THE CAREFUL ASSESSMENT TOOL FOR MANAGING PATIENTS WITH 
MEDICALLY UNEXPLAINED SYMPTOMS – THE EXPERIENCE OF 
SLOVENIAN FAMILY MEDICINE TRAINEES: A QUALITATIVE STUDY
Vojislav IVETIĆ1*, Špela MARTINJAK1, Alem MAKSUTI2
1University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska ulica 8, 2000 Maribor, Slovenia
2Persuasion d. o. o., Medvedova cesta 26, 1000 Ljubljana, Slovenia
Received: Aug 30, 2021
Accepted: Nov 19, 2021
Original scientific article
*Corresponding author: Tel. + 386 2 620 2490; E-mail: vojislav.ivetic@um.si
10.2478/sjph-2022-0008 Zdr Varst. 2022;61(1):48-54
48
ORODJE SKRBNA OCENA PRI OBRAVNAVI BOLNIKOV Z MEDICINSKO
NEPOJASNJENIMI STANJI – IZKUŠNJE SLOVENSKIH SPECIALIZANTOV
DRUŽINSKE MEDICINE: KVALITATITVNA ŠTUDIJA
© National Institute of Public Health, Slovenia. 
Ivetić V, Martinjak Š, Maksuti A. The Careful Assessment tool for managing patients with medically unexplained symptoms – the experience of Slovenian family medicine trainees: a 
qualitative study. Zdr Varst. 2022;61(1):48-54. doi: 10.2478/sjph-2022-0008.
ABSTRACT
Keywords: 
medically unexplained 
symptoms, Careful 
Assessment tool, family
medicine, qualitative 
studies, family 
medicine trainees
IZVLEČEK
Ključne besede: 
medicinsko 
nepojasnjena stanja, 
orodje skrbna 
ocena, družinska
medicina, kvalitativne 
raziskave, specializanti
Introduction: Primary care physicians use various tools and methods to identify medically unexplained 
symptoms (MUS). The main purpose of our study is to determine the views of Slovenian family medicine trainees 
(FMT) about using the “Careful Assessment” tool for managing patients with MUS.
Methods: A qualitative study using open survey questions focused on the experience of family medicine trainees 
in managing patients with MUS. The sample consisted of surveys from 184 family medicine trainees. These 
trainees analysed a total of 702 patients with MUS. Manual coding was used for quantitative content analysis.
Results: In the coding process, 49 codes were developed that included broader research fields about using the 
“Careful Assessment” tool for managing patients with MUS. The codes were grouped into four theoretically 
grounded, logical categories in accordance with the elaborated theoretical concept: multi-purpose utility; 
improved patient management; in-depth knowledge and new skills; and patient response.
Conclusion: The study demonstrated that, in the view of Slovenian FMT, the “Careful Assessment” tool 
has multi-purpose utility. The study showed that FMT felt that this tool helps them in systematic patient 
management. Their opinion is that it helps them establish a trusting relationship with patients, which is a 
precondition for providing further treatment.
Uvod: Zdravniki primarnega zdravstvenega varstva uporabljajo različna orodja in metode za prepoznavanje 
medicinsko nepojasnjenih simptomov (MNS). Glavni namen naše študije je ugotoviti stališča in prepričanja 
slovenskih specializantov družinske medicine (SDM) o uporabi orodja skrbna ocena za zdravljenje bolnikov z 
MNS. 
Metode: Analizirali smo domače naloge 184 specializantov družinske medicine iz sedmih modularnih skupin 
(skupine 17–23), ki so v okviru izobraževalnega modula medicinsko nepojasnjena stanja (del obveznega 
izobraževanja v okviru specializacije družinske medicine), od leta 2016 do 2018, skupaj analizirali 702 bolnika z 
MNS. Specializanti družinske medicine, ki so sodelovali v študiji, prihajajo iz različnih regij Slovenije, torej smo 
oblikovali čim širši vzorec. Kvalitativna študija z odprtimi anketnimi vprašanji se je osredotočila na izkušnje 
SDM pri zdravljenju bolnikov z MNS. Pri metodi kvalitativne analize vsebine smo uporabili ročno kodiranje, s 
pomočjo katerega smo razčlenili odgovore anketirancev, oblikovali kode in jih potem združili v kategorije (kode 
višjega ranga), ki jih je možno logično povezati in metodično opisati.
