To be so hurt to have been replaced by a Physician's Associate?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's odd though isn't it, I am going to guess that you would be less unhappy with a statement about barristers being typically of higher intelligence than paralegaks, or teachers compared to teaching assistants. Why do we have a collective difficulty with articulating the same about the mist senior decision makers in healthcare?

Apologies for the typos there!

A level grades to go on a teaching assistant course are not the same as those for teacher training. They are often very similar for science degrees (depending on the university) and medicine. Anyway, I don't know about barristers but I certainly don't think all teachers are of superior intelligence to teaching assistants. Many teaching assistants are doing the job because it fits in with child care and many were previously professionals including teachers. One of my friends who is a teaching assistant was previously a surgeon.

It's not a competition as to who is 'brightest'. Lots of people are bright, has v little bearing on their success (I mean, look at our politicians 😡).
Doctors are bright. Hard working. Good at exams. Why deny that ? It's not about comparing to others.
Personally I will now always ask if the person seeing me is a doctor. If not , that's fine. I know nurse practitioners are amazing at sorting things out. But if I rock up at A&E in an ambulance I want a doctor. If I'm being anaesthetised, I want a doctor. If I'm being given drugs I want a doctor to assess me before prescribing them.

Currently on Twitter. Apparently Highland Trust. Bonkers.

Who is denying they are bright, hard working or good at exams?

I did just say that it is the training that makes the difference so not sure why you are saying "it's not just the A levels"

It seemed 'but other people are bright too so doctors aren't special '. Well I think they are 😊

No, it was specifically a reply to a comment that doctors are more intelligent than everyone else.

@coffeeaddict77 well lots of them are. Surely that's unarguable? They are brighter than your average bunny

I would never recommend a career in medicine to my DCs. There are so many other degrees people can do that will make better use of stellar A level results.

Me too Mums. If I'm ill I want to see a Doctor, who has been to med school.

I have met a few phenomenally intelligent doctors over my career but I would say that most of us are just fairly bright, with good memories, a decent work ethic, communication skills and problem solving abilities. You could say that about a lot of people in many professions. My DH is an engineer and apart from our salaries I wouldn't say there is a huge difference between my friends and colleagues and his. Thinking back to my University days, all the people I knew that I would have said had really impressive minds were studying a pure science, maths or things like philosophy. The medics were on the whole more practical types, much like the engineers in fact.

I have no doubt that many more people could make perfectly good doctors than currently get the opportunity to do so - it's hard, but not that hard. Many, possibly most, of those who train as PAs could manage a medical degree and post grad training. But the point is that for whatever reason, they haven't. That's where the difference lies. Doctors are not necessarily intrinsically "better" people in terms of intellect, integrity or anything else, but we are trained to do doctoring and PAs aren't. There are roles for both but it's the blurrring of lines that's the danger.

Of course they are brighter than your average bunny. That is true of a lot of professionals though. The main difference between medics and many other professionals nowadays though is the intensity and difficulty of training rather than intelligence.

I agree.

Me too. Again, lots of people are clever. Including doctors. But only doctors seem to get grief for saying they are better trained. Apparently that's elitist.

So do I

My 'So do I' was a reply to @coffeeaddict77 's reply to @AgeingDoc btw!

I'm not sure it's even "better" trained mumneedswine, just appropriately trained for a defined role. I wouldn't say a doctor was better trained than a physio for example, just that a doctor is trained to be a doctor and a physio is trained to be a physio. They are different roles and neither would be very good at the other's job, and nor would they be expected to be.
The problem with PAs is that as far as I can see the role is not yet clearly defined so how can we know if they're appropriately trained? It seems to be evolving in many places as a kind of "doctor lite" role but without the consistency and accountability that is needed.
There's also an issue in my opinion with breaking down clinical care into increasingly smaller chunks provided by different people. You can train people to be quite expert in a narrow field fairly easily, but patients have the inconvenient habit of having more than one thing wrong with them at a time, so breadth as well as depth of knowledge and experience is so important. You just can't get that in shortened training programmes, and even though there's always the option to refer to someone else, you need to know enough to recognise that you don't know enough. I'm not convinced that training for PA and similar roles equips people for that very well.

Definitely bonkers. Not sure how this can be happening.

@AgeingDoc you put it so much better than me. Appropriately trained sounds right.
I am doing my best as a one woman moaning machine to explain pay, and training log jams, to as many as I can - I was so shocked to realise that we actually do have enough doctors, they just can't get the jobs they want. Utterly bonkers.

