Three main themes and 13 sub-themes were identified (Table 3), which condense professional experiences on how medical specialists constructed MUS-related phenomena and the challenges of dealing with MUS in health services, education and intercultural context.
Theme 1: Adaptation to the personal world of patients
1.1. Listening to fears and concerns
The three groups highlighted that efficient communication from the physician's part involved listening to the beliefs, views about symptoms, and expression of fears of patients with MUS.
‘I have to explore the reasons why she visited me. 'Cause if I learn her language [i.e., the way she expresses herself], she will tell her fears’. (FG2; subsequent numbers denote the referred focus group)
Conversation without anger and carefully listening to the problems of patients were experienced as good strategies. In this manner, in FG1, all group members supported the claim that physicians did not need to answer each question. According to a GP (FG2), the ability to discuss patients’ emotions and frustrations was beneficial for physicians. He had extensive experience asking MUS patients about the emotions they manifested and the social context behind them. The others in the group approved and validated his approach.
1.2. Validating emotions and perceptions
One GP emphasized that they seriously considered the description of symptoms, feelings, and solutions of patients, even when deemed absurd. All groups agreed that telling patients, ‘there is no problem’ equated an insult to most patients with MUS.
‘You must not say that she is all right. And in fact, I don't say that either because this is an insult on her. This is a negation of her problem’. (FG2)
Other interviewees complemented the validation of the patient's feelings and notions by transmitting that doctors cared about their health. They deemed this feedback successful in making patients feel comfortable.
1.3. Shared understanding of symptoms
Understanding the family background and social context of the patient turned out to be an important topic in FG3. Unfolding these themes could promote shared understanding when patients talked about other symptoms apart from their original reason for the visit. Therefore, one GP initiated conversations on intimate or taboo issues (i.e., sex, money, position, and fears) in the case of MUS. Their practice promoted a shared understanding of symptoms in most cases.
Two groups highlighted the role of psychologists in the mutual understanding of symptoms. The health psychologist in the third focus group focused on involving patients in the process of understanding the diagnosis rather than presenting it to them (FG3). The health psychologist in FG2 cited a case in which the symptom (inflammation) that appeared during consultation was related to an actual family conflict stemming from the patient's childhood. In their opinion, a psychologist's goal was to attain a deeper understanding of the patient’s experiences while the patient can increase her awareness about the connection between mind and body.
1.4. Communicating ‘lack of knowledge’ and referral
Apart from understanding a patient's symptoms and fears, multiple methods of referral were mentioned as part of physician’s routine. As physicians stated, one of the most frequent strategies was referring the patient to systematic physical tests (i.e., laboratory tests and X-ray). ‘Then there's a mental guidance, and there's “a test” ’ (FG3). Aside from referral, physicians had to communicate the uncertainty of diagnosis and ‘lack of knowledge’ in the case of MUS. Physicians were frequently concerned with only probabilities at hand. Enabling the patient to understand that physicians could not pinpoint the cause of a blackout and only assumptions could be made was difficult for them. Physicians used different phrasings (e. g. ‘may be caused by internal or external factors’) (FG1). At the same time, the physicians expressed that the role of physicians forbade the presence of uncertainty despite the lack of explicit knowledge on the diagnosis. Moreover, this is how patients could accept the opinion of the physician (FG1).
‘I think it's not OK when the patient sees the physician being uncertain or unsure. So, it shouldn't be revealed, I suppose, or at least I'm trying not to reveal it but to show a calm, determined action’.
2. Theme: Adaptation to cultural differences
2.1. Culturally sensitive doctor–patient relationship
To increase adherence, physicians selected family members with whom they could communicate most effectively. With Roma patients, addressing family members (e.g., grandmother or a ‘voivode’, the leader of the extended family) was found crucial (FG1). The physicians with different professional backgrounds elaborated the cultural aspects of communicating the results of MUS diagnosis to patients (FG1).
‘A.: Maybe about them, about the Roma people, the problem is that it's even more difficult for them to accept that: when I can't answer that question … because the question, of course, is always “what's my problem?” That's the question always’.
MOD.: Yes.
