Twenty-two GPs agreed to participate of whom 68% (n = 15) were male, 59% (n = 13) were working in partnership practices and 73% (n = 16) were working in practices located in urban areas. Ten of the GPs were trained according to the TERM model. GPs’ mean age was 55 years (SD 6.8). Two GPs were excluded from the statistical analyses due to deviations from the consecutive registration procedure. Another two were absent from the focus group interviews.
Focus group interviews
By exploring the GPs’ perceptions of and experiences with the new diagnostic category of ‘multiple symptoms’, we identified three main themes of importance to its clinical usefulness: Categorisation of patients as having ‘multiple symptoms’ was hampered by (1) lack of consensus on categorisation practices and by (2) the complexity of the patient cases, whereas (3) relational continuity (i.e. continuity in the doctor-patient relationship over time) was disclosed as an essential prerequisite for the application of the diagnostic category of ‘multiple symptoms’.
Lack of consensus on categorisation practices
In the focus group interviews, GPs were clear and unanimous about the theoretical boundaries between the four diagnostic categories for MUS, whereas boundaries became blurred in clinical case descriptions. Discrepancies between GPs illustrated that the process of categorising or diagnosing was not simply a formal process of deciphering symptoms through a lens of objective criteria, rather the process of diagnosing was equally an informal process influenced by GPs’ experiences and attitudes. In our material this became evident in subjective predefined concepts of patients with ‘multiple symptoms’.
They are not suffering from the symptoms. They are not disability pensioners. They are living their lives and for periods of time they have this kind of reaction and they show up with these things. (I03F01, no TERM-training)
I think that these patients, to some extent, are suffering from a personality disorder. Thus, I’m not sure whether you can conclude that symptoms are not attributable to a psychiatric disorder. (I05F02, TERM-training)
According to the GPs, patients with ‘multiple symptoms’ were difficult to distinguish, especially from patients presenting with unwarranted fear of a disease and patients with a somatoform disorder; and this difficulty meant that subjective and individual criteria were applied. The GPs’ distinction between patients with ‘multiple symptoms’ and patients with unwarranted fear depended on the ease with which patients could be reassured and the frequency of their visits. The extent of the patient’s impairment, health concerns and distress were additional factors that helped discriminate patients with a somatoform disorder from patients with ‘multiple symptoms’.
The subjective categorisation practices demonstrated that the GPs perceived the patients’ presentations of MUS to be of a more complex nature than reflected by the defining criteria of ‘multiple symptoms’, and hence this seems to demonstrate a discrepancy between the defining criteria of ‘multiple symptoms’ and the clinical experience. While the GPs’ subjective categorisation processes caused inconsistency in their application of ‘multiple symptoms’, their individual work with the diagnostic criteria made ‘multiple symptoms’ a tool for reflection and awareness that challenged their pre-existing perspectives.
As a matter of fact, his wife has been ill. I’ve come to think whether this has been such a burden to him during the last couple of years that it’s now surfacing. I don’t know, but I’m certainly not done with it yet. […] Due to his personality, I didn’t even think of somatisation. Now, I suddenly realise that he fits this category very well. (I13F03, TERM-training)
The heightened awareness of MUS was perceived as being instrumental in altering current practices because it gave the GP an opportunity to change patient management and thereby protect the patient from an endless odyssey in the healthcare system and possibly from development of a chronic condition of MUS.
Complexity of patient cases
Diagnostic categories are supposed to reduce complexity. However, in our study the GPs did not find that the category of ‘multiple symptoms’ was helpful in reducing the complexity faced in the encounter with patients suffering from MUS.
An issue related to the difficulty embracing the identification and classification of MUS mentioned by the GPs in our study was that patients often present with a large variety of problems that may obscure symptom aetiology and make it difficult to rule out disease. The complexity of the patients’ complaints made the GPs fear misclassification and, not least, overlooking serious disease. Unless absolute certainty could be established in regard to ruling out serious disease, the GPs were reluctant to consider patient complaints as medically unexplained. Thus, the diagnostic category of ‘multiple symptoms’ was articulated as a diagnosis of exclusion although the GPs were aware of the dilemma of unnecessary and less reasonable referrals.
