Kitchen staff were canaries in the coal mine (2022)

63 pointsposted 15 hours ago
by toomuchtodo
(economistwritingeveryday.com)

69 Comments

avidiax

14 hours ago

People still work in literal coal mines, and their pay is still < $31/hour.

This discussion is about an effect at the margins. The marginal nurse that decides to quit, the low-seniority teacher that is paid less than their peers for the same work.

When the canary dies in a coal mine, everyone is in danger. But when working conditions worsen, only those employees at the margins (close to retirement, low seniority, worse than average assignment) will leave.

The question is whether there is some exponential effect on service from decreasing kitchen/nursing/teaching staff. Those fields all look like they have linear degradation of service to me.

https://www.salaryexpert.com/salary/job/coal-miner/united-st...

jp57

13 hours ago

If everyone dies when the canary dies, then there wasn't much point in bringing it down there. The canary is at the margins, and thus it dies first when the gas comes. When it dies, everyone else should GTFO, because if the gas gets worse, they're next.

ajb

14 hours ago

Good analysis. Not sure I agree that they are all linear in degredation. Anything that serves a queue has superlinear degredation; as the service rate goes over the arrival rate. We've hit that tipping point in the UK and waiting times for access to medical treatment have ballooned; in our case aggravated by the exit of GPs.

Kitchen staff also serve a queue, but I don't think that will have the same effect as people always have the option of eating at home.

RangerScience

14 hours ago

I think the idea with the “canary in a coal mine” isn’t that it’s the margins that are at risk - it’s a signal that those margins have moved.

When working conditions worsen, and those at the previous margins leave, does that mean there’s now new people in the margins who were “safe” before?

dividefuel

14 hours ago

Nursing seems like one where a feedback loop could happen. As others quit, your patient burden increases. The higher your patient burden, the more likely you are to make a mistake. Mistakes are often, as far as I understand, held against the nurse, so you could lose your license. At a certain point, the risk becomes too great and you're better off quitting.

devilbunny

10 hours ago

Nursing boards are extremely capricious. I'm a doctor, I've heard it too often. Shitty nurses who shirk doing work but do everything required according to protocol are fine. Great nurses who make one tragic and understandable mistake to try to help a patient get their license pulled.

The US needs to adopt one particular British slang that hasn't made it across the pond: jobsworth. As in, that's more that my job's worth. Sitting there and doing nothing gets them left alone; trying to intervene without following a long and detailed protocol gets them screwed.

I protect the nurses that I work with (and they don't work for me, they work for the hospital, and I don't) as best I can if they are doing the right thing. I can't be there all the time. I need to be able to trust them, and they need to be able to trust me.

I was part of a bad patient interaction in the hospital a long, long time ago, when I was a resident. Nothing bad happened, ultimately. But I was harsh to a patient who was being verbally and physically abusive to the nurses. The patient complained a few days later. It was an emergency situation, and we will leave it at that (it didn't happen in the ER). And I was summoned to explain myself some days later. I said that I would not let that patient behave that way toward "my" nurses. And that was the end of it.

I don't think all of them liked me before or even after, but after that, they never bothered me about trivial things because they knew I would defend them and their actions done in good faith and without idiocy.

Medicine and the military are very similar in terms of command structure: doctors and officers issue orders, nurses and NCO's make them happen, and a doctor or officer who defends their nurses or NCO's for doing the right thing in the moment regardless of the rules will find their path much easier.

sofixa

13 hours ago

> Nursing seems like one where a feedback loop could happen. As others quit, your patient burden increases. The higher your patient burden, the more likely you are to make a mistake

Or your burden becomes insufferable and you burn out and quit.

vundercind

14 hours ago

Good high-seniority teachers can walk out of their job and straight into the white-collar office job world for more money and usually less bullshit. Probably even a remote role for extra improvement to QOL. It’s far from just new teachers leaving (that’s always been a thing).

pipes

14 hours ago

Two siblings who are teachers, and a parent who was a teacher. What sort of white collar work can they get? Only example I can think of is a teacher who left after two years and got a job as a Business analyst at my place of employment (they were in their 20s). I've honestly never seen any other teacher do this. Teachers are very underpaid in the UK, but they do have great job security and pension security. Not to mention amazing holidays. Neither of my siblings would give this up.

