title: What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms.
abstract: The term 'difficult' is pervasively used in relation to medically unexplained symptoms (MUS) and patients with MUS. This article scrutinises the use of the term by analysing interview data from a study of secondary care specialists' experiences with and attitudes towards patients suffering from MUS.
  
  
  
  Qualitative design employing semi-structured open-ended interviews systematically analysed in three stages: first, data were analysed according to the principles of content analysis. The analysis subsequently focused on the use of the term 'difficult'. Iterations of the term were extracted by summative analysis and thematic coding revealed its different meanings. Finally, alternative expressions were explored.
  
  
  
  Three NHS trust secondary care hospitals in North-East England.
  
  
  
  17 senior clinicians from seven medical and two surgical specialities.
  
  
  
  Unsolicited use of the term 'difficult' was common. 'Difficult' was rarely used as a patient characteristic or to describe the therapeutic relationship. Participants used 'difficult' to describe their experience of diagnosing, explaining, communicating and managing these conditions and their own emotional reactions. Health care system deficits and the conceptual basis for MUS were other facets of 'difficult'. Participants also reported experiences that were rewarding and positive.
  
  
  
  This study shows that blanket statements such as 'difficult patients' mask the complexity of doctors' experiences in the context of MUS. Our nuanced analysis of the use of 'difficult' challenges preconceived attitudes. This can help counter the unreflexive perpetuation of negative evaluations that stigmatize patients with MUS, encourage greater acknowledgement of doctors' emotions, and lead to more appropriate conceptualizations and management of MUS.
authors: Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital, Zurich CH-8032, Switzerland. Electronic address: anke.maatz@puk.zh.ch.
authors: Anke
authors: A
authors: Maatz
authors: Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, South Africa.
authors: Megan
authors: M
authors: Wainwright
authors: Department of Anthropology, Durham University, Durham DH1 3LE, United Kingdom.
authors: Andrew J
authors: AJ
authors: Russell
authors: Centre for Medical Humanities, Durham University, Durham DH1 1SZ, United Kingdom.
authors: Jane
authors: J
authors: Macnaughton
authors: County Durham and Darlington NHS Foundation Trust, Durham DH1 5TW, United Kingdom.
authors: Yan
authors: Y
authors: Yiannakou
mesh_terms: D000328:Adult; D003695:Delivery of Health Care; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D000071896:Medically Unexplained Symptoms; D008875:Middle Aged; D010820:Physicians / Q000523:psychology / Q000592:standards*; D036301:Qualitative Research; D063127:Secondary Health Care / Q000379:methods / Q000592:standards*; D013038:Specialization / Q000592:standards*
keywords: Attitudes; Communication; Medical education; Medically unexplained symptoms; Qualitative research