'It’s like a Gordian knot' - the management of patients with persistent postconcussion symptoms in general practice: a qualitative study

Abstract

Background

General practitioners (GPs) function as the primary coordinative healthcare professionals for patients with persistent post-concussion symptoms (PPCS) who are at risk of protracted disability. The study aimed at exploring GPs’ perspectives on managing patients with PPCS and at identifying the barriers they perceive in treating this patient group.

Methods

Semi-structured in-depth interviews with 12 GPs from different geographical regions. All GPs had experience with management of patients with PPCS in general practice.

Results

The study identified three main themes representing the perceived challenges: (i) managing patients with PPCS, (ii) coordination with other actors, and 3) GPs’ clinical gaze on patients with PPCS. GPs perceived management of this patient group as challenging due to the limited guidelines, diagnostic consensus, and resources. They struggled with insufficient referral options in the public healthcare system both regarding secondary sector and municipalities. The absence of biomedical evidence lead some to be skeptical about the condition, especially in female patients. However, ultimately they strived to embrace the biomedically unknown and approach their patients with trust.

Conclusion

GPs face significant challenges in managing PPCS due to insufficient translation of guidelines, diagnostic uncertainties, and scarce referral options. Despite skepticism fueled by the lack of biomedical evidence, they endeavor to approach each patient with an open mind. The results underscore the need for improved resources and referral pathways to support GPs in treating patients with PPCS effectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-026-03331-4.

Key messages

• General practitioners face challenges managing persistent postconcussive symptoms (PPCS) due to insufficient translation of guidelines, resources, and referral options.

• Skepticism regarding PPCS exists, especially for female patients, due to lack of biomedical evidence.

• Nevertheless, general practitioners aim to approach PPCS patients with trust and openness toward the biomedically uncertain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-026-03331-4.

Introduction

Mild traumatic brain injuries (TBI) such as concussions pose a significant public health challenge. They represent up to 90% of all TBIs and are the most frequent neurological diagnosis in adults of working age [1]. In Denmark, the incidence of concussion based on hospital contacts is 308 per 100,000 person-years [2]. However, studies including both persons diagnosed at hospitals and in general practice indicate incidence as high as 1153 per 100 000 inhabitants [3]. Concussed patients have lower odds of resuming work [4–6], reduced chances of completing education [7, 8], higher use of healthcare services [9], increased risk of developing comorbidities [10] and increased risk of suicide [11]. Especially highly educated and younger individuals are at risk of long-term sickness absence and social transfer payments [4, 12] and face challenges to their work identity [13].

Patients with concussion experience physical, cognitive, and emotional symptoms that for most disappear quickly [14]. However, about 30% continue to experience symptoms which can last for months or years [15]. The identification of patients at risk of persistent postconcussion symptoms (PPCS) remains a challenge despite development of many prognostic models [16].

General practitioners, GPs, play a pivotal role in the management of patients with PPCS. In the Danish healthcare system, the GPs are consulted both in the acute and post-acute phase, as they serve as the primary coordinating healthcare professionals [9]. In cases of acute head trauma, patients can contact either their GP or the hospital emergency department. GPs are often responsible for the initial assessment, including determining whether referral to hospital care is necessary. They are then responsible for follow-up consultations and monitoring, providing guidance on rest, gradual return to activity, and the management of symptoms. When post-concussion symptoms persist, GPs remain the main point of contact, ensuring long-term monitoring and coordinating further care by referring patients to relevant specialists, such as neurologists [17]. Further, GPs provide sickness certifications and coordinate with employers, schools, and the municipal health care system, when extended sick leave or rehabilitation is required. All these services are tax-funded and therefore free of charge for patients.

Studies focusing on GPs’ management of population with PPCS are sparse, in contrast to hospital-admitted patients [18, 19]. Research indicates that information provided by GPs is highly variable and insufficient [20], and that GPs rarely use clinical guidelines or standardized assessments [21].

While GPs play a crucial role in patients’ recovery process, we have very limited knowledge about their perspectives on this patient group and the challenges they encounter while providing care. The aim of this study was therefore to explore GPs’ perspectives on managing patients with PPCS and to identify the barriers they perceive in treating this population.

Methods

Study design

This was a national qualitative study using semi-structured in-depth interviews. The study followed Consolidated Criteria for Reporting Qualitative Research (COREQ).

