Juggling “choices”….


Doug is a middle-aged man in my family practice, who works a steady job with daytime hours and a regular paycheck. Like many in my practice, his work is also low paying. For those like him, working for minimum wage or with precarious contract or part-time jobs, that means no benefits.

Not for prescription drugs, or psychotherapy, without dental coverage or a day of paid sick leave.

Despite this, more often than not, he’s able to cover his monthly expenses. Sometimes even with a little left to spare.

But lately has not been one of those times. And it’s weighing heavy on both our minds, leading to some very difficult conversations.

Doug has a medical condition that requires life-long blood thinning. To treat it, he’s on a blood thinner called warfarin. It’s a medication notoriously sensitive to diet and interactions with medications, sometimes thinning your blood too much or not enough. But it’s cheap. Even though there are better medications out there, they’re just too expensive for Doug to pay for out-of-pocket. There’s nothing I can do as his doctor to change that.

Recently, despite his close monitoring and diligence, Doug’s blood was just a little too thin. He began vomiting blood and was admitted to hospital. Thankfully, he was stabilized, treated and eventually able to return home.

That’s only part of his recovery story. Despite this major bleed, he still needs to continue on his blood thinners. He also needs a new regime of medications to make sure he doesn’t have another bleed that puts his life at risk.

Like so many patients on the razor’s edge of making ends-meet, this hospital admission may force him to choose between his financial security and physical well-being.

Everyday he’s been in hospital, is a day of lost wages. Everyday he stays home from work to regain his strength from his lost blood, means another day without any income and a depletion of his limited savings. Combined with the cost of the new medications he needs, he’s left with an impossible choice.

Despite being too sick to work, does he force himself to go back to the job to pay his bills? Or, does he stay home to regain his strength, making sure a premature return to a demanding job doesn’t cause him to re-bleed?

As his family doctor, this is a conversation I dread having. It’s one that no prescription pad and no amount of motivational interviewing will fix. It’s a conversation that happens far too often, for too many patients, in too many doctor’s offices.

Does he choose to pay his bills, or does he choose protect his health? What kind of choice is that?

Racism is alive and goes both ways…

I am a Caucasian doctor covering a maternity leave for a physician of Pakistani descent in Mississauga, Ontario.

She is born and raised in Canada, speaks English fully and has no accent.

She wears a hijab and other forms of dress consistent with her religion and culture.  She clearly identifies with her ethnic background and religion.

She is Canadian.

I had no idea racism was so prevalent in Canada when I agreed to cover her maternity leave.  It has shown itself in multiple ways in daily interactions–none so loud and overt as the video we have all seen about the woman yelling for a “white doctor” in a walk-in clinic in Mississauga, but present nonetheless.

Several of her patients, within minutes of meeting me, have asked me to become their permanent family physician since they “connect with me more”.  They known nothing about me or my skills, and have had no opportunity to connect or establish a rapport.   They simply know what I look like.

Then there are the many other patients who I have to work so much harder than expected to win over. They inherently don’t trust me, won’t listen to my opinion or advice and will automatically assume I am wrong.  They are often rude.   You may expect it’s because I’m not their regular doctor except there is a consistent theme as to who these patients may be.

The sad part is I am now able to predict which patients will love or hate me often based on their skin colour.   Something I never expected or anticipated.

Many of the patients of South Asian descent over 50 years old seem to have decided prior to meeting me they don’t like me before I open my mouth.  There have been a few who try to undermine me by asking the reception staff to call the doctor I’m covering for in an attempt to get what they want because they don’t trust me and others who have point blank said they won’t come back until their doctor is back.

There are only a few I have won over and now trust me with their health care.

I find both groups difficult but in light of the video,  I think it’s also important to point out how rude and degrading many people are to those from other ethnicities period. There is a nurse in our clinic who is of African descent and is black.   She faces significant attitude and rude behaviour from the predominantly South Asian descent patient population.