Rezultati: V procesu kodiranja je bilo ugotovljenih 49 kod, ki so vključevale širša raziskovalna področja o 
uporabi orodja skrbna ocena za obravnavo bolnikov z MNS. Rezultat kodiranja so štiri oblikovane kategorije: 
večnamenska uporabnost; boljša obravnava bolnika; poglobljeno znanje in nove veščine; odziv bolnikov. 
Kot nove veščine, ki so jih pridobili s pomočjo uporabe orodja skrbna ocena pri obravnavi bolnikov z MNS, 
SDM izpostavljajo predvsem: poslušanje bolnika; večino umeščanja simptomov in znakov v biopsihosocialni 
model; komunikacijske veščine; veščino vpogleda v zgodovino bolnika; prepoznavanje psihosocialnega okolja in 
socialnih problemov bolnika; veščino hitrejšega in boljšega vpogleda v družinsko anamnezo.
Zaključki: Naša raziskava je pokazala, da je po mnenju slovenskih SDM orodje skrbna ocena večnamensko 
koristno za uporabo pri obravnavi bolnikov z MNS. Slovenski SDM menijo, da jim orodje pomaga pri sistematičnem 
vodenju bolnikov z MNS ter da jim pomaga vzpostaviti zaupljiv in poglobljen odnos z bolniki, kar predstavlja 
osnovo za kakovostno vodenje in zdravljenje.
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1 INTRODUCTION
Medically unexplained symptoms (MUS) – physical symptoms 
that cannot entirely be accounted for by a known somatic 
disease – are extremely common in primary care (1, 2). 
MUS and methods to identify them thus constitute an 
important topic in primary health care (1). The authors of 
studies from multiple countries agree that almost a third 
of symptoms remain unexplained when managing primary 
care patients (2, 3). Primary care physicians often face the 
challenge of how to identify MUS, and numerous scientific 
studies deal with methods and evaluation models aimed 
at identifying MUS in order to help physicians manage such 
patients (4, 5).
Physicians use various diagnostic tools and methods 
to deal with MUS patients, and simultaneously try to 
assess the usefulness of these tools and methods, which 
mostly include standardised questionnaires (4, 7-9), 
comprehensive psychological theories and approaches 
(10-12) and qualitative data collection techniques such 
as interview or focus groups (7, 13-17). Using this data, 
several studies aim to standardise the MUS identification 
procedure in primary care patients, with some authors 
going as far as trying to provide a paradigmatic, holistic 
framework for managing patients with MUS (18). 
A successful, and notably early identification of patients 
with MUS is essential both for primary care patients and 
physicians. Therefore, it is important to develop a holistic 
approach based both on the information from the patients 
with MUS and the information (views and experience) 
provided by primary care physicians. Empirical studies 
support the assumption that using comprehensive models 
provides an incremental database (and meta database) 
useful for predicting future situations and providing 
better insight into the situation of the entire population 
of patients with MUS (4, 18). 
The study assumes that tools such as the “Careful 
Assessment” tool (Table 1), based on the “P-P-P 
model” (predisposing factors, precipitating factors 
and perpetuating factors) (18), allow family medicine 
trainees (FMT) to better manage patients with MUS, 
which is reflected in standardised procedures, systematic 
medical history taking and an inclusive approach in which 
the patient is actively involved in the medical history 
collection and treatment of MUS (19, 20).
The main purpose of our study is to determine the views 
of Slovenian FMT about using the “Careful Assessment” 
tool (during the MUS module as part of their specialisation 
program) for managing patients with MUS. 
2 METHODS 
2.1 Study design
This was a qualitative study. We used semi-structured 
coursework surveys, done by Slovenian FMT, during their 
MUS module (part of their specialisation program). 
