Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Thu, 30 Mar 2017 17:06:38 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwWHplVPYaJqCZ4Pg3mrG4n5hS4_Al2I2ls4wQ0bPHH_qj5ybmmyuMw72EQCFOyR15i44RHyPs6qjL9a2KHiJGqh1V0YlnuX7JblFoETqne8D6fu7wgiT3CXE1KBbxNsNR1ncxBn4wMVZ&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
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The Fickenscher Files, Vol. 5, Issue 3
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwTtlyvdc357CFAUnLU7kxjxXMzp_1PRJbdceuMBdf4fRlfK0GLbTEjZ-8sFkpZIyyhiMbZ4dZRv2t2a_zlUXzRI5T1MkPw2cpxA7grsJRmGPwoiThf2eX4BsPUM0mKxXMNVpvUWn7iLDxQSgmslRPKTBJ9oa3s54lPSWALEyJIDzN6cvMDxbnojnfzoQmSCfeAk8tgd53U6mV5X_ynjN1Tc=&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==],
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.
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Quote(s) Of The Week
"Basically...90 percent of our members of the conference were there and ready to
 go and be a governing party and were happy with where we were, and around 10 percent
were still in what I would call 'opposition party mode."
Speaker of the US House of Representatives Paul Ryan, in comments following his 
withdrawal of the American Health Care Act from a vote before Congress last week.
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Consulo Indicium
Information for your Consideration...
Disabling Health Care Through The Visa Ban: The Tale Of Two Programs - In a statement
made a year ago during the campaign, President Donald Trump made the following statement:
"I will end forever the use of the H-1B as a cheap labor program and institute an
absolute requirement to hire American workers for every visa and immigration program.
 No exceptions."  The problem with this philosophy is that it directly impacts on
the ability of America to sustain an adequate supply of physicians, nurses and other
health care workers for the country.  For example, fully one-quarter of all physicians
in the USA immigrated from other countries.  Most arrive here through the H-1B visa
program.  On the other hand, he's OK with the H-2B visa program - which is used 
by the hospitality industry to attract low-skilled, low-cost workers on a seasonal
basis.  According to the Palm Beach Post, the resort - Mar-a-Lago - which has now
essentially become the "Southern White House", is the employer of more than 60 foreign
workers for jobs in the $10 - $13 dollar range - primarily from Haiti and Romania.
 Why?  Because, as Trump has said in response to queries on the issue (again, prior
to becoming President): "...getting help in Palm Beach during the season is almost
impossible." The contradictions are obvious.  An "America First" program designed
to keep the country strong - if it fully incorporates what Trump promised during
 the campaign - would disable the ability for the healthcare industry to recruit
 and hire "skilled", "technically trained" workers such as physicians, nurses, pharmacists
and other healthcare workers.  In addition, there would also be a perverse impact
from such a program on Rural America. This segment of the USA has relied upon the
H-1B program for decades to help resolve the workforce shortages.  And, these shortages
are becoming even more acute in recent years as the aging of the rural population
accelerates more rapidly than the rest of the nation.  We could even go one step
 further and note the work of Giovanni Peri, Ph.D. a University of California at
 Davis economist who wrote a report in 2014 noting that the tech industry would 
have recovered much quicker from the 2008 recession if the government had not pulled
back the H-1B visa program for technology workers.  Hmmmm!!  There's data here. 
 Perhaps we should consider it rather than ignoring it.  We are already seeing the
beginning calls for a change in direction on the issue.  It deserves our attention
and focus otherwise, healthcare especially - and, the rural communities specifically
- will be affected (NOTE:  Adapted from reading "The Financial Page" in the March
20, 2017 The New Yorker, p. 34).
