Abstract

Background. Medical consultations are replete with conflicts, particularly in the current era of explicit and implicit rationing practices in health care organizations. Although such conflicts may challenge the doctor–patient relationship, little is known about them or their consequences.

Aims. To systematically describe the nature of doctor–patient conflicts in medical encounters and the strategies physicians use when faced with conflicts.

Methods. Analysis of 291 videotaped routine encounters with 28 general practitioners, using a novel adaptation of the Roter interaction analysis system software, provided quantitative empirical data on the conflicts and on the communication process. Seven focus groups (56 GPs) provided qualitative insights and guided the analysis.

Results. Conflicts were identified in 40% of consultations; 21% of these were related to the rationing of health care resources. In conflictual encounters, both the opening and closing phases of the encounter were shorter than in non-conflictual encounters. In coping with resource rationing, the commonest strategy was to accept the dictates of the system without telling the patients about other options. When conflict of this type occurred, doctors showed more opposition to the patients rather than empathy.

Conclusions. Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult and expose the dual loyalties of the doctor to the patient and to the system. Insights derived from this research can be used to design training interventions that improve doctors’ efficacy in coping with conflicts and ultimately allow them to provide better patient care.

‘How this fits in’

Patients and doctors often disagree and it is important to assess the different types of conflicts that emerge in doctor–patient encounters.

Because of rationing requirements, GPs are faced with divided loyalties—between their patients and the health care system—with measurable adverse effects on the quality of doctor–patient communications.

It is important to learn how doctors respond to resource rationing, and it appears that one of the dominant modes is by acquiescing to the system, without actively justifying its decisions to the patients.

When confronted by conflicts with patients over resource rationing, it appears there is a tendency among doctors to show less empathy with their patients than in other sorts of conflicts.

Introduction

Effective communication between patients and their physicians is considered one of the cornerstones of high-quality medical care1 and there is ample evidence that it contributes to diagnosis, therapeutic outcomes, patient and provider satisfaction and efficient use of resources.2 However, medical encounters are also replete with opportunities for conflicts, which may disrupt successful communication and challenge the doctor–patient relationship.3 Conflicts may arise around a host of concerns; though in the current economic climate, many may arise from the explicit and implicit rationing practices of health care organizations. While rooted in specific contexts and topics, the principles and insights surrounding such conflicts may be generalizable to Western health care settings.

Israel presents a case, in which both the explicit and implicit rationing issues that may raise conflicts occur in routine encounters between doctors and patients. The National Health Insurance Law4 (NHIL) was passed by the Israeli Parliament in 1995 with the objective of creating a national structure for the universal funding of health care to all citizens. The new law, modelled after similar systems in other Western countries, was designed to create uniformity in collected premiums and in the range of services provided to all citizens. A key feature of the NHIL system is the uniform package of insured services. Within this package, citizens receive a standard set of medications, laboratory investigations and medical procedures, irrespective of their particular health provider. The four Health Funds [equivalent to Health Maintenance Organizations (HMOs) in the USA] receive capitation payments from the NHIL system and, in turn, are required to provide all the standard services to patients at no additional cost. The Funds and other private providers can provide additional services but patients are required to pay an additional co-payment or carry voluntary supplementary insurance. The NHIL also includes a process for the assessment of new medical technologies to be included in the package of services, as they became available in the country. The NHIL created new realities in health care and social welfare, producing both expected and unexpected consequences. It is not surprising that within the framework of a system with limited resources, tensions developed between patients, doctors and Health Funds over the allocation of medicines, tests or procedures. These tensions have become the source of numerous patient–provider conflicts. Coping with these, conflicts has both important technical and ethical dimensions. Although training in the clinical skills of doctor–patient communication is now offered in almost all medical schools,5–7 the issue of doctor–patient conflicts or their management has received relatively little attention in the literature.

