Subject: News from Dr. Kevin Fickenscher
From: "Dr. Kevin Fickenscher" <[email-masked]>
To: <[email-masked]>
Date: Mon, 1 Feb 2016 11:16:25 -0500 (EST)

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggFwugUzFH3FyjroX8WGc1pZbPAHlk1iimohlL7htYlTgcOOnkonY6a2x-bHj-in9hnHhKU6WHMRPV9BSAYAj5tXMZwHaSj8acrqWcNU2uH4o4EMvQUAJqeBL2fDtTBdXgQ==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 4, Issue 3
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggF1jz1XNTcpH9vTG1MHI-BlOgUVFJ60hYswE4rFvvO-IhMI2wo08b6ypefiLuKf1IDcjGwSuMszzUXrJubNomGfdUa69gKrGXZdjOUgDZzZLdudZZnP84LvF2G7DXWH_2BO0s6UGQUsLo3ot7C2IX7cahpK1m9PkmIX1MLk-oG1RKLNuEKGtPasKN-YU7HJo8B_OJR8Re5x4xa_91QPUm-c=&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==],
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
Thoughts we should listen to...
"Knowledge generation is always a good thing even if it stresses the system."
Glenn Steele, MD, Ph.D., Past President - Geisinger Health System in comments on
 the impact of technology on care delivery
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your Consideration...
Physician Burnout A Growing Problem - The Mayo Clinic Proceedings recently reported
out a new study which reported that 54% of physicians reported at least one symptom
of burnout in 2014 - up from 45% in 2011. By comparison, the prevalence of burnout
in the general population is 28% in the most recent period.  One of the interesting
findings reported in the study is that at the outset of medical school, students
 have a lower than average mental health profile for burnout symptoms compared to
the general student population but by the end of the basic sciences, the profiles
are reversed.  In a separate study from 2013, the Rand Corporation found that the
major drivers for physician burnout included burdensome governmental regulations,
insurers that refuse to cover medically necessary services and unsupportive practice
leadership.  However, the latest study would seem to imply that there is something
else, more endemic, going on if students are experiencing the shift so early in 
their careers.  The American Medical Association (AMA) has recently stepped forward
with their new
STEPS Forward [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSkdqInCPpcVKMsZwzUhKdrNH5BOEkdkBNy18yV3sYRrkE7QnhJBgGHYJJ5z4k7vln1-VneeCMP9xMKL2A3CvpVDgpC6AiSs-VFxXpOn--US1Ee_ls94E4Iw==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==](TM)
program [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSkdqInCPpcVKMsZwzUhKdrNH5BOEkdkBNy18yV3sYRrkE7QnhJBgGHYJJ5z4k7vln1-VneeCMP9xMKL2A3CvpVDgpC6AiSs-VFxXpOn--US1Ee_ls94E4Iw==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
which includes online modules to help reduce burnout specifically directed at physicians.
 It's a growing problem that needs our attention.  Burnout leads to disengagement
and anger - two responses from the medical community that we must avoid at all costs.
 Now is the time to do something about this growing problem...
Drug Shortages An Increasing Problem In Emergency Rooms - The University of Utah
 Drug Information Services recently released a report [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSUuYcXTGLn48xYhIW3A6RO_jcLXD6xwr8AWAfBqotvFtJnjjSuy8zN4IV3bhQFh0Lp52_ponXs5lblmUBPSIFaEW6nWiResK5kxwMP-o54wWz_C0GJBba-QwHMsYcHzGd7ykDXl6DM91Fz-6zAGGjhi98kKHvTkMBFZTpDoZRUuCgU0vpQoaz2-SIIacE7ROcwlWP8tsegUeZiaskexDcV0x8CboCJR_Mbr3HIlXSKCQ9BPGFWJzcKAaOb1F1BrUqmeP32c2EHx3lJJubA7tW5V1i33fPromkdeKGqCHJqu8tnR2wFpNJZUf2KEgw73cyiNDQ72YjSZVcnqgjdlTJvj7CxkJasQUYeWrrGXRthFBVc0ddLn2MobbjWrWePfE1H7czy_DasLXwrO7eUrfyVXQhxy15Y9_-gL-pslLmhq2qr8ZpNubIUKxRLuU9qBLi2S6KIWjSmMcqm-lYJzKuFxcLWGypIzPXIM720mg1tqKol4PxHAOrXk_lJinA7G6yFKnhO-BeDUG_07-FNiHNAT3oLjRZnM4WQzmRGRwBz9XI9KEG_7UbM_fE-KM2TU4yftNjRDMHRpXbuyW8Fo-raQ==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
noting the widespread shortage of certain drugs in emergency rooms across the country.
