Dr Ian Ellul interviews Professor Dame Clare Gerada, a few days after being awarded a damehood in the 2020 Queen Elizabeth II’s Birthday Honours, for services to General Practice. Based in the UK, Dame Gerada is the first Maltese to attain this prestigious acknowledgement.

YOUR FATHER DR ANTHONY GERADA WAS A FAMILY DOCTOR HAILING FROM ŻEJTUN AND YOUR MOTHER WAS FROM SLIEMA. IN 1948 THEY DECIDED TO VENTURE IN NIGERIA WHERE THEY STAYED FOR 15 YEARS. WHY EMIGRATE, CHOOSING NIGERIA?

During the forties Nigeria was undergoing a period of rapid modernisation. I clearly remember my father stating, “In Nigeria, the Italians build the roads and Malta provided the doctors”. In fact, at that time it was home to approximately ten Maltese doctors. So when my father finished his house jobs in Malta he applied for colonial service and was eventually detailed as medical officer to a large Nigerian community. Now, can you imagine my 20-year-old mother accompanying my father and transitioning from tiny Malta to Nigeria during a period where there was no telephone or no long-haul flights? Really amazing …

IN 1963, WHEN YOU WERE FOUR YEARS OLD, YOUR PARENTS RELOCATED TO PETERBOROUGH. YOUR FATHER SUCCESSFULLY MANAGED TO OPEN SINGLE-HANDEDLY A GENERAL PRACTICE, MAKING INROADS AMONGST THE NUMEROUS ITALIAN IMMIGRANTS. WHY MOVE OUT OF NIGERIA AND GO TO PETERBOROUGH?

In the sixties Nigeria started becoming dangerous because of civil unrest. This was more so for the expat community. So, in 1963, before the civil war broke out, my father decided to move to the UK. Nonetheless, those were challenging times for our family since we were not well-accepted as immigrants. We tried to get accommodation in Liverpool but did not manage, possibly because of our large family of six – I had three Dr Ian Ellul interviews Professor Dame Clare Gerada, a few days after being awarded a damehood in the 2020 Queen Elizabeth II’s Birthday Honours, for services to General Practice. Based in the UK, Dame Gerada is the first Maltese to attain this prestigious acknowledgement. A Trailblazing Ball-breaker in the UK siblings – and the fact that we had a foreign-sounding name. However, Peterborough worked well since it was home to the largest Italian community in the UK. My father was fluent in Italian and the Italians did not speak English. Eventually he convinced Dr Joe Pace, today still living in Sliema, as his partner. Later on, the Gerada and Pace General Practice enrolled Dr Ray Zerafa, also a Maltese doctor.

DID YOU SPECIALISE IN PSYCHIATRY BECAUSE OF THESE LIFE EVENTS? I REMEMBER INTERVIEWING PROF. MAURICE CAUCHI, A RETIRED PROFESSOR OF PATHOLOGY BASED IN AUSTRALIA, WHERE HE DISCUSSED THE PSYCHOSOCIAL ADVERSITY OF IMMIGRANTS.

I always considered myself as an immigrant. I clearly remember my father saying that, as an immigrant, one must work much harder to achieve the same things and also, that one should give something back to the country which adopted you. After I graduated from medical school, the natural thing for me to do was to join my father’s general practice and become Gerada & Gerada since I would not have needed to do additional training. However, I decided to go to London to train in various areas, even though I knew that I wanted to become a GP. I believe that my father would have been disappointed if I simply joined his practice since he always wanted me to achieve something under my own steam. Between my surgical shifts I used to visit the library and read about Freud in the Journal of Psychiatry. This interest branched into the area of schizophrenia (as there were lots of articles about this illness in the journal). So I decided to study psychiatry and got into the Maudsley hospital because, to be blunt, I wanted to learn more about Freud and schizophrenia. There I met Dr David Cassar, who became a friend of mine, and also my husband-to-be Simon Charles Wessely. I eventually attained my postgraduate exam in psychiatry but afterwards I turned to general practice. This stemmed from the fact that during my training in London I came to realise that I loved every area in medicine. This reaffirmed my conviction that I was a generalist and that my heart was set on general practice.

LIVING YOUR CHILDHOOD DURING POSTWAR BRITAIN MUST HAVE BEEN CHALLENGING. DO YOU BELIEVE THAT YOUR SOCIALIST VIEWS HAVE BEEN SEEDED DURING THAT PERIOD?

Definitely. I used to accompany my father on his medical visits to postwar slums in Peterborough where I saw poverty first-hand … barefoot and hungry children, fifteen children living in two rooms, homes without any inside lavatory, the list goes on. If I close my eyes I can still see them today. Further to this, my school was in a community that at the time included many very poor families which meant that many children who attended there were deprived. In keeping with all this, I knew that I was privileged; my father constantly conveyed the message that I needed to give something back to the community where I belong. This, I remember him saying, starts from being a good observer and listener.

