Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Wed, 9 Nov 2016 13:51:21 -0500 (EST)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KU6__V37qL9YFPbhHvPKAoIaihlZ4Wuplkm6oI8kXoEXa9XDP4pVvN5U8bcMIthypLf7MPAiRS_361eZH4LJVs3oYfqldF54QLcdLLVqRP6GP0Ot6tZpMwv-FwgTW3nXgr3fcgTCxaVD&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 4, Issue 15
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8Kaz22p9KmMMqOhl0g4Oq5R08cPQ-GzTeDgGyicw_LAOWWKWj_zQc4stqDJX51QJp75t-Bi9S8EoVWTt21WjyQ-hVsMvKoqADznLvaZBc9wWmZOhVK9EZXn-HKLJFlQcXhHPYpm8Ny05MBawZzTeXw57zLF8dTajVf8MrAgQ2-RP_ugTFsTJ5a0Y9FGl9Su2Y5k7QyxNPEW1jSPNPVv3K3S4=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==],
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
"Collective insanity has taken hold in the US as well as the UK. This looks like
 some
very uncomfortable years ahead on both sides of the Atlantic, with populist resentment
and nationalism on a march along a path that can only end in tears. The people we
should all be sorry about are our kids who will be left to clear up the mess our
 generation has left them with."
An anonymous leader from the UK who wrote me the morning after the US election results
were announced.
"I've never had a failure because I always turned a failure into a success."
Donald Trump, Candidate for President of the United States in an article, "What 
Drives Donald Trump" - The New York Times - October 25, 2016
"My fellow Americans, our long national nightmare is over... Our Constitution [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1M8KOEXtJ4nGPzWxAnht5e_TTtBSJSQzJ9_85oPtDYR5aB3zQ54b3vyJKAdI0CeCIMX-aecg4bcQiOMeR_8mgW_yPlKB2uLINojup-yi1mVULNP9xyI0ooc-7ptkpx8_LsonUk17nXE4l-pg-X9Qw7OVtuhsLuNV3&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
works; our great Republic is a government of laws and not of men. Here the people
rule. But there is a higher Power, by whatever name we honor Him, who ordains not
only righteousness but love, not only justice but mercy."
Gerald Ford, 38th President of the United States on August 9, 1974 following his
 swearing in and the departure of Richard Nixon from The White House.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

