Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Fri, 30 Mar 2018 14:37:53 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnPx3PuCuGeOI0FPsytDZH5H9X5QQGNIwbxiyhN3f7BQK57EzFrY7Gi2B7I2o8QzaayKgznzHQKoK7j95oMA-q9Gi7fmVeEcpsgrv0Gw3qUcOLTAHZSBFHmSHlZFEImuYXakKoxjXsh7C&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
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The Fickenscher Files, Vol. 6, Issue 5
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGyOSCJKhFF06JJ2A8BPZYk49t1ZAUxBe44gDa3bsbgcLkj2oR0Kvx9hJXfHDa6HFrY_eahjcwDuPT8GVco-EOuERe4rJxqI4WfSZnD80UJlnKGQNWmNOxQWSVgIB4pyaaOEMALKA7-Op52xExECa_hQyYZZk4SjPA==&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==],
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
"Change is possible. Change is necessary. And change is coming... This administration,
and this president, are not interested in incremental steps... We are unafraid of
disrupting existing arrangements simply because they're backed by powerful special
interests."
Alex Azar - Secretary, US Department of Health and Human Services at the annual 
policy conference for the Federation of American Hospitals
"Every spring I'm reminded of the fact that healthcare is the one industry where
 the same old ideas are considered fresh for decades..."
Jonathan Bush - CEO and co-founder of athenahealth, in a note on a LinkedIn post
 [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlPuBoDHagBm07Yf-6qS8f836B3kFUdeeag2Ssq5d83zmVw8t4JKO9wCzpZtzc9qVhpF_M7698tCUufJHtEVvONnSof6Tbh26kfM5K3erL5B4aFPqhHkBzyYv3AQxOXnIyaZkClkf43NbvyXwXAlomKFfdEQskhn3ak5VdGzHoOemv9OUNubGB2VVdkHPKNXRe&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
March 23 where he outlined three steps [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlNusRha0PAg3GA7pSkaDHiPPxmwV55a4X_fG7LYP4ce4349M3IKS_SgkOBqQzkdvoZDJ8bx1-qtmBOyR0nDByKr2S_9wByZTWBCkt2a3dZwFln96WY8VbTRflmK9ZX5QnsX5g_IWTkW2RbIvJCP11kJ_DgljZVFLSeNdbk5v_sQZZWzbJoz30_AiNaTA_2d0OfVm1DUTXipKQfCZZPK68m0CP24F1h6p6t0yRYqfdVTpWI1ECRBvfLUMr8Fit1drv4gXdweVdTTSPttselTri3hQ8C52_iWHWrOVjKSiTkvp-oTP7Zo-IlIf8kNYytD0k&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
to take healthcare transformation beyond "buzzwords."
"...I am convinced that privatization is a political issue aimed at rewarding select
people and companies with profits, even if it undermines care for veterans [and]...
As I prepare to leave government, I am struck by a recurring thought: It should 
not be this hard to serve your country."
David Shulkin, MD - Immediate Past Secretary of the US Department of Veterans Affairs
in comments for a New York Times editorial on why privatization of the VA will "hurt
veterans"
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Media To Consider
Books, Articles or Videos worth a Review...
