What it’s like living as a doctor under the (Toronto) poverty line

“Hey, would you like to come catch some lunch with us? There’s this new Mexican place around the corner.”

“No thank you, I have a lot of work to do, I’m going to stay here and catch up on some documentation, next time though!”

“Alright, have a good lunch.”

I quietly closed my office door and flushed pink with embarrassment. I hope that was convincing. I reached for my battered book-bag, and pulled out the two slices of toast and the bag of almonds I had laying around the apartment that morning. My chopped up frozen peas and corn were still frozen.

It tasted a little like cardboard, but it was OK. As I sat eating, I couldn’t help but think about other social events I had to come up with some elaborate excuse to avoid, because I was broke. Beyond broke. I recalled the Tim Horton’s server earlier that week, who stood by annoyed as she counted out my forty nickles – or I thought it was forty. I was five cents short; luckily the annoyed customer behind me overheard and threw a dime down on the table, a little in kindness, but also to help get the line moving, I thought.

That was three days ago. I haven’t been able to afford a coffee all week.

It gets more difficult some days, particularly when tempted with succulent chicken polo frito I know I can’t have. I looked down at my jeans, which I had worn every day this week. They looked shabby and I saw a small yellow dot of something – mustard? – on one pocket. I tried to brush the spot off but it only smeared the yellow-goo deeper into the fabric. I felt the seam of the jeans, gently rubbing the pale, white thread I could tell was going to give out, at some point. Hopefully they last until my birthday… I only owned two pairs of pants that fit me you see, and one was in the wash.

And the drier was broke.

kid s blue shirt hanging on the clothesline — Photo by Lisa Fotios on Pexels.com

This scene may seem vivid, I hope it is. These events don’t begin to touch on the poverty many residents of the world, country, and Toronto face on a daily basis. I have a relatively safe apartment in a decent neighbourhood, and most months I can afford to get a transit pass.

This story is also about me, and it’s not where I expected to end up as a doctor. So what gives?

For those of you who have read this blog for some time, you will know that I am something called a resident physician. Residents are kind of primordial doctors, having finished medical school, and now completing a program in the specialized area of medicine they will eventually work in for the rest of their life.

Becoming a resident, and a doctor, takes many things. It takes academic rigour, professionalism, dedication, and mental toughness. It also takes a tremendous amount of money.

To enter medical school, you need an undergraduate degree. For most people in Canada, those degrees, four years in duration, can cost anywhere from $10 000 to $50 000, depending on the school you attend. Most young people in Canada don’t have this kind of money just sitting around, and ultimately the vast majority of university students depend on one of two sources of funding – student loans, or help from their parents. Leaving conversations about how the education system is designed to discriminate against the poor aside, I’ll mention here that I was one of the more fortunate undergraduate students at Memorial University, and only graduated with about $15 000 in student loan debt.

In the fourth year of my BSc (Hons) in Cell and Molecular Biology, I began applying to medical schools – at about $700/$800 per application. Those of you who know anything about medical school admissions knows that you don’t want to “hang your hat” on one school, it’s not unlike the lottery. Keeping this in mind, I ultimately opted to apply to seven medical schools, which stung my pockets, but felt necessary at the time.

I was ultimately offered two interviews, one of them here in Ontario, and after some reflection and my acceptance, I found out I was going to medical school! In Windsor, Ontario.

Most Canadians mistakenly associate things like $25 000 a year education to places like the United States. Not so, for medical school. I was dismayed to realize my tuition would be that, and more per year, considering the various $1000 “enrollment fees” and the “one time $800 course fees,” for the odd mandatory skill seminar put off by the school. I did the math, and yes, this was going to cost me $100 000. And I was going to pay interest on that money, as well as my $15 000 student loan, every single day, until the time I graduate. (As an additional fuck-you from my medical school, they went on to increase the cost of tuition every single year I was in medical school; my fourth year, initially supposed to be $21 000, the cheapest year since it was essentially six-months in duration, costed $26 000 by the time for me to pay).

Now of course, as anyone with student loans will attest to, the cost of education is hell of a lot more than tuition. There are textbook costs, transit passes, rent, groceries. All of these things costed money, and since I was going to school 3000 km away from my nearest relative, I had nobody to lean on.

It’s here my trajectory deflected from my colleagues. You see, not everyone enters medical school as equals. The vast majority of my colleagues received significant financial help during medical school from their families. Most people in medicine you see, have doctors for parents, many have a trust fund. A quick Google search can shed light on the tremendous problems of socieoeconomic skewing in medical school classes – it seems like hiring and accepting people from penthouse suites doesn’t increase physician availability in the projects (no s*** guys I could have told you that)!

This is also the case in all education programs, where some students have it better than others, but when you’re surrounded by people without student loans, travelling across the world on the odd weekend, you feel it a bit more. Everything I paid for in medical school was on my back, and it still is.

And I’ll be the first to admit it. I had housing costs, groceries, living expenses. I also enjoyed myself during medical school, not excessively, but in an effort to feel like a part of my class. It was difficult, living in Ontario, and being the only person not travelling to Europe over the summer. It hurt wearing shabby mall-bought clothes among my peers when most of them shopped at expensive outlets.

I eventually finished medical school, and it was finally time for a pay day.

I also fell in love.

I ended up being accepted into a residency program at the University of Toronto, and I moved to the city to be with my partner. She had just finished a different academic program herself, and we had very little money. We accepted the cheapest apartment we could find that had access to the subway. You see, with both my partner and myself working in health care, we worked 12 hour days, if not longer, and a two-hour-each-direction transit ride was not an option. We found something that was a 45 minute transit ride away from our work, 700sqft, at $1800 a month. Yes, that’s obscene. It’s also the reality in Toronto.

