Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 18 Jun 2018 15:51:59 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0zzIAAMwHq37G7rLQr5ivTEA6RsiOZL8HYfECG1AY3Wn95Rph595nsSPrBu9X3UxxwCpxjRCQ9jz-VSof4PykECG2yk1fRJvBIIi86BWLGxVH3TQ4gBKY5UDF50bGBguTS54ctq5LeBzK&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
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The Fickenscher Files, Vol. 6, Issue 9
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0zx9yv3-0IXS-bdx2BqU0c6wv7M3Brkho4-CS7u0unyCxuNuJQWeGI5Hxtej32vIAEMsDkE-QErS59bCZpbxvdAHZRMKDn378kwSPageKiQXwJC-WYFP6hEUu_UsxlFz3HhOYeQY-f4-Bn0udv2BUQ06R7NMrt_yriA==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==],
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
"If a lie be believed only for an hour, it hath done its work."
Jonathan Swift
"PM Justin Trudeau of Canada acted so meek and mild during our @G7 meetings only
 to give a news conference after I left saying that, "US Tariffs were kid of insulting"
and he "will not be pushed around." Very dishonest & weak. Our Tariffs are in response
to his of 270% on dairy!"
President Donald Trump, in a Tweet from Air Force One following his early departure
from the G7 Summit in which he disparaged the Canadian Prime Minister for disagreeing
on the notion of tariff implementation across the G7
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Consulo Indicium
Information for your Consideration...
A Diversionary Thought: I Thought I Was Useful - As most of my readers know, I moved
into executive and managerial roles some time ago and when I'm asked by those I 
met the question - "So, where do you practice?" - my usual response is: "On United
Airlines!" I answer that way because for the last 20+ years it seems that the clear
majority of my time has been spent on planes traveling across the world. So, you
 can imagine my dismay when I recently picked up The New York Times and there was
an article titled: "Is There a Doctor on the Plane? Increasingly, Airlines Hope 
Not". I've always known that there was a company in the background someplace providing
support to the flight attendants and pilots on in-flight medical emergencies. Evidently,
the major company is MedAire, Inc. which provides services to more than 100 airlines
- and, by all accounts very high-quality support. According to their data, only 
1.6% of their flights are "diverted" for a landing due to an in-flight medical problem
which generally costs about $200,000 - so the emphasis of the airlines is to avoid
diversions. Now the diversion results of MedAire are different than the results 
of a study reported in a 2013 issue of the New England Journal of Medicine which
 revealed that there was a medical emergency once in every 604 flights and 7.3% 
led to diversions. The study also reported that 0.3% of medical emergencies on planes
end in deaths. The dismaying part of the article was the statement that the airlines
"hoped" that no physicians were available on the flight in large measure because
 in-the-air physicians have a much higher propensity for diverting a plane to land.
It got me thinking. What were my results? So, I did a quick tally. Over the last
 20 some years, I've experienced about 3 - 5 "medical emergencies" with 0 deaths
 and only 1 diversion - which was for a gent who was having chest pain and all the
symptoms of a myocardial infarction. But the vast majority of my clinical experience
has been related to in-flight patients who either drank too much the night before
or the hours before a flight or, drank too much during the flight. These have been
interspersed with "real" medical emergencies like acute asthma due to peanut dust
in the air, an apparent appendicitis (although I never did get the final diagnosis),
a TIA-like presentation and other assorted "real" experiences. My most challenging
was when one of the flight attendants collapsed in the cockpit and I had to work
 with the crew to extract her from the floor so that they could continue the flight.
We made it... Anyway, I decided that zero deaths with one diversion is a record 
that's not bad. Hopefully, United will continue to let me fly the (increasingly 
less) friendly skies. I expect to continue answering the call when I hear, "Is there
a doctor on board" or the flight attendant approaches me with a quiet whisper, "Dr.
Fickenscher, please come with me right now!"
