MedNet - Interview with Dr Antony Garelick

Q1: What is MedNet, where is it based and who can it help?

A: MedNet is a confidential consultation service for doctors, covering London, Kent, Surrey and Sussex. It is a self referral service and is funded by the Deaneries.

We are based at the Tavistock Centre (Camden) and the Maudsley Hospital (Camberwell), so doctors can choose the service which is most geographically convenient or furthest away from where they work, as they prefer. We can be contacted on 020 8938 2411 or via mednet@tavi-port.nhs.uk

MedNet is one of the few services that will see all doctors, whether trainees or trainers provided they live or work in the London or KSS Deanery areas.

Q2: For doctors in other parts of the country are there any similar services youre aware of?

A: There are well established services in Leeds and in Newcastle, as well as a small service in Oxford. There's also a different type of service for GPs in the West Country.  Provision elsewhere is more patchy. Some Deaneries have links with counselling services for trainees - but not all do.

Q3: Are there any typical issues doctors tend to come to MedNet with, or is it a pretty broad range?

A: The dominant issues tend to be those generated by pressure, instances at work and/or personal life which in turn generate stress, anxiety, depressive and confidence issues in trainees.

Q4: If I come to MedNet for help, what can I expect?

A: First of all, this is a self referral service. You have to contact us. We don't accept referrals from third parties.

If you ring you'll be given an appointment and seen, usually within two weeks (more quickly if urgent). There's no screening, no triage. Someone with sensitivity and experience will listen to you, whatever your issues.

We usually offer something like six sessions, arranging further treatment if needed. As we don't have funding for this, we're unable to offer long term treatment ourselves, although we may be able to facilitate this.

Q5: Who works at MedNet and what is their background?

A: MedNet is staffed only by consultants, with experience in psychotherapy and psychiatry. Together we have seen over 750 doctors face to face over the last ten years.

Q6: How confidential is the service?

A: Totally. We don't write to anyone, like GPs, tutors, trusts, NCAS or the GMC. There are no records kept on any networked computerised system and we don't write reports for third parties. So the service is as confidential as can be.

Obviously GMC Fitness to Practice requirements apply. We could not protect doctors who were of actual or potential harm to patients but in our experience this is rare and practitioners tend to preserve high quality practice at the expense of their own health.

Q7: Have you noticed any change in recent years in the type of doctors seeking help or the type of issues raised?

A: The changes reflect the organisational changes in the NHS. In primary care there's so much uncertainty. Practices are now reluctant to appoint permanent partners. Job security is a big issue and has a big impact on managing stress and life planning.

In secondary care four month rotations and shift systems have resulted in much greater fragmentation in terms of peer support and peer relationships, which is throwing up all sorts of problems. Medicine for doctors has become lonelier and that has a cost.

We get a mix of doctors, juniors and seniors and there's often a mirror image when it comes to issues. Juniors have a high level of clinical anxiety because of the rapid rotations, which also make it harder for seniors to know their juniors and have confidence in them, which causes them anxiety. The system takes it toll on everyone.

Q8: Without breaching confidentiality is it possible to describe, in general terms, the kind of difference youve found MedNet can make?

A: The feedback we get is that it is a relief to talk with someone who is knowledgeable about the nuts and bolts of medicine and has experience in the field of psychological stress, someone who knows the language and knows the issues. For example you can talk about prescribing mistakes and feel some rapport with a colleague.

For those in relationships and with a family their partners/families often feel a great relief. They don't feel so alone with the problem.

The thing about doctors is that they have a sense of stigma, a sense of failure, if they need help. They know intellectually that, as members of the general population, a number of them will fall ill but they still feel humiliated when it happens.

Q9: Are any further developments planned for MedNet?

A: MedNet has been running for about 12 years now. We have increased the staffing because the number of referrals has gone up.

On the clinical side we're not planning any particular changes. However, we're hoping to do more in terms of education, to destigmatise the issues, for instance through talks to medical students and to trainee rotations.

Q10: Prevention is presumably better than cure what can doctors do to reduce the risk of problems arising in the first place or the scale of the problems they might face?

A: We've started more discussions with medical schools to try to get away from the culture of the invincible doctor and to recognise that the work is very stressful. There are the technical aspects, plus the emotional aspects (where patients are concerned), which generate constant demands throughout one's entire professional life.

We're also discussing with the Deanery as to how more peer support can be arranged. There is already mentoring, which is a step forward, and we're trying to encourage more group/peer support.

There used to be informal support networks, for instance through the doctors dining room but these have become less and less. We need to be quite creative and inventive to provide that kind of emotional support system.

Q11: How far is the increase in reported depression simply a feature of modern society and how far are there issues specific to doctors?

A: Doctors are part of society and their working environment tends to reflect this.

However, there are demands and anxieties specific to doctors like seeing 20 - 40 patients a day, every day, which can create an enormous emotional toll. This is linked in with a society whose expectations are that medicine should be error free and risk free. This also takes a great toll. Have I missed something? Am I going to get a letter from the GMC?  And because of the pressures on Trusts the threshold for putting doctors off work has lowered significantly and this has financial implications, adding to stress.

Also, the profession doesn't feel respected by government. It feels bullied. Instead of being supported, they feel more likely to be jumped on.

Q12:  How does MedNet's work compare with that of the new Practitioner Health Programme?

A: There's some overlap but a lot of complementarity,  partly because there were all sorts of things that needed doing that we weren't able to do, partly because of funding.

For example PHP has funding from the Department of Health and can provide specialist drugs and alcohol treatment. Also, before the internal market we could place a colleague out of area, without requiring funding and a contract. As soon as contracts had to be agreed this meant we couldn't maintain confidentiality and the process became too bureaucratic. PHP can pick up on this in certain cases because it is centrally funded.

Dr Antony Garelick, Consultant Psychiatrist in Psychotherapy, Associate Dean, MedNet, London Deanery (for the Counselling of Doctors) Tavistock & Portman NHS Trust.