The Canada Mortgage and Housing Corporation estimates that housing becomes “unaffordable” when it takes up more than 30% of your income. Many people in Toronto are in an unaffordable housing situation, myself included. This rent costs about 52% of my income per month.

Now I know what you’re saying. “That’s not a lot of money for a doctor.” It is for a resident. My resident salary in Ontario is $58 000, before taxes.

And before my $1200 of student loan INTEREST payments a month (barf).

And before groceries.

And before cell phone.

And before my transit pass.

At the end of the day, it’s really not a whole lot of money. There’s often a month where I have no transit pass for the first few weeks, and I count dimes I have left around the house in hopes of getting on. A few times, I’ve had to sneak onto the bus. Often the bills go unpaid. Don’t ask me about my VISA.

All of that to say, I’m hurting, and a lot of young professionals in this country and city are as well. It’s atrocious that medical schools, or any school, can gouge you for money they know is going to sit on your student loans – I’ve paid enough interest to my bank at this point I could have almost paid off a quarter of my debt. It’s disgusting that the government of Ontario does not account for the school of residency when determining salary – you make the same in Thunder Bay, with a significantly lower cost of living, than you do in Toronto, the most expensive city in the country.

So what’s it like living like a doctor near the poverty line? Just ask me.

selective focus photo of pink tablets — Photo by Dear W on Pexels.com

It was happening again. These damn asthma attacks. My shortness of breath was getting worse, and I was bent over breathing to try and get a sufficient breath.

“I think I need to go to the hospital.”

An ambulance costed $75… I checked my Uber app – declined. “Please update payment method.” Fuck.

I got in the subway, wickedly coughing, and then transferred to a bus, which I took to the hospital. I was somewhat blue by the time I got there, and they admitted me right away. They prescribed some puffers, and told me to take my allergy pills.

The following day, I went to the pharmacy with my two puffer prescriptions. I left the allergy pills in the aisle – $15 for ten pills? Not happening.

“Alright, that will be $15.”

“I thought my insurance plan covered the drug costs?”

“It does, but for this medication, there’s a co-pay.”

“I’ll only take the one then.”

Dr. Travis Barron is a resident physician in Toronto, Canada.

Are you manic right now?

I recently had a patient who was diagnosed with pneumonia. We had been treating with antibiotics, as well as some temporary puffers, for symptom relief. Unfortunately the puffers did not suffice, and the antibiotics had not acted quickly enough. One evening, after he finished dinner, this gentleman began experiencing shortness of breath. He was concerned, and called an ambulance, who took him to the hospital.

On arrival to the emergency room he was offloaded from the ambulance and given some oxygen, which helped him immensely. His breathing actually settled relatively quickly and he was able to breath without the oxygen mask. The emergency room physician (ERP) took this opportunity to get a more wholesome history from him.

man pushing hospital bed — Photo by rawpixel.com on Pexels.com

“Do you smoke?”

“Not for the last few years.”

“Do you take any medications?”

“Just the puffers and antibiotic my doctor had prescribed.”

“Very good. Do you have any medical illnesses?”

The patient paused for a moment to think. He had been through this rodeo before, for other medical problems. He was wondering whether or not to mention to the doctor a previous diagnosis of bipolar disorder.

In the past, he had told physicians and paramedics about this diagnosis to underwhelming results. Instantly, the affect of the providers would change. Suddenly, his credibility was drawn into question. Where before he was allowed to speak and describe his story without interruptions, he was now met with requests to, “slow down.” The questions like, “are you feeling like yourself right now?” seemed to bother him the most.

This ERP on this particular day however seemed professional enough, and the patient wanted to be as transparent and honest as possible, so that his medical care could be the most informed it could be.

“I’ve been diagnosed with bipolar disorder, though I’m not on any medications, and I don’t know that I agree with the diagnosis.”

The silence was deafening, although it only lasted a second. The physician quickly regained her composure and started down another line of questioning.

“Have you used any drugs recently?”

“No.”

“Do you smoke?”

“I already told you I didn’t.”

“Are you manic right now?”

He tried his best not to role his eyes.

“I feel perfectly fine, I’m sleeping eight hours a night.”

“Are you having thoughts of violence or suicide?”

He looked at her sternly and decided not to answer this question – he was here, after all, for pneumonia. No razor blades had been held at any wrist.

adult doctor girl healthcare — Photo by Pixabay on Pexels.com

The conversation continued and eventually the physician left to order some investigations. Various nurses were in and out of his hospital room, all of whom seemed to suddenly have a lot less to say.

The patients condition improved, and he was eventually discharged on a low dose steroid for a few days to aid in his recovery.

“I don’t think I’ll take this tonight but I’ll take it in the morning.”

It was the ERP’s turn to role her eyes. The patient felt obligated to explain himself.

“If I do have bipolar disorder, the absolute last thing I want to do is take a steroid tonight, be awake the whole night, and have an episode.”

“Alright, see ya,” the doctor said as she left the room.

Now I had heard this story from the patient second hand of course, and I’m sure the dialogue wasn’t exactly as I have described above. But there are some things that are certainly true. This man was extremely aware of the prejudice he received, by virtue of the (unconfirmed) diagnosis he carries, and suffered because of it. He felt insulted, degraded, and less than human.

