Compression fx PNG

It’s amazing how quickly my role switched from physician to patient, thanks to a silent assailant: osteoporosis.

I went to the gym in the morning before work 12 days ago, as I often do now that my children are all grown up and out of the house. First, a couple of light sets of leg exercises served as a warm-up, and then I started a set with a barbell on my shoulders. I’ve been doing weight training for years, since my mother suffered badly from osteoporosis and I knew I was at risk. Weight training, along with calcium and Vitamin D, can help maintain bone density.

The weight was average for me, and I was halfway through my second set of 12 repetitions when suddenly there was a loud noise, like a sharp crack or pop, that people in the gym heard 10 feet away. I felt my mid-spine collapse downward what seemed like an inch, accompanied by sharp pain. The trainer grabbed the weight, helped me lie down, and called my husband.

I did a quick self-assessment.

Can I move everything? Check.

Is anything numb? No.

Can I do a straight leg raise without more pain? Yes.

This confirmed that I didn’t have any spinal cord injury and probably didn’t have a herniated disk. The most likely diagnosis was a spinal compression fracture, which turned out to be exactly what happened.

Off to the emergency room

My husband insisted on driving immediately to the emergency room, which gave me a little time to reflect.

By coincidence, September is “Pain Awareness Month”, and I had been wanting to write a piece in support of the American Chronic Pain Association and the American Society of Anesthesiologists‘ recognition of pain as an endemic problem. Chronic pain ruins lives, and inappropriate treatment of pain with narcotics too often leads to addiction, overdose, and death.

But what to write?? I treat acute pain in my daily work as a physician anesthesiologist looking after patients in the immediate recovery timeframe, right after surgery. Sometimes I take Aleve for a headache, but that’s about it. Now, of course, it seemed much likelier that I would have a story to tell.

Luckily for me, the Cedars-Sinai Medical Center emergency room was relatively quiet at 6 a.m. The staff whisked me off to X-ray, and the technician quickly took supine and lateral films. He said, kindly, “Ma’am, I’m not a doctor, but it looks to me like you have a compression fracture.” He printed out the films for me to see, and of course he was right. A nurse gave me some morphine, which eased the pain considerably, and then it was time to consider next steps.

Conservative treatment or intervention?

My fracture was at the level of the 12th thoracic vertebra or “T12”, the commonest site for compression fractures. This is hardly a rare problem. One in four American women will have a vertebral compression fracture during her lifetime, and men can suffer them too. The most common cause is osteoporosis, a condition in which bone loss over time results in weak, brittle bones.

The emergency room physician ordered a CT scan to see the extent of the fracture in more precise detail, and to see whether or not any bone fragments were endangering the spinal cord. Then he called a neurosurgeon, Dr. Khawar Siddique, to see me.

The neurosurgeon outlined treatment options. Basically, there were three:

Conservative treatment: a back brace, pain medications, and 6-8 weeks of rest, with gradual mobilization;

Surgery: thoracic fusion;

Kyphoplasty: a less invasive procedure to stabilize the fractured vertebra.

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Dear Diana, Again, I think treatment choices are many, and should be decided by each individual in concert with your physician. As far as I am aware, estrogen therapy alone isn't enough to stop postmenopausal bone loss, but of course it may have multiple other symptomatic benefits. All best wishes, and thank you for writing-- Karen Sibert


Dear Dr. Sibert, What about estrogen therapy? And maybe even some testosterone therapy. btw, This is my first post ever on a blog. I feel so strongly about the benefits of estradiol therapy, in the form of brand Vivelle Dot patch, I had to respond to your story. Estrogen therapy may help prevent future fractures. I use Brand Vivelle Dot myself, for osteopenia. All the best to you during your recovery.

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Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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Dear Dr. Vercammen, "Burnout" is a colloquial and imprecise term which means different things to different people. Major depression is a clinical diagnosis, a very serious illness, and a threat to life; that is not and has never been my subject. I'm sure you know the difference. Confounding the two, as you do in your comment, is sensationalism. To imply that my opinions make me either responsible for or indifferent to physician suicide is not only unjustified, it skirts close to the edge of libel. Please--and I ...Read More

Chris Vercammen, MD

Dr. Sibert- As a current senior resident looking forward to my chief resident next year, I was profoundly disturbed by your article, in particular that it found its way into wider circulation via KevinMD. I would hate for any current resident, in any field, who is experiencing burnout to have read your piece. It represents a particular type of fantasy, retrograde approach to how physicians work and live. 1) Burnout is a real phenomenon. Having experienced it myself during my training, it is a profoundly troubling ...Read More

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Anesthesia Books2

This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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Asha Padmanabhan, M.D

Dr. Sibert, just found your article and thoroughly enjoyed it. There is a wealth of information in here for medical students considering a future in anesthesiology. The one point I would add for the future of anesthesiology is the disappearance of the small group private practice model which at least in my part of the country (South Florida) has completely given way to the large national groups.That might be something anyone going into anesthesiology should consider. There are advantages and disadvantages to being an employee of ...Read More
Great post here! I think lots of medical students trying to decide whether or not to specialize in anesthesiology should DEFINITELY read this - definitely goes into things a lot of others don't. Thanks so much for sharing this!


Dr. Apgar

Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine:  Then and Now“, in the journal Anesthesia and Analgesia.

I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:

“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.

2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.

3. Women should be careful not to fall into the trap of feeling entitled to special considerations or engage in special pleadings. Our patients want their physician to be the best, whatever his or her sex. There is no room for a physician of either sex who is less qualified or less committed because of outside responsibilities.

