Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Wed, 5 Jul 2017 16:32:47 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXB9Y4Ge1J8gpQFQDIXrH1CcGXIOM5gwRSbw6Fy4KdLHJm0pYjqMm-qXVpawlDW0kO2jPKv7m6Xrk043IQhgzZYwg_5IG6dVjXzVR5Qq_nMtZEzM9VVXchPGohqr0PNaHq9He_toRmSXt&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
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The Fickenscher Files, Vol. 5, Issue 5
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXJljYGxqVjZHI6tAPekJSn0uA_4pNm-isaDCaV3mPMTocwLNJ4Q4LlKSHUSFXoUfU43OkxCW15_vBKB2jTE-7-162CxPgxenqNSv1DW-eSrTYScKN7gc0pgcLTpR_nwcKk_wKQDkBixPPXXgh8ojBRG-N3eqXzckJg==&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==],
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
"Can we have a crisis free day?  That's all I'm asking."
Senator Susan Collins (R-ME and, my senator), in her reaction to the announcement
that President Trump had shared highly secret information with Russian representatives
at The White House.
"Is anybody listening to anybody?  I can assure you that talking is a much better
way than demonizing others."
Leslie Griffiths, Pastor of The Wesley Chapel in London, England on Sunday, June
 4th (Pentecost Sunday) in his sermon before a packed crowd of officiants
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Considering Everything - Except What We Should...
Periodic random thoughts on growing older but hopefully wiser...
First, I've actually been negligent in keeping my blog up-to-date - probably much
to the delight of some of my readers J.  In large measure, the negligence was due
to our family's preoccupation with Mom's worsening Alzheimer's.  So, I apologize
 for missing blogs in recent weeks during some of the most important discussions
 on health care since the passage of the Affordable Care Act during the formative
period of the Obama Administration.  My attention was diverted from my normal obsession
about all-things-health-care-and-Washington to a more normal obsession that is faced
by millions of families across the nation on the next steps they need to consider
in providing care for Mom or Dad or other elders in their lives.
And, while I missed sharing thoughts on events over the last month, you no doubt
 noticed that there was an abundance of thoughts and perspectives on the issues 
of the day shared by many of my health care colleagues.  It seems that everywhere
I turned over the last several weeks there was an ample supply of pundits sharing
thoughts on the tenor of our times - both health care and non-health care related.
 Our nation seems to be obsessed with the ongoing soap opera which unfolds daily
 on the small screens in our hands and the larger screens which light up our living
rooms.  But, as we follow the whims and whispers of "party politics" in our nation's
capital, it seems to me that there is a much larger "people politics" issue befalling
our nation.  While I don't disagree that the machinations of Washington require 
our worthy attention, we should not forget the equally important and looming issues
that will shape our society for decades to come.  Decisions being made in the near
term over the next several years will affect our nation for years to come.  The 
GenXers, the Millennials and those who come after them will be the recipients of
 our decisions.  It's all about people...and, the people are getting the short end
of the stick - from my perspective.
Which brings me back to health care.  I'm increasingly concerned like others that
the demographics of our society is a huge problem (i.e. we are getting considerably
older as a society than previous generations).  The demographics hang around the
 neck of the USA like a lingering albatross!  Why?  Because if we do not fix our
 health care system - the health care system will be the singular issue that bankrupts
the nation!  I realize that I've said this before and that it is a bit provocative
but - it is true.  Each quarter the percentage of GDP consumed by health care inches
up.  In fact, unless something is done, we are clearly reaching for 20% of GDP consumed
by health care - on the conservative side.  As one who has been around for a while,
I remember the cries from the pundits when we reached 10% of GDP, then 12%, then
 15%...  Each of these hurdles were described as "...not sustainable."  But, while
we have sustained ourselves in the short term, it seems that our nation is digging
a deeper and deeper financial hole for itself due to the large amount of resources
we invest in health care to the exclusion of other important societal needs. It 
cannot continue and we need to solve the problem - Now!!  ObamaCare - as passed 
- did not fix the problem.  ObamaCare with changes could set the right course.
