The biomedical frame accentuated what is missing in MUS (objective signs of disease), and problems thought to flow from this absence. Consider excerpt A from FG1:
GP1
[T]here are rarely any specific issues with subjective complaints. That’s definitely what I find the most difficult [mhm]. What the patient says and feels, that’s what you have to deal with. And it’s very difficult to assess, say, pain, objectively. Or to assess … sadness, objectively [yes], anxiety, worries. So really, we’re in a situation where we have to listen to the patient, and perhaps sick list based on that. And, when the law says that (…) we have the opportunity to sick list, even when we cannot point to anything specific. Then we have no choice but to trust the patient. And, of course, in principle, the patient decides what he or she wants to say. And then that can be entirely correct, or it could be entirely wrong [in-breath yes]. But often it’s somewhere in between. Those are the difficult sick listing cases, definitely [mhm] ….
GP3
Mhm. Tremendously difficult. (FG1).
The excerpt exhibits what was typical and related features of the biomedical framing of MUS. First, the focus throughout is on the lack of objective evidence. Thus, according to the GPs, ‘there are rarely any specific issues’ with MUS, GPs ‘can’t find anything’, possibly because ‘there’s no disease’ to be found (all from excerpt A). Some also pointed to the lack of scientific knowledge and explanation. For instance, one regretted not having ‘an explanation for these conditions (MUS) in medical science’ (FG2). When employing the biomedical frame, GPs thus understood and defined MUS negatively, in contrast with “normal” conditions for which evidence is obtainable and medical science has explanations on offer.
A second feature, and related to the former, is the strong emphasis on subjective testimony as a problem. Without objective evidence, GPs ‘have no choice but to trust the patient’ (GP1 excerpt A), i.e. they are ‘dependent on what the patient says’ (GP3 excerpt A). Having to trust the patient was unpopular, as it involved the risk of being misinformed or even deceived. Patient testimony was thus framed as unreliable: it could be ‘entirely correct, or it could be entirely wrong’ (GP1 excerpt A). In other words, subjective testimony was considered a problematic source of knowledge about patients’ conditions. Health insurance policy stipulates that impairment should have disease as its primary cause. Without evidence, the plausible presence of disease must be determined based on testimony. In the biomedical frame, sick listing thus becomes a problem of trust, and this is why some GPs felt it difficult to act responsibly as gatekeepers (see excerpt A).
Third, related to both lacking evidence and the low epistemic value attributed to testimony were frequent references to negative feelings, such as uncertainty and doubt. Some physicians were afraid that the patient might have a serious undetected problem, as expressed by a participant in FG2: ‘Perhaps there’s something else that I haven’t seen?’ Others emphasised how inability to obtain evidence spawned feelings of uncertainty, doubt and powerlessness. Consider excerpt B:
(…) we start to doubt how sick the patient is. Because we can’t quite objectively grab a hold of these things. We can’t do any blood tests, we can’t scan them or anything. And then we begin to doubt a little. (FG2).
The GP explicitly ties his doubt to the inability to ‘objectively grab a hold’ of MUS. It is because he ‘can’t do any blood tests’ or the likes that he begins ‘to doubt how sick the patient is’. It is noteworthy that lack of evidence results in doubts in patients rather than doubt in medical knowledge. Some voiced suspicion of malingering. For instance, a participant in FG3 talked about two cases concerning young men with back pains. She ‘couldn’t find anything wrong’ with their backs and concluded that they were unhappy with their jobs and wanted sick notes for their ‘supposed back pains’. Some also complained about feeling powerless. Consider excerpt C:
I can urge, or give medical counsel, and I can suggest that we try and up the workload in accordance with what is considered medically appropriate. But, in the end, when she says ‘No, I actually cannot work more (…) I have no choice but to trust the patient, and I really feel forced into doing what she wants [in-breath yes, mhm]. (FG1).
We emphasise that GPs feel powerless; their powers are no more restricted here than they are with biologically verifiable diseases like hyperthyroidism (legally, GPs cannot make patients do anything – they must counsel). But with MUS, GPs feel inhibited. Note also that the participant believes the patient to be healthier than the patient does. The GP’s problem, then, is the lack of authoritative warrants. Without evidence to back him, he feels that he cannot (or should not) force or sway the patient.
The biomedical frame thus accentuated the lack of objective evidence, the problem of trust and subjective testimony, and various troubling emotions. For those reasons, the frame also brought up frequent references to how MUS made GPs’ work difficult. Because the symptoms are ‘difficult to assess’, sick listing becomes difficult (‘what are we to do about it?’), elevating the risk of going into what one GP called ‘a stalemate’, i.e. an unfruitful therapeutic situation (FG1).