 Over the period of 2001 to 2014, the shortage increased 400%.  The primary reasons
given for the shortages related to three major areas: 1) manufacturing delays (=
 25.6%), 2) supply and demand (= 14.9%); and, 3) availability of raw materials (=
4.4%).  It seems that the pharmaceutical companies are failing us.  And, it's unclear
whether the same shortages are occurring in other countries - especially those of
the OECD.  Hmmmm?
Zika, Zika, Who's Got The Zika? - The news media went bonkers over the past weekend
with reports on the spread of the Zika virus across the Americas.  There is no doubt
it is a problem.  No doubt about it whatsoever.  But, just like I argued that the
media should not spread panic about Ebola, we should also not allow the media to
 spread panic about Zika.  If we step back from Zika and Ebola, their spread is 
yet another manifestation of the worldwide economy and physical connectivity we 
have in the world today.  Twenty-one countries and territories in the Americas have
reported Zika cases since Brazil reported the first cases in May 2015, according
 to the World Health Organization.  The association with microcephaly - which appears
to have a strong correlation with women who are infected during pregnancy - is a
 tragic finding.  Clearly, the public health officials are working to get on top
 of the problem and figure out what to recommend as points of intervention.  Mosquito
control is - of course - the biggest point of intervention.  And, there are certain
interventions you can make to keep Zika-bearing mosquitoes away [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSknddsuytWc4Rrx1po_yH9TDdgmdptI6Og4fiITAmpnP824VfqUcm0_7VItQetUajccqP9_5BKWvXcBXSpeJPuSFLtFy7YDo0NhjXnwVBxcqnSnTWek5iGo2HaV7W2vyjJVcAZmWSKYkuVhculUHaAWFBa2e1tDi0jWyQ9DktczjENJE3YXQZReu8xxcoAvJRJqX1EPkJwV8naexPyWjn-q7KAKE_y8lt&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==].
 The Aedes mosquitoes, the primary vector for Zika transmission, are present throughout
the Americas except for Canada and continental Chile, according to the WHO.  Symptoms
of a Zika viral infection include fever, rash, joint pain and red eyes. The symptoms
can last from a few days to about a week but, 80% of those who are infected have
 no symptoms.  Finally, please note that the American Medical Association (AMA) 
added a Zika Resource Center [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSKOm7xuCdRFV_UVmCV5A8wIf_EvguWZ2GVILwTyOWm13uh0UYHUGHziV3xZGRwiAh3ZCWxakxKtwOG0_bGlEAdxF-8FhgZBkUsw-GOz6VDVjChwkmPChOTbRSlcUiuVZQamYkrgjcBi5Z7Ozvfxgr5o_F680X_Y5HLsuwQF8iXaqQiGtLwai7Lo_ZaC56nwjyvs_p-KJXnADCvWhuReM_MYv_7heepV_pBV3cRfbYmWwoFz1OOBCS9y41KGvE5L3TZX3DO2YSqgCM15KXRqph8FrdrQbWYzOTOtXtnC8inaC67bOH-my3fGvFJBnc5QYpJDtbwqokAZmbq0PNbJs3EX1yHXOJSBGxeF5L6M95rZARgM2KIXU6h5ASzY6ZnfJZ&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
on their website over the weekend.  As more details become available, I'll report
out my thoughts...
Happiness Is Not Correlated With Healthiness! - In a study that was widely reported
in Lancet [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSo8y4MTvOWO7ON4_E5zvdfZCGur9gJD7lzN6QBFD5XHLt1Q35uXXSWWcJocvXEB8HddromNZuTj5S9GWMj4x2a2xvRH1g2-HSwnwN8x-6NwFQSyTHF-GTJvYkY1jaDKlO1E5WzpZHsugszOxo8mZ8pG2953CdSR6PNZPLx-MfwRd8nEPce5NS0W-RhscA4W0VoC_ry3kggZE=&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==],
a research project that followed one million+ middle-aged, British women for a decade
revealed that happiness was not correlated with health and longevity. This refutes
a widely held belief that stress and unhappiness ultimately cause disease. The study
evaluated women who had depression, anxiety, arthritis, diabetes, high blood pressure,
and asthma.  When the answers on the "happiness" scale were analyzed and compared
to the "healthiness" scale, unhappiness and stress were not associated with an increased
risk of death. It is not clear whether the findings apply to men. While the results
are important, it is clear from other studies that unhappiness can be tied to alcoholism,
drug abuse, suicide and other comparable unhealthy behaviors.  But, regardless of
the study, I would recommend that everyone should still smile.  After all, going
 through life the other way - regardless of the outcome on one's health - would 
be as we said in the sixties - a bummer!!
