Subject: News from Dr. Kevin Fickenscher
From: "Dr. Kevin Fickenscher" <[email-masked]>
To: <[email-masked]>
Date: Wed, 23 Sep 2015 14:19:24 -0400 (EDT)

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6ieI7Ba2ZX5uh35U-no_wNsjQaK5h0cFVOl_P7TALz6iZwqlDrxtcqysoG5lG7L5LU5h-dtOCQFzQq4bqICYxJ-tHSUWV9weXR-fd6OWCK-OMcQ1HtAEAfp6UvgHD-y_aSA==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 3, Issue 36
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6icYbfKCF4MgeRoHHAuZeFtZgOZqeP8jAjyvUP1eeYSThYLNJft3EycME0C7XQrzcT5AqmtIXKdgyBh-TVvhZTJ2YbElivYamIccJ0Bjt6g0w6h3LLldLGneQ7QZKOsqIy3TcxGMd-wmaHIm1cRJZHfApBk6ADGLxNddo9-G56WEaGhDKcrIjNWzYeeoGIIQQUIlgbzZrOxkajrfuqMVo82o=&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==],
MD, CPE, FACPE, FAAFP
@MDKev

A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Quote(s) Of The Week
"This study provides potentially lifesaving information that will be useful to health
care providers as they consider the best treatment options for some of their patients,
particularly those over the age of 50,"
Gary H. Gibbons, M.D., the Director of the National Heart, Lung, and Blood Institute
(NHLBI) and the primary sponsor of SPRINT research project on high blood pressure
"And, I know many families here in Iowa are worried about even more rural hospitals
closing.  Telemedicine can help - and, we should streamline licensing and explore
how to make that reimbursable under Medicare."
Presidential Candidate Hillary Clinton (D-NY) at a speech before an audience at 
the community college in Ankeny, Iowa on a range of issues on her campaign wish 
list
"He's not a conservative.  He's not a liberal.  He's not a Democrat.  He's not a
 Republican.  He's not an independent.  He believes in Donald Trump."
Presidential Candidate Bobby Jindal (R-LA) at the Republican debate held recently
at the Ronald Reagan Presidential Library in California
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your consideration and reflection...
My "Nolo Contendere" Plea On Vaccinations - OK, OK!  Call me a doctor!  Call me 
too closely aligned with the field of medicine.  Accuse me of not being very political.
 And, most importantly, wrap the accusations in the literature over the last several
decades which clearly articulates that vaccinations are a "good" thing for children
and adults.  I know.  I know.  I may never be a contender for President of the United
States. But, at least I'll have my ethical standards in place and they'll be backed
up by not just my opinion but scientific research.  As for the two physicians who
were on the panel when the contentions were made and, who simply stood there - I
 was embarrassed.  Their lack of response in the moment seemed gratuitous at best.
 It seems that it is more important to appeal to potential constituents - no matter
how wrong they are - than it is to maintain certain boundaries no matter how accurate
they are...  Now, about that climate change thing...
And, Now - For The "Medical News" On Vaccinations - A review of recently released
federal data shows that vaccination rates for children are now over 90%.  If you
 believe in science - that's a good thing.  But, the rate of immunization of adults
over the age of 60 for flu, pneumonia, tetanus and shingles is not close to reaching
our national targets.  The rates for shingles run around 25%, for Tetanus almost
 1/2 and the flu about 2/3 get the immunization with pneumonia topping out the recommended
list for those over the age of 60 at 60%.  It seems that the miscommunication on
 the impact of these shots contributes to the insufficiency of adult immunization
as well.  So, I wonder what the naysayers are saying about the implications of Grandma
getting her annual immunizations?

