To be so hurt to have been replaced by a Physician's Associate?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

They are increasing medical school places, but this year I think it was 3 out of 4 doctors who applied for specialty training did not get a place. So what will that mean?
The problem is that Junior Doctors at the start especially, need a lot of support, guidance and ongoing training. And who dies it? Higher trained doctors and consultants. How can these have time to give if they are spending clinical time seeing patients other less qualified are perfectly capable of doing just because they want to?

This is why managers are required because many clinicians do struggle to understand economies of scale and benefit optimisation. They only see what they do and want to do, and assume it is the best way. OP herself admits she doesn't understand the system. This is why medical students are now taught about the functioning of the NHS and role of management.

It doesn't make sense to pay more for someone to do a task someone cheaper can undertake whilst patients who require their skills wait longer and longer to be seen.

As said, PA's role is often to assess symptoms, review benefits or detriments of the drug regime they are on. Do general checks, consider social needs, gather all information a consultant needs to decide on treatment. PAs with experience can then start to come up with options, follow treatment pathways because for some patients, it will be the same for a large group of patients they see.

I see your point, but did you see my post up thread about what an assistant could do that would really free up doctor’s time?

My own experience with PAs is that they took up valuable consultant training time that I myself would desperately have wanted. Could we not have junior doctors in clinics taking the less complex patients, having vital learning experiences discussing patients with the consultant before and after? What does having a PA in that situation gain vs a junior doctor? They were also often in theatre assisting, while I was left on the ward because I was the only one who could prescribe (which is rather essential when you’re the only doctor for the afternoon post ward round!)

Having children frequently changes how we're able to do our jobs, in all kinds of fields. I entered a career with significant foreign travel as part of it. I couldn't do that with kids, it just wasn't possible.

I was able to side step into a slightly different role, but plenty in my industry weren't and ended up falling out of that career or retraining in something else. It's not unusual at all.

I miss what I used to do - I loved it - but it's simply not possible with different commitments. 🤷‍♀️

Waiting at 24 is one thing - getting into your early/mid/late 30s and waiting is very different (again, speaking as somebody juggling medical training, albeit in a non-on call specialty alongside ivf)
I totally agree. There's also a difference between deciding to have a child in your late 20s and early early 40s.

Also, many female doctors manage both. Some are even pregnant before finishing medical school! Those with children do get priority in where they are located. Even males whose partner is pregnant. It can be done but with a level of sacrifices that are above what most professions require/expect. That however comes with the choice of career.

Can you do both? Yes. Can you do both easily? No. Can you do both whilst you prioritise you role as a mum and still get the same opportunities? Rarely, unless you are extremely lucky.

Lack of flexible childcare is a massive issue for HCPs. I'm a nurse and am a single mum to my little one. I can't do shift work as early shifts start at 7am, late shifts finish at 9/10pm and there are weekends as well. Neither can I do community as they expect me to do 1 in 3 weekends, which I would be happy to do if there was childcare available. So presently, I'm doing vaccination shifts on the nurse bank, however when these are no longer available (they peak in winter and tail off at the start of the year) then I don't know what I'll do.

What an absolute shame that we're losing knowledgeable, experienced healthcare professionals due to how family unfriendly the NHS is.

What does having a PA in that situation gain vs a junior doctor?
Some areas, they can't even get the junior doctors. Junior doctors also need a lot of support. Many consultants complain that the just graduate ones are more hard work than many HCAs! Top qualifying doctors go to the top Trusts, so there is a big difference between top graduates and those who just scrap by and where each pick to go in terms of skills, confidence, independence etc...

Another issue is that when you invest your time and money in Junior Doctors, you do with an expectation that they will look for promotions, so you have to start over and over again, wasting more time and money over the years. Band 7 staff are much more likely to remain in their role for much longer so training them is more cost and time efficient.

They are also under Agenda for Change so more time to spend in clinics specifically. Junior doctors need time to further their studies, dedicate time for training to meet the requirements of promotions etc... They can also be fetter used to do evening, nights and weekend shifts.

And more reasons but these are the nain ones.

I’m afraid I don’t understand your point about “not enough junior doctors” when there is so much competition for specialty training, resulting in doctors having to take consecutive F3 years.

Your other point seems to be the fact that we’re rotational. We hate this too. It is not a choice. If rotating is cost ineffective then why make junior doctors do it? You can’t on one hand say it’s essential, and on the other say it’s so bad that it means we’re replacing you with PAs.

I also don’t understand your point on “top doctors”. Are you saying that an average PA is better than a doctor who didn’t get into the top deanery? I would contest that strongly. (And I don’t have a chip here. I personally got into my first choice - and nationally most competitive - deanery).

There is also a sexist stereotypical assumption made here that female doctors are (or should be?) main carers. It's actually more and more the case that their partners become at least half if not mainly the carers for the children.

That's how many female doctors make it work. One of my closest friend is a doctor and married to one. They have 3 children and always shared everything 50/50 with the help when required of a nanny.

