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As a family physician, one of the more fun conditions for me to care for is pregnancy, childbirth, and the well child checkups that follow.
I meet women at the start of their pregnancies and learn a little about their lives beyond their pregnant “condition.” I see them every month for a long stretch, meeting mothers, mothers-in-law, friends, and husbands along the way. As things progress I see them every two weeks, and then weekly.
By the time the weekly visits occur I find out what my patients are made of – and they get to know me, as well. Mama is very pregnant, and my job is to convince her that every day inside, even past the mythical due date, is good for the baby. I then get to witness the miracle of childbirth (and occasionally play a larger role).
In my practice, mother and baby come back to visit weekly, monthly, and then annually as the children reach toddlerhood. We continue to have conversations around the new family and the transitions up until the age of three. After that, if the child is well, we are limited to an annual “Hi, how are you doing?” For the most part, they are moving on with their lives as a young family and fortunately do not need my help. In the words of the Lone Ranger,”My work here is done.”
However, it isn’t quite as easy as that. Doctoring is a funny gig when it comes to personal relationships. I’m sure there are others just as funny, dentistry probably being one. I see these folks back for a visit after a couple of years, or at a community activity, or elsewhere in Mobile and surrounds, and the mothers will proudly say to their (very embarrassed) twelve-year-old, “There’s the first person who ever saw you.” We’ll make some small talk — what do you say to a twelve year old after nine years? — and typically the mother will ask about my family and my kids.
Because, as it turns out, while they were sharing a part of their story with me, I was sharing a little of my story with them. I used my children as examples for feeding and discipline problem-solving, as both good and bad examples. I discussed my wife’s meal-time solutions for feeding grown-ups and kids at the same table. In other words, I shared with them as they were sharing with me. A little piece of my version of how we put our kids to bed has entered into the bedtime strategy of many of the families that I have cared for. If “Good Night Moon” did become a successful part of their ritual, I hope they think of Dr. Perkins in a really good way (after the toddler is actually asleep, of course).
I don’t get to care for a lot of young families any more, given my other duties, but I do still see folks that I have cared for over the last twenty years, people with whom I have shared family anecdotes in this manner in the hope of leading them to better health.
It has been six months since my wife’s death. Many of my patients, coming in for a variety of reasons, or running into me around Mobile, have wanted me to know that they are here for me just as I, and our family, and some of my
wife’s child-rearing strategies, were there for them. It has meant a great deal to me.
I interview approximately 60 prospective physicians for medical school over the course of the year and 40 physicians who are applying for the residency program. The pre-med students (almost all of whom are the age of my children) tend to have pretty good interview skills and are trying very hard to get into medical school (“I’ve wanted to be a doctor for as long as I can remember”) so the interviews tend to be somewhat predictable. Every so often I’ll get one who considers ObamaCare to be the devil’s work but for the most part they are good but non-controversial interviews.
The resident interviews are more fun for me. These are physicians-to-be who want to be in Family Medicine, want to see what our program has to offer, and have at least a passing understanding of the advantages our program might have over our competition. These are interviews with much more substance. The three on Friday were especially enjoyable.
One of the candidates was from Louisiana and grew up in a part of the state that my family is from as well. After a discussion regarding Cajun territory, the conversation veered towards Family Medicine and why he wanted to become a Family Physician. The candidate had done most of his clinical work in Lafayette, a regional clinical site where Family Medicine is taught. Like all good clinicians-to-be, on every clinical rotation the instructors not only focused on his clinical learning but also on his career choice. “Why Family Medicine” they would ask. He worried about the prestige factor as he was choosing a specialty. His decision was cemented, though, by a decision LSU made to place him with a rural Family Physician for an extended period. He saw this physician as a mentor and it was this relationship that cemented his decision to go into Family Medicine. He said “At the (teaching) hospital in Lafayette, the Family Medicine team is down here and the specialists are up here. Out in the community it is completely reversed.”
The second candidate was a student who had come for an interview the previous year. I remember the interview from last year very well. I was very surprised when I heard that this student selected Pediatrics instead of Family Medicine. She came back to re-interview because she said she had discovered her mistake and wanted to be a “Family Doc.” She said she was admitting a very young patient to the inpatient service for failure-to-thrive. It is uncommon for infants to fail to thrive and it is almost always a parenting problem and not an infant problem. In this case the mother seemed to the resident to be suffering from post-partum depression. Unfortunately, she was told that it was not her place to treat the depression, only the poorly fed infant. She said to me “I want to be able to treat the whole family.”