NIH Closes Down Study On Treatment of High Blood Pressure Early - What was labeled
as "outstanding news" resulted in an unusual early closing of a study on high blood
pressure in early September.  The National Institutes of Healthhalted a major, ongoing
study [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQLQk4fLVQydpP3eOF95snkD5pk5U8DVWLCpmkYQeIl_doJq41sSo_GzSWhga6kGIHK7cmSMHaon0O5X-aFGnL1PxKQq8GzLV8lUYOEwtz34mEXwc3TfO4tqO6PCssAg_LoHaedlqIHATkdRGOjl2FMg==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
that was attempting to answer a debated question among those treating patients with
high blood pressure - Are the current guidelines the management of hypertension 
too high?  Or, do they need to be lower?  The so-called SPRINT study - started in
2009 - was designed to address the question.  Researchers enrolled over 9,000 men
and women over the age of 50 and who had high blood pressure and at least one risk
factor for heart disease. Half of the cohort were treated to reach a systolic blood
pressure of below 140, while the other were even more aggressively treated to lower
their systolic blood pressure to less than 120.  The study was intended to run until
2017 but was abruptly stopped.  Why?  Because the researchers compiled compelling
data showing that those individuals who were managed to a systolic blood pressure
of less than 120 saw a 33% reduction in their risk of heart attack, stroke and heart
failure and a 25% reduction in rate of death.  By any standard, that's compelling!!
The study is also examining the impact of blood pressure management on kidney disease,
cognitive function, and dementia but, the results are not yet complete.  It is anticipated
that they will be released sometime in the next year.  The primary results of the
trial will be published in the next several months.

On The Average Life Expectancy - I must be at the right age.  OK, I admit it - I
 am at the right age to be receiving all of those mailings from the AARP.  While
 I'm not retired, I'm nearing eligibility so the mailings are coming on strong. 
 So, it was with prurient interest that I opened a website that contained a prediction
on my average life expectancy [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQEz-hUK74w84GHwoJQFgjAnriMgsaokMecxUz2MzJ8M9JbHMjHIBOGLCXx0hyaxgTMDgOcaXmNJhpgPNKEqrBY0nOPuOMzf-OG79htloVPFCx45e45bzf5uQDVWIwJpObD_xJ_A5PwGI=&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==],
based strictly on age and gender.  They left out a lot of lifestyle variables like
smoking, weight, blood pressure control and the like.  It seems that the Social 
Security Administration tables predict "on average" that I've got 18.4 years left.
 While there are no predictions on the quality of the remaining years, the quantity
is straight forward.  So, like the gazelle in the jungle who simply needs to run
 faster than the other gazelles to stay ahead of the lion - I've redoubled my efforts
to keep my weight under control and eat those six cups of vegetables (yes...6) a
 day that are associated with greater longevity.  And, I'm getting my flu shot.

Considerations On Meaningful Use - I received a notice recently from one of the 
brightest minds in medical informatics - Larry Ozeran, MD - who pinged me on the
 question ofMeaningful Use - A Prudent Conversation [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQjshdpyi06J5kjv2CXDhRGiwvtxlL0-925kMIM2WRCPbX1HCAzc5YpfQwrmBYeYz15x57spKfG9pHXdxAenhXM-jJkHKuBYFYDtkyWhI6Mv4VXW3sBCmIIUaI9swFwNpZPi2E0U_MFQGJrAqZgTuA6DpPgrukP08crxcUnLlIB0S6GJ2oK-ks0A==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==].
 Dr. Ozeran's primary observation is that Meaningful Use Stage1 was designed to 
assure that physicians who purchased electronic health systems actually used them
in the treatment of patients.  He argues that subsequent versions may be off track
and that the focus of the debate should be shifted toward better definitions of 
"cost", "quality" and "outcomes".  In reality, it seems that healthcare is long 
overdue for such a focus.  Underlying his arguments is the notion of "interoperability"
or the ability to extract data from various devices that is consistent, comparable
and reliable rather than disparate and lacking in integratability (my word).  I 
concur with Dr. Ozeran's assessment.  The time has come for all of us to move the
conversation to a new level.

