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A surgeon’s account of physician burnout and depression

How the social dynamics of Canada’s health care system may obstruct patient care

A surgeon’s account of physician burnout and depression

The growth in mental health awareness and advocacy around the globe has exposed the psychological limits that individuals can reach in academic- and career-based paths. Terms like “burnout” — the intense emotional, physical, and mental exhaustion connected to excessive stress — are often linked to depression and anxiety.

In sensationalized careers like medicine, it might come as a surprise that burnout plagues the medical world to a staggering extent. A 2018 national survey by the Canadian Medical Association indicates that one in four physicians experience elevated levels of burnout, while one in three screen positive for depression.

In a recent editorial published in the Canadian Urological Association Journal, Dr. Martin Koyle, the Head of the Division of Urology at The Hospital for Sick Kids, recounted his personal experiences grappling with burnout and depression as a physician.

The Varsity sat down with Koyle to discuss his challenges with depression and burnout in his lifelong career in medicine. He contended that his experiences stem less from the practice of medicine itself and more from the bureaucracy and social dynamics entangled within the Canadian health care system.

Koyle’s experience in the medical system

Koyle’s recollections began in 1976, when, as a fresh medical school graduate, he moved from Canada to the United States to begin his long and accomplished career. He’s practiced medicine in Los Angeles, Texas, San Francisco, Denver, and Seattle. He was employed in positions varying from academic faculty to Chief of Pediatric Urology and Renal Transplantation.

While practicing in the United States, Dr. Koyle spoke highly of the Canadian universal single-payer health care system, placing it on an esteemed pedestal which he hoped the US could one day emulate. 

However, the intense public scrutiny that came along with his position as Division Chief at the Seattle Children’s Hospital, coupled with a personal family tragedy and a physical injury, led him to return to Canada in 2011. In Toronto, he began his practice as the Head of the Division of Urology at The Hospital for Sick Kids.

Upon returning to Canada, Koyle promptly realized that the Canadian health system was quite different than the romanticized version he had been promoting during his time in the US.

“I realized from day one that all that I was, was a number,” he said. The system, although advertised as universal, lacked strongly in quality of patient care and career gratification. In the US, Koyle discussed his feeling of belonging to a “community” and being “part of a family.” He personally knew other physicians, and trusted them with his patients when referring them to other specialists. He also felt a general feeling of gratification and mutual appreciation within this supportive network.

In Canada, however, this community aspect was lacking for Koyle. He especially felt uncertain of who would assess his patients in the future. “I didn’t know any of my patients. They didn’t know me. I didn’t know who would see them in follow up,” he said. These factors were further discouragement which added to the climate of emotional hardship.

Koyle also mentioned that the sense of entitlement to health care in Canada contrasts to that of the US, where patients failing to respect wait lines and no-shows are more common, causing other patients to wait longer in order to receive the care they need. To top it all off, recent intense hospital budgeting in Ontario has undercut the quality of patient care available, in ways such as limiting operation times for patients during surgery.

As Koyle summed up his contrasting experience practicing in Canada: “My support from the institution is very different, my control in my environment is very different, my relationship with my patients and with their families and with their providers is very different, and the outcomes are very different in that in the States where my primary physician… was the quarterback in the system in that patient’s care.”

“Here, the buck stops at me… I’m not providing the healthcare that I want to provide to people [due to these social dynamics of the Canadian health care system].”

Koyle’s experiences in a wider context

Although Koyle emphasizes that these experiences are his own, and that some aspects of his burnout and depression are connected to personal challenges faced in his life, he is most certainly not alone in his experiences with mental health challenges in medical careers.

A recent review underscores the factors contributing to Koyle’s burnout: most cases of physician burnout in Canada are neither related to patient care, nor to the practice of medicine itself. Factors such as bureaucracy in the health care system, as well as negative social dynamics with other health care professionals and coworkers, play a more prominent role. 

Factors such as bureaucracy in the health care system, as well as negative social dynamics with other health care professionals and coworkers, play a more prominent role [in physician burnout, compared to the practice of medicine itself].

