To be so hurt to have been replaced by a Physician's Associate?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

You are right to be angry - it is all part of the dumbing down.

I had a phone consultation with what I at first thought was a doctor and after she planned to prescribe something for me that I knew was incompatible with my ongoing medication I asked her if she was a doctor - it turned out not.

Thanks @AgeingDoc and @Oliviant. I think these things all end up being junior doctor jobs because there is no one else to do them and we're most likely to get a bollocking for the natural consequences of not just doing it when told (e.g. printer not fixed, discharge letter doesn't get sent, discharge delayed, charge nurse and consultant not happy). Anyway, glad to hear it's not like that everywhre! Thanks for the support you've both given me. Funnily enough it's made me think a bit more about the good parts of the job so thanks for that!

@mumsneedwine that sounds so relatable. Perhaps I should spend less time being confused about PAs and more time being confused about why so much time is wasted to stuff that would be so (seemingly) cheap and easy to solve! I can't tell you how much time I'd save if every ward had one functioning printer, a supply of paper and pens, a few tourniquets etc. It would be even better if I didn't have to traipse across the whole hospital to find a functioning ecg machine and then battle it down 3 flights of stairs because the lift is broken again and then find out there are no ecg stickers anywhere anyway.

Don't give up hope! Remember your babies will be older soon. I'm 31 and hoping to have them as an ST4/5. So at that point yours will be more independent whilst other people have toddlers. So keep your hand in, look at what is required to get into training and slowly build a CV for it. Go 60% LTFT if needed. Don't give up on your dreams yet. I've met consultant surgeons who had babies during training, if they can do it then so can we!

Say you want to do psych, do CT1-3 at 60%, it might take a while longer byt that's ok. Then if it's too much do an OOP year as teaching fellow to break it up. After CT3 you could locum again infrequently and spend time with kids before going into further training. You can have allowances made as a mother.

If your husband has good earning potential then pay for a nanny/cleaner, even if this is in the future. The key issue here is this used to be a very well paying profession but it isn't now, 20 years ago doctors earned far more and housing was much much cheaper. It's not as much of an issue if you can afford a nanny/cleaner/gusto boxes, money doesn't fix everything but it makes it easier to manage. This is why strikes are so important, or women will leave the NHS. I have a partner who earns well, a huge mortgage and I don't know how we'd afford the kind of childcare we need with my acute rota.

Whilst I think it's not wise as a female doctor to have babies in your 20s, it's worse to try at 38 once you are a consultant and realise it's too late to have any babies. You can smash on ahead as your babies get older. I've met registrars in their late 30s who spent a decade working in developing countries and travelling the world who entered training later, or who did a PhD and no on cares that they're 42 and a registrar still!

@prawncocktailskips I think almost daily about when I can have babies. Due to my career. I worry I will leave it too late. I have a great city life with fiance, friends, socialising and a busy job. When do we fit the babies in? This job makes it so hard as it's so all consuming it's hard to imagine what you do when your baby is sick and can't go to nursery but you're on call with no emergency childcare.

@prawncocktailskips things get better as a registrar. If you stay as perma SHO you get more of the dross, it's more stressful and it's busy but you get more respect from colleagues.

www.independent.co.uk/news/health/mental-health-nhs-patient-deaths-b2148501.html i don't like cutting and pasting newspaper articles but this is why having the correct skill mix on psych wards/units is important.

@wudubelieveit thanks for sharing that, I’d not seen it before. You’re absolutely right and it’s something I feel very strongly about!

Guardian 13/12/23

https://www.standard.co.uk/news/health/british-medical-association-general-medical-council-nhs-england-mps-government-b1126556.html

It's just insulting. The disrespect shown to our doctors. The F1, who can prescribe and has had 5 years intensive training? is paid half the person who can't prescribe or order scans, and as done 2 years after any random science degree (I know a PA who has a BSc in food science ).

No wonder so many young doctors are voting with their feet and going abroad. From a wider perspective as a potential patient, it is terrifying. I had to take an elderly relative to hospital a few weeks back after a fall and we were seen by someone who had their badge covered, didn't introduce themself but launched in a very self-assured way into exactly what was the problem was. Usually we get the "Hi I'm xxx and I'm an A&E doctor etc." I pointedly stopped them and asked what their position was. A PA. And as it turns out, they were wrong, as confirmed later by a real doctor.

It is worth pointing out here that an FY1 is a provisionally registered doctor, and there are limits to what they can do (and their prescribing can be scary). It's also very much a training post so that's reflected in wage too

@Possimpible I'm going to assume you're not currently an F1. As mine is holding the cardiac bleep tonight. As well as 4 others. And they are so understaffed her registrar managed to speak to her twice last night. Be nice if she was supervised but there are not enough staff to do this, so she does things anyway. 350 patients yesterday in A&E and a 13 hour wait (she's not in ED but the pressure to discharge is huge). Thankfully the nurses are amazing support.
Do you really believe a PA, who doesn't work nights, can't prescribe or order scans should be paid twice as much ?

