• Borrow money from pessimists - they don't expect it back.
• If you want the rainbow, you gotta put up with the rain.
• A clear conscience is usually the sign of a bad memory.
• The early bird may get the worm, but the second mouse gets the cheese.
• OK, so what's the speed of dark?
• If everything seems to be going well, you've obviously overlooked something.
• Depression is merely anger without enthusiasm.
• When every thing is coming your way, you're in the wrong lane.
• I intend to live forever, so, so good.
• A conclusion is the place where you got tired of thinking.

More and more physicians are opting out of solo or small group practices and joining larger groups often affiliated with hospitals or commercial for profit enterprises. We have seen this trend in our own community. It's unusual now for new physicians out of training to start their own independent practices. What impact, if any, will this have on the delivery of healthcare?

The percentage of US physicians who own their own practice has been declining about 2% per year for the past twenty-five years. Small physician practices "those with ten or fewer physicians" decreased 15% between 1996 and 2004. The decline in independent practice has been less among primary care physicians and general surgeons than other medical specialties.

Many factors contribute to the decline of independent practice. New physicians just out of training have often accrued much more debt than in years past and are loathe to risk starting their own practices. They often opt for the security of a salaried position. The greater percentage of women in medicine has also influenced this trend deciding on financial security and greater flexibility of hours that comes from working with a larger organization. In 2000, 56% of female physicians were employed versus 35% of male physicians. The hassle factor of paperwork, the hiring and firing of employees, providing benefits are often tougher for independent practices. The cost of new technology and software for electronic medical records are more easily purchased in larger groups. These groups also are able to give their employees, both, physicians and staff, benefits such as paid vacation, malpractice insurance, and retirement, etc. Hospitals have also been more aggressively pursuing independent lucrative practices which they believe will help their bottom line and referral base.

Why should we worry about this decrease in independent physicians? Will it make any difference if they become extinct? There is something to be said for the autonomy of having ones own practice, of scheduling appointments to suit ones own style, to hire ones own staff, to set ones own hours. Some patients just like the intimacy of smaller practices. Studies comparing the quality of large and small independent practices have been mixed with most showing no difference in the quality of care.

Because the business model has so overtaken the practice of medicine, I worry that decisions for patient care will be driven by economic factors and not what is best for the patients care. Whatever model of practice physicians join we need to be true to our oath of putting the patient's best interests ahead of our own self interests.

John J. Mohr, MD