To be so hurt to have been replaced by a Physician's Associate?

[prawncocktailskips]

I'm a junior doctor who 'specialises' in psychiatry. Due to having a young family, entering training is not the right thing for me to do currently. For those who do not know much about the training pathways, these tend to involve moving around a lot, a fairly high out-of-hour burden, keeping a portfolio and revising for exams. I just can't make this work around my family, my husband's job (involves a lot of travel) and the childcare I have access to.

For the last few years, I've worked as a locum at my local psychiatric hospital. I've worked pretty much full time and gone well above my designated hours and work load. In particular, in addition to my usual responsibilities, I've taken on the physical health needs for a lot of patients and (I think!) made some real progress. This is something that can get overlooked in psychiatry.

I am perfectly happy with my pay but for context, I am not one of the mega-rich locum doctors the newspapers talk of. I earn around £23/hour and obviously have no sick pay or AL. Several times I've been approached about having a full time non-locum role for around £32k. I've always been really enthusiastic about this but there has never been the funding.

Anyway, I've recently been told that they don't need me anymore as they have a new physician's associate. I'm really sad and hurt. I've gone above and beyond for this job. I can't understand how there is funding for a PA who will earn more than I would have done and can't do a lot of what I can do. They won't be able to prescribe (I spend a lot of time prescribing and dealing with very heavy duty psychiatric medications) or detain patients (I perform emergency detentions under the MHA not infrequently). They won't have the same medical background I have to manage the physical health of the patients. I just can't really understand what they can do that I can't!

This isn't a problem unique to me. Lots of junior doctors locum not because they want lots of money (as the media might tell you) but because they can't make training work - or, in many cases, because there aren't enough training positions at all! Many of these positions are now being replaced by PAs. I know people who have left medicine because of it and now, I think I might have to too.

AIBU to be so hurt and sad and think it's just not fair?

It doesn't sound fair, and I worry about physician's associates who end up taking on tasks and responsibilities that are above their training - which isn't necessarily their fault either. It all seems a cost-cutting exercise and is not going to be good in the long run.

But it also seems surprising that you can work in that role if you've not doing the training pathway yet either - how are you able to prescribe and deal with heavy duty psychiatric medicines without being on the training pathway for psychiatry?

Perhaps they have realised that it's not a sustainable situation and are replacing you with a PA to do only the basic parts of the role, and will be recruiting someone more senior for the other parts?

It doesn't seem fair to do it without discussing with you, though, or giving you the opportunities to change role - could you have applied for the PA role with your qualifications?

Sorry @MapleSyrupWaffles I should clarify - I don’t make the decision to start these medications (although I do make the decision to prescribe emergency sedation and physical health meds frequently) but I prescribe them for seniors. Some are quite complex to prescribe and need a lot of monitoring and adjustment. It’s a big part of a junior doctor’s role in psychiatry.

It's part of the long term plan isn't it, most of which makes little sense. Replacing doctors with lesser qualified, less knowledgeable, less experienced people who crazily earn more than a JD (someone calculated it and it takes years to catch up) doesn't make sense. Having doctors fighting for training posts and being rejected due to crazy application ratios when there are huge shortages of doctors makes little sense yet is used as a reason for flooding the NHS with PAs. The idea that well a PA doesn't rotate so is a greater asset when actually the vast majority of doctors hate rotating and would love to not have to.

Sadly the NHS is on its last legs, patient safety is bottom of the pile and things won't get better for qualified healthcare staff. It is sad though.

It is sad @Peablockfeathers. I feel like I’ve given my best years to medical school and this job. Everyone says not to go above and beyond because you’re just a number to the NHS. I’ve always ignored this but turns out it was true. Feeling really down about it. I genuinely can’t understand how and why this has been signed off. I can do more than a PA and will accept less pay. I know the team and the patients (many are long term). I have good working relationships with the doctors and nurses. I frequently go above and beyond my responsibilities. If I can, I always cover last minute sickness. I’ve tried so hard and out so much into this job!

You are not being unreasonable. PA ‘s and ACPs complement the nhs workforce, they are not a replacement for drs. I’m surprised that as a junior dr, you have had so much responsibility -especially when you’re not on a psychiatry training programme. Who is your senior support? I hope this doesn’t become another thread where the sole purpose is to criticise groups of health care workers.

I'm really sorry this is your experience.