But, lest I make it theoretical, I would like to be more personal.  All of these
 thoughts are shared in the context of the much larger, more socially important 
phenomenon - the aging demographic of our society.  The aging of the boomers (i.e.
my generation) are beginning to stress the system - just as we have for each era
 through which we passed.  Now, instead of Schwinn bicycles for every kid, or marching
in the streets, or finding jobs for every Boomer, or raising families, or paying
 college tuitions - we are now faced with caring for family members.  Such has been
my dilemma for the past number of weeks.  And, while there are many diseases that
are painful, protracted and difficult such as cancer, or debilitating neurologic
 problems, or severe heart disease - the plight of a person afflicted with Alzheimer's
is like a blackening abyss from which there is no escape.  While there are displays
of thought, they are random at best, mostly about isolated and unconnected events;
or offered only as snippets left behind and reflecting the personality of the person
behind the mask.
The heartening part is that the snippets which come through often convey the essence
of the person.  My Mom still loves coffee and asks for "a cup of good coffee" every
couple of minutes.  While she is easily distracted, her personality comes through
in bursts of commentary about keeping the house clean or washing the dishes or some
other every day domestic task.  It's probably why - except for my desk and office
- I really do try to keep things picked up around the house.  After all, I wouldn't
want her to show up and chastise me for being a slacker...
But, while there are lighter moments and interludes of banter, there is also the
 pain of watching the person that guided you throughout your entire life - whether
you wanted the guidance or not - wither away like a flower who receives no water
 on an unseasonably hot day in Arizona.  It's difficult.  Then, there are the hard
decisions that accompany Alzheimer's about which medical interventions seem appropriate
and which are not?  Where should the family draw the line?  And - while I'm a physician
who has faced these situations many times when I was in active practice - it's a
 whole other matter when the people you are advising are your brother and his family,
let alone the weight you feel on yourself.  Are we making the right decisions?  
What would Mom want?  These are the experiences of every family, everywhere about
everything related to Mom, or Dad or whoever we happen to be providing care for 
at the closing of their life...  Since there seems to be insufficient "talk" about
these familial decisions - perhaps including them in a blog is the next best thing
one could do.
And just as important as the personal side is the societal side of these questions.
 How we will care for the aging demographic in a period of flattening resources 
is increasingly the tenor of our times.  As a society, we are no longer the only
 economic engine in the world.  So, what does that have to do with Mom?  Well, Mom
is the canary in the coal mine.  As the boomer generation comes fully of age, the
experiences Mom is facing will increase from 5.4 million to 7.1 million afflicted
individuals by 2025 or, a 40% increase.  So, one of the questions we should be asking
ourselves is: What can we learn from caring for the current generation to pass along
to the next generations?  And, learn we must!!  For - unless something changes -
 we boomers will be responsible for bankrupting the nation if not because of demand
but because of sheer size.  It's not just about Alzheimer's.  Pick your favorite
 problem.  The percent of increase is comparable for all diseases.  The resources
that will be consumed over the next couple of decades make that last century look
like a cakewalk for society.  Yet, we are consumed about outbursts on Twitter, the
who-knew-what-when questions, investigations of importance such as the potential
 Russian meddling in American elections; and, investigations of naught such as the
one on election fraud by Americans.  So much ado about so little.  And, while all
of these temporary flights of focus capture our energy, the back channel is filled
with warning signs about realproblems like the looming crisis in health care, the
need to consider how best to support education for the next generation, the aging
infrastructure of our cities, and...I could go on but will not bore you with the
 litany of problems.  Which is why I decided to start by sharing my personal thoughts.
 We are Considering Everything - Except What We Should...  Let's get back on track
and demand the right focus on the right problems.
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Readings To Consider
Books and Articles worth a Review...
First, you should take a look at Health Effects of Dramatic Societal Events - [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwTWave7O5yIHj-PFKb4IWLNo3ECrDGltN-oG5Ppd31BsMKcmFqM-srVZohy5yGB1j7ICJT4is6aBg8nQutYzmsHsvBE2nZqA2BcxZogtFsOwMpVvr_Np-_dnSI9zsBb9Fr5A5Ks4s7vCwjCCjYpTxoagc4V6NC4vUZk0Vl59n7js=&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
 Ramifications of the Recent Presidential Election [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwTWave7O5yIHj-PFKb4IWLNo3ECrDGltN-oG5Ppd31BsMKcmFqM-srVZohy5yGB1j7ICJT4is6aBg8nQutYzmsHsvBE2nZqA2BcxZogtFsOwMpVvr_Np-_dnSI9zsBb9Fr5A5Ks4s7vCwjCCjYpTxoagc4V6NC4vUZk0Vl59n7js=&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
by David R. Williams, Ph.D., and Morgan M. Medlock, M.D. in a recent issue of the
New England Journal of Medicine [NEJM, 376;23; nejm.org, June 8, 2017].  It discusses
both the positive and negative affect of electoral politics during campaigns.
