RESEARCH AUSTRALIAN FAMILY PHYSICIAN VOL. 42, NO. 7, JULY 2013 1 Medically unexplained symptoms are common and disabling. 1,2 When symptoms are severe and remain unexplained, both doctors and patients can be caught in a cycle of health anxiety. 3 Doctors worry about missing disease, and patients experience symptoms that fuel concern about illness. 4 It is therefore difficult for doctors and patients to navigate the transition from investigation to coping with an illness that remains poorly defined. 5 There are a number of sociological frameworks, models and theories around the lived experience and care trajectory of chronic illness. 6–11 Most identify an important moment when the diagnosis is confirmed and therapeutic effort shifts from investigation to treatment. The situation is different with medically unexplained symptoms. Patients describe having their symptoms discounted, and their suffering dismissed when there is no name for their illness and no associated management protocol: their illnesses are often described as ‘contested’. 12,13 Doctors may describe these patients as ‘heartsink’ patients, 14 because they engender feelings of frustration and helplessness. Kleinman 9 describes the social expectations around illness as an ’exoskeleton’ that shapes the way doctors and patients experience, conceptualise and interpret symptoms. The following common cultural expectations are particularly problematic for patients with medically unexplained symptoms. ‘Every disease has a name and a remedy’ Most patients and carers tend to make sense of illness by thinking of it as a narrative, preferring above all a story in which treatment restores the patient to health. 6 In this ‘restitution narrative’, every disease has a name, the name drives the choice of remedy, and the remedy restores wellness. This narrative parallels the medical story of diagnosis, evidence based treatment and cure. With medically unexplained symptoms, it is impossible to ground illness experience in a restitution narrative, because there is no name, remedy or cure for the illness. Without a satisfactory diagnosis, the patient with medically unexplained symptoms, their family, and health professionals are left without a helpful explanation for their illness experience. In the face of their own discomfort, many carers and health professionals abandon the patient because ‘their troubles are too complex, in both medical and social terms, for fixing’. 6 ‘Chronic illness follows a predictable course’ Corbin and Strauss 8,15 developed the trajectory model through a series of grounded theory studies focused on nurses and patients with a range of chronic illnesses. They describe a series of phases that describe the way chronic illness develops over time. The first phase, the trajectory onset, incorporates early assessment, and closes with the diagnosis. This diagnosis then shapes trajectory projections: predictions about the chronic illness course. Medically unexplained symptoms lack a diagnosis and this means patients are left without vision for the illness course. ‘Coming to terms’ with the illness is difficult when the illness trajectory is unpredictable. Chronic uncertainty is very unsettling for everyone involved in the care of patients. ‘The doctor decides whether the patient is sick’ Kleinman 9 describes the process of diagnosis as ‘domesticating’ illness, where diagnosis brings Background Diagnosis brings order, predictability and validation to suffering. Patients with medically unexplained symptoms experience vulnerability and cultural invalidation. Doctors also struggle to manage these patients. Objective To explore the strategies general practitioners use to manage patients with mixed emotional and physical symptoms and no diagnosis. Method Thematic analysis utilising semi- structured interviews of 24 Australian GPs. Results Validation of the patient as a person involved building a helpful therapeutic alliance. Commitment to the patient, which the GPs described as ‘ownership’, involved advocacy and support. Holding uncertainty involved managing the need for a disease name. This included harm minimisation, including uncertainty management. Shift to coping involved the challenges of managing ongoing symptoms that had no name, no cure and no predictable outcome. Discussion Managing patients with medically unexplained symptoms involves professional and personal challenges. However, many of the GPs in this study found managing these patients rewarding in the long term. Keywords attitude of health personnel; general practice; communication; physician- patient relations; somatoform disorders; qualitative research Reframing chaos A qualitative study of GPs managing patients with medically unexplained symptoms Louise Stone