This study explores the frequency and types of doctor–patient conflicts present in general practice, particularly those related to the rationing issues. It also examines the associated communication issues and physician coping strategies surrounding such doctor–patient conflicts. The ultimate goal of the research is to understand the dynamics of doctor–patient interactions that include conflicts, in order to design training interventions that can improve doctors’ efficacy in coping with conflicts and allow them to provide better patient care.

Methods

This multi-method multistage study employed focus groups of GPs and videotapes of routine doctor–patient encounters in general practice to explore conflicts in doctor–patient communication, especially those related to health care rationing. Insights from the focus groups were used to help direct the detailed analysis of the videotapes. Together, these two data sources were utilized in order to afford an initial typology of the areas of conflicts, to identify the impact of conflict on the verbal interactions between doctors and patients and to construct a theoretical model. Based on this model, training interventions were designed and field tested for feasibility.

Data collection

Focus groups.

Seven focus groups with 56 GPs were conducted in order to learn about their perspectives on conflicts in doctor–patient communication. Focus groups8 are semi-structured meetings of individuals to discuss a topic using a prearranged moderator's guide, consisting of general questions supplemented by probes. The topic of the semi-structured group discussions was defined as the difficulties and conflicts in medical encounters, particularly those engendered by the limitations imposed by the NHIL package of services. A non-participant observer performed process recording, and the discussions were audio taped and transcribed for further analysis.9 The analysis yielded categories of conflicts and coping strategies used by the doctors when faced with conflicts with patients associated with health care rationing. These categories were utilized to help construct the list of variables for the videotape analysis.

Videotaped doctor–patient encounters.

Two hundred and ninety-one routine primary care doctor–patient encounters were videotaped in the clinics of 28 GPs. Digital videotape recorders were set up by research assistants twice at each site and allowed to record routine general practice encounters, each time for 1 hour. In all, 56 hours of videotape were recorded, including 291 encounters, representing on average five consecutive visits per recorded session.

Setting and participants

The 56 GPs who participated in the focus groups were recruited by region and by Health Fund, in order to provide approximate representation of the country and the different health provider organizations. Invitations were sent by mail with phone reminders. Groups were led jointly by social scientists experienced in this methodology and a senior family physician.

The 28 GPs who participated in the videotape portion of the study were selected by random numbers from the Health Funds’ lists of GPs. A random rather than purposeful sample was chosen since the aim was to recruit 30 participants from diverse geographical settings and social background who might be roughly representative of all those in the Health Fund. Doctors over the age of 60 years, or those with <1 year experience in Israeli primary care, were excluded. Of the 60 physicians who were approached, 30 agreed to participate in the study. Two doctors who originally agreed to participate withdrew. Fifteen of the 28 participating doctors were male; the mean age was 45.4 years, distributed fairly evenly between 30 and 60 years; 22 held specialization certificates in family medicine. Their practices represented the northern (n = 10) and central regions (n = 18) of Israel and the two largest of the four Health Funds.

Ethics

This study received approval from the Institutional Review Board (Helsinki Committee) regarding human subjects at the Rabin Medical Centre, Petah Tikva. Participants in the focus groups provided their written consent to participate in the recorded group discussions. Written patient consent to videotape their consultation with the doctor was obtained in the waiting room and included an assurance that no identifying features would be recorded and that the tapes would be used only for research purposes and for the doctor’s own further education. Thirty percent of patients approached refused to be filmed and no data were collected on them.

Data analysis

The transcripts of the focus group recordings were checked for accuracy and then subjected to textual analysis using a combination of immersion crystallization10 and coding, based on grounded theory.11 Four analysts studied the material separately, derived categories, themes and major topics relevant to the study and searched for unanticipated insights. The analysts compared their results and together built a hierarchy of categories and a model for analysing responses to conflict.

