Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Fri, 14 Sep 2018 16:14:34 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW-JPpbZAUczJo9KtENd3_1cfGW9kSTQBO3ixOHh0Dn__iqehT_oUCL9TfHW-n72clMoytXfOt--iz7hCe6bgrk_QtBflzeSR-r0Lt-0n8bukDOBWyamG--CySOZXc2ob6CGZ5ivOuGKu&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==]
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The Fickenscher Files, Vol. 6, Issue 12
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW4m62b7xTEaCJgfmbvsYryp__0z12kDfaQZ5wwMQAQB89I1-lozws89JbgiVxST22uhyuM3Wwd8pfixixzWpJ30-Y83_3xbixhRNIaKqlzUrVn-Dh1Q2cdb7Z3QFc4wnbYEqlRabjhqoE1kNIVerW0RchOAFaP7CcQ==&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==],
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
"Personally, I feel to ignore the intersection between health care and social media
is to potentially ignore our own relevance as a health care practitioner during 
the next decade."
Howard Luks, MD - Orthopedic Surgeon, Digital Medicine Specialist
"...It's on all of us to vote this fall if we want leaders who reflect the civility,
character, dignity, and goodness of the American people. The stakes couldn't be 
higher, but Americans always rise to the occasion."
Joe Biden, Former Vice President, United States of America - in reference to the
 upcoming US mid-term elections
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Thoughts and Readings To Consider
Books and Articles worth a Review...
As Simple As A Cup Of Coffee - Several weeks ago, I arrived at Boston Logan for 
a very early morning flight to someplace. As I got to the airport, I realized that
I had left my credit cards and cash at home due to the very early morning hours 
of my departure. So, there I was credit- and cash-less heading out of town on a 
couple-of-days trip. But, always the prepared traveler - I have traditionally carried
a stash of $100 dollar bills in my briefcase for just such emergencies - which have
only occurred twice in 40+ years of continuous travel. Here's where the interesting
part comes in... I went to the Starbuck's, ordered a cup of Vente to get myself 
going to mentally regroup and offered up one of my $100 dollar bills. The attendant
looked at me and said, "Are you kidding?" and refused to take my money but - she
 also refused to give me the coffee. I responded, "No, I'm not kidding. It's called
money." - obviously in a bit of snarky retort. At this point, the Millennial gentleman
standing next in line reached over with a $5 dollar bill and said to me and her,
 "Don't worry, it's on me!" And, I responded, "Are you kidding?" with a laugh, of
course. He said, "No, really!" I offered to walk away. He insisted. I relented and
walked away thinking - yes, the next generation is prepared to assume authority!
 I continued to shake my head - in a positive way - as I walked toward my gate thinking
it was, in fact, time for my generation ("The Boomers") to give way to the next 
generations - all because I got a cup of coffee when I really needed it. Long story
short, after about five minutes, the young man showed up at the gate and was headed
to the same city. I walked up to him, thanked him and gave him my card and offered
that if there was anything I could ever do to help him in any way - he should reach
out. I would try to do whatever I could do to help him. I'm waiting for the call...
Forever In Favor Of Biden - Many do not know this but I served as Joe Biden's health
policy advisor for his Presidential campaign in 1988. I had high hopes for a corner
office in The White House when with a one-two punch the campaign was knocked out
 rather quickly over the course of a couple of weeks. First, Biden gave the exact
same speech that Neil Kinnock had given in Parliament to a group in Iowa including
references to his father - not a good thing to do. Plagiarism is not a good thing
on the campaign trail. Second, he developed excruciating headaches and was diagnosed
with a brain aneurysm which ended the campaign. So, I've been a Biden fan for a 
very long time!! But, his eulogy for John McCain, III was not only touching but 
memorable for what he brought to the forefront for at least a couple of moments 
- the need for civility in our public discourse. He articulated so very well the
 passion that both he and McCain brought to their respective roles in the U.S. Senate
which was based on trying to reach an understanding between two different assessments
of the same situation. We sorely need someone like Joe - for as much as I believe
him to be the type of person we need as a leader in our nation, the nation probably
needs someone other than Joe. It's time for the next generation to step forward.
