Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Tue, 2 Jan 2018 11:40:34 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEQjY-hSOPx32zzxk0-UpdhP8fk60xnsjghAowFgb6SG2gAu_Z1MQWjR7MDms95bejLPRUjQnqR4L0qIqMPwVgNj0JQpkQtRogHbftv9kZPluqaug9drp7fr5fQKJGUK0zH6BjOp9O-c8&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
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The Fickenscher Files, Vol. 6, Issue 1
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEWGXmJidL8k6LtsFwPdz5_EFQ27ve6z266xYbKEQSIRns37Lz5ok-gdrUb9u-F4k_jc4hJ-54J1WzfsKeOClnToXt-wHpWGkbMWw61mBnmtGnYha99GE0RXkHYiff-iuDst05SuunJKbdFSn0e0amuXRIwq-84-ABQ==&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==],
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
"I don't think it's in our society's best interest to expend energy in repealing
 the law."
David Cordani [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GXdTPynWpPXKk_13vop_8xr4r2AITEVe7RuDbjhjFV5wachB3Mr1tAAG4nfA_vaM4oJcA5dlewlZrjhDp1wQY_GN5wuFWSxRAIG1CoNRDNYs1uLzL3PUQSE2H1Q-_Sq_KIy3zmA2vzhICmR4uuVZ8ZQ==&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==],
the CEO of Cigna, the fifth largest health insurance company in the U.S., commenting
on Republican pledges to continue their efforts to repeal the Affordable Care Act.
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Readings To Consider
Books and Articles worth a Review...
While there are lots of technology books I could point out for you to consider as
part of your portfolio of readings, I instead encourage you to take a break from
 the usual fare and consider, River of Doubt: Theodore Roosevelt's Darkest Journey
by Candice Millard.  It's gotten all sorts of awards and is a page turner.  It documents
Roosevelt's journey down the - at the time - uncharted River of Doubt [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GufSOZv7fMY5611KS2hW7C9t7R2RoFK1iUz72w2dhh3MPhHJK7oy6h9q-hqIELmSJrz_sv6-3y6_AyaeCQhOjOPYmRgvy-JYP1gqaxRdw41I8G4uH54uXjXOdABlxVsZtx9NrI0pf1SMXmJJ6yow5I9qMsNYtuLPSPPoX9utWkt8=&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
in South America.  You will learn about one of our nation's most revered and heroic
figures and how he was brought to his knees in the jungles of the Amazon.
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Future Health
Delivering care in the new virtual world...
Making Predictions About The Future - Rather than offer up snippets of thoughts 
and ideas for you to consider in the post-holiday humdrum, I decided to focus on
 what we should be anticipating in the coming year.  It's always risky to make predictions
or as Yogi Berra said, "I never make predictions, especially about the future."1
  But, it seems that as the New Year rolls around, I'm always asked by readers about
what my thoughts are for the coming year.  So, here's my Top 10 list for 2018.  
While it will be an interesting and challenging year in health care, "interesting"
and "challenging" may be understatements in other parts of USA life.  But, here 
are my thoughts for the coming year:
#1 - 2018 Will Be The Year of the Virtualist - I have actually been working with
 a number of colleagues on an article related to the "virtualist" movement - when
the article came out in JAMA.  So, we will not be the first and, most likely, not
the last to comment on the movement.  However, the "virtualist" movement is not 
and should not be confined to the medical profession.  Virtualist training and education
should be of paramount important to all the clinical professions for the future.
  In my estimation, training in the virtualist sciences (use of technology, digital
human interaction, artificial intelligence, and other areas) will become as important
as physiology, biochemistry, anatomy and the traditional educational areas.  The
 time has come for convening an educational task force to define the critical elements
for the clinician of the future (physicians, nurses, pharmacists, medical social
 workers and the like) who will be involved in virtual care delivery.  To date, 
there has been an insufficient amount of work done on the field.  However, in 2018
we should expect more than a step function.  There will instead be a rapid acceleration
of attention toward the need for "virtualist training" among the health care professions.