This is why managers are required because many clinicians do struggle to understand economies of scale and benefit optimisation. They only see what they do and want to do, and assume it is the best way. OP herself admits she doesn't understand the system. This is why medical students are now taught about the functioning of the NHS and role of management.

It’s not that they don’t understand, it’s that they know what their patients need, which the managers may not understand or be able to fund.

OP is not saying she literally doesn’t understand the system - but that the system makes no sense and is poorly considered.

One of my best friends retrained as a doctor having done a first degree in science and gone into management consulting

She was sent off to the NHS in the north for consulting work and her conclusion was that a. If you call in management consultants they will tell you to employ managers regardless of whether they are necessary and b. The NHS needs more doctors and fewer managers. So she retrained as a doctor and is now a psychiatrist.

PAs are a short term stopgap , not insured , no professional body to oversee standards and fitness to practice. The NHS is shooting itself in the foot by failing to invest in doctors. We don't need more med school places we need more training places

I’m afraid I don’t understand your point about “not enough junior doctors” when there is so much competition for specialty training, resulting in doctors having to take consecutive F3 years
Because some disciplines and deaneries are very popular, others are not at all and indeed struggle. Try to get maxillofacial junior doctors in a non specialist trust....

I also don’t understand your point on “top doctors”. Are you saying that an average PA is better than a doctor who didn’t get into the top deanery
You are right to put this in parenthesis as it does come across as a general statement the way I put it and that's not correct but yes, I heard often enough from consultants that less popular deanaries attract new junior doctors that require more supervision and that some require more support than their more experienced PAs.

I don’t know where in the country you’re familiar with but I don’t know anywhere where being a parent allows you to be prioritised for location.

At medical school yes, potentially for foundation but for the vast majority of us there is no choice. This is additionally challenging for medical couples - you can link applications for foundation but once you’re into specialty training there’s no such provision. I’m lucky enough to live in a small deanery where you can commute to pretty much everywhere within an hour/hour and a half. Thankfully DH is also training (on a different programme) in the same deanery. As we’re both in run through training we have the security of being able to stay on the same place for at least 5 years - the next hurdle will be trying to find consultant jobs in the same area but we’ll cross that bridge.

I have colleagues who are expected to rotate around deaneries that have 3+ hour commutes who are married to doctors in the same deanery who are given contrasting rotations. If you cannot get onto a local training scheme then your partner may not necessarily be able to transfer - although parental responsibilities are an acceptable reason (if classed as ‘unforeseen’ which can be difficult to argue) to request a deanery transfer nobody has to accept you if there aren’t spaces. I have a colleague who’s husband got a training job 4 hours away from where they currently lived. It took the wife 3 years to get a deanery transfer to the same location.

As the NHS is a monopoly employer they have you over a barrel. If the husband above had turned down that training job it would be a mark against him the next cycle and he may not get another. If the wife had resigned to move she’d have given up her training number and almost certainly would not be allowed back into that training scheme. If she wanted to stay training in the specialty she’d already spent years in then the only option was to live apart and wait.
You can only apply via the national system at certain parts of the year. The lack of control and flexibility over rotational training is one of the big factors pushing people away from medicine.

I’m not stupid - I knew medicine wasn’t going to be family friendly, I knew it was going to be hard work and involve out of hours work etc. I never minded working out of hours (in fact I preferred some of the OOH work to standard days in quite a few jobs) but I didn’t appreciate at 17 how constantly being treated as nothing but a number on a rota, no compassion for you as a human being and just how toxic and resentful the NHS is to staff with absolutely no alternative employer would be. I never thought about not being granted time off to go to family funerals. I never thought that conditions would deteriorate so much that I’d be working to my absolute limit and still providing shit care. I never thought I’d start most consultations with an apology for something beyond my control. I never thought the pay would decline so quickly that I’d be worse off than the doctors I was shadowing on work experience/at medical school undermining my ability to pay for childcare. If I had my time again I wouldn’t do it and I sure as hell wouldn’t encourage anybody to become a doctor in the UK now. The NHS has already wanted me to sacrifice my mental and physical health, it’s not having my fertility too.

OP is not saying she literally doesn’t understand the system - but that the system makes no sense and is poorly considered
And that is not understanding it if it doesn't make sense to her. That's what I'm trying to explain. Of course managers also don't understand the need of patients and that's why managers AND clinicians working together and respecting eachother roles make the most effective decisions.

@PlusThyme and @Salacia I’m really grateful for your comments on this thread.

@vivainsomnia I can understand on paper why PAs are attractive. However, there’s a lot of assumptions that doctors will stay, see the complex patients and do the OOH work. We won’t, as this thread shows. We’re not just numbers, we are real people with real families and egos (dare I say it) and wants and needs and priorities beyond our jobs. All being equal, I can see the attraction of PAs. When comparing two people who want to work the same hours in the same role, no, I can’t understand choosing the PA.

At medical school yes, potentially for foundation but for the vast majority of us there is no choice
This is what I said. I was referring to those who have children whilst still in med school.

