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Table 1 Illustration of the analytical process with examples of themes and categories developed during analysis

From: Epistemological and methodological paradoxes: secondary care specialists and their challenges working with adolescents with medically unexplained symptoms

Themes Subthemes Categories Subcategories Quotes
A First topic: the epistemological paradox: explaining the unexplained
 A1 Language and the dilemma of explaining the unexplained The inherent problem in communicating inner and embodied states Alternative approaches to communication Using metaphors
Using visual tools
Connecting to the senses
Sharing experiences
“We have tried to close in on the problems by using visual methods. (…) For example, they have taken with them a picture they have drawn or a photo, and we have looked at it together. Or we have watched film clips that sort of captures some of the things they struggle with.”
The problem of diagnosis Nomenclature
Interpretation as negotiation
“It’s not so easy to create a sense of coherence and understanding that maybe I have, and make it meaningful to them.”(…) “A big challenge is to create that basic mutual understanding of what this is about”
 A2 Creating explanatory models and clinical prototypes Clinical prototypes The “good girl” Personality
Lack of assertiveness
Pressure to achieve
“Some of them are very focused on performance and accomplishments, trying to be perfect and live up to some sort of ideal.”
The “trauma victim” Negative life events
“A lot of these patients have traumatic experiences.”
Explanatory models (Bio)psychosocial model
Vulnerability-stress model
Psychological factors
Societal factors
Acute or chronic stress
“I’ve been wondering about the school system that we have today, that there is more pressure on young people… maybe in general in our society… that we have so much to do and are so busy. I think that I have seen an increase in tired and exhausted kids the last few years.”
B Second topic: The methodological paradox: the uncertain expert
 B1 Empathy and the dilemma of clinical uncertainty Focusing on emotions and relational aspects Creating a good working alliance
Building on principles from patient-centred care
Believing in the patient´s story
Building trust and acceptance in clinical encounters
Working towards a common goal
“You have to believe that this is a person who really is in pain. They are really suffering. You have to believe that to create an alliance and really help them.”
Creating an in-group identity of engaged professionalism Identity markers
Performative aspects
Advocating patient interests
Distancing themselves from biomedical parts of the health system
Connecting to like-minded colleagues
“It’s very frustrating when your referrals are declined because the person doesn’t fit the diagnostic criteria, when you know that this is a person that is suffering and could have been helped if they had been given the opportunity. That is one of our biggest frustrations. Diagnostics and the systems that we are forced into.”
 B2 The dilemma of the uncertain expert Balancing opposing roles and tasks Opposing roles
Opposing tasks
The gate-keeper
The expert
The caring and nurturing helper
The humble servant
“Sometimes you feel you have some sort of diamond, that they so desperately want. And then it’s sort of up to the clinician to give an approximate evaluation of whether they should have it or not. Some of them can get very disappointed, cry or make a scene if they don’t receive the diagnosis they had expected.”
Relying on knowledge and experience Tacit knowledge
Years of experience
Clinical intuition
Knowing their own limitations
Tried techniques for themselves
Having a “tool-box” of interventions and techniques
Having seen several patients with similar problems
Being able to seek support from experienced colleagues
Being able to share responsibility with patients when appropriate
“I’m old in the game; I have a lot of experience to keep me floated. I don’t think you should start in this job as a young psychologist or doctor. That wouldn’t work.”