#2 - ObamaCare Moves from Option to Entitlement - For all the foibles where I may
disagree with politicians on both sides of the aisles, Mitch McConnell (R-KY) is
 a very smart politician - putting aside his political perspective.  There are many,
many people who have gained access to health insurance through the ObamaCare program.
 It has moved from an option to an entitlement for many many citizens across the
 political spectrum.  The fact that the enrollees increased for the 2018 sign up
 in the Fall is a signal that the demand will only continue to increase.  We are
 slowly but surely moving toward an "expectation" that basic health insurance is
 a right rather than a privilege.  Once people have it they don't want to give it
up.  From a practical standpoint, taking on the ObamaCare program yet again would
be a political suicide mission for the Republicans.  The 2018 mid-term elections
 are already going to be a tough sled to pull.  Why would any practical politician
want to do that?  And, Mr. McConnell is quite practical.  So, the move toward entitlement
gains even more traction in 2018...
#3 - Remodeling Health from the Outside In - Have you been watching the transportation
and automotive industry lately?  It's been interesting.  Aside from all the competition
"inside" the industry between Toyota, Ford, GM, Chrysler and others - there's all
the accelerated competition coming in from the outside by Amazon, Google and others.
 We should expect that the same phenomenon will begin to occur in health care.  
Innovation by the health care systems does not move at the same pace as outside 
interests.  The end result will be that innovation that appeals to consumers will
be coming from the outside in.  Expect non-traditional players to move into primary
care.
#4 - Telehealth Moves to Telecare - Much of the discussion in the telehealth space
has been about mHealth and wearables, etc.  While these approaches to technology
 provide some degree of value - at the end of the day, it's all about reducing costs,
improving outcomes/quality and enhancing customer service.  While these tools to
 date have focused primarily on the consumer services side - the other two areas
 really rule the day in health care.  "Telecare" or, the provision of care using
 remote and virtual technologies preferentially over traditional face-to-face models
will come to the forefront.  Watch as the investment community finally figures out
that yet another isolated, "sliver solution" on pick-your-favorite-problem (e.g.
 diabetes) may provide some degree of individual value but ultimately does little
to touch the core problems of reducing cost and managing quality.  These supposed
"solutions" will be found to only touch on the problem.  The move toward telecare
as a comprehensive redesign of traditional care delivery is an inextricable force
for the industry.  Expect some entrants to finally emerge as dominant players of
 note in the coming year.
#5 - Clinically Augmented Intelligence Rules - There is lots being written about
 "artificial intelligence" or AI [NOTE: For further information on AI, go to the
 AI Index 2017 Report [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GvL3hSa3Fj0r_OR4D25G0lr0K_LZYgLJXG7BIqfKUUHsTO2lNEulqBvi8SUTQ64PIc87XyBVpZCcQwXjTtx_WiTSxIZEovcnigheA-u8S3QLAYe--pZJbQaobXDY4j-ID&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]].
 In fact, hardly a quarter of a day goes by without getting some notice on the topic.
 It's important and the question being asked is will this set of technologies replace
the humans in health care.  This is where I may be a Luddite but, I don't think 
so...  In my mind, the AI movement is a precursor to creating tools that will offer
"clinically augmented intelligence" to people.  Computers and AI are great at augmenting
capabilities but teaching these technologies enough skills to replacepeople capabilities
is a step too far.  Think of the stethoscope.  It didn't replace doctors.  Rather
it created fields we call cardiology and pulmonology.  The MRI didn't replace radiologists.
 Rather it augmented their ability to read and interpret findings that could not
 be visualized with traditional x-ray technologies.  So it goes for AI.  The focus
will shift from replacing to augmenting to handling the repetitive skills and functions
where humans cannot process enough information fast enough to see the forest for
 the trees.  Think of large data sets and the analytics for population health.  
That represents clinically augmented intelligence.  Humans will still be needed 
to go "Aha!" - at least for the foreseeable future...