Notes From The Commonwealth Fund Scorecard - The latest edition of the Commonwealth
Fund Scorecard on State Health System Performance [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZa3UIv5Vu17HJID1ImtR0bPdpNPG3wn9nhXjieLkkxvDQCgMfvSui87mrOs1RL7ydhQqVuUf8PXawQ5S-Nc8UGWVuZ5sW-S4l2Tpo-P6D1tVNXvr4E0IZlXitXeagiVsYP3jzqcJD7alWLekOycE91XmsUZD5N5ays_tiDJ4hUWt26cyrBhSEn_A==&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
was recently released and found that nearly all of the states improved on an array
of health indicators over the period of 2013 to 2015. The period coincided with 
implementation of the Affordable Care Act's (ACA) expansion of healthcare coverage
expansions which resulted in uninsured rates dropping - especially in those states
that expanded their Medicaid programs. But, it was not all positive news.  Between
2011-12 and 2013-14, the premature death rates rose slightly following a period 
of long decline. So, it's clear that the implementation of ACA did not solve all
 the problems - but, none of us in the health care community thought that was the
case anyway.  The top five states - in rank order - were Vermont, Minnesota, Hawaii,
Rhode Island, and Massachusetts. The top five states in terms of the biggest gains
since the last report were California, Colorado, Kentucky, New York, and Washington
with New York and Kentucky showing the greatest movement among those in the top-performing
group.  The reported noted that there were four broad themes evident in reviewing
the date, which included the following:

* States that expanded Medicaid      under the ACA saw greater gains in access to
care than those states that      did not take advantage of the new program,
* Overall, improvements exceeded declines      in states' health system performance,
* Premature death rates crept up in      almost two-thirds of states - a fairly 
remarkable change that is now      receiving closer scrutiny from researchers; and,
* Across all measures, the variation      between the top- and bottom-performing
 states was a threefold variation,      which denotes a significant opportunity 
for improvement across the states.
Those are remarkable statistics!!  If you are interested in a more detailed review
of the 40 measures used in the Scorecard go here [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZaWlIBFwjR56xyWPAN-tOa5nSmzfAM5wWFWBhLO8zeMSO9BT_ljlgmf1Ec_kx_7DEdMncnzRiINO9svQRKFXQlMfANjQ3Fh91ElmOCk9A_3TEBFqkZPSf2oRyhCwWxu1F3STnqFxUhDi25f6zKkSGTLtxgu4Tr-6eZkA_fdwi3n65un6NfnO2OLsJSKkgGc99j&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==].
 The big message from the Commonwealth report; however, was that by 2015 fewer people
in every state lacked health insurance, which resulted in patients benefiting from
better quality of care in doctors' offices and hospitals.  For example, Medicare
 beneficiaries were readmitted to the hospital less frequently. Why? The change 
coincides direction with the federal government's initiative in levying financial
penalties on hospitals with high rates of readmissions and the creation of hospital
improvement innovation networks to help spread best practices across the country.
 What was particularly notable - from my perspective - was the fact that if healthcare
in America achieved the levels of the top performers, the USA would achieve the 
following results:

* 20 million more adults and children insured,      beyond those who already gained
coverage through the ACA,
* 14 million fewer adults skipping care      because of its cost,
* 26 million more adults with a usual source      of care,
* 12 million more adults receiving recommended      cancer screenings,
* 513,000 more young children receiving all      recommended vaccines,
* 1 million fewer Medicare beneficiaries      receiving a high-risk prescription
 drug,
* 124,000 fewer hospital readmissions among      Medicare beneficiaries ages 65 
and older,
* 1.4 million fewer emergency room visits for      non-emergency care or conditions
treatable with primary care; and,
* 90,000 fewer deaths before age 75 from treatable diseases.
That's a lot of "fewers" and "mores"!!  Embedded in this report are clear "lessons
learned" that we need to further apply across the healthcare industry.  Programs
 like the Medicare Learning Action Network and the healthcare system funded Institute
for Healthcare Improvement have clearly made a difference - and, deserve our support.
The full report deserves a read and offers guidance on next steps.  Check it out!
The Opioid Crisis And ACA - Following the passage of the ACA, 32 states and the 
District of Columbia took advantage of the Medicaid expansion provision.  The impact
on drug addiction - a growing scourge in the USA - has been significant.  What is
particularly disturbing is that the rate of death from drug overdoses has increased
from just over 19,000 deaths in 1999 to over 55,000 in 2015.  We now have more drug-related
deaths from overdoses - to say nothing of the deaths occurring related to drug violence
- than we do from car accidents.  The attention given to making cars safer gets 
far more attention that the drug-related problems.  Now, that is "sad".  Furthermore,
DHHS recently reported in January that the number of hospitalizations of uninsured
people due to substance use has dropped in expansion states by 75% as of 2015. In
fact, 1.29 million people are receiving treatment for substance use disorders or
 mental illnesses due directly to the Medicaid expansion.  Of that number, about
 220,000 received treatment for opioid addiction based on the work of researchers
Richard Frank (Harvard) and Sherry Glied (New York University). Without the Medicaid
expansion, the vast majority of those people would have fallen into the "treatment
gap" populace - those that lack of insurance or are not enrolled in public programs.
