Difficult, dysfunctional, and drug-dependent: The roles of structure and agency in physician perceptions of indigent patients.

Physicians exhibit great reluctance to care for 90 million Americans who are uninsured or on Medicaid, citing concerns about litigation, reimbursement, and complexities inherent in treating indigent patients. This paper uses qualitative data from a nationally-representative group of 275 doctors to explore physician attitudes about working with indigent patients, focusing on their perceptions of the indigent, and the strategies they use in caring for this population. This work moves beyond prior studies through its revelation of negative physician views about the medically indigent, critical of patient spending habits, health decisions, and "abuse" of the system. This paper argues that despite these negative perceptions of the underserved, physicians engage in innovative strategies to assist indigent patients by distinguishing between the deserving and the undeserving poor. This distinction, based on physician perceptions of the constraints and choices in patients' lives, enables physicians to exercise agency in choosing who and how to serve. Physician perceptions of patients as active agents stand in stark contrast to views of their own actions, which are seen as dictated by rules of medical practice. This work adds critical insight to our understanding of relational power and the recursive nature of structure and agency between multiple actors. [ABSTRACT FROM AUTHOR]