The videotapes of the routine clinical encounters were digitalized and coded using the Roter interaction analysis system (RIAS) software.12 This software enables us to identify and systematically describe many facets of the interaction and important aspects about the way the doctors communicate with their patients. RIAS is used to summarize the clinical dialogue by coding the smallest units of communication into 40 predefined standard categories. The unit of analysis is the utterance, defined as the smallest phrase or expressed thought.12 The system also allows for adding categories that are specific to individual studies. For this study, we defined a novel set of coding categories related to ‘conflict’, which was defined for this analysis as any disagreement (expression of a difference of opinion) by the patient or doctor. The specific categories refer to the structure and duration of conflict, including the following: the relative frequency of conflictual versus non-conflictual encounters, frequency of different types of conflict (for example, those associated or not associated with the package of services under the national insurance), duration of doctor versus patient talk, distribution of doctor and patient talk across the various stages of the encounter, expression of empathy and doctors’ response to conflict. In this way, we were able to identify and compare conflictual and non-conflictual encounters (further details can be found in the Appendix).

RIAS has been previously validated in primary care in Israel.13 Two independent trained coders blinded to the provenance of the tapes coded the tapes. Inter-coder reliability was confirmed on a 10% sample (30 encounters).

Results

Frequency and types of conflicts in the doctor–patient encounters

Conflicts were common in the doctor–patient encounters observed in this study and were found in nearly 40% (113; 38.8%) of the 291 encounters; about a fifth of them (24; 21.2%) were found to be related to concerns associated with the package of services under the national insurance. The conflicts identified in the 113 doctor–patient encounters could be further characterized according to three main topics: (i) conflicts regarding medical management of the presenting problem such as medications, lab tests, imaging, specific diets, psychologist, second opinion, double-checking results and ‘wait and see’ approach; (ii) conflicts regarding management of background health issues, including different diagnoses, test results and lifestyle and (iii) conflicts regarding bureaucratic aspects, including authorisations and certificates (see Table 1).

TABLE 1

Typology of conflict issues between doctors and patients

Conflict issues (N = 113 encounters) Percentage 
Medical management of the presenting problem: medications, lab tests, imaging, specific diets, psychologist, second opinion, double-checking results and ‘wait and see’ approach 52.3 
Management of background health issues: different diagnoses, test results and lifestyle 19.4 
Bureaucratic: authorisations and certificates 27.5 
Conflict issues (N = 113 encounters) Percentage 
Medical management of the presenting problem: medications, lab tests, imaging, specific diets, psychologist, second opinion, double-checking results and ‘wait and see’ approach 52.3 
Management of background health issues: different diagnoses, test results and lifestyle 19.4 
Bureaucratic: authorisations and certificates 27.5 

Expression of empathy in conflict situations

An analysis of doctors’ empathetic responses to patients’ demands revealed that there was a significant difference between situations in which the conflict was associated with rationing issues and other types of conflicts. We found that conflicts associated with resource allocation were characterized by more non-empathetic statements by the doctors compared to conflicts related to other issues. An empathetic response was defined as the expression of positive feelings to the patient. For example, ‘I understand that you must feel frustrated by this’. A non-empathetic response was coded when a doctor reacted negatively to the patient's feeling; for example, the doctor would say ‘I don't care about your situation’; ‘this is none of my business’. When the conflicts were specifically about resource allocation, physicians were twice as likely (30%) to use non-empathetic expressions as compared with other conflictual encounters (18%). Empathetic expressions were identified in 17% of conflictual encounters, with no difference according to the type of conflict.

Structural differences between conflictual and non-conflictual encounters

In both conflictual and non-conflictual encounters, doctors dominated the conversation. In both cases, they spoke more than patients: mean distribution of talk for doctors and patients, respectively, is equal to 53% versus 47% (P < 0.0001) for conflictual encounters and 55% versus 45% (P < 0.0001) for non-conflictual encounters. Analysis according to the different stages of the encounter revealed differences between conflictual and non-conflictual encounters. Consultations were analysed as comprising five stages (opening, clinical history, physical examination, counselling and closure), the three middle sections not necessarily following one another in a strictly linear fashion. The opening phase is defined as the time when the patient presents the problem before the doctor joins actively in the conversation, and the closing phase is devoted to resolution and summary. Conflictual encounters had significantly shorter opening and closing stages than non-conflictual encounters and more time spent in counselling patients (see Table 2).

