The most cushy vs. rewarding job in psych?

[Chimed]

---

Members don't see this ad.

So, just as a point of discusion, within the field of psychiatry, what do you think is the most cush job out there? This is higly open to interpretation with level of stress, finicial benefits, job security, etc. On the flip side, what do you think is the most rewarding and/or of benefit to others? Can the two go together?

 

[whopper]

I think this may be to broad a question to answer and its highly dependent on the individual.

Most cush job for me was outpatient--but I thought the job was too easy. At one of the offices I worked, about half of the patients didn't show up for their session and I found myself just surfing the net most of the day.

Most rewarding experiences were a few cases I cracked that several doctors missed--kinda like a House episode. About once every few months there'd be a case several attendings & residents couldn't figure out and I'd spend about 3-5 hrs a day for a week on medline & pubmed trying to find anything to fill in the missing pieces.

The other rewarding experience was to stop a malicious cycle that had been going on for years due to the managed care infrastructure. Several patients are often just turfed to the next level of care, and often times their problem is not dealt with. It was a good feeling to finally get the right thing done.

 

[strangeglove]

Outpatient isn't so cush when your patients actually show up. And if they don't, then you you don't get paid, which isn't very cush, either. In some ways, outpatient may be more intense that inpatient, since you are dealing with one patient after another for the whole day, as opposed to inpatient, where you only spend a portion of your time actually with the patients and the rest of the time dealing with social workers, family, consults and the like.

 

[JMC_MarineCorps]

Outpatient isn't so cush when your patients actually show up. And if they don't, then you you don't get paid, which isn't very cush, either. In some ways, outpatient may be more intense that inpatient, since you are dealing with one patient after another for the whole day, as opposed to inpatient, where you only spend a portion of your time actually with the patients and the rest of the time dealing with social workers, family, consults and the like.

I've heard you can charge your patients for no shows...just saying.

 

[DrRazberrySwirl]

I've heard you can charge your patients for no shows...just saying.

you most certainly can. a good policy i've seen a lot of docs use is
1) a patient's first no show, for whatever reason, no penalty
2) if you cancel before noon on the day before your schedule appt, no problem (plenty of time for someone to be rescheduled to fill that slot)
3) if you call ahead and cancel, but it's after noon the day before, a small fee is charged (for example, the pt's copay)
4) if you simply no show (and you've already had your freebie) and you dont call, then you're stuck with the entire cost of the appt.

obviously, you give the pt a print-out with this information at their first appt and make them sign a paper acknowleding that they read it and understand it ..

but back to the original question.

cushiest job? psychiatrist at a university counseling center. lots of time off (winter break, spring break, fall break, every government holiday). in the summer, maybe you only have to work a few hours in the morning, a few days a week. no call. probably salaried. not exactly the most varied patient population, but i still think its an interesting one, especially if you were at a big state univeristy.

 

[whopper]

Wanted to clarify--not all outpatient was easy.

Just the place where the patients often didn't show up-that place was easy.

In some ways, outpatient can be harder-the patients aren't monitored 24-7. Also if a patient decompensates in outpatient, the cops won't show up for about 15 minutes.

 

[Chimed]

How about doing C&L? No overhead and no call?

 

[whopper]

I have found C&L personally very frustrating.

& I thought I would've loved it because I love medicine as well as psychiatry (but psyche more).

What I hated about C&L is the lack of communication between "entitled" attendings & the bullspit consults.

About 70% of the consults I did had nothing to do with psychiatry. E.g. the patient was mad because he waited in the ER for 8 hrs before being seen so now there's a psyche consult. The patient shows no sx of an axis I disorder and is simply upset that he's been made to wait so long. He also can't leave the ER because in NJ you can't leave the ER without a doctor's permission and the ER doc won't give this guy permission until he sees him. If a pt attempts to leave, security will tackle him, or the ER will call the police.

I got a long list of totally BS consults where the attendings were asking you to do something that they really should have done.

Or I get a consult and the attending didn't document why they felt the patient was "depressed" and all it says on the consult sheet is depression. So I call the doc up and he makes me wait for about 50 minutes because he won't beep back in a timely manner. As we know several docs do this--they make you wait as if you're not busy.

Then when I ask him why he ordered the consult--he gives me some idiot answer like "oh well I thought he was depressed because the Eagles lost yesterday".

