Making Time for Underserved Patients: Identity Conflict and Care Appropriation in the Time-Constrained Primary Care Office Visit

Abstract

This study uses the Structurational Model of Identification (SMI) to investigate how resident primary care physicians (PCPs) manage multi-level identity conflicts during the routine activity of the medical office visit. Drawing from interviews with 27 physicians and more than 47 hours of office visit observations, the data build a Structurational Model of Identity Conflict. The model depicts how physicians encounter a taxonomy of identity-centered constraints, including financial (e.g., insurance availability), material (e.g., computer-use), and temporal (e.g., waiting times), among others, that disrupt their identification during office visits, creating multi-level (e.g., relational vs professional) identity conflicts. PCPs created and shared care appropriations (i.e., workarounds) to reposition their identities and re-engage with important social contexts of work (i.e., compassionate, patient-centered care). The model also depicts how the micro-level strategies that PCPs employed to manage their identity tensions during office visits were shared, routinized, and reified, generating structurational change. This study offers practical implications for professions beyond medicine, such as education, social work, and legal aid, where practitioners must balance competing structural demands with relationship-oriented goals through creatively appropriating identity and work tasks.