Honestly, I will think twice before I agree to cover another doctor of a different race. 

It wasn’t something I considered when I took this locum position because I know I am not racist.

However, I hadn’t realized so many of the patients would have such a problem with me and be so blatantly rude.

My own family physician is a male of South Asian descent.  I have moved away from him quite a distance, but I still always go back because he is great.

My Canada doesn’t discriminate.


Why I did (but shouldn’t have) become a doctor…

There are a million terrific reasons people go into medicine. Sometimes it’s to follow in the footsteps of a parent or cherished uncle. Sometimes it’s to harness your gifts with people to a higher purpose. Sometimes it’s to build on a budding career in science or community engagement. Sometimes it’s a passion to be in the ER or OR, in the thick of things to save a life, sleep be damned.
And then there are those of us in medicine for the wrong reasons.
I’ve identified five of them: ego; greed; spite; cultural conditioning; and a phenomenon I’m sure I’ll come with a catchy term for someday – the societal understanding that medicine is what smart, accomplished kids are supposed to strive for.
There’s naturally all sorts of overlap here, and I’ll admit to at least three.
Realizing that your place in life is to serve as a poster child for bad career counseling is disheartening to say the least, but it’s also somewhat liberating. I’m free to describe the realities of life as a doctor free from any sales pitch or sugar-coating.
Yes it’s a great career, but it’s not the be-all and end-all, even when you’re a smart and compassionate do-gooder.
So why did I go into medicine? I’m still not entirely sure. In hindsight, my calling might very well have been a wrong number.
(the following is an excerpt from my memoir, The Flame Broiled Doctor: From Boyhood to Burnout in Medicine)
LIKE ANY BRAINY big-city secular Jewish boy, I grew up with an impressive but limited menu of career options. At the top of the list, naturally, was Doctor. If I couldn’t hack organic chemistry, second choice was Dentist. If I couldn’t handle blood, Lawyer. If I wasn’t good with people, Accountant. Family Business was a fallback #5, but nobody in the family had built any kind of “empire”, and I had neither any passion for business nor a head for making deals. I seem to remember Pharmacist somewhere in the mix of recommended careers – “How hard is it to count pills?” my irascible Nana oft inquired – but that one was only pushed on the girls for some reason.
But bright and brainy I was, standing out even amongst the crowd I went to school with, the children of lawyers, psychiatrists, and professors. Granted, my grades couldn’t reach the rarefied heights of those on the Asian kids’ report cards. Too many hours of Nintendo games and reruns of Three’s Company saw to that. But I could walk into a two-hour calculus exam with nothing but a pen – I would never sully myself with something erasable – and stroll out forty minutes later having answered every question and double-checked my work. My aptitude for science didn’t fall far behind my gift for math, and my essay writing was never less than solid.
Coming into university, I was the Total Academic Package, maybe the best from either side of the family.
I was destined to be the family’s first doctor. As far as I knew, or at least convinced myself, that was the endpoint.
Get into med school, game over. You win. That part I understood. Medicine was as close as you could get to lifelong job security, if not always in the city of your choice. Your income ranged from respectable to stratospheric, depending on the specialty, although it honestly wasn’t about the money in my eyes.
And therein lay the problem. Why was I pursuing medicine? I craved the degree, to prove myself to family, friends, and the doubters from times I wasn’t on my game at school. A chip on the shoulder and a little ambition can take you pretty far if you have the right skills.
I just never put much thought into whether I wanted the job.   
forheadshot   Follow Dr. Frank Warsh at http://drwarsh.blogspot.com

My Godmother

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My  biggest hero has always been my Godmother.  She delivered me five decades ago, when my Mother was  considered to be an “old and high risk first time Mom”. My Mother’s age and previous miscarriages made her a high risk patient thus eligible to be consulted on by my Godmother.  My Godmother… She was the Professor of Obstetrics and Gynecology at the time … but also a 35 year old dynamo woman with a great knowledge and reputation.  She was brilliant, dedicated, and when she let her hair down a beautiful woman who had a tinkerbell laugh and smoked coloured cigarettes when she was out with a group..  In that day and age smoking was acceptable.