It may vary between institutions but out of 3 hospitals I've worked at, I've had about the same results.

The only time I really loved consults was when it was a REAL one and I was able to help the patient out.

I suggest if you do consults, arrange it so you get paid per consult. That way for each bullspit one they give you, at least you're getting compensated for it.

 

[MBK2003]

How about doing C&L? No overhead and no call?

I second whopper on this, C/L is the least cushiest! I would rather pull out my fingernails that constantly deal with narcissists who aren't my patients and not in treatment (i.e. consult requesting attendings). The patients and type of psychiatry that you practice on C/L is great, the other part of the consult is torture.

I'd nominate for cushiest (although clearly not the most intellectually interesting or professionally fulfulling) the unit psychiatrist at a long-term state psych facility. Pension, unable to be fired, patients who are going nowhere, and in NY once a week progress notes. I'd be bored out of my mind, but maybe I could do a little Whopper-esque daytrading to make it interesting.

 

[whopper]

C&L: I ranted several times about this in the past year during my time at SDN.

Another thing I suggest is if you're an attending doing C&L, request the hospital if you can have permission to not do consults that are bogus, or to be able to give very quick & short consults with very specific time limits on how long you're supposed to wait for them to call back after a beep.

E.g. "The patient does not complain of any sx of depression, and the doctor requesting the consult for depression did not document any sx of depression. The staff report no sx of depression. Please request another consult after documenting on why you feel the patient needs a consult for depression."

As a resident, I'm not allowed to do that. I got to freakin beep the attending who doesn't call back for 5-60 minutes later (often times never while I have to sit there when I got lots of more work to do), and most of the time the reason for the consult is bogus.

Then, even when I find out its bogus, I still got to do a mental status exam and interview the patient as if I'm doing an H&P (minus the physical exam).

Pension, unable to be fired, patients who are going nowhere, and in NY once a week progress notes.

I don't know how it works in your neck of the woods--but this job would be frustrating for me (although easy) because in the state LTCF hospitals in NJ, same thing goes on--and the patients get poor care. That level of care bugs the heck of out me.

 

[cleareyedguy]

Assuming you aren't thoroughly surrounded by axis II peers/bosses/employees, no job should be cushy and no job onerous.

Anyone who thinks outpatient psychiatry is easy is stupid, lazy, or heartless. Same goes from inpatient state hospital jobs. These jobs can tax the best of us but can be done by some of the worst.

As for c-l, it is very different being the trainee and the attending, at least partly because attendings wouldn't wait on a phone for 50 minutes for much of anything (though as an attending, I'm skeptical that you did, either). There are plenty of "dumb" consults, and I resonate with the frustration over seeing people who have expectable degrees of frustration/sadness--though it should also be remembered that hospitalized patients have more of a consultation reason than most outpatients. At the same time, your job is not only to see the 3% most ill as a consultant but also to do liaison work with staff who may not be well versed in diagnosing depression, may not be adept at handling axis II pathology, and whose focus is different from ours (i.e., they have a different job to do, and it seems okay to me that they might view psych as a means to speed the patient's workup and discharge). I agree that they shouldn't abrogate their responsibility as the patient's physician, but we should remind ourselves that are not simply dumb and narcissistic, that we are on the same team, and that they are likely to recognize residents who are antagonistic and dismissive and then treat that resident with commensurate disrespect (i.e, it's possible that one's rants reveal as much about one as they do about the other).🙂

 

[cleareyedguy]

Most cush job for me was outpatient--but I thought the job was too easy. At one of the offices I worked, about half of the patients didn't show up for their session and I found myself just surfing the net most of the day.
.

One can always learn more about one's countertransference...

 

[prominence]

One can always learn more about one's countertransference...

or the disorganization of one's psychiatry residency program...

excellent response cleareyedguy.

 

[whopper]

Or...

The locations & types of patients. I did mention that the "easy" outpatient was at a specific location.

One office I worked at, most of the patients showed up on time and hardly missed a meeting. That place had a lot of work.

the other office--very few people did showed up. Both offices were part of the same healthcare system--but servicing different types of patients.