4. Women no longer need to “prove themselves” against the sea of doubters who dominated medicine 40 years ago. Fortunately, we are now past that point and such doubts, are I hope, antediluvian. Women are where they are today, however, because many of us felt that demonstrating that women really could “do it” was a moral imperative and one to which we were fully committed.

5. Parents need to manage their work and family responsibilities to ensure that both receive their full attention. This will often mean ensuring that they have excellent childcare to allow them to have the confidence to focus on work when that is required. This may be expensive, but it is a critical investment by both parents in their family’s future. Successfully raising children is a joint responsibility of both partners; what is critical to women is also critical to men, and vice versa. Women starting out on this journey can be assured that it is possible to raise well-adjusted children in a home in which both partners have challenging and successful careers, provided there is a true partnership in the family.”

Is Dr. Wood a curmudgeon, or perhaps a dinosaur? That could be, but I find her honesty refreshing.

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Glad to see you publishing again, I missed reading your pithy stuff. I think Dr. Wood never had to worry about patient satisfaction scores or the other myriad of obstacles that stand in the way of what we physicians really love - patient care. Personally, I don't believe that burnout and work-life balance is a gender specific problem in medicine. Instead, I think it is a universal problem as physicians feel the futility of resisting the third-party demands of submission (compliance).
Interesting. I spoke to a friend last month who used to be one of the most engaged, committed physicians I have ever known. During residency she would pull every extra shift she could get here hands on, and was extremely dedicated to improving her craft as a surgeon. Since she moved to another state I hadn't seen her for a couple of years and she recently had her second child. The difference in her approach to work was extreme when compared to before she became a ...Read More



The best way to avoid being sued for malpractice is to make certain that all your patients are happy and all their outcomes are good.

Reality is seldom so rosy. Patients aren’t necessarily happy even when their clinical outcomes are as good as they can get. In the event of an undesired outcome, an unhappy patient may easily become a litigious one. A 2011 study in the New England Journal of Medicine estimated that 36 percent of physicians in low-risk specialties such as pediatrics, and 88 percent of physicians in high-risk surgical specialties, would face a malpractice claim by the age of 45. Those percentages climb to 75 percent of physicians in low-risk specialties and 99 percent of physicians in high-risk specialties by the age of 65.

Flaws in clinical practice guidelines

Can clinical practice guidelines protect us? We are all beset by the proliferating standards and guidelines of evidence-based medicine. It’s comforting to think that a court may consider adherence to a legitimate clinical practice guideline (CPG) as evidence of reasonable prudence and acceptable practice. At the same time, physicians know that guidelines are imperfect. Many guidelines are debated and revised over time, some are discontinued when they are found to do more harm than good, and some have been found to be contaminated by conflicts of interest.

Some examples:

>  How long should dual anti-platelet therapy be continued after drug-eluting stent placement? Guidelines currently advise dual antiplatelet therapy for six months to a year after stent placement, and aspirin for life. More recently, the Dual Antiplatelet Therapy (DAPT) study suggests that some patients may benefit from extending dual antiplatelet therapy beyond one year in terms of protection against myocardial infarction, but this benefit is accompanied by increased bleeding risk and a possible increase in all-cause mortality. Physicians are advised to “balance risk factors”.

>  Starting in 2001, there was a push toward much tighter control of blood glucose levels in ICU patients. Tight glucose control after cardiac surgery became a quality measure tracked by the Surgical Care Improvement Project (SCIP) and the Joint Commission. The only evidence basis for tight control was a single-center study that associated intensive insulin therapy with improved outcomes including fewer infections, less ventilator time, and a lower incidence of acute renal failure. But the results couldn’t be replicated. In a landmark multicenter report published in 2009, patients receiving intensive insulin therapy with glucose levels kept between 81 and 108 were shown to have more hypoglycemia, higher mortality, and no difference in morbidity or length of stay. Intensive insulin therapy promptly fell out of favor.

>  Many hospitals in the last several years abruptly switched from povidone-iodine antiseptic solution to chlorhexidine-alcohol (ChloraPrep®) for skin preparation before surgery. They did so on the basis of a 2010 study that claimed substantial benefit for ChloraPrep in reducing the risk of surgical site infection (SSI). But in 2014 CareFusion Corp., the manufacturer of ChloraPrep, agreed to pay the government $40 million to resolve Department of Justice (DOJ) allegations that the company paid kickbacks to boost sales of ChloraPrep, and promoted it for uses that aren’t FDA-approved. The DOJ complaint said the company paid $11.6 million in kickbacks to Dr. Charles Denham, who served at the time as co-chair of the Safe Practices Committee at the National Quality Forum and the chair of Leapfrog’s Safe Practices Committee. He championed the use of ChloraPrep without disclosing his relationship with CareFusion. Subsequent studies have not demonstrated the superiority of any commonly used skin preparation agent in reducing the risk of SSI.

Though the evidence may be flawed, evidence-based medicine has shown an alarming tendency to evolve from guidelines into inflexible rules, especially if payment is linked to them. Physicians may come under pressure from regulators and hospital administrators to apply these rules mechanically, with inadequate attention to context or to a patient’s other health issues. As an excellent article in the British Medical Journal last year pointed out dryly, “The patient with a single condition that maps unproblematically to a single evidence-based guideline is becoming a rarity.” A guideline for the management of one risk factor or disease “may cause or exacerbate another—most commonly through the perils of polypharmacy in the older patient.”

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