A Comment And Consideration...
A Periodic Thought on the Tenor of the Times...
Two weeks ago, I had dinner with my nephew and his wife.  We were talking - as most
people were two weeks ago - about the potential outcomes of the elections.  As the
conversation went back and forth, I shared that I was deeply disappointed in the
 tenor of the times.  In fact, I had actually thought about creating a not-for-profit
group - the "TTRO" for Throw The Rascals Out - with the intent of trying to rid 
Congress of any Member who did not collaborate from either side of the spectrum.
  The kernel of an idea is to get us to regain the political perspective following
the rancor of the 60s with the higher degree of bipartisan cooperation that dominated
70s and 80s when collaboration among the Members was the norm.  It was at that point
in the conversation, where Hannah stopped me and shared an observation that really
struck home.  She said, "You know, I don't remember an election before 2000 so I've
never experienced the type of cooperation you are talking about."
Her comment is an extremely sad commentary.  We have a whole generation of Millennials
- the second largest cohort of American citizens - that have not experienced bipartisanship.
 They don't recall a time when the two parties actually worked together to solve
 our problems!!  Now, that is a tragedy.  It seems to me that we must pause our 
partisan rhetoric for a moment and return to that notion - and, as quickly as possible
from my perspective.  The nation does - in fact - have important issues that need
reconciliation.  But, I must say, I'm not optimistic.  The election results only
 confirm that more rancor and discord is on the horizon.  But, we await further 
results...
The primary consideration is that aside from catchy political phrases like "Repeal
and Replace" - we have no sense of the real direction proposed by the new Trump 
Administration.  As my readers know, my favorite policy issue is health care.  While
"ObamaCare" or the Affordable Care Act has issues that need resolution, it does 
not seem that simply throwing it out is the right course of action.  I've stated
 many times that if WE - the health care community and our collaborators in political
positions - do not come forward and help solve the problem of health care costs 
and access, WE - the health care community and the politicians - will bankrupt the
nation. Simply repealing leads us in the direction of national bankruptcy.  Replace?
 With what is the question of the day?  No answers have been forthcoming, only platitudes.
 There are some who even argue that we are already at the point of looming bankruptcy
because of inaction.  Regardless, it is incumbent upon those of us who are in health
care leadership positions to step forward with solutions - regardless of who occupies
The White House.
But, even if solutions are put forward, I'm fearful that they will not be heard 
if collaboration among the policymakers in Washington does not prevail.  Again, 
as it relates to health care, we need to take the practical route - from my perspective
- and work to improve the Accountable Care Act.  The practical route seems to have
been blocked by the recent election results.  In keeping with how government works,
it is therefore incumbent upon the colleagues who are on the "red" of the aisle 
to put forward a strawman proposal.
As a result of the Accountable Care Act (ACA), we have increased the number of insured
but the underlying solvency of the program is shaky at best without further policy
changes.  If we are to replace - what happens to the 20 million Americans who now
have health insurance? Will we simply take it away? The problems with the ACA are
much the same as when Medicare and Medicaid were passed in the 1960s.  They were
 not perfect pieces of legislation either.  I believe we would be in much better
 stead if we were to "fix" the problems.  But, then again, that's practical.  If
 we were practical, fixing the problems would require bipartisan collaboration. 
 The problem there is that such an approach is likely impractical given the tenor
of the times.
But, it's not just the lack of focus on real "policy" - like health care considerations
- that has been troubling in the most recent campaign.  The challenges put forward
in the Presidential campaign to our American political institution it seems to me
have compromised our ability to govern as a nation.  Donald Trump's continuing exhortations
represent very troubling mantras. These populist Trumpisms which attracted considerable