Menu

News

Markets  [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQnrKCflgdFCuv8h05_BAPGrfeDkuy9rByIW7i8JjfvlZU7eRVn0ArpCCYBislG--i4VL9BXM9zy8exYE8LnN1XDpf6J5fUjVVeY8SjYyldmvM4kYTFF4Pfg==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]

Insights  [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQK32HBGEmDRUv2Ur4lDOwm8EU6Ug5jUMqMSUNfVm4dvDkwWoA9Zze07iBtFNt73fC3JjSLm56m5yst1hddKuEy7ixJ-IQwbNjvDYKoTzgsHHZCqWS4TKoPg==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]

Video  [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQoFiahbt6M_wJPw9gXy_e76lcvFxqRZzZqUhZBW58qqjpLglgHzOem8edjtZ8MidvxQ1dGbXfVWL1rbS_RHkYDPdgZoLHnzXuEQZ0Lp1pTBFFu3yGkpndpQ==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]

Health Jobs Hit USA Record - If we ever needed evidence that healthcare was impacting
the economy, the recent jobs report should provide enough data. Health jobs made
 up nearly 11% of all USA jobs as of August, 2015 or, 15.2 million people compared
to 14.7 million a year earlier. The two primary drivers of the trend were the aging
demographic of the boomer population and the influx of the newly insured from the
implementation of the Patient Protection and Affordable Care Act or Obamacare as
 it is affectionately referred to in the USA.  The Accountable Care Act provides
 subsidies for individuals to purchase coverage and, in many cases, requires employers
to provide insurance. The addition of about 1.5 million people to the Medicare-eligible
group; however, was a significant component of the overall growth in the number 
of healthcare workers.  There were 54 million people with Medicare in 2014 which
 is expected to grow to 88 million people by 2050. The problem is that healthcare
workforce reflects the demography of the general population.  My argument is that
there is "NO WAY" that we can continue to deliver care in the manner we've done 
it for the last half century.  We need to reconsider our licensure rules.  We need
to adopt more telecare (i.e. actually delivery of care using remote technology management
of patients).  We need to embrace self-management of care.  We need to offer better
support and training for the familial support network in their care of parents and
others in their family circle.  And, we need to think about how we can best provide
care to the population - not just the individual.  Without a new framing of our 
care model - we will fail to deliver.  Think about it.  We need to get ahead of 
the curve.  While empowerment and rule changes will definitely make a difference,
my argument for any number of years has been that the adoption of new remote care
delivery technologies will go further than all other initiatives in driving greater
efficiency and effectiveness in the delivery of care in the new future world of 
healthcare.  So, what is the impediment?  It's clearly not the technology.  Rather,
it's the incentives.  Let the discussions begin...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Future Health
Delivering care in the new virtual world...
The New Breed Of Physicians Embrace Telemedicine - For the generation that has never
been without computers or handhelds for that matter, it's only intuitive that the
tools should be used in caring for patients.  A recentMedscape study [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQreBmuXCk7Ub9I5Dx3DLJZ_E1_Fd1Dq3OcOL_s_ijOCtnjaVewvjgFYESrugFuNKUudaxdqaxr5gUrbXDtVzSrMzZhYm7M9XSAogH1iJuYgDO1pGmSRwjZ93WmKNtCKmnmr5JkULz30c=&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
found that 70% of medical students would be willing to use telemedicine in the treatment
of patients using telemedicine technologies. For medical residents - representing
24 specialties - the trend was also supported with over half concurring that the
 use of telemedicine is an effective tool in the treatment of patients.  My prediction
from 1976 that "The computer is the physician's next stethoscope - we simply need
to learn how to use it" is finally coming true for providers as well as techno-healthcare
geeks.