One was in a middle class area-where patients wanted treatment & had emotional insight, the other in a poor inner city area where the patients were often referred immediately after discharge from inpatient, most of them not feeling they had a mental illness after discharge. (Most of those patients I hadn't even met since the day they were supposed to meet with me was the first meeting).

they are likely to recognize residents who are antagonistic and dismissive and then treat that resident with commensurate disrespect

Actually, where I'm at, they often don't know who's doing the consult, since coverage responsibilities often change depending on the day.

50 minutes for much of anything (though as an attending, I'm skeptical that you did, either).

Policy here is to beep the attending, wait 15 minutes, then if no answer, beep again. Up to 3 times. Equals about 50 minutes. Happens more often than I'd like (about once 1/3 of the days I'm doing consults).
The program on the IM end has a policy with their attendings where if the attending is a teaching attending, not answering in a timely manner can remove that attending from teaching status. However several of the consults to psyche are not from teaching attendings.

One can always learn more about one's countertransference...

Ouch--trading barbs eh? I certainly hope I didn't somehow offend you cleareyeguy or anyone else. My comments were part of a rant, had a bit of a tone of sarcasm, (kind of in a Sam Kinison manner), though still frustrations with C&L which I've also heard from several others doing this. I apologize if I did offend you, or if my tone was too sarcastic.

But yeah, thanks for recognizing & acknowledging that this type of thing does happen. One other side, another point of frustration is dealing with internal medicine consults on the psychiatric inpatient unit-where the psychiatrist ordered a consult for a "dumb" reason as well. I don't claim to be an expert in IM, but I feel there's a lot of consults that didn't have to be ordered.

 

[TheWowEffect]

Policy here is to beep the attending, wait 15 minutes, then if no answer, beep again. Up to 3 times. Equals about 50 minutes. Happens more often than I'd like (about once 1/3 of the days I'm doing consults).
The program on the IM end has a policy with their attendings where if the attending is a teaching attending, not answering in a timely manner can remove that attending from teaching status. However several of the consults to psyche are not from teaching attendings.

Although it might appear important that one should talk to the attending about the reason for the consult, I don't see a point in waiting so long. May be that is why we don't have such a policy at my program. I think time is better spent in talking to the patient. One good question in such a case would be to ask the patient why they thought a psychiatry consult was sought, and more often than not, the reason for the consult becomes apparent. If one finds that there is no Axis I pathology, one might state that and get done with it.

I am also not sure if a consult for "depression" is a "dumb" consult. It would be great if the consulting service explains more but just saying "depression" is quite telling, and especially for a member-in-training, it might be a good learning experience to hone the interview skills.

 

[whopper]

Good questions, and I'm sorry if I didn't clarify these a bit more...

I think time is better spent in talking to the patient. One good question in such a case would be to ask the patient why they thought a psychiatry consult was sought, and more often than not, the reason for the consult becomes apparent.

The problem here is in this specific situation, the patient often times says there's no problem. So to be thorough, I feel I need to talk to the attending because the staff nor the patient feels there is any depression.
So, I do the beep, and waiting a long time--for what probably is not an appropriate consult is frustrating.

I could also just write a consult like I mentioned above--something to the effect of "not enough information, waiting for attending to call back" but this doesn't make the attending (nor the floor manager who wants to avoid red flags on the chart) on the other end happy (documentation that he didn't call back), and this leaves an extra consult for my colleague to fix the next day which I don't believe is fair to them.

Or--often times the attending writes "depression" and its really something else. E.g. "the eagles lost yesterday", or the pt keeps calling for a nurse to the point where its annoying the nurse. The latter would be important if it were due to an axis I pathology. Often times its not. Some examples of the latter were--the patient had pets at home that needed to be fed, with no one to do so. Another--the patient didn't speak english and the nurse didn't feel like getting a translator.

If one finds that there is no Axis I pathology, one might state that and get done with it.

I am also not sure if a consult for "depression" is a "dumb" consult.

Depression of course is never a "dumb" consult-if it is depression. If its an issue that the medical team should've handled on their end, I'll put it in the "dumb" (forgive the sarcasm) category.

I think the better solution is in-services & communication between departments heads. Again, I think IM gets a lot of the same problems from the psyche unit.