TABLE 2

Distribution of talk during doctor–patient encounters (as percentage of total utterances) in conflictual and non-conflictual encounters

 Opening History Exam Counselling Closure 
Non-conflictual encounters 10.5* 38.7 9.0 35.4 6.4** 
Conflictual encounters 5.3* 39.3 10.2 41.9 3.2** 
 Opening History Exam Counselling Closure 
Non-conflictual encounters 10.5* 38.7 9.0 35.4 6.4** 
Conflictual encounters 5.3* 39.3 10.2 41.9 3.2** 

*P ≤ 0.05, **P ≤ 0.05.

Doctors’ ways of coping with rationing-related conflicts

Drawing on the analysis of focus group data, four types of coping strategies were identified and classified with RIAS codes for the videotaped consultations analysis. These coping strategies may be described by two intersecting axes, one describing how far the doctors demonstrated an active response to the conflict and the other describing their level of acceptance of managed rationing (see Fig. 1). Active strategies involved the doctor engaging the patient in conversation about the rules of rationing. Passive strategies were identified where the doctor chose not to involve the patient, although the doctor herself or himself might have tried to manipulate the situation behind the scenes. In acceptance strategies, the doctor's behaviour was consistent with supporting the rationing rules, whereas in rejection strategies, something was said or done to criticize or change the rules. In our data, the most common strategy was passive acceptance (41%), where the doctor did not tell the patient about relevant management options that are not offered in the NHIL package. Less commonly (25%), doctors chose to explain to patients the need to accept the rationing criteria. In 22% of the encounters, the doctors acted to circumvent the system by modifying the diagnosis to fit the criteria without making this explicit to the patient (passive rejection). Active rejection was chosen in only 12% of conflictual encounters, where the doctors instructed their patients how to formally appeal against the system or helped them to do so (see Fig. 1).

FIGURE 1

Coping strategies: proportion of physicians adopting the strategy

FIGURE 1

Coping strategies: proportion of physicians adopting the strategy

Gender effects.

We analysed the association between physician and patient gender and conflict. For all physicians with all patients, the odds ratio for conflict by gender was 1.191, 95% confidence interval (CI) 0.7214–1.973. For male physicians, comparing gender concordant and gender discordant consultations, the odds ratio for conflict by gender of the patient was 1.236, 95% CI 0.5762–2.682. For female physicians, the odds ratio for conflict by gender of the patient was 1.864, 95% CI 0.7971–4.606 (see Table 3).

TABLE 3

Gender congruence between physicians and patients in non-conflictual and conflictual encounters

Participants Number of non-conflict consultations Number of conflict consultations Total number of consultations 
Male physicians–any patient 76 43 119 
Female physicians–any patient 86 58 144 
Male physicians–male patient 34 17 51 
Male physicians–female patient 42 26 68 
Female physicians–male patient 22 31 
Female physicians-female patient 64 49 113 
Participants Number of non-conflict consultations Number of conflict consultations Total number of consultations 
Male physicians–any patient 76 43 119 
Female physicians–any patient 86 58 144 
Male physicians–male patient 34 17 51 
Male physicians–female patient 42 26 68 
Female physicians–male patient 22 31 
Female physicians-female patient 64 49 113 

Discussion

This study yielded interesting findings regarding doctor–patient encounters and the occurrence of conflict in them that may have implications for communications training for doctors. The first is that overt conflicts between doctors and patients are surprisingly prevalent. Second, the structure of the encounter appears to differ in conflict situations. Third, doctors’ expression of empathy differs across these types of encounters. In addition, doctors most commonly react to rationing-related conflicts by accepting the rationing rules and not telling the patient about ways of appealing rules or about alternative treatment options available outside the national insurance system. Female doctors were less likely to get into conflict situations with male patients, but the numbers were small and it might have been a chance finding. Finally, the methodology utilized in this study provides useful lessons for future research.

