Coping with Patients with Medically Unexplained Symptoms Work ...

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Coping with Patients with Medically Unexplained Symptoms Work-related Strategies of Physicians in Primary Health Care

KARIN C. RINGSBERG Nordic School of Public Health, Göteborg, Sweden

GUNILLA KRANTZ Centre for Health Equity Studies, CHESS, Stockholm University and Karolinska Institute, Sweden

AC K N OW L E D G E M E N T S . The project was supported by the Research Department at the Nordic School of Public Health, Göteborg, Sweden. We are grateful to all the GPs who shared their experiences with us in the focus-group discussions. We also thank Taina Mäntyranta MD for her assistance as a co-moderator.

Journal of Health Psychology Copyright © 2006 SAGE Publications London, Thousand Oaks and New Delhi, www.sagepublications.com Vol 11(1) 107–116 DOI: 10.1177/1359105306058853

Abstract General practitioners (GPs) often meet patients with medically unexplained symptoms (MUS). From a patient perspective, MUS is a well-acknowledged problem within the primary health care services today, but less is known about the GPs’ perceptions. This study aims to elucidate GPs’ perceptions of patients with MUS, focusing on stressing situations, emotional reactions and coping strategies. Twenty-seven physicians participated in focus-group discussions. In the analysis, where a phenomenographic approach was used, six situations were identified as being especially stressful in the encounter with these patients. The GPs described how they used both problem-focused and emotionfocused strategies, but with emotion-focused strategies slightly dominating, indicating that the GPs had difficulties in managing their own stress when working with patients with MUS.

Keywords ■ ■

COMPETING INTERESTS:

None declared.

ADDRESS.

Correspondence should be directed to: School of Public Health, box 121 33, 402 42 Göteborg, Sweden. [email: [email protected]]

K A R I N C . R I N G S B E R G , Nordic

■ ■ ■ ■

behavioural science coping strategies general practitioner medically unexplained symptoms phenomenography primary health care 107

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Introduction P H YS I C I A N S I N P R I M A RY health care often meet patients with medically unexplained symptoms (MUS) (Wileman, May, & Chew-Graham, 2002). These are physical symptoms, such as chronic neck–shoulder pain, low back pain, stomach pain and headaches, as well as mental complaints, such as sleeping disorders, nervousness, anxiety and depression, which upon investigation appear to be unrelated to any organic pathology. Most patients present with combinations of these (Berntsson & Ringsberg, 2003; Katon, Sullivan, & Walker, 2001; Peveler, Kilkenny, & Kinmonth, 1997; Ringsberg, Åkerlind, & Segesten, 1997). Brage, Berntsen, Bjerkedal, Nygard, and Tellness (1996) found that, of all the cases appearing in primary health care, a well-defined disease was diagnosed in 61 per cent, while in 21 per cent of the cases a symptom or a complaint was used to make a diagnosis. These symptoms are also commonly found in epidemiological studies (Jenkins, Lewis, & Bebbington, 1997) and predict long spells of sickness absence (Krantz & Östergren, 2002). Psychosocial conditions at work and at home (Krantz & Östergren, 2000), stressful life events, anxiety and depressive disorders, childhood and adult trauma and specific personality traits (Katon et al., 2001) have all been found to be associated with multiple symptoms among primary care patients. From a patient perspective, MUS is a wellacknowledged problem in the primary health care services today but less is known about the situations that are perceived as stressful by the general practitioner (GP), the emotions that are involved and the coping strategies that are used when encountering these patients. As the patients with MUS do not fulfil the criteria set for a biomedical diagnosis, they risk being viewed as ‘difficult patients’ by the GP (Steinmetz & Tabenkin, 2001; Woivalin, Krantz, Mäntyranta, & Ringsberg, 2004), creating frustration that also affects the interaction in the consultation and treatment. Coping has been a core concept in research on adaptation to illness and disabilities during the past three decades (Antonovsky, 1988; Lennerlöf, 1988; Scheier, Weintraub, & Carver, 1986). Lazarus and co-workers have been most influential in this research area by looking upon