As I grew up she continued to play a passive role in my life, too busy to be involved on a day to day basis but appearing from time to time to visit and follow my progress.  Subliminally I wanted to be like her.  Have a profession, and make a difference.  She was so different from the other women that I knew.

What I learned from her was to be a role model at all times.  To understand the small differences that make the big differences.

I honestly believe that she played the largest role in me wanting to be a Doctor. I did not grow up knowing any other Doctors personally ~  just my Godmother who was different from all the Mothers that I knew.  She is still alive and was recently honoured by her department for “Outstanding Achievement re Women’s Health Issues”. Still a goal to aspire to.



It was 1964…

My mother was a young new bride, an Italian immigrant, and pregnant with her first child.  She moved to Toronto with her husband, leaving her family including her parents back in Italy.   Nervous, but looking forward to her new family eagerly, she prepared for me in the tiny apartment she rented with my father.

My mother had little understanding of how things worked in the human body and even less knowledge of pregnancy and what could go wrong.  Around the time she was due, she began to bleed.  She was terrified–remember there were no ultrasounds, no “Google”, no phone calls to Tele-health or her doctor.  My father wasn’t home.

She called her neighbour who helped and brought her to the emergency room at St. Michael’s Hospital.  She was wheeled up to Labour and Delivery where her Italian speaking obstetrician was on staff.

When my father arrived, they had to get his written consent in case she needed a caesarean section, not hers.  

That’s how things worked even in Canada in the ’60s.  Women needed consent from their husbands for treatment.

While my mother laboured, the nurses told my father to leave and go home.  Husbands weren’t allowed to stay in the delivery room back then.

So he listened and left.  What did he know?

You listened to the doctors and nurses, without complaining.  No questions asked.

My mother delivered me, but I was not well.  Her obstetrician told her not to worry, saying “la bambina c’ha un problema con la respirazione”  which meant “the baby has a breathing problem.”  

She was told they put me on her belly to hold and her doctor told her not to worry.  She was so happy to have had a little girl.  Caterina was what she would name me.

I was born with a congenital diaphragmatic hernia, but no one told my mother this.  I was whisked away to the Hospital for Sick Children where I was fortunate enough to have life saving surgery to repair my birth defect.

For three whole days however, my mother was unaware.  When she would ask the nurses to see her baby, they told her that they had already fed the baby and that I was sleeping.

When my father and their friends came to visit her in the hospital (back then you would stay in hospital for a week),  she noticed they all looked sad.   She would ask them “what’s wrong? …is my baby not beautiful?”  They all continued to with-hold the truth from her, thinking I might not live.

They even called a priest and had me baptized in keeping with the Catholic faith.

They kept this from my mother also.

On the third day, a tall doctor stopped by my mother’s room to speak to her.  He introduced himself as the surgeon from the Hospital for Sick Children.  My mother barely understood what he was saying.  He told her that her baby was fine; that I was very strong.  She was in shock.

My baby is fine?  What was he talking about???

The surgeon was in shock that she had not been told anything.  He explained to her:  her daughter had been born with a hole in her diaphragm and that her abdominal contents were spilling into her chest at birth.

But I was a very strong baby, and by then had passed the point of danger.

My mother was shocked, angry, worried and grateful all at once.  How could her doctor, nurses, husband and friends have all kept this from her for 3 days?

She felt betrayed for trusting the nurses when they told her that I was resting and fed.

But what did she know?  She was a young Italian immigrant with a grade 6 education.

My mother was brought to see me at the Children’s hospital but could not touch me for the incubator.  I was in there for 45 days and every day she took the bus to come nurse and hold me.

And so with this experience, my mother became determined that I should become a doctor.  She planted the seed in my head from when I was a small child.

