Review articleWhat is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies
Introduction
General practitioners or family physicians (GPs) daily meet patients with symptom presentations that are not attributable to a specific diagnosis. Several of these will be categorized as suffering from medically unexplained symptoms (MUS). These represent conditions ranging from mild self-limiting symptoms to severe, disabling disorders [1], [2] and account for 10–15% of all GP consultations [3], [4]. When trying to classify these patients and offer them treatment and support, GPs face several management challenges.
Assessing, diagnosing and treating these patients is difficult, especially in terms of defining ‘medical’ and ‘unexplained’. GPs tend to embrace and attend to the complexity of patients presenting with diffuse complaints, and to resist the classification of MUS [5]; this may be because the diagnostic category of MUS does not cater for the inherent complexity and uncertainty in medical practice [6]. Hence, the clinical usefulness of the diagnostic category MUS in primary care is questionable [6]. In general, both clinicians and researchers agree that the term MUS is unsatisfactory as it implies a not yet found explanation and maintains a mind-body dichotomy. The biopsychosocial model [6], [7] is often emphasized as useful for the management of MUS. When using the three dimensions involved for a holistic assessment, the model is suggested to be a key to patient-centeredness [8], [9]. One aspect of patient-centeredness [9] is the therapeutic alliance. According to many studies on management and perceptions of MUS, the doctor-patient relationship is often a source of frustration due to differing illness perceptions [3].
Several qualitative studies have attempted to explore the above-mentioned challenges, i.e. doctors’ and patients’ illness and disease concepts, management strategies, and how to maintain a well-functioning doctor-patient relationship. However, despite the development of certain educational tools [11], [12], GPs still face severe challenges in the management of patients with MUS. Qualitative studies of the management of MUS have mainly provided self-contained and descriptive results, confined to the context of the immediate sampling. Our aim is to contribute to a deeper understanding of the problems that GPs encounter when meeting patients with persistent medically unexplained symptoms, and to look for possible ways to solve these problems. To achieve this, we will present a specific type of synthesis, a meta-ethnography, of qualitative studies on GPs’ perception and management of patients with MUS.
Section snippets
Methods
Meta-ethnography is one of several methods for synthesizing qualitative research (Dixon-Woods et al., 2005). It was developed by Noblit and Hare [13], adopted by Britten et al. [14] and has since been increasingly performed, also in the field of MUS [15]. In meta-ethnography, the idea is to translate studies into one another, rather than to aggregate findings, and to develop a new interpretation through comparison and conceptual innovation [13]. Such interpretations may result in different
Results
The third order concepts developed during reciprocal translation appear in the upper row of Table 2. We will now present these concepts while illuminating how the key concepts from the original papers (see the left column of Table 2) underwent reciprocal translation.
Discussion
In the translation between studies, we found that GPs struggled with incongruences at a professional knowledge level, at an illness conceptual level and at a relational level. They struggled with their learnt biomedical concepts of disease (in some cases with added psychosocial approaches) and the opposition of those to the personal illness and symptom experiences and explanatory models of patients, both claiming authority and trying to gain legitimacy. GPs also struggled with incongruence in
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