On The Other Hand - Medical Specialties Witnessing High Burnout - In a new national
study, work-related burnout rates among the various medical specialties are increasing!
 Emergency Medicine had the highest rate with over 70% of those docs reporting symptoms
of burnout.  The study was reported in the Mayo Clinic Proceedings [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSgHH7IVpM1YWhG5nVQXbvqkV98DdKykm_yRaeCbSudsBDJdEAEaGvm1rsGrrCIFs__jcY9c5m9EmaQis3cIhwqA2wt9F7JaESX5cSWePAYh8wbhF1jwkYXQFz8Ztn94jWZEAiNb_NtyTJUfJYMFGt5kPhZnoZBAjyoTHymyvdrNsKUt--AiQEv4hxTIJ91dQW&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
and included more than 6800 physicians, comparing results over the period 2011 to
2014.  All physicians in the study were assessed using questions on the Maslach 
Burnout Inventory. The disturbing part of the study was that more than a dozen specialties
had increased by 10% or more in the rate of burnout.  That's alarming!!  The top
 5 were: 1) Family medicine (51.3% of physicians reporting burnout in 2011 versus
63.0% in 2014), 2) General pediatrics (35.3% vs. 46.3%), 3) Urology (41.2% vs 63.6%),
4) Orthopedic surgery (48.3% vs 59.6%); and, 5) Dermatology (31.8% vs 56.5%).  Two
other important findings were that the rate of burnout was increasing the fastest
among the mid-career physicians; and, that physicians had higher rates of burnout
than the general population. There are resources available to help physicians, including:

* Information on the signs of burnout [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSJhSTqcGJ7HVUCmJnhJHsimXgy6VuhMHtxMMBLVWjgIgWSQYbjhy0DNhdg_gZJrl6n_TUXa5-8emR_AyT1dA-xhOLSBsZIdTvLKwek708p9Jku4qYx89DimZyKzPh_V6FfiXdn5JAWJEkmbvgT6gR9gZ3ZiSDrCyE8c05OXSKNjLfQHvbc2XTTzW7Vlf4Hz4v&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
and how to prevent them [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSa0Ec-h7KrEYOQTFaYwmuBTcpVwb6RrEo2yDYpn24T-28HfpdheLEAJha2g3F4H7W1Uf6UbfqWxZIH-tlfLSdnDHODw_00uQ8-yCdh6TfyMF-eYjMSDMHgozWGyfTVvDFf2tllyMV0V45Z_UL5OEbH3ySy3KuZJdm_S5rNSA2e8ELbeTpnCjZtA==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
in your practice,
* Approaches toward increasing satisfaction [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSJeNns0omiMor0vX9LWaQfLX1ld64ZdW-PCM3jYJT81jAukhojJcWHjCvP0n8KrpnLiL2jtDc2Tk1qGQBcNBUsOcfe5qrtH9_fryQvecqIDGUFqjkSoDs5h7C5VRjeuupGhPrKHzH7wz9tVctG8i2-Qf6G1u32WpEMQ7Yd3mZPk-12cUssilDJIOEW_Wj8V7pj419IgSiRTZFccrmqmSBQw==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
with your practice; and,
* Resources that are available through the American Medical Association STEPS Forward
[http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSkdqInCPpcVKMsZwzUhKdrNH5BOEkdkBNy18yV3sYRrkE7QnhJBgGHYJJ5z4k7vln1-VneeCMP9xMKL2A3CvpVDgpC6AiSs-VFxXpOn--US1Ee_ls94E4Iw==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==].
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Future Health
Delivering care in the new virtual world...