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coping as a transactional process involving cognitive and behavioural efforts to manage psychological stress (Lazarus, 1993a, 1993b). From this perspective, coping changes over time and in accordance with the situational contexts in which it occurs. When studying the way GPs cope with patients with MUS, it is important to identify particular threats of immediate concern to the physician, rather than broadening the focus of attention to cover the overall situation. It is then important to study coping strategies related to each of the threats, to describe what the physicians think and do in their attempt to cope, intra-individually as well as inter-individually, and to analyse the corresponding emotional reactions throughout the investigating process. In line with this, the aim of this study was to elucidate primary health care physicians’ perceptions of patients with medically unexplained symptoms, focusing on stressing situations, emotional reactions and coping strategies.

Method Selection of informants Five primary health care centres, strategically selected to represent rural areas and towns of small and medium size in Sweden, were contacted. Only fully qualified general practitioners with several years of clinical experience were invited to participate. In all, 27 physicians, 16 female and 11 male, agreed to participate. For the characteristics of the participants, see Table 1.

Data collection and analysis Data were collected in five focus-group discussions (Barbour & Kitzinger, 1999). When collecting and analysing data the qualitative approach phenomenograpy was used (Lepp & Ringsberg, 2002). The discussions were conducted at the participants’ workplaces and lasted for one-and-a-half hours. All the groups were mixed in terms of sex and work experience and the participants in each group knew each other in advance as they were close colleagues. The discussions were tape-recorded and typewritten verbatim. The guiding questions were of a comprehensive character, with follow-up questions, such as: ‘What comes to mind when discussing patients presenting with medically unexplained symptoms?’, ‘What emotions do

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RINGSBERG & KRANTZ: PATIENTS WITH MEDICALLY UNEXPLAINED SYMPTOMS Table 1. Characteristics of the study participants

Group

Men/women

Mean age (range)

I II III IV V Total

4/4 1/3 3/4 2/2 1/3 11/16

47 (33–57) 48 (40–57) 49 (46–57) 49 (45–54) 39 (44–57) 50 (33–57)

these patients arouse in you?’ and ‘How do you cope with the situation, practically and emotionally?’ One of the authors, a physician specialized in general practice (GK), carried out the focusgroup discussions together with a co-moderator, also a physician. The other author, a social scientist (KCR), was the person with prime responsibility for the analysis. A co-examiner, not involved in the project, was assigned to test the inter-subjective agreement of the findings in the following way: the themes and the selected quotations were presented separately to the coexaminer, who was to mach quotations with themes. The agreement between the two assessments was unanimous. The quotations presented here are intended to facilitate the reader’s evaluation of the validity of the findings. A number within brackets after the quotations represents the number of the focus group (Group 1–5) and the sex of the GP (M = male, F = female).

Ethical considerations The Research Ethics Committee at Göteborg University approved the study. All the GPs were informed about the project orally and in writing and about their unquestioned right to withdraw from the project at any point in time.

Results Six particularly stressful situations in the doctor–patient encounter as experienced by the GPs were identified. These situations are described in Table 2, together with the GPs’ emotional reactions and ways of coping with each of the stressful situations.

Total workexperience; years (range)

Specializing in general practice; years (range)

15 (1–22) 17 (6–30) 14 (9–24) 13 (12–23) 14 (4–25) 15 (4–30)

13 (4–27) 15 (5–27) 13 (7–17) 15 (8–23) 14 (3–20) 13 (1–27)

