Ken Wilber ­"Everyone is right".

John Gardner ­ "What we have before us is a glittering opportunity of unrivaled promise, which
is disguised as an insoluble problem".


This relationship at its foundation is the quintessential interrelationship that gets many of us energetically out of bed each (and every) morning and keeps us up reading and thinking, investigating and innovating each (and every) moment into the night. Moment after moment. It is unarguably one of the three most precious, sacred, intimate, personal, intricate, and noble interactions ever conceived. The others, of course, are parent child and united couples. The "relationship", as labeled and defined , in today's healthcare space, is far too narrow. Certainly care and cure can be provided by a physician at a bedside in a hospital. But caring can also be rendered by a neighbor or family member using social media training tools and telehealth monitoring with nurses and advanced practice MD/DO extenders. PA s, APRN s, physical therapists, trainers, occupational on worksite specialists, nursing home volunteers should also be in the giving and contributing equation, often unpaid and always underappreciated in work force analyses and projections. And, to be equally clear, today's hospitals are hardly ideal places for health and wellness actualization. Hospitals are good at symptom abatement, disease and sickness crises management, vital sign rebalancing, and as intensive focused facilities for death preparation and life prolongation. Here too we must broaden our horizons and fracture our constrained mindSETS and be more co ­ creative as we address the US (and planetary/global) non system of health, wellness, and well ­ being delivery to each and ever one of us. For no one is immune or exempt from dys-ease or, ultimately, death.


Volume, in this context, implies more, just ­in time, quantity, speed, velocity, numbers and similar performance metrics. There are a lot of us who now, and will, need carors, not just payors, for these ministrations: 7.3 billion on Spaceship Earth and growing. The cost spiral is unsustainable, we are repeatedly told. Bend the curve before it breaks, bankrupts us. Providers must do more services with fewer and dwindling resources. The patient must refrain from asking for the latest and greatest technological advances and assume greater and greater copays and enlarging deductibles cost sharing and shifting as premiums skyrocket. Volume and increased throughput with elaborate marketing schemata will assure improved market share and continuous cashflows. Be like Disney, and patients will gladly endure long lines and protracted queues to end in a 5­ 10 minute visit with a harried and distracted human staring into a pre ­templated computer screen while texting on an iPhone. Volume implies more and more, faster and faster, ever increasing flow. Electronic health records and Big Data analytics are tools to effect this transition. Efficiency experts and time matrix management protocols are added to our recording requirements by myriad consultants. Operating rooms must start on time, eliminate turn ­ over time, squeeze time from hand offs and minimize breaks and lunch reliefs. Wait times in ED s and clinics must be shortened to increase the patient satisfaction scores and increase volume of services delivered. We will compensate for falling reimbursements by increasing volume ­and, of course, volume equates to more hospital beds filled, more services, more prescriptions, more imaging, more treatments and interventions. This generates more fees paid for more charges billed. And we wonder why, with an aging and (because of our discoveries and research) healthier and expanding population, expenditures are spiraling.  !REALLY?