The New Era Of Telecare - In recent weeks, I've been struck by the number of articles
emanating from the literature and on the blog pages related to remote monitoring
 and telemedicine technology.  It's very clear that the recent healthcare reforms
embodied in the ObamaCare legislation as well as the evolution of new value-based
care delivery models have pushed the dissemination of telemedicine technology and
other advances which support alternative care delivery approaches.

Telemedicine technology got its start in the late 1970s when experimentation started
after the National Aeronautics and Space Administration (NASA) and the Nebraska 
Psychology Institute jointly published a paper in the International Journal of Environmental
Research and Public Health [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSWpw_fRZBf46nPQ08hsSWGkVQkNCljlegQ6VFyClwq0EmqfG23xmACOv0INOkXeOZQ-ZYLPHUdl2v-kLWT5Wag2QR_fDQdqcUCZzewPGORIco4W-TlBqki6gQA9WMhrYeMUKLpFIetDN1FmE4zTfl5tFqLg2W61pI&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==].
In the 1980s, the idea got legs from the potential described in my original field
of "rural health" where telemonitoring technologies were deployed for cardiac care
and care for prisoners in underserved areas.  In fact, many of the advances in telehealth
started with rural health initiatives.  I harken back to my days as the Director
 of the Center for Rural Health at the University of North Dakota where we were 
involved in working with rural practices on the idea. Kaiser - as always - has also
been a leader in the field.  In the early days, Kaiser also deployed remote monitoring
systems to rural areas as well.  Some of the other notable advances were supported
by the Western Provinces in Canada, NASA, and the prison system in Texas.  Some 
of the history [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS_c4zoVeDmRX_49j54Sm7Rq4b7xmN92c_lMG8w8AhS_pSrBUTCQVkPBT4qTeAG0HHQ3WDsbZe-2FPQelMjilZNJ56CikrIlUwPIjMkRH9WQNfNeSZGCeV-PXwWj5osN6rRszK_s0Ot34ETRuWXHJakQ==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
has been documented on these early efforts to use remote monitoring and telemedicine
technology for delivering care.
But, despite the enthusiasm of many of us in the healthcare community, telecare 
has languished due to many financial and regulatory policy barriers and obstacles.
 In more recent years, the technological barriers have largely fallen by the wayside
as the leaps and bounds of technology in other areas have been adopted in healthcare.
Aside from the policy roadblocks, the other major impediment has been the availability
of ubiquitous broadband infrastructure. Even that impediment, however, is falling
away with the advent of the "Connecting America" plan put forward by the Obama White
House in 2010, which was designed to improve broadband networks across the nation.
 Slowly but surely the ball is moving forward which will allow the healthcare community
to engage in more robust remote patient monitoring, telemedicine and other capabilities
which ultimately lead to a more robust "telecare" model.
One of the other problems that I see is that our language for defining what we mean
in using technology for remote services is not concise.  At the risk of splitting
hairs, let me offer a set of definitions for these various models.  I offer it because
I think the healthcare community is a bit muddled in its thinking on services which
use technology for the delivery of care.  So, my preliminary definitions (NOTE:feedback
is appreciated [mailto:[email-masked]]) are as follows:

* Telemedicine - the dynamic, real-time interaction of information exchange and 
sharing between a healthcare professional and person seeking healthcare services.

* Telemonitoring - the use of technology to gather, monitor and assess biometric
 individual markers ranging from preventive to chronic care indices for the purposes
of providing feedback to both individuals and care delivery professionals

* Telecare - the process of integrating information derived from a variety of sources
including telemonitoring, direct interaction, traditional care delivery venues, 
digital data sources in alternative settings and other sources for the purposes 
of proactively providing healthcare services to preempt deteriorating functionality
of the individual, thereby enhancing quality, outcomes and efficiency while simultaneously
reducing costs.
As we move toward "value-based care delivery" models, it's clear that the use of
 telecare technology, mobile health tools and other information and care delivery
technologies will become increasingly important.  I've argued for some time that
 the use of telecare technologies will fundamentally alter who, what, where and 
how care will be delivered in the future.  It will be the most fundamental advancement
in care delivery since the advent of antibiotics.
