Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Wed, 29 Nov 2017 11:21:41 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtS4z8jwnTsPhe53TIKWQHkY57LE1TyuQp3-nxp6JW8jMh0o-YgQQ7UfhvSnju1dJW6VGb0oSrXpPIn93A0vbvr80k87CQ8pWzXNv3pps5slpWBqJtCYjOerbxdiED9tdu0uzCIluxeLD&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
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The Fickenscher Files, Vol. 5, Issue 10
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtb-XnEBJLKAPAjB8SGO1CeajjqewqoFfJhJwlCycjryXiQMTYCI9Ar-gSNq-yX1KABRHYzbKPD_HOgYk9vXgNF7HwQnnBycoDgk54UJfOlaDZLZ7HdZtjfCW-eAy43vfxB5uxJ_qNfMrZIlU5V66asiO1AvGVKpJEA==&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==],
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
"As some of my closest colleagues have also come to realize, those of us who came
to Congress to change Washington for the better through good governance are now 
the outliers.  In legislating, we previously fought against allowing the perfect
 to become the enemy of the good. Today, a vocal and obstinate minority within both
parties has hijacked good legislation in pursuit of no legislation."
Rep. Frank LoBiondo (R-NJ), in a statement [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN812sIhxjbChZdpZsrVjdt5fBdNUppfhw57RfWdNhveuaYqcwMT4v4YgGJiA3P21ntvcMAkn7qN6ZPbJT6P5Vpi7OcltMHc4x4DKOGhVvX0aV1sBLFPdD5BRA4h0AYfRpiRt973P4LJC-SaMHPJmbLqeHqoQFtR1xf8zbsV6QPsPXCQGzqfRuWXA==&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
on why he made the decision to not seek re-election to the US House of Representatives
in the upcoming mid-term elections.
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Consulo Indicium
Information for your Consideration...
Costs Continue To Climb - According to the Wall Street Journal, the average cost
 of health coverage in the USA for employers increased by 3% over the previous year
to $18,764 in 2017.   Employees with families picked up 31% of the tab on average
or, $5,714.  For individual employees, they picked up 18% on average and incurred
a 4% increase over the previous year to $6,690.  While the cost of care lingers 
in the background - we as the professionals providing the care and leaders organizing
the care - a need to do a better job of managing health care costs.  It is the lingering
and tenacious aspect of health care that will be moving to the forefront of society's
concern over the coming decade as an unsustainable expectation...
Meanwhile, Back At The Ranch - In an article published in USA Today, it was noted
that of all "salaried" employees in the USA, the physicians - on average - make 
the most of any employed sector according to Glassdoor.  Physicians took the pole
position by coming in at $187,876.  Coming in at a distant second were pharmacy 
managers with an annual compensation of $149,064 followed by patent attorneys at
 $139,272 and medical science liaisons (who are they?) at $132,842.  So, it appears
that health care professionals took the top three positions.  Humm...  Back to the
first item under Consulo Indicium in this week's Fickenscher Files.
And, Why Health Care Costs Are So Important - One of the themes I've attempted to
share with my readers since starting The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtS4z8jwnTsPhe53TIKWQHkY57LE1TyuQp3-nxp6JW8jMh0o-YgQQ7UfhvSnju1dJW6VGb0oSrXpPIn93A0vbvr80k87CQ8pWzXNv3pps5slpWBqJtCYjOerbxdiED9tdu0uzCIluxeLD&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
is that the USA society cannot continue to sustain increases in health care costs
that exceed the cost of living increases.  Why?  First, the USA is coming to the
 very end of an era where it was dominant as the only significant economic engine
in the world. Now there are many.  In part, due to the global economy, our goods
 and services must be competitive with similar products produced in other parts 
of the world.  Second, if we allow health care costs to continue the trend of the
last half century, we will not be able to make up the difference with productivity
increases alone.  The end result will be the need to control those fixed costs like
health care. According to OECD data [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN8CtbaIFwauC3CCLVKVGcB4n6lyXF-i7hTnHaJBvUrNEWG4wCiWsCtwzNmvgnv4k_snYapR20thBvrlU48pwwjXs0PlB4gN3axJ7K26Xffhxy_nS4BUDgHfeC_dyMPk3uEsGpApgy0-I4sqVnMVdLpblFUvsPgOVBwkjXcbaKK1zsszktKJExXEg==&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==],
the USA ranks 12th in the list of all nations.  The highest debt-to-GDP ratio goes
to Japan at 239.2%. And, are they worried about health care costs?  I just returned
from Japan.  You bet they are!  It's a major percolating public policy issues.  
