedish standards, it is an easy way out to use different technics to get the patient certified sick. Out of this do I question the validity of the study. To describe the informants in the wrong way is a serious mistake and to exclude fundamental theories diminish the result of the study.

I have some concerns about the article "Unsanctioned techniques for having sickness certificates accepted: a qualitative exploration and description of the strategies used by Swedish general practitioners" written by Mani Shutzberg [1]. At first the informants are described as GP:s in Sweden. I believe that Dr Shutzberg have a mix of GP, GP-trainee and interns in the study. It is impossible to be a GP in Sweden, at 29 of age and only have 0.5 years of experience from primary care. The experience of a physician is of most importance in how a physician handle different problems.
The second concern is about that the study only have one author. How is it possible to triangulate the result? He has some supervisors, but he doesn't let us know who they are. In a qualitative study are the context were the study is conducted of most interest.
The third concern is the interview guide were the informants are asked in the first question "Which aspects of the sickness certification process do you find most difficult? Examples?" This makes this study biased as a qualitative exploring study from the beginning. By saying "most difficult" he influences the informants to describe a certain part of their work with sick leave certifications. Maybe can this be used in a quantitative study but not in a qualitative.
The fourth concern is about the DFA-chain. Dr Shutzberg writs that the DFA-chain is introduced in 2009, this is wrong, it was introduced already in 2005. He doesn't describe how the WHO classification ICF (International classification of functioning) are linked to the DFA-chain [2]. It seems that he doesn't know. This is a qualitative study were the author doesn't know the most fundamental theories about how the Swedish sick leave certificate are constructed. In his references ICF is described [3]. Has he read the references? The result from the interviews must be compared to the theory of ICF. He doesn't mention activity limitations. He uses the word work ability in the discussion instead of activity limitations. In the Swedish certificate activity limitations must be described, not work ability. It is possible that both the physicians in the study and the author don't know what the Social insurance officer are expecting in the certificates. If this is the fact, then the result shows their lacking skills in how to formulate a sickness certificate and the result are a description of mental defends. If they don't know how to formulate a sickness certificate out of Swedish standards, it is an easy way out to use different technics to get the patient certified sick.
Out of this do I question the validity of the study. To describe the informants in the wrong way is a serious mistake and to exclude fundamental theories diminish the result of the study.

Disclosure statement
The author declares no conflicts of interest.

Author's reply
The findings of my article published in SJPHC [1], which showed the different informal and unsanctioned ways in which primary care physicians can navigate in the sickness certification process, seem to displease Dr. Starzmann. The preferred course of action is therefore to question its validity. I will address her concerns in the order presented in her letter to the editor.
1. As Starzmann points out, the experience of the primary care physician informants in my study varies. A deliberate decision was made to include specialists, trainees and interns, to ensure that the informants reflect the "demographics" of those who actually work at primary health clinics. Starzmann takes issue with the term used to designate this group, claiming that the term GP should only be reserved for specialists. I have found no such definition for the English term "GP," but it is true that a customary distinction is made between specialists and "primary care physicians" in the literature. However, I fail to see how it puts the validity at serious risk. The aim of the study was not to compare how different groups of physicians use techniques, but rather to explore and describe the different techniques deployed. Including only specialists would be more problematic in this regard.
2. The reason for having one author is stated in the acknowledgement section of the article. The supervisors-professor in the theory of practical knowledge Fredrik Svenaeus and associate professor in the theory of practical knowledge Jonna Lappalainen-have participated in the analysis of the collected data as described. However, none of them qualify as co-authors according to the slightly narrower publication tradition of our humanistic field.
3. I am perplexed by Dr. Starzmann's third concern, that a qualitative study aiming to explore a difficult aspect of medical practice skews the data by asking about that very same difficult aspect of medical practice. The aim of the study is clearly stated in the introduction of the article. Interview studies present many interesting and difficult challenges to validity, some of which I have addressed in the article, and will expand upon in my dissertation. The concern raised by Starzmann about the phrasing in one of the interview questions in the interview guide is, however, not the most urgent.
4. The fourth concern-also the one most passionately expressed-focuses on the lack of theoretical understanding of concepts. Allegedly, both GPs and I succumb to this ignorance of the inner workings of the DFA-chain and its conceptual genealogy that traces back to the ICF. Dr. Starzmann seems to believe that if only GPs could be made to truly understand the concepts, there would not be a problem, no friction between GPs and the Swedish Social Insurance Agency (SSIA). By elevating to this level of abstraction, Starzmann misses what the article actually aims for: "to explore the informal and unsanctioned techniques employed by GPs as a means to increase the likelihood of sickness certificate approval".
I believe that Starzmann's position reveals a deeper flaw in established thought concerning relations between institutions and its grassroots. After the 1953 popular uprising in East Germany, the poet Bertolt Brecht remarked that the East German state preferred "to dissolve the people and elect another", rather than to criticize itself [2, p. 119]. When ideals and reality clash, too often reality is forced to submit, or declared invalid. I think Brecht's insight carries over to the relationship between the SSIA and GPs, as well as to Starzmann's reproach.

Disclosure statement
The author declares no conflicts of interest.