I believe primary care docs are rebelling against the system.  The system has made primary care physicians suffer emotionally and financially.  The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it.

Now I talk about “the system” in an anthropomorphic sense, but “the system” is virtual.  “The system” has no conscious, it is not deliberate, rather it represents the constellation of ignorance that the insurance companies, CMS and policy works have wrought.

The system has constrained primary care fees while systematically increasing overhead.  The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement.  The system has undervalued the value of a good primary care physician.  The system has, without consciously meaning to, held primary care in contempt.

So what do primary care physicians do?  They do what any sensible economic citizen would do, they alter the rules to their benefit.

So decreasing numbers of primary care physicians are taking Medicare or Medicaid.  So primary care physicians are leaving their jobs to do hospital medicine.  So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.

The rebellion is a quiet one.  No one has declared this rebellion.  This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera.  This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.

Some believe that NPs and PAs can fill the void, but those who believe it do not understand the complexity of primary care.  Retreating from physician led primary care will increase costs by increasing subspecialty referrals.  The problem is that too many see primary care as simple, when in fact it is complex.

So I believe the rebellion will continue.  Every anecdotal sign that I see tells me that the rebellion is gaining speed and power.  Now if Congress is dumb enough to once again fail to fix the SGR, they will encourage more rebellion.

One day the wonks on Capitol Hill will realize the problem.  AAFP and ACP (amongst others) have tried explaining the problem to the politicians.  Until they understand that their constituents are angry because they cannot find a physician, they will not focus on the problem.  The quiet rebellion will eventually stimulate a response.  Unfortunately, the fix will cost so much more then than it would have 5 or 10 years ago.  Our health care system will be changed, and likely in a very negative way.

And the quiet rebels will not be the ones suffering.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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