Second, if you are considering "analytics" as part of your solution to solving administrative,
financial, operation, clinical or consumer-facing issues - first read, Health Analytics
[http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwFBlowGVQptAW-uYJeffMl49yUSvV7RiL3OkeV-LfcPuLys_VyBCljmyCCJY-YZQZPZMGqaGQjbsJjTiaem6vTN-ygXCeTJrklz6nee1JZmqbP7iwVd3e7FQO_tfakrU0xMT0bfAKoDXD35mLOAoMS754_wqYQoQxpZRKzbqLtMlj1Qe4LTXMO_W0JHMDpkI9OGMx7RGdmWymI_AMlkc9QUrvAVvEPoNlM_XU9qhSWOB-k-jd4gzgbz0o1Nf3PkpUhb-o2Q_nwzFU7LagGhhx3w3d7-gQ8_dNkj0QREFrXLUwpeez1WFrzHPs2-NjE5a9mFceuDxYE4tpRif_3t1ZBFU5KtelLZUeDHnSlI0zCOYhWN-MwZup5BINj-v1wIQWBos0L0nwBXyI70knMhNFz44TClMYZkmIEsCVFiPFILwIvud3ALct29Tw-dQu5_mt&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
by Jason Burke [Wiley Press, 2013].  It's written in plain, straightforward language
and filled with practical considerations for any health care leader who wants to
 do a better job of delivering high quality health care.  My copy is filled with
 many underlines and lots of rabbit eared pages for future reference.  Yours will
be too...
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Consulo Indicium
Information for your Consideration...
Meanwhile - Back At The Farm - Now that I unloaded on the multitude of issues related
to our brains, you may be interested in the revised recommendations of the MIND 
diet which recommends two servings of vegetables every day, five half-cup portions
of fruit or berries, and fish once a week.  On the other hand, if you want to be
 safer (supposedly) you can try the Canadian diet which recommends five servings
 of vegetables per week, four servings of fruit each day, and three of fish or seafood.
 Or, to be really safe - simply follow my wife's dictums = two cups each of fruits
and vegetables per day - no excuses!
Go Figure ???? - Here are some factoids that make you scratch your head...

* The Source of Chocolate Milk - In a recent national poll conducted by the US Dairy
Innovation Center, 7% of Americans [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqw6-jbD_zri1XCG92a5bzmghjzEDCk7Pd2JD-3S0WeQ3cLpUdk6RMV_DO9fKs7q5SWA_ofzNT9cAj7uhAoBnjmHIrxI4garXF48PK-GPf27m9X-EVWyHUvbfwVj_9HLJ7KUbgrPkApBIdwvisJiJmIjn29r8xNdAVPTXOvEpuRME7PbNZi36a41rNfOgufrgJz&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
believe that chocolate milk comes from brown cows - How now brown cow? But, you 
probably do not know where chocolate milk was actually invented.  Who first thought
about mixing chocolate and milk together? The credit goes to Sir Hans Sloane, an
 Irish botanist according to the British Natural History Museum [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwau0AdOjLbL0kko6hlCkLtQ4ryJW148IY9GsRdwT3UReshV-wBlWpKA-Q9RQBUnN919dwBPlPdsWGkmwiaywSZkd1M6wBbSYk8gZdENVPgsOkDU5Gl7VC__k5dQ9AsSHWvlEjBpuYK36A4khqNE2OB7uV-HnBk9L6XtSvtO3u1Ypl0XRl1P_fwGWx7blhHxwQUwmupr-AU7acnz_UH8hiO0pErt_G6toHdwsPGYD8eAefCDVdUuHuPxGVjVO_hOesru7199avtYuZ-OES3rV-fA==&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==].