Politics Before Health Care So That Health Care Trumps Politics -Lancet had a very
interesting article several weeks ago entitled, "The world has been warned [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWXQQMWOPkI8sPIYWqyKhbZTvUF-gBv2GddXQPJqGmVML0ZYqD4yRjpm7rAK7X23mkabDPRF2Ecx8I5XMuezZwXFkbADVnAgENazX88B4ZZnE9RKGRPympOKWsTkg_sDhKeOJICuZ_eMtd5pdsahoILA==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]"
by Richard Horton. The essence of the article is that it makes the case for greater
involvement by the health care professions in the politics of the day if we are 
going to be successful in continuing to make the case that investments in health
 care research and programs make a difference for society. Our focus tends to be
 on the more immediate questions related to patient care services with strong advocacy
for a proper financing and functioning of the health system. Beyond those core areas
of focus, the health professions tend to scatter. The article makes the case the
 we need to listen to the advice of the economist, Dambisa Moyo, Ph.D. who argues
in her new book Edge of Chaos (2018) that the support for public investments in 
health programs and services is weakening. Why? She argues that it all comes back
to sustainable economic growth and development - which is not the first order of
 concern among most health care professionals. Without it; however, the ability 
of governments to provide the necessary funds for health care programs will wane
 even though demand is rising. In fact, her central argument is: "politics, and 
not economics, will be the key driver of human progress and prosperity in years 
to come".
In essence, the message is that threats to democracy, factors that diminish economic
growth (e.g. growing debt, aging of the populace, natural resource depletion, deepening
income disparities and a host of other "economic" considerations are key factors
 that will be driving the health care debate in future years. We need to listen.
 The point of the article by Horton is that "Taken together, these pathologies are
laying foundations for an unprecedented period of government failure, political 
instability, social fracture, and community unrest." You definitely need to read
 this article and check out Moyo's conclusion that, "liberal democratic capitalism
is in retreat". There are ten prescriptions offered that could help move us back
 toward a position of stronger support of health care - a core offering of most 
governments throughout the world. The ten prescriptions have little to do with health
care and everything to do with democratic stability. Check it out.
Are We Prepared For Value-Based Care? Short answer, "No!" A new study [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dW_XxrrF3NuBkmYv1Q-6s8NRwJDs_rP7cV8xA4gWKFndlRx4lndm1rGCtfmdorxkDp8z35YAcvBJ4VGm_cvsrlLqzHoHXva6TYyWuWpQGyF1THzmHvO--7yQvfYZhXJCPCqTF2CJqmtQM8o1qElYDbWGwkthMwXNgUOSKW8ti7ZeW8CEfgKQ4Zq9r4AOcNzmxMXS3-QaoRMxo2qsSUsZp2hWKvJH_d7tOi&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
of over 900 physician organizations by Black Book, a consulting firm, reveals that
physician organizations are increasingly concerned about their readiness for the
 move toward value-based care. Independent and physician-led practices represented
72% of the study group. The essence of the findings; however, was that the groups
felt that they were not prepared for a move toward value-based payments. In fact,
the study found that 93% of the practices did not have a strategic plan in place
 "for transforming [to] population health management or value-based care solutions..."
My prediction: The coming decade will be littered with also-ran medical groups that
failed to prepare for a tsunami of change that is about to sweep the fiscal structure
of our health care delivery models. The current system is unsustainable from a purely
financial perspective. The Boomers (my generation) will bankrupt the nation if we
continue the current course. Change will be led by the states. It already is! Things
need to change.
Secondhand Smoke And Marichiwanna - A new study [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWC5-ajayfFfA_o_Jy_KnX8Bc8kOT7idilz4AqCwsJjLnEN706Rl7fyuwhSvNOkkn-6NZi3SrZHiSU4VZyCDX4SuVNdCgp_840glnseYz7tKM0znGyOU6_FPSsb6aVdzxPFlaArx2xjJr_PWJSHUukLmVjvWkjxtKyfODNF6-mU9xoC6oKhdIwiazUNMbG-FbsugbD-RI1xgncaP6XwkFU1u_Aj7rRwyyRFcdkU6Fp-GcovD1vp7PgemoK6lpHCPStxQ4wKSsXaKDD-TClCFLk1i7vFMssyZiMmuf98GS_YQhx4al4ryfdxxQpJmZDj0WGEGd3R9piYSNMj3W5otynY6jL_2LqAaJiX2iXmkBuzx884g_2FpQ2QJ3ynaGNlVZCFeCGACM68fg6vZub3HnoyL6rOvKzNOMp_hIcESo4_612ClVtKI3_c7Q0-PzBiGXtNg3Ox1wsuLoIqZpm3omDZ6baKTkedcRmUmlMUW4euMfHTsiLt55Qqh-I6PANugGQX4F4RjCY8oebKtiMLZ1V8TA9_USzy9Iz4IBQFSwaPAOscaQyqBvlt7Ivadl7H1LcxhHyVusCJC0cS4N290ZpQg==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
was recently published online in the journal Pediatrics suggesting that the warnings
we've made about the use of cigarettes in the home by parents should also now be
 extended to the use of marijuana in the home. The assessment of the study was that
"an increase in parents smoking pot around their children could undo decades of 
effort to protect" children from the effects of secondhand smoke. The homes as risk
were those where parents already smoke cigarettes. In those families, the percent
of marijuana smokers increased from 11% (2002) to 17% (2015), a notable rise versus
those families where cigarette smoking did not exist with an increase of 2% to 4%,
respectively. I mean, after all, smoke is smoke...