Recruitment

The GPs were recruited through convenience sampling but with emphasis to capture variation across gender, age, years of experience, and geographic location. During recruitment, we continuously kept track of the characteristics of the recruited individuals and made efforts to ensure diversity through seeking participants with characteristics that were not yet represented, e.g. targeted announcements in a particular geographical location. Initially, we prepared a short project description specifying the purpose of the study and methodology. We emphasized that we were interested in hearing the GPs’ perceptions and experiences with managing the patients suffering from PPCS and that we were interested in experienced physicians. This was rooted in our wish to interview participants, who were knowledgeable about the phenomenon of interest and thereby able to provide the most information-rich descriptions [22]. The short description was announced in newsletters of the Danish Organization of General Practitioners, and the Danish College of General Practitioners, DSAM. Through these channels, eight GPs from across the country showed interest to participate in the study. Additionally, we used the network of The Danish Concussion Center that announced the study in its newsletter and social media. The center is the national resource and development center and its network consists of professionals across disciplines with interest in the field of concussion, including physicians. Lastly, we also used the Danish eHealth Portal sundhed.dk to make direct contact with the practices. The GPs who showed an interest in participating were subsequently contacted via phone or email. The recruitment of GPs followed a case-study logic in field-based research [23].

Interviews

The first author (ASHS) conducted in-depth interviews. These were semi-structured and followed an interview guide developed according to the principles of Socratic dialogue employing careful questioning, critical reflection and systematic exploration of the topics while allowing free answers (Table 1). The interview guide was developed by the two authors and included both exploratory and theory-driven questions based on the literature. It was also based on previous dialogue between GPs outside this study and the last author (HMR), who had extensive experience with postgraduate education for GPs regarding this patient group. The first author pilot-tested the interview guide in four interviews with GPs who showed interest in the study and we employed minor revisions to get the GPs to elicit more concrete and detailed experiences. The interviewer informed participants about having interest in the topic and was reflexive about potential biases during interviewing [24]. The interviews were conducted from December 2023 to March 2024 using Zoom and lasted on average 45 min. They were audio-recorded and transcribed in verbatim. The interviewer was unfamiliar with the informants prior to the study. The recruitment continued until reaching data saturation. As we applied case-study logic in our study [23], we tried to replicate each new interview to include increasingly refined questions about various aspects of the GPs’ perceptions. Each new interview therefore included subtle variations. Data saturation was discussed continuously by both authors. After 10 interviews, saturation on the major themes was obtained and the two subsequent interviews confirmed this pattern. The data was coded in NVivo 13 by two independent coders with several rounds of inductive and deductive coding.

Table 1.

Questions in the interview guide

Themes	Examples of questions
GP’s treatment of patients with PPCS	1. How many patients with persistent symptoms after concussion do you approximately consult in your general practice per month? Has this changed over the years?
	2. What is your primary role in their treatment?
	3. When you have a patient with persistent symptoms, can you describe how you approach them in your practice?
	4. When and how do you assess these are persistent symptoms?
	5. How long does a consultation last? How much preparation do you have for each consultation?
	6. What guidelines or knowledge do you draw on in your encounters with the patient group? Which approach have you learned from your education?
	7. Have you changed your approach to the patient group over the years?
	8. Do you have a standardized approach to the patients? Can you give a specific example of how you plan their treatment in your clinical practice?
	9. How do you experience the framework in general practice for your treatment of this patient group? Do you have examples of you bending the framework to accommodate their specific symptoms and needs?
Referral options and coordination with other actors	1. Can you describe how you collaborate with other actors and sectors in your management of the patient group, including the secondary healthcare system, the social system, municipalities and regions?
	2. What challenges and barriers can be experienced in this regard?
	3. How do you experience your referral options?
	4. Do you experience that your patients’ socioeconomic status can affect their course and the ability to manage their own treatment?
	5. How do you handle your patients’ dealings with the private healthcare market?
	6. According to previous studies, some patients experience being left on their own and that the public healthcare system does not offer them sufficient treatment, and they feel that the help they have received from general practice has not been sufficient. Why do you think this is the case?
	7. Many patients also experience that their diagnosis and symptoms are not taken seriously compared to other injuries and illnesses in the healthcare system. This is supported by studies of diagnostic hierarchies. Why do you think this is so?
Medical gaze and recommendations	1. How do you differentiate between your patients’ symptoms in your assessment of them?
	2. Do you think that people can have persistent symptoms for many years after a concussion? Or have you experienced specific patients where you think that their prolonged symptoms are due to other things than the original head trauma? If yes or no, what do you base this on?
	3. Have you experienced disagreeing with your patients about what is the cause of their symptoms and, if so, what treatment or intervention could help them best?

