By GARDINER HARRIS
Published: April 22, 2011
CROFTON, Md. — “So there we are, miles from shore, fishing since 11 o’clock at night, and we haven’t gotten one single bite until finally we gaff one that’s about this big.”
Dr.
Ronald Sroka held his hands about three feet apart, and John Mayer — fishing
buddy and patient — smiled from the examination table. Dr. Sroka shook his
head, glanced at a wall clock and quickly put his stethoscope to his ears.
“All
right, deep breaths,” Dr. Sroka said. It was only 10 a.m., but Dr. Sroka was
already behind schedule, with patients backed up in the waiting room like
planes waiting to take off at La Guardia Airport. Too many stories; too little
time.
“Talking
too much is the kind of thing that gets me behind,” Dr. Sroka said with a
shrug. “But it’s the only part of the job I like.”
A former
president of the Maryland State Medical Society, Dr. Sroka has practiced family
medicine for 32 years in a small, red-brick building just six miles from his
childhood home, treating fishing buddies, neighbors and even his elementary
school principal much the way doctors have practiced medicine for centuries. He
likes to chat, but with costs going up and reimbursements down, that extra time
has hurt his income. So Dr. Sroka, 62, thought about retiring.
He tried
to sell his once highly profitable practice. No luck. He tried giving it away.
No luck.
Dr.
Sroka’s fate is emblematic of a transformation in American medicine. He once
provided for nearly all of his patients’ medical needs — stitching up the
injured, directing care for the hospitalized and keeping vigil for the dying.
But doctors like him are increasingly being replaced by teams of rotating doctors
and nurses who do not know their patients nearly as well. A centuries-old
intimacy between doctor and patient is being lost, and patients who visit the
doctor are often kept guessing about who will appear in the white coat.
The share
of solo practices among members of the American Academy of Family Physicians
fell to 18 percent by 2008 from 44 percent in 1986. And census figures show
that in 2007, just 28 percent of doctors described themselves as self-employed,
compared with 58 percent in 1970. Many of the provisions of the new health care
law are likely to accelerate these trends.
“There’s
not going to be any of us left,” Dr. Sroka said.
Indeed,
younger doctors — half of whom are now women — are refusing to take over these
small practices. They want better lifestyles, shorter work days, and
weekends free of the beepers, cellphones and patient emergencies that have long
defined doctors’ lives. Weighed down with
debt, they want regular paychecks instead of shopkeeper risks. And even if they
wanted such practices, banks — attuned to the growing uncertainties — are far
less likely to lend the money needed.
For
patients, the transition away from small private practices is not all bad.
While larger practices tend to be less intimate, the care offered tends to be
better — with more preventive services, better cardiac advice and fewer
unnecessary tests. And the new policies that may finally put Dr. Sroka out of
business are almost universally embraced — including wholesale adoption of
electronic medical records and bundled payments from the federal Medicare
program that encourage coordinated care.
“Those of
us who think about medical errors and cost have no nostalgia — in fact, we have
outright disdain — for the single practitioner like Marcus Welby,” David J.
Rothman, president of the Institute on Medicine as a Profession at Columbia
University, said of the 1970s TV doctor.
Dr. Sroka
has not taken a sick day in 32 years. After his latest partner left in September,
he was unable for five months to schedule any time off until another local
doctor volunteered to cover for him. His income and patients depend upon his
daily presence. This resiliency is part of a tough-minded medical culture —
forged in round-the-clock residency shifts, constant on-call schedules, and
workplaces in which revered doctors made decisions and staff members followed
orders — that is fast disappearing.
Had he
left a decade ago, Dr. Sroka might have been able to persuade a doctor to pay
$500,000 or more for his roster of 4,000 patients. That he cannot give his
practice away results not only from the unattractiveness of its inflexible
schedule but also because large group practices can negotiate higher fees from
insurers, which translates into more money for doctors.
Building
Relationships
Handsome,
silver-haired and likable, Dr. Sroka is indeed a modern-day Marcus Welby, his
idol. He holds ailing patients’ hands, pats their thickening bellies, and has a
talent for diagnosing and explaining complex health problems.
Many of
his patients adore him.