 My generation should guide them and support them. The torch needs to be passed...
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Consulo Indicium
Information for your Consideration...
Breastfeeding And Stupidity - At the July World Health Assembly in Geneva the delegates
barely passed a resolution promoting breastfeeding. What? Barely? Why? Because the
USA delegation - by completely ignoring all available scientific evidence on the
 benefit of breastfeeding [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW1w-x3ygi5Hn943XbFzhRChrZnR6Qk5eBRTQxfvEGJ7isGHCjYtlvUdW-IxnjXBfokxGsx827Ptz-Uqhm9mCn2pAhPx2RncQGwr8fzg3WN2zuBXeMuQxoVw-h3IwZMyuV4eQsb1kCvuGpT7MCVlziYjOLU0_c1ndlyrPaddoqGzE3Foa_CaBPf1rfhjygwgackcpDch2uUlN&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==]-
put forward a resolution to remove language asking the governments of the world 
to "promote, support, and protect" breastfeeding. These same USA delegates also 
wanted a resolution which discouraged the promotion of food products (i.e. infant
formulas mixed with untreated water in developing nations) that have deleterious
 health effects on infants. Just one small statistic among the extensive body of
 literature on the benefits of breastfeeding suffices. In a 2016 study reported 
in The Lancet, universal breastfeeding was highlighted as the approach that would
save the lives of more than 823,000 children and 20,000 mothers with an overall 
savings in excess of $300B worldwide. In my book, those are real savings across 
the board. As a Family Physician I always, always, always tried to get the Moms 
I cared for to adopt breastfeeding and almost all did so... Let's not let the stupidity
of delegates rein unharnessed. I'm apoplectic and - that's after nearly four weeks
of waiting to write about it... Argh!!
Should We Get Excited? Or? - In a step that could very well move data sharing in
 a new direction for the health care community, Alphabet, Amazon, IBM, Microsoft
 and Salesforce recently announced that they intend to put energy and resources 
into solving the incorrigible problem of "interoperability." While I have many complaints
about the health care system and how we could fix them - this singular issue is 
the elephant in the room of all problems facing health care. Here's the joint statement
that they released:
"We are jointly committed to removing barriers for the adoption of technologies 
for healthcare interoperability, particularly those that are enabled through the
 cloud and AI. We share the common quest to unlock the potential in healthcare data,
to deliver better outcomes at lower costs."
Unfortunately, the bulk of money in information technology support was used over
 the last decade in making our filing systems electronic rather than addressing 
the core problem of moving information around seamlessly. As a result, the big winners
have been the big EMR companies, among them Cerner and Epic as two notable examples.
Data from one does not move seamlessly to the other. While their effort is to be
 applauded, there is a need for one more change if interoperability is to be realized
in the short-term. We need to address incentives. The healthcare system needs to
 move toward value-based reimbursement instead of fee-for-service models. Why? Because
in value-based systems, the results are measured based on "results" or "outcomes"
rather than just "doing". Without that shift, the front lines will not be incentivized
to get behind the IT company's quest. It takes more than a bunch of IT companies
 making a statement of commitment to realize interoperability. What are your thoughts?