Notably, with physicians expected to constantly project a “healthy” image, it’s not surprising that studies show that only eight per cent of urologists suffering from burnout seek professional help. This strikes a chord for Koyle, who recalled his own hesitation and fear in initiating regular appointments with his now-psychiatrist.

“You’re afraid that somebody will find out, that you’ll go in and somebody will say, ‘he’s crazy.’” But Koyle, who is now open to discussing his appointments, has found that his psychiatrist has helped him to a great extent, in addition to his yoga and practice of meditation. Today, he is a strong mental health advocate, and encourages those battling with burnout and depression to seek the help that they need.

When asked about his thoughts on hope for the future, Koyle is cautiously optimistic. Having recently finished a Master’s degree in Quality Improvement Patient Safety, with another Master’s connected to international health policy and leadership underway, he aims to develop a skillset to change the climate of the system he works in — both for the benefit of patients under the system’s care, as well as for physicians who impart treatment.

Opinion: A national pharmacare plan could rein in soaring drug prices

Lack of prescription drug coverage has led to some of the highest costs in the world

Opinion: A national pharmacare plan could rein in soaring drug prices

Canada has one of the highest prices for prescriptions drugs in the world. Prescription drug spending has become the second-largest cost to the Canadian health care system, ranking only behind hospital expenditures.

That cost is only rising.

A number of factors, such as demographics and prescription volume, are responsible for this increase. However, the main factor driving up overall spending is the ballooning cost of prescribed medications itself.

The drug development process

The pharmaceutical industry has made incredible advances in recent years. There are now medications that can help manage and even cure diseases that were once untreatable. However, these medications often come with hefty charges. For example, the cost of hepatitis C treatment can well exceed $100,000 per patient.

It is estimated that these high-cost drugs will account for 42 per cent of prescription drug expenditure by 2020, a figure that is well above its 17.5 per cent share in 2010.

According to pharmaceutical companies, the steep price is needed, in part, to finance the extensive drug development process. This process takes well over a decade and includes preclinical testing, clinical trials for safety and efficacy, as well as the federal drug application review.

For every 5000 compounds discovered, five drugs enter clinical trials and just one new drug receives federal approval. Although most firms decline to disclose the cost of research and development, it can vary from several hundred million dollars to over $12 billion.

Once the drug is approved for sale in Canada, the Patented Medicine Prices Review Board (PMPRB) — a federal agency — sets the maximum price of the drug based on the price of similar medications on the market.

Prescription drug coverage in the Canadian health care system

Canada is the only high-income economy — nations with at least $12,056 USD in gross national income per capita — with a public health care system that does not include prescription drug coverage. Although drugs administered in hospitals are provided to patients at no cost, patients out of hospitals must purchase prescription medications either through insurance plans, whether public or private, or from their own pocket.

Public insurance plans are offered by provincial and territorial governments to special populations, such as the elderly, individuals with disabilities, and unemployed individuals. Private insurance plans may be available as a benefit to individuals through their employer.

The number and type of medications covered by public and private insurance plans vary significantly. Patients who have neither a public nor a private insurance plan must pay for their prescriptions themselves.

Furthermore, due to the presence of multiple public and private insurance plans in Canada, there is no single agent for pharmaceutical companies to bargain with when setting drug prices.

“When you have a single agent, [that agent has a] much stronger ability to drive down what [Canadians are] going to pay,” said Dr. Jodel Lexchin, an associate professor at U of T’s Institute of Health Policy, Management and Evaluation, in an interview with The Varsity.

“Drug companies know that if they cannot reach a suitable price with that bargaining body, then they may still be able to sell the drug in the country.”

However, Lexchin noted that companies are disincentivized from selling prescription drugs directly to the public. The firms would receive less revenue, as insurance providers can afford to pay higher prices for prescription drugs as opposed to patients who are paying out of pocket.

The role of the Patented Medicine Prices Review Board

The PMPRB attempts to mitigate the lack of a single payer health care system in Canada by controlling the prices of patented drugs. The organization can challenge the price of patented drugs sold in Canada and demand pharmaceutical companies to repay some revenue.

While the number of investigations into high-cost drugs has been rising, regulations proposed by Health Canada would allow the PMPRB to assess the value of new drugs by reviewing cost-effectiveness analyses, which may lower maximum drug prices.