Analysis

The data was analysed using thematic analysis [25] in six phases (familiarization, initial coding, searching for themes, reviewing themes, refining themes, producing report) and an abductive approach to ensure findings were grounded in both empirical data and existing knowledge [26]. Both authors (research assistant ASHS; associate professor HMR) performed the analysis. The initial coding was performed by two independent coders. This was carried out as a cyclical act with several rounds of inductive and deductive coding to create a broad and diverse set of codes. Interpretative phenomenological analysis (IPA) underpinned the study’s methodology [27] in order to explore and get an in-depth understanding of the GPs’ experiences with managing the patient group as well as the barriers to treating them. We had an overall abductive approach during the analysis, switching between an exploratory approach and a more theory-driven approach, as this offered a flexible and nuanced way to understand and interpret data [28]. The first search for themes was theory-driven and deductive, guided by the interview guide’s three main areas. The next round was inductive and data-driven, allowing new insights to emerge outside the initial framework. In the third phase, we organized codes into potential themes using an abductive, theory-informed approach. In the fourth phase, we refined a set of candidate themes, identifying major and minor themes and diverse cases. Finally, we ensured internal coherence and distinctiveness among themes.

Results

Informants

Of 15 GPs initially contacted, 12 served as informants. The rest did not respond to subsequent inquiry. The GPs were aged 43–71 years, seven women and five men. They were all GP specialists and had three to 37 years of experience. They were from different country regions, urban as well as rural areas (Table 2).

Table 2.

Characteristics of the participants

ID	Age	Years of experience	Gender	Geographical location
GP1	51	12	F	Capital Region
GP2	53	13	F	Central Denmark Region
GP3	51	17	F	Capital Region
GP4	64	24	M	Capital Region
GP5	54	18	F	Capital Region
GP6	48	3	F	Capital Region
GP7	60	20	F	Region Zealand
GP8	55	18	M	Central Denmark Region
GP9	47	7	M	Capital Region
GP10	71	37	M	Region Zealand
GP11	43	7	F	Capital Region
GP12	54	19	M	Region Zealand

Abbreviations: F female, M male

Themes

Three main themes regarding challenges emerged: (1) Managing patients with PPCS, (2) Coordination with other actors, and (3) The clinical gaze of patients with PPCS. Figure 1 presents the final thematic map.

Fig. 1.

A Gordian knot in general practice related to management of patients with persistent symptoms after concussion showing three themes that represent the perceived challenges

Theme 1: Managing patients with PPCS

This theme illustrated that GPs perceived the patients with PPCS in general practice as a Gordian knot and as a substantial healthcare challenge due to their heterogeneous characteristics and complex symptoms.

Subtheme: Individualised management

The GPs expressed a considerable variation between the initiation of management, as the patients would consult them for the first time in both the acute phase, sub-acute phase and post-acute phase, ranging from hours to months after having sustained a concussion: “It depends entirely on when they call us. Some people only call when they have had some problems for several weeks after hitting their head.’ (GP1).

There was also significant variation in the following consultations depending on the GPs’ assessment. They described that they have individualized and self-invented approaches to their patients: ‘I do have an approach, but I have not written it down, because my approach is that I guide each patient based on where they are, and that differs, so I cannot have uniform instruction for all of them’ (GP11).

The patients with PPCS constitute a significant healthcare challenge in GPs view, but the incidence varied in their experience. Some stated that they had experienced a significant increase in patients with PPCS over the past decades.

They found it challenging to identify patients at risk for developing PPCS due to lack of clear prognostic models. Some perceived PPCS as a Gordian knot, as they needed to carefully approach the various aspects of patients’ symptoms to solve the intricate problems at an early stage to avoid long-term courses of illness:

‘It is like a knot that has become stuck, and if you tug and pull on it, it just becomes a tighter knot, and you must untie it gently and carefully in different directions. It may take several attempts, but it does not help to give it a hard time, because then it gets stuck even harder.’ (GP9).