Fear of missing a serious diagnosis Stressing situation and emotional response A stressing situation that was brought up by most of the GPs was the fear of missing a serious diagnosis. They discussed their anxiety that the patient might suffer from a serious, unknown disease although there were no signs or tests to indicate a disease. Another source of stress was the dilemma of maintaining a balance between how often to refer a patient to a specialist and how much to investigate at the primary level. It was regarded as important not to be looked upon as a physician who often refers patients to a specialist at an early stage. One GP said: ‘So you are afraid that there may be something after all. There could be an organic disease that you eventually discover, even if you don’t find anything, no matter how much you search’ (Group 1 M). Some GPs stated that with patients who turn up repeatedly, suffering from the same symptoms, there is a risk that the GP will not be able to mobilize sufficient interest and energy. Some meant that, the more symptoms the patient complains about, the less credible he or she is. Coping strategies • Taking tests and making referrals: to ease anxiety, taking blood tests and/or referring the patient to a specialist at the hospital for further medical examinations were described as common strategies, especially when the GP was not so experienced. Some said that, as their experience grew, they had developed a sense of ‘instinctive feeling’ for when there was something seriously wrong with a 109

P P+E

2. The patient turns up without having booked an appointment

Booking a new appointment Preparing mentally Showing a negative attitude

P E P+E

3. The power to issue certificates

Assessing working ability

P+E

4. The demanding patient

Applying a systematic approach Meeting the patient on an intellectual basis Using positive affirmation Showing authority Referring to other professionals

P E E E P+E

Reflecting over transference Meeting the patient on a regular basis

E P+E

Bouncing the problem back to the patient Explaining the symptoms

E P+E

Seeking social support Issuing a certificate for sick-leave

P+E E

Referring to other professionals Time for reflection Reflecting on whose demands are involved Sharing responsibility

P E E P+E

5. Getting stuck

6. ‘The doctor’s dilemma’

Planful problem-solving (P) Planful problem-solving (P) + Self-control (E) Planful problem-solving (P) Self-control (E) Confronting coping (P) + Excape-avoidance (E) Planful problem-solving (P) + Escape-avoidance (E) Planful problem-solving (P) Positive reappraisal (E) Self-control (E) Distancing (E) Planful problem-solving (P) + Distancing (E) Accepting responsibility (E) Planful problem-solving (P) + Accepting responsibility (E) Distancing (E) Planful problem-solving (P) + Distancing (E) Seeking social support (P + E) Escape avoidance (E) Planful problem-solving (P) Planful problem-solving (P) Distancing (E) Accepting responsibility (E) Seeking social support (P + E)

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Taking tests and making referrals Having an alternative diagnosis in mind

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Classification according to WOC

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Stressing situation

Our classification problem/emotionfocused

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110 Table 2. The six stressing situations described by the GPs, their coping strategies our classification as P = problem-focused or E = emotion-focused and classification according to Folkman and Lazarus Ways of Coping (WOC)

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patient. Others admitted that they sometimes had difficulties in resisting the patients’ demands as they felt it could jeopardize the doctor–patient relationship. • Having an alternative diagnosis in mind: some of the GPs underlined the importance of examining for both somatic and mental problems, always having an alternative diagnosis in mind. Others concentrated on not missing an organic disease and described how, at the beginning of an investigation, they analysed one symptom at a time, to rule out a possible serious disease in a structured way. When no medical explanations were found, they considered social or psychological explanations.

The patient turns up without having booked an appointment Stressing situation and emotional response The GPs agreed that patients consulting with MUS are time-consuming and, when a patient of this kind turns up at times allocated to emergency cases, the GPs are no longer in command of their working situation. One GP said: ‘They simply present a flora of symptoms and they surprise you. You can’t see any structure and you think, Oh, God, I have 15 minutes to get out of this’ (Group 2 F). The GPs described endless discussions with patients while other patients were waiting. This gave rise to feelings of incompetence and even of approaching chaos, especially when the GPs were less experienced. Coping strategies • Booking a new appointment: the GPs said that they generally dealt with the situation by booking a new appointment with the patient, ensuring that regular contact was established with one of the GPs at the health centre, if this was not already the case. However, if the patient came for the first time and no earlier contact with a physician was established, some said that they worried about missing something of importance if they did not take care of the patient immediately. • Preparing mentally: one strategy described when a patient with MUS was discovered on the patient list was to prepare mentally before the patient turned up. To prepare

mentally was described as encouraging oneself to avoid becoming emotionally involved at this visit, and to try to keep the consultation short and not use time allocated for other patients. • Showing a negative attitude: showing the patient a negative attitude was used by some GPs as a strategy to make the patient understand that he or she should have booked an appointment and not come on unplanned visits.