#6 - Boomers Demands Start to Exceed System Capabilities - With 10,000 Boomers moving
into retirement and the use of Medicare everysingleday the demands on the health
 care system are going to accelerate appreciably over the coming year.  The first
wave of Boomers have hit but the second wave which started this year and will continue
for the next several is far larger and, some would say, more demanding J  I'm one
of them.  I've consumed more health care resources in the last bunch of years than
I consumed in the previous 60 years of life.And, I'm a typical Boomer.  We are not
a quiet lot.  We are, in fact, quite demanding.  And, while we may not be as facile
with modern technologies as our Millennial counterparts - we do use the stuff and,
we find the best options, the best providers, the best outcomes, etc.  Boomers will
clearly start to exceed "the system's" capability for responding to demand...
#7 - Consolidation Continues and Accelerates - Consolidation is not only going to
occur among "like" parts of the health care delivery systems (e.g. hospitals merging
with hospitals, large clinics buying practices, etc.) but will also spread across
the "different" parts of the health care system (e.g. insurance with providers, 
analytics firms with primary care groups, etc.).  As the need for innovation begins
to gather speed, expect further consolidation which is already moving along at a
 fairly healthy clip to only accelerate.  We will not only see more hospital-to-hospital
system mergers a la Aurora and Advocate but also more cross-industry consolidation
like the recent CVS and Aetna merger.  And, beyond that why not Microsoft, or Amazon,
or Dell or Google or Baidu or pick your favorite winner and you will not be far 
off track.
#8 - CRISPR Gets Crisper - In 2013, the first CRISPR capabilities were deployed 
by snipping a section out of a living cell.  Now, just a short five years later,
 the technology is coming of age with high hopes for curing - yes, curing, major
 diseases.  The target for the CRISPR capability are those genetic diseases where
we know the specific targets like sickle cell or thalassemia.  However, there are
an increasing number of cancers as well that could be targeted.  On the docket for
future study are melanomas, sarcomas and multiple myelomas - all with varying degrees
of genetic predisposition.  With the pace of change occurring in the field, I believe
that CRISPR interventions will become de rigueur by 2025.  Keep a close eye on this
one.
#9 - Equity Moves Beyond Genealogy to Include Gender - Over the last 20 or 30 years
we've seen a fair amount of civic dialogue on issues related to "racial equity" 
but little on the issue of "gender equity".  2018 will see a surge in dialogue, 
discussion and debate on the topic.  I remember starting medical school in 1973.
  Our class had 60 admissions and instead of the usual 5 women that had been admitted
every year for many years, we suddenly had 10 and, the ramifications were very significant
- in a positive way!  But, when we look around at leadership in the health care 
industry, we are still in the nascent stages of a shift toward more equity in leadership
based on gender.  The situation can and must change.  It's about time.  For me, 
those new entrants to medical school had a profound impact on me personally.  In
 fact, if it had not been for Cynthia (the smartest person in our class), I would
not have survived the first couple of basic science years.  Expect more on this 
front over the coming year...
#10 - Data Fluidity Ruptures Traditional Sovereignty - The evolution of technology
platforms that span the globe are creating a new fluidity in how, where, who and
 what is governed from a data standpoint.  The policies of lore adopted any number
of decades ago by governments across the globe will prove to be wholly inadequate
for the new world of information technology.  We will see the clash of state with
corporate sovereignty in terms of who, what, how, where and when data can be used,
managed, controlled and used.  Not only will this present technical challenges, 
there are also economic implications on all sides of the equation.  The battle lines
that get drawn will play out in "state's rights", federal prerogatives, international
treaties and global economic development considerations related to privacy, data
 management, licensure, intellectual property, among other considerations. And, 
if all of these issues were not enough - the political understanding of these issues
is at the very nascent stage.  Simplistic solutions will no doubt arise on the horizon
but will end up being like a balloon where when you push in one spot, it expands
 in others.  I don't have solutions on this one but, it may likely be the biggest
issue of 2018 as it rears its head from amid the many exciting evolutionary aspects
of new technology trends on the horizon.
Predicting The Future of Work - I recently read an article by Stephane Kasriel, 
the CEO of Upwork [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0G6PJ60FKXnO8-JZFcsdnmKBPilZPXGN8AJHoC_4eraPZfE3m6958vZCIs0OiOgE6hrGko6zne2ioPQSP1zM2uDOhQI3Z-KQIcFg_m3IfFP0k=&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==],
a website that finds and filters freelancer staff of all types for the gig economy.