When I was doing my paediatrics rotation in my third year of medical school, I went to medical records at Sick Kids hospital to track down my own records.  Wearing my own lab coat, I told them that I was there to retrieve my own medical history now.

This is why I became a doctor…for my mother.

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Why I became a family physician…

Watching a loved one suffer is one of the worst experiences you can go through… it’s worse than having the pain inflicted upon you directly.

My sister has always had health issues.  Throughout our childhood she struggled -hospitalizations, chronic illness. One thing after the other.  It shaped our lives as kids. My parents were always trying to stay on top of it…I saw how the struggled with the health system but of course I had no insight as to why.

This time was different.  I saw it the day she picked me up coming home for a visit from med school–her right eye was opaque.

“What’s wrong with your eye”? I asked her as I climbed into the back seat– “you need to go to ER!”

” I know,” she replied, “it just started a few hours ago and it really hurts but I want to wait till later so the ER isn’t so busy”

“No! It could be an ulcer, it could be acute glaucoma! You can lose your vision” …all my newfound knowledge flowing as I panicked.

But my sister was adamant. She did not want to wait for hours in the ER as she has been through this many times before.  She would wait.  She was “working” the system.

I went home and worried. Sure enough, she came home in the early morning with a patch over her eye,  antibiotic drops for a corneal ulcer and a plan to see the eye doctor (opthamologist) again in a few days.

The pain was excruciating-I could see it. She went straight up to bed, in the dark room with ice over her head and cried.  Nothing we had at home for pain would touch it.

I debated.  Who was I but a fourth year medical student to call the on-call resident?  But I knew. I knew that this pain was wrong; she needed more.  I even looked it up to make sure I wasn’t over-reacting.

I called.

I was a fourth year medical student.  I wasn’t certain about anything but I knew that I had to do something-in this case, I summoned up my nerve and called the doctor on call and pushed. In the end, the resident agreed to have my sister come to the clinic the next morning for re-evaluation and treatment.

That was my first time advocating for a family member directly and it taught me a lot about our system.

That it relies on advocates to speak for patients, to push for help; resources are stretched so thin that if there isn’t someone to speak up, that person will fall behind.

So where does that leave those who have no one to speak for them?  The ones with no voices?

That experience may have been the driver for why I became a family physician.  It is part of my role now – a big part.

It is my job now to speak for my patients-especially the ones who’s voices are not heard loudly.

It could have been me…

pexels-photo-341378She was 49 and was excited for her 50th birthday the following year.   We developed instant rapport–she had 2 young children and so did I.  I knew multiple members of her extended family.  While doing her introductory visit and exam, we chatted about our common interests–interior design and real estate.  She was my patient and about 10 years older than me, but we could have easily been friends in another setting.  

 I could have been her.

A little while after I met her, she had an episode of chest pain and went to the ER.    They checked her heart and lungs -all was normal. She went home, the pain having passed.

I called her when I got the ER report and asked her if she was ok.  She reassured me everything was fine, she was feeling better.  Nevertheless, we made an appointment to follow-up so I could check on her.

She didn’t tell me about  the severe headaches she had been having.  She didn’t think they were relevant.

When I saw her later that week, I questioned her about her symptoms.  She told me that one day, a few weeks ago, she noticed her mouth was drooping for a few hours.  It went away so she didn’t think it was anything important.

I kept calm and directed my questions but inwardly, I started to panic.  Of course I worried she had had a mini-stroke, and was at high risk for a full blown stroke.  I started mentally reviewing her risk factors as I did a neurological exam.  She had none–no family history, not a smoker, no high blood pressure, no diabetes etc.  

We discussed her returning to the ER that night for an urgent MRI but she declined.   I agreed. It was unlikely that they would be able to do one for a symptom from a few weeks ago.   But I knew it would take me months to get an MRI if I requested it so I asked a neurologist colleague to fit her in urgently.  I figured that would expedite things if there was a concern.