Healthy Diets = Big Brains - In a new 10-year study from the Netherlands, it was
 determined that eating a healthy diet like the Mediterranean diet seems to be associated
with larger brain volumes. In fact, the brain matter in these individuals had a 
higher volume of grey and white matter along with a larger hippocampus. The study
is consistent with my wife's missive that I need to eat six cups of fruits and/or
vegetables every day, less red meat and less fat (i.e. far less bacon). And, potatoes
are not considered a vegetable in her ruling which doesn't make sense to a farm 
boy of German heritage unless I decide to become Greek - which she notes is always
a good option! But, I'm learning that I should not argue! Besides, now I have a 
reason - a bigger brain. That and $2.00 will get a Grande dark roast at Starbucks.
But, we do seem to be getting consistent results related to the impact of the Mediterranean
diet. It's worth adopting in my estimation.
Sovereignty Of The Tribes Indirectly Challenged - The US Department of Health and
Human Services is seemingly stumbling into what could become a decade long litigation
nightmare as it continues down the track of requiring Native Americans to hold jobs
to keep their health care. The move by HHS directly assaults long held agreements
between the US government and the tribes by challenging tribal sovereignty which
 has been recognized for centuries - not, decades. The Trump Administration has 
put forward a proposal [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWo79Yi9qo4tff7WNKrIvlGgeeBlE4GcQCRhRCbk-8dyot9ibWjUHOokT7U51IOXW9cI-OrnKtV-9gRps1shvi4HHGO3XXrbyEgB7jydpva4-t0F5tD-z9ylSV_ebMgUmN8RlLLvO8oinOE9aglzYslXzQ4xIr0pwCLNs04cabb0kBjb3r_2fDF18Ffe2Cf4kOkhtzVh7Aj1by1fbaxyIJHA==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
stipulating that the tribes are a racial group and not separate governments. Needless-to-say,
the reaction from the tribes and many members of both parties was quick and negative.
In making the preliminary ruling, the feds are passing along the implementation 
to the states which will no doubt result in a series of inconsistent proposals and
approaches toward the tribes. This is not an arcane legalistic argument. Rather,
 it cuts to the core of agreements made between the US government and the tribal
 nations over the last two hundred some years. The decision has also split the department
where the political appointees have taken a seemingly softer position (i.e. let 
the states work it out) while the HHS Office of General Counsel have taken a distinctly
opposite position (i.e. work requirements apply to everyone and the tribes are not
exempt).  So, the question is whether the Trumpee discord will be resolved in the
Agency or in the courts? HHS political leaders have tried to avoid the controversy
by suggesting the matter is a local issue that could be resolved as the federal 
government and states negotiate the parameters of their proposals. But, duly negotiated
agreements between sovereign tribes and the US government would be a difficult thing
to undo to say nothing of the political fallout.
Here A Tweet, There A Tweet, Everywhere A Tweet, Tweet - It was only a matter of
 time before academia caught on to the use and impact of Twitter. In fact, in a 
recent article, Jason Frank, MD (@drjfrank [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWPncMXyOhj5X7lrK0P7I789Xg8hcKht0AjktMsGuqWecjRltgWgEctp3GETEoKlQZvSn7pIySrjTuwsm1E-U0WNBTGeeJOeKaUAnltwhV1Qi0HtzzHpboKw==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]),
a clinician-educator at the Royal College of Physicians and Surgeons of Canada (@RoyalCollege
[http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWIbSHgVrXHrdGAqeLWOE4WVBIxjMtT9mUWqr_lFVp3wIS8l-E5PwEiEzHkJ3MWb_1gBfyfYQEAPL8lt9Tx1DCeBUhwpETDkH6a3VFLLRYmUIBmkvSFl4_3g==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==])
made a bold statement when he offered this thought: "Within the next decade, you
 won't be able to be a successful scholar without having some activity on social
 media." Hmmm... Dr. Frank's thinking is that social media is becoming a ubiquitous
tool for sharing one's scholarship, engaging with the public on the findings of 
research, advocating for change in public policy and in building new social networks.
