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I think there's a key issue being missed here.

Why would anyone want P4P? In theory, you get sick, you go to a doctor, you get accurate and appropriate treatment, and you get better.

But that's not what happens is it? Medical mistakes cost lives. The horsification of zebra patients costs lives (or quality of life). In my case I spent 18 months going to my doctor and the ED multiple times in serious abdominal pain following a laparascopic appendectomy. Not once did a doctor actually visually examine or palpate the area. What finally happened is an ED visit where I had pain and a fever so a CT was ordered. The CT showed a hernia the size of a soup bowl (talk about killing a mosquito with a cannonball).

When I saw the surgeon, all he had to do was have me lift my head, and there it was, plain as day, big, fat, protruding hernia.

I also have an autoimmune disorder, that took me years to find a diagnosis for, in spite of rapidly multiplying lipomas. I had a 5 year delay in diagnosis of endometrial cancer following AGUS results because my HMO felt that the standard of endometrial biopsy was "unnecessary". I asked repeatedly but was told I was merely being "paranoid" because I have a significant family history of cancer (no, really?). Even as I became increasingly symptomatic they refused any follow up. It wasn't until I was severely anemic from the heavy bleeding and passing orange-sized clots that they finally agreed to do an endometrial biopsy, and still that day I was sent home with progesterone, because they assumed it was hormonal.

My son's autism was misdiagnosed for 2 years, in spite of being moderately autistic with a classical presentation. I can't really fault the medical community for this one, it's going to take time for information to catch up with autism, but the end result for him is the same, 2 wasted years with no interventions.

I'm one person, we're one family. That's barely the tip of the iceberg in my own personal medical history. It's easy to see where there are so many fatal medical mistakes each year.

Why is it that every doctor I go to outside of our former HMO says how bad that HMO is? Why do they only speak up in the relative safety of their offices? Why are they not speaking up publicly?

Let me be clear: for too long, doctors have been trusted to police themselves to a great extent. In many states patients can't recover anything near actual ecconomic losses. Our options are few. Either doctors are going to have to do a better job of regulating each other, or get used to the idea of greater outside regulation. That regulation may take the form of something that really doesn't benefit doctors or patients. Is that what we want? It's not what I want.

From my perspective there is a discussion about these issues that needs to take place with the core dyad of healthcare, doctor and patient. There has to be some win/win solution....

How do we create that public discourse?

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