Foundation Training - medicine

[Feelingblue77]

https://www.bbc.com/news/health-68849847.amp

I saw this article today and as a parent of a 3rd year medic it’s quite worrying.

it sounds like places will be found for everyone in the end but I just wondered if anyone had any experience of this?

It is UCAT. The UKCAT name was replaced back in 2019. You seem very confident regarding the relative value PAs and yet have only had a rapid perusal of the various entry criteria for the courses with 100% success stats. The role is very different in the US.

@Saschka I am in contact with many many colleagues across the country as well as internationally due to my role in a tertiary centre with a large number of SpRs. I hear the difficulties from understaffing in many UK DGHs and they are open to having PAs.

@knitnerd90‘s post provides further information on the PA role in the USA, which is more extensive than in the UK.

Apologies for my typo regarding UCAT. For the record again I am not involved in training or recruiting PAs

My trust awards additional payments for managment responsibilities. I don't do any private work but there are waiting list payments (£500/PA).

In answer to why they are expanding medical school places without expanding training posts I don't know what the government is actually thinking but my assumption is that they do not actually want all the medical students to progress to consultant as this would be far too expensive.

Traditionally medicine has functioned off the back of 'middle grade Drs' who do a lot of the grunt work. These are registrar and 'staff grade' Drs. Staff grade is a non training approx registrar level job from which you cannot (usually) progress to consultant. Every hospital has a lot of these Drs providing experience and continuity whilst people in training jobs come and go. Women and IMGs were traditionally a lot of these. I have always assumed that the reason training is so crappily organised and has bottlenecks despite an apparent undersupply of Drs is to push people out into staff grade jobs. That is certainly often the effect.

Foundation doctors require a lot of training and supervision and are a future investment rather than current value for money. About senior SHO level and certainly registrar js where Drs can practice sufficiently independently to be better than a B7/8 specialist nurse. Up to that level I am afraid to say that probably other professionals could do the job (this is what nurses usually think if you ask them).

The other reason medical consultants are paid more than other professionals is the level of risk and responsibility. It is a given that the buck stops with the consultant who is responsible for the performance of their team and their service as well as themselves. Specialist nurses, junior Drs, staff grades and presumably PAs are usually only responsible for their own practice.

I have no idea about today's PA roles and their value. I have only ever worked with the very limited phlebotomist type ones a decade ago but I do work a lot with specialist band 7 and 8 nurses who are prescribers. The advantage a Dr has over them is the theoretical background and breadth of knowledge. A specialist nurse can be amazing in her or his area but gets stuck when stuff crosses boundaries or is atypical. They usually are very careful on the limits of their practice too.

I think I am value for money and that I do something that no-one else can substitute but I would say that I guess. I can diagnose difficult stuff correctly including when it is not in my specialty area or at least recognise 'this is not one of mine', I can take a risk on off label prescribing or a bespoke management plan where more junior people have to stick to the rules (I usually do stick to the rules but I know when not to) and I lead and manage my whole team including training and supervision of more junior people and step up to take the flack when shit hits the fan.

BTW I don't earn 180k or anything like it and never will. I think I make about 110k 20 years after qualifying but I have worked part time for some of that and I don't do private work or apply for CEAs. Fine if others want to but it's not for me. I am not mainly in it for the money.

I do believe I've read that there is a deliberate bottleneck to keep doctors from progressing to consultant, and since consultants can make money privately, they have a vested interest in controlling their numbers. In fact, my own GP here in the USA is originally from India and worked in the NHS before coming here.

At the recent deanery training event I went to there was talk of 'multidisciplinary training' sessions for junior Drs, PAs and pharmacists (who are also gunning for extended roles now) which seems to me a pretty overt agreement that at junior levels these roles are being seen as much more interchangeable than they were in the past.

Maybe we will stop training a surplus of Drs to stay in middle grade roles and substitute those with other professionals. In a way perhaps that is more honest than pretending everyone who graduates from medical school has a shot to be a consultant (or GP partner) which I think has actually never been true. I don't know the factors associated with progression to consultant but I suspect gender, ethnicity, country of origin and class will have more to do with it than straight aptitude

@sendsummer I’ve read that comment back and it was much more flippant and lighthearted in my head than it reads on the page - apologies for that, I was not intending to be insulting. I should have added a 😜emoji.