Approaches To Alternative Care Delivery
Ideas and thoughts on how care delivery can be transformed...
The Mandated Nurse-Patient Staffing Ratios Debate - Earlier this year, the Massachusetts
Health Policy Commission voted unanimously to implement the nation's second nurse
staffing [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQucKSbCmOjqB2bj_9KYWDRe_JWlMLkU_Q2tkci8uWFxxecJ9n-utkWTC-Os_Epj9TKXvzRCbnvvkqwrf9bkeQVVxR9aS1CotSnBzqsWn2vgDGxL-yanqSfFc4Hn_4zgycY4mZUSkhVkTJv8gL1PKV3DzyElKx1kDaq777fbTTQHrDHsBsGYa-6J5GxWcVb_Wt&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
mandate [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQucKSbCmOjqB2bj_9KYWDRe_JWlMLkU_Q2tkci8uWFxxecJ9n-utkWTC-Os_Epj9TKXvzRCbnvvkqwrf9bkeQVVxR9aS1CotSnBzqsWn2vgDGxL-yanqSfFc4Hn_4zgycY4mZUSkhVkTJv8gL1PKV3DzyElKx1kDaq777fbTTQHrDHsBsGYa-6J5GxWcVb_Wt&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
following the lead of California, which implemented its requirements just over 11
years ago. The Massachusetts requirements call for a maximum assignment of two patients
to a single nurse in intensive care units of all types (surgical, medical, burn,
 neonatal, etc.).  The requirements went a step further in requiring the use of 
an acuity tool [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQucKSbCmOjqB2bj_9KYWDRe_JWlMLkU_Q2tkci8uWFxxecJ9n-utkWTC-Os_Epj9TKXvzRCbnvvkqwrf9bkeQVVxR9aS1CotSnBzqsWn2vgDGxL-yanqSfFc4Hn_4zgycY4mZUSkhVkTJv8gL1PKV3DzyElKx1kDaq777fbTTQHrDHsBsGYa-6J5GxWcVb_Wt&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]and
a process to be used in the event of disagreement between management and the nurses.
 In addition, the state is requiring the hospitals report on four ICU quality measures,
including: 1) central line-associated blood stream infection, 2) patient falls, 
3) catheter-associated urinary tract infection; and, 4) hospital-acquired pressure
ulcers. The data is not clear on the benefits except for a lower rate of nurse burnout
- which has value by itself.  But, the question remains: Are nurse managed staffing
ratios the way to manage the issue?  Do we really want legislatures and policy groups
mandating specific requirements that could easily change over time as a result of
technology or other changes in the care is provided?  If it applies to nurses, what
about pharmacists and medication management?  Or, physicians - now there's a group
that appears to be suffering from burnout as much as nurses!  We seem to be moving
into the slippery slow phenomenon which has significant implications for how care
is delivered.  If it's not clear, I question the wisdom of the specificity of the
regulatory approach being taken.  Clearly, there is an issue to be resolved but 
is this the best approach?  The debate is only beginning - in my estimation - particularly
as technology continues to change the fabric of how, where and who is delivering
 care services.  If you're interested in the research, check out the California 
HealthCare Foundation study [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQYI2BWo_cUyuJA0gqprmtx2Ain6y0dt4qy8vSsQt_aZDUQ-AzVo6PDETEg9oDinOPTCAefzWslKVcoca8X2VWIFS1xzn0-cH4C4e4kNJavTDypQmOwMbI8YFo0iYUBlXcfiij0X0zWPyOAQS9nSBwWdBMTKjXQQWIlTUWSkFXDbnxaCpvZiTYsyBrwARCc4h-c6HIrIbtYu-EOjFhNiqIwmfwzNCXyUsj_ukOvCl1DJQ=&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
which reviewed the impact in California.  It deserves more attention than it has
 gotten. Thoughts anyone?
A Specific Shortage In The Looming Workforce Problem - For the last several years,
I've been commenting on the looming workforce shortage crisis in healthcare.  The
figures vary somewhat but it's estimated that we will have a shortage of up to 40,000
primary care providers (i.e. family physicians, general internists and pediatricians)
over the next seven plus years.  Why?
Two major reasons are implicated.  First, the demographics of the USA are shifting
