Physicians cannot give even give thier practices away!

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.