A bit leftfield, if clinical medicine is not working out for you. Have you thought about training in Public Health? I know it is not clinical but it would progress your career and allow you to earn more with greater job security. The hours are 9 to 5, with lots of WFH. After being a specialist registrar for five years, you gain an Assistant Director/Consultant role that has a wage of about £72k leading to up to £106k if you keep NHS t&C's (which as a medic you would try to as you still pay for the GMC). With your experience in MH, you would probably be given proj cts and portfolios that were interesting to you.

I totally agree. I also couldn’t make training work as a doctor with a young family, so have left medicine altogether. It’s impossible to get a nursery to do Wednesday and Thursday 8am-10pm (to cover a 9-9shift) then next week have them not go in on Monday and Tuesday, the week after on a Friday from 12pm-midnight… and if the public think you can afford to get a full time live in nanny on a junior doctor’s salary then they are kidding themselves.

People will only wake up when more mistakes start being publicised (as is inevitable!). I just hope we haven’t lost all of our doctors before it’s too late.

I am sorry for you of course, but unfortunately this kind of thing has been on the horizon for a while.

Almost exactly the same thing happened in education. It used to be the case that every class had to be taught by a qualified teacher, at any given moment there was supposed to be a qualified teacher in the room. If a teacher didn’t want to work full-time they could easily work ‘supply’ and cover absences in different schools (i.e. locum). There was a huge demand for supply teachers and the day rates were equivalent to a full time salary.

Then the government said that TAs could also cover classes. Before you could blink, the supply teaching rates plummeted and many schools were recruiting for their own ‘cover supervisors’, the majority of whom had no teaching qualification whatsoever. Now you read posts on MN where a primary class has a qualified teacher for three days per week and is ‘covered’ by a TA the rest of the time…not good at all!

Then academies came along and there was no requirement for them to employ qualified teachers either.

The government is coming for doctors in exactly the same way…

Oh that must really sting. I suspect the impetus is there is a funding pot they can access to put a PA in but they can’t use that money to hire a doctor.

@Spacecowboys I don’t think I have an unusual amount of responsibility. I’m a ‘middle grade doctor’ and do what the f2s / ct1s do (I’ve completed f2 and am technically ‘f5’). It’s a heavily senior supported specialty - part of the reason why I like it so much! But we are all encouraged to assess and review patients independently. The consultants are incredibly busy and see the newest and sickest patients frequently but more stable patients tend to be seen by junior doctors with less frequent consultant reviews. This isn’t uncommon at all I don’t think. My role in physical health is due to the fact I don’t rotate (and am more keen to take this on than psych trainees). It’s normally split between juniors (and often just shunted to the GP at discharge!) I’ve worked with the consultant for a long while and she’s increased my responsibility accordingly but there are some things (such as detention beyond emergencies) I definitely can’t do without training - but neither can most core trainees at their stage.

Several times I've been approached about having a full time non-locum role for around £32k. I've always been really enthusiastic about this but there has never been the funding.

I don't understand this part - you were approached about a role, but then there wasn't funding for it? Who was approaching you?

I wonder if one of the issues is with pay progression. I know in my field that sometimes they will hire someone who is slightly more expensive to start with but that role is a fixed rate and won't get more expensive over time. Whereas I was hired on a lower rate but my pay expectations are to rise far more over time, costing the organisation more in the long run.

It must be so frustrating to be in this situation and it must feel like your skills and training are completely unvalued, I'm so sorry

The consultants I worked with were always lobbying for this role. It would have been cheaper than paying me as a locum! There were several times when I was told it was confirmed and then it wasn’t. No idea what goes on higher up! I just know it’s different funding for PAs.

In my trust, as lot of the JDs are coming in saying they don't want to do nights, weekends etc. Great for them and their life/work balance, but not so great for the patients needing 24/7 care.

PAs and ANPs are a way for us to get the cover the service needs, and whilst it's not ideal, if there's only money for either a JD who will only work day hours and a PA who will cover the service needs, then the post that covers more will get it.

I think in the long term you will find the job unsustainable for your own development working in isolation with no chance of progression - so hopefully you will look back and be glad this happened

The government is providing extra funding for PAs as they can be trained much quicker
Unfortunately they don’t have the training experience of Junior Doctors so are a big safety issue

Undoubtedly the consultants would much prefer you so try not to take it personally because it sounds like you are a very committed doctor
Their hands will be tied

@PosyPrettyToes I can’t tell if you’re joking or not. PAs almost exclusively work 9-5. Junior doctors are almost unable to refuse weekends / nights. I was typically doing 1 in 2-3 weekends and a week of nights per month. I don’t know where you have got that junior doctors don’t do nights or weekends from??