@mumsneedwine you're her mum, obviously you're not going to be objective about it. I don't agree with PAs, as I've said multiple times on this thread. Just pointing out that an FY1 is very junior, and not in fact on the full register

Well I'm not her mum and I couldn't agree more with @mumsneedwine.

@MaraisCinnamon I listen and am horrified. I'm a teacher, whose job involves supporting students to get into medical school. It's tough to do this at the moment.
@Possimpible of course she's junior. She's an F1. But nothing she does sounds junior to me. For £15.33 an hour (she'd earn more as an elf at Lapland).

@mumsneedwine a good staff nurse will be on about £17 an hour, and for a lot of them that's where they'll stay. As you say, the nurses are a great support to the juniors. Healthcare wages are shite overall. I'm amazed to see a PA locum shift for that money tbh

I have to agree with this. I work with fantastic medical staff who through their years of training will reach a level that ACPs, PAs etc never will. All well and completely appropriate. But F1s are very junior and need a lot support, from the senior drs, the nursing staff, everyone really. There’s nothing wrong with that at all and it’s not a criticism- they are fresh out of medical school and not fully registered. Any f1 who is left completely unsupervised and without senior support needs to raise it with the deanery and their nhs trust. In fact, any health care staff ( whatever their level) who feel they are being asked to practice outside their scope and competence have a responsibility to report it.

@Spacecowboys so what is the scope of practise of a PA ? Since they earn twice the F1 they must have twice the responsibility and ability ? Otherwise it doesn't make sense.
I'm v v sure all F1s would love the utopia of always having someone be by their side, but there don't seem to be enough staff. Mine has often found herself on the ward with just an SHO. Her consultant on her first placement reported it every time, but nothing changed. And also, should they be paid the same as an elf ?
And it is not guaranteed that they will ever earn more as the bottleneck to get into training gets worse every year. 1 in 4 chance of getting a training post this year.
All this with £100,000 debt. 5 years of hard slog during Covid (where many volunteered on wards). Not sure it was worth it. Unless she heads to Australia where they actually seem to like doctors.
But hey, be a PA and start on £40,000.

And yes, as her mum I'm angry. Seems she's been working hard all these years to now earn less than she did as that elf. Not what she signed up for 6 years ago,

OP, I'd much prefer your role to a PA. there's a PA where I work and I love her, she's great. She isn't a prescriber but she prescribes by proxy (eg. Diagnoses pt with strep throat, asks GP to sign a script for antibiotics).

However, we need people with specialism in psychiatry. I recently had a patient who was seen 3x by GPs in the same week, I saw the patient and immediately diagnosed psychosis. This had been missed! (Same symptoms in the notes, just no realisation it was psychosis)

Psychiatric meds are pretty intense. Someone with the knowledge and ability to adjust monitor and prescribe would be heaven sent to me.

PAs are not doctors but they are treated as such.

Our PA is on 45k, same as the paramedics.

I'm on 28k.

Beggars belief.

But the answer to all these issues is not tearing apart a group of health care workers - namely PAs. As individuals, they are not to blame for junior drs feeling undervalued. Our PAs are actually very good at their job, a benefit of remaining in the same clinical area for a period of time. They don’t earn twice as much , a dr fresh out of medical school does not earn 20k. PAs also have huge debt- both undergraduate and post graduate . I personally think that the govt should pay fees for medical students, nurses, physios etc and then tie them in to the nhs for a number of years afterwards. Thats a whole other thread though.

It is very difficult. I had babies as a young lawyer (and took 2 weeks off and have always worked full time). That of course has been brilliant for my earnings but most women don't want to do that. The psychiatrists in our family including my late father did/do a fair bit of private work, court work etc. My father sat on mental health tribunals until he was 70. Those things helped earnings. He also did some lecturing for extra pay when I was a small child.

It is so variable. I did one f1 job where I was well supervised in hours and rarely made a single decision. But then out of hours I was left to manage 70 medical inpatients with no one but a registrar on the other side of the hospital who rarely answered the bleep let alone actually came over. I did a surgical job where we were totally alone on the ward the whole time managing very complex medical patients. The registrars and surgeons were bemused at best and pretty scary at worst if we asked them for help with ill patients. The unit couldn’t retain nurses so most were lovely but also new without much experience. Other specialties would come to provide input when requested but obviously didn’t have responsibility for the patients and couldn’t come straight away. Some wouldn’t come unless the referral came from someone more senior and our seniors would refuse to make the referral. We’d be stuck in the middle watching the patient get sicker. To be honest I felt more supervised as an f2 as we took referrals and so seniors were a bit more interested in what we were doing! F1 is very junior but that doesn’t mean they don’t have a lot of responsibility.

@Spacecowboys the locum rates I posted were twice as much for the PA over the F1. And I have nothing against the PAs who stick to that job, but not the ones who act on the SHO register and take the training opportunities of the doctors. And try and force the F1 to 'just sign the prescription'. Er no, you take no risk as the PA, as it's all on that v junior F1. BMA guidance to send them all to consultants seems the only option.
It's sad. Studying medicine should be something to be proud of. Not something to regret. Many now do.