YOU ARE MEDICAL DIRECTOR OF PRACTITIONER HEALTH WHICH IS A NHS SERVICE FOR DOCTORS AND DENTISTS WITH MENTAL ILLNESS AND ADDICTION PROBLEMS. THIS PRACTICE TRACES ITS ORIGINS TO A 2007 WHITE PAPER DRAWN AFTER DR DAKSHA EMSON, A 34-YEAR OLD UK-BASED PSYCHIATRIST WHO SUFFERED FROM BIPOLAR AFFECTIVE DISORDER, COMMITTED SUICIDE AFTER STABBING AND SETTING HERSELF AND HER THREEMONTH BABY ON FIRE IN 2000. WHAT MAKES YOU SO PASSIONATE ABOUT YOUR WORK?

As you correctly said, both mother and daughter died because the mother felt too ashamed to get help through normal routes. She did have access to support but her psychiatrist retired and she could not open up to the new psychiatrist since he was a college friend of hers. Other healthcare professionals told her, “You are a psychiatrist, you know what you should do”. This is, of course, untrue since she was having post-natal psychosis … and she killed herself. Every time I hear about doctors killing themselves, I ask myself what would have happened if only that doctor came to my service! I won the contract for services in 2008. Anybody who works for me should have what we call ‘it’ … putting your metaphoric arms around doctors who took considerable courage to come out and seek help … to make them better in a patientcentric setting. In hindsight I can confidently say that general practice was my calling but later on in life the calling was to look after my own kind.

YOU WERE CHAIR OF THE RCGP BETWEEN 2011 AND 2013. WHAT WAS YOUR LEGACY?

I must start by stating that I have always regretted the fact that my father, who was severely demented, never comprehended the fact that I had risen through the ranks and been elected head of the profession. He would have been so proud! At the helm of RCGP I faced an unpopular piece of legislation, the 2012 Health and Social Care Bill. No-one seemed to want to rock the boat but I decided to speak out and highlight its flaws – many years later I was proven right. I believe that my legacy was also to take the college to the modern era by stepping up the engagement with its members. This has been reflected by a surge in memberships during my stewardship. This was complemented with public engagement; I was all over the media answering questions and conveying the role of the RCGP to the general public. I also contributed to shatter the glass ceiling, through merit, when I became the college’s first female chairperson for 55 years. I believe that this has helped motivate my two fellow female colleagues to become chairs after my term was up. This, together with my other work around the edges, has positioned me as a well-recognised GP amongst peers.

YOU FEEL STRONGLY ON ASSISTED DYING AND ABORTION. HOW DID YOUR PERSONAL EXPERIENCES AND YOUR DECADES OF DISTINGUISHED PRACTICE MOULD YOUR VIEWS?

On assisted dying I am in favour that colleges and medical professions have a neutral view and not use their power to influence people. A recent survey by the British Medical Association has revealed that most doctors either want a change in the law to support assisted dying or want that the Association adopts a neutral position on the matter. I believe that doctors have no more nor less authority than anyone less in coming to a view about assisted dying. Similar to abortion, we would only have more authority if a law is enacted, in that then we would see who is eligible, how it is done, and so on. Taking abortion, I am in favour of persons having a choice over their bodies. It is quite extraordinary that people in Malta do not have access to legal abortion. Abortion has three victims … the mother, father and fetus. However, a woman has a right to her body and her life and should safely access termination of pregnancy. Having said that, ideally one should not get pregnant in the first place and this stems from access to good contraception. I believe that the Maltese Medical Association might be expected to have a position on this matter, even a neutral one, since it is very powerful.

DO YOU BELIEVE THAT, LAW PERMITTING, A PERSON SHOULD PLAN ONE’S INFIRMITY?

I believe that we, me and you, will be the last generation that does not have a choice relating to care during endof-life. My hypothesis is that the next generation will have access to legal assisted dying. Although my views on a living will are personal and private, I do believe that the medical profession as a group needs to be neutral on this.

YOU ARE MARRIED TO PROFESSOR SIR SIMON CHARLES WESSELY WHO WAS AWARDED A KNIGHTHOOD FOR SERVICES TO MILITARY HEALTHCARE AND PSYCHOLOGICAL MEDICINE. HE WAS ALSO HANDPICKED BY FORMER UK PRIME MINISTER THERESA MAY TO CONDUCT A REVIEW OF THE MENTAL HEALTH ACT 2007. HOW DO YOU MANAGE YOUR BUSY WORK-LIFE BALANCE, WHICH INCLUDES YOUR TWO SONS?

Early on in our relationship we invested our income to support our ability to work, engaging the services of a cleaner as well as childminding personnel. We also decided to live near work to reduce commute time. Another important decision was that we made regular holidays abroad, going away from it all, as a family. However, we were lucky since we were healthy and we had healthy children.

