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
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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
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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 a patient or a client?

Depending who you’re asking, you might not always get the same answer.

I had just begun working at a psychiatric hospital in Ontario when this quirky word suddenly became part of my vocabulary – client. I had met countless patients before but these clients, it would seem, represented a new hurdle. What is a client? What do they want? Do they like the Raptors? Do they drink water?

Well as I would come to learn, clients are not so different from patients. Clients breath air, live in cities, and walk among us. They suffer from depression, anxiety, mania, and psychosis. They have addictions.

So what makes a client? Themselves.

man and woman shaking hands
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Medicine is rooted in a millennia of traditions. Some of the principles of medicine still used today date back as far as the Ancient Greeks. Hippocrates, and the Hippocratic oath, remain a quasi-initiation at the front end of most medical schools. Leonardo DaVinci, and his drawings of the human body, can be considered to still have an impact on the field of medicine today.

With all history, we tend to focus on the highlights, and leave the dark corners undiscussed and ignored.

Paternalism is part of medicine’s darkest legacy. What is paternalism? Here’s a long, winded answer.

In broad strokes, medicine is super #$%&ing complicated. No doctor understands all of medicine perfectly, and we certainly don’t expect a patient/client to understand all, most, or even some, of medicine. As a physician, my job is to explain the relevant information to you, so that you can make your own decisions. I have the responsibility to give you the required information, and to ensure that whatever I do, is in your best interests. This results in something called a fiduciary relationship, meaning that if you need a test ordered, it is on me to order that test, even if it’s seven o’clock in the evening on a Friday and the Blue Jays are about to take their first swing. Fiduciary relationships are a great and essential part of medicine. I reiterate my comments on just how complex medicine is! However, there are also some unwanted side effects.

person using black blood pressure monitor
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As a doctor, if you are under my care, as we would say in the field, I am taking ownership of your care. This doesn’t mean I own you or your property, but basically that I am the captain steering the boat that is your health into harbour. Ownership in many ways is how things get done in medicine. If nobody feels responsible, than who would make sure your x-ray was ordered or that the proper consultations had been made, after all. Like all captains, we have a natural aversion to back seat drivers. “I know how to lay the anchor, so bug off!” kind of deal. We can even start feeling this way when the patient has different opinions from our own. Sometimes, we can even have a natural tendency to dismiss a patient’s thoughts when they conflict with our own. This would be paternalism, or in other words, a medical care model where the doctor’s wishes are given the highest priority, although presumably to save your life (whether or not you want your life saved – a whole other discussion there).

In another time, only decades ago, you might find that this is actually how medicine was practiced. What the doctor says goes. Forced sterilization and lobotomy being some more infamous examples. Today, we know better.

You are the captain, and I am the first mate. I help you navigate, but it’s up to you to steer. As a physician, it’s my job to listen to your concerns and give them thoughtful reflection, no matter how they may conflict with my own thoughts. This doesn’t mean ordering unsafe medications or needless tests, but giving an honest, thoughtful, patient-centred approach to care in all respects. This is the opposite of paternalistic medicine.

So what does this have to do with the whole patient/client conundrum?

Patient is a physician-born word. It’s language we have always used to describe those we care for and it’s comfortable. But some people take offense to that word, and that’s OK. This is particularly important in psychiatry. The reasons for this? They’re many and complex, the stigma associated with being a “mental health patient,” born out of 20th century mass media being the most surface-level example. In psychiatry, the word “client” carries particular meaning, and has more voluntary connotations than “patient” can sometimes imply, given the history of (at times necessary) coercive treatment in psychiatry. The point is not every “patient” likes the word, and they have a right to not be addressed that way. Mental illnesses are to many, after all, not considered illnesses, and people would prefer to describe their experiences as something akin to psychological distress.

space needle under blue sky
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At the hospital I worked at in Ontario, the alternative term adopted by the institution was ultimately “client.” (As a side note, we borrowed this word from out psychologist colleagues!) They chose to institute an institution-wide movement to address every single patient as a client. As you can see from reading this blog, I obviously don’t do that. But I also do not call everyone a patient. The reality is, I am more comfortable with the word patient and it’s been what I’ve always used. But the moment my client or patient or glerblegerker let’s me know that they disagree with the idea of being a patient, I’m quick to change my language with them. It’s about them, after all.

So you tell me – are you a patient or a client?

 

 

Editor’s note: Mental illnesses are true illnesses from my perspective, but not because of any of the particular symptoms you have – hear and chat with the voices in the empty room all you want. To me, your experience is an illness when it begins to interfere with your functioning and safety.

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

Goodbye Psychiatry, I’ll miss you!

Getting off of the 501 streetcar, I realized this may be the last time I make this trip for a while. I soaked in the Ossington Avenue intersection, after almost being ran-over by a passing car (ah, the familiar feeling), and walked towards the doors of the Centre for Addiction and Mental Health (CAMH). As I peered at the campus, my sense of loss was accented with fondness and the strange intervention of excitement at what is to come.

I had officially departed the Department of Psychiatry, and joined the Department of Family Medicine.

19623600_1882847292039496_9104144131264872448_nI know what you’re thinking. This guy with the mental health blog, leaving psychiatry? That doesn’t make any sense!

All I can say is, we all have our own journey.

During my time in psychiatry, I worked in a variety of hospitals across the city of Toronto, CAMH being among the most memorable. I had the privilege of working with some of the world’s – that’s rights, world’s – leading experts in mental health. It was truly an honour. Psychiatry has given me more than I can possibly express through the lens of a blog post. I know that because of the Department, I am a better person, and a better physician.

So what gives? I just wasn’t happy.

The supervisors and colleagues I have worked with in psychiatry have done, and will continue to do, amazing work and help heal some of society’s most marginalized. For myself, the opportunity to see a broader variety of people, and be more of a utilitarian with my skills, as opposed to a specialist, has come to reveal itself as important to my happiness. I remain passionate about mental  health. Every single one of us is touched by mental illness, in some way. There isn’t a patient that presents to a physician anywhere in this country who hasn’t been influenced by their own psychology.

_DSC3796The absence of a mental  health system in Ontario has played a role in this difficult decision. The number of times I have recommended CBT to someone, knowing their options are 1-2 year waitlist or out-of-pocket, is heartbreaking. Discharging severely unwell people, with attenuated psychotic symptoms, or severe drug addiction, to the street, because the waitlists for supported mental health housing can be almost a decade, is gut wrenching.

This is no fault of my amazing colleagues, who at this very moment continue to fight and advocate for the patients for which they care. Malignant neglect by the government’s of this province – and frankly, the country – have resulted in a patchy system with too many holes.

It’s not all bad – change is coming. The programs CAMH continues to create and advocate for are world-class and industry-leading. But as I am sure many of you know, there remains a way to go.

Which for me, means it’s time to move on. And I’m excited. For new beginnings. For a change of pace. For brighter days. And for my General Surgery rotation (just kidding, terrified about that one!)

Goodbye Psychiatry, I’ll miss you.

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