The third was a non-traditional candidate who was originally from Mobile. He left Mobile almost 18 years ago and after a roundabout life course ended up in medical school. He told me “I want to take care of people who are underserved in a holistic way and I want to do it here at home.” The fact that he was of African-American descent was meaningful. Traditionally we have had trouble attracting African-American candidates from Mobile into primary care, as have others, in part because there is a tradition in the community to encourage minority medical students to pursue limited specialty choices. I suspect this is a reminder of our racist past in this region, where African-American physicians were excluded from specialty training. Having Family Medicine seen as a “specialty” by this student is clearly a victory.
So three candidates and three conversations that give me hope for our specialty and the future of medicine.
Although I’ve alluded to the organizational structure known as the ACO here and posted a link to a really funny video about them here, I’ve never actually made the effort to fully describe the organizational structure or the implications for primary care and primary care training. This was because of fear that I might fall asleep writing about it. This changed after my discussion with Paul Grundy this past week which I spoke of here. Paul encouraged me to look into the structure because he is convinced that it is a mechanism to fund the Patient Centered Medical Home method of care delivery. I tend to believe him because he has been correct so far about “where the puck is going to be.” I will attempt to describe this in such a way that I will not sleep while writing and hopefully you won’t sleep while reading, either.
Accountable Care Organizations were first described in Health Affairs by Elliot Fischer and others in 2007. They described an established pattern to healthcare delivery where physicians tend to use the same “referral networks” either because of formal relationships or informal arrangements. The relationships tended to involve groups of primary care physicians, specialists, and hospitals. These relationships resulted in care that could be characterized on a spectrum with some care being predictably very high quality, some very low quality, and the majority of care delivered in the middle. The question not answered by this research was “whether changes in incentive would result in improved care for all?”. The investigators clearly identified that a level of accountability, organization, and aligning incentives with desired outcomes tended to predict patients getting measurably better care.
Fast forward to 2010. The Patient Accountability Act is passed and included in it is language that holds CMS responsible for implementing Accountable Care Organizations by January 2012. CMS has identified the following groups as being able to form an ACO:
Who can form an ACO
A: The statute specifies the following:
1) Physicians and other professionals in group practices
2) Physicians and other professionals in networks of practices
3) Partnerships or joint venture arrangements between hospitals and physicians/professionals
4) Hospitals employing physicians/professionals
5) Other forms that the Secretary of Health and Human Services may determine appropriate.
The American Hospital Association published a summary of what an ACO is believed to be in May 2010. They identify the minimum that is in the law:
ACOs must have a formal legal structure to receive and distribute shared savings to participating providers.
There must be enough primary care professionals to treat their beneficiary population (minimum of 5,000 beneficiaries) as deemed sufficient by CMS.
Each ACO must agree to at least three years of participation in the program.
Each ACO will have to develop sufficient information about their participating health care professionals to support beneficiary assignment and for the determination of payments for shared savings.
ACOs will be expected to include a leadership and management structure that includes clinical and administrative systems.
Each ACO will be expected to have defined processes to promote evidence-based medicine, report on quality and cost measures, and coordinate care.
ACOs will also be required to produce reports demonstrating the adoption of patient-centered care.
I must admit I was a little disappointed when I read this summary because it didn’t seem to me that this organizational structure would do anything to reduce the profound overutilization we have in this country and we were in for more of the same. I was more heartened when I read the Health Affairs policy brief published in August 2010. In this brief (worth a read in its entirety) the basic features are fleshed out in much greater detail: The speculation is that ACOs will be able to qualify in one of three categories based on willingness to accept risk. The reporting of outcomes will be mandatory but the acceptance of risk for bundled care (for example, treatment of congestive heart failure which involves a primary care doctor, cardiologist, and a hospital) will offer greater reward.