However, these individual successes are unlikely to have a significant impact on the pricing war between pharmaceutical companies and bargaining agents. The PMPRB can control the price of a single high-cost drug on the market, but subsequent drugs may also be priced outrageously upon entering the market.

Considering it is not feasible for federal agencies to open investigations into all emerging high-cost drugs, Lexchin believes that a system-level change to address drug prices is needed.

Drug prices in the global pharmaceutical market

“The only group that really benefits [from high drug prices] are the companies that are making the products,” explained Lexchin. These are multinational companies that have substantial power in the United States. For this reason, the US has the highest drug prices in the world and a considerably larger market than Canada.

Pharmaceutical companies worry that similar prices could spread into the US, if Canada attempts to lower our drug prices. Therefore, these companies lobby the American government to put pressure on Canadian officials and prevent regulation that would result in lower drug prices.

Despite having lower prices than the US, drug prices in Canada are already greater than the global average. Drug prices in other high-income countries, such as Denmark, can be less than half of those in Canada.

Many of these high-income countries have a universal health care system that includes prescription drug coverage. Having a single payer system for prescription drugs gives them greater bargaining power and effectively reduces drug prices. Other countries may have profit controls.

Either way, pharmaceutical companies must control drug prices such that their profits are within the designated margin.

Next steps for Canada

There have been growing efforts within the federal government to establish a national “pharmacare” program. This means that prescription drugs would be covered as part of the universal health care system.

A national drug plan requires a national formulary, explained Lexchin, which is a list of medications covered by public insurance. Drugs on this formulary would be selected based on evidence of cost effectiveness.

For example, if five drugs in a class of medications are equally effective and safe, but vary in price, the government may only elect to pay for two of the five medications. The plan would only pay for the most cost effective medications in that group, without compromising safety or efficacy.

Patients may still be able to use private insurance plans or out-of-pocket payments to purchase the other, more expensive medications.

But without effective reforms, such as national pharmacare, drug prices in Canada will continue to rise. Several drugs already have an annual cost exceeding hundreds of thousands of dollars,  which can mean a difference between life and death.

For most Canadians to be able to afford these life-saving medications, however, reform must take place to rein in these current drug prices.

Menstruation frustrations

A cycle of quiet suffering on campus

Menstruation frustrations

Several days ago, I was having a conversation with my friends about the worst bathrooms we have seen so far at U of T, and while some of the characteristics that came up were expected — such as laughably-bad lighting, poor design, and lack of hygiene — a recurring theme also emerged: most of the bathrooms mentioned were not designed with menstruation in mind.

Whether it is dim lighting or cramped space, these spaces are already frustrating on a regular day, but when it comes time to deal with all of your period blood, the ridiculousness of the situation becomes even more evident. Since these unpleasant and tough situations only come about once a month, it seems much easier to just forget about those problems entirely.

This perspective is often shared by those who don’t see the value in investing in better bathrooms or creating better policies. In high school, my friends and I would have issues keeping up with school events and exams while dealing with our periods, but we were advised to “just deal with it,” since the ‘issue’ would go away in a few days and then we could forget about the problems until next month. But the real systemic issues never go away: somebody is always going to be menstruating, and members of the community will continue experiencing the same problems day by day unless the problems are addressed.

Although the taboo surrounding menstruation has lessened quite a bit over the last few decades and conversations surrounding it have become quite normalized, important changes have yet to be made with how the topic is handled. One would expect U of T to be better at this than other institutions, given its work on inclusion and its position as a global leader, and yet it still fails to have the most important conversations surrounding menstruation and provide appropriate avenues for support.

On a small scale, it’s generally much easier to have conversations about menstruation face to face, but even that approach has its own difficulties. How comfortable can it be to approach an old, male professor to talk about your bodily functions? In any case, these face-to-face conversations are nearly impossible at U of T, where classes are being taught to over 90,000 students every semester, making staff members even harder to communicate with and access.

But why are we even having these conversations? Why can’t we “just deal with it” and move on with our lives? Shouldn’t we be used to it by now? Can’t we just go to the doctor and get our problems permanently fixed? Why is menstruation such a big deal?