 If you need a virtual assistant, they find you one.  If you need a specific skill
for your website management, they've got 'em.  If you need a consultant, there are
a number lined up to help you solve your problem.  It's the new way of managing 
in the etherworld we live in!  In the article, Ms. Kasriel refers to the world of
the Council on the Future of Work, Gender and Education [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GtN5cEhIbIW_vnEKDHuGlsJZU0gyKXXjsl4bNtMSYD5yEuA-fdtCmquBYMhVtd8z963Wo0w4PsYaoH5MlE9DLxZLJ4GY9MIWg1tTFctV0O1O3WI9qwQuTTLjDekQuzeNoyicLTR4vf1L4UVuyiLRvwuB0gMJjMoDYjLE8xWQ0vmhKSQzeGfGb9w==&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
of the World Economic Forum where their members hold deep dive conversations on 
the future of work and the impact of such issues as artificial intelligence.  She
made four predictions about work that are worth noting:

1.  AI and robotics will create more jobs, not mass unemployment - as long as we
 responsibly guide innovation - artificial intelligence will not - as Elon Musk 
describes it become "...our biggest existential threat."  AI will change work and
make it far different than it is today but it will not replace us (Whew J).  It's
an observation that I share.  For health care, I refer to the use of AI as providing
support to clinicians with "clinically augmented intelligence" (SEE above).
2. Cities will compete against other cities in the war for top talent - We've already
seen this prediction play out in the battle for Amazon's "second but equal" corporate
headquarters.  With an investment of over $5 billion in whichever city is finally
selected, Bezos and Company (i.e. Amazon) receive more than 200 proposals to serve
as their new headquarters.  We will see where this ends up but at the end of the
 day, the final decision will likely come down the availability of talent or people
resources.  Expect more on this front in the coming years.
3. The majority of the US workforce will freelance by 2027 - Ms. Kasriel points 
out that at the present time more than 57 million workers or, nearly 36% of the 
US workforce participate in the gig economy.  She cites a study completed by Upwork
[http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GU2wvGwaI2YSzBxfEqoJNppsK2r0HqwJ6IV_uAhXH7U3cPzusFRFFXSpBitVhwttknxe52kJr6SVy7zk1rjHH4pmucH7gepJ4U4lsFWDS73eFjtBUZ15_LztL-hFoFdUCXrK3hoRfyDqgekTYlyk0-gNusT6JCSMr&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
in 2017 which projects that by 2027 more than half of the economy will be comprised
of freelance workers. Now, while it may be a fit self-serving for a freelancing 
website to tout such numbers, it seems to me that she is on the mark especially 
among Millennials where more than half are already involved as freelancers.
4. Education breaks out of the silo - she makes the argument that our "education
 system is broken". It's ironic.  I serve on the Board of Directors for an acclaimed
university and have been making the same arguments in the last year.  The approach
we've taken to education at both the undergraduate and graduate levels does not 
speak to the needs and requirements of future generations.  Our focus needs to be
on providing a core set of "integrated skills and capabilities" as part of our degree
programs that allow the individual to ebb and flow with the evolving economy.  We
also need to prepare students on how to actively learn by incorporating a model 
which provides ongoing education and learning rather than only offering segmented,
defined and structured modules.  As she points out, "Preparing students for tomorrow's
jobs requires breaking down the silos within education."  I couldn't agree more...In
fact, check out my podcast interview [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GWlHXZb5tbNlQlTQux0fU71SmuGYWJMaHCkxQXVqVJzORfxeECE4Laolvyj-mbdcXkR-B08mCf9dk3UctSEh4LeXhCRpaMoa-mZH5VfrXeKqkslb8-ifooWUGKbOQzELo7Qm4GquwbCx_-TWS33KQItwcMKP8-kZzJuoq4Hn16K_Td17wM2PqVb3Zl22dQZGv6K-NlcnMw84=&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]with
@sandboxSNHU about what #highered can learn from #healthcare.
Read the whole report by going to the Upwork website as noted in the hyperlink above.
 You'll find it an interesting read and worthy of your considerations.