The next 10 countries are: Greece, Lebanon, Italy, Cape Verde, Eritrea, Portugal,
Congo, Bhutan, Gambia and Singapore.  Countries with comparable economies to the
 USA have considerably lower debt-to-GDP ratios such as France (96.8%), Canada (89.6%),
United Kingdom (89.5%), and Germany (65.0%), among others.  The disconcerting part
of the whole issue is that the proposals for tax cuts emanating from Republican-dominated
US House and Senate will result in an increase of the USA debt by over $1 trillion
(yes, that is trillion with a "T"). As we say back on the farm, "...that dog don't
hunt!"
The move toward value-based payment models was on track to make a dent in the problem.
 Those of us in health care need to make sure that those model efforts continue 
and that from the lessons learned, we move toward payment systems that foster efficiency,
require quality outcomes, drive effectiveness, while simultaneously reducing costs.
 A fee-for-service system will not push us in that direction, from my perspective.
 The policy for supporting these new models will come through active dialogue, debate
and compromise between the liberal and conservative elements of our two party system.
 So far, that notion has been missing.  However, based on the results of the recent
election, it appears that more and more of us are becoming dismayed by the continuous
impasse in Washington, DC.  Around 2008 or 2009, I proposed creating a new Political
Action Committee called, "TTRO" or, "Throw The Rascals Out".  It was intended to
 serve as the PAC for those of us who gravitate toward the middle. The intent would
be to drive out the obstinate ones on either end of the spectrum so that we can 
begin to solve some problems for the country.  I better stop or I might get into
 a rant J.  But, you all get the point...
Burnout High Among Physicians - The news is not great.  In fact, it's downright 
discouraging but increasingly it's what you hear in the hallways and in the quiet
conversations over coffee in the cafeteria.  In a national survey reported [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN8naTz8DCALs8Ri5PsJH2jwDG_6Okoi9liyURMUIRjdYyRPUw1RQOiNAItG8fdF2ZmKTYQD06tYn1LmvbziS3iKcJ72OiXbW1_oIWU9AZ_x_z9MmAX5deM-oCqCEMl_l9PuUGcPNQHrmcOMcTBE2JFX5fXcn3GGxnTX0oNczpwFYAxksOqhiEysB05xGAzPQzd&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
in the November issue of the Mayo Clinic Proceedings (2017;92:1608-1611, 1625-1635),
a survey across all specialties of physicians in clinical practice in the United
 States from 2014 revealed that nearly one in five respondents indicated their plan
to reduce practice hours within 12 months.  Equally troubling was the report that
one in four indicated they would leave their current practice within 2 years.  These
findings speak to the major looming crisis on the horizon - the pending shortage
 of clinical providers.  And, based on data from the AAMC and DHHS, it appears that
the situation is even worse for primary care. The leading cause of physicians' decisions
to reduce their clinical work hours or leave practice relates to professional burnout.
 Specifically, the survey respondents showed that 19.8% planned to switch to a part-time
clinical schedule within 1 year, increasingly to 26.6% within the next 2 years. 
 Other options included retirement (37.4%), pursuit of a different practice opportunity
(35.2%), and movement to an administrative position in healthcare (9.7%) [NOTE: 
having done that I could provide counseling that administrative work is not exactly
stress free J] or switch to a different career entirely (7.4%) [If there were not
so much standing associated with it, culinary would be a good choice J]. The most
likely physicians to seek alternative directions with their lives were in the age
50-59 bracket.