One of
them, Alicia Beall, 53, came in for a consultation after a pain in her foot
grew worrisome. She has been seeing Dr. Sroka for 30 years, and he quickly
guessed that she was suffering plantar fasciitis, a painful inflammation.
“So take
off your shoe,” Dr. Sroka said. She did, and Dr. Sroka lifted her foot.
“If it’s
plantar fasciitis, it’s usually right there,” Dr. Sroka said and pressed his
thumb into her heel.
“Ow!
Don’t do that,” Ms. Beall said and smacked him with a magazine. They both
laughed.
They
discussed possible treatments for her foot and for swekking in a hand,
including steroid injections. But he settled on a prescription for diclofenac,
an aspirinlike pain pill. While writing his notes, Dr. Sroka asked Ms. Beall
how her husband liked his new job. He told her to return if the pills failed.
“We’ll do
the steroid injections another time,” Dr. Sroka said. “We never would have
gotten the insurance company to pay for them all. When you bill for both a
medical and a surgical visit, they always deny one.”
Patients
and doctors often complain that appointments are rushed, but the time that
doctors spend with each patient — 16 to 20 minutes, on average — Has remained Largely
unchanged for years.
Instead,
patients have gotten sicker and treatments more complex. Half of Americans have
a chronic disease like high blood
pressure or diabetes, and a quarter have two or more such conditions. For
diabetes alone, the American Diabetes Association’s recommendations for basic medical care extend for nine single-spaced
pages. For many of their patients, doctors must increasingly rush through a
blizzard of questions and tests, leaving little time for the kind of intimate
chit-chat for which doctors and patients alike yearn. Some patients must
schedule two or three office visits to have all of their medical issues
addressed.
In a
later interview, Ms. Beall said that Dr. Sroka “has real conversations with
you, and he remembers what’s going on in your personal life. I really like
that.” At appointments, she is assured of seeing him and not a colleague she
does not know. Even his assistants know her on sight.
“At some
medical offices, you feel like you should pull a number like at the deli,” she
said. “But Dr. Sroka’s office is small-town medicine, and I like that. I’m
dreading the day when he retires. I know it’s coming.”
Two
Paths
Dr. Tim
Biddle, 43, worked with Dr. Sroka between 2001 and 2005, making about $120,000 annually. Born and
raised in Eastern Maryland, Dr. Biddle had intended to become a country doctor.
But more than $100,000 in school debt and a desire to attend his four
children’s soccer games led him to reconsider. Doctors in less populated areas
tend to work longer hours seeing patients than doctors in more populated areas,
according to government studies.
“Ron was working his
butt off during the day seeing patients, and then he has the business of the
practice to run at night,” Dr. Biddle said. “He’s got to balance the books, pay
his employees and negotiate the reimbursement rates.” Like many doctors who own
small practices, Dr. Sroka relies on his wife, Nancy Sroka, for much of his
bookkeeping.
Instead of taking
over the practice, Dr. Biddle left for a job as a physician at the Defense
Department, where his salary is higher, his hours fewer and his vacations more
frequent.
“I don’t work nights,
weekends or holidays,” he said. “I get all the government holidays, and whether
I see 3 or 30 patients a day, I get paid the same thing. And I never get stuck
at the office because I’ve got too many patients, too much paperwork or because
I have to go to the E.R. to see a patient.”
Dr. Biddle said that
he missed the intimacy he once had with patients but suspected that he provided
better care now because he practiced near other doctors, many of them
specialists, whom he can consult on difficult cases. “When I was with Ron, we
didn’t have 10 other doctors pulling the charts and providing the level of peer
review that we have here,” he said.
Dr. Sroka was once
deeply idealistic about his profession and used to speak with great feeling
about a higher purpose to his work. He still fondly recalls standing on his
front porch and stitching up neighborhood kids injured in evening ball games.
But when insurers stopped paying extra for after-hours care, he started telling
those kids to go to nearby emergency rooms. Like so many in his generation of
doctors, the nickel-and-dime efforts of insurers have left him deeply bitter.
Dr. Sroka estimated
that he was making about $250,000 annually in the 1990s — high for a primary
care doctor — because he practices in an affluent region and his patients had
generous insurance plans. Even as late as 2006, his income was $324,000,
according to records he provided for this article — double the median income
for family practice doctors that year.