Prevalence and types of conflicts

The analysis enabled us to identify both the frequency and type of conflict situations in general practice encounters and the different issues over which conflict arose. Perhaps, the most significant aspect is that overt conflicts between doctors and patients are surprisingly prevalent; in our study of nearly 300 encounters, they were found in nearly 40% of the encounters. It was found that arguments between doctors and patients arose most often around medical issues, where the patient and doctor had difficulty in reaching agreement about diagnosis, investigation, referral or treatment for the current illness. General health issues such as the need for lifestyle change or for screening tests were also frequent sources for disagreement between doctors and patients. Arguments were often related to bureaucratic issues, typically certification of sick leave.

Disagreement is not necessarily a negative feature in general practice consultations, as it may be part of the process in which doctors and patients are both engaged with the aim of reaching a cooperative plan of action or an agreed approach towards management. The question is whether doctors are capable of maintaining empathy with their patients despite differences of opinion or whether they allow disagreements to damage the therapeutic partnership. Either way, a new source of conflict has arisen with the advent of rationed care, where the health insurance agency, be it government, HMO or Health Fund, attempts to represent the common good in terms of fair distribution of limited resources. The GP is now required to balance and present this public interest with the individual patient's interest. In the current study, one in five conflicts were related to rationed resources. This means that on average, the doctors in our sample had to face a conflict specifically related to resource allocation or rationing of care at least once a day. In these cases, the negotiation is not just for the patient's benefit but for the benefit of others, as represented by the rules of rationing.

How the structure of the encounter differs in conflict situations

Traditionally, the medical encounter has been analysed as comprising five specific segments: opening and agenda setting, history taking (data gathering), physical examination, counselling and closing. In this study, it was found that whereas history taking and counselling were the largest segments, as is commonly the case, in conflict-related encounters, counselling was found to be the larger part of the visit. Similarly, it was also found that the sizes of both the opening and the closing segments of the encounters were significantly shorter in the conflictual encounters. This may indicate that when an encounter includes a conflict, the issue of the conflict dominates the encounter in terms of content and time and often emerges immediately. One alternative interpretation is that during these types of encounters, the patient came with his or her own agenda and with precise goals. Thus, the duration of the agenda setting and history-taking parts of the encounter were shorter than usual. In contrast, the counselling or the negotiating part of the encounter was relatively longer, and the closing summary was then understandably shorter. Thus, such conflict situations may have been predetermined and represent cases in which patients pursue their agenda and doctors respond negatively to them. Another alternative interpretation is that physicians react to conflicts around rationing issues by moving towards counselling modes of discourse, and therefore, it consumes a relatively larger part of the encounter.

Physicians’ differing expressions of empathy

Interestingly, physicians in this study differed in the manner in which they expressed empathy across types of encounters. During conflicts about rationing issues, the doctors showed less empathy for their patients than in other conflictual encounters. Reflecting back to the focus groups may facilitate interpreting this unusual finding, in which physicians described their discomfort in the gatekeeper role. In the videotaped interviews in this part of the study, we may have seen the special difficulties doctors face in the conflicts, caught in the vise between employer and patients. This raises the explicit question whether doctors show less empathy in conflict situations related to rationing and could this possibly be related to their ambivalence about their role? The literature relating to this area is very thin, particularly the effects of sociocultural conditions and medical technology on social behaviour and values14 and on the gatekeeper role15 should be explored further.

Doctors’ ways of coping with conflicts

This study identified and documented the relative frequency of several coping strategies that doctors use when they are forced to serve as what the literature has described as a ‘double agent’. The double-agent role in this context is the difficult position of the doctor poised between the employer/insurer and the patient, and exposed to financial constraints from one and clinical needs from the other, was well described as the double agent.16