[1] NOTE:  There are many different individuals who are cited as having said these
words in various forms.  For details on the origin of the quote, Check this site
 out: https://quoteinvestigator.com/2013/10/20/no-predict/ [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0GH6zV_IXf5vN-00V0Ct7io39jlikXWZl1CcJ_Oi8Aw10XVf-H_oCYAWiGne8WlVQhO0rtZDJ6etu1I_YZRr-rr1NioBVNMQoYcI3elFY1Li89SdnYKOt05ehIkaNpqhWwTlbhLupgFlqk48fWmzAOIzKNzpsPBx5I&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
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The Weekly Whisk
Musings from a foodie...
Ah yump!  Café Miranda is a nice little find up in Rockland, Maine.  Over the holiday
weekend, we traveled up to Belfast, Maine for the annual bonfire on the beach celebration
to bring in the New Year.  On the way, we decided to take in the Farnsworth Museum
in Rockland, Maine which houses the largest collection of Andrew Wyeth paintings
 of any museum in the country.  He is an iconic painter who captured the imagination
of the public with his still life paintings of various topics while living in Maine.
 It was a great review of his work.  Following a couple of hours of pondering the
paintings, etchings and watercolors we wandered over to Café Miranda [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEbzQT3HyRM0Gz6zJ745CpgH0RI3cpaWws-6ugAZG-OpbIYQbQk4fNq-Yil7skbMWfGapnNYps2n1muU-yrAWPva3zskt_klHrCG4E3kw_gvEnOI3r_0a-gB3CuPfif9ehA==&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
[* * * *], which is adjacent to the museum.  We had been advised that it was a great
little eatery and, we were not disappointed.  Our team of hungry exhibit goers started
with some soup.  After all, it was nearly -10 degrees with blowing winds.  So the
wind chill was somewhere further down the Fahrenheit scale.
We started our lunch with some soup and decided to try a couple of different options.
 The black bean soup was hearty but unremarkable.  The roasted vegetable soup; however,
was of another order.  They veggies had actually been roasted before being simmered
in a simple vegetarian broth.  It was exquisite and perfect for a cold winter day.
 These were followed by a Reuben with pastrami that was enough for two people and
perfect fries (a tad salty, crispy on the outside, warm and softer on the inside
 - or, at least how I like 'em).  But, the crème de la crème was the fish and chips.
 As somewhat of a connoisseur of F&C - which has become my go to lunch when I'm 
out and about - these were some of the best I've tasted either here or in London.
 First, the haddock was fresh and cooked to perfection.  The coating was a panko
 crust that had been left in the fryer just the right amount of time.  It wasn't
 too soft and was not overdone.  I'd go back to Belfast, Maine just to have the 
fish and chips.  In fact, there are other exhibits so, I will go back... If you 
happen to be in the neighborhood, I heartily recommend Café Miranda - 15 Oak Street
- Rockland, Maine - (207) 594-2034.  So, you see visiting Maine is good any time
 of year - summer, fall, winter or spring!!
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - It was a fabulous holiday with family and friends.  I hope you enjoyed
as much as we did!!
The Good - The end of 2017.  Now we can start with a new set of tweets... J
The Bad - The decision by the FCC to undo the "net neutrality" policy which was 
in place over the Obama Administration.  This is a BIG, really, REALLYBIG issue 
- more on the topic in a future Fickenscher Files edition...
The Ugly - The ongoing show down of words and provocations emanating from both North
Korea and the United States.  The solutions are not pretty but the words of provocation
don't help the situation.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001IAkJMX164XPqLudlc6mbu3KPBt-AISLh_z1EZ_BVUi5E6OYNLQVNEQjY-hSOPx32zzxk0-UpdhP8fk60xnsjghAowFgb6SG2gAu_Z1MQWjR7MDms95bejLPRUjQnqR4L0qIqMPwVgNj0JQpkQtRogHbftv9kZPluqaug9drp7fr5fQKJGUK0zH6BjOp9O-c8&c=RwT1gMrxDfZP7XyEp5DBnFR8LcoHjDEj4OOIKvM7KrjZAJ6eevrP3g==&ch=NKfyrgdklL0uhBgVINTkqwImz6OvOIYgyRGEQL0al_9u8HQt1PiKzA==]
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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