attention seem hollow at the moment.  There is no there there.  Not only do we have
fractionation along party lines but the Republicans are not aligned either.  The
 end result is that embracing opposition is a far easier path forward than an approach
of collaboration.  And, without collaboration, efforts to solve the litany of problems
facing the country will surely be undermined.
I've said for a long, long time on these pages that the problems in our nation will
not solved by the extremes on either side but in the middle.  I continue to believe
it regardless of whether the proposed solutions come from the left or the right.
  It is through "compromise" that solving problems actually occurs.  It is not a
 nasty word.  It is a practical word.  It is a word where the focus is on all of
 the American people.  Practical does not offer nice sound bites.  Practical requires
consideration of nuance.  Practical is more difficult to realize but results in 
solution.  As we move forward in these "interesting times", stepping across the 
aisle from either side should be applauded by all of us on either side of the political
spectrum if we are serious about solving the many problems that lie on the doorstep
of our nation.
These ideas are particularly important in the face of a globalized economy.  Protectionism,
high walls and other un-American ideas will only worsen our situation it seems to
me.  Globalization has been disruptive to our society but building walls higher 
and thicker does nothing to mitigate the ensuing problems.  Rather we should redouble
our support of education, consider the types of investments that will stabilize 
our communities and create policies that support fair trade.  Those efforts will
 require compromise.
So, the end result is that we need to move beyond the polarization and tribalization
of our society.  We are better than that - don't you think?  My friend from the 
UK got it right when he noted that "Collective insanity has taken hold...[and]...this
looks like some very uncomfortable years ahead on both sides of the Atlantic, with
populist resentment and nationalism on a march along a path that can only end in
 tears. The people we should all be sorry about are our kids who will be left to
 clear up the mess our generation has left them with." We are at the point where
 we can show the world that our democracy can actually prevail or we can succumb
 to partisan bickering.  It is incumbent upon those of us who care - on both sides
of the aisle - to lead the way.  Now is the time...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your Consideration...
Whither The Support for Telemedicine And Telecare - Most of us who are telemedicine
and telecare advocates were more than a bit disappointed with the final Medicare
 Access and CHIP Reauthorization Act (MACRA) rule - especially since it essentially
left this new, evolving modality for caring and treating people off the table.  
It seems that the rationale for not addressing the issue is to gain more freedom
 from Congress in defining the rules and requirements for using tele-technologies.
 While the MACRA law - passed in 2015 - included telehealth and remote monitoring
as part of the scoring approach for the Merit-based Incentive Payment Program, the
rule adopted by CMS limits it markedly.  So, the rationale for legal limits on payments
for live interactions (i.e. telemedicine and telecare) is unclear.  Regardless, 
the decision has mobilized the advocates who are mobilizing to lobby Congress so
 that an explicit inclusion of telemedicine and telecare is included in future legislation.
 Based on recent advocacy positions, it appears that they want Congress to attach
an amendment to the CONNECT for Health Act, a bill from Sen. Brian Schatz (D-Hawaii),
to an omnibus appropriations bill when Congress returns after November's elections.
 We will be watching closely...
Bedtime For Children / No Time For Devices - In case you don't have children at 
home and missed it, the American Academy of Pediatrics recently issued new screen-time
guidelines on the use of tablets and other devices by children.  The AAP analysis
was derived by examining data from 26,000 children.  The result?  Their analysis
 provides the strongest evidence yet of a link between bedtime use of electronic
 devices and poor sleep, inadequate sleep and excessive daytime sleepiness - not
 good results if we want our children to be alert in their educational programs.