So, why?  The two biggest factors contributing to burnout were dissatisfaction with
work-life integration and, with the burdens associated with the use of the electronic
health record (EHR). For those physicians making the decision to pursue a different
career, the correlations were even higher than those who were simply dropping out.
 The EHR problem has been reported in several different places in recent years but,
most notably, has been followed and reported by [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN8BwKv7wHasags4MdODD3f9P5HmucRZ3nTcsef-dVybup7jJB31G25CpZU40wb9yfE2StZIw_ry5y2toWG2BsC2Spbi2qt_3EkSPIR-0GQb3xh2vtTReEYTYjQqedsVQ8bD1KqEudjkJg=&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]Medscape
Medical News with the same results.  The issue is the looming crisis on the horizon
and does not seem to be getting much attention in the medical community.  Based 
on the data I've been reviewing on this topic, about 1/3 of all the primary care
 providers will become disabled, retired or die over the next 7-10 years.  And, 
primary care is among the specialties with the highest burnout rate.  We've got 
a problem!!!  The Mayo Clinic Proceedings report goes on to point out that: "Replacing
physicians is costly to institutions, with one recent analysis suggesting costs 
of $800,000 or more per physician," the authors report. "In addition, turnover is
disruptive to patients, staff, and organizational culture. A physician workforce
 that has one eye on the door may not be optimally engaged and aligned with advancing
the institution's goals." And, furthermore, the problem will not be solved by simply
turning over the care delivery to other providers.  The same phenomenon is evident
among all of the health care professions.  When I speak to health care groups about
this issue, at least I'm getting nodding heads.  Even as short as two years ago,
 there was silence.
These findings are one of the major driving forces - I believe - which are driving
us toward "telecare" as an option for care management and delivery.  Through the
 appropriate deployment and use of technology, we will be able to care for those
 individuals with both acute and chronic diseases more effectively.  However, we
 need changes in our reimbursement policies and attitudes among the profession to
move the ideas forward.  Now is the time...
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Future Health
Delivering care in the new virtual world...
Snipping And Solving - A remarkable note in the journal Nature [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN85JKLPhb8vErmUHHfIQqatNo0rn-tdYmg-TWsMRWrKuqTM1tf_y36oEhjX5Zr4W4C3MmCeeZ4xUGhwF4YPoWjcaMBCaNPYMkscpOBD0NBE15qsVuYbetqIMiXpxYNhO7XmwCO4VNnlSnki3IwsoaXrKiY9YPWLauu2_Il4XDROH4=&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
report [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN85JKLPhb8vErmUHHfIQqatNo0rn-tdYmg-TWsMRWrKuqTM1tf_y36oEhjX5Zr4W4C3MmCeeZ4xUGhwF4YPoWjcaMBCaNPYMkscpOBD0NBE15qsVuYbetqIMiXpxYNhO7XmwCO4VNnlSnki3IwsoaXrKiY9YPWLauu2_Il4XDROH4=&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
was finally made public last week by the physicians and researchers at Children's
Hospital of Ruhr University in Bochum, Germany.  In 2015, a boy (age 7) was brought
to the hospital with blisters over his entire body.  He was diagnosed with Junctional
Epidermolysis Bullosa - a rare genetic mutation of the skin where patients lack 
critical proteins that attach the epidermis with the dermis, the layer of skin immediately
beneath the epidermis.  As a result, patients lose massive amounts of their top 
layer of skin - like burn patients.  It is incredibly painful and most individuals
with the disease only live into the early teen years, at best.  They tried skin 
transplants with his father and a donor to no avail. The physicians in Germany then
decided to take a radical step and try something that had not been done.  They took
a small piece of the young boy's skin and did a snipping procedure or gene therapy
where they removed the "bad" gene from his skin and replaced it with a normal "good"
gene from another source.  They then grew sheets of his skin for transplant.  In
 an amazing turnaround, the new skin - when transplanted - grew quickly after multiple
procedures and after 8 months nearly all of the boy's skin has been regenerated 
using the new genetically modified skin.  He's now playing soccer - like most young
boys in Germany!  This is an example of what technology has been able to accomplish
over the last decade as new techniques and procedures have evolved to solve problems
that were previously unsolvable.