It was never a permanent job OP. You are acting as if they owe you anything. These contracts are 1-2 weeks notice for either you or the NHS to allow you to move on easily and for them to place whoever is cost effective.
And yes as harsh as it seems, you leave today they replace you tomorrow.

Get another Locum job that pays well so you can support your family otherwise you may as well go into training if you are a Locum doctor for a pittance. You usually don't get treated well and don't get paid annual leave anyway.

Yes, locums cannot expect job security. And, unfortunately finances are skewed to encourage hospital administrators to hire more expensive, less qualified and less flexible PAs instead.

This is down to "the Government" or more accurately to the policy makers, with in Whitehall or in the NHS who ought to be able to understand short and long term priorities and ensure that any short term decisions don't have adverse longer term impacts.

DD is an F1. Much to our surprise as both DH and I have Whitehall policy/economic backgrounds, and DS seems to be headed down a similar track. She is sporty and dyslexic and we first assumed she would be a physio or a games teacher until her coping skills improved and she realised she could get the grades to study medicine. It is a good fit and she seems to enjoy the work, even though her first placement, long hours in a hospital with a very deprived catchment, was brutal.

However something is wrong. If DD is pessimistic about her career path, I would assume most of her peers will be.

Foundation years have always been tough, however:

• this is the Covid generation. They either missed great chunks of medical school through lockdown, or worse still were graduated early into complete chaos. One robust and capable girl DD knows worked flat out during Covid. Now she struggles with PTSD, lives at home and works a p/t locum job.
• students now coming through were almost certainly recruited on the basis of UCAT. DD was one of the very last (gap year and intercalation) to get in on academic results and Personal Statement alone. UCAT is seen as fairer, however it is unclear the extent to which empirical results confirm that it is helping recruit the right people. (I would be interesting to see statistics from Bristol who went from no aptitude tests to a heavy reliance on UCAT within a couple of years - virtually none of DDs friends would get in now, though they make great doctors.) The skills helping DD through this year have been gained from long hours working as a chalet girl, being a school prefect, interpersonal skills as a volunteer with disabled people and from working in a care home, and the resilience she needed in sport. UCAT is clearly a cheaper way of sifting but is it really fairer and does it help recruit better doctors?
• This generation also has larger student loans than any other, whilst salaries that mean they lose chunks from their salary from the start. Add in the de facto need for a car in many deaneries, both because of spread out placements and late night working, and F1s are feeling the pinch.
• Working conditions. From what I can see in each deanery there are hospitals and/or departments in crisis. DD heard early on which placement in her deanery to avoid because they lost a couple of F1s last year. A doctor friend said one of his DDs placements, in Hertfordshire, was awful causing a couple of her peers to quit medicine almost immediately. Some departments have even lost their ability to take on F1/F2s. DD decided to avoid London because a good friend found herself in departments so overwhelmed that there was little time for training. The consultants where she is, see the training of junior doctors as part of their role and are very generous, but there is no getting round the staff shortages, which means F1s are taking on more than they really should.
• The biggest one, at least from DDs perspective. The shortage of specialist training. Many of the junior doctors we know are working as locums, often because they can't get the specialist training they want. So a friend's son is working as a locum in order to have a second go at a training place. At some point he may either find himself in the position of the OP and lose his job overnight to a PA, or start looking for alternatives (Australia? a non medical career?) If three out of four are missing out on training places, that is a lot of newly qualified doctors the NHS is at risk of losing. Which will do nothing to help the shortage of senior doctors. DD will be 27 when she finishes F2. Already school friends are settled, buying their first flats etc. She may have to do a couple of locum years, and then uproot to whatever training she can get on. It is quite possible she will be in her mid 30s before she can settle. Several of the CTFs she had at medical school reached their late 20s and chose to give up their ambitions.

It is quite mad. I can see a capable doctor that the country has spent a fortune training, who likes the work and is dedicated, but who now sees no long term future. I understand the demand for more money, but this is too simplistic. The fundamental problem is working conditions (including job security for those forced into being locums) and career progression. Policy makers need to go out and start talking to some junior doctors who have either left or who are thinking of doing so.

Please sign and share this 10 Downing Street petition to allow GP practices to use ARRS funding to employ practice nurses and GPs. https://petition.parliament.uk/petitions/652965 

Done. Felt like a turning the tide a bit today. Idiot woman saying 'in training' and then seemingly shocked that PAs earn more.
Happy Xmas to everyone in the NHS. And everyone I know is behind the doctors - they are shocked they earn so little.