vundercind

10 hours ago

A lot of it’s about transferable skills, which good teachers tend to accumulate a lot of. For one thing, they have to have their shit together better than your average office worker, just to get by in their profession. They tend to have excellent organizational and planning skills, and are very good at packaging and presenting information. That’s a very-partial list, and doesn’t even cover topic-specific skills they may pick up. They’re often very good and quick at picking up things like project management, or any other communication- and organization-heavy role. Marketing. Lots of things they can get up to speed on really fast. It doesn’t hurt that in a lot of places (in the US) the pay’s so poor that they don’t exactly need to move directly into even a mid-tier office job to make more than they do with 10+ years teaching—a tad above entry-level can match or beat what they’re making, and it goes up fast from there (something they tend to find thrilling and surprising—hey, look, you get actual rewards and advancement in pay for doing great at your job, not just a a monochrome certificate someone ran off on the school laser printer!)

tqi

14 hours ago

> The only solution will be to raise compensation for teachers and bring labor into the industry and, well, the failure to raise teaching salaries is maybe the single greatest of example of the divergence between what people publicly support and what they actually vote for.

It's hard to read sentences like that and wonder "what more do you want?" Yes teachers should get paid more. The average teacher in the SFUSD gets paid ~$84K, which is clearly not enough for the city. But the district has an annual budget of 1.3 billion dollars for less than 50K students. Maybe the district should spend more of the money it already has on teacher salaries instead of wasting money and time on stupid / mismanaged projects[1][2][3].

[1] https://missionlocal.org/2023/12/san-francisco-unified-schoo... [2] https://missionlocal.org/2022/10/firm-awarded-no-bid-contrac... [3] https://www.nytimes.com/2022/06/23/arts/design/san-francisco...

bongodongobob

13 hours ago

I wouldn't use SF as a baseline for anything. It's way outside the norm for any metric you could pick. That's $30k/student. Try Oshkosh, WI or something. $13k/student.

willcipriano

13 hours ago

OECD average is 9k.[0]

US spends more per student than everyone else save Luxemburg, Switzerland, Austria and Norway.

[0]https://nces.ed.gov/programs/coe/pdf/coe_cmd.pdf

bongodongobob

13 hours ago

I don't disagree with that. But as soon as you bring SF or NYC into a discussion about general issues in the US, Im out. Those places are extremely unique outliers and don't represent normal life for the majority of US citizens or cities.

slt2021

13 hours ago

these places are held captive to internal political clique, regulatory capture, and union

k__

14 hours ago

My partner worked as a nurse for almost a decade. In the end they were in psychiatry, most chill job you can get as a nurse if you don't want to go into management. No manual labor, only bringing people their meds and writing down what they did all day. It still sucked. The pay was bad and the night-shifts and constantly covering for sick coworkers took their toll.

In the end they switched to a study assistant job. Better pay and they can work whenever they like, even from home for half of the tasks.

OgsyedIE

13 hours ago

Is there a useful way to separate the effects that wages not keeping up with inflation has on workforce retention has from the effects that customer/student/patient violence towards staff has on workforce retention?

My gut instinct tells me that the latter would be a much bigger driver of resignations but I'm not involved in these industries so maybe the former matters more to them.

user

14 hours ago

[deleted]

jppope

14 hours ago

Probably something that can be learned from this information, but I doubt the conclusion the author arrived at is correct.

trynumber9

14 hours ago

Labor shortages in nursing, cooks, and teachers. But unemployment increasing since 2022. Sounds like it might work itself out?

mschuster91

14 hours ago

> But unemployment increasing since 2022. Sounds like it might work itself out?

No. Partially because these are high stress jobs and not everyone is willing to take them - and honestly, no one should become a nurse or a teacher if they don't want to, because the damage potential is so high, partially because becoming a teacher takes a lot of study and in the US it carries the non-insignificant chance of getting shot.

Our_Benefactors

8 hours ago

> and in the US it carries the non-insignificant chance of getting shot.