A considerable literature has grown around the conflict of interests doctors currently face exploring both the physicians’ perspective17 and the patients’ perspective.18 From our data, a typology of coping responses was developed for conflicts around rationing of resources, and the commonest mode was for the doctor to accept the dictates of the public health system and to protect him/herself from getting too caught up between the patient and the system by not revealing to the patient all the possible options available inside and outside the system.19,20 The relatively higher prevalence we found in the ‘passive’ coping strategy suggests that the doctors in our sample found it the least threatening in terms of having to confront either the patient or the system. This finding has implications in terms of offering doctors specific training in coping with conflicts over rationed resources. Patients have the right to a more transparent approach and to fuller information as to the treatment options available and as to their rights of appeal against the rulings of the system. Vanderford et al.3 have suggested an advanced communication curriculum aimed at building skills in identified challenging communication areas that ‘could reduce clinician frustration and enrich the practice of medicine’. Such advanced training could potentially have the simultaneous effects of increasing physician conflict resolution skills, reduce frustration and positively impact patient awareness, education and rights.

Lessons from the methodology

The methodology used in this study was relatively innovative, with videotaping of a large number of real consultations and analysing them semi-quantitatively using the RIAS software adapted for local use and for the specific research issues in question. This provided a systematic description of what is essentially a highly complex process—the doctor–patient encounter in family practice. We found RIAS both usable and reliable, with replicable results. It is flexible and does not require the researcher to subscribe to a particular evaluation system because the videotape captures the fullness of the encounter, and the coding scales may be extended to accommodate various systems of analysis.21,22 Specific research questions may thus be studied by defining and coding for novel variables and descriptors that are not coded in the basic RIAS set.

Limitations

The sample for this study was taken from Israeli public sector medicine and may or may not be generalizable to other Western health care setting with universal health insurance coverage. In addition, because no identifying information was collected, it was not possible to compare the characteristics of the patients who refused to participate with the participants. The participants in the study nonetheless represent a large series of otherwise unselected patients in routine primary care.

In addition, insights from this study were limited to the doctors’ perspective since patient groups were not studied. Although the focus groups provided insight into the complexities of the situation, they highlighted doctor-related factors and health care system-related factors. The broad definition of conflict used in this study introduced greater sensitivity in detection and resulted in a higher prevalence for conflictual encounters than might have been expected. In addition, we did not gather broad data on the patients involved in the study (such as ethnicity, socioeconomic information, medical conditions, etc.) that might have been analysable in terms of conflictual versus non-conflictual encounters and in relation to physician variables. Further study is clearly needed if we are to progress any further in understanding the issue of doctor–patient conflict, particularly if we want to incorporate patient-related factors.

Conclusions

Three main conclusions can be drawn from the findings of this study that have implication for doctors’ training in the era of explicit rationing of medical treatment resources: (i) as our study has shown a large portion of medical encounters in primary care practice include conflicts. This suggests that doctors need to be provided with training in how to cope with various types of conflict situations. (ii) Conflict situations have a different structure than regular medical encounters. Though the reasons for this are unclear (whether physician response to the gatekeeper role or predetermined patient agenda), doctors need to be aware of and trained in how to deal with rationing-related conflicts without limiting potentially therapeutic elements of the encounter. They may be able to purposefully increase the length of the consulting part in order to conclude with a more mutually satisfying resolution. (iii) Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult to deal with and expose the dual loyalties of the doctor to the patient and to the system. Doctors need to be made aware of and trained in coping with their role as gatekeepers of treatment resources, as determined by insurance (whether national or private); they appear to resort to what can be described as passive strategies that may either deprive patients of information they are entitled to or circumvent the system. Clearly, there is more need for both further explorations of the issues of conflicts in medical practice, as well as interventions to assist physicians in managing conflicts in ways that are effective and improve patient care. This topic deserves more attention than it has received and represents a possible new avenue for furthering the doctor–patient relationship and therapeutic alliance.

Declarations

Funding: Israel National Institute for Health Policy; Health Services Research.

Ethical approval: approval regarding human subjects for the study was obtained from Helsinki Committee at the Rabin Medical Centre, Petah Tikva.

Conflict of interest: AZ is the director of the Israel Centre for Medical Simulation where part of the simulation-based intervention was carried out. DR is the creator of the RIAS system.

