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. Sroka shook his head, glanced at a wall clock and quickly put his stethoscope to his ears.
"All right, deep breaths," Sroka said. It was only 10 a.m., but Sroka was already behind schedule with patients backed up in the waiting room. Too many stories, too little time.
A former president of the Maryland State Medical Society, Sroka has practiced family medicine for 32 years, 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 Sroka, 62, thought about retiring.
He tried to sell his once highly profitable practice. No luck. He tried giving it away. No luck. 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 Sroka are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well.
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 provisions of the new health care law are likely to accelerate these trends. "There’s not going to be any of us left," 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 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.
Handsome, silver-haired and likable, 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.
CHOOSING A DIFFERENT PATH
Dr. Tim Biddle, 43, worked with Sroka between 2001 and 2005, making about $120,000 annually. Born and raised in Eastern Maryland, 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.
"Ron was working his butt off during the day seeing patients, and then he has the business of the practice to run at night," Biddle said. "He’s got to balance the books, pay his employees and negotiate the reimbursement rates." Instead of taking over the practice, Biddle left for a job as a physician at the Defense Department, where his salary is higher.
"I don’t work nights, weekends or holidays," he said. "I get all the government holidays, and whether I see three 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."
Biddle said 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.
THE ECONOMICS OF IT ALL
Sroka estimated that he was making about $250,000 annually in the 1990s 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.
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. At that rate, he breaks even at three visits an hour and needs a fourth to turn a profit.
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 practitioners 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," the younger man said. "There will be a final straw, a new mandate, and he’ll just say, ‘I’ve got to close my doors."’
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. Sroka told her to come to his office instead of going to the emergency room.
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," 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 often that day.
In a later interview, Dorsey said she passed the stress test "with flying colors" and that 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."
"He takes the time with me," she said. "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."