The power to issue certificates Stressing situation and emotional response The GPs reflected on the responsibility associated with issuing certificates for sick-leave and early retirement pensions and described how difficult it is to assess a person’s working ability, especially regarding patients with MUS. A few admitted that they would have preferred not to be in control of these tools at all, as it sometimes hinders a good therapeutic relationship. One GP said: ‘We find ourselves in another role. We have to act on behalf of the authorities and decide whether it is reasonable for the patient not to work’ (Group 3 M). The GPs called attention to the difficulty in this situation related to ways of labelling multiple symptoms—whether they involved stress, sorrow or burn-out syndrome—and who should then make the diagnosis and assess the patient’s working capacity. Some GPs reflected that on the one hand, assessing working ability of patients with MUS is not ‘a medical matter’ and should therefore be handled by other professionals. On the other hand, they realized it was still relevant for these patients to come to the primary health care centre, as they had nowhere else to go. Coping strategies • Assessing working ability: a male GP admitted that, in a few cases, he had handed over the assessment of a patient’s working ability to the social insurance office as he did not consider it to be the medical professional’s task to assess this. However, most of the GPs were not prepared to give this responsibility away to any other professionals as they claimed they were the most competent people to decide when to issue sick-leave certificates. 111

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The demanding patient Stressing situation and emotional responses The GPs stated that some patients were more demanding than others. These were the patients who ‘know everything about their disease’. They were described as being well informed after having read books and weekly publications, watching TV-programmes, listening to the radio or searching the Internet for information. The GPs described that they occasionally felt questioned by these patients and found themselves being pushed into negotiations to perform various investigations, without any longer being able to establish a sense of mutual trust and confidence in the consultation. When the patient gives you a list of things that he or she thinks must be done, you feel as though it is being thrown at you and you almost push your chair backwards to protect yourself. (Group 2 F)

•

•

•

It makes you feel you’re being used. You swallow and you accept it up to a certain point. You prostitute yourself. Sometimes you have no other choice. But there is a point where the patient’s demands are beyond all reason. They are not medically justifiable. (Group 2 M) The GPs also felt that these patients had unrealistic expectations about what the health care service could do. Some of them raised the question of whether they are in fact allowed to dislike a patient. Others, stressed how stimulating it was to create a good doctor–patient relationship, built on trust and confidence. This was seen as a professional challenge, demanding time, skills and the use of not only pure biomedical knowledge but also involvement in the patient’s psychosocial problems. Coping strategies • Applying a systematic approach: to analyse systematically the patient’s worries in depth, and to sort them out one by one together with the patient was experienced as being a helpful strategy when trying to find reasonable explanations for each of the symptoms. This was also seen as a way of educating the patient about physical signals and how they could be related to stress and worries. • Meeting the patient on an intellectual basis: some GPs described how they took the 112

•

patient’s level of knowledge as their point of departure, and then kept the consultation on a more intellectual level, in this way indicating respect for the patient’s standpoint. Using positive affirmation: a female GP explained how she persuaded herself not to get angry and then took a deep breath before encountering the patient. Another male GP described how he told himself to smile and think ‘here comes my old friend again’. Showing authority: most of the GPs stressed the importance of using their authority as medical professionals when they felt pushed up against the wall for not being able to make a biomedical diagnosis. Setting limits, putting forward convincing arguments and showing no hesitation were seen as important strategies on these occasions. Referring to other professionals: some of the GPs admitted that they occasionally became tired of the patients. One way to ease the situation was to refer the patient to a medical specialist, to a nurse or a physiotherapist to get breathing space for a limited period of time. Others sent referrals in the first place to obtain a second opinion on the patient’s problem. Reflecting over transference: when negative feelings arose towards a patient, one GP reflected that this would most probably also create a transfer of the corresponding feelings from the patient to the GP.