The GPs perceived the patient group as heterogeneous, complex, and challenging to understand and manage in general practice, and they saw themselves as project managers with numerous responsibilities, including initial clinical examination to rule out other diagnoses, providing referrals to the secondary healthcare system, private healthcare services, the municipal system, private pension funds, insurance companies, and providing information and guidance to patients about their situation and symptoms.

Subtheme: Variable guidance

Due to the lack of formalized education, diagnostic consensus, and clinical practice guidelines, the GPs described basing their management on variable information sources, including mainstream media, scientific articles, or professional training days. They did not consistently diagnose their patients with concussion or PPCS, nor did they express a standardized definition of PPCS.

Most of the GPs did not make use of official international or Danish guidelines, as they were not aware of them. The pace was too high, and the workload too extensive to seek out and make sense of existing guidelines:

‘The challenge every time is that they are so long, and we get so many of them, so expecting general practice to understand and orient themselves in 97.000 different guidelines does not work.’ (GP3).

They expressed a need for specific guidelines and assessment tools aimed at general practice, and that researchers pay attention to the knowledge-to-practice translation to ensure the dissemination of new research findings into the practice setting.

Several GPs found it difficult to manage their patients due to lack of consensus and evidence. However, many GPs also saw the lack of evidence as a general condition in general practice when navigating a complex field. Consequently, some did not ascribe essential meaning to consensus. Instead, they emphasized the individualized approach based on assessment of each patient: ‘Consensus is not crucial to me. I base my approach on the individual’s symptoms and the individual’s problem’ (GP10).

Subtheme: Therapeutic caregiving

The GPs experienced many complex patients requiring frequent follow-ups. They tried to resolve their lack of time by deciding on the frequency of consultations or offering conversation therapy consultations. Due to lack of resources and lack of specialization to treat patients with PPCS, they emphasized their primary role as therapists and caregivers:

“I think part of the treatment is being a therapist. At least I have a lot of experience with that as a general practitioner with patients with chronic diseases, whom I continue to follow, and maybe see every other month and thus become their life companion’ (GP7).

Several GPs described how they had to learn to embrace the patient group:

“Often you have to embrace them, listen, give them a new consultation, and be there. Just as you want to be there for a cancer patient, for whom you also cannot do anything more either.’ (GP8).

Theme 2: Coordination with other actors

The GPs expressed an imperative need for specialized help from other healthcare professionals to treat the patients with PPCS. However, they experienced a lack of referral options and were frustrated with the scarcity of systematic help in the public healthcare system, which they perceived to be the greatest barrier to the treatment of this patient group.

Subtheme: Lack of referral pathways

The GPs described that they were unable to secure access to secondary healthcare sector, despite recognizing their crucial role as gatekeepers to public healthcare services:

“The biggest barrier is that it is far too difficult to get patients into the secondary healthcare sector, including private practice neurologists, headache clinics, and pain clinics’ (GP2).

Some GPs described how they got rejected, if they tried to refer a patient to the hospitals’ departments of neurology:

“There is no cooperation. They do not want those patients. They do not have the capacity for them. So, I just get a referral rejected if I send it.’ (GP7).

Other GPs described how neither the headache and pain clinics nor the neurologists were specialized in treating the patients with PPCS, and how accessing a neurologist only helped to exclude other injuries or diseases.

Several GPs attributed the difficulties in cooperation with the secondary sector and Danish healthcare system to the low status of the condition. Consequently, several GPs saw themselves as the last resort for patients rejected by the secondary sector:

“I am the backstop for everyone, where the secondary sector says: We have no further offers. Then they will come back to me, and I must do the best I can’ (GP2).

Some GPs experienced that this reflected the increased focus on specialization in the Danish healthcare, where management of many complex patients requiring rehabilitation has been delegated from hospitals to general practice, and where the prioritization of diagnoses and treatment is influenced by governmental interests, patient organizations, and pharmaceutical industries:

“There is no doubt that cancer is at the top, and then there is diabetes with all the Novo Nordisk drugs, and the Heart Association is also doing well. And then at the bottom comes fibromyalgia, functional disorders, all the mental disorders, and PPCS also belongs there.’ (GP3).

Furthermore, the GPs often expressed how they cannot refer to specialised concussion programs and how municipalities would not finance their patients’ treatment: ‘The municipalities do not want to refer them [to specialized programs], and they do not want that for one reason: economy (…)’ (GP4).

