A minister decided that a visual demonstration would add emphasis to his Sunday sermon. Four worms were placed in to four separate jars. The first worm was put into a container of alcohol. The second worm was put into a container of cigarette smoke. The third worm was put into a container of chocolate syrup. The fourth worm was put into a container of good clean soil.

At the conclusion of the sermon, the Minister reported the following results:

The first worm in alcohol - Dead. The second worm in cigarette smoke - Dead. The third worm in chocolate - Dead. Fourth worm in good clean soil - Alive.

So the minister asked the congregation, "What did you learn from this demonstration?" Maxine was sitting in the back, quickly raised her hand and said, "As long as you drink, smoke and eat chocolate you won't have worms."

That pretty much ended the church service.

Only someone in a deep sleep would not agree that the practice of medicine has changed dramatically over the past decade. Independent private practice is being abandoned in favor of hospital based salaried and employed physicians. Even smaller communities with few physicians are turning to for profit entities or larger neighboring hospitals with which to partner. In our own community the two major hospitals now employ a large number of their staffs and are aggressively recruiting new physicians. Will closed medical staffs be far behind?

Many factors are driving this trend. New graduates coming out of medical school and residency face an increasing debt burden which necessitates a set salary to begin to repay these loans. More women are entering the profession and wish to balance family and professional life without the stress of managing their own businesses. Employment often brings more regular hours, call, vacation benefits and malpractice coverage. Auxiliary help is employed by the larger sponsoring institutions which have more generous benefit packages etc. for the employees. The uncertainties of the new healthcare plan, the push for electronic medical records, the high cost of capital equipment, the coding enigmas and burdensome paperwork are also factors in this trend. Fear may also play a major role. No physician wants to be left without patients to care for and therefore when they see their colleagues lining up for employment they are not far behind.

Fee for service independent practice has been criticized because it incentivizes physicians to do more, to see more patients, to order more tests and to do more procedures. A similar criticism may also be made of larger institutions which insist their employed physicians refer within their own group and send their tests to the mother institution.

There is something to be said for being one's own boss, for setting one's own schedule, hiring one's own staff and setting one's own appointment schedule. Efficiency is rewarded.

Does all of this make any difference? I think so. I'm sure good quality of care can be delivered in any system. Any conscientious physician knows it's their primary duty to be their patients advocate and to treat the patient without regard to personal financial gain. Everyone fondly remembers the horse and buggy doctor who made house calls and knew his patients families. I'm not suggesting a return to those days but I remain convinced that independent private practices offer a unique perspective in the profession of medicine.

John J. Mohr, M.D.