But in 2008, his
income dropped to $97,000. It rose last year to $130,000, but only because he
worked about a third more hours. Growing practice expenses played a significant
role in this decline.
Walking into Dr.
Sroka’s practice, it is easy to see why. On most days, visitors are greeted by
Betty Alt, a sweet 68-year-old who knows many patients intimately. Patients’
medical folders — many bulging with decades of aches and test results — are
retrieved by Jennifer Simmons, a 41-year-old office assistant who spends much
of her day faxing. Before appointments, patients often give a urine sample to
Chris Minner, 58, a medical technician.
Altogether, Dr. Sroka
employs 10 part-time employees, or the equivalent of five full-time workers. He
does not provide his staff members with health insurance. His expenses amounted
to $420,000 last year, or about $200 an hour. Most of his patients have either
Medicare or CareFirst, the local Blue Cross Blue Shield plan, which pays him
$69 (including a $20 co-pay) for most consultations. At that rate, he breaks
even at three visits an hour and needs a fourth to turn a profit.
While Medicare
reimbursements have been unchanged for 10 years, private reimbursements have
declined twice in that period while his costs — and those of family practices
across the country — rose steadily.
Keenly aware of these
numbers, Dr. Sroka is decidedly cheap. When the toilet in his office broke
recently, he went to Home Depot to get the replacement parts himself. When his
office flooded, he spent the weekend mucking it out. His weight scale for
patients is a battered, ancient disk that he kicks out from under his desk. The
posters lining the walls are yard-sale Norman Rockwell reproductions.
Dr. Sroka said that
he did not deserve anyone’s sympathy. Frugality and wise investments have left
him with a net worth of about $5 million, which includes his office building,
he said. He cannot bring himself to join a large group practice or work for a
hospital because he opposes their growing use of nurse practices for primary
care.
His eldest son, Ron
Jr., sells group health insurance plans — the kind of product that is putting
his father out of business.
“My dad’s way of
delivering medicine is going to be extinct very soon,” Ron Sroka Jr. said in an
interview. “He’s a dinosaur.” The money and time needed to buy and master an
electronic health record system will alone be too much for his father, he said.
“My honest opinion is
that one day he is going to lose it and just walk off the job,” Ron Sroka Jr. said.
“There will be a final straw, a new mandate, and he’ll just say, ‘I’ve got to
close my doors.’ He wants to maintain contact with his patient base because
they’re like family to him, but he’s not going to be able to do it.”
The
Personal Touch
Mary Pat Dorsey, 64,
came in for an appointment after having heart palpitations,
a pain in her jaw and a bad headache.
A friend was concerned that she might be suffering a heart attack,
so she called Dr. Sroka. He told her to come to his office instead of going to
the emergency room.
Dr. Sroka gave her an
electrocardiogram, took her pulse and blood
pressure, and listened to her heart with his stethoscope. After a
series of questions (was she at rest or active, sweaty, light-headed, fatigued
or still taking estrogen
replacement therapy?), he learned that she had been taking Excedrin for
migraines.
“That has caffeine in
it. It helps with the headache problems, but can bring on heart ones. That may
be the thing that’s setting this off,” Dr. Sroka said. Still, he insisted that
she soon get a stress test “because in this day and age, we’ve been ignoring
too many women with symptoms of ischemic
heart disease.”
He counseled her to
go to the hospital in the future if she got chest pains with drenching sweat,
light-headedness, or nausea and fatigue. “But I think you’re good for another
100,000 miles,” a line he used countless times that day.
In a later interview,
Mrs. Dorsey said that she passed the stress test “with flying colors” and that
Dr. Sroka had on several occasions over the previous 32 years saved her from
unnecessary trips to the emergency room and thousands of dollars in medical
bills “because he knows me.”
“I’m having trouble
with menopause
and having weird things happen to me, and he knows that,” she said. “He takes
the time with me. He knows my family. He talks about fishing, and that makes me
comfortable. He lives around the corner from my daughter. He grew up and came
right back and did his practice around everybody he knows.”
“He’s just special.”
A version of this article appeared in print on
April 23, 2011, on page A1 of the New York edition with the headline: Family
Physician Can’t Give Away Solo Practice.