Subtheme: Social and geographic lottery

Some GPs described how they had to advocate for their patients’ needs and credibility of their disability in the system. They expressed that they encountered barriers to recovery, if patients were pressured to go back to work or to prove their level of disability, and that such stressful circumstances might increase patients’ risk of ending up on disability pension.

The GPs experienced many highly educated, young, or resourceful patients having long-term sickness absence due to PPCS: “From a societal point of view, it is a costly group, because it is a condition that causes younger patients to end up completely outside the labor market. So, I think there is much money to be made or saved …’ (GP8).

The GPs also described how publicly funded rehabilitation for patients with PPCS varied significantly across the different regions and municipalities in Denmark, and that patients often had to find a relevant offer on their own. Consequently, socio-economic status and geography became a decisive factor in patients’ recovery. GPs in affluent areas described that their patients often do not need their support, as they have resources, insurance, and pension funds to manage their recovery and afford private healthcare. In contrast, GPs in low-income areas noted that PPCS can devastate the livelihoods of especially vulnerable workers and less well-off patients.

Subtheme: Private healthcare market

GPs reported that many patients with PPCS seek treatments such as physiotherapy, chiropractic, osteopathy, neuro-optometry, craniosacral therapy, healing, massage, reflexology, acupuncture at private healthcare market.

“I think a lot of patients, at least the ones I am thinking of, probably run two tracks concurrently. They see a bit of what the general practitioner can do and a bit of what the alternative treatment can do.’ (GP8).

Several private healthcare professionals such as chiropractors, osteopaths, and neuro-optometrists have gained some medical authority in general practice, as some GPs described forming collaborations with them in areas where public treatment is unavailable. Other GPs expressed skepticism about the effectiveness of certain private treatments.

The GPs acknowledged that they lack a comprehensive understanding of the benefits and potential side effects of treatments offered in the private healthcare market. They also expressed concerns that some of their patients were too disabled to seek treatment on their own, putting them at risk of not recovering.

Theme 3: GPs’ clinical gaze on patients with PPCS

This theme highlighted how GPs’ clinical gaze on patients with PPCS is shaped by the lack of biomedical evidence.

Subtheme: Lack of biomedical evidence

The GPs often described feeling helpless and frustrated when managing patients with PPCS. They described having a hard time figuring out, why otherwise healthy patients develop long-term symptoms, as none of the available medical tools can measure patients’ impairment.

“It is a group where you as doctors think, what should I do? Now she is coming for the 10th time. I have said the same things we are not getting any further. Then you feel powerless as a practitioner… (GP5).

The GPs also graded concussions based on the apparent severity of the initial trauma. They were confused when seemingly minor head traumas, in patients’ descriptions banging head into a wardrobe, bookcase, etc., caused severe symptoms for months to years. As there was no straightforward connection between the severity of the initial trauma and the subsequent course of illness, they found it difficult to identify patients at risk of developing PPCS:

“It is grotesque that what physically is not a serious head trauma is actually a serious head trauma, and it is impossible to predict who will have long-term symptoms.’ (GP4).

Subtheme: Skepticism and medical stigma of patients with PPCS

The GPs viewed the lack of clear prognostic tools as a barrier to improving care and preventing persistent symptoms. They relied on their clinical judgement, rather than a protocol, to predict outcomes for each patient.

However, they often felt a sense of skepticism toward long-term patients, as they struggled to understand why these patients continue to experience symptoms for long time, while most people recover shortly after a concussion:

“When doctors cannot figure out what is wrong, they throw suspicion on people. I think this is the case in the entire healthcare system, you do not have the same respect for those patients when you cannot find the fault, figure it out, or solve it.’ (GP5).

Many GPs expressed being aware of the complex predisposing and perpetuating bio-psycho-social factors that influence patient’s recovery, including the presence of pain, other somatic symptoms, preinjury mental or physical health issues, stress, vulnerable work status, or being involved in financial compensation cases. To navigate the complexity, the GPs often attribute patients’ symptoms to psychological or personal factors.

“Do they have an underlying anxiety problem, or what in the old days was called a slightly neurotic personality structure? Do they have any burdensome psychosocial conditions on top of that? Because it is all something that increases the risk of a prolonged course’ (GP1).

Some GPs also described that they perceived and categorized patients with PPCS as being the same as other patient groups with subjective and non-detectable physical symptoms. One of the GPs argued that it would be better to classify PPCS together with conditions such as fibromyalgia, abdominal pain, and chronic fatigue syndrome under the collective term functional disorders in general practice:

“I think it is completely wrong to look at the group of patients with post-concussion symptoms alone because I think it is so similar to the group of patients with functional disorders (…) it is basically the same patient group, and it is the same problem, and it is probably also basically the same methods that we need to use to help these patients.’ (GP8).

