To be so hurt to have been replaced by a Physician's Associate?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

There is more reliability though in a contracted HCW than a locum. A locum has no commitment (theoretically) and can leave, pick hours, not turn up (theoretically) as they wish. So I guess the hospital has more reliability with a PA than a locum junior Dr, from their perspective

@SD1978 but doctors HAVE to rotate. It's not a choice they make. If this is the issue then let doctors stay in one place once finished foundation. Problem sorted. No need for PA.

Wow, glad to see people still commenting.

@Possimpible I don't pass judgement on someone's intelligence by their spelling. I know lots of very smart people with dyslexia, and plenty more without who are liable to making spelling mistakes, particularly at the end of an 80 hour week ... I think @Nearlythere80 is making very good points. Of course it's not the case that any given doctor is more intelligent than any given PA. Of course doctors are as capable as anyone else of saying and doing silly things. However, it is also the case that every doctor has had to pass pretty rigorous exams. You can't coast your way through medical school. Widening participation is very important and something medical schools are increasingly aware of. However, IMO the focus should be on ensuring all capable students have an equal chance of getting into and through medical school rather than in reducing the academic requirements to be a doctor. It's not fair for the public to accept lesser healthcare to make up for elitism in medical school, and no one has the god given right to be a doctor / doctor figure at the expense of their patients. I'm very willing to hear and learn about the roles of PAs in the NHS and where they might be useful. I'm more uneasy when people's arguments involve the fact they weren't able to go to medical school. Being a doctor isn't a right. It's a massive responsibility, and fitness to practice and accepting our limitations is drummed into us from day one. By the way, I was state educated. It's true that a higher proportion than average of my cohort were privately educated. They are still fab doctors and I think it's pretty impossible to be tutored through interviews and medical school. There's an awful lot of differences between the 'haves' and 'have-nots' in this country - ensuring everyone has access to doctors who have met rigorous academic standards seems pretty important to me.

@mumsneedwine you sound like such a lovely supportive mum, and thanks for being so lovely and supportive on my thread. I've really appreciated all of your comments.

@Hayliebells good point. I earn by far the least of all my friends (despite the best A-levels and longest most rigorous degree). Funnily enough, there are some who really refuse to believe how much I earn and have always insisted I must be presenting figures without overtime or that I can't really work the hours I claim!

“They are still fab doctors and I think it's pretty impossible to be tutored through interviews and medical school.”

Oh come on let’s be honest that’s why people pay for private because their dc get the tutoring on top of an elite education. And if mummy and daddy were doctors their offspring will be getting interview tutoring the like of which others won’t ever have access to. Doesn’t mean others would make lesser doctors.

Let's not get distracted here. Lack of diversity in current doctors is not the reason for the overall number of doctors.

Coi: posh public school educated white female doctor. None of those features have stopped me from working hard and doing, frankly, a hard job really well.

Private education definitely gives you a leg up at interview and getting into medical school (as somebody who interviews for my local medical school and knows a bit about admissions stats etc). A lot of medical schools are doing great work in widening access but there’s still a long way to go (not that I’d encourage anybody from any background into medicine in the UK).

I’m not convinced it makes much difference in terms of getting through the actual medical course and professional exams however. Anecdotally a lot of my peers from a private background struggled a little with the self study nature of medicine. Certainly the majority of those who didn’t make it to the end of the degree in my cohort came from the more privileged end of the spectrum. I believe the big decider in professional exams is if a candidate studied at a UK medical school or abroad (presumably due to familiarity with exam styles).

@Nearlythere80 Exactly. Widening participation is a totally different issue and not unique to medicine. I think all students good enough to do medicine should have the support and financial means to get there and would support any policy to achieve that. I also think all patients deserve the best doctor possible and no one has the right to be a doctor. I think it's incredibly sad and unfair that there are so many out there who would make excellent doctors but never got the opportunity due to their background. However, I do not believe that this means they are entitled to play doctor without a medical degree to make things fair. As I said, the priority is always, always, always the patients and it would also be incredibly unfair to support any policy that will lead to worse healthcare for poorer patients.

Getting bogged down in doctor privilege helps nothing in this situation. Of course private school helps, as does tutoring, as does having doctor relatives and not having to work throughout university. We all know that and we acknowledge it where relevant, but I really can't see how it is when it comes to PAs as I really can't agree that PAs should exist as a non-traditional route into medicine.

I just meant that ultimately these doctors still have to sit their own interviews and pass many, many exams.

Whilst I get conditions are clearly shit for doctors atm I do wonder if students with trickier backgrounds would make doctors better able to cope with stress. If you have managed to get into med school and fund it whilst coming through the state education system and a challenging background surely you will have a better skill set. Why is the widening of access still taking so long?

That's just a variation on the idea that those working under poor t&c with bad employers should be more resilient. Junior drs aren't lacking in resilence, but in the resource and respect given to them.

@Cranb3rryF122 it's not. My own DD is comp educated. As are many of her peers.
And I support medics from my own, and a couple of other local schools, to apply to medicine. We get lots in every year. I am an expert on finding bursaries and WP schemes.
No idea if it makes DD more resilient, but she has worked since she was 13 (baby sitting, supermarket work, HCA during covid), so hard work is nothing new.
Being called privileged is. She's worked her backside off to get here. Didn't expect to then be treated quite so badly.

I think access to medicine should be widened for many reasons but none of those are because I think disadvantaged students will be better able to put up and shut up with the bad conditions...

I'm really sorry, but I'm not surprised. NHS is all about money. Cost cutting, Replacing you with a PA. In my local MSK they've got no Doctors, just a Physio and an ACP. Disgusting.

