To be so hurt to have been replaced by a Physician's Associate?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

I take it you are in an administration role rather than medical because JD do work weekends and out of hours.I certainly don’t want a PA diagnosing me after only 2 years basic first aid traing.It’s madness

@Viviennemary go on, please tell me how I work childcare around a shift pattern that I get only 6 weeks in advance with seemingly randomly scattered evenings / nights / weekends on the pay of a junior doctor. I’d absolutely love a solution of how to work around that, because I do miss medicine in many ways.

What accommodations would you propose? Would you staff the night shift entirely with men? Or just tell people to only get sick Monday-Friday between the hours of 9am and 4pm?

Emergency services are 24hrs a day 365 days a year and as a result a lot of jobs involve hours which aren't compatible with family life, regardless of gender, unless you have a partner who is able to pick up the slack.

You’re a minimum of 23(ish) when you graduate, then two years of foundation training (now 25-26ish) then you enter specialty training which can range from three years to seven plus depending on the programme. And that’s if you get into training straight away. Many programmes are oversubscribed so you end up taking a year or two working as a locum whilst you CV pad and work on your application. Most doctors are lucky to have become a consultant by their mid-30s (and that’s assuming there’s a suitable consultant post available). If you’re going to put having a family on hold until being a consultant you therefore risk not starting trying until the point where your fertility starts to decline. as a doctor with a known fertility problem there is no way in hell I was taking that risk.

I’d be arguing that an NHS that supports women (and men) to have a family/work life balance would mean that more doctors would stay in training and stay in the UK (how many people have mentioned on this thread that they’ve left medicine alone). That’s to the benefit of all parties (the doctors, the NHS and the general public).

If you think it’s acceptable that having a family life and having a career in medicine are unachievable to the average person (as your average junior doctor salary isn’t going to be able to afford a nanny etc) then you’re advocating a return to the old days when only a certain sort of person (nearly always male, nearly always middle class/well off) could do the job.

Think how overlooked women’s health is already? Think driving the women out of medicine will help that?

“People know what is required during the training of junior doctors and they must work their personal life round this.”

Bit harsh…

Several of my neighbours are doctor couples. Female neighbour 1 got to consultant level years after her DH, of the same age, met at Med School, because they had 3 young children (second was twins). She only got through the years of study with a combo of nanny and her mother doing all of it and that is with London hospitals accommodating the rotations quite locally somehow and great public transport. I used to be up late at night when one of my DC was a baby and would see her studying with her lights on at 1am most nights.
Doctor couple No 2, both from India, with 2 young girls, ended up getting help from India to live in permanently and had to fly the help back every few months for visas.
Why should female medics not have children when many others tend to have children and when it is healthier/easier to have children?

I don't know anyone in psychiatry but I do know medics that have been in this situation and here are the options they chose:

• hiring a nanny
• contacting the deanery to negotiate a part time contract, making up the hours doing locum work on top
• making sure the deanery prioritises you, regarding childcare commitments when creating rotas and placements
• moving to a more rural location where they are so desperate for staff that they will give you what you want and there is less competition for the local placements
• taking a few years out/on the side to do a PhD

Some of these people found someone to really fight their corner and make it work, it might be best to really network and find someone who can accommodate you.

@Hivernal you could offer more pay for OOH work to cover the cost of OOH childcare, perhaps? You could allow doctors to work near their home and near their support networks rather than applying to cross country training schemes? You could give them time during their working hours to revise for (essential for progression) exams rather than expecting them to do that for free at home while looking after their children?

Just off the top of my head.

But you knew the set up. The point is medicine isn't a 9-5 job and is unlikely to be. Shift work is part of the job. If folk want a cushy WFH job they can work round family life then they are in the wrong career.

You think that at 17 I had truly factored in the ins and outs of finding OOH childcare for any potential children I may have in the future? You’re kidding yourself.

To go down your path of zero accommodations would lead us to 100% independently wealthy men. And I’m not even sure many of them would want to work in the NHS!

Something has to give or we will have no doctors left, and I’m not sure that many will be keen to come back from Australia even if you improve life here once they’ve settled down abroad.

And I never wanted cushy. I’m happy to work nights, just pay me enough to afford childcare to cover it.