Basic Features: The version of health reform legislation originally passed by the House would have given the Centers for Medicare and Medicaid Services (CMS) authority to pilot test a variety of different structural and payment approaches for ACOs. The Senate version that was enacted into law focused instead on one model that is now able to become a part of Medicare, not just a pilot program. The model embodies a few basic features proposed by some policy analysts:
- Invisible Enrollment. Patients who receive most of their care from ACO-affiliated providers would be treated as “assigned” to the ACO. At least at the outset, they would not be formally enrolled, would not be required to obtain services through the ACO, and might not even know the ACO existed. The assignment process would allow payers to define a population for which the ACO could be held accountable. Critics of this approach believe that patients should have a choice about participating in an arrangement that could reward providers for reducing services.
- Performance Measurement. Over some period of time, payers would collect data on utilization and costs for the ACO population and on measures of quality of care and population health. A provider could be required to meet minimum quality standards in order to continue to participate in the ACO. In addition, quality reporting requirements would encourage improvements in ACO-wide information systems, a key factor in developing coordinated care.
- Shared Savings. Spending for the population of patients in a particular ACO could be compared to targets based on past experience for the same patients, or to spending for similar patients in the community who were not assigned to the ACO. If the ACO was found to have saved money, it would receive some share of the savings. Just how the savings would be divided among the participating providers is a major question that each ACO will need to resolve on its own.
- Evolution Toward Stronger Incentives. In the beginning, there would be no downside risk: The ACO would not share in the losses if treatment of its patients cost more than expected, though this could change over time.
Elliot Fisher (who conceived of the idea) has published another Health Affairs article (subscription required) entitled “A National Strategy to put Accountable Care into Practice.” where he discusses the types of information that the ability to act will determine which the level risk the organization will be allowed to undertake. For Tier 1, for example, care providers will have to identify numbers of patients who have been screened for easily detectable and treatable cancers to allow prospective patients to compare groups. Tier 2 will be expected to maintain high levels of childhood immunizations, high levels of glucose control in diabetics, and high levels of blood pressure control. Tier 3 will need to control entire episodes of care such as hip replacements, diabetes care and this control will include the patient experience.
So the question comes up…isn’t this just another name for an HMO (which the American public rejected)? Fellow blogger Jason Safrin has put together a comparison. He points out that
However, there are three main differences between ACOs and HMOs.
- The “accountability” rests with the providers. Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care.
- Direct contracting with provider organizations without the reliance on a health plan intermediary.
- The ACOs allow for flexibility in the type of organization. Some regions may prefer independent practice associations (IPAs) while others may prefer a physician-hospital organization (PHO).
In short, it just might be worth a closer look if you and a couple of your closest primary care friends (need at least 2-3) have a robust electronic health record and are willing to take on chronic illnesses and figure out ways to deliver preventive services effectively. Good care should lead to more money. Stay tuned and good luck.
As Family Physicians, strong supporters of structural change in healthcare, and the Family Medicine Department of the 8th most socially conscious medical school in the country we are not content to sit on the sidelines and wait to see “what form health care takes.” The Department has undertaken several initiatives that help us to demonstrate to students the full impact an engaged family medicine team can make in the health of a community. I sat down with each of the faculty over the past month and asked them to brief me on how these initiatives are progressing. Below I have chosen to highlight three of these initiatives:
First, at the entry level into medical school and throughout the preclinical year, it is important to identify those students interested in being a family physician. Dr Carol Motley is working with the 1st and 2nd year students (and lower) to develop an early interest in Family Medicine. I had the privilege of attending the organizational meeting for the Family Medicine Interest Group and was pleased to see the level of commitment and enthusiasm. The group will offer additional instruction for those interested in Family Medicine as well as an opportunity to interact with peers who share this interest. One of the things our specialty has done well is developed an infrastructure to assist departments such as ours in developing and maintaining interest. However, without dedicated students it doesn’t make much difference. I am excited to see committed, engaged students who want to be someone’s doctor.
Second, the medical students have a very intense clinical year where they learn the basics of clinical medicine and determine which type of doctor they want to be. Dr Ehab Molokhia has transformed our educational experience for our third year students. He has chosen to emphasize the Patient Centered Medical Home as his core curriculum. To that end, all of the educational activities that are not patient focussed targeted to teaching the students about what advantage a Patient Centered approach would bring to the patient in the exam room and collective ly to all te patients served by a Patient Centered practice. In addition, he is using actors to demonstrate effective care of the patient with chronic conditions to the learners. The evaluations are very good and the criticism that Family Physicians only take care of minor illnesses is being debunked.