The "new" mantra is value. We have traded "outcomes" for the old "results". We speak of consumer driven healthcare and patients as engaged co ­ participants despite the exponential complexity of the healthcare space. Value is often defined as quality divided by cost. Some more recent publications have modified the "equation" as quality divided by cost over a timeline. How should value be measured? How long should follow up be on the timeline? Econs, quants, MBA s,  administrators, managers, academicians, and theoreticians are bright and prolific . What societal value is appropriate for a QALY: $50,000, $100,000? How should DALY s be introduced along with intangible and less concrete deliverables? What value is well ­ being and productivity? Which social determinants of health and wellness are to be prioritized, most valued? Comparative effectiveness guidelines are developing to measure and compare our actual deliverables so as to attempt to qualify AND quantify benefits and determine what will be covered, insured, allowed. What happened to Hygeia and the customized, individualized, precision, personalized craft, art, AND science we have to offer. While, as an Orthopaedic surgeon, I am delighted that total hip and knee arthroplasty, herniated discectomy, and fusion for degenerative spondylolithesis made the effectiveness QALY cut, what about my revision Dupuytren's contracture releases after failed collagenase treatments to allow me to continue working for another decade, or for my experimental cancer care and surveillance? How also do we bring value to the impoverished, rural, medically underliterate population groups who lack sufficient and necessary access for universal participation to the new tool kits of telehealth and quantified ­ self monitoring wonders and health apps (h apps). And, what exactly is QUALITY? That bar for humans should be very, VERY high indeed consistent, exceeding expectations, durable, reliable, enduring, dependable, based on best evidence now (BEN), and deliverable across the entire spectrum of care by responsible, accountable carors. But not perfect. Quality, like safety, must be carefully and deliberately improved, and lessons from less optimal outcomes AND extraordinary miracles must be learned and disseminated quickly, if not immediately. But the blame game, the economic credentialing, the micromanagement, the "never" events, sentinel event reporting trails in an imperfect, very human, non ­ system cannot, and will not, get us all to the value stream, value added, value propositions to which we aspire . And the time component is paramount. We must re­ vision all timelines to be patient centered, lifelong. We must increase the time for true listening to our patients ­vital clues are in each patient's stories ­ his ­ story and her ­story. Interventions in the value healthcare space must be intentionally re ­ designed to last a lifetime. But again, repairs fail, acute becomes chronic, and mechanical substitutes for biology wear out and fatigue ­ as expected and predicted. The reality is life. A life, at present, is a chronic condition with a known but timing uncertain end point that is finite. Life is a terminal condition. Optimizing health and well ­ being during that life, each human life, is an honor, pleasure, a profound privilege, and an ennobled greater purpose for any true caror. Thus, value is double edged and contributions to productivity and flourishing, even eudemonia, are inherent in the value the patient provider/caror ­caree relationship encodes.