Getting stuck Stressing situation and emotional response The GPs described how they, after lengthy investigations without finding reasonable explanations for the symptoms, had feelings of unease and disharmony. ‘Getting stuck’ was described as being caught up in something that was impossible to solve. One GP said: When you can’t find a line to pursue. When the patient’s teeth chatter and his or her knees ache. (Group 1 F; the GP is talking about no logical explanation to the symptoms.) They take up a lot of time and you get frustrated because you can’t get a grip on the problem and that makes them more demanding. They take up more of your intellect. (Group 1 F)

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Coping strategies • Meeting the patient on a regular basis: one strategy described was to set up regular appointments at fairly long intervals to handle a situation in which both the doctor and the patient felt that further investigations would not lead anywhere. Some GPs expressed a sense of relief after having arrived at a point where the patient could come to talk about his or her feelings and worries in the first place, instead of talking about which disease they might suffer from. This was looked upon as a way to help the patient to reduce his or her anxiety. • Bouncing the problem back to the patient: the GPs stressed the importance of not taking over the patient’s problem but bouncing it back, thereby making it visible to the patient, while still offering empathy and support. One way of achieving this was to ask the patient for his or her opinion on the cause and his or her expectations of the consultation. Some GPs described how they made an effort to arrive at consensus with the patient on the interpretation of the symptoms. Others described how, in the consultation, they used techniques inspired by cognitive behaviour therapy. In this way, the patient could become involved, be more realistic about outcomes and assume responsibility for his or her own problem. • Explaining the symptoms: explaining the symptoms and relating them to normal ageing processes, for example, was a strategy described which was used to make the patient calm down. • Seeking social support: some GPs described how they evaluated themselves by asking ‘Is it me who is the strange one?’ Asking for emotional support from colleagues in formal groups but also as private conversations then became an important strategy. Two GPs described how they worked together by consulting each other regularly on patients with MUS, to secure better management of the patient. It was also stated that support sometimes was sought from the patient’s close relatives, a husband or a wife, by involving them in the problem. • Issuing certificates for sick-leave: to put the patient on sick-leave for a shorter or longer

period was described as one way of coping when some of the GPs felt that they had reached the end of their resources in terms of explaining symptoms and treatments. This served the purpose, it was explained, of postponing a decision about measures to be taken and made way for some ‘breathing space’ for the GP. At the same time, the GPs were aware that this strategy legitimized sickness absence for what could not be described as a medical disease. • Referring to other professionals: some GPs described how they openly told a patient about their inability to help, but that other professionals, such as a physiotherapist, a psychologist, a family counsellor, a psychotherapist or a nurse, might be able to. Some GPs also recommended that patients join self-help groups. • Time for reflection: in order to cope, one GP described how he used 10 minutes for reflection at the end of each day.

‘The doctor’s dilemma’ Stressing situation and emotional response The GPs reflected on their role as medical doctors in relation to society. As medical doctors with a long and prestigious education, many impose heavy demands on themselves. They also described how they felt that society assigns to them a high level of trustworthiness and almost infinite wisdom. As a consequence, feelings of insufficiency occasionally developed when they could not help to cure these patients. But what is it (referring to the meeting with a patient with MUS)? It’s just a feeling of uneasiness. It’s hard to say why. Because they (the patients) are not really a threat to us. But we’re not used to not knowing the answer, not knowing what to say. (Group 4 F) You realize that you don’t really know anything. (Group 5 F) Coping strategies • Reflecting on whose demands are involved: some GPs explained how they regularly had to remind themselves about whose problem it was, so that they did not take over the patient’s problem. They meant that there is a risk of imposing overly heavy demands on 113

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oneself, to be the problem-solver, while the patient might not demand or expect immediate solutions. • Sharing responsibility: those GPs who had experience of working in multi-professional teams underlined the success of this mode of working. They explained that the different team members do what they are best suited for. In this way the GP could share the responsibility with other professionals.