The NHIL provides a fixed proportion of income from the health tax to be set aside for health services research to assess the effects of the implementation of the law. We also thank Shmuel Reis and the Department of Family Medicine at the Technion, Haifa, for financial support for the training of our research assistants in RIAS coding.

Appendix—RIAS categories used for the study of conflicts in medical encounters

100 Doctor’s talk 
101 Relates to issues of availability of patient’s medical resources 
102 Relates to expenses incurred by patient 
103 Relates to inconvenience incurred by patient 
104 Explains that public resources are limited 
105 Blames the system for lack of services 
106 Makes an authoritative personal statement (‘I can/cannot authorize this’) 
107 Explains medication test or other technology 
108 Explains the workings of the Health Fund/the law 
109 Explains about costs/coverage 
110 Explains other (related to resources or Basket) 
111 Explicitly states that he/she is on the patient’s side against the system 
112 Explicitly says that he/she is short of time 
113 Interrupts patient 
114 Says not covered, cost 
115 Says not necessary, not effective and not advised b/c of prior hx 
116 Gives prescription substitute or alternative (note name) 
117 Gives non-prescription substitute or advice 
118 Says wait and see, conditional 
119 Gives trial period 
120 Summarizes plan 
200 Patient’s requests 
201 Medication (new, not refills) 
202 Referral 
203 Tests 
204 Non-specific request (e.g. ‘I've got to stop smoking. Do something for me.’) 
205 Administrative request (e.g. ‘Can I get my disability coverage re-evaluated?’) 
206 Gives motivation for request (note: TV, media, friend’s recommendation) 
207 Repeats request 
208 Expresses approval of service/Health Fund 
209 Criticizes service/Health Fund 
210 Criticizes doctor or other provider 
300 Disagreements 
301 About medical issue 
302 About treatment 
303 About investigation 
304 About administrative issue (certificates, letters, etc.) 
305 Other 
400 Doctor’s style and response to request 
401 No response 
402 Response/passive (audible signs of agreement are minimal—e.g., ‘Ah-hmm’—and resolution or action not heard on tape) 
403 Response/agrees to request (e.g., ‘I think that’s a good idea. I’ll write a prescription.’) 
404 Response/agrees to negotiated or substitute request 
405 Disagrees and sides with patient 
406 Disagrees and sides with the Health Fund 
407 Disagrees and sides with system (public good) 
420 The active-acceptance mode: actively tells the patient he/she has to conform; believes in system 
430 The passive-acceptance mode: does not inform patient of all options, helps accept situation by not disclosing options; accepts system as is 
440 The active-rejection mode: discloses frustration with the system, tells patient there are ways to appeal or to go through advocacy organizations; appeals him/herself 
450 The passive-rejection mode: finds various ways to circumvent the system 
500 Patient’s response to request 
501 No response 
502 Response/passive (e.g., ‘Ah-hmm’ ‘OK’ only) 
503 Response/agrees to negotiated plan (e.g., ‘That’s a good idea. I’ll try it.’) 
504 Mentions request covered in other Kupot 
505 Patient’s attitude: ‘I deserve it.’ 
600 Type of conflict 
601 Doctor–patient 
602 Doctor system 
603 Doctor–doctor 
604 Patient system 
605 Patient–patient 
606 System–system 
610 Conflict related to basket of services 
700 Conflict outcome 
701 Agreement 
702 Partial agreement 
703 Disagreement 
704 Indeterminate 
800 Competencies 
810 Conflict recognized 
811 Yes 
812 No 
813 Indeterminate 
820 Patient factors recognized 
821 Yes 
822 No 
823 Indeterminate 
830 Organizational factors recognized 
831 Yes 
832 No 
833 Indeterminate 
840 Empathetic response 
841 Yes 
842 No 
843 Indeterminate 
850 Strategy/solutions provided 
851 Yes 
852 No 
853 Indeterminate 
860 Negation of conflict 
861 Yes 
862 No 
863 Indeterminate 
870 Advocacy for patient 