Great way to make people want to seek treatment for mental illness, eh?

There were a few things that bothered me about the story, the least of which was this physician’s skill in assessing mental illness. For the record, you could ask a naked man screaming about Jesus on top of a Walmart, who hasn’t slept in eight days, “are you manic right now?” and I would be shocked if they said yes. To those of us in the field, we recognize the mental status exam and the whole picture as key instruments leading to diagnosis. Personally, I don’t see the utility in asking seemingly well and euthymic (normal emotion) people what they think of their mental status, irrespective of their diagnoses, when they are seeking help for an unrelated medical problem.

Bipolar people get pneumonia too, y’know.

The physician’s apparent novice skill in this field isn’t why I chose to write this post – it’s the prejudice that came attached. Because this man had a diagnosis of mental illness in the past, and one of the “scarier” ones, his credibility was immediately drawn into question. Are you sure you didn’t accidentally take a bunch of cocaine before you arrived here? Are you positive you don’t want to blow your brains out after you leave here?

That’s not to say that this information doesn’t matter, because it does. On a professional level, whenever I assess someone with mental illness that may put them at risk, I’m always on the look out for any red flags or warning signs.

I’m also sure to treat the patients like humans.

Medicolegally, I understand the need. “Oh Doctor, you didn’t ask about suicide when you assessed Mr. so and so five months ago? And why is that? He did have bipolar disorder, after all.” And Im not saying theese questions shouldn’t be asked. How you go about it however, is another story.

Do any of you have real life examples or prejudice inflicted upon you, or a friend as a result of mental illness? Without going into too much personal detail, share below!

Dr. Travis Barron is a resident physician in Toronto, Canada.

Keeping your faith when you’re a doctor

Often times, late at night, I find myself reflecting. Reflecting on life, myself, all I have become, and all I have lost. Growing up, I didn’t have the most friends, but I could always count on my brain. Looking at where I am now in life, is a tremendous source of pride. I was the first in my family to attend post-secondary education, and the first physician as well. In many ways, to my family, I’m seen as a stepping stone for the Barron clan to exit from rural poverty.

brown wooden cross pendant on closeup photography — Photo by Thijs van der Weide on Pexels.com

That doesn’t mean there aren’t some regrets.

One thing I reflect on often, is faith. Growing up, the church was a huge part of my life. I ached to attend Sunday mass, and volunteered as an altar boy at the first chance I had. At my parish, Confirmation was typically reserved for 12 and 13 year old children. With special permission from the priest, I was allowed to be confirmed at age 8. And I came in top of my class. One of the highlights of this part of my life was when the priest at my church – Holy Trinity Parish, sharing a name with my elementary and high schools, Holy Trinity Elementary and High School – asked my mother and I to be the parish’s representatives at a special visit by the Archbishop of Canada, to the largest Catholic church in St. John’s, the Basilica (as a side note, on that day, I tripped on my way into the pew, and muttered, ‘Jesus, Mary, and Joseph!’ under my breath; my mother made sure I heard it later!).

As these things go, you get older, and you try your best, in many ways, to differentiate yourself from your family. Religion took a smaller role in my teenage life, although it remained important to me. Friends and school and manhood became my primary concerns.

Eventually, I attended post-secondary university at the Memorial University of Newfoundland, majoring in Biochemistry and then switching to Cell and Molecular Biology. That was followed by medical school, in Windsor, Ontario, and eventually residency in Toronto, where I am today.

When I moved to Windsor, a sense of community was lacking. What was this foreign place, so very different from my home? People avoided eye contact in the street, there were no friendly greetings or short conversations with the server at Tim Horton’s. And I missed that. So, I went to the nearest place I could think of, to help bring back that sense of community. I went to church.

A church service is a church service and in many ways the mass at Our Lady of Assumption in Windsor (the oldest church in Canada west of Montreal, now tragically shuttered and closed down), and I felt at home. Though the parishoners and the priest were different, the prayers remained the same, and in some ways I was at peace.

After my second service at Assumption Parish, I began to worry. Something wasn’t feeling right, and it took me a while to realize what it was. I stopped going to the church and looked elsewhere for community. If anyone out there has gone to medical school, you’ll know that my only option was the medical community, a sort of cult, comprised of medical students, residents, and doctors, and where the conversation invariably turns to the latest asthma medication or multiple sclerosis study.

Eventually, it came to me. I had lost faith.

Putting in to words what this meant to me is difficult. If any of you have faith, you know what I mean. God and Jesus were in many ways part of my own being, and the Catholic faith was for me the compass by which I navigated the world. Religion, to my perennially teased and tortured by my classmates in grade school soul, was for many years my anchor. And here I was, drifting off to sea.

I struggled with this for some time and eventually religion moved from my mind. I immersed myself deeper in medicine, and intentionally avoided any religious themed discussions, out of fear it would rip my being in two. To add some context, I’ve been in post-secondary education for eleven years at this point. Eleven years of fanatic education, of evolution, world religions, the big bang, science, and medicine. Eleven years of learning men (and women) are the masters of this world and that it is ours to discover. God, in fact, was only ever mentioned in discussions surrounding the unreasonableness of a Jehovah’s Witness refusing a blood donation. The problems caused by belief in Allah during Ramadan for kids with nutritional disorders. Never did that lens turn inwards, never was the question asked about our relationship with God.

That’s not to say I’m the only religious person that attended medical school, I know I wasn’t. I have friends and colleagues that were and continue to be active in the church. Me, I was Captain Scott, frozen in the Antarctic ice lost and without hope of rescue.