The major impediment in the use of telecare technologies has not been the technology,
per se. Rather, it has been the reimbursement policies of Medicare, Medicaid and
 the larger insurers.  Hopefully, the combination of the Patient Protection and 
Affordable Care Act (PPACA) which has led to the creation of Accountable Care Organizations
(ACOs), the American Recovery and Reinvestment Act (ARRA) of 2009 and the HITECH
 Act have - as a combined legislative effort - served the purpose of advancing the
use of telecare technologies [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS41dudNAo1DPQa8wVYIXYcoOup-1RmRiLqDh1L6HZfOvzqAwlMvybVD1yJm-8QumFBjdhSn3Wk2VuWSXFuJ3lj871fERJEmd5iyfSfLka_xGBMuj8-bOs2SbPlfDyTN37-o5Udz-yAyytKRYh-vh76I2Bx7lxOEbocjSwPfSqdxlmV5waQoVzxvbxFxP7gzOWG5EHNFE2nX8Rsq8XDkXSXA==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==].
 As the value-based movement gains footing amidst the traditional model of fee-for-service
care, the next several years will be crucial in the USA especially since it appears
that the results of the next Presidential election will be an important predicate
on the move toward telecare.
Cancer's Next Big Leap? - In the last month, researchers at Boston Children's Hospital
reported on the first ever visualization [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSnIDfS3wfRyLtuKzTjpahPyYtJ-MCmSJVVFDpOxZMlOvkRLRU7vLIAIGQZP3ppNDCf-74N65owwoTiCxoeYM0UyQcAeV_J04u-kuNiQXOuVM2IlXbbfpXiRWM1Byx_5C6jsaFb0CF9pFcv6o5x7QRs0VKo_bNn0B4bM8IWcR67Sg8NpORwDC_VfZoyfC60dQh6YcTmyWGwiKUWCs85n7K_01T7G5aPiw1uN3hp-6CGIHAgOIccjaKsQ==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
of regular cells transforming into cancer cells in a live animal. The research was
published in the most recent issue of Science [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSk48IoJfeVwP1kdM-g2chE3Os6lonqyGEzUCLTApPrQW420pNdzAxKX8_SoMqlhMcuHobJVz1AcVaD3a17APlOb1AXcRNujufEJYURWcQUDVHPOk9CImON3vtFLJWcfJS3q7oMJuXXYXII2OoZ3XM_FIYcPRAiebT&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
and focused on melanoma although the potential application of the findings to other
forms of cancer is already clear.  Specifically - with attempt at providing a more
lay-oriented explanation - the cancer cells become activated after a normal cell
 is activated by either an oncogene or loss of a tumor suppressor substance.  In
 either case, there is a genomic foundation for the activity which means the answer
to solving cancer treatment could lie within in our own human genome.
The study tracked the development of melanoma in live zebrafish over time.  The 
fish had the human cancer mutation BRAFV600E - a mutation that is evidently a part
of most benign moles.  In addition, the fish also did not possess the tumor suppressor
gene p53.  The end result is that the fish would grow a tumor (i.e. presence of 
the mole mutation) which could not be suppressed.  The combination resulted in some
of the cells reverting back to the stem cell state and becoming cancerous.  While
only a very few of the mole cells convert to the melanoma cells - when they do, 
it becomes cancerous.  Long story short - one bad apple rots the entire barrel.
The researchers theorized that the normal tissue becomes cancerous when a combination
of events occur.  First, the oncogenes must be activated and the tumor suppressor
genes are silenced or lost.  Then, the tissue cells need to revert back to the stem
cell state, which is a primordial "beginning" state for all cells.  When that happens,
these primordial cancer cells replicate and grow - causing cancer.  I think I've
 got it and, if I don't - I'm sure someone will tell me.  Regardless, it's obvious
that this report is a game changer in the cancer field...
How Smart Are Smartphone Apps? - One of the positions taken by advocates of smartphone
apps is that - if used properly - for monitoring patients with chronic healthcare
problems (e.g. high blood pressure, heart disease, diabetes, etc.) health care costs
will be reduced while simultaneously increasing quality.  I'm clearly in the camp.
 But, at least on the cost front, the various reported studies so far are not showing
much of a difference on the cost side of the equation.