Well, periods can range from merely irritating to debilitating, and they don’t stay the same from month to month, much less throughout one’s lifetime. Along with a loss of blood, accompanying symptoms include headaches, exhaustion, cramps, nausea, light-headedness, and even fainting. There are several options to deal with these effects, such as birth control pills or painkillers, but the fact of the matter is that for many people, menstruation is difficult to endure, and no matter how many times they experience it, there’s still no guarantee that they’ll be prepared.

What are the systemic challenges that can be expected for someone getting their period at U of T? Let’s say that you go to the bathroom half an hour before the beginning of a midterm, and you’ve been feeling a bit off all day. You realize that you’ve gotten your period early and you’re completely unprepared: you don’t have anything to stop the flow and you’re freaking out in your stall. While U of T bathrooms have sanitary waste disposals for period products, some bathrooms don’t have operable pad and tampon dispensers, with some appearing to have been around since the dawn of time.

So, instead, you can ask a friend, or even a stranger, if they happen to be carrying a tampon or a pad. But this isn’t high school; your friends might be in a class on the opposite side of campus or there might not be anyone around. If you want to buy period products, you’ll likely have to go to the nearest drugstore, since they’re not nearly as easy to get on campus as free condoms and lube. As a last resort, you may be left relying on paper-thin toilet paper, an option that is used far too often, even in today’s day and age.

Now that you’ve successfully staunched the flow, you start feeling those dreaded cramps, and nausea on top of that too. What can you do? Perhaps you can buy some painkillers and ginger tea, but your midterm is now in 15 minutes and you know that it might take up to an hour for those cramps to go away, even with the painkillers. If you take the midterm, there’s a chance you’ll screw something up because of the pain, but there’s also no guarantee that you’ll be able to take a makeup test.

It’s generally more likely that you’ll be allowed to reschedule the test last-minute if the class is a small one, but for larger classes, you might run into trouble; some courses require valid documentation to be sent within 24 hours of a missed test. This documentation should either be the equivalent of a doctor’s note or a note from your college registrar, and missed labs require a doctor’s note. It’s easy to see why this system is flawed: doctor’s notes can be bought and faked; some doctors give notes too easily, while others never give them; and ultimately, pain is difficult to prove in any circumstance.

It’s challenging to figure out how the rules should be fixed, since a balance should be maintained between not encouraging people to lie about their pain, while also helping those who really are experiencing it. In terms of solving these bathroom problems, all bathrooms on campus should meet certain standards. All stalls should contain proper sanitary waste disposal, and functioning pad and tampon dispensers. For such a necessary part of daily life, menstruation products are quite hard to find, and U of T certainly isn’t making it any easier to get them where they’re most needed.

How should we start addressing these concerns? First, we should acknowledge the problems and ask students and staff what changes they want to see across campus. Then, the bathrooms on campus should be improved, starting with those in colleges and buildings with higher foot traffic. Course and testing policies concerning sudden illness should be updated, and U of T should explicitly outline what measures should be taken when conflicts arise between schooling and personal health issues, such as those brought about by menstruation.

It’s important to realize that most of the people dealing with these issues are female, and failing to address them would mean giving half the students at U of T, around 45,000, a systemic disadvantage. The issues aren’t going to go away by themselves, and it’s incredibly easy to forget about them unless it happens to you. Once you start noticing flaws in U of T’s system, though, it’s impossible to stop, and every time you count yourself lucky for not being stuck bleeding in that dark, cramped bathroom in the basement, you’re neglecting to realize that your inaction only means that someone else will experience it instead. 

Bernie Sanders speaks at Con Hall

Former Presidential candidate talks health care, human rights, Tommy Douglas

Bernie Sanders speaks at Con Hall

Convocation Hall buzzed with energy the morning of October 29. Senator from Vermont and former Democratic presidential nominee Bernie Sanders was in town to give a talk titled “What the U.S. Can Learn from Canadian Health Care” to a packed house at the University of Toronto. The talk came a day after he toured Toronto hospitals as part of his broader efforts for American health care reform.

“We had a wonderful trip,” said Sanders. “We learned a lot about your system and the extraordinary things your system is doing.”