Digital Health: The Future of Health Care - According to a new IQVIA (the former
 Quintiles/IMS Health) report [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN8eJPuJrVw6hXFtWrWuhrJH8VsFGZj0gqpH1pfZtBhoknUADQrStvwkkfnUP_X9qGxYPo5vGRh-ZMsj7CH0l8g5QFwHt7i4pcMxwzs4WmOksUXnPfX5j6PuF1qP2GwzVgjLNABvR1v9wKyvMIaVjXI4ttCppL8aZqqxJaF849E7Ve-YaqVC6HZYw==&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
digital health products have the potential for reducing our nation's health care
 costs by as much as $46 billion in healthcare spending if the health care system
would utilize these tools on a comprehensive basis.  To give you a sense of how 
ubiquitous the tools have become, there are now more than 318,000 health-related
 consumer apps available on the web with about 200 additional more apps coming out
every day.  But, while they have become ubiquitous, the vast majority of apps have
been downloaded fewer than 5,000 times. While it's clear that the market is maturing
based on the ongoing research in the area by Quintiles/IMS Health from their prior
reports in 2013 and 2015 - the health care community has a ways to go in incorporating
digital health strategies into ongoing care.  The group estimated the potential 
impact of digital health on the overall health care costs by evaluating the impact
of five major problems, diabetes prevention, diabetes care, asthma, cardiac rehabilitation,
and pulmonary rehabilitation.  The group modeled the application of the digital 
health tools and based on research to date estimated that for these problems, the
USA health care system would save as much as $7B per year.  It then extrapolated
 those results and noted that if all the tools were used in the same manner, the
 overall savings would reach $45B per year.  I actually think this far understates
the potential because it relates to the use of the "apps only" versus using digital
health tools as part of a comprehensive strategy of "telecare" - which I've written
about previously.
Getting traction with the apps is one of the major problems and there seems to be
little research on the topic but I suspect it has much to do with user interface,
information value and whether or not the app actually provides real-time support
 to the individual.  In the app world, 41 apps make up about one-half of all downloads.
 In addition, of the downloads, 40% are related to chronic conditions - which tends
to make intuitive sense because the people that are the most motivated to use tools
like these are those with chronic health care problems.  Again, from the report,
 it appears that the apps are getting better since 55% are now rated as "four stars"
or higher compared to just 31% in 2015.  The ongoing and "in-the-moment" value will
no doubt be the predictors of how these tools are accepted by the users.  As the
 learnings evolve, I anticipate that the app producers will get better at producing
the right kinds of apps that help support the problems people face in their daily
lives.  We'll keep monitoring this evolving area.
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The Weekly Whisk
Musings from a foodie...