In research that was reported in the journal, PeerJ [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS9ObAVFOJ7HskQKX9Z155Qb3ipaL0fhtMzHLzvUD8kRQFSRK6JKZ45Y8kUmxcgjtN1otC-byVVKb9FnUsMHh4pVgpu6ES4UUWTphde8yo0Kt8yCNM6hb0dhCXkzXmTewn&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==],
[http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS9ObAVFOJ7HskQKX9Z155Qb3ipaL0fhtMzHLzvUD8kRQFSRK6JKZ45Y8kUmxcgjtN1otC-byVVKb9FnUsMHh4pVgpu6ES4UUWTphde8yo0Kt8yCNM6hb0dhCXkzXmTewn&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
in a study that involved Eric Topol, MD [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSL4wpqohPyBsF_aKOWH9XkTzIYVtpPnI5lIYHMG8zjA24S8-VIOCIXlks4LzVmpLDf2DCKWhAh318ifAsZHp1YGn0XHvosPGIm5FZAeUUjJjOfeYfCJKprOHScNLLYPZh8wJQfTRR2DNvl-6_Pe43DS1Q7TsTWwsn4ID38_Tzx-k8geJkOFEYSA==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==],
researchers found that while personal well-being and control over their chronic 
health condition was demonstrated, there was little difference on the cost front.
 The study only lasted about six months and was hampered by a relatively small size
but, it did use a randomized-controlled trial approach and limited the number of
 problems to three conditions: hypertension, diabetes, and heart arrhythmia.  However,
it's early in the race to demonstrate the potential value of patient self-monitoring.
 Evidently, the smartphone companies have now stepped up to the plate to cover the
costs for a larger study so it's clear that further studies will be forthcoming.
  Stay tuned.  I'm baited and waiting the next results...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Comments On Alternative Approaches To Care Delivery
Ideas and thoughts on how care delivery can be transformed...
One of the common themes we've heard over the last two hundred years or so of the
Industrial Revolution is the alarm bells ringing on the potential displacement of
workers.  Remember, Charlie Chaplin in Modern Times [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSuU-0WnTF2-JnC94SKb9y3yUE5bYUyvs2x_tbE_8YeIAj3-wCpvCFDjucSlkbqPJbs34LLB0vWk_L7_BoR52joEc7drx59xbNk44AxzC0gSaw01JtMunhOQ==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]?
 It was man against machine...
Periodically, the alarms get shrill.  For example, back when Lyndon Johnson was 
President, a report was issued on the "Triple Revolution" which described the potential
impact on society of the nuclear arms race, civil rights and automation of the workforce
through technology.  More recently, the latter issue has received attention with
 the new Google cars, the displacement of traditional taxi drivers by Uber drivers,
the investment by General Motors of $500 million in Lyft to create a person-less
 taxi service; and, any number of other new initiatives which dramatically alter
 the current state.
From my perspective, technology has been critical in solving some of the problems
we face as a society.  Imagine the ability of farmers to produce the quantity of
 food we do without the intervention of technology.  Just like agriculture was transformed
in the last century so we are poised for healthcare to be on the forefront of change
in this century.  And, in particular, the use of robotic technology is getting a
 fair amount of consideration in Silicon Valley.  While I believe that healthcare
will always remain a more "people-intensive" industry compared to other areas, we
will soon be facing the invasion of the bots.  Robots are being used for simple 
administrative tasks like monitoring and managing medications in hospitals.  They
are now used to provide "assist" services to surgeons in surgery.  And, at a more
micro level, they are used in providing "nanobot" level treatment of cardiac plaques
and other kinds of problems which do not lend themselves to human hands.
The clear advantage that we have seen across all other industries in the past is
 a decrease in the cost of service.  And, rather than wide scale unemployment, we've
seen a movement of people into new job sectors.  I'm a classic example.  If I had
been born 20 or so years earlier, I would have been a farmer - no doubt about it.
 Agriculture is a good metaphor because the number of farm workers fell from just
over half of the USA workforce at the turn of the 20th century to just under 2% 
at the turn of the 21st century.  That's a remarkable shift in workforce allocation.
 And, we are more efficient, more productive and offering better products at lower
cost.  Do those three elements ring bells for those of you who are intimates in 
the healthcare field?  They should...
We are at the formative stages of a revolution in how, where and who will be involved
in delivering care.  The "telecare" idea I mention above is at the core a way of
 framing how the revolution will affect us.  Information technology is at the core
of the capability and as we move more towards ubiquitous availability of information,
the revolution will extend.  In addition, the cost of information will increasingly
be viewed as a utility that is foundational to the industry. We need to embrace 
that notion and move aggressively towards adopting new technologies which solve 
problems, make decisions, and help us to learn. This is the trifecta that will make
healthcare better.