Subtheme: Why always women?

The GPs also perceived that PPCS and other biomedically unexplained conditions were more pronounced among their female patients:

“It is a special group of patients who get post-concussive headaches. This is the group that 10 years ago got whiplash, fibromyalgia, chronic pain syndrome, or bodily distress. It is the same group. They are somehow predisposed to these disorders (…) young, ambitious, perfectionist women.’ (GP2).

When the symptoms are subjective and difficult to quantify, some GPs begin to question the legitimacy of the patients’ symptoms:

“I know there are others, who think: Is this a slightly hysterical young woman? It is like fibromyalgia. In the beginning, almost all doctors did not think it existed. Or myalgic encephalopathy. I think many think it does not exist.’ (GP7).

Some GPs also perceived especially menopausal women at risk of developing PPCS and adopted certain stereotypes in their views: “The children are moving away from home. They come up with some symptoms that cannot be diagnosed. Pain in various places. And I think there may be something psychological that affects them and keeps them in a pattern.’ (GP5).

Distinguishing between psychological and physical symptoms was challenging for the GPs. Some patients may insist their symptoms have a physical cause, while GPs view them as psychologically driven. However, several GPs noted that arguing over the nature of the symptoms feels futile. Instead, they prefer to focus on helping patients as much as possible, rather than denying their pain.

Subtheme: Embracing the unknown

Despite the lack of prognostic tools and biomedical explanations, many GPs explained that they ultimately embrace the biomedically unknown when managing the patients. One GP compared their management of patients will PPCS with that of managing patients with tuberculosis in the 19th century:

“I sometimes tell the patients that in 30 years, there will be a pain scanner (…). But that scanner does not exist yet. It is a bit like what you had to say about tuberculosis 150 years ago, you knew there was a disease that was called tuberculosis; however, they had no idea it was a bacterium that caused it (…) So, we must deal with this like my medical colleagues had to 150 years ago.’ (GP8).

Consequently, a majority of the informants emphasized that the most important thing is to trust their patients rather than judging them for their medically unexplained symptoms:

“I believe in my patients. I have chosen to trust my patients, meaning that whatever their lives are like, and what science says about the premorbid psyche, I do not care. It is not for me to judge that their headache is a good compromise in an otherwise crappy life. I do not think that is my job. I must help the patient. I am the patient’s medical consultant.’ (GP12).

Discussion

This study shows that GPs perceive the management of patients with PPCS in general practice as a Gordian knot. The patients are complex and heterogeneous, the GPs have extensive responsibilities in their trajectories, there is a perceived lack of guidelines and consensus, and limited resources in general practice. GPs also experienced significant barriers regarding referral of their patients – either due to getting rejected (e.g. secondary sector) or because they could not refer the patients directly to existing treatments (e.g. municipality). Further, as publicly funded treatment is limited, many patients seek treatment in the private healthcare market. Patients’ socioeconomic status therefore also becomes a factor. Finally, the GPs’ clinical gaze was affected by lack of biomedical evidence. Some may feel powerless and/or have a sense of skepticism toward this patient group, often attributing the symptoms to psychological or personal traits, especially in female patients.