Preparing For The Virtualist - As my regular readers will know, I've been an advocate
for some time that we need to be considering how best to appropriately train clinicians
to become "virtualist" care providers. I do not believe that you simply take good
clinicians, place them in front of a computer and say, "Have at it!". If we do not
prepare these clinicians to understand the nuance of voice inflection, to detect
 the potential meaning of facial reactions, to understand the basics of large data
analytics, to have a core understanding of the field of informatics - and, a host
of other "to" items, the Health Care Virtualist will not be adequately prepared 
to provide high quality care in a virtual environment. And, while I'm on the topic
- this is NOT just a medical or physician's domain. I believe that if we are to 
be successful in adopting, adapting and effectively using tele-technologies - it
 will require a team model. In essence, I'm making the argument that "virtualist"
training should become a core element of training for all clinicians just like physiology,
or microbiology, or pharmacology are consider part of the core curriculum. There
 is the JAMA Virtualist article [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlFCR3npG--JaFHU14NKKFwjK-Yyg2Eft9oTOCgKG56cwj4xb9zXGv9pka5iYNaZjsaBEdUfj50z3cNSaQsSfSyQMxhpaZmxxeF7hgScGKIQcE6qlH_sYIRGBt6HoewALT9tJVphGbBtWDVGi6pq2SDlpLEUbvot6ZaXyvP5p4U2uFo_7xe742v0CZl7m5FPK4&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
by Michael Nochomovitz, MD that advocates the need for considering a "Virtualist"
specialty. While that may actually evolve over time, I think the real discussion
 needs to be centered on cross-disciplinary approach toward "virtualist care" training
for all clinicians [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlnpXbvz4pZnma407eyTdUqoDsJhBzZOmz31cymg9CTjwxUD6MhJsLRxXFdcES9a6Tg6oFC0HbDtv9XLjp34gBk1mBz-ksTOTKsgx_umRpFDjM5RbPTsAKUtNPVESjEFnf5S5fw7ys_liEsZIL5JBn1XoK8kow34ga4yXBDsIv0Q-egUC3S2bpkQ==&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==].
Virtualist care will be the norm in the not-too-distant future - just like a stethoscope
hanging around your neck.
The Siren Call From The CDC - For those who missed it, Ken Thorpe and team had an
article in Health Affairs [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlIOWbSFpZFSjxCgE3PcG1bqiP2l2QUmPZc5NewkkXJ8WSLjRIe3lShZsKDlbk1NM2lABzPhNwTM3PCx00XaFQwoKSAlWd-V95zpqv4Vg25chdtVAVb5R0Z1-r5Hj9c4mNuQu6NogkoqcvBugBcIg-EUqtXn0DmhltIX5pSqxG_dk=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
last week on the lack of attention to a major, growing problem - antibiotic resistance.
There is not much known about the contribution of antibiotic resistance to rising
health care costs. So, the researchers reviewed the data from the Medical Expenditure
Panel Survey to derive an estimate. Their assessment was that antibiotic resistance
adds about $1,400 or, about $2.2 billion annually across the entire nation. So, 
you can see that if we extrapolate the data on an international basis, the cost 
is very substantial. More importantly, it's growing at a very rapid rate. Something
needs to be done and, it starts with educating physicians on the use of antibiotics
and in how pharmaceutical companies manage antibiotic manufacturing - especially
 in foreign countries. Dr. Thorpe's team called for new infection prevention programs,
antibiotics, and vaccines to prevent and treat antibiotic-resistant infections as
an international priority. This is one of those looming problems that is on the 
horizon and my fear is that when the problem finally hits us on a massive scale 
- the health care community is going to look at one another in bewilderment.
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Consulo Indicium
Information for your Consideration...
The Opioid Problem - It's appalling. The numbers are staggering. 175 people die 
every day in the USA from opioid use. About 110 people die every day from car accidents
in the USA. Medical error cause 268 deaths per day (Institute of Medicine) and iatrogenic
surgical-related deaths come in at 88 deaths per day (Agency for Health Services
 Research). So, what are doing about the opioid problem? Really?
A Correction Of The Headline - Paul Keckley - a friend, colleague and respected 
consultant - recently offered an alternative viewpoint to the question on whether
or not there is a physician shortage. He argues that "There Is No Physician Shortage
[http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_Rlc9scJScv55Umo4FI76iYE5F0ci3dFz3MzlYy-thWMkU1G9niO5G4vOfsOD1hrjtN9exH_27IYp-27UHYiMfMW72hEPeOws2EM2mHWUKF7b5vismyzqrr1FUATocbia_j7ztvReyUw95vrinuKn0cDMd8IuQqSVp0b1aAdpDPzC723wVCG-HlQKesofI-IOn2UWULY4RzCQI=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]".