Thirdly, it is important that we model care unique to the new model of Family Medicine. Dr Shyla Reddy, our resident geriatrician, is delivering care to elderly in a clinic without walls. She is partnering with the Mobile Housing Board to deliver care on site to elderly, home-bound residents in one of the need based elderly housing units. She will be using our electronic health record, practice resources, and resources from the community to allow seniors living in the complex to “age in place.” What she has found so far is that the residents of this complex (like elderly everywhere) are plagued by poorly coordinated care that often results in poorer health. She will make a real difference as will the rest of the team.
The faculty who work with me (I consider myself to be a member of their team, although I do get to set tone and direction) are dedicated to the delivery of high-end primary care. They are now finding ways to instruct students in these new methods of care delivery and model this care delivery to the populations who need it the most. This is happening in almost every College of Medicine with a Family Medicine department in the country. These are exciting times.
I was pleased to read a student impression of the National Conference for Family Medicine Residents and Medical Students. I go almost every year and am impressed by the student interest and the efforts of those of us in Family Medicine to get students to the conference. This year South Alabama sent 11 students to the conference and they all seemed to come away with good knowledge about the specialty and an excitement about Family Medicine. The Medical RNinja reported on one session on the Patient Centered Medical Home where prospective residents were given a list of questions to ask prospective programs when interviewing. It is a very good list, so good that I will reproduce it below and encourage anyone applying for Family Medicine residencies to look at it before your interviews…
Access to Care
1. How does your practice provide patient-centered enhanced access (e.g., evening or weekend hours, open-access (same day) scheduling, e-visits)?
Electronic Health Records
1. What aspects of your medical home are electronic (e.g., medical records, order entry, e-prescriptions)?
2. Does your practice use a Personal Health Record that allows patients to communicate their medical history from home to the healthcare team?
1. Do you use patient registries to track your patients with chronic diseases and monitor for preventive services that are due?
2. Does your practice use reminder systems to let patients know when they are due for periodic testing (e.g., screening colonoscopy, PAP smear, mammogram) or office visits (e.g., annual exam)?
1. Who comprises your medical home team and how do they work together to deliver comprehensive care to your patients?
2. What services can non-physician members of the team (nurse practitioners, medical assistants, social workers, etc.) provide for patients (e.g., diabetic education, asthma education)? How do you train them and ensure competency?
Continuous Quality Improvement
1. How do you monitor and work to improve the quality of care provided in your medical home?
2. How do you monitor your ability to meet patients’ expectations (e.g., patient satisfaction surveys)?
3. Are residents involved in helping to enhance practice quality and improve systems innovations?
1. How does your practice ensure care coordination with specialists and other providers?
2. How does your practice ensure seamless transitions between the hospital and outpatient environment?
1. What procedural services are offered in your medical home (e.g., obstetrical ultrasound, treadmill stress testing, x-rays)?
2. Does your medical home provide group visits (e.g., prenatal group visit)?
I’m back in Mobile from the Alabama Academy of Family Physicians meeting in Sandestin Florida (why an Alabama meeting is in Florida is a story for another day) and I was struck by three separate observations. The first was the participation of students in the meeting. The Alabama Academy Foundation has recently begun sponsoring students at the meeting and this year there were 20 students who had enough of an interest in primary care and Family Medicine to come to the meeting. You might say “So what, how tough can a trip to Sandestin be.” I can assure you that Dr Coleman made sure these students were at more meetings than beaches. They all seemed engaged and eager to learn about and participate in the delivery of primary care upon graduation. Here’s hoping we get the payment structure improved before the students graduate so they will not be actively discouraged from going into primary care due to income potential.
The second observation was regarding the visit of gubernatorial candidate Robert Bentley. These meetings do not usually take on the tone of a political rally, but because Dr Bentley is a physician I suppose it was felt by the leadership to be okay. Dr Bentley stated that having a physician in the governor’s mansion would help Family Physicians to succeed (because we all have medical school in common). He then outlined his platform of fighting against “certain provisions” of the Patient Protection and Affordability act throughout his governorship. His belief is that we can delay long enough to allow the Obama administration and the Democratic Congress to be replaced, then the entire bill can be repealed. He favors replacing the coverage provision with Health Savings Accounts, tort reform, tax breaks, and the traditional doctor goodwill. It will be this goodwill that physicians draw upon when asked to see an uninsured patient. I would like for Dr Bentley to come and speak to some of the specialists in Mobile who seem to have lost the goodwill aspect of their practice and let’s see if we can create a more collegial atmosphere down here. In particular, I would like to draw his attention to the dermatology situation.
