Patients' and doctors' strategies in consultations with unexplained symptoms. Interactions of gynecologists with women presenting menstrual problems.

Patients commonly receive invasive investigation and treatment for subjective symptoms, but little is known about how this decision is reached. Therefore, the authors audiotaped the interactions of gynecologists with 88 patients presenting menstrual problems without confirmed physical pathology. From these, eight interviews that led to hysterectomy were chosen for detailed qualitative analysis, together with eight of those leading to other responses. Dialogues leading to hysterectomy were characterized by a framework dictated by the patient. She presented deteriorating subjective symptoms and psychosocial distress in a way that placed responsibility on the gynecologist. She imposed a biomedical model on the dialogue, which entailed presentation of an anatomical cause and a surgical solution, with criticism of conservative treatments. Interviews leading to conservative responses were, by contrast, characterized by a strategy whereby gynecologists established authority by confirming their ability to "look inside" the woman's uterus and see that it was normal. The results suggest a novel view of consultation in the absence of physical pathology. The patients and doctors in this study were opponents who used specific strategies to assert authority by emphasizing contrasting areas of expertise: knowledge of subjective symptoms vs. the inside of the body. The use of these strategies helps to explain whether hysterectomy is chosen as a response to menstrual problems in the absence of pathology.