He took issue with the recent AAMC analysis which projects a shortage of 40,800-104,900
physicians by 2030.  While Keckley noted that the AAMC makes a credible case in 
support of a pending shortage of physicians. But, he feels that the case overstates
the shortage for the following reasons:
1)    Increased supply of alternatives to traditional physician services - He points
to the number of urgent care and retail clinics (7400 and 2000, respectively) which
are expected to double in the next five years. He also points to the use of pharmacists
as primary care providers, new fitness facilities, mindfulness and yoga programs,
chiropractic services, acupuncture and other initiatives that use mid-level providers
of various types as substitutes for traditional physician services.
2)    Consumer receptivity to physician alternatives - He makes the argument that
consumer confidence in traditional medical physician providers has decreased substantially
over the last several decades. With the move towards increasing co-pays and out-of-pocket
requirements for consumers, they are seeking less expensive options.
3)    Hospital employment of physicians - As health care becomes more consolidated,
the traditional role of the physician will be eroded. The consolidation is primarily
occurring with large integrated health care systems that are much more inclined 
to use health care providers who practice at the top of their license. Such efforts
will reduce the demand for more traditional services.
4)    Clinical innovations that change how health is defined, delivered and by whom
- Technology in all of its forms is altering the process and approach toward care
delivery. He makes the argument that "machine learning, artificial intelligence,
 precision medicines and mind-numbing innovations are the future of patient care
 delivered virtually or on-site". These types of capabilities are projected to alter
- in very dramatic ways - our entire approach to care delivery. Just to be clear
 - I absolutely agree with this point.
5)    Public policies that enable new approaches to health delivery - He makes a
 solid argument that due to the growing allocation of society's resources towards
health care, the move toward "value-based" care is an inextricable requirement for
the US economy. As such, the number of providers that will be required in a value-based
model is called into question. He summarizes that "...the public policies impacting
the health industry will accelerate changes that are disruptive to enable lower 
costs, better care and more direct engagement of consumers." Again, I absolutely
 agree with this point.
It is these last two points where Paul and I have a confluence of perspective. The
implementation of new, evolving technologies and value-based payment systems will
clearly facilitate a move toward new models of care delivery. I believe the combination
of these two factors will facilitate the nation moving toward the use of "virtualist"
care providers. So, does this mean that there's no shortage? I'm not so sure... 
We currently do not have any virtualist training programs in the nation poised to
educate care providers on the nuance of virtual care delivery. There is no standard
curriculum. There is no recognition that virtual care requires a cross-disciplinary
approach for it to be successful. In the face-to-face model - unless you are in 
a solo or a small-group practice - there are often a variety of professionals available
to assist in the care process. Long story short, Paul may be right in the far longer
term (i.e. after 2050) but that seems a ways off.
In fact, there is a looming shortage of primary care physicians. Fully one-third
 (1/3) of the general primary physicians will either retire, become disabled or 
die over the next 7 - 10 years. Why? In large measure because they reflect the same
demographic as the boomer generation. But, as importantly, the number of young physicians
moving into the primary care fields has decreased in recent years. So, there IS 
a shortage of physicians AND it requires the health care community toTOTALLY rethink
the approach to care delivery.
Increasingly, however, I'm convinced that the solution will come from an "outside-in"
model rather than an "inside-out" model. We shall see...