She postponed her appointment without telling me.  Things had come up with her kids and as a mother, she put their needs before her own. 

When she eventually went, and finally did a scan of her brain…it showed multiple tumours.  Her bone scan and other tests showed metastatic cancer but it took weeks to find out what type. Eventually a hip biopsy confirmed lung cancer.

A life time non-smoker, who’s only complaints were one episode of chest pain and a droopy mouth. I was dumbfounded. 

She could be me.

I remember sitting at the kitchen table in my office, reading the report.  I started crying as I filled in my colleague.

She’s so young.

Over the next several months, I left her medical care mostly to her oncologists and then her palliative care doctors.  I went to her home to meet with her husband and her–to provide support, and answer questions.  I had nothing to give them but my time.

Knowing  what was to come the whole time. 

She made it to her 50th birthday but died that year, surrounded by her family at the bedside.  I attended her funeral visitation because as her family doctor it was important to me to say goodbye. To give words of comfort to her husband and children. To let them know that no matter what, their mother’s love and her presence would always be with them.

Journey to New Life

baby-408262_1920I walked trembling and tearful into one of my mentors office interrupting him at his work. His initial smile turned to a look of alarm.  “What’s wrong Chief?” was his response. I had just come from the ultrasound department with the bad news.

Again no fetal heartbeat.  No baby. I was to be admitted later that day for a D and C.

So he let me cry for a few minutes, and before I asked him if I could become a patient, he reassured me that he could help me.  Of course he could help me, he was and is the Guru of Fetal Loss.  He specialized in helping women through high risk pregnancies including repeated miscarriages.  He would joke about how he just sprinkled pixie dust to get results, but we both knew that his expertise and interventions were scientific, sometimes complicated and always carried out with the greatest compassion and knowledge.

So started my “Journey to New Life”.  That was my 3rd miscarriage over a period of about 14 months.  The first felt like a normal happenstance,  the second upsetting,  the third desperate.

I became a patient with little control over my situation.

I relinquished that control and allowed myself to follow the advice given to me.  The pregnancy “stuck” with low dose Aspirin and Progesterone.  I required bedrest for most of the second and third trimesters.  It was my own journey  but my doctors accompanied me with the most detailed maps.  I am not sure I would have reached my destination without them.

And then I remember looking at my baby,  3 weeks early and screaming like a madman. He was the greatest gift then and still is today.

Sometimes it takes an entire team to make a baby.  Sometime it takes an entire team to become a mother.  For this, I am eternally grateful.

Confronting myself…

I knew I had PCOS (polycystic ovarian syndrome) so as soon as I got married, we started trying for a baby. After 1 year of trying on our own didn’t get us anywhere, we sought out infertility treatment. 10 months after that, we got our first positive pregnancy test.

I was on call one weekend early into the pregnancy.   I started spotting during my anaesthesia shift but I covertly used a mini ultrasound in the operating room I was working in, to check that the baby’s heart was still beating.

Two days later, the spotting was worse and when I again checked for the heartbeat, it had stopped.

 I stopped.

I hadn’t told anyone yet that I was pregnant, but I had to share it with the staff now so I could see my doctor.

An ultrasound through my family doctor confirmed the loss.  I took a day off work, and then went back.

Waiting to miscarry.

It took a year to get another positive pregnancy test.  A year of endless trying-ultrasounds, blood tests and injections to try to get pregnant.  I did this in the very early mornings before the operating rooms started at 7:45 a.m.

This one ended a few days later, even before it really began.

I couldn’t keep it private.  I was immediately sent home and soon, the entire department knew about it as they tried to cover my shifts.  I was an anaesthesia resident and our on-call schedules didn’t really leave room for anyone to be missing shifts.

It took 4.5 years.  4.5 years of heartache and tears.  We finally did IVF just at the end of my residency and were blessed with our beautiful daughter.