 

[Anasazi23]

As for c-l, it is very different being the trainee and the attending, at least partly because attendings wouldn't wait on a phone for 50 minutes for much of anything (though as an attending, I'm skeptical that you did, either). There are plenty of "dumb" consults, and I resonate with the frustration over seeing people who have expectable degrees of frustration/sadness--though it should also be remembered that hospitalized patients have more of a consultation reason than most outpatients. At the same time, your job is not only to see the 3% most ill as a consultant but also to do liaison work with staff who may not be well versed in diagnosing depression, may not be adept at handling axis II pathology, and whose focus is different from ours (i.e., they have a different job to do, and it seems okay to me that they might view psych as a means to speed the patient's workup and discharge).

I actually don't think this is okay, and I get unbelievably frustrated when other services use psychiatry as a way to "speed discharge." I also think this is part of the reason why psychiatry might be viewed the way it is in some hospitals. There is not a good appreciation for the type of work that a psychiatrist might do....they are nowhere near social workers and shouldn't be made to do such work under the guise of 'mental illness.' I've been involved in plenty of situations whereby the patient is helped to transition to a more appropriate living facility, and I've even transferred patients to the inpatient unit to help a very difficult case that had some degree of what was probably outpatient-manageable illness. But to 'speed a discharge?' I don't do that.

One of the most profound lessons I've learned in residency is the unabashed laziness of how many attendings operate. There are many, many attendings that I know that would simply ever refuse to work in a non-academic hospital, not for the fact that they would lack an audience to 'teach,' (since they dont' do that anyway. But, for the simple fact that they would have to fill out paperwork and actually work a few hours. That said, I know of many residents who are guilty of this as well....I'm especially keen on it since it comes overy my plate since I'm a chief in my program, and I have to have "discussions" or even take disciplinary actions at times. Guess what these lazy and/or unmotivated residents grow up to be?

I agree that they shouldn't abrogate their responsibility as the patient's physician, but we should remind ourselves that are not simply dumb and narcissistic, that we are on the same team, and that they are likely to recognize residents who are antagonistic and dismissive and then treat that resident with commensurate disrespect (i.e, it's possible that one's rants reveal as much about one as they do about the other).🙂

If one can't use the internet to complain and garner support, where can one go? Certainly not to attendings...they are far too busy. This may be the ideal medicum for myriad reasons.
What was that study about countertransference and subversively hostile use of internet smilies? Can't seem to find the link. Though I hate to use the term improperly...

 

[whopper]

Regarding the frustration with consults: One other thing to add is a lot of this probably varies quite a bit between hospitals.

In a big university hospital in a poor city, I'm thinking this problem may be more prevalent.
In a rich community hospital, this problem perhaps may be less prevalent.

The place where I'm working now (an eating DO clinic in the University Medical Center at Princeton) this type of thing I'm noticing is much less prevalent than for my colleagues at Newark or Camden.

So, ahem, please walk a mile in the other person's moccasins. If things are very good in your area-might not be so for your colleagues in other areas. Again, I apologize for my rant tone & sarcasm.

 

[prominence]

i typically enjoy reading ur posts, but whopper, u seem very sensitive/defensive in this instance. u and anasazi sound like u have chips on your shoulders with regards to the politics of your C&L training experiences.

 

[whopper]

OK, that's fine.

I think part of it maybe the way forums posts are. I think the comments I had are more acceptable in a more casual setting. For example, sometimes its funny to hear a rant. Lots of comedians entire act is based on a rant schtick.

I've seen people get real ticked off with each other over emails/posts that I thought had no intention of rudeness.

Anyways you've been on this board for some time, and so have I, so if I did offend/irritate you, again, sorry. I have a lot of respect for you based on your past posts.

I have ranted about the type of thing before, and didn't seem the get the jeers I got this time. Oh well, I guess the crowd can change, & perhaps I overstepped a bit.

Actually the frustration with consults is good training, though yes, frustrating.

Maybe it may be easier at your neck of the woods Prominence. Have any problems like Anasazi & I have been having?

 

[Anasazi23]

It's not that I, or if I can speak for Whopper, have chips on our shoulder. This is a fact of major metropolitan psychiatry life, I think. Every person I know that's rotated through a C/L rotation in psychiatry residency here in NYC has had similar complaints. I have my co-chief going to psychosomatic fellowship next year who just accepted a prestigious position, and even he is concerned with how this can run at times. In fact, he made sure, according to him, that he chose a place where this sort of thing was kept to a minimum.