Leadership Through Walking - I got a notice recently from The Wharton School about
an old tool that has gotten new support as part of the armamentarium of effective
leaders - walking [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW1w-x3ygi5Hnhx9upe1QbcsuTykLzCKq0D65ll5BcV7dE5uVWgvBTh0UWm4IAlBx0gQM9aOiTB5O1lHLrbG2nP2Wtun312_-firanYj8iliXJ7egcWI13vUcYuuC4GVwgDWYhKhft7WDx2FyPOK2wlCTwqE8PLHoDU5x9ir0fmux89ykGuvt1Dkbvq1u5G5qgvmf_F1-BT6qNhnts0_eOJ1vpSbmeHelMUK21Hf6_CISQDg_4-btxd4Hh_TfoyHIFyo2Myvw49Zr89WzQeQTj6xFrjYfwrHEMF4JBvAQS8hOoMOItKvFVStyebVz5HnhXJpNPCCf4PvvC2-MTsX9JHtlq8qo-0s0lESLxRESd-6aBQ3pch1A4O6KVXU5QFzBXpMSZ-CB-2vfg07qWzOl8FKt3uldaZRTVilM43rSZrfhz62drraz7lwZW34-46HGdA841E6gaw-kXoAbjQS0hSuK4A3dJvz0VnTGjyjml6ujEHnkz4mT-Ly-gz9mF9F4cQEwkFwpGe0TIds2F22Kio5Ay5LIFV46UlR2XNMSF-Y-9Un4NgTflnhHYhVxVlxilvPM6cRCyx8V1D_5qP69Hm3jpHNyaFjdf03gCOK18i9CNlAgcnyCDjnkOyQVobtAcWcrVn63Kr-cDpvVc5zXEjGwavpLEp5-LWEFXZynWNMvwuFMCIcgE9mZ5m4x6LrCgcjQa_zVkh7I&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==].
It actually seems to be the rediscovery of something Nietzche said over a century
ago: "All truly great thoughts are conceived by walking." Read the study to get 
the details but it's compelling. The folks at Wharton even offer up places that 
help you engage in active walking, including: 1) walk in the city, 2) walk in nature
(NOTE: that must be "rural" as compared to city?); and, 3) walk in the forest (also,
mostly rural  J). The study also noted that even walking on a treadmill increased
creativity by 60% and that backpackers scored 50% better on creativity tests during
a wilderness trip (again, rural
J) compared to their pre-trip performance. It seems to be the New Old Thing. Consider
it. Enjoy it. Take your dog along. My faithful companion - Toto - loves it!!
Follow The Money - The Medicare Payment Advisory Commission (MedPAC) recently reviewed
a Medicare staff proposal that would create a unified payment system for skilled
 nursing facilities (SNFs), long-term care hospitals (LTCHs), home health agencies
(HHAs); and, inpatient rehabilitation facilities (IRFs). Under the new payment model,
payments would be based on patient characteristics rather than the site location
 where services are provided. In addition, the model would create two payment tiers
- a basic tier for "typical patients" (yet to be fully identified); and, an advanced
tier for "patients with highly specialized care needs" (e.g. post-hospital stroke
rehabilitation, ongoing cancer care treatment, ventilator care, etc.). The intent
is to reduce the disparities in payment for equivalent services that are provided
by the different agencies. For example in 2016, HHAs received only $18.1 billion
 for 6.5 million episodes versus SNFs receiving $29.1 billion for 2.3 million stays.
In addition, the new payment model would stipulate requirements for patient care
 regardless of location. The full Medicare report [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW1w-x3ygi5HnjsvQU0RY4dQ3lLrTpbKHEEw3eO9aMUS18T95u3l5gCvbhGHi7_BjI3HIEWTvBifVhZRQx5as3GqxcYeP-o0K-WQqlvCmdPzbYJ0Yw1UE1OsDC7jhcWQXJfbYBTftFtVuyOUn7QM1uokhdLlVFfxKoL6wF8ebqlTm4I4Aou5covw3LWzJHUuOicLsUs5XMBks&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==]
is available for review. The report is now out for review. Expect the health care
community to weigh in with financial losers complaining and financial winners championing
the changes.
What Is The House Of Medicine And Health Care Doing To Stop The Anti-Vaccine Movement?