The Longest Study of Human Aging - In Southern New Zealand in the district of Dunedin,
there's been a study going on for 45 years that is providing some very interesting
results on the "health" of the population. It's a one-of-a-kind study. To understand
all of the details you need to read the review, which provides a more comprehensive
overview of the project. With more 1200 reports in the literature over the period
of the study, there are certain facts that can be extrapolated which from a health
care standpoint are quite interesting. They include: (1) The importance of self-control
- The researchers have noted in several publications [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlpCzmCwmK1b2LICCv7OZqcS1SSWhx3W-Itpjw0mtNhiuxhi074bH1kQn07eYl4HlKMSCbOEdMcrKMB9TTEAzEG-4kCKGp0ahkcdhH6D8YgP4iQip7XpEFYon5QQSuiNtn1CU7X94aRvI=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
that the level of "self-control" exhibited by a child was a more important predictor
of physical health, wealth, life satisfaction, parenting, and levels of addiction
and crime as an adult than all of the other more traditional indicators. The study
has documented that the degree to which young children have less self-control is
 directly correlated to worse health, less wealth, and more crime as adults; (2)
 Ubiquitous Under-reporting of Mental Health Disorders - The researchers have documented
a finding that shows the prevalence of anxiety, depression, and substance abuse 
in the Dunedin birth cohort is more than twice the rate [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlzrDEMcI6uHp8-rrWWIjVxQYuJ3tp9X5wuFizUPE7qzZxDGBbPqnPpPuvEuSo1I-NOK0jJ874zOdLlX_1HMd3evlCWVlWFnFYY4G8nCumRVwe5V9e7BjRhcW6bXGwGxvEPzuowtEVc6GEYcpa8d1TlxnWJDbhvKX0&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
that the mental health community has traditionally predicted. The Dunedin project
not only recorded a much higher rate of mental problems but also identified approaches
to identify the problems much earlier through cognitive testing and digital imaging
[http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlyrR9mOm_o7bydn_HIv5boUtnl2W1xB7ZGhlEnUs-xH3wZrZer7dLjO5Q5U1O_n154R6fzXX8fxMYm-_8OuzCZEpaeV_NBobEXXkR8P0RSMiHr3Dpvtrh-IPrRzip92x2AUUc0QOkuCo9k3HplTHuRn0x3qaggHahsHc2jagwL4HdQ8su1XCVZg==&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==].
Through earlier diagnosis, there are better treatment outcomes; (3) Identifying 
Aging Markers - The study has been studying "aging" at the other end of the aging
continuum by looking at young people. In particular, the study has identified a 
number of biomarkers related to aging, which are helping in quantifying the pace
 of the aging process. The study has been fodder for other studies related to higher
levels of tissue inflammation [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlFmOjpvzmsQosf_FQoZwGUWZ4IECJ_mrZ3OxYJi2OK_VJIxS0-d7W-u2JQvP9cvUxQv1gzdiCAl-euTMpC2v7C6sxhmICopwFaTPtwvgw6Gtj7EB3JdXEcQXzTEY9ysjBCuCeF5OjHomUHpUWd2SDjGVJWad7gw0Q&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
and the length of telomere [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_Rlw_WT6j3JwBdf3rBn2gsntC4Q7aPgQOfuK8ALgGyCRMAwRuSip2ph_XkiaWUjPGxi1hn_5XHxUf0e3JkntgcyJzSBRyKJWpNnhOpmpwvGxrBD6vvymFPL1dzpi6ujBgP3AoabIr9u7Sw=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
as signs of aging and age-related disease; and, 4) Considering "Nature Versus Nurture"
- This particular issue has been a dominate consideration for many decades.   Did
the genes do it? Or, did the environment do it? For example, one study showed that
genes were involved in predicting which abused children later developed antisocial
violent behavior. Another study showed a correlation between one's genes and predicting
whether or not highly stressed adults developed depression. A replication of the
 study is still pending. So, the nature versus nurture question continues...
There are any number of other findings which have evolved from the Dunedin study.
Read more about the study [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlKxoS_698NnjMt8HRAWMhJ_bGNnzvViee-mmifgaENHcO_tnAMYyapylP-031Ku7fvass0rCyiSqOG1MMltJRW3WpoOhIuAhMSlCYDwWfmKBAk3PAjgV03VcxAFLs6TAonvzDJ-YQ_3KlNdoF6JYkqFodPDbEbGn2QOfhPXZStXI=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==].
It's quite interesting. We should expect more...