Health and wellness should be acknowledged to be a COMMONS. If you are well and happy and I am well and fulfilled, our society is well ­ er and happier because of us both. If you, on the other hand, infect me and I become sick and need services and cannot function for a time, the gross domestic product declines and society loses a bit of productivity. Those bits and losses add up quickly. So, is it volume, or value? It is both ­ therefore, VALUME. The answers to our perceived problems and costing conundrums must be more inclusive and next curves co ­ created by purposeful novel designs, new paradigms catapulted and launched, not just shifted, like costs. Honor and laurels must be given to the giants on whose shoulders we stand: Bortz, Teisberg, Christensen, Millenson, Porter, Cosgrove, Lee, Kuhn, Meadows, Merry, Morrison, Watson, Crick, Venter, Flexner, Darwin, Cutler, Berwick, Sackett, Bhandari, Fleming, Pronovost, Cousins, Hippocrates, Nightingale, and so many, many others. They have tackled and masterfully addressed in thoughtful writings, solutions to parts of the gaps, lapses, and lags in the healthcare space ­ the healthcare behemoth. Our inventors and their inventions, discoverers and their discoveries, researchers and their research, the partnerships of companies and organizations, government and NIH grant awarders, private and public foundations and think tanks all must be celebrated for the past 100 years + of cures and deeper molecular understandings, explanations, and clarifications . But the volume AND value of health preservation and well ­ being is a humanistic interrelationship of the highest order, truly a hierophany. We must re ­vision our philosophy and re ­ purpose our skill sets and tool kits accordingly. Volume and throughput are totally appropriate for the routinized, solved and solvable, straightforward healthcare needs. Minute clinics and focused factories (eg the Shouldice Hospital for inguinal hernias) with rapid diagnosis and instant availability of known end points are very satisfying and cost efficient ­ and with high and predictable quality. Yes, they are fragmented and piecemeal and tend toward impersonal mass production, but, when merged with fungible and searchable electronic health records and integration to robust medical homes, more acceptable. TPS and lean principles have been fitted to these "assembly line" processes with Ford, Deming, Shewhart, and Codman as exemplars. Quality is actually heightened at these rights points of care. Efficiency is a term most appropriate in these routinized, commoditized realms. As more knowledge, and ultimately universal wisdom, is accumulated, guidelines, checklists, protocols, and algorithms can be developed, pruned, refined, and disseminated to h apps, to patients, and to the right licensed level provider/caregiver/intervenor/caror. "Cookbook" medicine and surgery paint by numbers, I hear rumbling in the background! Remember, great chefs write cookbooks to distribute kitchen wisdom, prevent preparation pitfalls, assure consistency, and share their refined "secret sauces" for the benefit of all, at all levels of taste and preference. This is the "chefing commons". This, furthermore, does NOT prevent or preclude other burgeoning "chefs" from improvising, improving, experimenting, exploring, combining, or celebrating the original, the source. And, in this intimate human domain of healthcare, mechanisms must be co ­ created that allow value exponentiation. Genomics, proteomics, metabolomics, microbiomes, and Nature/nurture and environmental co ­ factors are applicable. This is complexity science writ large. Time must be allotted and incentivized and aligned in the true health ecosystem (h ­ecosystem) for the five time operated "failed back patient" in chronic pain with 28 prescriptions, 5 comorbid microsystem diseases, and 8 subspecialists opining on each subsystem. (This is a real case in my practice.) This person came for hope, help, care, mending, trending, treatment, and to have all of her issues and questions addressed. A 10 ­ minute initial visit with high volume throughput parameters, I think not. Life goals and expectations must be aligned with deliverables from biochemistry and molecular biology to techniques and surgery. What is value to this human being? What is quality? Is cost an issue? What are priorities? Is picking up a first grandchild without pain too much to ask by her of me? Every caror has unique and wrenching anecdotes and intimate highly personal stories in memory. We all have nightmares about our mistakes and failures and failings ­ whether personally or systemically through root cause analysis and gut twisting malpractice venues. Our inadequacies and insufficiencies weigh heavily . But we are learners, and these are teaching moments. We love our profession and calling for the continued wonders of cure and correction and rejuvenation our skills have wrought, and the gratitude earned from those helped and restored. Value, therefore, is an absolute, a must, a given, a default moving forward.


Can business and medicine/surgery/care co ­exist? They already do. If we have a mission (and we do, and it is a noble one), there must be a margin whether in a not ­ for ­ profit or for profit economic structure. And, if we have positive margins, then reinvestment is possible and critical to broaden and enhance new missions ­ thus, the TRIUMPH of the commons. Panacea AND Hygeia converge again, just as value AND volume merge. The routinized and commoditized production line templates do not necessarily have to be impersonal and cold and dehumanized, but patients must expect the tradeoffs to get the benefit of rapid access and attention, convenience, and lower charges with appropriate level of expertise. The more complicated, involved, convoluted, and difficult or, even unknown, diagnostic dilemmas and multi lemmas require our highest expertise, research commitment, time, patience, and a spacious open mind and open tool kit. Our humanistic calling demands nothing less, and our individual humanity will allow nothing less. Therefore, our new healthcare delivery models must be designed, co ­created, crafted with all these noble and valumed ends in mind with no barriers, excuses, qualifiers, or constraints to our thinking and ingenuity. Next generations of carors and carees will be similarly ennobled by our concerted and deliberate efforts to re ­ vision our fragmented, dislocated, broken non ­system of healthcare and wellness delivery patient by patient, caror to each caree.


May each of you, dear readers, have a mindspacious day/life!

Looking forward, always forward,

Frank W Maletz MD FACS



VALUE = Quality / Durability / Worth / Contribution /
Positive ­ Exponential Outcome / Output /
Performance / Ingenuity
x Lifelong / Long Timeline /
Extended Follow up
Cost / Price / Charge / Bill / Expenditure /
Reimbursement / Input / Resources

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