- In a harbinger of things to come here in the USA, the Wall Street Journal [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW1w-x3ygi5Hn0Ea_2JbG00xM1afQlNnfiD_ajRBbUDCcpWdX9IK3Usziy_NFtx4-D5PsWUcEYZRDX1zd4Z_CRWjEe_8W5p-VLisk04ew8pUrlXVFgpU0J-gXryQGxOtCagCRA45Qkj3cYJIJxGgpkoQNJIOhZYF5h5YxNyzDTyPT6mpcYrrNwgBo_8TwkusbqoEIeccDvmtxeOucNsVSjJ71N-wJSord6t8-jlQxrlLarUi6xMz95NfDOW5HFGcNq8NdJ0HQIm2FjaVO-4-cT1ZqtxCZsbDbPY9gGVlXUkkDW1Ai9plowIJpcAOkUDL-vIdb0yJ5qUIn29OG-dBETZX99_loVV8Yyh-sGychDicCCxBMCrOo77_V2PmedKbBrWdNzsKzrwPj3dURwelesu-CP9JXRxx1pflvVgo8AlcYvr7iZDuuVdOsMMVCxUi7qee5yGCrreq_IECsGkUMO5cOfe8ahfPul1gZZYr9IoVI30e-lLijIq96n2xf7BGy0ma3xH-AKClKaS8rKOe4vwBHrGanNRaQgQwbiODajkgpwwQEVtZ07hYjaPgLUdIiAC3aTcJppPesGvWKUYJaDp1UxsCbO5SppA==&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==]
recently reported that Romania has been combating a measles outbreak since 2016.
 In fact, the London School of Hygiene and Tropical Medicine in a 2016 survey reported
that 7 out of the 10 countries with the strongest skepticism about vaccination safety
were in Eastern Europe. The Romanian outbreak has resulted in more than 15,000 people
with measles infections resulting in 59 deaths. The anti-vaccine movement is alive
and well here in the USA as well. It's spread by specious arguments that seem to
 drift hither and yon on various web sites. As I read the article, it occurred to
me that we - the medical and health care professions - are NOT doing enough to combat
bad information. And, it's not just about vaccines. There are a whole host of issues
that are percolating up with inaccurate and even dangerous mis-information. The 
professions should ban together to prevent this type of spurious information.
Fighting Back...Finally! - It's all too common. Whether it's IV bags, Lidocaine,
 tetracycline or some other common product - the shortage of common tools and products
used in the treatment of problems is becoming all too common. In an effort to solve
the problem, Intermountain Healthcare along with HCA, Mayo and other providers plus
support from a number of foundations have decided to get into the generic drug production
business by starting a company Civica Rx. And, it's not just the shortages that 
are a problem. It's also the outrageous cost for some of these medications, devices
and products despite their longstanding use in the medical community. It's simply
a matter of price gouging. The new company is going to focus its initial efforts
 on producing and marketing 14 common generic drugs that are in short supply or 
whose prices have abruptly increased in recent years. Applause, applause!! Even 
better, the Association for Accessible Medicines - a generic drug manufacturer trade
group - issued a statement extending support to the initiative by stating that it
"welcomes into the generic drug manufacturing community any entity that shares our
commitment to bring safe, effective and affordable treatment options to patients,
providers and payers."
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Future Health
Delivering care in the new virtual world...
Let's Be Careful - You will not find a bigger fan on the use of artificial intelligence
and machine learning as a tool for "augmenting clinical intelligence" among providers.
At the same time, I took pause at a recent issue of JAMA Network Open [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW1w-x3ygi5HnQbPXK-SgKzdu07tiC0GgEVDPFxpjLWThyrNxrqDos1L126y1FQL4Z5ehviZ_Px5E-lRwBf1drlmpQbXUOIgRHn5n8nAfWO32dKQO3j65GGpEB_hQHiccGkvPcJbmg48Tw2ClVCZJcrE5p4MSYgKFEtfmMa40L8ozNRo5aUZPMX-5gjY2uRNWEDVGNAHOEezlaYuX_q0tZKhLxI-Tq4FX311gc3bOqOrhFDLc725Cj8BPCWr3F5iTlGV1jrYFh4ymf8472bCS4gpQqI_L6nqZoqgtIHMRDppu2zT-7RuttKdSm-TJogYr5pUTpUR6-zSp4s9yX1kdcQJ6CUBYCpBTq8BrGm6hzId49pBzbp9AAb7IP2r8a3fPcwtkDyQIAEJaqbVQ_SLXthYceQGQmEaY6ByNT7EU7B7XDWBs5IyWO7Qxn3HEUizm1NRYJzwhyDQ8ysvuovhKtgGBxzA4Z3jdVFOhL6ByIOlc&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==]
(2018;1(3): e180926.doi: 10.1001 - 2018-0926) which report on the application of
 machine learning as an approach toward assessing short-term mortality among cancer
patients who were starting chemotherapy. The study included a cohort of 26,946 patients
with cancer who were starting a wide variety of discrete chemotherapy regimens. 
