For Dr. Michael Franklin, the moment of truth came last year in the form of an income statement.
After 17 years as a neurologist and part-owner of a private practice in St. Petersburg, caring for patients with everything from migraines to multiple sclerosis to massive strokes, the bottom line showed that his earnings were half what they were six years ago. And he saw no signs of a turnaround.
So this month Franklin is abandoning private practice and moving to Philadelphia, where he will join the faculty of Temple University's College of Medicine.
"I asked myself, 'Do I want to continue running around like this, making less than I did six years ago?" he said of his decision-making process. "It's illogical."
Franklin, 47, is not the only neurologist pulling out of the Tampa Bay area. Another physician in his four-doctor practice, K. Vongxaiburana, is relocating to Gainesville.
Across the bay in Tampa, Dr. William Tatum will be closing his neurology practice of 18 years to take a job at the Mayo Clinic in Jacksonville. Though Tatum, 51, said revenues for his practice, including surgical procedures, were fairly stable, he anticipated erosion.
"Expenses are going up and income is going down," said Tatum, who specializes in epilepsy treatment. "It's the reverse model of what you'd like to see as you advance your career."
Turnover in the ranks of Tampa Bay's neurologists reflects the dissatisfaction driving physicians of all kinds nationwide. Insurers demand more paperwork in return for lower reimbursements. Hospitals swap staff privileges for unpaid ER call duty.
Big doctors' groups can handle the overhead cost and overtime rotations, and have greater leverage when negotiating contracts with insurers. For small, independent practices like Franklin's, the burden can become overwhelming.
Neurologists, who deal with disorders of the brain and nervous systems, are particularly disadvantaged if they don't have deep pockets or a staff position with a university or hospital. Patients dealing with progressive neuromuscular diseases require lengthy office visits and pricey medicines, both red flags to insurers. New stroke treatments require neurologists to show up at the ER, stat, but if the patient is uninsured, they get nothing for their time. Meanwhile, back at the office, a paying patient might be fuming.
"We're constantly chasing money and worrying if there's enough," said Franklin, whose practice employs 10 nonphysicians. "Patients are slaves to their insurers, who determine what tests and drugs I can order. I'm not the boss."
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While neurologists have their peculiar pressures, the forces splintering Franklin's practice are being felt across medical specialties. An article in the Feb. 12 issue of the New England Journal of Medicine said the percentage of specialists in independent practice has declined 18.6 percent since the mid 1990s. Primary care doctors have also been migrating to larger groups or jobs as employees of hospital systems or HMOs.
These trends are being driven by financial concerns as well as demographic factors. Older doctors want more security and fewer hassles. The growing number of female doctors, meanwhile, want work schedules compatible with family life. There has been little consideration of how these changes will affect access or quality of care.
"Is this decline (in independent practices) something that we, as a society, should be worried about?" the authors of the New England Journal of Medicine article asked. "The honest answer is that we don't really know."
Dr. Ann O'Malley, a senior researcher with the Center for Studying Health System Change in Washington, said residents of small towns could find themselves scrambling for primary care doctors and specialists as solo practices close. And patients who transfer to large groups or hospital-based practices may miss the continuity of care from a trusted physician.
"The coordination and continuity of care don't get looked at,'' she said. "We need to ask the patients what their care experience is like if they've had to switch doctors. They're the ones moving through these systems and experiencing different providers. Only they can tell us what it's like."
Vicki Pollyea thinks she knows all too well what happens when medical care is provided by a revolving door of physicians. The Tampa resident, 52, has suffered all her life from Charchot-Marie-Tooth syndrome, a progressively debilitating neuromuscular disease. Recently she was also diagnosed with cancer and landed in the emergency room of a local hospital, having difficulty breathing.
"I was seen by four doctors, none of whom knew me, and I kept thinking, 'Why doesn't someone who knows my history come take care of me?' '' said Pollyea, who showed up at the ER with her husband and a typewritten medical history. "Not having that rapport with somebody that knows you is very frightening. I just wanted to scream."
Pollyea was looking for a neurologist who specialized in her disease, which causes muscle weakness and nerve deterioration, when she was referred to Franklin, the St. Petersburg neurologist. After an hour-long initial visit, she came away unimpressed.
"Dr. Franklin had been on call the night before and I thought, 'He's just not getting it,' " said Pollyea, who is an occupational therapist on disability. "But when I went back to my internist, she handed me his report, which was four pages long and got all the details right. I was pretty astonished that, as tired as he was, he was processing and listening."
Franklin's patients praise his attentiveness. "He'll spend 45 minutes to an hour with me,'' said Judy Wall, a MS patient in St. Petersburg who has been seeing Franklin for about 15 years. "This is a doctor who answers your e-mail, for criminy sake. I can't imagine he does anything but work."
True enough, said Franklin, who regularly puts in 12-hour days, with weekend hospital calls once a month, MS support groups on Saturday mornings and paperwork in the office Sunday mornings.
He reads neurology journals rather than novels. The Yankees are his only distraction. Dated pictures chronicling the growth of his children, Robert, 18, and Melissa, 14, cover the wall of his cluttered, closet-sized office.
Flopped behind his desk after office hours last month, shirt rumpled and tie askew, Franklin came to life when he talked about why he became a neurologist.
When he was 14, he suffered a brain hemorrhage and seizure that triggered a lifelong curiosity about the brain. Regular migraines keep him searching for solutions.
"I like to be able to solve problems and lay hands on patients,'' said Franklin, who graduated from medical school at the State University of New York in Brooklyn and completed a fellowship in neuromuscular diseases at Albert Einstein College of Medicine in the Bronx.
"Right now, we're on the cutting edge of learning how to treat, not just diagnose, acute strokes, Parkinson's, Alzheimer's. We're not there yet, but we're knocking on the door."
With a research and teaching position at Temple, Franklin is looking forward to the regular hours, guaranteed pay, no more battles with insurers over drug approvals or reimbursements.
Franklin's departure creates a vacancy not only for his office caseload, but also at St. Anthony's Hospital, where he has been an active member of the stroke-response team. Bill Ulbricht, president of St. Anthony's, said he is confident a replacement will be found, but no one has been hired yet.
Tatum, the epilepsy specialist in Tampa, has been trying for months to get someone to take over his practice. So far, to his frustration, he has not found any takers.
"In this climate for subspecialists, it's virtually impossible," said Tatum, who has about 1,500 patients. "Everybody coming out of medical school now wants to be an employee. They don't want to go into private practice, with the worries running a business brings."
When Tatum closes his office next month, he plans to refer his patients to an epilepsy specialist at the University of South Florida or another in St. Petersburg.
Franklin's patients, meanwhile, are waiting for his advice of where to head next. For Barbara O'Dell, a St. Petersburg woman whose MS was diagnosed a decade ago by Franklin, there's only one attractive option.
"If he said he was accepting patients in Philadelphia, I'd seriously consider going up there despite the cost,'' said O'Dell, who sees Franklin quarterly. "But I'm probably just dreaming."
Kris Hundley can be reached at firstname.lastname@example.org or (727) 892-2996.