Such a qualitative study means research determining 
the selection, collection, and analysis of data during 
the research process (21–23). The collected material was 
processed using qualitative content analysis (22, 24). 
2.2 Participants
Coursework surveys done by 184 Slovenian FMT from 
seven module groups (groups 17–23) were analysed. 
These trainees examined a total of 702 patients with MUS 
THERAPEUTIC EFFECT -> possible change in patient beliefs -> better understanding of the patient’s own condition (e.g. pain, fears). 
THERAPEUTIC GOAL: decreasing the power of predisposing factors, limiting precipitating factors, controlling perpetuating factors
PREDISPOSING FACTORS 
chronic childhood medical illnesses 
childhood maltreatment 
low resilience – childhood deprivation 
low social support
PRECIPITATING FACTORS 
psychiatric disorders (depression, anxiety, panic… )  
social, financial, or occupational stress 
changes in social support 
change in routine
PERPETUATING FACTORS 
decreased physical activity 
weight gain 
social isolation 
decreased self-confidence
Table 1. “Careful Assessment” tool, based on the “P-P-P model” (18).
CAREFUL ASSESSMENT OF THE SITUATION (active listening as part of the careful assessment):
10.2478/sjph-2022-0008 Zdr Varst. 2022;61(1):48-54
between 2016 and 2018 within the MUS training module 
(part of the mandatory training within the family medicine 
specialisation). All of the 184 FMT completed their 
coursework, partly or in total, and responded to closed- 
and open-type questions in the “Feedback on Careful 
Assessment Use” questionnaire. The open part of the 
questionnaire was composed of five essay-type questions 
answered by the respondents in writing (Table 2).
The content and program contained in the assignments 
for family medicine trainees were approved by the holder 
of the modular part of the specialisation, the Department 
of Family Medicine, Faculty of Medicine, University of 
Ljubljana. 
FMT who took part in the study came from different 
regions of Slovenia (Table 3), which allowed us to obtain 
a broad sample.
2.3 Data collection
During the MUS module, FMT become familiar with the 
problem of identifying and recognising  MUS patients, 
and among other skills master the practical use of the 
“Careful Assessment” tool for identifying and treating 
MUS in family medicine practice. Their assignment was 
to find 3 to 5 patients with MUS and to use the “Careful 
assessment” tool and test the newly acquired knowledge 
and skills in practice. The patients were identified based 
on the inclusion criterion for identifying patients with MNS 
presented in the module (Patient Health Questionnaire 
(PHQ-15) value ≥15 points and an additional three criteria: 
that the symptom is present for at least three months, 
that the symptom causes clinically significant problems 
and that symptoms cannot be explained by a known 
physical illness).
2.4 Data analysis
Manual coding (25) was used for qualitative content 
analysis. The respondents’ answers were analysed in 
accordance with the research questions, and codes were 
prepared and subsequently combined into categories 
(higher-level codes) that could be logically linked and 
methodically described. Coding was performed by two 
independent coders (V.I. and A.M.). When they failed 
to reach agreement on the coded text, an intercoder 
agreement was attempted on the differently perceived 
parts of the analysed text in order to match the created 
category (also known as the unitising process) (26).
3 RESULTS 
In the coding process, 49 codes were developed that 
included broader research fields about using the “Careful 
Assessment” tool for managing patients with MUS. The 
codes were grouped into four theoretically grounded, 
logical categories in accordance with the elaborated 
theoretical concept (21-24): multi-purpose utility; 
improved patient management; in-depth knowledge and 
new skills; and patient response. These are discussed in 
more detail below. 
