To be so hurt to have been replaced by a Physician's Associate?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

Feel for you. I'm an ACP in an intensive care setting. We have recently had PA's and I'm starting to feel a little threatened. They are lovely people but I just worry they don't have the clinical knowledge background that doctors/ ACP's have years of. Plus they are going on OOH rota next month. I've mentioned to a few consultants that I feel it's going to be tricky. Not being able to prescribe in itu is a big problem. Plus we are going to have to supervise all of the procedures they are learning to do. It's going to put a lot of work onto me. I'm all for new roles in the NHS, but it's ludicrous they have replaced an experienced doctor with a PA.
The PA should be working days only and be there to assist, not take on patients independently.

It's coming.

All the medics I know had Nannies, in some cases borrowing money / remortgaging to cover the cost. Their kids are now at senior school, no childcare costs and one or both parents now at consultant level (and able to pickup lucrative private work too). I’m talking about 8 couples in my local area / at school with my DC.

What you describe sounds very difficult and I would devastated too: but could you try and think 10 - 15 years ahead to being a consultant with a brilliant pension (yes I know it’s not as good as it used to be but I have moved from the private sector to the nhs and I am blown away by the pension…).

take the hit on the childcare - yes you’ll be working for free - and think to the future, financially but also job satisfaction wise.

@PlusThyme in the example given both partners were doctors, so earning potential was (presumably) the same. There's always the chance the husband had potential for lucrative private work once a consultant, depending on their specialties. I feel like men are more likely to be in those specialties.

@Araminta1003 My point is, men can look after children too. In a heterosexual relationship the woman doesn't have to be the main caregiver. If you're talking about enabling more flexible training for the whole workforce then fine, but your wording is very sexist.

But that’s not what the OP is saying at all. She was working out of hours shifts for her employer. She just didn’t want to get into a rotational training programme. I don’t think people have any idea what that then involves. You can be sent anywhere in the deanery (in the North West this stretches from Stockport in south Manchester to Lancaster - a distance of 61 miles) for 3 month rotations. You have no say in this. I start working in Lancaster on 1st Feb and have no idea what my shift pattern will be. I have a non medic partner and it is the only way I can see that this is sustainable over the 10 years it has taken me to train in my speciality. This is not an acceptable way to treat people and is incompatible with any kind of stable home life. Obviously I could leave and of course I knew I would need to work out of hours but the reality of junior doctor training is harsh and brutal. Suggesting we should all just leave is fairly short sighted as there will be no consultants in 20 years if we all did that. The OP found a job where she could work as a non training doctor (of which there are many) adding a massive amount of value. She has been replaced by someone who has less experience, can do less and costs more. This is typical NHS short sightedness.

Even the job title 'Physicians Associate' is obfuscation.

'Physicians Assistant' would be far easier to understand.

@IncompleteSenten it is financial - different pots of money. There is another doctor in the same position. It took me six months to procure the funding for a new computer monitor in our office (!!) so trying to champion a new paid doctor post with management is really never going to happen. There apparently is funding for PAs.

Really grateful to all the lovely supportive posters on this thread and so sorry to all the other doctors who have also been stung by childcare. Also really grateful to the doctor who commented on how much things have changed in 15 years re childcare costs.

Thanks also to those who have suggested alternative career options within medicine. I knew this was never a forever set up but I did think it would work until my children were school age and was led to believe so. I do need to have a think but I just feel so bitten and undervalued and burnt out by it all at the moment. I’ve always really struggled with OOH. I get really bad migraines. They’re also just unsupported and stressful. I knew doctors did nights at 17. I didn’t know I’d frequently vomit with migraines after nights until I did them!

Its not just about working shifts though, it's about being forced to rotate until a set point further down the line in your career. How many parents, male or female, would find it easy to move about regularly on the whim of someone else deciding where abouts to put you? Yes you get preferences etc but it's still very hard to manage, even if the other parent equally or more so parents.

The Daily Mail has been airing concerns about PAs for a while. One issue is that they lack the broader training Doctors receive, so are less able to spot the anomaly. Perhaps an apparent psychiatric problem that has a physical root.

DD is an F1. Getting the specialist training, especially if you are not able to uproot to where the vacancy is, is a real issue. If you can't, it seems as if you locum for a year or two and then if nothing comes up you have little option but to try elsewhere, eg Australia. If find it very strange that we have a system that almost encourage recently trained doctors to move overseas because there is insufficient specialist training, and then recruits either more expensive but less qualified PAs, or specialists who have trained in places like India.

I really don't want DC not to have a professional future in the UK. Either for her, or for the UK. She is, like most junior doctors, intelligent, hard working and empathetic. The system is mad.

There are many stories of PAs vastly overestimating their own abilities.

This happened very recently.

Did you mean to quote me? I literally said "If you're talking about enabling more flexible training for the whole workforce then fine, but your wording is very sexist". I know it's not flexible for either sex, but I took objection to PP's posts about women needing more support to be 'allowed' to train as a doctor, as though childcare is only their responsibility. People should have more support to enable a reasonable work life balance while training as doctors.

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
Exactly that. Deciding to go for PAs is a longer term strategic move. It usually requires an element of training for quite a few months.