 Sloane made the discovery while visiting Jamaica in the early 1700s, where he was
given cocoa to drink. He found it "nauseous" but by mixing it with some milk - it
tasted pretty good.  The other factoid to put away in the back bench of your mind
is that 60% of the milk consumed in New York City in the school system is chocolate
milk.  What does that tell you?
* Hmmm - Fried vs. Boiled - In a study from Italy by researchers at Brescia University
Medical School, the potato consumption of more than 4,400 USA adults was studied
 - especially in processed forms. As reported, the US Department of Agriculture 
(USDA) reports that processed potatoes (= french fries and potato chips)  accounted
for 64% [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwLQbGqloQkoq_F8unFgfstzJ38GOIrM0R6HUPCyxH_UkZgr083XLHLCkufEG13rJUxvxTdv2-Pix6ZNqGr5BYcZyApZ9LpQK_hoDHeSAjx6dUCTAcmDk_HffouRuKijqJn3HHXSlHfAP8q4mZlXPHRbfejAb-iMGk1K-JMQG8rFr337LNwTuvjg==&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
of the total potato use for US consumers during the 2000s, compared with just 35%
in the 1960s.  Long story short - processed potatoes are bad for you.  In fact, 
the incidence of acute myocardial infarction is considerably higher for those consuming
french fries.  Hmmm...didn't we know that already?
* Spending On Health Care - The regional per-capita health spending in 2014 for 
hospital care had an extremely large variation.  It ranged from a high of $11,064
in Alaska to a low of $5,982 in Utah.  In fact, that sort of makes sense.  After
 all, the folks in Utah are the healthiest in America and the people in Alaska are
the farthest away from all sorts of resources. The details by region are as follows:

* $10,119 in New England;
* $9,370 in the Mideast/Mid-Atlantic;
* $8,389 in the Great Lakes;
* $8,379 in the Plains;
* $7,629 in the Far West;
* $7,562 in the Southeast;
* $6,978 in the Southwest; and
* $6,814 in the Rocky Mountains.
So are the people in New England nearly twice as healthy as everyone else OR, do
 they just spend a lot more for the same services?  However, the authors of the 
study noted that the state-to-state variation in per-capita health spend seems to
be tied to other factors like those states having relatively higher personal income
per capita, higher percentages of residents enrolled in Medicare or Medicaid; and,
greater health care capacity.
Cooler Is Better - According to a recent study [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwX84yHKRsq3OOGbARq91KC15Tum5YluZoLVoIieLLsNzxhOfxWB29lph8UlyYBkmf8WFyE1wgXrIC7bIe3MFtNy4v-6nbj7InxDnnqEYrAhsXk2vuj3Bh_DhEt6Y-J0jvxbKwnrmMl7XalWrCyMOr5DdwBfVsioCOQjhhi51T7CZyxzyG9bg63oXgfq-J2KgeY8YT8lWyuzn8V-rkrr9XJA4Hop5U_3p4N3Un3tbw6SOuCTYTXsHkEg9OLq-6reLEKIk07KencWrtGa4FVevurLTFymkcRv2tsp4Yd4f_YAlmxtHgHI8pFXC7C9_2DVZVwHFoW33CNejXMWI2tke69OSlxg8TEHVsThn7fBE8V-gkq46gr0Ssujr7sPFdXocCAmy2DZw7gBkapK5UACTbVgeJDfsQLRPr1apLpV9Aq7Dfb_xZ2Oqfhno9y5qgeQD3Fd33RFbraVrjknVJSE7SumSEteuWTImgNU5Ox9i0e8Y5Bc_T981abLshzi_OkaWAHVrdR3bQFYAotkuhNJDC6Xs8Yy44RBtbha8revc3nzOEVIRk9ANiGgyMikkoghQzqZ0YNCpZxLMRCwPJfBkG9A==&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
released in Infection Control & Hospital Epidemiology warmer weather increases the
risk of "developing an infection at the site of a surgical wound." This is one of
the studies that is intriguing where we can tie together disparate data to gain 
better insight - in this case the USA hospital discharge database on surgical site
infections from 1998 to 2011 and local temperatures derived from the National Oceanic
and Atmospheric Administration (NOAA).  There are no doubt other interesting results
just waiting for us to discover...
