Dr. Michael Wasylik hung his shingle in front of his Tampa orthopedic practice 30 years ago and patients streamed in.
But as economic and lifestyle factors change the face of American medicine, solo practitioners like Wasylik are becoming a rare breed.
More common today is Dr. Scott Graham of St. Petersburg, a young family physician and father. Overwhelmed by paperwork, lacking clout to bargain with insurers and wanting time with his family, he abandoned his dream of solo practice. Instead, he is opting for a regular paycheck and schedule as a hospital employee.
Years before health reform dominated politics, the medical industry started undergoing a dramatic transformation with doctors leaving small private practices for larger and hospital-owned groups. The upside for doctors is getting to focus on medicine rather than running a business, and a better quality of life. Patients gain access to conveniently clustered practitioners and technology such as electronic medical records that may improve care.
But critics fear that physicians stand to lose their independence in deciding treatments and making referrals. And patients may lose close relationships with doctors.
All agree, however, that this trend appears unstoppable.
Just a few years ago, the nation's largest physician salary survey indicated that two-thirds of doctors owned their practices. But by 2008, that figure plunged to less than 50 percent, according to the Medical Group Management Association. The recession has accelerated this trend.
"What we're seeing now is a lot of people throwing their hands up and saying, 'I'm tired of the rat race,' " said Dr. Bill Jessee, president and CEO of the association. He added that the biggest trend is doctors becoming hospital employees.
"There will always be a place for physicians in smaller practice, but that may be outside the mainstream in a few years."
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The medical landscape is shifting around the Tampa Bay area, often without patients even noticing. Some recent examples:
• All Children's Hospital in St. Petersburg has almost doubled its number of employed physicians, absorbing dozens of private practice doctors. Recently, it even picked up an ob-gyn group.
• In offices from Tampa to Naples, 69 physicians have merged to form Florida Cancer Specialists, an oncology practice with the combined resources to purchase the latest (and often pricey) chemotherapy drugs and access to clinical trials.
• Morton Plant Mease Primary Care, created years ago to address a shortage of primary care physicians, now employs about 90 at locations in Pinellas and Pasco counties.
• Diagnostic Clinic, a large, physician-owned group that calls itself a one-stop medical home, recently built a six-story office in Largo, one of its three locations. Recent hires include former private practice doctors in primary care, dermatology, urology, neurology and gastroenterology.
"One thing that we promote when we are talking to physicians who are trying to think about joining a larger practice is, 'Don't you just want to practice your profession again?' " said Dr. Jim Rivenbark, Diagnostic Clinic's chief medical officer. "Poor guys out by themselves have to worry about a lot of stuff."
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When Wasylik, the veteran Tampa orthopedic surgeon, went into private practice, he simply took out a bank loan to cover his startup costs and set up an office. Soon patients came in, and he paid his bills.
As in any small business, Wasylik scrambles when an employee calls in sick. Costs and paperwork are growing all the time. Still, he wouldn't trade the headaches for a job at a large practice.
"I think the bond between the physician and the patient is less" in large practices, Wasylik said. "I feel personally responsible for each and every one of my patients. I work for myself and I work for my patients."
He understands why private practices are dying. Between insurance barriers and hefty student loans, he noted, young doctors can't start out as he did.
Graham, who has been a family doctor for just six years, knew it wouldn't be easy to open a solo practice. But he was determined.
"My goal was to keep my overhead low, so I could practice medicine in a way that I could enjoy it, and I could actually spend more than five minutes with each patient," he said.
But mundane tasks like ordering drug refills, dealing with lab reports and getting prior authorizations took a great deal of his time. And he quickly saw he had no leverage with insurers.
After three years, he joined Suncoast Medical Clinic, where he no longer fretted over billing and disposing of biohazardous waste. The money got better, but not the long hours.
After his son was born, Graham took an academic job supervising medical residents at Bayfront Medical Center. He works mostly 8 a.m. to 5 p.m., and gets a paycheck every two weeks. Although he still sees patients a few mornings a week, Graham had to drop most of his private practice.
"Physicians that are very busy, very successful, very well-liked by their patients, do a great job, but they are often working 14-hour days," he said. "It wasn't something that I was willing to do."
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Large and hospital-focused practices long have been part of the medical landscape. Locally, the most prominent such practice is the USF Physicians Group, the 350-doctor academic practice affiliated with the region's medical school.
What's new is the growth.
In 2005, hospitals were the employers in 23 percent of the physician jobs that a national recruiting firm was hired to fill. In 2009, that figure rose to 45 percent, according to Merritt Hawkins, a national physician search and consulting firm.
Hospital leaders note, however, that employing doctors isn't cheap.
In the bay area, hospital-employed doctors typically earn a base salary with incentives for productivity, which can include patient satisfaction and quality.
"If anything, it's a significantly more expensive model," said Isaac Mallah, president and CEO of St. Joseph's Hospitals. He has been adding doctors to HealthPoint, its multispecialty group in Hillsborough.
Big groups like HealthPoint like convenient locations, which can mean higher rent. Investing in technology is costly.
Yet HealthPoint, now employing about 100 practitioners, also helps bring to the region hard-to-find specialty physicians in pediatric and general surgery, Mallah said.
All Children's Hospital, in particular, has embraced the model. Its leaders see a future in which doctors and hospitals will need to better coordinate care.
The hospital's new outpatient building resembles a traditional doctors' suite, but the floors feature a back hallway where doctors have their offices, designed to promote collaboration.
"It's all about higher quality, lower cost," said Bill Horton, All Children's senior vice president for strategic business services.
"The employment model allows (physicians and the hospital) to sit down at the table and go at those very complicated issues that you run into every day."
Many physicians now working for All Children's were already affiliated with the hospital, so many patients might not even be aware of this quiet yet major transition.
Brianna Eastridge, 19, began seeing Dr. Stacie Stapleton, a pediatric neuro-oncologist, for a rare blood disease around the time Stapleton's practice was joining All Children's.
"We haven't noticed any changes. It just seemed to flow real smoothly," said her mother, Linda Eastridge of Pinellas Park, who has Stapleton's cell phone number and e-mail address.
"We just love the staff of the hospital. You call and they know who you are. Not just the doctors, all of the staff. They make a tough experience not as tough."
Letitia Stein can be reached at firstname.lastname@example.org or (813) 226-3322. For more health news, visit www.tampabay.com/health.