880 Global quality of doctor–patient relationship 
881 Good 
882 Fair 
883 Poor 
900 Unexpected insights 
901 Confidentiality 
902 Listening/relating to patient 
903 Computer face/screen time 
100 Doctor’s talk 
101 Relates to issues of availability of patient’s medical resources 
102 Relates to expenses incurred by patient 
103 Relates to inconvenience incurred by patient 
104 Explains that public resources are limited 
105 Blames the system for lack of services 
106 Makes an authoritative personal statement (‘I can/cannot authorize this’) 
107 Explains medication test or other technology 
108 Explains the workings of the Health Fund/the law 
109 Explains about costs/coverage 
110 Explains other (related to resources or Basket) 
111 Explicitly states that he/she is on the patient’s side against the system 
112 Explicitly says that he/she is short of time 
113 Interrupts patient 
114 Says not covered, cost 
115 Says not necessary, not effective and not advised b/c of prior hx 
116 Gives prescription substitute or alternative (note name) 
117 Gives non-prescription substitute or advice 
118 Says wait and see, conditional 
119 Gives trial period 
120 Summarizes plan 
200 Patient’s requests 
201 Medication (new, not refills) 
202 Referral 
203 Tests 
204 Non-specific request (e.g. ‘I've got to stop smoking. Do something for me.’) 
205 Administrative request (e.g. ‘Can I get my disability coverage re-evaluated?’) 
206 Gives motivation for request (note: TV, media, friend’s recommendation) 
207 Repeats request 
208 Expresses approval of service/Health Fund 
209 Criticizes service/Health Fund 
210 Criticizes doctor or other provider 
300 Disagreements 
301 About medical issue 
302 About treatment 
303 About investigation 
304 About administrative issue (certificates, letters, etc.) 
305 Other 
400 Doctor’s style and response to request 
401 No response 
402 Response/passive (audible signs of agreement are minimal—e.g., ‘Ah-hmm’—and resolution or action not heard on tape) 
403 Response/agrees to request (e.g., ‘I think that’s a good idea. I’ll write a prescription.’) 
404 Response/agrees to negotiated or substitute request 
405 Disagrees and sides with patient 
406 Disagrees and sides with the Health Fund 
407 Disagrees and sides with system (public good) 
420 The active-acceptance mode: actively tells the patient he/she has to conform; believes in system 
430 The passive-acceptance mode: does not inform patient of all options, helps accept situation by not disclosing options; accepts system as is 
440 The active-rejection mode: discloses frustration with the system, tells patient there are ways to appeal or to go through advocacy organizations; appeals him/herself 
450 The passive-rejection mode: finds various ways to circumvent the system 
500 Patient’s response to request 
501 No response 
502 Response/passive (e.g., ‘Ah-hmm’ ‘OK’ only) 
503 Response/agrees to negotiated plan (e.g., ‘That’s a good idea. I’ll try it.’) 
504 Mentions request covered in other Kupot 
505 Patient’s attitude: ‘I deserve it.’ 
600 Type of conflict 
601 Doctor–patient 
602 Doctor system 
603 Doctor–doctor 
604 Patient system 
605 Patient–patient 
606 System–system 
610 Conflict related to basket of services 
700 Conflict outcome 
701 Agreement 
702 Partial agreement 
703 Disagreement 
704 Indeterminate 
800 Competencies 
810 Conflict recognized 
811 Yes 
812 No 
813 Indeterminate 
820 Patient factors recognized 
821 Yes 
822 No 
823 Indeterminate 
830 Organizational factors recognized 
831 Yes 
832 No 
833 Indeterminate 
840 Empathetic response 
841 Yes 
842 No 
843 Indeterminate 
850 Strategy/solutions provided 
851 Yes 
852 No 
853 Indeterminate 
860 Negation of conflict 
861 Yes 
862 No 
863 Indeterminate 
870 Advocacy for patient 
880 Global quality of doctor–patient relationship 
881 Good 
882 Fair 
883 Poor 
900 Unexpected insights 
901 Confidentiality 
902 Listening/relating to patient 
903 Computer face/screen time 

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