The last observation is regarding the update from the Academy. Every year the national Academy sends a representative to fill in the membership on the ongoing activities and upcoming plans. The update this year included the details of the Patient Protection and Affordability Act. In particular, it included information regarding the Medicare Pilot Programs. The law requires that these programs be developed, evaluated by CMS (not by Congress), and if shown to save money be rapidly replicated. The Accountable Care Organization (2012) and Bundling Payments (2013) are going to be rapidly piloted, evaluated, and replicated. It is clear that this will happen because CMS wants to be out of the business of paying for fee-for-service medicine and sees this as a huge opportunity.
So my advice to the students (and folks already in Family Medicine) is this: The wave of payment reform is going to happen. Primary care in general and Family Medicine specifically is being positioned to be in the driver’s seat of a changed healthcare system. The battle to keep government out of health care delivery was lost 60 years ago. Rather than working to negate the law, I encourage all of us to work to make advanced primary care techniques a part our practice and to work to make our medical neighborhood a place where safe, effective, and efficient medicine takes place. Rather than wait to see if another wave comes along, I would suggest we paddle as hard as we can to get in front of this one.
Dr Lamar Duffy had an article published in one of our more prestigious specialty journals this past week. Several years back, we made a decision as a practice to use “e-prescribing” for all of our prescriptions (took away the pads). Lamar and Angela Yiu (among others but they were the main ones) had the vision to begin collecting data before, during , and after this transition. They found a decline in the number of after hours phone calls. Not an earth shattering finding but it proved that we can study the process of care with enough rigor to get papers published. This is important because a lot of our health care mess is due to a broken process that needs to be described and improved in a systematic fashion. Also, it showed that even in a small department like ours we can occasionally keep up with the big boys.
Coming back from the Society for Teachers of Family Medicine meeting in Vancouver, BC. Lots of buzz, excitement, fear, concern about the “new law” and the implications for healthcare. I always find this a very energizing meeting and this time was no different. I had the opportunity to share a project that our residency program is doing with the Mobile Housing Board around chronic disease self-care in elderly residents of an independent living facility near our office. My co-presenters were Brian Halstater of Duke and Lisa Weiss of Youngstown Ohio who shared what their residents are doing in the community as well. The Duke program I have been following with interest for a while and I remain impressed (funny what tobacco money and guilt will make you do). I was blown away by what Lisa is doing in Youngstown. Her program is in a town with 20% unemployment, the hospital is in a poor financial situation, many of her residents are not from the area (or even the country) but they are out in the community providing care, educating the healthcare TEAM about their own community, and working with the hospital to obtain needed care for folks who have no coverage.
Teaching community medicine in a family medicine residency program requires a certain mindset. One mindset is to shoot to be above the floor. Another mindset is to shoot for the ceiling. STFM is a bunch of people describing their efforts to reach that ceiling. Lisa Weiss of Forum Health/Western Reserve Care System Family Medicine Residency Program is awfully close.
As I was pondering my own departments inability to attract new faculty (if you or someone you know wants to teach Family Medicine, please contact me), I ran across this article (on Robert Bowman’s site) published by the Millbank Memorial Fund about the future of Academic Medicine, which apparently is in worldwide trouble. The authors point out:
- We have trouble translating basic research findings into practice
- Evidence based medicine is not utilized to make patient care decisions
- Academic and practitioner linkage is poor at best
- An individual physician cannot be highly functioning in the clinical, teaching and research world simultaneously
- Traditional research assessment tools place emphasis in the wrong place
- Research careers are not desirable
- Academic medicine does not pay as well as clinical medicine
- The academic career path is unclear and inflexible
- Problems with career progression particularly salient for women
- There is a disconnect between research focus and global (or local) health needs
- Medical education does not prepare graduates for a career in medicine
- Pressures to participate in care delivery squeeze other academic pursuits
- Leadership is problematic, particularly in countries with a limited leadership infrastructure
- Academic medicine relates poorly to its stakeholders: patients, policymakers, practitioners, the public, and the media
Fortunately, this country has just passed the “Patient Protection and Affordability Act“. Included are several provisions which will make Family Medicine educators more valued and Family Medicine Education more effective. These provisions include Title VII enhancements, rural training grants, the primary care extension program, teaching health centers, and some reform of the way Medicare pays for education in a community setting. In addition, many of the enhancements in the Center for Medicare and Medicaid Innovation change the training environment as well. It is entirely likely that only 5 years after the Milbank Fund published this report, President Obama may have bent the education curve as well. Only time will tell.