Oh brother. Citation fucking needed. Show me statistics that support your claim that a teacher is more likely to be a victim of homicide than a member of the general population.

mschuster91

4 hours ago

Well, given that firearm-related deaths are the top cause of child mortality in the US, that there have been 139 shootings in schools just this year (that isn't even over yet...) [2] and there's about 115.000 schools in the US [3] it's about a 0.12% chance that any given teacher's school is about to be the site of a massacre in the US in a given year. That definitely fits my claim of a non-insignificant chance of getting shot, and in any case it should be zero - children should not fear getting shot to the point that 95% of schools have to hold (some even mandated by law...) regular active-shooter drills that end up traumatizing a truckload of children [6]. THESE DRILLS ONLY EXIST IN THE USA among civilized, developed countries ffs. Other countries may hold drills for natural disasters such as earthquakes, there's no chance to avoid that, but shooting drills? Come on!

In contrast, there have been about 22.000 murders per year since Covid [5] (a significant uptick) on a population of 345 million people, so the risk of getting murdered is significantly lower for the general population. The risk might be even lower in rural areas but higher in high-crime-in-general areas but seriously I lack the time and will to do a per-county analysis.

[1] https://www.nejm.org/doi/full/10.1056/NEJMc2201761

[2] https://everytownresearch.org/maps/gunfire-on-school-grounds...

[3] https://mdreducation.com/how-many-schools-are-in-the-u-s/

[4] https://www.statista.com/statistics/191134/reported-murder-a...

[5] https://www.statista.com/statistics/191134/reported-murder-a...

[6] https://www.theguardian.com/us-news/2020/feb/29/teachers-cal...

behringer

14 hours ago

you'd have to be a complete idiot (or love the craft so much you don't care what it costs you) to go to school for nursing or teaching in the US. Now chef'ing, that's not a half bad idea :)

behringer

14 hours ago

And yet school administration and hospital administration are making more money than ever. There's no labor shortage, there's a pay shortage.

Workaccount2

14 hours ago

Really there is just a housing shortage. Every road of struggling lower/middle class finances leads back to housing being outrageously expensive. All these other costs/wages are in mostly functional and liquid markets. They are being priced/valued more or less correctly.

Except housing. It's artificially choked to bolster home values by home owners.

onlyrealcuzzo

14 hours ago

Teachers and nurses still don't get paid enough even in cheap places, where housing is extremely affordable like Detroit, Cleveland, all of Mississippi, etc.

So maybe it's a bigger problem in HCOL areas like California, but it's a problem everywhere.

The problem is, in the last ~20 years we went from ~7% of the population being retired to ~20%. Over the next 10 years, it's going to get close to ~30%.

dividefuel

13 hours ago

I can't imagine that nursing's problems are just fundamentally housing. Tracing back rough work schedules, unreasonable administration expectations, and hostile patients to housing costs feels like a stretch.

cogman10

13 hours ago

Pay is part of the problem, but also prioritizing profit margin above all else.

The fundamental problem is if you understaff and overwork your employees, you make more money. The actual drop in quality for the service doesn't degrade enough to stop people from using it.

This is why hospitals are horror stories of nurses/doctors working 60+ hour weeks with no vacation and managing a huge patient load. It's because admin has found that even if you don't have enough nurses, that just means 1 or 2 patients suffer or wait in line for longer. Perhaps someone dies, but in the meantime you'll save 10s, 100s of thousands or even millions of dollars over the course of a year.

It's a pay problem, but it's also a staffing problem.

wffurr

13 hours ago

Working conditions too. Pretty bad for nursing and teaching.

miki123211

13 hours ago

What I find very interesting about the examples here is they cover the whole spectrum of government-managed to free market.

Most teachers are employed by state-owned schools, and as far as I understand, they're very often unionized in the US. Nursing is mostly private but regulated, probably with some mix of non-profits / government thrown in. Restaurants are as free market as it gets, there are both large chains and small restaurants, there's lots of competition, most customers have more than one option, reviews exist and a lot of people are repeat customers, making it hard to overpromise, underdeliver and stay in business.

I don't have the answers as to why this is a problem, but clearly "evil capitalists", "mismanaged government", "underregulation" or "overregulation" are not it.

paulcole

14 hours ago

> If the daily threads at on r/nursing subreddit are even mildly representative, the status quo in nursing is unsustainable

Call me a skeptic but every career subreddit is dominated by the whiniest complainers imaginable (easily lapping even the HN commenters who froth at the mouth at the thought of RTO).

Using this as a key point of an article seems flimsy at best.

> Personally, I’m betting on two out of the three, but I’m not telling you which two.

