To be so hurt to have been replaced by a Physician's Associate?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

Or used as another reason the NHS is failing and should be privatised for our own good.

Interesting. In my Trust, PAs are all or almost all 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
That doesn't make sense. Surely the part of signing off is only a very small part of the all appointment and decision making, so it isn't doubling the workload. Otherwise, the system is not working as it should, ANP not having the expected skills or Junior Doctor spending too much time reviewing everything as if doing themselves.

I do sympathise though, it's frustrating and dehumanising. My niece just finished her training last years. She would love a child now but won't because of the implications. She knew this before starting her training. She's made that choice and is fine with it. She is only 24.

As a MH nurse this is absolutely terrifying to me. I’m a competent and capable nurse. I know how to support people with serious mental illness and manage risk. I’ve even completed extra training in psychotherapy to become BACP registered. The point is, I’m good at my job. What I’m not, is a doctor. I need there to be someone medically qualified to rule out the more complex physical causes just in case. A PA can’t do that. Honestly, I’d be better off doing it myself as I have more experience than pretty much all of them-but that’s exactly why it’s terrifying. I know what I don’t know and, IMO, most PAs definitely don’t.

The whole reason for reviewing the system is that ultimately, there are not enough doctors, so their time absolutely need to be maximised sound what noone else can do.

The issue here is not the system but the fact you made the decision to have your family when you did.

It doesn’t make sense, you’re right! The consultants wanted it all repeated. Just completely unregulated and not thought through and a waste of everyone’s time .. Anyway not really relevant, just interesting as I do think ANPs are fab.

I need there to be someone medically qualified to rule out the more complex physical causes just in case
And that's why there must always be a doctor to supervise and take clinical responsibility of the patients. They can then dedicate more time to the more complex patients.

I agree on maximising doctors’ time, but how are they supposed to rule out a rare diagnosis if they haven’t reviewed the patient themselves and simply sign off the PA’s prescription? How can you take clinically responsibility for a patient you have never interacted with? This is why they do not reduce workload, they just cause two people to do the same review!

A real assistant to maximise efficiency would be amazing. Someone to find the notes, place cannulas, print off blood forms, scribe the notes etc! This is what we were sold with the initial phases of - what was then known as - Physician’s Assistants. All doctors would be pro that role!

@vivainsomnia you know nothing about my health, my husband’s health or why we had children when we did. That could possibly be a very hurtful thing to say to someone. Anyway, I don’t think that’s relevant. My AIBU is that I’m hurt and don’t understand the system. I’ve not demanded a job or argued with those who signed off on it. I’m just saying I don’t understand. Is it really better to lose doctors than give some flexibility?

It’s fine to say doctors can remain for the most complex stuff but actually we don’t all want to, and in this case, the PA is just taking on my job minus some of the things I did. It’s not freeing up any doctor time! It would be great if we all just wanted to work OOH and see the hardest cases and spend the rest of time over seeing PAs and ANPs but .. we don’t. And we still need to be trained!

@PlusThyme I agree. I spend so much time doing bloods, printing forms, filling out basic paperwork, performing ecgs. An assistant really would save time. The PAs and ANPs I’ve met don’t want to do them. Plenty of nurses want to but the trust won’t pay to train them.

I’d also argue that pretty much every patient meeting the threshold for inpatient psych treatment is complex…

That’s one positive of the new nursing curriculum. All MH nurses now come out of uni bloods/cannulas/ecg trained which might take some of the pressure off.

@prawncocktailskips totally agree. People are deluded if they think doctors will be willing to work mostly OOH and weekends for £14-20 per hour in order to take on only the “most complex” patients and 100% of the clinically responsibility for patients they have never seen or reviewed.

@JennieTheZebra as I understand it almost all nurses are trained in these things at university, but each trust requires them to attend training at their individual trust post qualification (and these courses are massively oversubscribed) so in practice they mostly are unable.

Hi OP. If you think maybe public health specialty training might work for you, and would like to discuss it, DM me. Some OOH but it's phone calls from home rather than patient facing. Placements can be spread out but it depends which Deanery you'd be with and there may be flexibility. LTFT is common. Lots of working from home as well. It might work well for you but I know some people miss seeing actual patients!

@PlusThyme That is supposed to be changing and in many trusts it already has, including the one I work in. There is really no need to repeat training already completed-and it really is all nurses now, not “almost” all. The new curriculum is very strict on proficiencies.