1. Did you gain anything in this clinical case (you as a young professional) using the Careful Assessment tool?
Please describe it: 
2. Did you learn anything from using the Careful Assessment tool in this clinical case?
If YES, what? Please describe it:
If NO, how do you explain this? Why not? Please describe it:
3. How useful was the “Careful Assessment” tool in this clinical case?
4. How did the patient respond to your treatment in this clinical case?
5. Do you estimate that you have improved the treatment of your patient in this clinical case?
If YES, please describe it: 
If NO, how do you explain this? Why not? Please describe it:
Gender 
Male
Female
No data
Infirmary location
City
Town
Countryside
No data
Employment
Public institution
Private institution
Concession
No data
Years of service in 
family medicine 
Maximum
Minimum
Average
 Number of GPs (N=184)
55
112
17
 
49
74
31
30
 
140
3
33
8
  
8
2
3.3
Percentage (%)
29.8
60.9
9.3
26.6
40.2
16.8
16.4
76.0
1.6
17.9
4.5
Table 2.
Table 3.
“Feedback on Careful Assessment Use” questionnaire.
Participant information.
50
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3.1 Category 1: Multi-purpose utility 
In terms of its multi-purpose utility, the “Careful 
Assessment” tool was seen by the FMT as very useful for 
managing patients. The tool allowed them to manage the 
patients systematically and to gain the patients’ trust, as 
well as to obtain a general understanding of the patients’ 
histories. Below are some of their statements.
“l believe the tool was very useful. At the beginning, 
I felt a bit lost because I was overwhelmed by his (the 
patient’s) problems and medical reports. I often felt that 
my management was not appropriate, since I was unable 
to find the main problem. I improved this by using the 
tool.” (GP 35).
“Very useful. It helped me establish a more trusting 
relationship with the patient, who then opened up and we 
were able to slowly reach the triggers of the problems. We 
needed four months of consultations and the tool enabled 
us to finally succeed in approaching certain topics.” (GP 5).
The FMT also evaluated the experience of patients 
favourably, who saw the use of the “Careful Assessment” 
tool as positive, indicating its general usefulness both 
for the physician and the patient. The systematic 
management was considered by the FMT to be the most 
valuable contribution.
However, certain concerns raised by some FMT pointed to 
the fact that the “Careful Assessment” tool was useful for 
the physician, but not so much for the patients, who did 
not identify the potential cause of their problems during 
such treatment. Below are two different experiences from 
respondents.
“For me, “Careful Assessment” meant a structure that 
facilitated my in-depth dialogue with the patient. It led 
me to review the patient’s medical records from her 
childhood, to investigate her susceptibility and to reflect 
on and ask about the triggers and the patient’s response 
to them.” (GP 12).
“It was mostly useful for me in terms of understanding 
the patient’s feelings and problems. The tool was less 
useful for the patient’s better understanding of their own 
condition.” (GP 40).
3.2 Category 2: Better patient management
The FMT specifically mentioned some elements of the 
“Careful Assessment” tool as being useful for better patient 
management. These included notably enhancing the 
physician-patient relationship, which is often called into 
question due to certain systemic problems in the health care 
system (e.g., overburdening of family physicians). Another 
useful element was the time available for consultations by 
means of the “Careful Assessment” tool. 
“I was able to deal with the patient comprehensively, like 
all patients should be if we had the time.” (GP 55) 
“In this case, I asked the patient in more detail about her 
current life situation and its impact on her thinking and 
experience. I usually do not ask this because normally I do 
not have the time for an in-depth medical history.” (P35)
Many respondents pointed out that they had succeeded in 
convincing patients with MUS to start taking better care 
of themselves and to change certain lifestyle practices, 
which contributed to the resolution of problems which 
had been the reason for seeing the physician. 
“In this clinical case, the patient’s clinical condition 
definitively improved, as she started to gain weight, she 
was feeling better and obtained at least a partial insight 
into her disease.” (GP 78)
“I believe I improved patient management in this clinical 
case. There are changes visible, since he started doing 
something he likes. He feels better on a vegan diet.” (GP 
90)
3.3 Category 3: In-depth knowledge and new skills 
In the opinion of the FMT, the tool proved to be generally 
useful for the physician to find out if the patient’s problems 
were associated with their psychosocial environment and 
mental health. Such patients most frequently present as ill, 
and the “Careful Assessment” tool allowed the physician 
to find various cognitive or psychological disorders and 
problems behind the patient’s physical symptoms. 