Female patients tend to have poorer outcomes after concussion and female sex is recognized as a risk factor for prolonged recovery [29, 30]. This is likely to be due to a complex interplay of biological, psychological, and sociocultural factors, although the precise mechanisms remain insufficiently understood [29]. Possible explanations include a higher prevalence of migraine, chronic pain, motion sickness, stress, PTSD and sleep disorders in women [31–35], as well as hormonal changes, greater symptom endorsement and reporting, increased help-seeking, experiences of intimate partner violence, and broader systemic demands placed on women in society [36–38]. Regardless, several GPs in our study offered their own explanations for why women have worse outcomes, often attributing characteristics such as emotional volatility or perfectionism to their female patients. Some GPs described female patients with PPCS as hysterical, reflecting potential gender bias. Historically, hysteria was used to pathologize women with unexplained symptoms, what Foucault [39] termed the ‘hysterization of women’s bodies’. Although hysteria is no longer a diagnostic category, the label persists as a cultural trope that continues to shape clinical encounters. Similar dynamics persist in debates on conditions, where the lack of biomarkers fosters skepticism [40]. Womens’ complaints may thus be reframed through gendered stereotypes, contributing to dismissal and unequal care [41, 42] starting already during early medical education and persisting into specialist training [43, 44]. Gender therefore functions as a prognostic factor, as discredited symptoms risk limiting recognition, follow-up, and treatment. These findings underscore the need for GPs to remain alert to gender bias to ensure equitable care for women with PPCS. Interestingly, nation-wide studies on labor market attachment after concussion did not find significant gender differences [4, 7, 12]. Importantly, poorer outcomes among women are also reported in a variety of other medical diagnoses, such as stroke, cardiovascular disease, and ADHD [45–47]. Further, women frequently encounter different care pathways, delayed diagnosis and less optimal treatment [e.g. [47–49]]. These patterns reinforce that sex and gender not just influence clinical outcomes but also the pathways to and through care, resulting in dissimilar patient trajectories for men and women.

GPs’ expressed a need for an individualized approach to patients with PPCS and exercised wide discretion in their assessments and guidance. Notably, all GPs reported feeling knowledgeable and experienced in managing patients with PPCS, however, none felt up-to-date with the latest evidence-based guidelines and prognostic factors. They attributed this to a lack of formal education and limited time and resources to keep pace with constant flow of new research. Nevertheless, the lack of consensus and uniform clinical guidelines was mainly perceived, since both national [50] and international guidelines expressing agreement in the field [51–53] exist. This increases the risk of disseminating misinformation and making inadequate advice and assessments. This finding aligns with the results of Graff et al., where Danish patients with PPCS perceived the GPs’ guidance on managing the condition as deficient, inconsistent, and confusing [54]. Our findings show that GPs call for improved knowledge translation, including specific guidelines and assessment tools tailored to general practice, to support the integration of evidence into clinical routines while balancing patient and contextual factors. Active implementation strategies are needed to achieve this.

In many countries, GPs are the first point of contact for patients with PPCS. Research shows that the information they provide is highly variable and often insufficient. In New Zealand, a study found that fewer than half of GPs routinely provided information to patients with concussions [20]. Similarly, studies from Canada report substantial knowledge gaps among primary care physicians in both adult and pediatric concussion, which limited their use of current guidelines and best practices to guide management [55, 56].

The GPs reported limited access to the secondary healthcare sector at the hospitals despite the need to find specialized treatment for their patients. The GPs perceived themselves as the last resort and ultimate backstop for patients with PPCS and expressed that the specialized physicians in the secondary sector were not interested in complex or chronic patients. This emphasizes the presence of a hierarchy between the medical specialties also pointed out by Hindhede and Larsen [57], where GPs are placed among the lowest in the hierarchy, and medical specialties with acute and lifesaving treatment at the top. The barriers of gaining access to the secondary sector can also reflect the increased focus on specialization, efficiency, and centralization in the Danish healthcare system, where management of many complex patients requiring rehabilitation and frequent follow-ups has been delegated from the hospitals to general practice and the municipalities. The GPs are however unable to refer their patients to the existing concussion programs, as the access is controlled by the municipalities, which constitutes another barrier for the GPs. These findings resonate with findings by Graff et al. [54], where patients perceived the GPs’ lack of referral opportunities to interdisciplinary rehabilitation as a barrier to their recovery, often having to advocate for their own treatment. Hence, the GPs and the patients share a common concern about better access to specialized care.

The GPs attributed the deprioritisation of PPCS to its low status in the healthcare system. They frequently compared PPCS to other conditions with unclear diagnoses and a lack of biomedical explanation such as fibromyalgia. Album et al. [58] performed a survey, where they asked Norwegian physicians to rank 38 diseases according to the prestige they imagined each disease had among health personnel in general. Fibromyalgia ranked the lowest due to the lack of objective diagnostic signs and diffuse bodily complaints [58]. Such conditions are considered even more problematic than mental diseases [59]. Mental diseases such as PTSD and anxiety receive greater recognition within medicine partly because they are well-defined diagnostic entities, supported by extensive research, and have validated screening tools and evidence-based treatments. In contrast, conditions like PPCS and fibromyalgia often present with heterogeneous and subjective symptoms, lack clear biomarkers, and remain contested in terms of etiology and classification. This diagnostic ambiguity coupled with a weaker institutional advocacy, contributes to their lower medical legitimacy and recognition. Additionally, having a clear diagnosis can explain pathology and justify sickness as well as the need for support and care [60]. Conversely, to be left without a clear or unrecognized diagnosis is to be left without a justification for the symptoms and disability. Furthermore, both fibromyalgia and PPCS are more common among women than men. This may also contribute to its low status, as literature also highlights gender as a disease prestige criterion [61–63].