rather dramatically as the boomers come of age and enter an era where they will 
be consuming far greater quantities of healthcare (i.e. we are getting old!!).  
Second, the demographics of the provider base mirror the demographics of society.
 The bulk of primary care providers entered practice in the 70's and 80's.  Those
same physicians are now entering an era of retirement, death and disability.  They
too will be existing the workforce pool.  There are other reasons like an insufficient
number entering the PCP specialties but the two major reasons loom large on the 
healthcare horizon.
Beyond the demand for primary care providers; however, is another more specific 
shortage, that is - psychiatrists.  According to Merritt Hawkins, who does recruiting
across the board for physicians, the need for psychiatrists [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQSWJVHAtHCw_iIMfuopCWeLkESmMDtrZwq9bA9NWgvege-cBQGmX74hAvzCorcoey1OQtYUcjB3ErSn0yWCd57zMwcOABWZmDs_E8uOMS7I8UN6vI9EADeeavm4eYvbiSf6xF7mRgNAi1tIxOp2HzwnOoEeG0PaJdMbOvE8gXjJ0G6PbAnnFhnWrQrT5xuF7A9ekrjZq4EHIHCAkvzqRlie1mH5rPJdl2NzEgtcowg-AiYUh7u8tI0_idgbbuIyvp&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
has reached a record peak in the past year.  In fact, following family physicians
and general internists, psychiatry is the third most-requested specialty recruitment.
Even more important is the fact that the crisis is geographically based.  According
to the report by Merrit-Hawkins, there are 185 counties in Texas with no psychiatrist.
 Actually, you can point to the data of virtually any state with a large rural populace
and the psychiatry shortage is a major issues.  According to a study by the Kaiser
Family Foundation [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQsJgCZvxXj_QReEXzY8RqKdzC-OGAMqHjZIe7P1CYvpWwteewBCB5IKvvEwzrfe0dB-1qQesdCfNVo_cV3xfcxRLGLNzKIyC7-cOQls1UDxjNUJVUGJm-2bs9eIsG1wspmp7gNM7GmCpwn64qTXeZ_Ad1QPgz0tC-IabGZ2PfiIv1Z0KeoL_BBaznTWStGQfoXucBJleTWaxIqK1DYbu6AqEAXmBrQTRQ&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
that was released this last spring, there were 3,968 mental health professional 
shortage areas in the USA or, less than one mental health professional to every 
30,000 residents.  To solve that problem would require the addition of over 2,700
providers - an accomplishment that will not be accomplished.
The issue of inadequate psychiatric availability is important for another reason.
 It is increasingly recognized that behavioral health problems underlie a considerable
amount of over-utilization of traditional acute and emergent care services.  As 
we move toward a value-based reimbursement model, the incentives will shift rather
dramatically and the need for solving the inadequacies of our behavioral health 
system will need to be addressed.  We are seeing evidence of this problem with the
seemingly higher incidence of domestic violence of all types across the nation.
One of the ways we are going to solve the problem is through the use of telepsychiatry.
In fact, psychiatry has been a leader in developing effective telehealth practices.
Anyone who has been reading my blog for a while knows that I'm an over the top telecare-and-telehealth-and-telemedicine-and-virtual-care-delivery-person.
 A review of the literature shows that for psychiatry the advantages are obvious.
 But, the compensation policies for services providing telepsychiatry have been 
inadequate at best.  Like the other areas, we need to move our telecare strategies
forward.  Now is the time...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
It seems that lately I've been stuck in reviewing the quick and easy type of eatery
that is focused more on convenience than on genuine quality.  So, I was quite heartened