I agree with you, I nearly stayed in such a position myself following the MMC debacle and for geographical stability . I was lucky that I had an amazing mentor who really encouraged me to re-apply for training. I am white and UK trained I am sure when she looked at me she " saw herself" although I am not massively privileged, went to state school ( perhaps why I am such a striver). I did have an amazing DM who stepped into the childcare breach many times over the years, couldn't have done it without that.

Now I am in the management structure it is nearly completely dominated by "people like me" although some of them are male and nearly all the bosses above me are. The NHS is certainly not perfect and I may well be overpaid (although I do work hard and have a somewhat niche skill set) but I don't think a PA has that potential.

Good luck to all your DCs.

I think the current junior doctors have no aspiration further than having a job next year. Consultant ? Never in most cases. Not in the UK. Lots will now be unemployed.

I still fail to understand how a PA is more useful than an F1. F1 trained to be a doctor for 5 years, loads of clinical training. PA has minimal theory and even less clinical, needs more supervision (as they are legally supposed to be supervised at all times) but lazy people who don't want to train their future doctors train them instead. While the lucky doctors get to be ward monkeys. Until 5pm. When they get left to look after 100s of patients as the PA goes home, often the consultant goes home and the junior doctors are left - suddenly they seem to become much more competent and important.

You won't see a PA at 2am when needing something, but you will see the F1.

Any consultant not supporting junior doctors and using PAs to replace them should be ashamed. Talk about pulling up the ladder. Who trained you ? The consultants of the past. Your one job was to do the same for following generations, but instead they train the non rotating staff because it's easier and they have to do less work. Shameful and v v sad.

I think the current junior doctors have no aspiration further than having a job next year. Consultant ? Never in most cases. Not in the UK. Lots will now be unemployed.

mumsneedwine you’re certainly not speaking for my DS’s peer group in London. This is a combination of university friends as well as friends made during rotations over the past five years. Over the past eighteen months they’ve all been sitting the various registrar exams and now the ones who passed the last stage have just been putting in for specialty registrar training for the next four years and many seem to have got that too, although not always top choice of location. I also know that DS was helped with his latest application by no less than four consultants each of whom offered interview practice (which he says was key: he didn’t drop a single mark at interview). He also mentioned that he was helping someone younger prepare her own application for core training/ F3&4/ whatever it’s called. The goodwill and mutual support is very evident indeed in the world that DS moves in, or else he just happens to have a uniquely generous set of senior colleagues.

@Karolinska there are obviously some who will be able to progress after F2. And your DS aced the exam.

But many have no job for August despite applying for many trust jobs. Locums are non existent in some places. So what do those 3:4 who didn't get a training post do. They are trying to!!!

And the landscape has changed this year. The bottom has fallen out of the F3 year.

Thank you to all the contributors on this thread. It has been really informative.

I wonder if our current F1s understand their likely career path, and whether that is behind their current frustration. They see PAs arriving, soaking up some of the training/mentoring and establishing themselves as experts within some of the specialities, at least more expert than those on 4 month rotations. Whilst they work longs and nights and weekends for less money, perhaps returning home to a quickly found grotty flat with no social support. And wonder what they are investing this sacrifice in.

It’s not just hours. Many consultants see F1s in specialist areas where short term staff are less useful. DDs F1 has been 2x general medicine and 1x general surgery. General really does mean general. Very deprived area. Intake via A&E from care homes, the pub, anywhere. Five expected deaths on her first night shift. Lots of basic questions: is it psych, is it real. Patients in for day surgery, prostate perhaps, but with a bunch of co-morbiditys and a bagful of pills. Plenty of very sick patients, and, during nights, weekends and longs, low staffing levels. One night there was no registrar. Clerical error, sickness, who knows. The 70 year old consultant stayed until after pub closing time, then left an F2 and two newish F1s as the only doctors in the hospital telling them to phone her if they had to.

DD phoned yesterday afternoon. She was clearly exhausted after an unusually busy weekend and one colleague down. She had allocated her day off to completing some required training before a deadline. Training they are apparently supposed to undertake during quiet periods on the ward. Yeah? Staff shortages that weekend mean no time to pee or eat, let alone log on to a training portal. Unfortunately she had found herself locked out of the system, and four hours later was still waiting for the IT guys to get back. Time off had already been punctuated by calls from the coroner and other stuff. She wanted the next day for herself. (She decided on a polite email to the course director. It’s the NHS. Make sure you have a paper trail.)