Trending - For the first time, health care has surpassed manufacturing and retail
to become the largest source of jobs  [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_Rls-mvE_mZJKBz72RzjjKRzc5-Etd5EuShJTD7pA4TFdciW3IcyPmheYXcYIr5dxidJibNqoPCcmSB5DSCRdumydTTCYEgmVlAD4WtvgLX-IssHQnKmlRWUnBdv7fvLHKpEvXuHf9VJWqwVoqGE1iKiQ1i_TBCNpan1DOcx47yd2UzT9kST1kpKeYriK4qSkI_IOz4gbl72pk=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]in
[http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_Rls-mvE_mZJKBz72RzjjKRzc5-Etd5EuShJTD7pA4TFdciW3IcyPmheYXcYIr5dxidJibNqoPCcmSB5DSCRdumydTTCYEgmVlAD4WtvgLX-IssHQnKmlRWUnBdv7fvLHKpEvXuHf9VJWqwVoqGE1iKiQ1i_TBCNpan1DOcx47yd2UzT9kST1kpKeYriK4qSkI_IOz4gbl72pk=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
the USA [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_Rls-mvE_mZJKBz72RzjjKRzc5-Etd5EuShJTD7pA4TFdciW3IcyPmheYXcYIr5dxidJibNqoPCcmSB5DSCRdumydTTCYEgmVlAD4WtvgLX-IssHQnKmlRWUnBdv7fvLHKpEvXuHf9VJWqwVoqGE1iKiQ1i_TBCNpan1DOcx47yd2UzT9kST1kpKeYriK4qSkI_IOz4gbl72pk=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==].
For those of us in the health care industry it's been obvious for some time that
 this would happen. The reasons given for the trend include: 1) an aging population
(= ah hum - that would be my friends and me). In fact, by 2025 one quarter of the
USA populace will be over age 55; 2) the increased subsidies as a result of the 
ACA implementation (= that means we now have people that are insured rather than
 uninsured); and, 3) the "immunity" of health care to globalization and automation
(= some of us are working on that problem). Despite the growth, the criticisms continue.
For example, despite all the additional labor growth in the health care field, quality
indicators have not improved all that much over the past 10 years. For example, 
the 30-day hospital readmission [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_Rl9GK5D8LZIbg_2NjRPfHw_Gw2vfGKtBgTmrFgU21FV5ZaUxAG4tpcu0JXYbKTDJzrPlI19fo0p7oBT-Y17DeqXXd_Xd7VZAkEVJuQqhsAhFQOcUVtVhm9VNrhQ0269FZuZdHPs-GY3hU8DmAwa9lVg4pRPyGppimcSxwF0XiVAPQ=&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
rate has only gone from an average of 19% to 17.8% according to Robert Kocher, Ph.D.,
a senior fellow at the University of Southern California Center for Health Policy
and Economics. So, the question gets asked: Is all of the additional money thrown
the way of health care getting us additional benefits, more efficiency or better
 results? Well - not according to the latest statistics. We've got to do a better
job...
A New Movement Is Afoot So, What Do You Think? - Since I started practicing medicine
in 1980, I've been a proponent of the "team" model of care delivery. I got started
early in my practice career using the team approach with the Nurse Practitioner 
in our clinic. Initially, it was by happenstance but then we realized that each 
of us brought different skills to the table and that working as a "team" made us
 better in our delivery of services for the patients we served. But, several decades
ago, the movement to allow NPs and PAs to practice independently started to gain
 traction is some quarters. And, while there are some who practice in the modality,
the majority work in collaborative practices with physicians and in some states 
such a relationship is required. Now, there is a new movement afoot, which has been
called "Cathopathic Medicine [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlSgeA72BvXMuwS-51HyqCq-IwaHs50fkhDDq7eWmd9A44hNpeQg_8EdEh8XQVxem_2hip_73iZMmvExoFrcmxEyxXTRLddX18sSNHBLgWqzJUAldgDHm8hg3tYHvvfxHR&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]".
The notion of this type of medicine came to me through a notice I received on the
American College of Cathopathic Physicians who purpose is defined as: "to protect
the professional autonomy and advocate for a full, broad scope of practice for DNPs
[Doctor of Nursing Practice] as a 'cathopathic physician' completely equal in every
way to our MD and DO counterparts."  My reaction was "Hmmmmm...how can one be a 
"Doctor of Nursing Practice" and an equal to MD/DOs? In particular, when one considers
the educational requirements for an MD vs. a DNP - there are substantial differences.