The study revealed a skepticism among some GPs towards the medically unexplained symptoms in their patients with PPCS. Some viewed concussion as the initial cause of the persistent symptoms, pleading for the diagnosis of PPCS, while others viewed the cause of the persistent symptoms as more psychosomatic, falling within the framework of functional disorders. Several GPs attributed their patients’ symptoms to psychological, personal factors and gender. However, many also expressed that they ultimately embrace the medically unknown and strive to meet their patients with trust. Studies across chronic conditions have pointed out that a strict biomedical approach to chronic care may collide with holistic and patient-centered care [64], which is needed when managing patients with PPCS [50, 65, 66]. A crucial aspect of the latter is establishing a strong and trusting relationship between the GP and the patient [67, 68]. GPs should therefore acknowledge patients’ experiences, even when biomedical explanations are unclear, and provide support grounded in empathy and transparency. Patients, in turn, can build trust by openly communicating their symptoms, concerns, and goals, fostering a collaborative partnership despite differences in belief about their disability. Such trusting relationships are essential for the management of complex conditions.

The GPs in our study varied greatly with respect to their years of experience. The years of experience shape clinical practice in different ways. Younger doctors may be more likely to seek new information and adopt evidence-based guidelines, yet they often rely more strictly on biomedical evidence and prefer clear guidance. Older doctors, in contrast, may depend more on established habits, which can reduce openness to new evidence [69], but their broader clinical experience can make them more comfortable with uncertainty and more attentive to the complexity of conditions such as PPCS. Patients appear to prefer a balance—physicians who combine clinical experience with up-to-date knowledge [70].

Strength and limitations

Among the study’s strengths are substantial variation regarding informants’ geographical location, years of experience, and generated perspectives. The results are based on interviews with information-rich cases, who provided detailed first-hand knowledge on the subject. Among the limitations is convenience sampling with a possible self-selection bias in that perspectives of those who have chosen to participate may differ from those who did not. This may lead to an over- or underrepresentation of certain perspectives, such as those who feel strongly about the topic, or who have particular experiences, positive or negative. The results of this study are especially relevant for those healthcare systems where GPs roles are similar to those described in this study.

Conclusion

Danish GPs perceive patients with PPCS as challenging due to barriers like the perceived lack of guidelines, diagnostic consensus, and resources. They struggle with limited referral options in the public healthcare system. The absence of biomedical evidence adds to their skepticism, leading some to attribute symptoms to psychological or personal traits, especially in female patients. However, ultimately they strive to embrace the biomedically unknown and approach their patients with trust. These insights highlight not only the complexity of PPCS management in general practice but also the need for better knowledge translation of the existing guidelines, stronger referral pathways, and policy initiatives that better support GPs in caring for this patient group.

Abbreviations

ASHS

Anne Sofie Hoffmann Schrøder, author

DSAM

Danish College of General Practitioners

GP

General practice or general practitioner, i.e. a family doctor

HMR

Hana Malá Rytter, author

PPCS

Persistent postconcussion symptoms

PTSD

Posttraumatic stress disorder

TBI

Traumatic brain injury

Authors’ contributions

HMR conceived the study and ensured funding. The authors designed the study in collaboration. ASHS was responsible for data collection. Both authors conducted the formal analysis, contributed to the data interpretation and prepared the initial manuscript draft. Both authors provided critical input to the article and approved the final manuscript.

Funding

Open access funding provided by Copenhagen University. Study was enabled by financial support from the Danish Concussion Center.

Data availability

Data supporting this study are not available due to privacy and confidentially concerns.

Declarations

Ethical approval and consent to participate

The study was approved by the Research Ethics Committee at the University of Copenhagen, jr.no. IP-EC-281023-02 and complied with rules of Danish Data Protection Agency, jr.no. 514 − 0344/23-2000. The informants gave an oral consent which was recorded.

Consent for publication

Participants gave informed consent for their data to be used in research and published.

Competing interests

The authors declare no competing interests.