But like Captain Scott, there was hope. Although he died, Captain Scott is famous for the journals he comprised while he and his crew used pick axes to try and cut their boat free of his frozen water coffin. Of course this was a failed venture, and not until a subsequent Antarctic expedition during which his remains were discovered were his journal entries found and disseminated. And what was found was remarkable. These men, faced with their inevitable death, had been singing. They were in good spirits and they sat and played cards and ate breakfast. They joined together in prayer. They had faith, and the spirit lived on.

“God help us, we can’t keep up this pulling, that is certain. Amongst ourselves we are unendingly cheerful, but what each man feels in his heart I can only guess.”
― Robert Falcon Scott, Scott’s Last Expedition: The Journals

I am not an Antarctic expeditionist, but like Captain Scott, my spirit lived on. The Holy Spirit? Maybe. I’m not going to call myself divine. Like an ember on the floor of a seemingly dead fire, I would soon realize my faith could again burn bright.

I was at a low point of my life in the third year of medical school, and I was wondering whether the choices I had made were truly the right ones. I felt like most of my friendships in Ontario were superficial, and that most of my friendships in Newfoundland were decaying. In many ways, I felt caught between two worlds and two provinces, not dissimilar to how I felt being caught between religion and medicine.

So naturally, I went to church.

And I went again.

And again.

And eventually the happiness I once had from sermon returned, and I found myself at peace. What had changed, I asked myself. I was still a physician-to-be, I still felt trapped in mainland Canada. Simply put, I had faith.

To this day I continue to struggle. Struggle with thinking about the impacts of evolution on the development of our planet and climate, and reconciling that with the Catholic calendar. Struggle with thinking about life saving blood transfusion and a deeply held belief having ones blood other than your own is a sin. Struggle with my obligations as a doctor to discuss treatments that in many ways go against the very fabric of Catholicism. Sometimes, it isn’t easy.

But I have faith. I have faith that both my lives and both sets of beliefs can co-exist peacefully. Faith that it will all work out. Faith that as a doctor who has tried to do nothing more than elevate his family and extended family out of poverty, and to help the sick and diseased and unwell and disadvantaged, there is a place for me in Heaven.

Some days are easier than others; today is a good day. I’ll continue to toe the line and think and reflect and consider what it means to be a Catholic in 2019. And in the end, I’ll always know, both things can be true. They have to be.

Editor’s note: There are many faiths in the world and I don’t think asking which faith is, “correct,” is a helpful question. What matters to me is that people feel at peace with themselves and their choices. Maybe that means Catholicism, Islam, Hinduism, or Environmentalism. However you identify, there are bound to be conflicts between your faith and what the modern world asks of you. The purpose of this post is to describe my own struggles in reconciling these two ideas.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The psych wards are full and why that matters

adult alone black and white blur — Photo by Kat Jayne on Pexels.com

“I can tell that things have been difficult.”

“That’s life, isn’t it? One thing after another.”

“Are you having thoughts of wanting to be dead?”

“All the time.”

“Are you having thoughts of attempting suicide?”

***

I recently met a patient in my family medicine clinic, a 28 year old gentleman who had immigrated to Canada as a young child. This man had experienced numerous struggles in his life, from escaping relative slavery in central Africa, to coming to Canada, achieving a professional education, and eventually got a job as an X-ray technician. That was, until recently.

For the last two years, the gentleman, “A”, had been struggling with depression and alcohol use, following the death of his mother. “A”‘s drinking quickly escalated over time, which worsened his depression, which caused him to drink more, and so on. “A” had disclosed these problems to his previous family doctor, who stressed the importance of alcohol cessation, and prescribed a medication.

As these things can sometimes go, “A” was not able to abstain from alcohol, and unsurprisingly (given the ongoing, heavy substance use), they found the medications ineffective for depression and stopped taking them.

“A” eventually ended up back in his previous physician’s office for a separate issue, and the physician decided to check on his mood. It quickly became apparent “A” had continued to drink, and was severely depressed. He was now off of work and almost entirely socially isolated. “A”‘s physician spoke to him about suicide, and it became apparent that “A” had recently attempted suicide via overdose. He was, “disappointed,” the attempt was not successful.

Because of this, “A”‘s doctor had recommended they go to an emergency department to be seen urgently by a physician. “A” had some friends that had previously been through the emergency psychiatry experience, and told his physician there was, “no way,” they would go through that.

The physician, in keeping with her professional and moral duties, issued a form 1; what is a form 1? In Ontario, a form 1 is a form issued by a physician when they have concerns regarding your safety, due to mental health. The form allows you to be apprehended and brought into a psychiatric hospital for assessment.

“A” was picked up by police and they drove him to the hospital. In hospital, they were admitted to the emergency department, and given a glorified, locked, jail cell to stay in. His clothes were taken and they were under constant observation by a security guard outside of the hospital room (cell) door.

After 48 hours, “A” was discharged, and had been lost to follow up for over the last year, until I had met them, again for a separate issue.

***

man in blue and brown plaid dress shirt touching his hair — Photo by Nathan Cowley on Pexels.com

“Are you having thoughts of attempting suicide?”

Silence.

“I need you to be honest with me here, I’m very concerned.”

“I’m fine.”

***

“A” was not fine. In fact, it soon came out that, yet again, “A” had covertly attempted suicide. He was actively planning another attempt, and had begun to set his affairs in order, as though he would soon be dead.

I issued a form 1.

Why does it matter that the psych wards are full?