I enjoyed my CL rotation a good deal, and even considered pursuing a fellowship in the same. I chose (as did Whopper) to go another route, but that doesn't mean that it doesn't have unbelievably frustrating moments...as does psych ER rotation, as does outpatient at times, and inpatient. But when you're overwhelmed with consults, covering for another resident perhaps, knowing you're not leaving anywhere close to 5pm even though you had made the stupid plan to have a dinner date, and receive a 4:50pm call from hospice for a consult on a fuliminant liver failure patient who is "lethargic," you cant help but get irritated...particularly when you get there and see the patient is half dead, and that this somehow made sense to the attending since the patient was on risperdal at some point in the past.

It's not unreasonable to consider how you might handle these situations for the rest of your life should you choose to enter this subspecialty of psychiatry. It's not about having a chip, or being bitter, I think it's about realism. Much like how a person who has difficulty with the functional psychopath addict patient might consider their potential for career satisfaction in addiction psychiatry, one should one might be colored by their experiences in a busy city hospital in C/L.

 

[TheWowEffect]

But when you're overwhelmed with consults, covering for another resident perhaps, knowing you're not leaving anywhere close to 5pm even though you had made the stupid plan to have a dinner date, and receive a 4:50pm call from hospice for a consult on a fuliminant liver failure patient who is "lethargic," you cant help but get irritated...particularly when you get there and see the patient is half dead, and that this somehow made sense to the attending since the patient was on risperdal at some point in the past.

I guess whopper comment would hold true in this case about things being different in different hospitals. At my program, like many others, any consult that comes in after 4 pm is done by the on-call resident, who has to do it only if it is stat. If it is not, it can be left for next morning. I guess policies like this can make life easy for residents.

Having said this, C/L does have its share of irrelevant and to use whopper's lingo, "dumb" consults. Every other day, there was a consult where we wondered, "Why did they call psych on this one." May be I, like a few others, have supressed the bad ones and remember only the good experiences😀

 

[whopper]

Every other day,

At my neck of the woods its every day--about 70% of the consults. The staff & attendings in those situations were in a position where they should've known not to ask for a consult. E.g. nurse wants a psyche consult ordered because the patient doesn't speak english, but they label the reason as "depression".

The rest--some of them aren't in real need of a psyche consult, but there was enough justification for the medical team to believe a psyche consult was needed, or they really were in need of a consult.

I'm working at another UMDNJ affiliate this month--the University Medical Center @ Princeton (no way afiiliated with Princeton U. Princeton U. has no medical school or residencies).

The UMCP services a middle to upper class community that is highly educated. Things here are very tame compared to the other UMDNJ branches.

However work in an ER in Newark, and its a battlezone.

Actually its funny because the attendings in Princeton hardly ever have to commit a patient; one time they asked me for help on the commitment laws, because where I usually worked, I did about 3 commitments a day--a few hundred by my 2nd year.

I mentioned this in a few other threads, but when medstudents ask for places with good clinical experience I tell them to go to a place with a good mix of rural & urban. Working in a hospital in Newark or Camden is far different than Princeton or the woodsy small towns of South NJ.

 

[Solideliquid]

Speaking of C/L...I am on call today (24hrs) and I get the dumbest consult. A resident from neurosurg calls me about a pt the C/L service rounded on days ago.

Now he tells me that this patient is on Celexa, and he is asking for a consult so I can write her the prescription as the patient is being discharged tomorrow.

I'm pretty speechless at this point, I say to him "so you are calling me for a consult so I can write you a prescription?" At the end of it he agrees to write the script but wants me to write a note in the chart that we agreed the patient should only get a two week supply.

 

[TheWowEffect]

Speaking of C/L...I am on call today (24hrs) and I get the dumbest consult. A resident from neurosurg calls me about a pt the C/L service rounded on days ago.

Now he tells me that this patient is on Celexa, and he is asking for a consult so I can write her the prescription as the patient is being discharged tomorrow.

I'm pretty speechless at this point, I say to him "so you are calling me for a consult so I can write you a prescription?" At the end of it he agrees to write the script but wants me to write a note in the chart that we agreed the patient should only get a two week supply.

This is the issue of liability most attendings talk about. It bugs most of us but that is the way it is. My inpatient will not even give something for a simple cough because he does not want "any liability." My outpt attending will not let me write a 2 week supply of seizure meds even though pt has an appointment in 2 weeks with her neurologist. Pt may run out. He wants her to go to an ER which, in my opinion, is a bad use of resources- I did give her the prescription though as another attending said that we can do it on a one time basis.