I mean… it’s due to the fear of overlooking something… serious disease; but, on the other hand, we are offering them all sorts of referrals and all sorts of peculiar investigations because they are presenting these diffuse complaints. All the time we’re in this schism. (I02F01, no TERM-training)
The GPs found the clinical context to be unsuited for addressing MUS. Time-restricted consultations made some of the GPs focus on what they considered more valid physical symptoms, thereby avoiding more complex and obligating issues in the clinical encounter.
If the patient presents a symptom which seems valid, this is what I plunge into… because this is what I can cope with in 10 minutes, right […] If I apply a symptom diagnosis [‘multiple symptoms’], which I can’t immediately explain, then I have an obligation to continue, to explore it in depth, to do conversations and…well, maybe a raft of conversations, which I strictly speaking didn’t have the strength for or didn’t find the opportunity for that day. (I10F02, TERM-training)
In our study, GPs expressed an obligation to take action if they applied the new symptom diagnosis. Established descriptive diagnostic categories for symptoms lacking a definite diagnosis do not offer a simple explanation or guide for treatment, nor does the diagnostic category of ‘multiple symptoms’. In our study, this caused uncertainty in the management of patients with ‘multiple symptoms’.
I like to help people, so I prefer when they present something where I can explain what it is and what we’ll do. These patients, they become something, where I don’t know what to do, thus they are… they are not so pleasant to deal with. (I11F03, no TERM-training)
Hence, the diagnostic category of ‘multiple symptoms’ was not perceived to bridge the gap between the identification of patients with MUS and the actions needed to help them.
Relational continuity
GPs perceived relational continuity to be essential to the application of ‘multiple symptoms’. Familiarity with the patient was perceived to be helpful in the identification of symptom patterns, the interpretation of symptoms within a bio-psycho-social frame and in taking what was thought to be the appropriate action in the understanding of the patient’s personal and family background. The participating GPs felt confident that they could identify patients with MUS as soon as they crossed their door step. However, they were reluctant to apply the diagnosis of ‘multiple symptoms’ based on a single encounter and expressed a need for a course of events in order to err on the side of caution. Because of a perceived incapability of judging about the origin of symptoms, the GPs expressed reluctance towards the use of the diagnostic category of ‘multiple symptoms’ if they did not feel sufficiently familiar with the patient. On the other hand, if the GPs considered applying a diagnosis of somatoform disorder, a perceived lack of familiarity encouraged them to use the category of ‘multiple symptoms’ instead. Thus, careful not to err or to do wrong to the patient, the GPs chose the less stigmatising category.
It is very objective/subjective… how well you know the patient before he or she is diagnosed with a somatoform disorder or whether you say: ‘what is this?’ I guess that is the way it is with diagnoses. You fear – in a way – to do wrong to the patient… (I05F02, TERM-training)
Relational continuity is disrupted in partnership practices where patients consult more than one doctor, when doctors in training see the patient or when patients choose to be enlisted in another practice. In these cases, GPs perceived that the diagnostic category of ‘multiple symptoms’ could serve as a tool for communication.
They are frequent visitors, and I think we overlook some of them, who maybe instead are being classified with single symptom diagnoses […] It would be a good way to inform each other that this is a patient with many symptoms and that we don’t have to refer her every single time she presents with a new symptom. (I04F01, TERM-training)
In this way, ‘multiple symptoms’ was thought to support informational continuity by decreasing the inherent risk of overlooking patients with MUS due to single symptom diagnoses applied by different GPs and to hinder patients from undergoing futile referrals. However, the GPs were also aware of the risk of not taking symptoms seriously and of overlooking serious disease due to a stereotypical image of the patient based on familiarity with the patient over time or application of a label of ‘multiple symptoms’.