To be so hurt to have been replaced by a Physician's Associate?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

You have misunderstood my meaning. The poster you originally responded to often pops up on threads to stir the pot so to speak. She's trying to get a rise out of several posters on this particular thread.

Sorry! Totally my fault. I did think that came from nowhere 😂

The thing is, and not to downplay the difficulties that junior doctors have generally as they really do have it rough, but PAs really can’t do the job of a junior doctor, especially in psychiatry. Unlike in general medicine where there’s lots of competent adult nurses/ANPs/ACPs to pick up on things that might be missed, psychiatric wards are staffed with MH nurses who do very little physical health care and are not that confident recognising rare physical presentations, myself included. I need a doctor to tell me whether something that looks like psychosis could actually be a brain tumour due to a specific type of eyelid twitching, for example. A PA can’t do that as they haven’t studied to do that.

You're not being unreasonable at all. I share your concerns. I'm a consultant psychiatrist and had my first child during training. Currently on ML with my second.

I would gently encourage you to explore going back into training though - I totally empathise with the difficulties in out of hours work and doing exams (my DH works away a lot) but personally I found training to be reasonably flexible and I was able to go LTFT and choose my days with minimal fuss. At 80% your pay isn't reduced too much and you get a consistent day off. After I had my DD I was clear that to keep me in training I would need rotations within a 50min commute of her nursery and I was accommodated. There are also some rotations even at CT2 and 3 which have non residential or partial shift out of hours patterns which can make it a lot more straightforward to organise life. Totally appreciate if you're not there at the moment though.

Are there no SAS posts available in other units near where you live? I know that where I am a SAS Dr with your experience would still be snapped up, even with the infiltration of PAs into some rotas. I'm really sorry you've found yourself in this position

Have checked NHS Scotland and there are 0 vacancies for physician associates. So that's good news. Hopefully it's deemed an ill thought out idea in the rest of the UK soon. Would sooner speak with a medical professional.

Or they’ve already been filled…?

Thanks @JennieTheZebra. I'm not sure if some of the meaning of my post is being lost as not everyone knows the reality of what junior doctors do in inpatient psychiatry. It's essential to have someone OOH who can detain if necessary and it's essential to have someone who can prescribe rapid tranquillisation. Also agree about the physical health element and this is why I've gone on about that particular role of mine a bit. Psychiatric hospitals are not like general hospitals and it's very important to have staff who can bridge that gap. Maybe a PA can, I don't know, but I'm not sure they can do it better than I can, particularly when I've been looking after some of these patients and their complex needs for years.

That's really helpful and kind @Scaraben. Perhaps this is a bit of a sign I should look into training properly. I haven't heard great things about my trust sadly when it comes to core training. No SAS posts. Very few jobs it seems in general! I was really lucky with my stint I guess, I was just really led to believe it would lead to a formalised job offer and feel really strung along. The consultants I work with have kindly invested a lot of time in teaching me and I felt I'd be in a really good position to apply to core training in a few years.

I am not aware of any in Scotland but stand to be corrected of course....

@prawncocktailskips As a fellow doctor, I hear you. I've had several colleagues in similar situations and it's so frustrating.

You may have considered this already, but have you explored options for doing the training programme flexibly/part-time? Trainees can work LTFT and it might be a way to get a bit more stability and job security? Depending on where you are and what other commitments you and your family have, of course.

A good speciality/staff-grade doctor or clinical fellow with experience in psychiatry can be a very valuable resource for a clinical team, so I'm surprised that your employer has made the decision to go with what sounds like the less cost- and resource-effective option. I suspect there'll be other mental health teams that would be glad to have you on board if they don't!

I'd suggest speaking with the BMA, too. They may not be able to do much as it's a locum post, but if nothing else it lets them know what's going on.

I have read about one scooping an award whilst working at the Golden Jubilee in Glasgow so they are out there.... just not in abundance like other parts of the UK.

@Scirocco I'm not sure how much my employer has really had to do with it to be honest. I've been working with 2-3 consultants who have managed all my shifts and repeatedly asked higher up for a full time post. I've never met 'higher up'. I've probably been really naive about it all. But I guess I've lost nothing as it's been good for the past few years. I just really, really can't get my head around how this all works and who thought a PA would be better.

Yes I've thought about LTFT training but still unsure how I'd make the OOH work with my husband's job currently. I guess we need to sit down and have a proper talk about it all. Just more pressingly than I previously thought. I've been down on medicine for a while though and this just makes me want to leave completely. I can't bear to go back into the realities of exams and night shifts and never getting my annual leave and rotating around and always being new ... It's been really wonderful working longterm with the same team and having people know my name rather than being 'doctor!'. This is why I get particularly annoyed when everyone gets excited about PAs as they don't rotate. I wish we didn't! In pretty much every F1/2 rotation I did I was working on at least 3 different wards and rarely worked with the same team twice. Do people think we actually enjoy that? I had one job where I worked on three different totally unrelated specialties (one on days, one on weekends and one on nights)! Totally unrelated but just having a little rant now

Just to add - I'm a GP who ended up in GP because I couldn't face the thought of another 5 years training in my first choice specialty. I'm now working in a bit of a niche GP role within that specialty, and not doing any "traditional" GP at all. I have certainly seen adverts for similar roles for GPs within psychiatry. The benefit here is enormous flexibility once you complete comparatively short training (assuming you're meeting the requirements for GP appraisal and revalidation).