F1s are intelligent educated and young. Most can cope. But there has to be a reason why they are doing it.

DD observed her fellow medical school graduates splitting into two rough groups. Some, often those from non medical backgrounds, who see becoming a doctor as the achievement, but who then wonder whether they might be earning more working nights in Tesco, and why they are not receiving the professional rewards: house, nice car, and so on. Indeed will there even be a job at the end of F2, or will a PA have replaced the previous junior doctor role. The other group, perhaps with consultant parents or from high achieving schools, know they are just at the beginning of the road. Except the road ahead seems to be disappearing. Some will make it, but the cost is high. Random geographical location at F1. Another move for a suitable F3. Head down to pass exams to land a competitive training slot, possibly somewhere else altogether and then more exams and possibly another move for a Registrar position.

It is frustrating that junior doctor strikes are portrayed as being about money. I don’t know if this is their leaders, or if it is the media. The issues are much bigger.

@mumsneedwine you are so off the mark with accusations of laziness and lack of good will to juniors by consultants it is actually offensive. In most cases it is about survival whilst trying to maintain an at least half decent service. Consultants don’t get paid time allocated to teaching but they obviously want to mentor the next generation to be the best possible doctors, it is in all our interests. You also forget how many hours consultants have already put in before getting to that stage and ignore all the rubbish and difficult decisions they have to deal with that juniors will have no idea of.
I get that you are worried for your DD but no need to be too alarmist as the situation is nothing new. It does require hard work (beyond what some think they are capable of) to jump through all the hoops needed plus some flexibility.

Karolinska, I think your DS' peers may be part of of a relatively small cohort, dubbed by others as the "overachievers".

DD was at a well known and high achieving private school who would send around 20 a year to medical school, almost all to Oxbridge or London. One boy in her year decided to to reapply rather than take up a place at Birmingham, whilst teachers had to persuade another that Manchester was "good enough". Though she could keep up DD, perhaps because of her dyslexia, wanted out of the competitive culture so did not take BMAT, only to spot similar types sometimes prioritising personal achievement over their share of group work, at the medical school she went to.

Overachievers took an intercalation (she was one of five from her school taking an intercalation at Imperial) and amassed points where they could, hoping for F1s at London teaching hospitals and good F3s. Bright, hard working, informed and focussed. Almost all will make consultant. DDs medical school friends were equally bright and hard working, often with more empathy and communication skills but largely without the necessary focus. Professional status, house and car, and an interesting, rewarding career were ambition enough.

I assume that random allocation, as well as taking away points for intercalation, is trying to open up something that was starting to look like a fast track for a, largely private or grammar educated, few. Will it work? Is there a cost to making medicine a less attractive career for the very ambitious? We already lose a fair number of high flyers to banking and law.

Also interesting the value of support your DS received whilst working in London teaching hospitals. Will DD receive the same in her deanery where even having worked in London is a rarity? Training places there will also be competitive as many of her very able peers will not want to move, and already have deep community links. Whilst elsewhere she will be up against those with London polish and preparation, where her skills of calming drunks, and finding a vein where none seems to exist, may count for little.

These peers are not just from his uni Needmoresleep, but friends he's made as he's trodden his junior doctor path. Arguably they're achievers - I'd argue against the over bit - although from a reasonable spectrum of backgrounds (the ones whose backgrounds I know that is). I'm aware of one who's disenchanted but that stems from choosing a pathway he now regrets.

I think it's fair to say that Oxford Medicine is a competitive environment though. I recently asked about that and (although he was extremely happy at Oxford) DS said yeah Oxford medics won't just throw you under the bus they'll actively find a bus to throw you under :) And he was clearly on the well liked end of the scale :)

But it's not a job for the boys thing at all and so being bright, hardworking and focussed are all necessary qualities and not the privilege of any one uni or social group. Being informed should come by osmosis as you go through uni and beyond (We only have dead doctors in our family who practised around the turn of the 19th century, so very much not in a position to give DS even out of date advice).