While Medicaid doesn't solve the addiction problem, it clearly goes a long way toward
making addiction services available for a population that is disproportionately 
affected by the addition crisis.
More Money = Better Care?  Not Necessarily - Researchers from Harvard recently published
in JAMA Internal Medicine [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZaDyfDGX3JLlEUCiOFVidxVG1gCUloYjiwJcdafAbsUuMzjj_BrFfYSinkZrxSAy6ieKvKvp24iqj-UCIyoTCupbt7EfFujKZGFpAK6nwX8uK28xw_IuFBRaS9AT-IWxeV3E8Z0M9kdDRtWSVg4yDbwA==&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]a
study on the impact of individual physicians' spending patterns on patient outcomes
and, the results were very interesting!!  One of the researchers, Anupam Jena, Ph.D.
noted that "If you spend more money on a car or a TV, you tend to get a nicer car
or a better TV.  Our findings show that's not the case when it comes to medical 
care. Spending more doesn't always mean you get better health."  Their findings 
are confirmatory of other prior research which has noted that the tie between expenditures
and outcomes does not translate directly.  The authors of this study argue; however,
that the issue is not overall expenditures but rather expenditures tied to individual
physician spending within the same hospital. Their findings will no doubt change
 the focus of healthcare delivery organizations which have been working at the macro
level for the most part.  The focus on individual physician expenditures - with 
the "power of the pen" - has not received the attention needed for impacting on 
the cost of care.  The researchers analyzed outcomes among Medicare fee-for-service
patients aged 65 and older who were hospitalized for a non-elective medical condition
and treated by an internist between 2011 and 2014. They found that health care spending
varied much more across individual physicians within a single hospital than across
hospitals - even when the differences between hospitals and patient populations 
were considered.  Their study revealed that 8.4% of the total health care spending
variation could be explained by differences in the use of resources, orders and 
tests by individual physicians compared to 7% which explained the differences among
hospitals. Next, researchers examined the link between physician spending and patient
outcomes. The researchers then compared the lower- and higher-spending physicians.
 There was "no difference" in 30-day patient mortality or readmission rate, which
are two outcomes that are frequently used as proxies for quality of care.  But, 
the findings are incomplete and the researchers intend to follow-up with further
 queries on the data.  Expect further reports down the road...
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Future Health
Delivering care in the new virtual world...
The Reprieve: Caffeine May Lead To A Longer Life - I recently had a good physician
friend over to my home one weekend and as the conversation ebbed and flowed, I kept
drinking coffee.  My friend - who had had only one cup during the course of our 
several hours conversation compared to my multi-cupped consumption - asked me: "How
much coffee do you drink during the day?"  I responded that I didn't keep track 
of my coffee intake but that it had to be "...on the order of at least a couple 
of quarts if not a full gallon".  He was shocked.  I was nonplussed.  Then, a study
[http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZaQJQKxdGXxOntyivA5OSnYJkB_zRIMwsfXS5sQLmspr8LJko_DQhGTRKYoulttw000gIEob7M22hYi_YsUH4Blc9IQ2-gZVTOJCT-V_rnUdZ_0PXDBCxcKwxlCtyiSzHz3L2rUCps2RgD7XCBwyYBYu1qCGPHFBXjU7d7YPMqngFAshS7Bf48vB5gFq_NFXgbYTVEoTVJ2XqTGXC0X8zBgKd5uMPAuqdZJ57jnCHpgek=&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
from Stanford was recently released that tied caffeine to the "inflammatory process"
linked to cardiovascular disease and aging.  Specifically, the study followed more
than 100 people over the course of years and found the inflammatory process was 
less prevalent in those who drank more caffeine.  They then conducted lab experiments
which found that the caffeine "directly countered" the inflammatory process. The
 lead author for the study, David Fuhrman, noted that 90% of noncommunicable diseases
- which aren't infectious or transmissible - are tied to chronic inflammation. If
you couple the research findings with research and data [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZaV8fHNlE1b-2-du1_tOt6wiyrxxO9Zi_24PUPdf9_LhmJ5oeEcrcZAVNw9D5Q0Q3ZeeoYhkHc4D21oMv2hH_J0UbUpOSGPbiL8Ag31xNTUwDDwq54JH_sp0C_SiInf9Vo5dum6KP7pj-30VSOhJfToF0d8wHWDdNP01GxWVRZrUctppu9OsoWtKemDsK7GynE&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
supplied by the Centers for Disease Control and Prevention (CDC) which reveals that
75% of the world's deaths are caused by noncommunicable diseases such as cancer,
 diabetes and cardiovascular diseases - everyone should be drinking coffee, right!!