“A” was very unwell, and to this day I don’t know how he is doing. After I submitted the form 1, they refused to return to my office. Let me begin by saying, this is the least favourite part about my job. On a personal philosophy level, I do not believe that physicians, or anyone, has the rite to tell people how to feel and what to believe. I also know when to recognize severe, serious depression, that may be treatable, which puts ones life at risk. This was the case with “A”, and I can sleep easy tonight knowing that I did not abuse my government-given powers to take away someone’s liberty.

But this didn’t need to happen.

Far in the past, or in some parts of the United States (if you have money), there is a mythical beast called the elective psychiatric admission. This is exactly what it sounds like – elective, meaning not mandatory. Examples of elective psychiatric admissions include people with a moderate depression, people with severe anxiety, or someone in the need of a mood stabilizer or antipsychotic titration. Useful stuff, no? The philosophy behind elective psychiatric admissions is that we tackle a problem before it gets to serious. You want to treat someone when they are climbing the stairs, not jumping off the balcony.

Unfortunately, I am sad to say that in my short psychiatric career, I could count the number of elective psychiatric admissions I’ve facilitated on one hand. Two fingers, to be exact. And that’s not to say I haven’t met people who may benefit from such an admission – I meet people like that at least once a week. But the reality is, because psychiatric hospitals are overcrowded, there is only room for emergency admissions. These are your form 1’s, the acutely suicidal, the emaciated psychosis.

car control panel emergency equipment — Photo by Pixabay on Pexels.com

Of course those people (emergent patients) need hospital, and indeed they need hospital more than an elective patient, by it’s very nature. But that doesn’t mean elective patients don’t need admission, as well. Inevitably, people who may benefit from an elective psychiatric admission are discharged home. Many of those people appropriately improve on an outpatient regimen, but not everyone – some people get worse. Way worse. So much worse, in fact, that they shortly come in need of an emergent psychiatric admission.

You can see how the cycle continues. As long as we deny inpatient treatment to people who are at anything but absolute crisis mode, people will become sicker, and further overcrowd the hospitals. Think of the bipolar man in need of a lithium titration who instead stops his medication and has a severe manic episode. He thinks he can fly, jumps off a building, and breaks both legs.

What about the effect on emergency rooms?

If there is any area of medicine and mental health who sees first-hand the effects of overcrowded, full psychiatric hospitals, it is emergency departments. As emergent psychiatric patients are felt to need admission, a back log is created when the psych wards are full. This results in psychiatric patients being housed, long term in the emergency department, hopefully awaiting some attrition from the wards.

I don’t know that you have ever been in an emergency department, but they aren’t pleasant. The psych beds in the emergency, even less so. They usually float somewhere between jail cell and operating room sterility. Not only is this an abuse of vulnerable people in need of help, but this causes further problems. Physicians are able to dedicate less and less time to each patient, as the mental health population of the emergency grows, which is a recipe for disaster. There are reasons there are nursing ratios on psych wards, because vulnerable people with mental health problems need support. This isn’t the case in emergency departments, and people often go neglected and ignored. Most importantly, it often escalates them with respect to agitation, and suddenly you’re in the position of having to inject someone against their will to keep the overcrowded jail emergency from exploding.

Similar experiences to this are why “A” was so reluctant to go to a hospital and seek help. And because of that, he’s lost to the system. I hope he isn’t dead. I’ve done everything I could to reach out, and now, only time will tell how that story ends.

What I do know, is that psych wards are full, and it matters.

Editor’s note: This post is awfully critical of a lot. If there is one thing I am not critical of, it is the excellent work of my emergency medicine colleagues, who often find themselves overstretched as they save lives, due to poor government planning.

I am extremely critical of the dehumanizing psychiatric rooms so common in our emergency departments, and stand by my description of them as jail cells.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Intrusive thought predominant

From Part 1:

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Part 2

Part 3

Intrusive thought predominant

“Hi Doctor, we have a consult for you,”

“Go ahead.”

“He is a 18 year old male with daily, intense suicidal ideation. We’ve placed him on a form 1 and he’s in the emergency waiting for you.”

***

ambulance architecture building business — Photo by Pixabay on Pexels.com

Early on in my career as a psychiatry resident, I met a young man, just graduated from high school at one of the hospitals I was working in. I was working in the Psychiatric Emergency Service (PES) at the time, and had been asked to see the man by an Emergency Medicine colleague.

As these things go, you don’t always get the most information. Really all I knew about this person was that he was eighteen, was going to university for engineering, and had daily, intense suicidal thoughts.

As I walked down the hallway to meet him, I considered a differential in my head. Could it be depression? Psychosis? Had a manic depressive fallen into my lap? Or a personality disorder, perhaps?

***

“Hi, my name is Dr. Barron, I’m one of the psychiatry residents.”

“Hi I’m Sam, nice to meet you.”

“Nice to meet you as well. My emergency medicine colleague asked me to speak with you, is that OK?”

“Yes of course.”

“Let’s start with your understanding of why you are here in hospital.”

***

We began speaking, and very quickly it became apparent that Sam was not depressed. He wasn’t psychotic. He definitely wan’t manic. I couldn’t even get a whiff of a personality disorder off of him. What the hell was going on?