And, What About Opioids? - Drug overdose deaths in 2016 exceeded 59,000 or, the 
leading cause of death for those under 50 years of age, according to preliminary
 data compiled by The New York Times [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwsyfHWtDnfjM8wOCYYUtduB0wDMSwIksO5BndskdpRPJgyv-FrKDsIRfwuhMNHZn5ZFXyUcrBtuvOMhISQKOJR4kgmAIoWODkGEXkDCYmKmsVUjHMo8dFlJNYokBj-b4VGrts_LeKx6uYPws0GtRpc_g8eZWosjvt9aQdyfInMNBIsKHP4SID1GLyDtucOBaLdqi3XkpqJUnYF0QzTN2WULPuSYre6GEsh0GnkXLekkr60ejK2sNN8a7-tQ0Q07OjxVjA614GeSTbAAGLuhC42BnKPSclAyJxFcAWeK65hsk=&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==].
The opioid crisis is a public health crisis, which is being made even worse since
the data was collected because of the influx of illicitly manufactured fentanyl 
and other biosimilar drugs. Drug overdoses are now the leading cause of death among
Americans under 50.  Ohio has taken the lead by filing a lawsuit [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwHylDazs_VZM3OrBwf2RRAh9StqkUwh87F23OvH4DGzQKLrtfigZcpr5kzUspwccJPoaMRZFISjdyPxk0lRFSKMRxTXc42adzm1RHeVoSuUnnCoMCPm9qrMNPKAClQ71fGryDSq1FoR4g3xTrbOpH3KEvWjUPaoM1eds57To_3uPdnyix3UvliQb8-jUNHImwJQ5eSw9D3AqPYiYsgfa6IY4BWQyg6xuE&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
against five drug companies accused of inciting the opioid epidemic through the 
encouragement of inappropriate use by health care providers.
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The Weekly Whisk
Musings from a foodie...
Many of you may not realize this but "The Weekly Whisk" is the most frequently read
portion of my blog.  Hmmmm - maybe I should consider a change of focus for the remainder
of my career?  I've had some interesting places I've visited in the last month but
none that was notable.  So, I thought I would point my readers in the direction 
of The World's 50 Best Restaurants [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXKia2vdRULqwZ6vnhZYjfn-A7l3g3SF1mh7CaRr92NUYrTVqGKotYPhCxI1IEMM-o0bCzLi1Rs-xVfwd4gkm7EvvtikR0nBdqIBvdxms30KwTMFxIlsOWejwFnHMi7GrtKo3bb5B8P0lmXcIxcw3Nqs=&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
  [* * * * * *].  For the first time since 2004, the top spot went to an American
restaurant, Chef Daniel Humm's contemporary American restaurant which took the title
away from Italy's Osteria Francescana or, #2 on the list.  #3 went to a Spanish 
restaurant, El Celler de Can Roca.  The list was notable from there down and is 
worth checking out.
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - Mom is recovering from her acute problems!!  And, our family is still
talking...
The Good - The drift among American politicians - on both sides of the aisles - 
toward the perspective that Twitter is not the best vehicle for dialogue in solving
problems.
The Bad - The continued fractionation of political perspectives into the Internet
worm holes of ideology and the lack of effort expended toward bringing us together
from our various perspectives to actually spend time working on solving societal
 problems.
The Ugly - The Twitter storms too frequently dominate our discussions and derail
 the important debates on issues which absolutely require our attention.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001YOCb1eTtpoGSZW6T1YEL2kq3tbfvVzyj-FesjmHMiA4exgJMjjnaXB9Y4Ge1J8gpQFQDIXrH1CcGXIOM5gwRSbw6Fy4KdLHJm0pYjqMm-qXVpawlDW0kO2jPKv7m6Xrk043IQhgzZYwg_5IG6dVjXzVR5Qq_nMtZEzM9VVXchPGohqr0PNaHq9He_toRmSXt&c=qIekdodZqWNIsMtnI_6zOSW-zWA-6Fov4Z6Hqzro0kUCj34-o-yrsQ==&ch=2xH7p7Bk9dDuvObcwlxZ37geQvZ4EQnFCSj_E9oP69V_CThWDHnX2Q==]
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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