His contention is that Twitter offers a means for educators, clinicians, and researchers
to communicate directly and accelerate information sharing by extending the network
from a handful of conference attendees to a worldwide audience of involved researchers.
In fact, the data from a recent Pew Research Center study supports the notion that
the use of social media is growing substantially among researchers (See graph below).
While I'm not going to get in the way of this rapidly moving train, I would like
 to point out that we need to be highly attuned to the unintended consequences of
social media use as it relates to public perception and interpretation of information.
My fear is that the nuance of an issue or problem or research finding cannot be 
effectively conveyed in many - if not most cases - with a string of 140  characters.
So, the question for academia is: what are the ground rules for engaging in the 
use of social media? How should this new communication form be integrated into traditional
avenues? And, what types of research needs to be completed to affirm the adopted
 approach? It's clear that social media can have a very positive impact on research
and the sharing of research results. We need to foster its use and support its deployment.
But, let's also keep a watchful eye on the results...
Percentage of All American Adults and Internet-Using Adults
Using at Least One Social Networking Site

Source: Pew Research Center surveys, 2005-2006, 2008-2015. No data are available
 for 2007.
Far be it from me that "Dr. Change" would get in the way of "change". At the same
time, I've strongly advocated for adapting to rather than resisting change, I've
 also always stated a strong belief that it is incumbent upon those of us who are
change agents to monitor what we change since the unintended consequences will sneak
up on us over time...
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Future Health
Delivering care in the new virtual world...
Integrating Routine DNA Screening Into Primary Care - Patients at Geisinger Clinic
will now have the opportunity to participate in a new program beginning this summer.
The Clinic intends to enroll 1,000 patients in a program where their individual 
DNA sequence will be completed and entered into the patient's record with the intent
of using it as a tool for informing how primary care should be provided. Assuming
the program is a success, the goal is to roll out the program to all 3 million Geisinger
patients in the coming years. Specifically, the Clinic will be analyzing the 77 
most common gene mutations which have been strongly associated with disease. The
 new initiative builds on a prior program, MyCode [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dW_i9NynDBTY2Q1YMPDNR3THDu2JdbHW8IWrCt8B1YD6SfYQ5Av_Wp0Hk1pLSo_LFS2NBhL1LF8brahLczFVTsPd5FLTCZ_iJcT5sHHFqtd-jyimrSh2A1gQDIsojKWOkQWoILEQAme8MPMWmRkzN-9g==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
established in 2007 to collect and analyze patient derived DNA from more than 200,000
individuals. The program was based on the whole exome sequencing approach which 
analyzes about 1% of the genome involved in providing instructions for the production
of proteins. By integrating the genetic testing into the primary care approach, 
it is anticipated that earlier interventions will be forthcoming and, as a result,
better outcomes will result. It makes sense and the time has come...from colon, 
lung and breast cancer screening to hypercholesterolemia to problems we haven't 
even really identified - we are on the cusp of a new model of primary care.
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The Weekly Whisk
Musings from a foodie...
In my recent visit to Southeast Asia, we had the opportunity to visit Cambodia. 
The focus of the visit was a trip to the temples at Angkor Wat, which are quite 
incredible. There's a reason that they are considered one of the top ten sites in
the modern world. While there, I naturally wanted to visit some local cuisine. Well,
if for any reason, you're in the neighborhood - I'd highly, highly recommend Viroth's
Restaurant [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWadNvHKRPFtx7ULTvCsc3fnpC5uZPB58OVdZiLIxVYpxJs_upYY-hDOPICJ2lNNZTGctgKoiozfb9-cwbV3JOEe_nr5NIjNtPB6bKCciMNc9jtCNJ5_ycXQ==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
[* * * *]. Our guide for the day recommended it as one of the best representations
of local food in Siem Reap. And, we were not disappointed!