Also lol at this.

vundercind

14 hours ago

The teaching trend is very, very real. Public schools are in crisis due to the dual shocks of Covid and inflation (which came on top of years of underinvestment and declining quality of the work environment, so the whole thing was already teetering before that shove) and nobody’s even talking about spending what it’ll take to fix them. The low-COL-adjusted-comp areas are worst-hit, but a marked decline in quality is in store for the whole sector, largely due to staff shortages and an associated, unavoidable decline in average quality.

tmpz22

14 hours ago

You post problems in addition to COVID and Inflation but you barely scratch the surface. No Child Left Behind, School vouchers, defunding public colleges, the list goes on and on and on as to how we’ve been chipping away at education.

vundercind

14 hours ago

Yep, you’re spot-on. The sector’d been taking a pummeling for years and years, that was just the final one-two punch (and a doozy, at that). If there’s a third thing, it’s the renewed and persistent negative political attention on schools from the right over the last eight years.

diddid

14 hours ago

I think the lack of quality is not being driven at the individual teacher level and isn’t related to covid at all. Covid made the issues that already existed visible. Removing AP classes and charter schools, graduating kids missing credits, downplaying test results, and failing to properly address poor student behavior are all usually made at the district level. I don’t think increased funding would change any of that and I think a lot of good teachers would still quit.

vundercind

11 hours ago

There are two main things reducing quality of the schools as this goes on:

1) There’s a really bad staff shortage. The ways schools are trying to compensate without significantly raising pay are making school worse. Three examples are reducing the length of the school week, cutting “specials” (art, music, languages, non-“core” classes), and replacing instruction with crappy computerized solutions (believe me, they’re mostly crappy).

2) Because there’s a shortage of teachers, it’s harder to turn down an applicant or get rid of a bad or mediocre teacher. These also aren’t disproportionately leaving—plenty of good ones are among the ones moving to other sectors, in part because they tend to have the best prospects outside of school, and it’s not like schools can really offer them more to try to keep them. So, the pool of candidates is at least not improving as it shrinks, and it’s tougher to get rid of teachers that otherwise might be let go. Further, the teacher pipeline is drying up and it’s quickly becoming a less-attractive option for students entering school. Result: average teacher quality may be expected to trend down.

slt2021

13 hours ago

the highest per student spend is at the most failing and underperforming school systems: Chicago, DC, Baltimore - and they haven't showed a trend to improve at all and keep demanding more and more resources

vundercind

11 hours ago

Low-performing inner city schools do sometimes pay quite a bit more than easy suburban schools—but the work environment is so incredibly terrible and the job so difficult that they struggle to retain good teachers anyway. They have to pay extra just to keep anyone at all.

slt2021

5 hours ago

It is not the money if kids have no capacity to learn.

MostlyStable

13 hours ago

Honest question: what is the appropriate level of investment? According to the national center for education statistics [0] Spending per pupil went up 13% from 2010 to 2021 after accounting for inflation, so that's a real increase of 13%, not a nominal increase. And 80% of those dollars are going to staff.

I'll admit that I'm anything but an expert, but a real increase in spending of 13% across a decade does not sound like years of underinvestment. I'm happy to be educated on this topic, but from an outsider perspective, it just doesn't seem like the issue.

[0] https://nces.ed.gov/programs/coe/indicator/cmb

vundercind

10 hours ago

Teacher wages lots of places probably need a 20% bump, or more, to stop the bleeding. Regardless of the total being spent, not enough’s going to comp for teachers. The whole thing’s worst in states that were already paying sub-par COL-adjusted wages (obviously) so states that weren’t screwing up quite so bad to begin with might not need so drastic a change.

slt2021

14 hours ago

Could private school vouchers and magnet schools fix it?

I feel like a lot of problems with teaching is due to overregulation from department of education and increasing scope bloat of their responsibilities.

Just stick to mass daycare with curriculum model and allow free competition from private sector and it should be fine.

The best compensated teachers are the ones that achieve results: train champions and elevate students to their highest potential.

Its not going to happen at public school

jgeada

14 hours ago

Private school vouchers are the worst idea ever.

How's removing yet more funding for public schools supposed to be an answer to public schools don't have enough funding?