  The study [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1-GV02l6GoPLTSSb4DI0NIfScAbZL8nRaoYimQXZAlCOFeUIf6epaIEzl7PM7mWLmscTS1MotkNo1QW2ijOKhRqAMQZGU2xnch_PCbeSSCceDxzB-jKEMj4nk5ALuWa0goNOVZjg9GbqfHbt3BYmY7b2myNZk5YDpoc5iNzUsmJyntM7opBPkW9qEopQ0PqbpOwtje3MRoKfh8eWcm7Tf1P-QFPTtEiHfQ3oPhg9SY4U33KOy6Gli-VB-5_ZCJMepCUMCfh75rgFBdXeTRwGIih6hTOEqVDv4&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
noted that sleep deprivation among children - especially teenagers - is contributing
to all sorts of health issues, including obesity, depression, anxiety, hyperactivity,
enhanced appetite, mood issues, slower reaction times and degraded memory. The study
by Benjamin Carter, MD, et.al. from King's College London involved an analysis of
past studies across North America, Europe, Asia and Australia.  The researchers 
found that children who used mobile media devices at bedtime were more than twice
as likely as others to sleep less than nine hours a night. Furthermore, those who
kept their gadgets in their rooms overnight were 50% percent more likely to get 
poor sleep and 200% more likely to be excessively sleepy during the day.  Houston,
we have a problem!  For a more complete generic analysis, go to The Washington Post,
October 31 [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1NuqE8s8XmPFuvMpU0F7gOiSqHvxCZjpUkggUD6cXcYiKpmzVeURngdJVsvR8d8fYF8dKV-rPBy4CL1vCUM510FBiLjjEtxXQVleqQK8wonMG3ls43VoolXEPkAqOYAUAxH2dq7r1mPWlSIpXT7hZxaEs8FmnneGfO7ez946NRfEWQdg4XAlCn4KWypx9SVVBw_XSqTzNGpV3xoS5MhyUmH1BcO500Dn7iaLPz2h6IFphoYAZKcqRfFHPKIONvR9IAwl4G8gB52AqP7rkpVVL5NZnEyFYDlRCbg1MngMTLjM=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]st
[http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1NuqE8s8XmPFuvMpU0F7gOiSqHvxCZjpUkggUD6cXcYiKpmzVeURngdJVsvR8d8fYF8dKV-rPBy4CL1vCUM510FBiLjjEtxXQVleqQK8wonMG3ls43VoolXEPkAqOYAUAxH2dq7r1mPWlSIpXT7hZxaEs8FmnneGfO7ez946NRfEWQdg4XAlCn4KWypx9SVVBw_XSqTzNGpV3xoS5MhyUmH1BcO500Dn7iaLPz2h6IFphoYAZKcqRfFHPKIONvR9IAwl4G8gB52AqP7rkpVVL5NZnEyFYDlRCbg1MngMTLjM=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
edition. [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1NuqE8s8XmPFuvMpU0F7gOiSqHvxCZjpUkggUD6cXcYiKpmzVeURngdJVsvR8d8fYF8dKV-rPBy4CL1vCUM510FBiLjjEtxXQVleqQK8wonMG3ls43VoolXEPkAqOYAUAxH2dq7r1mPWlSIpXT7hZxaEs8FmnneGfO7ez946NRfEWQdg4XAlCn4KWypx9SVVBw_XSqTzNGpV3xoS5MhyUmH1BcO500Dn7iaLPz2h6IFphoYAZKcqRfFHPKIONvR9IAwl4G8gB52AqP7rkpVVL5NZnEyFYDlRCbg1MngMTLjM=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
Smoking And Cancer - Is it any surprise that researchers from the American Cancer
Society recently reported that 29% of all cancer deaths or 167,000 people in the
 United States are caused by smoking?  The results of a new study [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1AQbrZ77GGwMiP4v-3c7xXamXm33KxJI6iB5LQSU4azymgzCRlmPUCaniU6zV-_gZkK4yFhihJxrv3kFRPICvghmc6Al32n9T8VsGrj_CImJbEn4BOJMQYHslSfPwdcz3BzQIBjiUxiVMLoOwICfpU2YecFgUQzw4-x7ZeZA_mJ4JCtWyZ8X3fz8vTGO7Dne2&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
were recently published in JAMA Internal Medicine. The researchers used 2014 Centers
for Disease Control (CDC) data on smoking rates and studies on the relative risks
for 12 smoking-related cancers to estimate the proportion of cancer deaths attributable
to smoking among adults based on state, gender, and race.  It's important to note;
however, that the rate of cancer-related smoking deaths varied considerably by state,
ranging from a low of 16.6% in the "always healthy" Utah to 34% in Kentucky.  Of
 particular note was the fact that many of the states with the highest percent of
smoking-related cancer deaths were in the South.  Why?  Well it seems that these
 states support policies and investments that contribute to the problem such as:
 a) 8 of the 21 states that spend less than 10% of CDC's recommended amounts on 
anti-tobacco initiatives are in the South; b) 9 of the 14 states with the weakest
restrictions on indoor smoking are in the South; and, c) many Southern states have
lower tobacco excise taxes AND, it's absolutely clear now that higher taxes help
 discourage smoking - especially among younger populations. The strong correlation
described by the researchers should make us wonder whether or not we should redouble
our efforts to push for stronger legislation in each of these areas.  Think about
it.  If we are interested in "health" and want to have a long-term impact - those
three areas - #1,  more spending on anti-tobacco initiatives; #2, restrictions on
indoor smoking; and, #3, higher excise taxes across all of the states - might do
 more for "health" than a lot of other areas where we focus our time and energy...