recently when I finally visit Sarma [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQ_PJKqGC8xo5lLYCHSM3ibJVW4NPYz6Fx25dirE9FDqVMLUfgqM1r8W8aVbnQTkaf8a_-VDBGIATvcrOeLmRnb6ANlBU4tbppF3UeM6h2sLa2O3HG-Kr0-Q==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==][
* * * * *
], a local Boston-based eatery which many foodies had been encouraging me to try.
Now, to set the stage it's important to know that I have a tendency to go through
culinary stages.  I've been through the heavy butter and cream stage of Paul Prudhomme.
 Then, there was the Thai phase, the Indian phase, the Chinese phase and, most recently,
I've settled into the "fusion cooking" phase - a blend of all styles.  So, I was
 absolutely more than delighted when I visited Sarma, co-owned by Cassie Piuma and
Ana Sortun. The concept is an offering of a bundle of food that is bite sized and
served as a meze or in the style of the Mediterranean and Middle Eastern cooking
 - an embrace.  The meze are the starters for any similar to the tapas of Spain.
  What Piuma and Sortun have accomplished in my estimation is one of the best restaurants
I've visited in the last year in the USA.  Each little portion was over-the-top 
wonderful with a flavoring of spices and sauces that were quite incredible.  The
 list of options is far too long to review but give you a flavor, when you visit
 consider the yogurt biscuits, the octopus with grapefruit charmoula and avocado,
the BBQ duck, the brussels sprout bravas with hazelnut migs (INCREDIBLE!!), the 
cauliflower with couscous or the pineapple glazed beef with charred cabbage.  And,
that's just for starters.  Every evening they also walk around with other options
that the chef decides on that evening.  We had sweet potato with feta, deviled egg
with black truffle and a couple of other items that put us over the culinary top!
As you can see, I really, REALLY like Sarma.  If you're in the Boston area, it should
be at the top of your list (call ahead 30 days as it is quite difficult to get a
 reservation). In fact, I would even recommend a special trip to Boston if you in
the region.  It's definitely worth the effort.  I'm heading back to Sarma soon located
at 249 Pearl Street - Somerville, MA - 617 764 4464 - www.sarmarestaurant.com [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6iZb2JhHA7zKQ_PJKqGC8xo5lLYCHSM3ibJVW4NPYz6Fx25dirE9FDqVMLUfgqM1r8W8aVbnQTkaf8a_-VDBGIATvcrOeLmRnb6ANlBU4tbppF3UeM6h2sLa2O3HG-Kr0-Q==&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==].
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - Check it out!! https://playingforchange.com/episodes/ripple/ [http://r20.rs6.net/tn.jsp?f=001txaALw5_gO9X0ljibFjdyC8OMzVc-zQWcpd2gamIeSjtN-2N2gd6icINSDrWfFk2Yr4L8Us5FyE34MsB_KgOdN3VnIOGse40zPRpNaJA_As_U31jGLA1XXdWmqsEpCnKlkX2S-CLdPWKw6vFyNhbGkpCl40bE1VrCuXPtODyVu7wHGQ78jn2h7_zSEq77_frGi7jZRSQNY4=&c=AN4V1Huv6r0p4jmVSCeIGEVdQZnk3880SFXF8DD_ioTYW1DkdinJUw==&ch=i3RA2YEwhu9Rjr6ImklAKlOp4QJ3vNVHtcaNJG6LgjsDa_TNOm4-Qg==]
The Good - Only 4 months and 8 days before the Iowa Caucuses (February 2, 2016) 
with the New Hampshire primary following 8 days later (February 9, 2016).  Do you
think we can last that long?
The Bad - I think it's correct that both Ben Carson and Rand Paul are physicians.
 But, I thought that teachings on immunizations and public health were the same 
for neurosurgery and ophthalmology residencies as they were for every other specialty...
The Ugly - If you read the history books, we are replicating the paranoia related
to immigrants that was generated at the beginning of the last century and which 
promulgated all sorts of immigration restriction laws that were ultimately reversed.
 But, we seem to be back in the cycle...
The statements in The Fickenscher Files are the personal views of Kevin Fickenscher,
MD and do not reflect the views or policies of any organization with which he is
 affiliated.
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