Martin Ford, the author of Rise of the Robots: Technology and the Threat of a Jobless
Future [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS3rtwPp7qrmSEf5pHuMt5RDeZ0Ma2QcRf06gNz_G2Zh7KOSvBmnak1ofsnhXX8raV2W6hSpwtLpWBEH2SntW7e648rK2Vs_lSXtCMbZERlx524X3wt52PJT63qIr78NhKP-c5GfDvoNGZSKlL5QDsX8dInWeilx-54cO9_ZTcJkqyRw-zhsOrSA==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]
- the winner of the McKinsey 2015 Business Book of the Year Award [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS0AH_eoyhLoc5gJNT_DQ0_LRXjb2pzSPO5DX7srYHDHMKLo3znX6vFPnaveXPBwLH1cGPIcBiVNCrpzq5xZIcLduPsjr5wcLdTqdexko1R5UpF9TQSsOopeXkBsNYSqe9QjlAs3kuaeh1Lvfj4kqsrIyw7TOkyP1jThEjRADkLSH6aJu6EebuXINjFPzri52S&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==]-
has written: "It's easy to imagine the technologies and industries that may loom
 large in the future-nanotechnology, synthetic biology, virtual reality, and so 
forth. What is not so easy is to visualize is the rise of industries that are highly
labor intensive."  Healthcare is an example of a highly labor intensive industry
 that is ripe for such change.  We are at a new age in healthcare and I really wish
I were going to be around for the next 100 years.  Using the word "transformation"
seems weak in comparison to the changes I anticipate will occur in medicine and 
health.  Stay tuned but, more importantly, stay involved.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
I was delightfully surprised this past week when I had a luncheon meeting and my
 host recommended that we consider the Persian Room [* * * *] in North Scottsdale.
 In the last year, I've become quite a fan of the Middle Eastern/Greek/Mediterranean
cuisine and, this place was great!!  We started with a "Persian sampler" that included
the usual hummus, stuffed grape leaves, flatbread (which was great) and salad with
a very spicy condiment (NOTE: I apologize.  I was too distracted by the meeting 
and forgot to ask for the recipe).  The lamb shank luncheon was great and was accompanied
by saffron rice cooked perfectly.  Having just been in Jerusalem a couple of weeks
earlier, I was quite impressed with the American-Iranian alternative for Mediterranean
cuisine.  It's definitely worth it if you get to Phoenix.  Check it out: Persian
 Room - 17040 North Scottsdale Road - Scottsdale, AZ  85255 - (480) 614-1414 - [email-masked]
[mailto:[email-masked]] - www.persianroom.com [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFS_6HANLmBjMUND9DgvaGmoJAsPo4cDgcSfgUT3_pBO3AspNsO3lYHVCfxeDrGCpYQThRQKny_E0uLWAz54BkQ2QiDG85VGVYCP-exgGePP23kLnWxE-a8WA==&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==].
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Good - By the time you get this, the Iowa Caucuses will be over!!  On to New
 Hampshire and - eventually - the general election!!!
The Bad - In the New York Magazine [http://r20.rs6.net/tn.jsp?f=001Pu6qg1ZAc3ck5X-MtYPRDe2d8GIU2KKWqILL_LXk4AVMtVlk-NbggLoaW2qVQUFSPNgqef1jxPBjUcdW8Aawv_yOlP0cZpKL0zhxTVXEfpqegGnxJ7JpwSGgD7XopO7pS0ya3t5JIhE9iVWRNyJZtRhX-8P8qOw56z-E78m1vu7Nc9xfGZlZd_Zj3VbnFT8_c-ens7QJmCc=&c=wClBY0U3wXt5ks1gWGsCkL0dWqx7Yx6jih3tm3z86um4j39cAqtlHw==&ch=bzFl9X9xd0QjdihsfFKVs1XB7KKtKFNlnr4ybG3PnaUbdKfzj6Dzrw==],
it was reported that when people are led to believe that things are falling apart,
it affects their decision-making and their politics regardless of whether or not
 the pessimism is warranted.  As reported last week, creating fear is a way of making
people feel threatened.
The Ugly - The more we hear about the water crisis in Flint, the more we see the
 failure of government officials to effectively deal with a significant problem 
that likely resides in other older cities throughout the nation.  Transparency is
part of the solution
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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