As the funny paraphrasing goes (https://x.com/teedjvt/status/1685251077753430016) "I don't really like the city parks. I want to join a country club so my kid doesn't have to play with 'those' kids and I want the city parks system to pay for my membership"

slt2021

13 hours ago

public school system is full of grift, politically appointed and allocated resources, and zero accountability.

if you face inefficient system that cannot manage resources - you cannot pour more resources and expect better results.

as a proof you can look at Chicago, DC and Baltimore school systems that have the highest per capita spend and the lowest academic achievement metrics.

we just need to provide parents an option to opt-out of crooked system

jgeada

11 hours ago

Nobody forces you to put your kids in public schools.

But just like other taxes you don’t get to opt out of paying and you don’t get to take your money back.

slt2021

9 hours ago

well the voucher system allows me to opt out of supporting this corrupt system with my taxes.

jgeada

8 hours ago

How about the pentagon, or homeland security, or …

Why are you picking on the fractional pennies in the budget and letting the millions go out the door? The system is corrupt precisely because people with influence are allowed to opt out & simultaneously benefit.

slt2021

7 hours ago

School is a local matter, I want tonhave a feedback mechanism of “taking my business elsewhere” in education.

If private school offers more competitive product with better teacher, I want it. There is not much sense to force people to pay for local school and pay for private school.

And there is a way to opt out of federal taxes: just move out and change tax residence

eesmith

2 hours ago

School is a local matter, but voucher systems are forced onto local districts by the state.

Voucher systems are not set up as “taking my business elsewhere” because a voucher doesn't contain just your money but includes other people's taxes, making it their business too.

> If private school offers more competitive product

That "competitive" is doing a lot of heavy lifting. If you think more religion in school make the school more competitive, then you can already choose a private religious school. If you think having a lacrosse and water polo team makes the school more competitive, then some expensive private schools have that.

These are more expensive, sure, but that's Pareto optimality for you.

If you want to choose a school where the graduating class all have high SAT scores, and they do it by ranking the class every year and expelling the bottom 10% as "deadweight", than that's an option at some schools.

But if you really want this level of competition, then you'll end up having a lot of smaller schools, and lose out on the economy of scale in a consolidated school system, where you can have a school with 3,000 students like I went to which offered classes in jazz music, Latin, machine shop, and differential equations.

> There is not much sense to force people to pay for local school and pay for private school.

Your argument seems to be that public tax money should not go to education.

After all, if I have no kids, or my kids have graduated, why should I pay taxes which go to the school system?

But in that case, why limit it to education? If I don't have a car, why should I pay taxes that go into highways? If I only buy books, why should I pay taxes which go to the library? If I have a private pool memberhip, why should I pay taxes which go to the city pool that I never use?

> just move out and change tax residence

Such a comedian! That "just" is neither easy not cheap.

Why don't you "just" use the feedback mechanism of bringing things up to your school board and convincing your fellow voters to change things?

eesmith

4 hours ago

If it were simply about your taxes, that's one thing. [1] But voucher systems aren't simply that.

For example, https://www.woodridge.k12.oh.us/m/news/show_news.jsp?REC_ID=... says the voucher then would be $6000 per student.

It is extremely unlikely that your family is paying $6000 in taxes earmarked for the school.

If you send your kid to a voucher school then your taxes, plus those of a lot of other people, are directed away from public schools and into private/voucher schools. Including by people who think the voucher system is corrupt, and without the "public audit, public representation, uniform accounting, teacher licensure, public records rules, student testing requirements, or many other mandates that public schools are forced to follow." (Quoting that link.)

The voters directly voted for local property tax levies for the school district. They did not vote for these levies to be sent to voucher schools. It was the state which overrode local democracy.

[1] Not a good thing, but it is a thing. I don't get to decide to not pay taxes for the new road construction even though I think the road construction system is corrupt.

eesmith

5 hours ago

> and zero accountability

That's simply not true, if only because most voucher schools insist their records don't have the same requirement for public access as at public schools. That's even less accountability, and accountability can't be negative.

> if you face inefficient system that cannot manage resources

Consolidated public schools exist because of the economies of scale. Break it apart into many smaller school and you lose that.

> as a proof you can

That is not proof. Get a forensic accountant on the case, look at the books, and identify the inefficiencies. Otherwise you can't dismiss the possibility that perhaps they are about as efficient as can be expected.