In this country we have an odd way of doing workforce planning for physicians. Many years ago medical schools in this country were optional, set up to supplement the apprenticeship system that functioned in the seventeenth and eighteenth centuries. As described by Abraham Flexner in 1910 “The likely youth of that period, destined to a medical career, was at an early age indentured to some reputable practitioner, to whom his service was successively menial, pharmaceutical, and professional; he ran his master’s errands, washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew toward its close, actually took part in the daily practice of his preceptor,—bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.” Students who desired to learn a more rigorous practice could supplement this apprenticeship with medical study in the larger towns in America. Mobile had medical schools early in its history and a very good one (Medical College of Alabama in Mobile) was established in 1859 to “supply physicians to rural Alabama, to reverse the economic and cultural drain among Alabamians that out-of-state education implied, and to educate medical students regarding the unique health care requirements of a predominantly rural Alabama populace.” Medical schools were commonly established near hospitals to expose students to people with various ailments with the Hospital Physician charged with oversight of these students.
The additional training of doctors freshly out of medical school in hospitals became popular in the 1870s and the City Hospital of Mobile had such a training program prior to 1895. The emphasis was on personalized instruction, use of laboratory to make diagnoses, and (after antisepsis became widespread) the use of surgery to cure illnesses such as appendicitis. Beginning in the late 1800’s but accelerating after WWII, physician specialization required additional training in a hospital after medical school. Where such training took place often dictated where one could practice following training (and still does to some extent) so there were not as many coveted positions as there were medical students. Medical students would go on interviews and were lucky enough to receive an offer would be given as little as several hours to think it over. This was not conducive to good medical student mental hygiene.
In 1952 a group of medical students got together and determined a method that internships (and further training called residencies) could be announced using a computer to match the medical student choices with the hospital choices. That process is now known as the match. In 1952, when the match was created, the money to pay for internships and residencies was put up by the hospitals. There were no work restrictions and the job became an apprenticeship type experience with some education provided. The book “House of God” is a good description of the training from that era.
Over the ensuing 50 years, much has changed regarding residency training. beginning in 1965 the federal government began paying for medical education through the Medicare program. Hospitals took advantage of this opportunity to add a number of training programs. These programs benefitted the hospitals by allowing them to provide more extensive care but did not necessarily lead to good training and the programs offered had no relationship to the needs of the community. In addition, physicians from other countries were encouraged to train here (and ultimately the system came to depend on these 5,000 physicians brought over every year) but were offered training that they could not use in their country for the most part because of a lack of available technology. Beginning in the 1980s efforts were made to control both the quality of the training programs and the importation of physicians from other countries, with mixed results.
What does this have to do with workforce? Graduating medical students select a specialty based on what they think they might like to do, where they might want to live, and (some more than others) how much money they anticipate making. Hospitals, who have little skin in the game when it comes to training residents and actually make money for having residents, want to be successful in attracting residents so they tend to offer training programs that are desirable to prospective residents. In an odd coincidence, those programs that graduates think will allow them to make a lot of money tend to fill first, before those that are needed to provide care for the poor and underserved (primary care). In the annual ritual, we offer more specialty care positions than we need as a country to provide optimum care, celebrate all of our bright students getting into these programs, and then bemoan the waste that comes from doing too many cardiac catheterizations. After all, a cardiologist has to eat.
After all was said and done, this years match actually ended on an optimistic note for my specialty. Although only reflecting an improvement of about 100 students, there were more US graduates going into Family Medicine than in previous years. Doctors in our specialty may not make as much as some of our limited specialty colleagues but I hope that one of the results of tomorrow’s vote will be to eliminate some of the stresses that contribute to professional dissatisfaction. It appears that at least some US students are anticipating this. Maybe next year will continue the trend…