That makes more sense. I suspect that the consultants will see their workloads increase going forward.

@PlusThyme can I ask how long ago it was that you were doing it....? Because we are absolutely getting pushback from JDs and hiring more ANPs as a result. This is the position we are in. And I can hardly believe that's unique to one Trust.

@PosyPrettyToes I quit 2 years ago. I’d be clear here - an ACP is very different from a PA. Which are you talking about?

I was working in London - your trust does sound very unique to me!

@PosyPrettyToes the cover was only ever 9-5 (and the PAs definitely do not out of hours because ability to perform emergency detentions is a necessity!) I always covered any OOH shifts I was asked to if I could. I can’t do much OOH because of childcare (I applied to medicine at 17 and the realities of this were never explained!) but I made it work as an f2. I now have a choice and my choice is either to do mostly in hours in the nhs or leave - surely the first is preferable? In my experience, junior doctors hate OOHs because they are incredibly unsupported and we all fear being the next Dr Bawa-Garba. I know ANPs who do do OOH (not PAs though) and they all have far more consultant supervision and far more defined roles than we do. I’ve spent OOH shifts running between sick patients whilst being repeatedly harassed over the bleep to come and fix a broken printer (and if I don’t a discharge will be delayed and my name will be given to the bed manager apparently!) Funnily enough, I have less appetite for this alongside raising young children!

General public here with no detailed knowledge of the “system”…

If you have done F2 then you can work privately? That is what I would do if you live anywhere with private practice options?

All my female friends have struggled with the training pathway to consultant whilst having young children. It is madness so many girls are allowed on Med Courses and then not accommodated properly once they have kids due to the “system”. There have to be alternatives made available, Med school places cost the tax payer a bomb and absolutely everything should be done to support you. You sound like a great doctor, don’t give up. Mental health needs you, that is a given. Don’t let the “system” get you down is all I can say.

This is interesting. At our trust, the PAs don’t do nights at all because there has to be a consultant present ‘on site’ to support them. Which there isn't overnight. PAs also remain at band 7 , whether they have 1 years experience or 20. There isn't progression and junior drs quickly overtake them in terms of salary. I can only speak of my experience in the trust I work. I don’t know about others.

It'll be some sort of special madness where there is either a ring fenced pot of new money for 'new ways of working' including use of PAs, or some non-clinical managerial scheme to look modern and cool to employ these new shiny things and 'save' locum budget at the same time in order to get extra brownie points. Unfortunately your consultant colleagues are likely so crushed under everything that they haven't been able to beat this off, as you predict they will find out that they now have more work to do rather than less.
i would be totally under surprised if in 2-4 months there is not a locum ad out for a doctor to fill the totally likely gap. Which in your shoes I would offer to fill for top whack agency rates only, and they would probably have to accept. Madness.
i would join a locum agency now

@prawncocktailskips precisely. PAs cannot cover OOH because they need supervision by, er, doctors and there’s very little of that overnight.

@Araminta1003 it’s sadly not really possible to work privately in the UK until you are consultant level.

I can understand why you are devastated by this. People don’t want to see the extreme need for well-trained medical professionals with a passion and empathy for patients with MH problems. One of my best friends is a very experienced psychiatrist. We were discussing the fact that in any society there has been roughly the same number of people with MH and/or addiction problems, but once upon a time there were more hospitals for those who were acutely sick and convalescent homes for those who were chronically ill or not yet well enough to return home full time. Now that the population has exploded exponentially, there are fewer and fewer beds for acutely ill MH patients and virtually no convalescent homes. They are releasing sick people from hospital all the time. Of course hospitals are blamed for releasing MH patients who are diagnosed as being still unwell when they cause harm as a result of their illness, but there is definitely more money in “sexier” areas of medicine, but more need in the trenches with MH.

hell yes you are right to be concerned, I've worked in mental health as a non-mental health qualified professional and I've seen it go very wrong (including patients die) when clinicians lack breadth of knowledge. Patients physical health within mental health settings can be very poorly managed, so they are reliant on receiving care from Dr's who will at least have done physical health rotations earlier in their career. Often a "junior" doctor can have more recent experience of physical care than a higher grade.