With the use of machine learning and AI, those patients who were at high risk of
 30-day mortality were accurately identified across palliative and curative chemotherapy
regimens and across many different types/stages of cancer. The researchers also 
compared the computer algorithm to more conventional tools such as predictions based
on randomized clinical trials and population-based registry data. The algorithm 
did a far better job. Their conclusion is what drew my attention. It said:
"A machine learning algorithm accurately identified individuals at high risk of 
short-term mortality and may help to guide patient and physician decisions about
 chemotherapy initiation and advance care planning." [emphasis added]
Lest we forget, it is an imperative - from my perspective - to always keep in mind
their conclusion that the use of machine learning and AI is a "guide" - not the 
definitive approach. In our enthusiasm to embrace new technologies, we always need
to keep at the forefront that computers and machines still do not think - and, until
they do, we should always hold their outcomes as support for "clinically augmented
intelligence". Make sense?
Bioprinting Your Medications - The new HP D300e Digital Dispenser BioPrinter technology
is being tested by the company and the CDC on the effectiveness of printing (i.e.
making and dispensing) and testing antimicrobial resistant strains of "super bugs"
which is an increasing problem. The idea is to provide a select number of hospitals
access to the technology nationally to cut down on the drug resistance problem by
identifying the bugs earlier and dispensing the appropriate medications quicker.
 In addition to identifying resistant strains, the HP BioPrinter can also dispense
medications in many doses thereby alleviating the frequent "wait" in pharmacies 
who need to obtain the correct dose prescribed by the clinicians. Soon, the antimicrobial
resistance testing will become a common place component of dispensing medications
for patients with the end result being a reduction in the 23,000+ people that die
in the USA every year from infections by super bugs that are not treated as rapidly
as can be managed using the new HP Bioprinter devices. But, the use for drug dispensing
is only the beginning of a revolution in the "printing" business. Bioprinters are
also being explored for use in human tissue and organ production, drug research 
and other clinical areas. Amazing!!
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The Weekly Whisk
Musings from a foodie...
This past couple of weeks offered up an opportunity to spend some time in my favorite
city in the world - Paris!! As always, when I travel to the city at the center of
culinary excellence, I try to visit a variety of places from hidden gems to upscale
once-in-a-lifetime experiences. On this trip, I found four very different places
 that you might want to consider for different reasons if you travel to Paris.
The first consideration is for those who are trying to find a gluten-free restaurant.
Paris now has a couple of choices so my friend and I selected Noglu. It was located
in a small inner sanctum walkway on the 7th. The inside seating offered 6 seats 
at a bar overlooking the grill an cooking area with three four-person tables outside
on the walkway. Intimate. We both had a burger with totally gluten-free preparation
including the mayonnaise which they make at the restaurant. It was a good place 
for its purpose [* * *] and for those in need of gluten-free, a definite restaurant
to consider but the food was not notable. Noglu - 69 Rue de Grenelle - Paris 75007
- +33 (0) 1 58 90 18 12 - [email-masked] [mailto:[email-masked]]
Another place to definitely consider for those without dietary restriction is Le
 Bistrot d'a Cote Flaubert [* * * * *]. Adjacent to the famed Restaurant Michel 
Rostang, the Bistrot is managed by the same restauranteur. The service was quite
 wonderful and the food way more than ample. In fact, our group of four felt that
there was literally "too much" food. It all started with a coriander mousse followed
by a pate with fruit and escargot with garlic emanating from every morsel!! What
 a way to start an evening of dining. We then "shared" the Bresse chicken which 
was served with a perfect au jus preparation and whipped potato. This is where the
meal got a little out of hand. The chicken kept coming even when we had satiated
 our desires and with no place to take the food, we kept eating
J. Two our number passed on dessert but being ever the consummate foodie, I had 
to try the chocolate souffle. It was chilled and a perfect way to end the evening.