Canadian and American health care

Sanders’ talk centred on the successes of the Canadian health care system in comparison with its American counterpart, and it reflected Sanders’ prescription of struggle, grassroots action, and human rights in light of an unequal society.

“We in the United States have got to ask a simple question,” posited Sanders. “How is it that here in Canada, you provide healthcare to man, woman, and child, and you do it for 50 per cent of the cost that we spend on health care in the United States?”

In her introduction of Sanders, Ontario Premier Kathleen Wynne said she hoped Canada’s system would serve “as a beacon for Americans as they consider health care options.”

Sanders is pushing a new bill in the US called Medicare for All. The bill would, in essence, bring a form of universal health care to the US, but it would go further than the Canadian system to cover dental care and prescription drugs.

Sanders identified prescription drugs and dental care as a shared gap in Canadian and American health care. “Our job is to tell the pharma industry that they cannot continue to rip off the people of the United States, Canada, or anywhere else while they are making unbelievably excessive profits,” he said. “Dental care is a part of health care and cannot be ignored.”

Dr. Danielle Martin of Women’s College Hospital and the University of Toronto joined Sanders on stage for a discussion after his remarks. Speaking to the media after the event, she addressed salient issues in Canadian health care head on. “We’ve been doing an excellent job in many Canadian jurisdictions in addressing wait times, but there’s a lot more work that has to be done,” she said. “There’s also a lot more work that we need to do in ensuring access to prescription medicines.”

Health care and “struggle”

Much of Sanders’ rise to mainstream fame came with his popularization of a new social democratic wave in the United States, and he played to the key themes of that in his talk.

He mentioned the work of Tommy Douglas, leader of the first social democratic government in North America, and its role in bringing public health care to Saskatchewan. Douglas’ political party was able to win 47 of the 52 seats in Saskatchewan’s legislature; Sanders praised this example of voter mobilization.

“It never happens from the top down. Real change happens from the bottom on up. All of you know that change never takes place easily,” he said.

Recalling the philosophy of Frederick Douglass, a prominent figure of the American abolitionist movement, Sanders said, “Freedom is never given to you — if it’s given to you, it’s not real freedom. You’ve got to struggle for it, you’ve got to fight for it, you’ve got to take it. And that is the history of all real change in this world.”

Sanders stressed the importance of asking questions in the face of injustice. “Our mission is to have the courage to ask the questions that may not be appearing on television tonight, or on the front pages of the paper,” he said, noting that many are “uncomfortable about asking those questions” because it involves taking on “very powerful special interests” like campaign donors and large conglomerates like the fossil fuel industry.

“I will tell you with 100 per cent certainty: there are people who are enormously powerful, who have more wealth than you can dream of, who couldn’t care less about your lives, about your children, about your parents,” he continued. “They want it all economically, they want it all politically… We’ve got to stand together and tell these oligarchs that this planet belongs to all of us.”

Ed Broadbent, former leader of the New Democratic Party (NDP) and founder of the Broadbent Institute — one of the event partners — said that when social democrats brought universal healthcare to Saskatchewan in 1962, it was widely expected to fail. “Instead, it spread across the country.”

Broadbent said that the struggle for progressive health care will continue with “the man who will lead that battle, Jagmeet Singh,” the newly elected leader of the federal NDP. When Broadbent motioned to Singh, who was in attendance, there was a round of applause from the audience.

In an interview with The Varsity after the event, Singh said that his campaign was “inspired” by Sanders’ ability to mobilize at a grassroots level, and he complimented Sanders’ Medicare for All plan. “I want to push our public health care to the next step and include pharmacare and dental care,” he said. “I feel the Bern!”

Students on Sanders

Sanders captivated American youth in his run to lead the Democratic Party in 2016.

“For me, at least, Bernie was a big part of my political awakening,” said Jeffrey Ma, a first-year student who waited in the rush line from 8:00 am. “It really enlightened me about a lot of the issues and injustices in our society, and American society.”

Azana Hyder, a third-year student who made it inside Con Hall, said that she thinks “everyone is a fan of Bernie Sanders, whether you admit it or not.”