This random system seems to me to run a very high risk of alienating those you call high flyers and there's a strong argument for not doing that, to do with a much wider good and not merely personal wealth and status for that group.

@sendsummer not about my own DD. She can go to America as is one of those over achievers (has an extra degree, presented at conferences, rep for her speciality, done the exam thingy letc). She'll be fine.

But I work with many students who don't have the advantage of being over achievers as couldn't afford to intercalate, do extra research. As they were working to earn money while doing the same studying and passing the same exams as their non working colleagues. Privilege is not a thing to the privileged until someone removes it 🤷‍♀️

ALL the consultants I talk to (& it's a lot as loads do outreach as we are a poor school in London) support their juniors and detest PAs. But the justification that F1s are not as useful as PAs annoys me. Why should I encourage students to become doctors ? Why would they even be allowed to take training places from doctors - because they are m, so some consultants are facilitating it. Why ? Because they claim it's easier and PAs are permanent staff. As if doctors want to rotate !

I am angry. I've sent many many students to do medicine, loads to Oxbridge (because it's cheap), and I feel I've let them down. They thought they'd have a job in this country. Didn't mind where or what. Hearing from them struggling to pay their rent as qualified GPs or F2s struggling to get a job for August is so so sad,

Needmoresleep in fact DS's recent interviews were allocated to a completely different region, not London. He was then ranked nationally and could make his choice of location based on that. And although I completely understand what you say about the deprivation in parts of Belfast, I can only say that those who come into NHS hospitals from Tower Hamlets etc are not the privileged in life. These issues are endemic. But for more generally fortunate patients, maybe don't touch London.

mumsneedwine if my DS can go through med school with no parental financial help and no savings then I'm not clear what the material difference in circumstances between your students and DS - who did early shifts in an Oxford cafe - is. Especially the 'loads' that you've sent to Oxbridge. Oxford and Cambridge are both very generous with financial support. Tbf he does have a bit of a can do approach to life. Hopefully your students do too.

If it helps, my experience of deaneries outside of London is that the training and experience is far better (more personal, basically).

You do get fewer opportunities for research papers and case reports, just because your supervisors are less likely to be research active. But that isn’t really an issue until ST4+.

@Karolinska my students often live in 2 bedroom flats housing 6-8 people. Some share bedrooms with 4 siblings on the 14th floor with no working lift. They have to work from 14/15 to help the family. Often full time at weekends. The fact they can get AAA is incredible - studying in a cold, crowded, noisy flat.

Once at Uni they still have to work - did you not even pay the rent ?

My ex students get no parental help so have to survive on the loan. Year 1 the £10,000 covers rents and leaves £3000ish to live on - for 52 weeks. No going home to mummy and daddy and if they do they have to contribute to the family income. Years 2-4 slightly easier as rentals go down - they live in the small rooms in houses. Year 5 is a nightmare as they lose the loans and get the bursary, which no one can live on.

I'm good at sourcing grants and bursaries to get them through, but they live on a shoestring. And work every hour. They are amazing humans. We have a fantastic alumni now who are giving back & help a lot.

That Tower Hamlet/Belfast deprivation yours are seeing as doctors. That's my students lives.

And forgot to mention those in care or refugees. Of which we have many.

If you want to see why I am cross please look into care leavers and the total utter lack of support once they turn 18. I have one ex student who is an F2 this year. Spent most of their life in the care system. They've managed to get into medical school, graduate, work v successfully as F1/2 but now can't find a job in an area they can afford to live. No one stumping up the deposit for the rental, no one to guarantee it, no help buying a bed or sofa, no help with living costs (NHS is try). They do it all alone.

Not sure any of my students would have escaped poverty if they did not have that 'can do' attitude. They just did it while cold and often hungry (Marcus Rashford is bit of a hero of mine as he fed, and still does, many of our families).

No I did not pay the rent mumsneedwine. I feel bad about it tbh but DS never asked for anything at all and seemed to manage, just.

I’m not going to enter a competition as to who has more vicarious experience of poverty but do try to take care not to patronise since you don’t know who your audience is.

I say that as the daughter of a refugee who arrived in the UK with one small case of belongings to his name. Possibly DS gets his can do attitude from his grandfather, who always spoke of himself as lucky.