Those were hard years–I spent my days doing epidurals and anaesthesia for expectant mothers, while dealing with failed cycle after failed cycle myself.  Occasionally I would be giving pain medication to a mom terminating a pregnancy in her second trimester for reasons I struggled with, or giving sedation for abortions of unwanted pregnancies.

Each time a baby was born,  I was confronted with my own infertility.  Each time a termination happened, I couldn’t help but think of how I would have loved to adopt.

Even since I became a mother myself, I’ve still had these feelings.  My heart aches a little each time I’m present at a caesarian section and see new parents overjoyed at meeting their baby, something that I’ll never get to experience again myself.  But I know that my experiences have also made me more compassionate towards those going through the same struggles and who are dealing with losses of their own.

Being a doctor makes me confront my infertility daily.  I do sometimes wish I wasn’t constantly exposed to things that still wrench at my heart. And then I put my chin down, buck up, and care for my patients as I was trained to do, relieving their pain and seeing them safely through procedures.

And at the end of the day (or sometimes at the end of the next working day if I’ve been on call), I go home and hug my daughter just a little bit tighter, eternally thankful that she’s ours.

Kate Ryan baby

Letter from a Mom of a Young Man with Autism

city-person-relaxing-sittingHere are some things that I would like to tell parents of children on the spectrum:
Try to not be totally devastated by the diagnosis.  Your child is still the same lovable, adorable child that you had before the diagnosis.  The diagnosis has not changed your child.  He/she is still the same wonderful person and you can still have the same dreams for that child that you had before.  The only difference is that there are going to be a lot more challenges for you and it is going to be a lot more work in the beginning.  But in the end it will be worth every ounce of effort.  Parents always love their children unconditionally and they always love their children for who they are.  That is never in question.  But have faith, there will also come a time, and it may take years and years, but there will come a time when you tell yourself that if you had to do it over again, you wouldn’t even want the path to change.  Even though it is tons and tons and tons of work, (and costs tons of money), it is totally worth it.  It is such a true high to be a parent of a 16 year old autistic young man and look at him and know that you totally have it made.  It is the best high on earth.
Don’t ever let other people put limits or ceilings on what your child can do.  Trust your gut.  Trust that inner brilliance that you see and work like hell to find people to help you pull it out.
A diagnosis is truly a double-edged sword.  I tried, in the first few years to keep it a secret.  I took my son to all the therapists and ABA and everything else, but I fought like hell to keep it a secret from the neighbours or the dentists or anyone else.  Honestly, it was a complete disaster.  People would think my son was being “bad” instead of having sensory challenges or receptive language challenges or a lack of awareness of social skills.  Once I started to share the diagnosis, the perspective of others, and their attitudes to him totally changed.  It went from judgement to  compassion.  Where there was frustration and dislike came patience and understanding.  If I can give you one piece of advice, don’t share this burden alone.  Give others a chance to step up and help you lighten the load.  Some won’t step up … they just don’t get it.  But you would be amazed at how others do … including children.
When sharing the diagnosis or telling people, the number one thing is to ensure that you never talk about your child in third person in front of him.  Maintaining your child’s high self esteem should be your number one priority at all times.  I made up a “Passport” that I would give to the optometrist and dentist and others before they met Stephen.  When the optometrist called my son in, I went to him and said, I have something for you to read first.  It had a photo of my son on the front and it said:
“Hi!  My name is Stephen!  I have autism.  I’m a really smart kid, but I need your help sometimes.  Please make sure that I am looking you in the eye when you talk to me to make sure that I hear what you say.  If I’m not, please say ‘Stephen, can you look at me?’  I have a hard time with new places and new situations, so if you tell me first about what is going to happen, it really helps me a lot.  I’m also really afraid of loud noises, so if you could tell me before there is a loud noise, it will help me to not be so frightened.  If you take your time, be calm and explain everything to me, things will be just fine and you will find out that I am a really awesome kid to meet!  Thank you so much for helping me!”  I cannot tell you what a difference that the passport made in the way that other people treated my son and I .