Robert Xu, a student Governor at U of T’s Governing Council, said before the event he had doubts about the productivity of the discussion. Sanders, he said, “is often criticized for not having enough real, practical ideas” and usually promotes “those general ideas we all think are really good.”

Another student Governor, Amanda Harvey-Sánchez, said she was excited to see Sanders — whose Democratic leadership campaign she campaigned for — but had some reservations.

“One concern that I have is that perhaps it’ll be a self-congratulatory thing where people are just patting Canada on the back for having universal health care and not noting a lot of the important issues we do have in our health care system and how a lot of marginalized people in the country still aren’t getting access to full health care,” said Harvey-Sánchez in lead up to the event.

Rose Gulati, a first-year who was with Ma in the rush line, was quick to vocalize her stance on the difficulty students had securing tickets for the talk. About 20,000 people flooded the event page when it went live, and the free tickets were claimed almost immediately. In addition, a number of tickets were reserved for people with ties to the host institutions. “It was honestly so disheartening, it was heartbreaking,” Gulati said of her inability to get tickets online. “I felt that because it was a U of T event, it should have been available exclusively to U of T students.”

Robert Xu sits on The Varsity’s Board of Directors.

Introducing Toronto’s first hospital-based refugee clinic

Large numbers of Syrian refugees are in need of healthcare, and U of T doctors are helping out

Introducing Toronto’s first hospital-based refugee clinic

Fifteen-thousand Syrian refugees are expected to arrive in Canada by the end of February; most of them are in need of general exams by family physicians, and U of T doctors are doing their part to help.

Meb Rashid is a professor in the Department of Family and Community Medicine (DFCM) at U of T and the director of the Crossroads Clinic at Women’s College Hospital, the first hospital-based refugee health clinic in Toronto. Due to the large numbers of Syrian refugees expected to enter Canada, Rashid created a program of rotating intake clinics comprised of family medicine health teams around Toronto to see refugees after they arrive in Canada for initial assessments.

Syrian refugees are checked twice for infectious diseases before coming to Canada, but chronic or latent diseases might go undetected, which is why seeing a family doctor is so important. Rashid’s network includes pediatricians, psychiatrists, dentists, and other specialists to provide quick and easy treatment for patients who need further care.

“I know from my own experience in Lebanon that Syrian refugees there have found it extremely difficult to receive adequate health care,” said Peter Goodspeed who is a journalist and volunteer at Lifeline Syria, an initiative to welcome and support 1,000 Syrian refugees as they settle in the GTA over the next two years through the help of sponsor groups. “So it is essential that they receive immediate attention on their arrival in Canada, simply to ease their own concerns and to speed and ease their integration into Canadian society,” explained Goodspeed.

Refugees may not seek out health care right away due to many different factors, such as difficulty in understanding Canada’s health care system. In late January and early February, Rashid’s network of clinics treated between 200 to 250 refugees in ten days. The network managed to see this many people, even though new refugees were not originally connecting with the clinics as quickly as they were arriving. The clinics were eventually able to reach such high success thanks to the help of Dr. Ben Langer and family medicine residents, who raised awareness of the clinics online and at meetings and fairs.

Some issues Syrian refugees are expected to face are uncompleted vaccinations, hypertension, diabetes, war-related injuries, and mental illness.

Concerns have been raised about a delay in psychological services for refugees suffering from post-traumatic stress or other psychological issues, but the refugee clinics around Toronto aim to offer friendly faces and a place to connect.

Many other U of T doctors are helping to connect Syrian refugees with health care as well. St. Michael’s Hospital doctors Ashna Bowry, professor at DFCM, and Gabrielle Inglis, U of T alumna, teamed up with Mike Evans, DFCM faculty member and YouTube creator, to create an Arabic-language whiteboard YouTube video. The video welcomes Syrian refugees to St. Michael’s Hospital and explains the procedures they will go through at the clinic. Evans said that the family medicine department wanted to create a welcoming experience for refugees.

“[W]hen you have more than enough, some people build fences… but some build a longer table,” said Evans. “We are in the table group.”

Thanks to the support of U of T doctors, the process of finding healthcare has gotten easier for Canada’s newest citizens.