Perhaps I'm getting older and more set in my ways but it seems to me that the additional
education afforded the physician provides a much deeper background in the issues
 related to disease than the two year addendum to a baccalaureate nursing degree.
It's not that I'm against DNPs. In fact, I think they offer considerable value to
health care. It's the demarcation of these professionals as "cathopathic physicians"
which is what the new College advocates - that seems to be a bit misleading. Any
 thoughts from readers would be appreciated. I think this moves us in the wrong 
direction. Just as I have not believed that physicians should be in "solo" practice
- unless it is absolutely necessary (e.g. rural areas). Even in those circumstances,
the technology has changed so that having a "solo" practice in a rural area is no
longer necessary. In sum, the "cathopathic" movement shifts us absolutely in the
 wrong direction from creating truly "accountable care organizations" (ACOs) towards
creating warring factions within the health care community.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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The Weekly Whisk
Musings from a foodie...
I've never been one to be a culinary snob although I must admit I adore good food.
At the same time, some of the best places are in out-of-the-way places. I traveled
to Chinle, Arizona recently which is a central node in the Navajo Nation that spreads
across the four corners region of the USA ("except for Colorado"). Chinle is your
classic Western community with slow speeds on the roadways; large pickup trucks 
with four-wheel drive; and, any number of greasy spoons. But, among the greasy spoons
- there are some treasures. In particular, I found Junction Restaurant [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnGr2R-L1f_RlTCOXMqKioSA4HQsNGZ0YCv-PCRBael6MMPu-VjYxFf_BN4PZTUH2tg1SEMeqvDSoQldDRVdiqq1eLvce6jQQy3fR3oVD-eJFBt7FQFJypXGJXqrvQbaJJ5vKHfY11XCrJ6ytReswUwDN-Zf_xdXqT9m_tU4vBm0ECB_VA4696EUkNjHUq5Iu3WLdxWYsoHTp3bjxcqjHbv9s7IapNlmJdS_Objd5sVOU&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
[* * * *] to be an exhibit of your classic rural, greasy spoon. The Yelp rating 
were all over the map - and, that's because everyone eats there at some point if
 you're in Chinle for more than 24 hours. It harkened me back to my roots in rural
North Dakota. The food was more than ample and, in fact, bordered on "way too much".
The Navajo renditions of the taco, hamburger and other traditional foodstuffs were
especially good - if you like Indian fry bread, which I do. Now, Chinle needs to
 be on your bucket list primarily because of the Canyon de Chelle (pronounced "Shay").
It is exceptionally beautiful. So, when you plan your trip to complete the bucket
list, make sure you stop at the Junction Restaurant - 100 Main Street - Chinle, 
AZ 86503 - (928) 674-8443.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The resiliency (hopefully) of American politics. I lived and breathed
the Watergate Hearings and walked away with a sense that there was no place else
 on the planet where what happened could happen. It provided me with a revitalization
of American spirit at those times when we have been challenged in the past. It is
a kindling flame that I continue to keep lit for the right moment...
The Good - There are health care professionals who should be commended for the commitment
to "making health care better" for underserved and economically challenged populations
like the Navajo who we recently visited in Chinle, Arizona. These professionals 
can be found at Community Health Centers, inner city clinics and many other similar
places. It's heartening...
The Bad - The continuing saga of American politics...
The Ugly - The continuing saga of American politics...
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001jbzqLPdkyySCthHbA1y1XwYH-n07kzDy9y5B13Mn3r7CiPSRxiQmnPx3PuCuGeOI0FPsytDZH5H9X5QQGNIwbxiyhN3f7BQK57EzFrY7Gi2B7I2o8QzaayKgznzHQKoK7j95oMA-q9Gi7fmVeEcpsgrv0Gw3qUcOLTAHZSBFHmSHlZFEImuYXakKoxjXsh7C&c=6p2KNoHSS_7AeeBXw6al3HQ9QBmc_pxq0YZ-6yLeF2ZymL8BNzZqGg==&ch=baQUlz0s3cJTmIaLdnlWGmIOWxAFkZVfV2BmUh-iCmo9AvwGALcZPw==]
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
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