“When concrete problems are manifested, the 
characteristics and psychological status of the patient 
coming to the physician’s office with the symptoms of a 
physical illness should be investigated.” (GP 2). 
“I learned that it is highly important to understand the 
background, since problems also arise from the mental 
state.” (GP 134)
“I learned that all factors pertaining to MUS should be 
considered. In this case, triggers (depression, interpersonal 
relationships) are at the forefront.” (GP 77)
Among the new skills obtained through using the “Careful 
Assessment” tool for managing patients with MUS, FMT 
particularly stressed the following: listening to the patient; 
identifying symptoms and signs within the biopsychosocial 
model; communication skills; the ability to gain insight 
into the patient’s history; recognising the psychosocial 
environment and the patient’s social problems; and the 
ability to have a faster and better insight into family 
history. FMT usually focus on the patient’s psychophysical 
symptoms and often fully neglect the importance of the 
social environment or so-called external factors. Below 
are two concrete examples from this category.
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“I learned that the patient’s condition and problems 
should be positioned into a wider context of their life 
and activities action, i.e., their working and living 
environment.” (GP 6)
“The tool really contributed to explaining the patient’s 
symptoms, and this module and the Careful Assessment 
tool made me see the bigger picture around the patient.” 
(GP 16)
3.4 Category 4: Patients’ response
FMT are convinced that the tool was also seen positively 
by the patients. The results showed that this sometimes 
happens during the first consultation, and sometimes later 
in the process when the patient and physician have built 
mutual trust and continue on the common path to seek 
solutions to the patient’s problems. Two examples of this 
are shown below.
“During the first consultation, the patient was upset, but 
came back in 10 days saying that she had reflected on 
her problems and started to see them from a different 
perspective. She acknowledged that she had many 
problems in her personal life that she was unable to 
resolve by herself.” (GP 1)
“First, the patient was surprised by the detailed questions 
and because new personal topics were discussed; then 
she opened up and explained her situation in a trusting 
manner.” (GP 17)
“At first, he would not hear a thing about psychological 
problems; he was convinced that his problems were 
physical in nature. Later on, he agreed to reflect on 
whether the cause of the problems was the family 
situation, he also agreed to see a psychiatrist.” (GP 19)
“The patient was highly satisfied with the consultation; 
when we cleared up the issue, she seemed more relaxed 
and came more rarely to the physician’s office and in a 
better mood.” (GP 88)
In some cases, the patients had reservations regarding 
the “Careful Assessment” tool. The FMT highlighted the 
patients’ lack of trust because they were used to their 
chosen physician (the trainee’s mentor), which resulted in 
denial, lack of cooperation and resentment.
“Negative response. She is convinced she is very ill and 
that activities she could do by herself are just a waste of 
time.” (GP 54)
“The patient responded very negatively, she refused 
to discuss her gradual work activation or professional 
rehabilitation.” (GP 44)
“Negative response; he had distanced himself from his 
psychological issues as the cause of his problems.” (GP 110)
Finally, both types of experience, positive and negative, 
can be important in the process of improving FMT 
education and better management of patients with MUS. 
4 DISCUSSION 
The first finding is that the “Careful Assessment” tool, 
when used by Slovenian FMT, was aimed at achieving 
more systematic management of patients with MUS. 
Physicians are able to obtain more information from 
the patients, thus gaining more insight into their family 
history and characteristics of their social environment, 
which is a frequent source of a patient’s problems. In 
his study, Stone (18) found that a key problem is the fact 
that physicians often simply copy strategies from others, 
and mostly manage patients with MUS based on their own 
experience. He suggests the creation of a comprehensive 
model according to which a bigger emphasis should be 
placed on the cognitive and emotional side of the patient’s 
problems when taking a medical history.
Our second finding is that, in the view of Slovenian FMT, 
the “Careful Assessment” tool is useful in improving trust 
and an encouraging an honest and open physician-patient 
relationship, which is needed when treating patients with 
MUS. Other authors in their studies on the subject made a 
similar finding (2-3, 5-9, 11-13, 27-29).