I didn’t know it yet, but what I was seeing was a common manifestation of OCD, called intrusive thoughts. These thoughts are intense, and are very bothersome to the person. Some classic examples include:

Suicidal thoughts (killing yourself)
Violent thoughts (killing a random person or a family member)
Sexual thoughts (homosexual behaviours if you are heterosexual, heterosexual behaviours if you are homosexual, or pedophilia)
Blasphemous thoughts (against your own religion*)

An important point here is that blasphemous thoughts typically only occur when someone cares about being blasphemous i.e. it would not be considered a blasphemous thought to pee on a church if you didn’t care about peeing on churches.

white concrete churchpeople under blue sky — Photo by Pixabay on Pexels.com

So wait. Suicidal thoughts can be intrusive? How is that different that a regular suicidal thought? Well, in intrusive thought predominant OCD, the thoughts are egodystonic, meaning they are in direct conflict with that persons values. In other words, a person with intrusive thought predominant OCD does not want to kill themselves, hurt someone, abuse a child, or disrespect a religion. In fact, they are often extremely disturbed by these thoughts.

Another important point to remember is that all forms of OCD have some level of intrusive thought based symptoms, however, the intrusive thoughts are not the predominant feature.

In contamination based OCD, intrusive thoughts of contamination cause extremely debilitating compulsions, focused around cleanliness, which tend to be the primary feature.
In doubt based OCD, compulsory checking tends to be the predominant feature.
In numeracy/symmetry based OCD, extreme cognitive rigidity and intolerance, as well as compulsions, tend to be the predominant feature.

***

“So doctor, what do you think is wrong with me?”

“Well, this sounds like OCD, a treatable illness. This doesn’t mean you have to kill yourself, or hurt anyone. These thoughts you are having don’t represent anything about who you are, or anything bad about you. In fact, the fact you’re so bothered by them shows how much you value human life. We’re going to help you.”

***

These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Of depression

Sitting in the doctor’s office, I hear the words. They leave her mouth like an anvil and slam upon the floor, the noise made by each previous contact making the next syllable more impossible to hear.

“You have depression.”

I leave my body and float out of the chair. I’m outside the hospital, gazing down on all that was. I’m flying further, and further, overcoming the very curvature of the world, and then I see it. My future, everything that will become of me, and all that was, laid before my very eyes.

My first sense is loss. Loss of mystery, of individuality, and most importantly, of choice.

My head is spinning. I’m falling, crashing through the sky. I miss the chair and my body and drown below into the depths of hell. I’m confronted by all that has ever scared me, a violent torture to my all-seeing soul.

I’m fired, divorced, my family has shunned me. Strangers spit on me, I’m left to rot. Slowly I decay into nothingness until the coolest realization, as I’m forced to linger while all I once loved is forgotten to me.

My heart skips a beat and I’m back in the chair. The doctor is still talking, I realize to myself. I haven’t heard a damn thing she’s said to me in the last five minutes. I hope it wasn’t important.

“The important thing is that there is hope, treatment, and I am going to help you.”

I stumble home from the office, dreading the moment I finally stop. When my footsteps no longer crowd my ears, I’m left with my thoughts. Depression. What does this mean?

It takes a while, but my life takes a surprising fork as I journey on the path to recovery. I actually get better. I’m working again, and somehow, my relationships are more fulfilling. It’s a Saturday, and I want to go to the park. Why? Just because. It’s a refreshing release, to finally do something because.

On Monday, I’m back in her office. She’s asking me questions and I can’t stop thinking about this chair.

“How are you feeling?”

I speak for a while and we exchange pleasantries. She’s happy to hear I’m doing well. In a way, it feels surreal. The doctor catches my smile and asks me what’s up, and I give a small chuckle.

“Last time I was here, I thought I was drowning.”

Editor’s note: The above is a fictional piece I wrote, as inspired by a recent conversation I had with a patient regarding the meaning of a diagnosis. They had felt a diagnosis made a lot of assumptions about them, and what their future looked like. They were glad to be proven wrong.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The pills aren’t working

“I’m never trying this again, it was awful. I thought you said this thing was supposed to make me feel better?”

“I’m sorry that happened to you. As we discussed, some side effects like nausea and headache are quite common when you start–“

“Start?! I took this thing for four whole days, doctor. I need a different pill. Will my depression and anxiety every go away?”

person holding white medication tablet — Photo by rawpixel.com on Pexels.com

Medication selection can be a painful time for patients. As with our diagnoses, often times there is trial and error in selecting the right medication that works for you. When it gets to the fourth, fifth, and sixth medications in some cases, it can be demoralizing, not only to the struggling person, but to their doctor. The fact is the science isn’t the most clear to the researchers in the laboratory, let alone a doctor in the office, and for that reason arriving at a suitable psychiatric treatment regimen can take some time.

Don’t despair – the medications work! Not only often, but usually. I see and help people recover every single day in my office, and it can be refreshing. However, that’s not always the case. Sometimes, struggling lasts a little longer than we would like it to. Sometimes, people lose faith in the system and look elsewhere for help. These cases can be tough; but there’s an upside! In my opinion, the majority of these treatment failures are actually preventable. So what am I talking about?

There are many reasons a particular medication regimen does not work. First and foremost, the most common reason I see, as described in the example above, is a misunderstanding of the expectations of an antidepressant or anti-anxiety medication.

Anti-depressants take time to work.

The textbooks would tell you that you need six weeks at a suitable dose to have a full effect. What does this mean? Here’s an example;

Week 1 – Sertraline (Zoloft) 25mg, oral, daily
Week 2 – Sertraline 50mg, oral, daily
Week 3 – Sertraline 75mg oral, daily
Week 4 – Sertraline 100mg, oral, daily
…
…
Week 9 – Sertraline 100mg, oral, daily
FULL EFFECT
Week 10 and onwards – Sertraline 100mg, oral, daily

The dose this person required was 100mg, and not until 100mg was achieved for six weeks do we see full effect.