Discussion In this study, we wanted to elucidate general practitioners’ experience of working with patients with multiple medically unexplained symptoms. Six particularly stressful situations were identified, as well as the emotional response and the coping strategies that were used. Data were collected in focus-group discussions. We chose focus-group discussion instead of individual interviews as we wanted the phenomenon under study to be broadly elucidated. When using focus-group discussions, it is important to remember that, unlike individual interviews, the informants influence each other by listening and discussing. It is a kind of group process in which a higher level of understanding might be reached among the informants. However, it is not a question of reaching consensus. A phenomenographic approach was used in the analysis of the discussions. This approach strives to reveal people’s qualitatively different conceptions of an experienced phenomenon and the focus of interest is on the collective experience (Lepp & Ringsberg, 2002). In this study, where the participants were eager to discuss this topic with trusted colleagues, it was obvious how they inspired each other and were able to pursue the discussion further to higher levels of insights. It would also be interesting to analyse how the individual participants influenced each other by discussing, but this was not the aim of this study. The impact of stress on the psychological well-being of an individual is mediated or buffered by different coping strategies. Lazarus identified two major functions of coping: problem-focused and emotion-focused. Problemfocused coping includes active efforts that are directed at solving or relieving the sources of stress. Emotion-focused coping aims to reduce 114

or manage the negative emotions caused by the stress. Most people use both problem-focused and emotion-focused strategies in stressful situations. However, people tend to use emotionfocused approaches instead of problem-focused strategies when they believe that they cannot do anything to change their stressful conditions (Lazarus, 1993a). In this study, both kinds of strategies were identified. From Table 2 it is seen that the emotion-focused coping strategies slightly dominated indicating that the GPs had difficulties in managing their own stress when working with patients with MUS. Our findings also illustrate how physicians have been trained in problem-solving and, when a patient problem emerges as being impossible to solve, there is a risk that the doctor feels he/she has failed. Accordingly, the GPs described how problem-focused strategies were applied in the first stage, which included taking tests and making referrals, and issuing certificates. However, when this was not successful, emotion-focused strategies were tried, such as preparing mentally, reflecting and using positive affirmations. Some GPs described how they were more inclined to use emotion-focused strategies as their experience grew, accepting that not all problems had to be solved immediately but could be subject to reflection and the patient’s own involvement. Refraining from ‘doing something’ seemed difficult, even when there was an obvious risk that this would be counterproductive. This is illustrated by the fact that the GPs, when they felt they had exhausted all the other possibilities, issued certificates for sick-leave. Hereby, they legitimized absenteeism from work, although aware of the risk of medicalizing psychosocial problems. According to Folkman & Lazarus (1988), most strategies can be categorized into one of eight categories, namely: confrontive, distancing, self-controlling, seeking social support, accepting responsibility, escape avoidance, planful problem-solving and positive reappraisal. In this study, the GPs gave examples of using all these strategies to different extents, but the strategies of ‘planful problem-solving’ and ‘distancing’ dominated, see Table 2. In a similar study, Steinmetz and Tabenkin (2001) found both supportive and overtly confronting coping strategies, while, in this study, confrontational attitudes were only discreetly discovered among

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the GPs. Even though these two studies were performed in very different settings (Israel and Sweden), they still reveal similarities and suggest a universal way of caring for these patients. In both studies, empathy, non-judgemental listening, understanding and patience were common features. In this study, GPs’ strategies for coping with patients with MUS have been described. It would be interesting to investigate further how the patients cope with their consultation with GPs. As the GPs in this study were strategically selected, the findings presented here cannot be generalized to apply to a wider population of GPs, but they may contribute to a deeper understanding of the problem of how to cope with patients with medically unexplained symptoms.