DD is resilient, but is finding F1 brutal. She is not in England and her contract is tough. Up to 10 days in a row and up to 13 hours per shift. A lot of nights. She is at an age where friends are starting to settle. She can't. She can't afford to buy in London where she is from, and won't where she is as next year she will be working on the other side of the deanery. Who knows where she will be after that. Even for GP training (which she does not want) she might have to move anywhere. She will be in her early thirties before she has any idea where she might end up.

There were five deaths on one of her early nights. All "expected" but even so it is difficult for someone who has just arrived in a new place without much of a social support network. As a previous poster suggested consultant cover is not always available at night, and a huge amount of responsibility is given to even new F1s. Social deprivation at her hospital is off the scale, far worse than she saw in medical school which is a lot for someone newly qualified. She is very lucky in that there was huge comradery amongst her peers and great support from consultants who saw part of their role as training (not always the case) - and in turn the F1s do quite a lot of work with medical students who are on placement. She is learning a lot. However the signals being given out by the NHS is that they would prefer and reward someone with a sports science degree and two years basic PA training.

I disagree with the idea that all doctors should have to be flexible. Once of her close friends has major health conditions arising from illness they had at medical school which means they will only ever be able to work part time with a need to avoid stress. It happens in all occupations. They will still be a great doctor, as will be the parent who is juggling shifts and family responsibility. There seems to be a bizarre macho element to some of the posts. Retaining staff involves understanding the needs of your workforce and making reasonable adjustments. The treatment of junior doctors seems to be stuck in the 1950s, but without support, job security or the value society used to place on the medical profession.

I can understand and empathise with your upset...Think it all comes down to trust politics and budget.

My trust had a covid budget, which has now gone and alongside it the agency nursing budget. Despite having more patients and less staff. Plus inability to fill Nursing posts.

It maybe that they have a budget for an AP and not junior doctor budget. If that makes sense.

Maybe try another trust instead of leaving the NHS.

From an outsider’s perspective, all I’m seeing is yet another woman willing to do extra work for little pay.

I hear that is is not unknown for PAs to push junior doctors to sign things off without proper review. (Not least because the junior doctor does not have time to see the PAs case as well as their own.) And that this can become very awkward/dangerous. The doctor is paid less and carries more professional responsibility.

Maybe try another trust instead of leaving the NHS.

But this means uprooting her family. The NHS is a monopolistic employer, there are often no alternative employers. It needs to bear that in mind. Yet people moan when Doctors migrate to Australia or to the Private Sector.

Love to your daughter @Needmoresleep. F1 can be absolutely brutal. At medical school, we were reassured constantly that we'd be so supported. How I laughed (not) on my third ever shift doing weekend medical cover for 70 patients with a totally absent registrar. I hope she gets through okay. She sounds very empathetic and I hope she doesn't lose that x

@Ktime you're right. I really want to work and I'm so desperate to avoid bad conditions and moving around lots that pay is very low down on my agenda... DH is really, really supportive of my career but ultimately he earns much more than I do and really does need to travel for this.

@GingerPanda I'd love to message you, very kind.

@JennieTheZebra Glad to hear it's changing! Many of our nurses come from a hospital less than 20 minutes away but are not allowed to take bloods or cannulate.

Off topic but I just had this conversation, do FY1s do nights now ? I thought that had been stopped around 10 years ago ?

Yes medicine is brutal that's why the junior doctors deserve a decent wage.

Exactly. We really don't have the options people think we do. I put up with it when I was in my early 20s and basically gave all of my time to F1 and F2. Now it's different and I have to prioritise my family. We don't have many options in where we work or who we work for but people do seem to forget we actually do have the option to leave and do something else. No idea why people assume that I knew what I was getting into and have to lump it. I didn't and I don't. It's just sad because I like my job and I'm good at it and try really, really, really hard for my patients who are often over looked and stigmatised.

My first ever shift as a doctor was a night shift!! It slightly varies hospital by hospital, but most FY1s will be doing nights. And often almost completely unsupported in change of up to 100 inpatients.

Some places don't have F1s on nights but they certainly still do in the departments I worked in. I spent my F1 nights covering specialties I didn't work in in the day (and surgical specialties at that with seniors who were either off site or in theatre). It was brutal and not that long ago.

£23 ph is appalling!

I think this is awful OP. We need good doctors to stay in the NHS.