Hear, hear, hear! Very well said. So many misconceptions about the reality of being a junior doctor from posters who have little understanding of the reality

Anyway, I can't think of a single job not helped by coming from a privileged background but getting into and through medical school and then working for years in the NHS is hardly akin to coasting through public school and being handed a high paying job in a family member's company. Regardless of background, every single junior doctor has to work in the same conditions and pass the same exams.

No member of the public wants to treated by a PA, or an ACP. We want a Doctor, someone who is qualified, someone who has been to med school, that's what we want.

But in an MSK team that makes sense.

@ginoohginoginelli
Oh really gin? Please do explain because obviously I don't know enough about each nhs dept. Why would you not have many different kicked of staff, within a big MSK dept. Why wouldn't you have doctors aswell?

Because MSK is more likely to be "functional" and so better managed with physio and/or steroid injections which don't need doctors to oversee. The ACP (likely a very experienced nurse) is there to assess and check bloods. She'll refer anyone more complex to either orthopaedics or rheumatology who most definitely have doctors.
In lots of areas MSK is self referral based and so the entry point for joint based medicine. Similarly, self referral CBT/counselling will be staffed by mental health practitioners and counsellors, not psychiatrists. As long as an experienced ACP is there to refer "up" it's safe, cost effective and makes better use of highly trained staff. I hope that makes sense?

Yes thank you for that explanation Zebra.

It's really annoying how inflexible the training is. There's no reason for it. I think the main issue is the deaneries are run by (mostly) men who had to train under a certain system and can't see why other people don't have to suffer the same way. What some of them don't see is that when they were trainees there wasn't such an over-capacity in the system, so there weren't so many high risk patients at the same time. It clearly puts far more stress on the junior doctors largely running the service.

Anyway because there are far more women in training, we have to make adjustments. It's crazy to invest £250k+ to train a doctor and then make it impossible to practise. I don't see the rationale in making doctors travel the country. Why can't you train in one hospital where you get to know the teams, the nursing staff and the layout? Also we need to be more flexible about training programmes. I must admit I thought there were part-time training positions? (although it's a long time since I've been in a deanery). If I were running the training programmes I'd see if it was possible to match two part-time trainees to one role. Surely two of you could work out your week so you could cover the core hours and the out of hours service? If you were being accommodated, like many part-time women, you'd be so grateful for the flexibility you'd go the extra mile!!!

I agree there needs to be more flexibility and consideration of individual trainees needs @Pelham678 - current training is far too much focused on pushing people through the same hoops at the same time in my opinion. (Though less than part timr is an option and I have occasionally come across job share as one way of doing it.) But no one hospital could produce the breadth of training required in most hospital specialities. Aside from the fact that there would be significant gaps and variation in training depending if doctors only trained in one hospital - very few Trusts provide every subspecialty in any service even if they are multi site, never mind single hospitals - there is a huge amount to be gained from experience working in different kinds of hospitals with different people.
We already have some issues with the fact that a great deal of training at both undergraduate and post graduate level is provided in major city hospitals whereas in most specialties the majority of doctors will end up working in DGHs outside of big cities which can be very different. Restricting movement further would make matters worse, both from service and educational standpoints.
Training hospital doctors in a single hospital (it's feasible and does happen for GPs in their hospital years of course) would be a disaster for service provision as most hospitals would not be able to have junior doctors at all and thus be even more dependent on PAs etc and would not be good for the personal development of the juniors themselves. There might be a few big city Trusts that could provide exposure to all training requirements but nobody could do their training in a DGH, meaning we'd be producing Consultants to spend the bulk of their working life in a type of hospital that they had no experience of working in.
Rotation is a complete PITA from a domestic perspective but there is no real alternative if you're going to get experience of the breadth of your chosen specialty. And seeing and adapting to different environments and people is an advantage not disadvantage of rotating in my opinion. I worked in some places I loved, some I hated and some I was ambivalent to but I learned something everywhere and came out at the end with a fairly good idea of the kind of place I wanted to work. Had I been stuck in one (presumably city teaching) hospital for the entirity of my training that wouldn't have happened.
It's true that things sometimes stay the same way for years because "we've always done it this way" but sometimes there are sound reasons for it.

I don't agree that medics are necessarily more academic. You generally need three As at A level to do medicine which many non-medics also achieve including those that have done science degrees and then gone on to be PAs. I don't think that superiority complex is helpful and is one of the reasons medics can be unpopular.

I do think that much more training to be doctor versus a PA though and that is the reason they shouldn't be replaced by them.

It's not just the A levels. It's the v tough exams through medical school. So can be 35 hours of lectures/practicals/on ward and then the need to study on top. Now I know other professions do this too, but not for the number of years doctors do. Still taking exams 10-13 years after finishing Uni. While working 60+ hour weeks. And paying for them themselves, at hideous costs for online, machine marked exams. Someone is raking it in.
Lots of people are bright and doctors are not 'the best'. But they deserve to be treated with respect, not disdain. I know 2 PAs who have food science and biology degrees and then 2 years of v basic medical training (yes basic, they admit this themselves).
As a patient, I want a doctor, who has studied everything in depth. You don't know what you don't know.
And to the person who said foundation doctors don't do much anyway. Last night my daughter pronounced 2 deaths and explained to 2 sets of relatives. Carried 4 bleeps (not really sure how this works but sounds a lot to me). After 14 weeks in the job. She is actually enjoying F1, because her colleagues and seniors are so supportive and kind. But £15.33 an hour. Strike incoming.

As a teacher, whose job it is to support future medics, I'm finding it harder to do this every year. These are bright kids, who could go off and earn loads of money in other areas.
The 2 PAs I know are ex students, who would not have got into Uni to do medicine at 18. They decided on PA as the hours are better, no moving around and great salary. Lovely people. Imagine they are fantastic at their jobs. But they do not want to be doctors, have the responsibility of doctors or the hours.