I can see why the Michelin star chefs eat here when they come to Paris. Good value,
good food, good atmosphere and friendly service. What more could you want? Definitely
try it: Le Bistrot d'a Cote Flaubert - 10 Rue Gustave Flaubert - Paris 75017 - +33
(0) 1 42 67 05 81 - [email-masked] [mailto:[email-masked]]
After a day of museums, our group of four was wandering down the streets when we
 realized that we had not made any reservations for dinner. So, I pulled out trusty
Dr. Google and identified the restaurants within a couple of blocks. There were 
multiple choices but everyone was thumbs up for Italian. We headed for Ristorante
Costa d'Amalfi [Service = */ Food = * * * * ] which was only a very short distance
from the corner where we were standing. We arrived to a very small restaurant of
 six tables of four each in a very cozy place. Simone was the chef (I apologize 
- I did not get his full name) and he opened the place in 2016. The food was quite
good. The waitress was horrible at best. And, it wasn't the language barrier that
got in the way. Rather, it was the unorganized and disorderly approach to managing
the whole dining experience. I must say that the tagliatelle with porcini and prosciutto
was exceptional as well as the saltimbocca served with fresh sage and a perfect 
sauce. I was truly impressed. But, the service was less than lousy. In fact, it 
was so bad that it precipitated an "Italian discussion" in the open kitchen right
behind our table between the chef and the waitress. We weren't sure who won the 
discussion but the both went about their business. Regardless, the next time you
 are in Paris, consider this place. If the waitress has not been replaced, enjoy
 the "discussions" between the chef and his help. It's sort of like having Italy
 in Paris. Ristorante Cost d'Amalfi - 65 Rue de l'Universite - Paris 75007 - +33
 (0) 1 45 56 03 71 - No email reservations available
Finally, for a great Parisian dining experience you will want to consider Le Dome
[* * * * *] . It is a seafood place of distinction. I don't know where to start.
 It was all excellent and a bit pricey - but worth it. Everyone picked their favorite
seafood and we discussed global warming and the changing patterns of fishing over
a wonderful meal. The pate with fig was over-the-top wonderful for starters and 
we were off and running. We then moved on to the main course. I'm a huge fan of 
Dover Sole Meuniere and was not disappointed. Located in the Montparnasse area, 
you should definitely try it for one of the penultimate Parisian dining experiences.
Restaurant Le Dome - 108 Boulevard du Montparnasse - Paris 75014 - [email-masked]
[mailto:[email-masked]]- +33 (0) 1 43 35 25 81
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The Good, The Bad, And The Ugly
The ongoing saga...
The Yet To Be Determined - The proposed changes in Medicare reimbursement will no
doubt cause a rift in the house of medicine in the USA. The discussions, dialogues
and debates which will be forthcoming over the next couple of months will likely
 dictate payment models in the year to come. The proposals deserve everyone's considerations
or, be left out in the cold...
The Good - The use of telecare is finally getting its due. Payment models are moving
in the right direction and the C-suite is finally getting engaged in trying to figure
out how to integrate such services.
The Bad - The number of lies per day emanating from The White House...
The Ugly - The quiescent approach to leadership being displayed by Republican leaders
in both the US Senate and House. Both political sides are - unfortunately - going
to their respective corners in appealing to their bases. All of the politicians 
need to step out of the shadows and exhibit some leadership.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001LJZSscMEVb0DtWvWbuISs9mXxKr8zTTx4NvCg7Fe8RiXPWvNeK0VW-JPpbZAUczJo9KtENd3_1cfGW9kSTQBO3ixOHh0Dn__iqehT_oUCL9TfHW-n72clMoytXfOt--iz7hCe6bgrk_QtBflzeSR-r0Lt-0n8bukDOBWyamG--CySOZXc2ob6CGZ5ivOuGKu&c=_Rgs90Mz4-Dd6lpXB6aK1Sa3cEUnJpFpqpAIzyIh2QCqqPDy2pEU2w==&ch=xrXLeoFaCopXjhIYn8DsRugCb_1nqmXr1BPfmQ5x55LY6vUPR4gOzg==]
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