 J
Well, maybe not everyone.  Perhaps we should be more targeted?  Researchers have
 studied and identified gene clusters.  Certain individuals exhibit high levels 
of an "inflammatory protein" which is associated with high blood pressure and free
radicals in the blood.  These free radicals are often the cause of cellular damage.
 In fact, those individuals with gene clusters containing low levels of the inflammatory
protein more often had family members who lived past 90 years of age.  My grandfather
lived to 89 (but he was markedly overweight).  My grandmother lived to 96.  And,
 my Great Aunts and Uncles all lived into their late 80s and 90s.  If it weren't
 for smoking, I suspect my Dad would have done the same.  Regardless, the genomics
seem to be in my favor.  Again, J  So, based on the research - which keeps piling
up in favor of coffee consumption - I think I'll keep up the pace.  Although, I 
am cognizant of the fact that "too much of a good thing can be bad."  I just hope
I haven't reached to "too much" stage.
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Approaches To The New World Of Work
Ideas and thoughts on how work is being transformed...
In a new study [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZaa94D64z_r5hDdqqXn_XphkcVorMqccWW3Tnio1qC8f9N2WJAVtayts77SiSuuq00L5O_GsGBmuzSdL7IVSJXDxDI-LZqdcXmnpYdHZ6_6P2Cuu1hU2_mP1FS79UyarIq7Q9xnf5cSljT6_ERKzchkeyJIt2lFSkuIAiOQMLgfCPwSkBNv2dT9wsHUP4HRE5K&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
from PriceWaterhouseCoopers (PwC), a major international consulting firm, it is 
projected that nearly 40% of USA jobs may be vulnerable to replacement by robots
 in the next fifteen years.  Actually, according to a 2015 Oxford University study,
the number of vulnerable jobs is more like 47% - yikes!!  But, let's turn back to
the new PwC study...  For the same time period (i.e. the next 15 years), it is projected
that Germany will lose 35%; the UK, 30%; and, Japan, 21%.  PwC projects that the
 USA has a higher percentage of potential job loss due to automation because the
 nation has more workers performing routinized tasks versus those jobs which require
highly technical skill sets.  In particular, the industries with the highest risk
of job replacement from new technologies are in transportation, manufacturing and
retail.  PwC developed an algorithm as a framework for determining the "routinization"
of work and which considered the "automatability" of the tasks and characteristics
of the workers employed in performing them.  As an example, the USA and the UK both
hold a fair amount of jobs in the financial services sector. However, jobs in the
UK financial sector are involved in international banking, which represents a set
of tasks and responsibilities that are far harder to automate and require more education.
 In the USA, the financial sector is dominated by retail banking, which is much 
more retail and repetitive in nature thereby lending itself to automation.
The issue deserves our attention although in a recent interview [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwVDRUPT_oLZaW9ON6ubnQAaXuRaSwRH1Q2InTUELNvWUmr_ZXH9FP27gwjkNMOq4EtK_vLVvrOh17pR7qO-TcZ20vW2aQMWP5iXkl5UUFk93uww2m4995cZanHdfMu2qWtXMXZTLk7Jm92KzB2cQyFDXR3EMmpfqttsqy1jG_7__LS2F9gtF93TqAFeW5ekD1Q2_NDRkO0xIZzZhnObY8c3CpkjhW7rRGJdSAdVlpZtH6w72lscBKkw=&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
the new Secretary of the Treasury Steve Mnuchin said that advancements in artificial
intelligence and robotics "isn't even on their radar screen" in reference to the
 Trump Administration.  He went further in noting that from his perspective, the
 potential for the changes described above are "50 to 100 more years away." In a
 more provocative or, shall we say "modest", proposal on the topic of robots, Bill
Gates - the founder of Microsoft and a leader in shifting much of what we do toward
electronic means - recently made the following call to action: "The robot that takes
your job should pay taxes."  Gates is clearly concerned about that the pace of displacement
is far more rapid than job creation.  The so called "robot tax" would slow the pace
of automation and generate revenue which could be used to replace the existing tax
revenue structure.  He goes further in explaining, "...the human worker who does,
say $50,000 work of work in a factory, that income is taxed. If a robot comes in
 to do the same thing, you'd think that we'd tax the robot at a similar level." 