A.: And to them, when I start to say this … (slight chuckle) or so to say, start to yak … yak that the MR was negative…, that everything's fine, the MR hasn't shown anything serious…, no tumor, not this, not that … I can only say what was negative, right, what isn't there. OK, but what then? So … “what's my problem?” And, of course, they ask this a million times. And after all, they are right, because they are visiting the doctor (slight chuckle) to find out what's their problem. So … it's harder for them to accept this, but I, I don't think that this depends on the culture, instead, it depends on the person; I mean there are also other than Roma people for whom it's hard to accept …, so it's not necessarily the culture. Of course, it surely plays a role in it …’. (FG1)
Although practicing culturally sensitive communication, physicians learned to change their conventional ways, which required continuous attention. According to a GP, women from the Middle East were always escorted by a man, and therapeutic decisions had to be made with him (FG3).
‘Well, as a GP, one practically always has to pay attention to how they relate to this, namely how I … it affects their adherence whether I communicate with them accordingly to their culture or not. For example, a, a religious, um, Islamic girl …. She is always escorted by a male relative. It was odd initially, but we got used to it. And they only accept my prescription on what to buy, what medicine to take if I speak directly to the male relative. I explain to him why they need those and then it's fine’. (FG3)
2.2. Openness without fear
To realize culturally sensitive communication, physicians had to accept phenomena during doctor-patient meetings that they may not accept as a person. Participants found that, as physicians, showing interest in differing cultural groups while ensuring they did not become part of it was beneficial (FG3).
‘Mm, I'm trying to learn from differing cultures what's different; that's what I'm interested in. I'm glad that as a physician, how to say, I can have a taste of a different culture while not becoming a part of it. OK? I have my choice, and most likely, I will choose my own culture. I was born here and all …, but I chose my culture because that's what I like, that's what feels good. I'm interested in other cultures, and, as a physician, I can fit in. I look around, taste it, and I can come back. And I'm not becoming a part of it’. (FG3)
2.3. Culture-specific meanings
The professionals recognized that in culturally sensitive healthcare, the goal was to understand the culture-specific meaning of symptoms (e.g., a broken left hand can lead to obstipation due to the ‘tidy hand–dirty hand’ differentiation). Several group members pointed out that the significance of physical symptoms had to be determined with the cultural context and cultural meaning of a patient's situation in mind. To this end, physicians had to switch between cultures every 5 min according to a physician attending international students. For example, where a lone Japanese student in an international student group was typically struggling to raise their problems, Iranian students told theirs immediately (FG3). In addition, the exploration of a patient's notions could promote the understanding of culturally distinct interpretations (FG1).
‘Cultural differences can come to light if I ask them about their supposition. In that case, well … sometimes, even things like … “I know, I've been cursed, so ….” (laughs)’. (FG1)
2.4. Interculturalism in education
Creating common principles of communication in groups of international medical students was found difficult because of cultural differences. According to a faculty member, Japanese students tended to act distant, which could be interpreted as a lack of empathy for others, whereas African students were struggling to maintain eye contact with female patients (FG2). Another group shared more positive intercultural experiences in medical training. This group agreed that such situations shed light on different worlds, thus enabling students to act ‘without judgment’. To support students’ ability to quit from their own world became a common point among group members (FG3).
‘Medical training should make you capable of not judging. You may have your personal opinion that he is responsible for his illness; but in any case, you need to learn how to overcome your preoccupations and just cure him. This makes you capable to deal with cultural differences too’. (FG3)
3. Theme: Need for interprofessional coordination
3.1. Need for consensus view on MUS
Searching for experiences and coping with uncertainty characterized recurring moments of interactions in the groups. This was also apparent around the concept of MUS. Only a few health professionals and medical faculty members used exactly the term MUS. For others, the focus group interview was the first forum where they met the exact term (FG1), while the group agreed that the phenomenon pertained to ‘psychosomatics’ or could be viewed as a synonym of other more common terms (i.e., conversion and somatization) (FG1). Eventually, during the group discussion, a young specialist remained doubtful about the genuineness of the term MUS.