Since MUS are often associated with psychological 
problems, which are frequently difficult for people to 
discuss, trust is essential for successful treatment. This 
is also shown by the results of our research, which are 
similar to the results of some studies from abroad. For 
example, Den Boeft et al. (4) found that the physician’s 
skills, understanding the patient’s context of the broader 
environment (work, social and family environment) and the 
physician-patient relationship all affect the management 
of patients with MUS. The authors stress the importance 
of systematic patient data collection. 
An interesting model for assessing long-lasting symptoms 
in patients with MUS was provided by Tyrer et al. (12), who 
used 470 patients to assess long-lasting symptoms in the 
patients, their characteristics and internal consistency. 
The study did not involve physicians (unlike our research) 
and was only focused on patients, which means that the 
experiences and opinions from physicians in managing 
patients with MUS were not covered.
A mixed-methods approach was used by Rask et al. (6), 
who used a combination of quantitative and qualitative 
data to characterise the clinical usefulness of a special 
diagnostic category called ‘multiple symptoms’ to identify 
the intensity of MUS diagnosis in the patients. Similar 
to our study, Rask et al. (6) concluded that trust and 
understanding the patient’s social environment were 
necessary for effective management of patients with MUS, 
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and that models or tools able to assist physicians to take 
high-quality medical histories and determine treatment 
are also important.
Similar to other studies (5-9, 11-13), ours showed that the 
standardisation of procedures and increasing systematicity 
in taking medical histories as well as an inclusive approach 
actively involving the patient are essential for successful 
management and treatment of patients with MUS. 
Moreover, the study showed that, in the view of Slovenian 
FMT,  such an approach is also supported by patients, 
who want to establish an in-depth relationship with their 
physician and be more involved in the diagnostic and 
treatment process. 
4.1 Strengths and limitations
In our study we analysed the collected data using 
quantitative content analysis. The advantage of such a 
research approach is a detailed insight into the experience 
of FMT in managing patients with MUS and the use of the 
“Careful Assessment” tool. The study constitutes the basis 
for future research in the learning process framework for 
managing patients with MUS. The findings from the study 
are also well-suited for improving clinical practice and 
conducting future studies. 
The study itself has some methodological limitations. 
First, it was a non-random sample of 184 respondents not 
representative of the physician population in Slovenia. 
If the findings are to be generalised to all primary care 
physicians, a larger random sample should be included, in 
accordance with a pre-set sampling frame. Moreover, in 
such a case, a survey method would be better.
The study is also limited by the method used. It was 
assumed that individuals were honest (and objective) 
when providing their answers, which is not always true. 
Respondents often provide conformist answers, and it 
should be noted that they were not paid to participate 
in the study. A study bias is also often a problem when 
issues related to people’s health are concerned, which 
is particularly typical of patients with an MUS diagnosis. 
It should also be noted that work in primary health 
care, which normally follows prescribed guidelines, 
can significantly vary between different organisations. 
There are also some systemic factors (lack of physicians, 
overwhelming workloads in some health care sectors, etc.) 
and differing workloads in different regions in Slovenia, 
which could significantly affect the validity of the results 
obtained. Such limitations should be taken into account 
by future studies.
5 CONCLUSION 
Our study showed that the “Careful Assessment” tool helps 
FMT in systematic patient management. It helps them 
establish a trusting relationship with their patients, which 
is a precondition for providing further treatment. Another 
important finding is that, according to the responding FMT, 
patients have a positive attitude to the use of the tool, 
and feel more involved with regard to their physician and 
their disease. They are thus willing to give their physician 
highly intimate details of their problems and go as far as 
talking about their social environment (job, family), which 
is often the source of their MUS and other issues in life. 
Our results are valuable in terms of future investigations 
of the treatment of patients with MUS and of the usability 
of the “Careful Assessment” tool. Since cases of MUS 
are a very broad, unexplored and unpredictable field 
of medicine, it makes sense to focus future studies on 
individual segments of a patient’s treatment, given 
the problems they face. In this way, future “Careful 
Assessment” tools would become more accurate and 
even more useful, contributing to both physicians and the 
scientific community.