These consults are primarily because ppl want to protect their own back but most physicians are guilty of this practise. Not that it's right but that is the way things work in this litigious society we have. Some attendings just practice with one primary motive- not to get sued, which is fine, but to be scared sh*tless all the time about it beyond any logic.

 

[cleareyedguy]

One of the reasons that I address the c/l complaints is that I think some of those complaints stem from a misunderstanding of the role of c/l. I DO think the c/l psychiatrist should "speed d/c" from the hospital. Not that the job should be to do shortcuts or the work of SW, but it is to diminish the regression, sadness, substance abuse, and axis II that interfere with the medical workup and d/c. The process of doing that work enlists some of the best aspects of psychiatry (tact, alliance, pharm, dynamics) and can provide a quick therapeutic pop (much quicker than most everything else that we do)

There is some disagreement on this thread about attendings. Some have said they're too busy, and others have said they're lazy and couldn't function outside of academic centers where their work is done by residents. While there is variability, I'd say that it's a drag that you have to page the attending for routine matters--aren't there medicine residents to call? Maybe the attendings are playing golf, but they are more likely seeing patients or in meetings or writing grants, and pages are a nuisance when you are trying to get a bunch of things done. They're a nuisance for residents, too, of course, but residents generally don't have as many different things to do. Who do you think those attendings are, anyway? They are just you but older...

Back to c/l: psych residents struggle when they define their role in a way that leads to inevitable frustration. Yeah, the celexa request is dumb on the surface, but it also hints at the fact that the surgeon doesn't understand depression and/or antidepressants. A quick reassurance/education can help not just that patient but that dr's other patients who are depressed, and it does seem akin to the internist giving a 2 minute bit of reassurance to the inpatient psychiatrist who is unsure about giving a diuretic; from their pov, drs should know diuretics, but it just doesn't take long to become deskilled.

Nothing wrong with venting, and I do my own share of eye rolling, but eye rolling without redirection and restructuring just makes people unhappy. And even if they do ask for dumb consults or act unprofessionally, our job is to suck it up and do a good job. If you happen to become an attending and stick around for a while, that sort of effort (by you and your team) can lead to changes in the environment.

Oh, and as for environment and group process, I think there are big differences in hospitals, but I wouldn't split it by rural/urban or public/private. It does make a difference if you are working in a place where c/l has been strong for a long time. Some of that strength is funding related while some has to do with the quality of the attdgs and residents and with the overall strength of psychiatry at the school/hospital.

Regardless of location, there may be things that you can change if you are willing and able to enlist your attending (vital), come up with a workable plan (vital), preferably one that serves the purposes of the institution (saves money, saves attending time, speeds consults, etc). By the way. a plan that is really just a complaint or that just saves resident time has little oomph (it's possible to develop a plan that only saves resident time, but then you have to frame it so that other things are also acomplished, which gets back to money and efficiency).

Finally, as for my "subversively hostile use of internet smilies"... I thought the rest of my post was subversively hostile and that the smile was relatively pleasant, but that's just me 🙂

 

[cleareyedguy]

My inpatient will not even give something for a simple cough because he does not want "any liability."

People sometimes misunderstand liability. The ostrich defense doesn't fly.

If your attdg is the dr of record, and simply doesn't acknowledge the cough, then s/he is responsible for the PE, pneumonia, manic episode resulting from cough-induced insomnia, etc. And if the attdg calls an internist to give robitussin, we should all be embarrassed for him/her.

That's why it's necessary to keep up with lots of medical stuff and one reason that there should be no cushy jobs in medicine.

 

[TheWowEffect]

People sometimes misunderstand liability. The ostrich defense doesn't fly.

If your attdg is the dr of record, and simply doesn't acknowledge the cough, then s/he is responsible for the PE, pneumonia, manic episode resulting from cough-induced insomnia, etc. And if the attdg calls an internist to give robitussin, we should all be embarrassed for him/her.

That's why it's necessary to keep up with lots of medical stuff and one reason that there should be no cushy jobs in medicine.

For some of these attendings, it's not that they do not know the stuff or have forgotton but because they simply don't want to do it. The reasons may be varied-not having enough time or not willing to take reponsibility or may be, a sadomasochistic pleasure of giving internists more work to do😀