BMC Public Health 2007, 7:45 http://www.biomedcentral.com/1471-2458/7/45 Table 3: Odds ratios (OR) and 95% confidence intervals (95% CI) of self-reported reduced working capacity due to longstanding illness in Model I (age- and sex-adjusted) and Model II (main effect model also adjusted for all other explanatory variables) among people with paid employment. Explanatory variables Categories and levels Model I OR (95% CI) 1 (Reference) 3.54 (3.09–4.06) 19.0 (16.7–21.6) 0.98 Model II OR (95% CI) 1 (Reference) 3.20 (2.79–3.68) 17.7 (15.5–20.2) 1.16 (1.06–1.27) 1 (Reference) 1.15 (1.04–1.27) 1 (Reference) 1.61 (1.43–1.81) 1.56 (1.38–1.77) 1.51 (1.33–1.71) 1 (Reference) 1.79 (1.62–1.98) 1 (Reference) 1.10 (1.00–1.21) 1 (Reference) 1.36 (1.23–1.51) 1 (Reference) 1.34 (1.23–1.46) 1 (Reference) 1.17 (1.01–1.36) 1 (Reference) 0.91 Sickness Absence (days) Sex De facto marital Status Occupational status Employment Housing Tenure Quality of physical working environment Presence of stress at work Work-related social support Model fit Hosmer-Lemeshow 0–28 29–90 >90 Male Female Living alone Married/cohabiting Unskilled manual workers Skilled manual workers Lower-level employees Middle-level employees and professionals Part-time Full-time Renting Owning Poor Good Yes No Poor Good p-value in reduced working capacity nor any other health prob- lems would be about 111,000 at most. It is critical to reit- erate that the exact dates of SA were not available in this study, which means it is likely that some Swedish Living Conditions Survey interviews took place before the illness or other health problem that led to SA and before the SA. For this reason, it is probable that the real number of peo- ple on sick leave of ≥29 days in Sweden with neither long- standing illness resulting in reduced working capacity nor any other health problems is much lower than the esti- mated 111,000: perhaps half as large (55,500 persons). Though it is alarming to find that slightly less than half the persons who had taken ≥29 SA days in a given year reported no reduced working capacity on a survey taken that same year, and about half of these reported no addi- tional health complaints at all, the result must be viewed with caution, because this is a cross-sectional study and because we lacked data on the exact dates of SA. In order to go on sick leave for more than a week, and in order to receive sickness benefit payments from the Swed- ish government after 14 days of absence from work, sick- ness certification must be obtained from a doctor. Physicians are thus the gatekeepers of the social sickness insurance system in Sweden. Not only general practition- ers but also psychiatrists, orthopedists, and specialists in internal medicine have ended up in a situation of conflict in which they are expected to act both as representatives of their patients and as sentinels of the insurance system. Studies suggest that many doctors feel they lack sufficient knowledge of insurance medicine to confidently and ade- quately fill this role. For example, many consider it diffi- cult to estimate a patient's inability to work [21]. So-called "soft" illnesses, such as ache without organic causes and diffuse mental problems, can rarely be proved objectively, so patients' statements become decisive. The doctor can neither prove nor disprove the story, and is obliged to issue a certificate [22]. Some studies have shown that the examination performed by the doctor is mainly a formal- ity, since it is patients who decide when they will go back to work [23,24]. A restrictive policy against taking sick leave can lead to a situation in which the ill are treated unfairly, whereas a generous policy might lead to abuse of the system. Over- use of the system occurs, for example, if older patients are granted an early retirement pension due to the politics of the labor market, due to incorrect diagnoses, or to an incorrect appraisal of their ability to work. It occurs if a patient unintentionally or intentionally deceives the phy- sician. Page 7 of 11 (page number not for citation purposes)