For starters, let me be clear that I thought it was a fabulous restaurant. In fact,
I've already had some folks visit who concurred with my assessment. We started with
the obligatory banana leaf adapted salad that included onions, shallots, pineapple,
shrimp and an unfamiliar spice from the parsley family. The dressing had a coconut
flavor which is always refreshing. They then brought a second salad of Green Mango.
It included spicy carrots, onions, green beans, shallots and small pieces of pork.
Again, quite tasty. We then moved into the main course with two major options. First,
the "Amok Fish" is a local white fish cooked in a ceramic bowl with a light curry
and coconut milk sauce. It also is flavored with "agor leaves" which are from the
basil family. Extraordinary and the fish was cooked to perfection = not overcooked.
We also had the Chicken Laab. "Laab" is basically ground up meat from various sources.
Chicken, pork, lamb and beef were the dominant choices during our Cambodian trip.
The Chicken Laab was seasoned with ginger to give a spicy flavor along with shallots.
There were some other spices as well but, they were foreign to my tongue... So, 
you'll just have to travel there and try them out. Finally, we ended the extravaganza
with Mango Sticky Rice (one of my very favorite desserts) and Gravita Lemon which
was incredibly refreshing. And, if that were not enough - they then brought us some
Bananas Flambe as the piece de resistance!! All of this for about $25/person!!!
Not only is the food outrageously good but the prices were incredible as well. It
makes me want to go back but, I think I'll wait till I recover from the 30-hour 
flight and 12-hour time lag first (in about a year &#xd83d;&#xde0a;) before heading
back. Cambodia is a wonderful country. It should be on your bucket list. Check 'em
out: Viroth's Restaurant - 99 Street Wat Bo - Siem Reap - Angkor, Cambodia - +855
(0) 12 828 346
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - I will not be able to listen to CNN, Fox or MSNBC for the next 10 days
as I travel to Vietnam. Ah - the silence and reprieve from the daily assault of 
"What has happened in the last ten minutes?" will be off my radar for a short time.
The Good - The vast majority of the American people. I predict we will get our act
together! Change is messy, and Americans can be the messiest in times of change.
The Bad - The seemingly downward spiral of American politics. The tenor, the tone,
the content of our discussions and debates has degenerated into thoughtless missives
that build barriers rather than listening. It's tragic to watch. The politicians
 who helped to build this nation must be turning over in their graves...
The Nasty and Un-American - The fact that the USA is ripping children away from 
the parents at the border is unspeakably nasty and totally Un-American. And, then
to quote the Bible inaccurately. It's as bad as the Taliban's abuse of the Koran.
Check out Steven Colber [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWb6C_-QZNHl589t3tBQwQ-tBxKqxZAYJhWTfqRiVdjGUOgh0SUQCLSm-y01EEAXz0MVtqMMC4mAd-IATENNC9Uu3KHOljKT00FLr3YkmkJ1O6GHgHOayqUA==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]t
[http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0z_zrwbF726dWb6C_-QZNHl589t3tBQwQ-tBxKqxZAYJhWTfqRiVdjGUOgh0SUQCLSm-y01EEAXz0MVtqMMC4mAd-IATENNC9Uu3KHOljKT00FLr3YkmkJ1O6GHgHOayqUA==&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
- who despite his very liberal leanings - gave a very serious response to Secretary
Jeff Sessions speech before a conservative religious group on the topic. He was 
right on the money...
A Notable Passing - Ted Dabney passed away recently. Many may not know him but, 
he was the co-founder of Atari and the creator of Pong. It was the very first video
game to sweep the nation back in 1973. It was the diversion that helped many of 
us survive the first year of medical school at the time.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001K8OImIBxNZlKo7udqmdXHMppKVsySnX-rdDIYQxSSsSRzoq5LaY0zzIAAMwHq37G7rLQr5ivTEA6RsiOZL8HYfECG1AY3Wn95Rph595nsSPrBu9X3UxxwCpxjRCQ9jz-VSof4PykECG2yk1fRJvBIIi86BWLGxVH3TQ4gBKY5UDF50bGBguTS54ctq5LeBzK&c=Bw3w9fd_322jxK7YrsBob6AQ7QGA0zU0uBHd0iADzi1UJizFa5K8nQ==&ch=cD8dT5hJowG9hbYpn6aOOk8u_TumCItMu1qcW6bG6chZJ_dQJIyUIQ==]
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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The Fickenscher Files | PO Box 840 | Kittery | ME | 039