I haven't come across a cover supervisor that wasn't qualified in some way. I worked as one in a highly academic school. I had been a college lecturer and have a degree which focussed on additional needs and behaviour management, which was a change of career in my forties. My colleague was a secondary school teacher. When we retired we were replaced by people with extensive teaching experience.
That's great that you were doing the role with that kind of background and likewise your colleagues. But there is no official requirement for that to be the case and no nationally-recognised qualification to be a cover supervisor. Nor are there any national standards for this role. And if your replacements had extensive teaching experience (and were qualified teachers?), surely they should have been paid as qualified teachers?

Here are the NEU guidelines on HLTAs and cover supervisors:
HLTAs and cover supervisors | National Education Union (neu.org.uk)

I searched cover supervisor jobs and the first one that come up only asked for A-Levels or equivalent, to work in an 11-16 school.

Cover Supervisor Dorking - Reed.co.uk

This one is also concerning - no qualifications mentioned in the advert and the role involves covering PPA in Reception, Year 1 and Year 2, where skilled teaching is essential for learning to take place. The NEU guidelines explicitly highlight that HTs should not use cover supervisors to cover PPA.
Primary School Cover Supervisor job with ACADEMICS | 8774577 (theguardian.com)

For what it's worth, I was once employed as a qualified and experienced teacher to cover PPA in a primary school - now the same role only requires an unqualified person who can 'support pupils with their studies'. It doesn't bother me as I have long since left teaching, but it is certainly a sign of changing times.

To draw this back to the parallels with medicine, the government playbook seems to go:

1. Resent a public sector profession as being over-qualified, over-paid and overly restrictive. The barriers to entry are high and they seem to have an over-inflated sense of their own role. It can't be that hard, can it? Locking horns with unions or professional bodies doesn't work (they are just too stubborn and not really getting on board with the free-market programme!) so resort to step 2.

2. Create or identify a pressing need for more staff. Ideally frame this as having some benefit for the professional workforce e.g. PPA for teachers. Extra marks for a recruitment 'crisis'.

3. Train up a cheaper alternative to the professional workforce but reassure the profession that there is nothing to worry about, AltDoctors or AltTeachers will just work in limited and circumscribed roles and always be supervised by qualified staff.

4. Set the first cohort free into the employment market with lots of encouragement for cash-strapped employers to innovate and make use of this truly exciting new workforce. Celebrate 'success' stories wherever you can find them! Ignore professional complaints and legitimate concerns about incidents - surely these are up to employers to handle and aren't AltDoctors or AltTeachers always being sort-of-supervised by professionals anyway?

5. Sit back and watch as the boundaries are bent left, right and centre by cash-strapped employers, the professional workforce finds themselves priced out of jobs, standards fall and risks increase.

Government is easy, isn't it?

And a rota with enough notice to arrange childcare. And a job that’s commutable without moving house every year.

@Salacia since quitting medicine I have been in the same house for 2 years for the first time since I was 18. It is truly blissful. Maybe even the best bit about quitting.

@Viviennemary I approached this up thread. I genuinely didn’t! I applied at 17. I didn’t even know what I didn’t know (if that makes sense) and so didn’t even know the right questions to ask. I didn’t know I’d meet a man who needed to work at the other end of the country from our parents and possible childcare, nor how tough my pregnancies would be or how hard I’d find night shifts, or how expensive childcare is, or how basically only a nanny is an option for the random junior shift pattern etc etc. Many women obviously do make it work so I’m not claiming it’s impossible. My aibu isn’t about the working conditions of junior doctors. We all have two options (sadly) - accept it or leave. I’m upset that I found a good middle ground and am being replaced by someone who can do less and is paid more for the privilege (and with zero warning - I was even asked to do a final shift to train the PA!!)

As an aside, is the best option really to say you knew what you were getting into, lump it or leave? As this thread shows, many of us leave (after having cost the tax payer a fair bit too!). Seems pretty short sighted. We should be supporting women to progress in their careers, not blaming 17 year old girls who couldn’t possibly fathom what working motherhood and arranging ad hoc OOH childcare looked like, nor what working through pregnancy and throwing up in hospital bins would be like … But anyway, not the point of my thread at all.