It is not a personal decision. YOU know that, at least believe now that the role works for you but are THEY to know that? That next year you might decide to move, or have another child and take a 5 years break? They cannot control what your decisions will be, they can however plan what suits the service, and that is to employ PAs.

PAs are extremely helpful in many circumstances. They are often nurses with many years of experience which mean they can do many things doctor can, just not able to because of what is limited under their role. It means that the consultant is there to advise, confirm decisions, and take clinical risks, allowing them to focus on areas that nurses don't have the skills to undertake.

Having a child at this stage of your career was your choice and that choice cannot drive what is best for a service, short and long term.

I am not saying it's easy it isn't. But until it changes folk are stuck with it. This is the reason why a lot women choose GP training and not hospital because they know hospitals are 24/7 Even overseas doctors training towards being a consultant need to move jobs to do the necessary training.

I think you’re thinking of ANP/ACPs with the comment about most PAs having a nursing background. Some PAs have a nursing background but most of the ones I’ve worked with have come in from undergrad bioscience or similar and have little to no clinical experience beyond their conversion course (2 years vs 4 for graduate medicine or 5-6 for undergraduate medicine). I’ve worked with some brilliant ANPs (in diabetes, palliative care, medical admissions, orthopaedics) who bring a great level of clinical knowledge and (importantly) have a professional body they are regulated by. I can’t say the same about the PAs I’ve worked with.

PAs often do not have a healthcare background whatsoever. Doctors also do not “quickly overtake” them in terms of salary. Assuming no children and no time off, straight into training etc it takes a doctor 15 years to out earn a PA (see here: https://x.com/dreilidhmaria/status/1706772891180683635?s=46)

if they can do “many things” a doctor can, then what is the point of medical school? Of rotational training? Of the multitudes of post graduate exams? Why are doctors forced to do these things and not PAs?

PAs are extremely helpful in many circumstances. They are often nurses with many years of experience which mean they can do many things doctor can, just not able to because of what is limited under their role.

Not in my experience. I am a huge fan of nurse practitioners who do tend to be nurses with many years of experience. PAs only need a vaguely health care related degree, and then two years of training. Looking at DDs peers, those that got into medical school had top A level grades. Those who have now become PAs certainly did not. Yet get better pay, fewer and less antisocial hours, and in some cases are taking the training opportunities junior doctors so badly want, away from them.

PAs are extremely helpful in many circumstances. They are often nurses with many years of experience which mean they can do many things doctor can, just not able to because of what is limited under their role. It means that the consultant is there to advise, confirm decisions, and take clinical risks, allowing them to focus on areas that nurses don't have the skills to undertake.

Not true at all, agree with a PP do you mean ANPs? They're completely different!

From the experience I’ve had of PAs at our surgery I’d be less hurt and more worried about safety.

@vivainsomnia there are plenty of doctors who don’t want to be training. I’d far rather sacrifice pay and get to live and raise my children in one place. I guess you’re right about the hope that a PA would stay long term though. Just feels a bit rubbish that there isn’t an option for doctors to do this. We are forced to move around lots and then the fact we do so is used against us! Like @PlusThyme, getting to stay in the same home has been amazing for my mental health. It’s also wonderful getting to know nurses and not always being an outsider who has to prove my worth. It feels like the long term plan is to happily haemorrhage junior doctors abroad or out of medicine completely and then use stick not carrot to ensure those who remain keep moving onto consultant posts. I promise you there is nothing a PA can do that I can’t. ANPs are fab but criminally underused and hence resentful in my trust as no one wants to define their roles and responsibilities and they’re seen as neither doctors nor nurses. I actually worked with a fab ANP who had been a senior psych nurse for 20+ years, did her ANP training and then sat twiddling her thumbs because the consultants didn’t trust her to do anything and wanted everything she did to be signed off by a junior doctor, essentially doubling the workload.

Sorry to hear this. Agree sounds wrong.

Any way you can go into private practice??

I guess my point is .. I am a post-foundation doctor with several years of psychiatry experience now. I prescribe and have a good holistic knowledge of the complex medications we use. I can lead meetings and have good working relationships with the MDT. I can independently discharge where appropriate. OOH, I can review possible admissions and make the decision to admit or discharge to community. I can detain if needed. I have a good holistic understanding of these patient’s physical health. I can see children OOH if required. There is nothing a PA can do that I can’t. And I’m happy to do it for less money! But it’s not an option. It just feels so unfair.

What about if you did GP training now and then went back to finish the consultant psychiatrist route later when the kids are older?

Thanks to those suggesting GP training. Unfortunately, there are 12-18 months of hospital jobs (I can’t remember which now!) to get through. I have a single parent friend who has been completely unsuccessful in trying to swap a high OOH rotation for a community one. She definitely can’t afford the childcare. They don’t care and I’ve no idea what she plans to.

It does seem ridiculous, however that is down the lunacy of the PA role it’s not a reflection on you.

A few years down the line, some major medical mistakes costing the NHS £££ in negligence, the PA role will be either reformed with much more training, or drastically reduced.

You are also subject to the GMC and the threat of professional sanction for any transgressions, even years after the fact. As are nurses, physiotherapists and so on with their respective bodies.

At present PA and AAs don't have the same regulation, which is nuts.