‘But, is there such a thing that medically unexplained at all? … I mean, is there a definition for that? 'Cause I might have been watching too much Doctor House probably, and it was always revealed that … some toxicological, I mean, some poisoning was there, heavy metal … or some infection was always revealed’. (FG1)
3.2. Coordination between the physical and mental health professionals
In certain ways, all groups considered the possibility of coordination between physician, psychiatrist, and psychologist in the care for patients with MUS. However, medical doctors were uncertain about the methods of psychological and psychiatric care in terms of whether the terms shared the same meaning, whether they understood the difference and which one they would propose as a physician (‘I understand the difference, or I hope so that I do, but I, as a physician propose psychiatry’ [FG2]). One of the GPs experienced difficulty in persuading patients to attend even free psychological treatment. However, this form of attendance could be introduced slowly (FG3). To increase the efficiency of referring psychologists, another GP encouraged patients to receive a psychologist's help by stating that the vegetative nervous system is accountable for these symptoms, which can be alleviated by peace of mind (FG2). However, another GP would oblige patients with MUS to undergo psychological treatment.
F.: ‘And um, essentially I was thinking about this, that if you can completely, so if you can trivially say that, that there's, there's um, psychological causes, then why don't I have the right to quasi oblige them to, that this person, that they go to such therapy and don't make demands on healthcare that is already lacking resources. Or, that …
E.: You have the right, you have the right, but it's very difficult’. (FG2)
When feeling helpless, referral to a psychiatrist was considered the ‘last refuge’ for the physician in case of patients with MUS. At the same time, the referring specialist was unaware about what happens with the patient in the psychiatry ward.
‘But we also have, you know, a kind of “last refuge”, the psychiatry (someone laughs). Well, I don't know even after more than 20 years however, what, what a psychiatrist can possibly say. ‘Cause in this kind of cases they are the, the last refuge …’. (FG1)
The psychiatrists, in turn, found MUS as a valuable concept because they understood the physical and mental aspects of diseases as well. However, patients referred to psychiatry due to uncertainty occasionally displayed physical problems (FG1). To this group, the most important conclusion of the interview was that members missed opportunities for interdisciplinary physician–psychiatrist–psychologist meetings. Thus, the current study was filling this gap for them.
3.3. Need for MUS-specific protocols
The lack of protocols on patients with MUS in either primary or specialized care appeared to be a general problem for all groups. The GP alternately working in Great Britain and Hungary missed clear protocols in Hungary as opposed to that observed during an experience abroad:
‘There was the experience in GB that protocols were for knowing one's rights, so we had to explain that they don't deserve more, that that's their right in this system. So there, they drew the line there, that's the protocol, that way. A, B, C, so … That's their right. And this, this has to be accepted, and they have to accept this, that this system means this. For us, it's looser; we give more to some and less to others. Not because we make a difference, but for … how much one needs to calm down or to accept the thing’. (FG3)
Lack of clear protocols on the treatment process and MUS-related interprofessional coordination also meant that specialists did not have feedback from referred patients. This, in turn, led to a low sense of accomplishment and lack of information: the only (negative) feedback was when patients returned again and again to specialized care (FG1).
3.4. Coordination in education
A psychologist opined that communication training was essential for preparing medical students to care for patients with MUS: students could learn a holistic approach for patients without focusing on symptoms. Physicians in the group agreed with this notion. Medical students had to spend much more time in a GP’s praxis ‘because that's where real life is’, that is, where they could see how to deal with MUS patients (FG2). Others proposed that self-knowledge and Balint groups should be part of medical education to help students gain self-confidence in patient-physician communication. However, these and other communication training groups were considered few and expensive (FG2).
‘There would be great need in the training of specialists (e.g., emergency) to learn about this. By now, there is no such theme in the specialist exam, they don't even hear about it (FG1). Even more, a resident physician gets warned when a patient education lasts too long. That contradicts to what is being taught about how to communicate MUS symptoms, namely, it is worth spending time with, listening to and informing MUS patients, because this can prevent frequent visits’. (FG1)
The psychiatrist in FG1 pointed out as a general problem that medical education continued to prepare students for biological and acute problems and saving lives, whereas the majority of patients presented with chronic conditions. In addition, positive physician-patient relationships and communication from the beginning were deemed important for healing chronic cases, such as MUS. According to the group’s final opinion, these aspects needed much more focus in standard medical education.