What if 100mg isn’t enough? Well, a further increase may be required. The maximum recommended dose of sertraline is 200mg. You and your doctor may ultimately try a 100mg dose for a few weeks, decide it is sub therapeutic, and titrate further. Yes, this means we can be talking week 15, 16 in some case. But remember – this is for full effect. In reality, a skilled clinician and a patient can often tell after the first four weeks of a treatment whether there may be a significant benefit from a particular medication. That’s what the doctor’s are for!

analogue classic clock clock face — Photo by Pixabay on Pexels.com

Side effects are expected and will happen.

And they aren’t permanent. Like anything, your body takes time to adjust to anti-depressants and anti-anxiety medications. In fact, the presence of side effects shows that the medications are getting to the brain and having some kind of effect! It’s important to appreciate that this is a normal part of the journey, not only with starting, but with significant dose increases.

Side effects suck and the last thing your doctor wants to do is make you feel worse – like all things in mental health, trust me, it’s an investment! Side effects like nausea and headache and anxiety tend to go away after the first half week-full week of therapy (yes, anti-depressants and anti-anxiety medications can cause transient anxiety – it’s your brain adjusting to the changes). Doctor’s are also all about safety, and don’t worry, the side effects are reversible with dose decrease.

What is considered a true treatment failure?

Part of my job when you come see me for a mental health problem is to take a detailed medication history; people have often tried multiple medications over time, and if something hasn’t worked in the past, it’s unlikely to help in the future. But what constitutes “doesn’t work?”

Not the above example. For a course of an SSRI to be considered a treatment failure, you need to have completed at least six weeks on an appropriate dose of that medication. A rough estimate of an “appropriate dose” is half the maximum dose.

***

The moral of the story? The medications work, they take time, and they can be a nuisance. Careful time, understanding, and collaboration with your physician is the best way to work through a mental health disturbance. With patience, I promise we’ll help you.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Numeracy and Symmetry

From Part 1:

Part 2

crown group modern motion — Photo by Burst on Pexels.com

Numeracy and Symmetry

Have you ever seen a kid walking in the mall (sorry Gen Z), jumping from small blue tile to small blue tile?

“Avoid the lava!”

“Watch out for the monsters!”

This is a completely normal behaviour, and many children, including myself, dabble a little in the lava-tile game.

But imagine if to you, it meant a little more. Imagine that your found yourself unable to walk on white tiles, because of a crippling sense of anxiety that if you did, something bad would happen. You would probably know this doesn’t make much sense, which only adds to the madness.

It wouldn’t be easy going to the mall.

This type of behaviour, in it’s extreme form, falls under the umbrella of a symmetry/numeracy based obsession. In this type of OCD, the obsessional thought is usually something along the lines of, “if this isn’t this way, than something bad will happen.” There may or may not be a specific type of “bad”-consequence perceived. Some examples;

***

An eight year old boy goes through the home and makes sure every single TV and computer has the volume set on an even number. His father has the TV on 15 one day, and the child gets very upset and throws a temper tantrum when his father doesn’t let him change it. The next day, his mother asks him what happened. The boy responds, “if the numbers are odd numbers, I’ll die.”

A twenty four year old woman is late for work every day. She’s eventually fired from her job, and ends up in a doctor’s office while she is off of work. “I think I need help doctor.” “OK. You’re in the right place. What do you think is going on?” “Every time I look in a mirror, I can’t leave until I catch my nose at the perfect angle, perfectly symmetric. I don’t know why, I just can’t. Some days it takes up eight or more hours.”

A fifteen year old is teased at school for his quirky behaviour. He doesn’t tell his parents why, and they only know that he is being bullied. One day, when dad is picking the boy up from school, dad notices the boy jumping from dark tile to dark tile on the sidewalk. “What was that about?” dad asks when the boy gets in the car. The boy blushes and says, “can we just go?”

***

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Doubt

From Part 1:

Doubt

Sometimes, OCD can be obvious. Other times, it is more nuanced. This is the case with obsessional doubt, one of the most common, but under-recognized, subtypes of OCD.

ask blackboard chalk board chalkboard — Photo by Pixabay on Pexels.com

So what makes doubt obsessional? To understand that, we need to remember what makes an obsession an obsession. An obsessional thought is unwanted, and comes about seemingly out of our control. This is called an intrusive thought. Obsessional thoughts occur over and over again, and won’t go away. Importantly, obsessional thoughts consume a significant amount of time, and result in a functional impact. Remember, if it’s not causing you problems, it’s not a disease!

Taken all together, obsessional doubt occurs when someone repeatedly doubts they have remembered something. Obsessional doubt is also often coupled with compulsions, to relieve the anxiety associated with the doubt. Compulsions in doubt-based OCD tend to complement the doubt, and therefore the compulsions tend to be reassurance-based. Now I know this sounds underwhelming, but trust me, it can be debilitating. The following are some examples of people I have met (with their stories altered, of course) with obsessional doubt.

***

Richard was a 27 year old man living in Toronto. He was getting ready to go out on a date one evening and found himself very anxious. He was getting ready to head out, and had the sense he had forgotten to turn off the stove. He checked the stove and realized it was off. He did this two hundred and twenty two times, for good luck. Before he knew it, he had missed his date.