If you were to consider that route, there are some training programs that offer 24 months of GP (so only 12 months in secondary care). LTFT training is easy to get. Good luck, whatever you end up choosing!

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!
The way it works in my hospital is that the doctor will see the patient in outpatient, so will get to know them and the issue. The follow-ups will be undertaken by the PAs. There is normally a 1/2h joint meeting before the start of clinic to briefly discuss patients and likely events. There is then another team meeting after clinics to review each decision, intention, future appointment etc... The whole process has saved the doctor about 6 hours to focus on more complex patients. They will always attend MDTs, undertake investigations, do research, teach etc...

Reviews very often consist of discussion on how treatment is going. Whether it is working, not, nit as it should, side effects etc...all this information is gathered by the PA and shared with the consultant, and together, or at MDT, the doctor suggest another course of treatment.

If this is not how it works, then the protocols are not being followed up as they should.

Out of interest @PlusThyme what job do you do now? (Fellow (potentially ex-) medic)

I’ve no idea I’m English. But a Scottish PA was awarded PA of the year so there must be some roll out somewhere.

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
But it's not just about what doctors want to do but what works best for the NHS. Doctors do currently find themselves doing things that other qualified people can do cheaper and where there is more available workforce. It is much easier to replace a PA than a qualified doctor.

I do apologise for my comment about children, I do appreciate that it is not all about choice of timing, but ultimately, going into Medical Studies is accepting that you're taking a pathway that involves your career being a significant focus of your life if not the main. This is why I understand interviews are so intense as it's not about picking just the cleverest students, but those who have big ambitions and a full understanding of the sacrifices they might have to make.

It does come across that ultimately, you'd be happier with a PA role rather doctor/consultant. Is it something you could consider?

@Moraxella I’m currently getting all of my babies out of the way before doing something more permanent. But I’ve been doing some writing - mainly about medicine so I might run out of topics soon…! (The pay per hour is exponentially better than medicine).

I wrote this for the times during Covid:
https://unherd.com/2021/01/inside-the-covid-ward/

If anyone has any suggestions of what to do please do let me know. I think we get a bit blinkered about other jobs in medicine, because it’s so different from the private world and you get into it so young! It can feel very daunting to leave.

Amazingly doctors are the only people forbidden from becoming PAs! It’s a specific exclusion on the PA course.

Apologies if this has already been suggested but have you shared your story with a newspaper? If you can find one to cover your story you could ask them to call for all staff to be funded from the same pot of money by allowing doctors and nurses to be funded by ARRS funds. The 'free labour' that ARRS funding provides is too tempting for hospital trusts. You could start a 10 Downing St petition calling for ARRS funding to include doctors and nurses. I'm currently waiting for one for GPs to be approved by the government and wish I'd included hospital doctors and nurses but can't edit it as far as I know.

😂 Seriously?

@Mirabai - yep! I actually know quite a few doctors who would have considered switching from medicine to PA for the quality of life/no rotations/better pay/no on call/better training which I presume is why…

Yes! I think because they know many of us would do it 😂

Yep with a quick Google search I spotted an article about one at the Golden Jube.

and nurses unless they do years of extra training. This means both practice nurses and GPs with become scarcer in General Practice too unless ARRS funding can be used to pay their salaries.

Yep - doctors can't become PAs. Otherwise I'd be the first in line to do my own job with more supervision and more pay

@vivainsomnia thank you for the apology re. the child comment. It's a very hard pill to swallow that having children really does set one so far back. Not sure how any medical school interview at 17/18 could really select for who will be best for the job. Would be curious to hear thoughts. I was a bright eyed and bushy tailed 17 year old who wanted to change the world. Now I'm an exhausted mother being run down by the NHS who just wants to use the degree I worked so hard to earn without major sacrifice. I really, really, really didn't understand the realities of being a doctor when I applied. No 16 year old gets taken on work experience to shadow the F1. I sat in with a lovely local GP who had come in on his day off to introduce me to some handpicked lovely patients. Night shifts, monopoly employer, exams etc. weren't mentioned. Yes I probably should have done my research but not much I can do about that now! Also, as it's been said in this thread, it's impossible to really understand until you're going through it. I tolerated it far better as an f1 and f2 but I've changed since having my children. I'm (far) more exhausted, more risk averse, far more stressed about getting time off, less time to revise for exams, obvious childcare concerns etc. Perhaps I'm not really meant to be a doctor at all reading this back. I'm not a type A go-getter for sure.