Same as it has ever been. Too many subpar residencies opening up. The usual suspects who hate their job yet continue to do it. The usual suspects who have a good job and don't mine EM. New program directors gleefully popping in eager to answer questions and then never returning. Americans still have no self-discipline and continue to take no blame in their medical problems that they helped create. There are still some patients that you really do help. As I said, same as it has ever been.