Review article
What is the problem with medically unexplained symptoms for GPs? A meta-synthesis of qualitative studies

https://doi.org/10.1016/j.pec.2016.11.015Get rights and content

Highlights

  • For GPs, dominant disease models (biomedical or psychosocial) often do not fit with reality.

  • Both patients and doctors struggle with and suffer from this incongruence.

  • In the lack of congruent disease models, a validating doctor-patient relationship can be a lifeline.

Abstract

Objective

To gain a deeper understanding of challenges faced by GPs when managing patients with MUS.

Methods

We used meta-ethnography to synthesize qualitative studies on GPs’ perception and management of MUS.

Results

The problem with MUS for GPs is the epistemological incongruence between dominant disease models and the reality of meeting patients suffering from persistent illness. GPs have used flexible approaches to manage the situation, yet patients and doctors have had parallel negative experiences of being stuck, untrustworthy and helpless. In the face of cognitive incongruence, GPs have strived to achieve relational congruence with their patients. This has led to parallel positive experiences of mutual trust and validation. With more experience, some GPs seem to overcome the incongruences, and later studies point towards a reframing of the MUS problem.

Conclusion

For GPs, the challenge with MUS is most importantly at an epistemological level. Hence, a full reframing of the problem of MUS for GPs (and for patients) implies broad changes in basic medical knowledge and education.

Practice implications

Short-term: Improve management of patients with MUS by transferring experience-based, reality-adjusted knowledge from senior GPs to juniors. Long-term: Work towards new models of disease that integrate knowledge from all relevant disciplines.

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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