But in greys they spend all day at work and all night drinking at each other's houses or bars with their many many DC in magical childcare.

Are you saying the NHS isn't like a privatized American fictional hospital? 😂😂

@Araminta1003 It is madness so many girls are allowed on Med Courses and then not accommodated properly once they have kids due to the “system”.

Woah, what do you mean 'allowed'? Should we refuse places to female applicants on the basis they may get pregnant..? Think there's a word for that.

Female neighbour 1 got to consultant level years after her DH, of the same age, met at Med School, because they had 3 young children (second was twins). She only got through the years of study with a combo of nanny and her mother doing all of it

Presumably they made the decision to prioritise his career, probably for financial reasons. Why didn't he take on the childcare burden and focus on her career? This is not wholly a system problem, they made the decision to prioritise the man's career

But anyway, OP YANBU, I'm a non-medical HCP who can prescribe, and it's awful to see doctor roles being replaced in this way. I don't trust PAs, and ANPs etc all have much more defined roles and supervision than doctors. It's madness, thought up by managers who wouldn't last a day in a patient-facing area.

If the person they have replaced you with is going to cost them more than it would have cost them to hire you then it's not a financial choice.
I'd ask for a meeting with whoever you think is best and ask for their feedback. Tell them you're keen to learn from this and ask them to be honest about areas of improvement etc.

Thankyou for explaining that makes sense 😁

If they are not going to allow women to be supported properly through the full training then be up front about it and not let a large percentage of women onto the med courses in the first place, because it is a terrible investment and costs the whole of society money. And all those talented women could have done well paid other jobs in which you can now work from home several days a week.

Fact of the matter is brilliant young women who care make amazing doctors. It is exactly what we need and they deserve full support and some flexibility through their full training. If a tab were kept on how much their training had already cost (aka sunk cost) then the system would not get away with this.

My law firm spends ton on trainees and we are held accountable if it does not work out with one of them. I have to do everything in my power to keep them on and train them and keep them happy because we have already invested thousands and thousands into them and if we have to hire elsewhere, we end up spending a huge amount on recruitment fees and often end up with less well trained staff. And our research shows that loyalty is also best from our own trainees.

The whole shambles of the NHS is precisely because nobody is doing the maths correctly in a long term constructive manner or communicating effectively across the whole sector. It is all last minute firefighting and passing the buck and ticking boxes for the sake of it (and far too much political interference). And because we all pay for it, including the doctors themselves, we should all care and our whole society collapses if people don’t get their basic health care needs met in an efficient manner.
And that is where we are at right now. We are an overall healthy family, but we talk about emigrating back to Europe a lot because we do not feel safe on the NHS. So it is not just doctors emigrating when your health system collapses, it will be others who can afford to do so as well and typically they prop up your taxes in the first place.

I’m 33 and a GP - I’ve always been a planner and aged 16 I did consider (in a very naive 16 year old way) how childcare might work. The thing is that 17 years ago when the current doctors made the decision to study medicine - a junior doctor could afford good childcare / nanny etc. 16 year old me knew that because it was true back then - but since I’ve been in training doctors wages have been eroded and childcare costs have shot up. I’ll bring home £35 after childcare and deductions to work an extra half day for 5 hours dealing with dozens of patients.
Also no one can really envisage the emotional and logistical realities of moving house 5 times in 5 years to accommodate training, or predict if their future partner will have the flexibility to help.

The push for physician's associates really scares me. When I'm seen by a medical professional I always ask what their position is and refuse to see PAs. Patients and doctors both need to take a stance against them IMO.

That's great. But they will never be doctors.

I take your point about prioritising your husband’s career, but this is often a consequence of medicine itself being badly paid. If your husband out earns you (not hard if you’re a doctor in London), then it seems like madness to get them to quit in order to cover your random shifts while you work a job that couldn’t even afford you a nanny.

There are no Physician Associate posts in Scotland as far as I know (move up here!!).

It's worth remembering that as it stands PAs are still unregulated in the UK.

The GMC wants them under the HCTPS like other non-nursing professions, the PA lobby wants full GMC regulation like qualified medics.

Some of the experiences reported on the UK doctors subreddit are terrifying.