Doctors INC.: Family Physician Can’t Give Away Solo Practice

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.