Dema was a 29 year old female admitted to an inpatient psychiatric ward for severe OCD. During rounds one morning, the word “complete,” was mentioned. Dema fixated on the word and became unable to answer any other questions. She repeatedly asked I repeat the word, “complete,” so that she could ensure she had heard me pronounce it correctly.

Mohammad was a 17 year old young man. He presented to my office one day complaining of difficulties studying. He found himself unable to move beyond the first few pages of his notes, as he felt he had to perfectly memorize everything if he were to succeed. He reflected on a similar incident a year prior, where he developed a fear he would forget his memories with a family member. He would repeatedly look at pictures of the memories he had, to ensure they were real memories. This would take hours a day.

***

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

What makes something addictive? Are ADHD drugs addictive? What about sugar?

“I’m going to head to Tim Horton’s for a coffee.”

“Sure, no problem.”

You walk to Tim’s and you begin to realize you’re hungry. It’s 11:45 AM and lunch is only fifteen minutes away. You’ve brought your lunch to work today as well so you should be good.

Just a coffee, you say to yourself.

“Hi, welcome to Tim Horton’s! May I take your order?”

“Hi, yes I’ll have a large coffee with milk, a vanilla dip doughnut, and a pack of those doughnut sticks you have.”

pink doughnut with bite — Photo by rawpixel.com on Pexels.com

What is it that makes fried, sugared dough addictive? Or deep-fried potatoes? Or sour patch kids? Or anything, for that matter?

In our brains, there exists something called the nucleus accumbens. This part of the brain is known as the reward centre. What does this mean? Every time you do something that feels good, this centre “pings,” and makes you feel good. Why does this part of the brain exist? Well, it’s actually essential to our survival! Things like eating, drinking water, and having sex, are vital biological functions for our species. Without them, we would not survive. Very few of us, however, are thinking about, “I need to survive and propagate my genes,” as we eat and have sex. No, most of us do these things because they feel good. That’s where the nucleus accumbens comes in. It pings and rewards us with a shot of dopamine, the brain’s “happiness chemical,” when you do something that’s good, biologically. It’s a built-in incentive system to ensure we are doing, and feel good about doing, those functions essential for species survival.

This system, however, is imperfect, and it is prone to being hijacked. The nucleus accumbens is where many substances of abuse act, including cocaine, crystal meth, and any number of drugs. This is why many people with drug addiction become very skinny, and can waste away. The drugs hijack the system, and reward you more than food. Drugs steadily train the brain that the best rewards come from the drugs, and not food or water or sex. A great example of how strong the craving for drugs can be is a study that examined rats, who had electrodes placed in their brain at the site of the nucleus accumbens. The rats were given the ability to hit a button in their cages, which would activate the electrode, stimulate the nucleus, and cause a reward. The rats eventually choose to die while hitting the button, and totally neglect vital functions such as eating and drinking.

animal cute little mouse — Photo by Pixabay on Pexels.com

But what is it that makes a substance addictive? Sugary foods can be addictive and cause cravings, for example, while carrots almost certainly do not. Cocaine and crystal meth are extraordinarily addictive drugs, while ritaline and vyvanse, medications for ADHD which act similarly, are not. What is responsible for this difference?

We think we know!

The nucleus accumbens appears to be sensitive the the size of a potential reward. Finding a penny on the ground, for example, makes us feel a lot less better than finding a one hundred dollar bill. Biologically, this discrimination has allowed the brain to prioritize eating high caloric foods, over low caloric foods, although both may taste good. (This function would have evolved prior to the food-availability we experience today in the Western world – the drive to eat higher calorie foods is a clear disadvantage to many of us nowadays.) The same principle applies today, which is why sugary, fatty foods are so addictive. The sugar and the fat, the nutrients essential to life which are activating the nucleus accumbens in the first place, are higher in doughnuts than they are broccoli, and therefore we crave doughnuts. This is actually a great example of how the advantage of a particular behaviour, and whether it is a mental illness, depends entirely on context. A drive to eat high caloric foods would have previously been evolutionary essential – now it causes heart disease.

So what’s the deal with drugs?

Well, the same principle applies. The strength of a stimulus is directly proportional to how addictive the substance is. So what affects the strength? Food that are higher in sugar and fat cause a higher level of nucleus stimulation, therefore we crave food that are slowly killing us. This is also true for drugs of abuse; crystal meth is several orders of magnitude stronger than cocaine, and meth is a hell of a lot more addictive. But there’s more! The speed of the stimulus also matters!

man standing beside train — Photo by Trace Hudson on Pexels.com

When a sugar/fat/drug reward is given to us suddenly, the nucleus reacts more strongly to it, and we get a higher reward. This also reinforces the strength of an addiction. This has implications for food, which is why a banana and a candy with the exact same amount of sugar make us feel differently. The candy which instantly digests and gives us a sudden jolt of sugar, is highly addictive. The banana, which takes time to digest and releases the same amount of sugar, just over time, is not addictive!

This principle also applies for drugs, and gets to the root of why ADHD medications are not addictive – usually. The medications used for ADHD tend to digest very slowly, and although they act on the brain in the exact same way as cocaine and crystal meth, are not addictive. This is because that, relative to drugs of abuse, the medications are released very slowly.

The exception can be if you use ADHD medications in ways they are not meant to be – such as snorting or injecting (neither of these are safe methods to use). By snorting/injecting, instead of digesting you get around the bodies need to digest, and you can get a sudden jolt of dopamine, which would potentially contribute to an addiction.

Dr. Travis Barron is a resident physician in Toronto, Canada.