 
ACKNOWLEDGEMENTS
We thank all our Slovenian family medicine trainees 
for commitment in their learning process of managing 
patients with MUS. We are also very grateful to Mrs 
Smerkolj and Ms Hadler for reviewing the English version 
of the manuscript. 
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
This research received no specific grant from any funding 
agency in the public, commercial, or not-profit sectors.
ETHICAL APPROVAL
The study was approved by the National Medical Ethics 
Committee of the Republic of Slovenia, Decision No. 
0120-587/2020/3 dated 3 Feb 2021. Informed consent 
was obtained from all family medicine trainees as well as 
assurances of confidentiality. 
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REFERENCES 
1. Creed F, Henningsen P, Fink P, editors. Medically unexplained 
symptoms, somatisation and bodily distress: developing better clinical 
services. Cambridge: Cambridge University Press, 2011. doi:10.1017/
CBO9780511977862
2. Khan AA, Khan A, Harezlak J, Tu W, Kroenke K. Somatic symptoms in 
primary care: etiology and outcome. Psychosomatics. 2003;44(6):471-
8. doi: 10.1176/appi.psy.44.6.471.
3. Fink P, Rosendal M, editors. Functional disorders and medically 
unexplained symptoms: assessment and treatment. Aarhus, Denmark: 
Aarhus University Press, 2015.
4. den Boeft M, van der Wouden JC, Rydell-Lexmond TR, de Wit NJ, 
van der Horst HE, Numans ME. Identifying patients with medically 
unexplained physical symptoms in electronic medical records in 
primary care: a validation study. BMC Fam Pract. 2014;15:109. doi: 
10.1186/1471-2296-15-109.
5. den Boeft M, Huisman D, van der Wouden JC, Numans ME, van der 
Horst HE, Lucassen PL, et al. Recognition of patients with medically 
unexplained physical symptoms by family physicians: results of a 
focus group study. BMC Fam Pract. 2016;17:55. doi: 10.1186/s12875-
016-0451-x. 
6. Rask MT, Andersen RS, Bro F, Fink P, Rosendal M. Towards a clinically 
useful diagnosis for mild-to-moderate conditions of medically 
unexplained symptoms in general practice: a mixed methods study. 
BMC Fam Pract. 2014;15:118. doi: 10.1186/1471-2296-15-118. 
7. Dowrick C, Gask L, Hughes JG, Charles-Jones H, Hogg JA, Peters S, 
et al. General practitioners’ views on reattribution for patients with 
medically unexplained symptoms: a questionnaire and qualitative 
study. BMC Fam Pract. 2008;9:46. doi: 10.1186/1471-2296-9-46. 
8. Sitnikova K, Pret-Oskam R, Dijkstra-Kersten SMA, Leone SS, van 
Marwijk HWJ, van der Horst HE, et al. Management of patients with 
persistent medically unexplained symptoms: a descriptive study. BMC 
Fam Pract. 2018;19(1):88. doi: 10.1186/s12875-018-0791-9.
9. van Westrienen PE, Pisters MF, Veenhof C, de Wit NJ. Identification of 
patients with moderate medically unexplained physical symptoms in 
primary care with a five years follow-up. BMC Fam Pract. 2019;20(1):66. 
doi: 10.1186/s12875-019-0950-7.
10. Proudlock S. EMDR and the treatment of medically unexplained 
symptoms: a case study. SAGE Open. 2015;5:4. doi: 
10.1177/2158244015615636
11. Ringsberg KC, Krantz G. Coping with patients with medically 
unexplained symptoms work-related strategies of physicians in 
primary health care. J Health Psychology. 2006;11(1):107–16. doi: 
10.1177/1359105306058853.