I recently had a layover in San Francisco, called my adopted daughter and suggested
dinner.  She suggested a new place in the Mission District that sounded interesting,
Burma Love [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN8vHh-QVVsJ0lHauFU1tKvr9cOk0EZmurtNGoyi12ju9BXnJ2TrvPzqBOXUhWzEsox0uA_nbOxSWLASXQ1kimWOfn7B7MBt4sNw7OJ4W8cOmx6C_FBChzzKA==&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
[* * * *].  Dressed in my usual best black suit with best black collarless sweater,
I was a bit out of place among the Millennials.  But, I jumped right in because 
the ambiance seemed great!  The food was a cross between high-mountain Burmese and
Thai styles cooking.  And, it was great!!  We started with samusa's - triangular,
ravioli-like pastries that are hand wrapped and made in the kitchen which were filled
with curried potatoes and Australian grass fed or, Halal lamb & beef.  They also
 offered a vegetarian version. The little samusa's are deep fried and served with
an in-house tangy spice sauce.  They were served up with a tea leaf salad which 
offered a cleanser for the palate that included a combination of lentils, peanuts,
lettuce, jalapenos (with just the right amount of spice to remind you it was Burmese/Thai
food J), sunflower seeds and garlic powder.  Needless-to-say, I thought the combination
of the two was GREAT!!! BTW, the salad was recently voted by Sunset Magazine as 
the "Best of the West-Salad".  The salad has been described as a "party in your 
mouth" and, I have to agree.  It was an absolute delight.  We then moved on to the
main course which was a fabulous chicken with jalapeno and mint sauce.  It's the
 type of street food found near the border between Burma and Thailand and is popular
among the locals in that geography.  Burmese Love has been successful in transplanting
it to the USA!!  The chicken was minced and prepared with diced jalapeños, mint 
leaves and cloves of garlic. It offered up a slightly spicy and very delicious course.
I was quite taken by the place.  In addition to the food we ordered, they also had
many other options in the chicken, seafood, beef, lamb and pork areas along with
 an assortment of vegetarian presentations.  Finally, the tea selection was also
 outstanding.  I would definitely recommend that you consider it for any kind of
 stay in the San Francisco area.  It's yet another culinary delight from a delightful
culinary mecca.  Check 'em out: Burma Love - 211 Valencia Street - San Francisco,
CA  94103 - (415) 861-2100 - www.burmarestaurants.com [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtVuC7umimPN8vHh-QVVsJ0lHauFU1tKvr9cOk0EZmurtNGoyi12ju9BXnJ2TrvPzqBOXUhWzEsox0uA_nbOxSWLASXQ1kimWOfn7B7MBt4sNw7OJ4W8cOmx6C_FBChzzKA==&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
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The Good, The Bad, And The Ugly
The ongoing saga...
The Good - There were no new revelations in the ongoing saga related to Russian 
interference into the 2016 USA elections.  Then again, the leaders of the CIA, DIA,
and FBI all confirmed their prior reports that interference did, in fact, occur.
  Not necessarily a good - but, their standing up to be counted is a "good".
The Bad - The timeframe for consideration of the US House and Senate tax bills will
not allow for the type of scrutiny required on a piece of legislation that only 
passes Congress once every couple of decades.  Already, the troops are rallying 
in a growing cacophony of "nay" - all for very different reasons.
The Really Bad - Judge Roy Moore has a problem in Alabama.  Quite frankly as an 
active Christian and lay minister in my church, I'm offended by many of wrappings
he surrounds his positions with as "Christian values" - but, that takes us down 
a philosophical route which is quite complicated.  So, rather than here, I'll take
it up at church...
The Ugly - Uncontrolled tweeting - there is no nuance and increasingly it appears
to be a tool that is not well designed for diplomatic encounters.  So, why?
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtS4z8jwnTsPhe53TIKWQHkY57LE1TyuQp3-nxp6JW8jMh0o-YgQQ7UfhvSnju1dJW6VGb0oSrXpPIn93A0vbvr80k87CQ8pWzXNv3pps5slpWBqJtCYjOerbxdiED9tdu0uzCIluxeLD&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
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=001WBVzeYFvdhy6FiELmObvDAXzCcQCJFEgtkYVy6e8wO6IPHR_GRdZtS4z8jwnTsPhe53TIKWQHkY57LE1TyuQp3-nxp6JW8jMh0o-YgQQ7UfhvSnju1dJW6VGb0oSrXpPIn93A0vbvr80k87CQ8pWzXNv3pps5slpWBqJtCYjOerbxdiED9tdu0uzCIluxeLD&c=RvUHYrs1lCgqriidfdNm-m-Z8HnX95X1OGonrI0p8Cdv7wmnmad7Eg==&ch=phLwmtuDzGH1yu-80HP4-qJ4OqJZim5TZWh7TPiPyMunBrDrPSbxiw==]
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