And yes, it is hard afterwards, but again, what about male doctors with families? Maybe they have career minded wives who are also not keen to follow.

And no, it's not just Medicine. My sister and partner are both in Post Doc Research. Different disciplines. They are in their 30s and still only had 2 years placements top and waiting to be offered permanent roles. They are currently in 2 different continents. Both have dedicated all their time to finally get to that position. They have to discuss what will happen when they become a family and one will have to follow the other unless they are extremely lucky somehow.

Ah I lost a long post.

YANBU to feel hurt that a lower qualified person who can do less in fewer hours has been brought in to replace you on more pay.

YANBU to feel hurt that your skills, training and commitment to your job and patients are not valued.

I am sorry you were sold a lie at 17, that you could have it all and that you would share you life opportunities equally with the father of your children.

I wish we could compare the lifetime earnings of women and men, coming out of school with equal grades and see what the real effect of the sex pay gap looks like taking into account gaps in employment due to childbearing and caring, preferential treatment of men when it comes to remuneration for work, promotions, investment. We cannot blame it all on choices.. not all choices are made freely and not all are made with full understanding of the long term consequences.

Anyone else think there is some inherent issue in the fact that since we have seen more women in medicine, the relative salaries in this area have decreased but areas of high salaries are still dominated by men...

Obviously it shouldn’t all fall to the woman in the relationship. Both myself and DH are LTFT and (if the ivf works) will split shared parental leave/childcare etc. But it’s naive to think that woman taking on the majority of childcare and domestic labour isn’t a huge societal issue. It’s not going to change overnight and we need to support women in the thick of it now.

The other argument with doctors have coped in the past is that pay has not kept up with the cost of living. There’s no way we could afford a nanny for example like the example above. Rotational training also moves you away from families/local support systems further depriving you of options for childcare.

@ChateauMargaux I have often thought that re: your point on respect and pay following men and disappearing once a job becomes female dominated.

People used to respect GPs. Now I often hear comments about how anyone could be a GP, GP didn’t do XYZ and just googled something, GPs are massively overpaid. I never, ever hear the same about orthopaedic surgeons. I wonder why…

As said, PA's role is often to assess symptoms, review benefits or detriments of the drug regime they are on. Do general checks, consider social needs, gather all information a consultant needs to decide on treatment. PAs with experience can then start to come up with options, follow treatment pathways because for some patients, it will be the same for a large group of patients they see.

But the PAs I’ve had contact with at my elderly parents’ practice have failed to: a. identify varicose eczema, b. failed to give the accurate drug advice in a case of hypertensive crisis and c. failed to identify an allergic reaction to medication (red rash across the torso - no it’s not sunburn in November). Just in the last few months.

Luckily I’m relatively experienced with elderly people and these betises were identified by me and appropriate action taken.

From which I conclude that the PA training is woefully and dangerously inadequate for the role they are being given.

However, there’s a lot of assumptions that doctors will stay, see the complex patients and do the OOH work
I think research have shown that the majority of junior doctors aspire to a consultancy role or at least progress beyond a F1/F2 post.

Very honestly, if you could go back, would you consider studying for a PA role instead of medicine if ultimately, you are happy at that level that allows you to dedicate more time to your family?

You say you are happy with your current low salary (although I assume you do get extra or are much PT for what you are on). Most who have gone to med school, are left with huge students loans (not all have mum and dad's able to pay it) would not be at all happy with this income by the time they are 30, let alone 40 and more.

I aspired to be a consultant. I’d say everyone who entered medical school does. That doesn’t mean they’re willing to put up with all the crap that comes their way when push comes to shove.

A lot has changed in the past 5-10 years, and I don’t think we can extrapolate that because most doctors in the past became consultants that the juniors of today will do so. They are already leaving medicine or emigrating.

Well no it may simply be that the system is naive, illogical, flawed and poorly considered.

Thunderstorms = clouds banging their heads may make sense to children.
It makes no sense to scientists.

But it’s naive to think that woman taking on the majority of childcare and domestic labour isn’t a huge societal issue
It isn't in medicine or indeed research. It's made clear before starting studies the impact this career path has on family/social life.

It used to be more common that the very clever, upper middle class plus were just expected and selected to consider medicine. This has changed a lot and more and more efforts is being made to attract from minority groups.

Women going into medicine have the same options as men. Putting having children on hold for a while, not being as present as they'd like in the early life of their children if having them earlier or downgrading their expectations. Men are more and more wanting to spend more time with their kids from birth. Why should female doctors get preferable treatment?

Women absolutely do NOT have the option of putting children on hold in the same way that men do. A man can father a child at 40, a woman may very well struggle over 35. If you want to have more than one child then you’re really pushing your luck as a woman to wait until consultancy.

I would support a male doctor who is the main care giver to their children in exactly the same way as I would support a female doctor. Can you clarify what you mean re: female doctors getting preferential treatment?

I have to go, but I would say that I think there is a place for PAs but with far better defined role, far more training and drastically reduced function.

Good luck OP, I hope you find an alternative role that suits you.