 It's an interesting idea that deserves consideration and, I should point out that
not everyone agrees with the concept.  But, it does deserve consideration...
Finally, it seems to me that the US Congress needs to redouble, if not triple or
 quadruple, it's investment in supporting the re-education of the American workforce.
 Making promises that jobs which disappeared nearly a decade will return rather 
than providing avenues for re-education and re-training is disingenuous.  But, Congress
has not stepped forward with such investments.  Taking care of one another is part
of government's job and our responsibility as citizens.  What am I missing?
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The Weekly Whisk
Musings from a foodie...
I had the opportunity to re-visit one of my favorite restaurants in San Francisco
- The Tadich Grill.  Established in 1849, The Tadich Grill [* * * *] is one of those
iconic restaurants that has withstood the test of time.  While they serve other 
kinds of food - the essence of the place is seafood.  They grill it, broil it, bake
it, or sauté it to taste.  Most of the waiters have been there, seemingly, for years
and they - like the restaurant - have withstood the test of time.  In my most recent
visit, I had the obligatory lump crab cake that was drizzled with lemon beure blanc
sauce and Peruvian baby sweet peppers = extraordinary.  The seafood cannelloni followed
and it met expectations as well.  This is the place where the former Chef John Canappa
taught me how to make a wonderful seafood cioppino.  I think the ambiance carries
me away and I'm a counter guy although booths are available if you're willing to
 wait.  Reservations are recommended and the countertop lemon slices are free J.
  Go for it: The Tadich Grill - 240 California Street - San Francisco, CA  94111
 - (415) 391-1849 - http://www.tadichgrill.com [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwSTRrTw04hIre1HAvRZ30GcIKpBSxhVJFn84kvJ_U-rymCezRx9p7TOCJClKix-OAbLkrNMUUJ5soUySBC2Mh4qJbiZgdzgp6MfRvZVZk0qfE2HRe_DoUVLC7Qoy0mjuQQ==&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The fact that Spring is here?
The Good - The apparent recognition that the way forward on the legislative front
in Congress will be through "bipartisan" discussions, debate and consensus.
The Bad - The ongoing lack of bipartisanship in Congress is disheartening.  If we
review history, it will be obvious that the great movements forward in American 
society were at points where collaboration occurred between all the various political
factions.
The Ugly - The opioid crisis is now killing more people than car accidents.  It 
needs attention, now!!
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwWHplVPYaJqCZ4Pg3mrG4n5hS4_Al2I2ls4wQ0bPHH_qj5ybmmyuMw72EQCFOyR15i44RHyPs6qjL9a2KHiJGqh1V0YlnuX7JblFoETqne8D6fu7wgiT3CXE1KBbxNsNR1ncxBn4wMVZ&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
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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Name | Company | Phone | Email [mailto:[email-masked]] | Website
[http://r20.rs6.net/tn.jsp?f=001DHNYkxlpVEU0ZQGRfVU_dB4rZ5VfFPc4o9c_9q1VG_xuh4I64DBuwWHplVPYaJqCZ4Pg3mrG4n5hS4_Al2I2ls4wQ0bPHH_qj5ybmmyuMw72EQCFOyR15i44RHyPs6qjL9a2KHiJGqh1V0YlnuX7JblFoETqne8D6fu7wgiT3CXE1KBbxNsNR1ncxBn4wMVZ&c=Sn-OygAi5V-SlJ-ueAGR0o-B6wBb4F5ZoZ2W-6mRQ-h7SNXiA6W7WA==&ch=3UzxdPd4cCRtrcv7CIH3jITf9egVZQyjRuPSdEJDo2USUFLfOdn5wA==]
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