Just A Little Time Exercise Makes A Big Difference - We've known it for some time
now but sitting [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE179DGVcL3RmXY4a2kZXrwPPPXSLF0tMnBaDcmwjHP9akFNPsK-jmgT1bzhoduhowCc5h-VAzx2a8seF0VIeyEj6HQXJnNGbL34Y8sL-nL7QFgZGeQ-VY3MyRNL7zEu1OoJErToyXIiXQ=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
around - whether in our office chairs, in our cars, on our sofas watching television
or at home in front of the computer playing games - means death knocks a lot sooner
for all of us. In a Lancet [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1cZ0LnU24iIk4_hdNkbQ1LFtbB7zvcQuaKEv1os3zXT1s20jlYaHxtW80ePDIC__xFu-BrZoeZrbvbH9xt1_XZTQqz5hvUdiqrvdfufbz4Pl52FY9_Kb0aWPfJ_BAST7-SG7-KjX2GoweO6-20rYNdd-C-XzHgNR6ldzsYyrCJ18E4XnTIsLT6IxvCBJi2cKTdOLA3YgPonY=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
study [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1cZ0LnU24iIk4_hdNkbQ1LFtbB7zvcQuaKEv1os3zXT1s20jlYaHxtW80ePDIC__xFu-BrZoeZrbvbH9xt1_XZTQqz5hvUdiqrvdfufbz4Pl52FY9_Kb0aWPfJ_BAST7-SG7-KjX2GoweO6-20rYNdd-C-XzHgNR6ldzsYyrCJ18E4XnTIsLT6IxvCBJi2cKTdOLA3YgPonY=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
published recently, researchers reviewed a whole series of studies that involved
 over a million subjects and came to the conclusion that 60 to 75 minutes of moderate
physical activity made all of the difference in the world.  So, walking the dog 
(Toto, my Glen of Imaal terrier will probably start pawing through those journals
on the floor to find this study) or walking to work or, any amount of moderate activity
like riding a stationary bike, dancing, playing golf, softball, or tennis - eliminated
the risk of death associated with sitting!  The study even found that a mere 25 
minutes a day of moderate exercise was somewhat protective.  So, the new mantra 
is less sitting - move moving!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
The Best Places To Eat In America - Jettsetter.com [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE1q4lf4Fxq_sJDuhrdtWwO5Le2CqR5BIto4WwKsm8NwdQd3Iadyg9T8yZiNMuQGaNgyLrbBxwzVnqJhhYpzZ5AkUkj5EKU37kfVo8FHCMAB1b08fgHIE456QxK9sBpWLkurrDa7V-DjUN6wK3ZUvtkVjiyvjX4O0i1bwmIo0EI1pibBuU821WXoPqEC_3DLyYHn3UHdEqSIizwCack5ofHbfXJT1vcOYfKpqrY_RFf68-rksRMxb2FH5SwL7KEnXQcZEj78vwn2wv1jRBEhjXpbcNR22sVdBj1Hz3ZA8MBVFhTIbwhMPxxbXzW1KQ4_YgMLjcuyigtqvs2bRX6FKNSipJqnB3vhlfgbkYpPkJC9Mht5_5rPFI0BQg-ALW6YDXHlZSECjZGlU8=&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
recently published their overview of the best restaurant cities in America.  Their
top cities included #1 New York City (no surprise), #2 Providence, Rhode Island,
 #3 Houston, Texas and on down the list.  I was a more than a bit surprised that
 San Francisco and environs did not make the list.  Hmmm?  What's that about?
And, not to be outdone, TripAdvisor.com [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KUQrs0jOzSE17EyRrbLyMxhYYU-bDGFzyq29Lg7aibwHQoKM_fuNU-u7ZExT7mLKQUelwjEM_iA8ZCwXu7SblRm21bUZ6ohkN_RSSmSwnGFPMcb7FMMJ75o-2tV1WUXAjQF7MRSBJA8ViaEfrHRn3199-OzYMMO0gaIsBPPcJw73LN3aaHrmyczgpXvd7ERMbBHnbwmRdQF-KXC98kQ_akJW9IdAHyRaEwzE9ePt1gqv2BPXOFcIKMa_2-SWYnkgFG2satIAWXMx8Yh4lKq7RaJdmrOtqQ-lVX5Be23irk2g2FeZRrZ6f-qutrR2u5mT_N9XCXuli-khOZE5JP53WM2VqlujmDxZAI8HxexOoaGvYAbFZturkitFl5PY9aoh1A==&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
came out the same week with their "Top 25" restaurants in America.  I decided that
I needed to be doing a better job for all of my readers in checking out the list
 of restaurants.  Out of the 25 restaurants listed on TripAdvisor, I've only been
to 11.  So, my hit average has slacked off.  Perhaps it's because I'm not traveling
as much these days except on the Boston-DC corridor.  Regardless, I would recommend
that you keep the list in your pocket for future reference.  As for the Top 25 -
 my personal favorites are Momma's Fish House (Maui, Hawaii), The French Laundry
 (Yountville, California) and Alinea (Chicago, Illinois).  You will never be disappointed
at these places.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The Cubbies first World Series win since 1908!!
The Good - The election is over.  Now, let's get on with solving problems!
The Bad - There are no strawman proposals from the new Trump Administration for 
starting real discussions on possible solutions.  We only have platitudes from which
policy is not made...
The Ugly - The depression sweeping over one-half of the American public.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Cartoon Of The Week
From the "I-couldn't-resist-Department"...