12. Tyrer H, Ali L, Cooper F, Seivewright P, Bassett P, Tyrer P. The schedule 
for evaluating persistent symptoms (SEPS): a new method of recording 
medically unexplained symptoms. Int J Soc Psychiatry. 2013;59(3):281-
7. doi: 10.1177/0020764012438484. 
13. Dwamena FC, Lyles JS, Frankel RM, Smith RC. In their own words: 
qualitative study of high-utilising primary care patients with medically 
unexplained symptoms. BMC Fam Pract. 2009;10:67. doi: 10.1186/1471-
2296-10-67. 
14. Ivetić V, Kersnik J, Klemenc-Ketiš Z, Švab I, Kolšek M, Poplas-Susič 
T. Opinions of Slovenian family physicians on medically unexplained 
symptoms: a qualitative study. J Int Med Res. 2013;41(3):705-15. doi: 
10.1177/0300060513480079. 
15. Pohontsch NJ, Zimmermann T, Jonas C, Lehmann M, Löwe B, Scherer 
M. Coding of medically unexplained symptoms and somatoform 
disorders by general practitioners - an exploratory focus group study. 
BMC Fam Pract. 2018;19(1):129. doi: 10.1186/s12875-018-0812-8.
16. Rasmussen EB, Isaksson Rø K. How general practitioners understand 
and handle medically unexplained symptoms: a focus group study. 
BMC Family Practice. 2018;19:50. doi: 10.1186/s12875-018-0745-2.
17. Warner A, Walters K, Lamahewa K, Buszewicz M. How do hospital 
doctors manage patients with medically unexplained symptoms: a 
qualitative study of physicians. J R Soc Med. 2017;110(2):65-72. doi: 
10.1177/0141076816686348.
18. Walker EA, Unützer J, Katon WJ. Understanding and caring for the 
distressed patient with multiple medically unexplained symptoms. J 
Am Board Fam Pract. 1998;11(5):347-56. doi: 10.3122/15572625-11-5-
347.
19. Stone L. Managing the consultation with patients with medically 
unexplained symptoms: a grounded theory study of supervisors and 
registrars in general practice. BMC Family Practice. 2014;15:192. doi: 
10.1186/s12875-014-0192-7.
20. Ivetić V, Pašić K, Selič P. The effect of an educational intervention in 
family physicians on self-rated quality of life in patients with medically 
unexplained symptoms. Zdr Varst. 2017;56(2):91-8. doi: 10.1515/sjph-
2017-0012. 
21. Flick U, Von Kardorff E, Steinke I, editors. A companion to qualitative 
research. London: Sage, 2003.
22. Schreier M. Qualitative content analysis in practice. Los Angeles: Sage, 
2012.
23. Legard R, Keegan J, Ward K. In-depth interviews. In: Ritche, J, Lewis, 
J, editors. Qualitative research practice: a guide for social sciences 
students and researchers. London: Sage, 2003.
24. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 
2008;62,107–115. doi: 10.1111/j.1365-2648.2007.04569.x.
25. Saldaña J. The coding manuals for qualitative researchers. Los 
Angeles: Sage, 2009.
26. Krippendorff KH. Content analysis: an introduction to its methodology. 
Thousand Oaks, CA: Sage, 2003.
27. Bonnesen CT, Jensen MP, Madsen KR, Toftager M, Rosing JA, Krølner 
RF. Implementation of initiatives to prevent student stress: process 
evaluation findings from the healthy high school study. Health Educ 
Res. 2020;35(3):195-215. doi: 10.1093/her/cyaa003. 
28. Musekamp G, Gerlich C, Ehlebracht-Kï Nig I, Dorn M, Hï Fter A, 
Tomiak C, et al. Evaluation of a self-management patient education 
programme for fibromyalgia-results of a cluster-RCT in inpatient 
rehabilitation. Health Educ Res. 2019;34(2):209-22. doi: 10.1093/her/
cyy055. 
29. Penšek L, Selič P. Empathy and burnout in Slovenian family medicine 
doctors: the first presentation of Jefferson scale of empathy results. 
Zdr Varst. 2018;57(3):155-65. doi: 10.2478/sjph-2018-0020.