SINCE 2020 YOU HAVE BEEN CHAIR OF THE CHARITY DOCTORS IN DISTRESS. IT WAS SET UP AFTER THE SUICIDE OF DR JAGDIP SIDHU, A UKBASED CARDIOLOGIST WHO COMMITTED SUICIDE IN 2018. EXPLAIN MORE.

I run a bereavement group for relatives of doctors who committed suicide and the brother of Dr Sidhu was in this group. He set up the charity with the money donated at his brother’s funeral. Running a charity is hard work and in 2020 it was either going to fold, otherwise it had to be resurrected. I was invited to take over in March and I accepted. The Charity lifts the lid on suicide and mental stigma and provides support groups for doctors so that they can talk about the emotional impact of their work and not suffer in silence.

RECENTLY WE SAW THE LAUNCH OF YOUR BOOK, BENEATH THE WHITE COAT – DOCTORS, THEIR MINDS AND MENTAL HEALTH. WHY SHOULD I BUY IT?

If I do say so myself, it is a really good read, most chapters drawing from my experience at the coalface of the provision of mental healthcare services to the medical profession. The book is a mix of evidencebased academic work together with my personal autobiography, with most chapters written in first person, also mentioning my father and Malta. Readers have told me that the book is easy to read. The book has some unique chapters on example, autism in doctors which is a subject which, as far as I know, has never been published before. It also has a chapter on bipolar disorders amongst medics, written from my experience of treating 200 doctors with this condition. Other chapters deal with shame, stigma and also, why doctors have high levels of mental problems and suicide rates when they have exceptionally good prognostic features such as job security, high income and intelligence. Possibly in our curricula we are taught that we need to deny our own vulnerability and actually work harder if one feels tired since this could be perceived as a sign of weakness by peers.

IN 2006 THE SYNAPSE, IN COLLABORATION WITH THE MEDICAL ASSOCIATION OF SURGEONS, LAUNCHED MEDICAL ELEARNING MODULES, WHICH WAS A FIRST FOR MALTA. WHAT ARE YOUR VIEWS ON ELEARNING AND DO YOU BELIEVE THAT THEY DECREASE BURN-OUTS AMONGST DOCTORS?

Between 1996 and 2005 I headed the addiction treatment services for primary care in the UK and I was one of the first to develop eLearning modules on addiction. The creation of eLearning looks effortless, but its development is a labour-intensive process, taking several weeks to make it accurate and interactive. It is a very important tool and most of our learning nowadays is being done digitally. Although eLearning is important it should never completely replace the face-to-face interaction with peers, but rather it should complement it. Covid apart, one must never underestimate the power of meeting humans in person. After all, medicine is all about connectiveness.

COVID-19: HOW DO YOU PERCEIVE THE BALANCING ACT BETWEEN PUBLIC HEALTH AND THE ECONOMY AND WHAT ADVICE WOULD YOU GIVE TO OUR PRIME MINISTER?

Advisers advice and politicians make laws. This renders the work of politicians challenging. As doctors we tend to prioritize health over economic health. Politicians, however, need to find a balance. It is clear now that those who suffer the brunt of this pandemic, including any restrictions which are imposed, are the socially and economically deprived. In the long run the economic problems will cause more harm to this population. In every generation it is the young who need to make sacrifices. It is the young who go to war … who work as frontliners … It is thus important for my generation to ask what needs to be done to help. I would rather wrap myself in plastic if this means that children go to school. I would rather isolate myself for six months if this means that the young can go to work and earn a living. We need to support politicians even if, in hindsight, it may appear that they took wrong decisions. A good politician gives us hope with a sense of reality. Also, everyone needs to take cognizance of the sacrifices that need to be done. Let this period be the yellow-brick road to a new way of life based on respect and self-awareness.

Beneath the White Coat

DOCTORS, THEIR MINDS AND MENTAL HEALTH Edited by Clare Gerada Associate Editor Zaid Al-Najjar Published October 29, 2020 by Routledge All royalties will be donated to Doctors in Distress – https://doctors-in-distress.org.uk/. Why do so many doctors fail to seek mental health support and what are the consequences when their emotional and mental well-being is overlooked by both themselves and the system at large? Studies over the decades have shown that medical professionals are at higher risk of burnout, depression and suicide than many other professional groups, yet there remains deep-rooted opposition on the parts of individual doctors when it comes to asking for help and often inadequate support structures on offer when they do. The new landscape created by Covid-19, and the unprecedented psychological demands that have been placed on medical staff, now creates urgent need for a new conversation about the mental health of medical professionals.

“This is the book I wish I’d read before I started as a doctor, and a book that every medical student and doctor should read. It’s thorough and exquisitely researched but remains accessible, and is shot through with Clare’s trademark warmth and humanity.” Adam Kay, Bestselling author and former doctor.