> academic achievement metrics

Which academic achievement metrics do you think are credible and appropriate? If a school spends a week on test prep, rather than teaching other topics, is that efficient? If a school does less music, arts, history, foreign language, etc. to focus on surface reading and arithmetic - the two tests which are cheapest to carry out - is that efficient?

> we just need to provide parents an option to opt-out of crooked system

That's been tried many times over the last 20 years. The resulting schools are not better, and the often even more crooked.

- only accept the students which are easiest to teach (no troublemakers, no kids with serious disabilities, no ESL students)

- if the school system pays more for students with disabilities, cherry-pick only those students with a disability which is easy to handle.

- use pretextual reasons to expel low-performing students, so your end-of-the-year test scores are higher

- have voucher school be a non-profit A owned by the same person who owns for-profit property company B and for-profit teaching materials company C. Have school A rent the building from B and pay C for teaching materials. Never report the finances.

- place requirements on parental involvement which can only be done by families with a stay-at-home parent. This biases the student population towards richer families, which are also well-correlated with good test scores.

- require additional tuition and other fees, again biasing the student population towards richer families.

- set up a voucher school in town where it's cheaper to teach, and let the public school handle transport for the rural school population

- define your catchment area to overlap with the richest part of town

And that list of real-world crooked policies comes simply from reading examples which have popped up on Peter Greene's Curmudgucation blog.

Jtsummers

14 hours ago

Magnet schools are public schools, but usually with more motivated students or involved parents. The more motivated students part can help, it's more enjoyable to go to work teaching when most of the class wants to be there.

jghn

14 hours ago

> Could private school vouchers

Ask Arizona how it is going [1]

[1] https://www.propublica.org/article/arizona-school-vouchers-b...

diddid

14 hours ago

It was an interesting read, but it only says how much they spend on school vouchers. I didn’t see a spend for the standard public schools. They said the average voucher was 7k which is almost for sure lower than what public school is charging per student. Maybe they just need to add an income requirement to it and if you make too much no voucher.

slt2021

13 hours ago

I read the article and think that Arizona's problems are not inherent to the voucher system per se, just how they administered it. People found a loophole.

Need to tie closely the money coming out with the voucher and the corresponding decrease in spend on public school system

Terr_

14 hours ago

"To open our meeting, good news: This year we managed to direct a ton of public tax dollars towards our favorite private entities and churches, and the budget shortfall gives us an excuse to strangle other safety-net programs we already didn't like!" /s

As a note for non-US folks, individual states cannot print currency the same way the federal government can, so budget shortfalls on that level are a lot more immediate and impactful.

user

14 hours ago

[deleted]

panzagl

14 hours ago

Private schools (and charters) usually pay worse than public schools.

slt2021

13 hours ago

private schools face fierce competition and immediate feedback loop from parents.

public school system is not accountable at all to parents.

this makes sure that interest of school and parents and kids are aligned and no political bs coming from above like DoE

vundercind

10 hours ago

Public schools are painfully accountable to whichever parents have the most free time and least shame. One of the greatest superpowers of good private schools is a long wait list of applicants that let them tell not just troublemakers, but anyone not on-board and cooperative with their approach, to get bent.

slt2021

9 hours ago

not at the district/state/federal level, unfortunately. These DoE bureacrats in DC (and lawmakers) send their kids to private schools, while over-regulate public schools with nonsense and grift.

Regular public school principal has very limited arsenal of tools he can do to meet parents' needs, unfortunately.

its like you can only complain to McDonald's store manager, but McDonalds shareholders dont give a damn about your complaints, unless you take your business elsewhere - and with public schools you cannot take your business elsewhere. Taxes always go to public schools.

and through teacher's unions regulatory capture and lobby they always make sure the grift continues.

dividefuel

13 hours ago

There seems to be a broad understanding among those in these fields that these jobs just keep getting worse, and so people are quitting. They may be getting worse for different reasons (worse conditions, less satisfaction, declining pay, more qualifications needed, etc etc), but there's a net sense of dissatisfaction. For people new to the job, there's usually an initial shock that the job is so far removed from its mission that there's no personal satisfaction, and they ultimately leave.

mschuster91

14 hours ago

> Using this as a key point of your article seems flimsy at best.

For nursing... just ask literally any nurse and they'll chew your ear off. I happen to know some via local volunteer emergency service work and they're all on the verge of burning out, only staying in because they don't want to leave their patients and colleagues.