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.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Name | Company | Phone | Email [mailto:[email-masked]] | Website
[http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KU6__V37qL9YFPbhHvPKAoIaihlZ4Wuplkm6oI8kXoEXa9XDP4pVvN5U8bcMIthypLf7MPAiRS_361eZH4LJVs3oYfqldF54QLcdLLVqRP6GP0Ot6tZpMwv-FwgTW3nXgr3fcgTCxaVD&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

STAY CONNECTED:

Facebook [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KU6__V37qL9YFPbhHvPKAoIaihlZ4Wuplkm6oI8kXoEXa9XDP4pVvN5U8bcMIthypLf7MPAiRS_361eZH4LJVs3oYfqldF54QLcdLLVqRP6GP0Ot6tZpMwv-FwgTW3nXgr3fcgTCxaVD&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]

Twitter [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KU6__V37qL9YFPbhHvPKAoIaihlZ4Wuplkm6oI8kXoEXa9XDP4pVvN5U8bcMIthypLf7MPAiRS_361eZH4LJVs3oYfqldF54QLcdLLVqRP6GP0Ot6tZpMwv-FwgTW3nXgr3fcgTCxaVD&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]

LinkedIn [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KU6__V37qL9YFPbhHvPKAoIaihlZ4Wuplkm6oI8kXoEXa9XDP4pVvN5U8bcMIthypLf7MPAiRS_361eZH4LJVs3oYfqldF54QLcdLLVqRP6GP0Ot6tZpMwv-FwgTW3nXgr3fcgTCxaVD&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]

Pinterest [http://r20.rs6.net/tn.jsp?f=001ySFhxm8Kq8SA3LoykiLJPjyrhZ2P3VfJXtQ0SVy92evd96iv74B8KU6__V37qL9YFPbhHvPKAoIaihlZ4Wuplkm6oI8kXoEXa9XDP4pVvN5U8bcMIthypLf7MPAiRS_361eZH4LJVs3oYfqldF54QLcdLLVqRP6GP0Ot6tZpMwv-FwgTW3nXgr3fcgTCxaVD&c=hUb_UB8PSILvILzERY-SDge4bazN6cl1Y5-L9e4ccgDFdvru5FA0TQ==&ch=oFSduZJYyTnwIvtooSY8PPGKxbONx6PGBTByc619yhbmLCgL6Jm3Cg==]

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Forward this email
http://ui.constantcontact.com/sa/fwtf.jsp?llr=svyssnfab&m=1105336033970&ea=[email-masked]$&a=1126364298916

This email was sent to [email-masked] by [email-masked].

Update Profile/Email Address
https://visitor.constantcontact.com/do?p=oo&m=001oshdCZaoslvWED8bsIAHcg%3D%3D&ch=d97b8ec0-5fcb-11e3-85fd-d4ae528ed502&ca=d144c3c3-425e-4869-9fec-2bbd60af4b64

Instant removal with SafeUnsubscribe(TM)
https://visitor.constantcontact.com/do?p=un&m=001oshdCZaoslvWED8bsIAHcg%3D%3D&ch=d97b8ec0-5fcb-11e3-85fd-d4ae528ed502&ca=d144c3c3-425e-4869-9fec-2bbd60af4b64

Privacy Policy:
http://www.constantcontact.com/legal/service-provider?cc=about-service-provider

Online Marketing by
Constant Contact(R)
www.constantcontact.com

The Fickenscher Files | PO Box 840 | Kittery | ME | 039