Clinical implications To treat this category of patients, primary care physicians appear to be in need of relevant further education and training, not only in medicine but also in the field of social psychology and communication. As the cause of the multiple symptoms is multi-factorial, collaboration in multi-professional teams or with single professionals, such as behavioural scientists (psychologists), social scientists and physiotherapists, would be valuable to enhance the primary care physician’s tools. Access to support groups of colleagues and to supervisory groups is desirable.

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Jenkins, R., Lewis, G., & Bebbington, P. (1997). The national psychiatric morbidity study of Great Britain: Initial findings from the household survey. Psychology and Medicine, 27, 775–789. Katon, W., Sullivan, M., & Walker, D. (2001). Medical symptoms without identified pathology: Relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Annals of Internal Medicine, 134, 917–925. Krantz, G., & Östergren, P.-O. (2000). Common symptoms in middle-aged women: Their relation to employment status, psychosocial work conditions and social support in a Swedish setting. Journal of Epidemiology and Community Health, 54, 192–199. Krantz, G., & Östergren, P.-O. (2002). Do a high level of common symptoms predict long spells of sickness absence in Swedish women, 40 to 50 years of age? Scandinavian Journal of Public Health, 30, 176–183. Lazarus, R. S. (1993a). Coping theory and research: Past, present and future. Psychosomatic Medicine, 55, 234–247. Lazarus, R. S. (1993b). From psychological stress to the emotions: A history of changing outlooks. Annual Review of Psychology, 44, 1–21. Lennerlöf, L. (1988). Learned helplessness at work. International Journal of Health Services, 18, 207–222. Lepp, M., & Ringsberg, K. C. (2002). Phenomenography—a qualitative research approach. In L. R. M. Hallberg (Ed.), Qualitative methods in public health research: Theoretical foundations and practical examples (pp. 105–135). Lund: Studentlitteratur. Peveler, R., Kilkenny, L., & Kinmonth, A. (1997). Medically unexplained symptoms in primary care: A comparison of self-report screening questionnaires and clinical opinion. Journal of Psychosomatic Research, 42, 245–252. Ringsberg, K. C., Åkerlind, I., & Segesten, K. (1997). Walking around in circles—the life situation of patients with asthma-like symptoms but negative asthma tests. Scandinavian Journal of Caring Science, 11, 103–112. Scheier, M. F., Weintraub, J. K., & Carver, C. S. (1986). Coping with stress. Divergent strategies of optimists and pessimists. Journal of Personality and Social Psychology, 51, 1257–1264. Steinmetz, D., & Tabenkin, H. (2001). The ‘difficult patient’ as perceived by family physicians. Family Practice, 18(5), 495–500. Wileman, L., May, C., & Chew-Graham, C. C. (2002). Medically unexplained symptoms and the problem of power in the primary care consultation: A qualitative study. Family Practice, 19, 178–182. Woivalin, T., Krantz, G., Mäntyranta, T., & Ringsberg, K. C. (2004). Medically unexplained symptoms: Perceptions of physicians in primary health care. Family Practice, 21, 199–203. 115

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Author biographies K A R I N C . R I N G S B E R G , PhD, Associate

Professor, is by profession a social scientist and a physiotherapist. Her main focus of research is on health, stress and coping and patients with multiple medically unexplained symptoms. Her research is within the field of public health and health promotion.

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G U N I L L A K R A N T Z , PhD, Associate Professor, is a general practitioner by profession, specialized in public health and social medicine. She is engaged in research on behavioural medicine issues such as stress and violence against women. The Centre for Health Equity Studies is a multi-disciplinary department organized by Stockholm University and Karolinska Institute in collaboration.