Dangerous medicine?

An interesting discussion has been going on over at TerraSig. Abel used his expertise in pharmacology to help explain some of the nearly-inexplicable events that led to the injury of dozens and deaths of several participants in a sweat lodge ceremony. The investigation led to a Michigan physician who runs a "men's health" practice and pharmacy. The leader of the sweat lodge ceremony was apparently found to have prescription medications prescribed by and purchased from this doctor.

The medications were putatively for "anti-aging" and "low testosterone" treatments. It would clearly be illegal for the leader to have diverted his own medications for use by others, but that isn't the point. The question in my mind is what to make of "internet doctors".

Many of the commenters at TerraSig have said that Dr. Crisler does in fact require a face-to-face consultation initially. This is a good thing. I do have serious ethical concerns though.

First of all, seeking out expert medical advice is tricky. You end up having to rely on the opinions and suggestions of others, more times than not. There are some standards though. First, a doctor must be licensed to practice legally, and must also have a controlled substance license and federal DEA license to prescribe medications. Licensing is a minimum requirement--it says that a doctor fulfilled the most basic requirements that lead to being labelled "doctor", including medical school, residency, and USMLE exams. That's it. Once a doctor is licensed, they can do just about anything. Theoretically, a dermatologist could take out a gallbladder if he wanted to (although in practice, he would have trouble finding a facility that would let him).

Most physicians claim a particular specialty, either a primary care specialty such and pediatrics, internal medicine, or family medicine; or a medical subspecialty or surgical specialty. This expertise is gained through years of specialized training, and most doctors will take the specific board exams of their specialty. Many hospitals will not allow a physician on staff without being board certified. This policy recognizes that board certification confers another level of (presumed) expertise and knowledge. I do not refer my patients to doctors who are not board certified, and I refer them to specialists boarded in the specialty they practice.

It is not illegal to practice medicine, as long as you are licensed by the appropriate agency. But not being board certified does not free one from the basic ethical constraints of practice.

Based on conflicting reports it's not clear to me whether or not Crisler is an "internet doctor".  His website seems to say that patients can be seen in-person or at a distance.  Telemedicine requires special technology and safeguards to insure privacy and safety.  Assuming for the sake of argument that all of his communications are HIPPA-compliant and ethically done, there are still several ethical concerns I have about Crisler's practice as it is represented online.  

Crisler bills himself as a "leading TRT expert".  I believe "TRT" refers to "testosterone replacement therapy".  If so, he is not a leading expert by any recognized definitions.  Most experts in medicine are not only boarded in their sub-specialty but also recognized by other experts.  A PubMed search for an expert's name would be expected to turn up many publications as opposed to Crisler's none. 

When discussing a case such as this one, where a doctor is billing himself as an expert and may be treating people without seeing them, there are are number of potential ethical pitfalls.

Telemedicine is largely limited to non-patient-centered specialties such as radiology and pathology.  If a medical service is readily available to a patient locally and of sufficient quality, I would not feel comfortable providing the same service at a distance.  This essentially diminishes quality of care.  If services are not available, for example in a rural area, then more leeway is appropriate.

I'm very uncomfortable with the potential conflict of interest discussed in this case.  In various documents and chat rooms, it was reported that Dr. Crisler owns his own pharmacy and requires prescriptions to be filled at it.  This may or may not be true, but if it were, aside from legal implications, this would be a profound conflict of interest, whereby a doctor profits from prescribing his own medications. With all the talk of doctors being "in the pocket of big PhARMA", very few of us actually gain anything by our prescribing habits.  A doctor who owns his own pharmacy would be a different case altogether.

Finally, when billing oneself as an expert despite not being boarded in a relevant specialty, having no significant peer-reviewed publications, no academic appointments, and not being recognized as an expert by other experts (...catching breath now...)  this significantly degrades informed consent and patient autonomy.  Patients are likely to believe doctors and to claim expert status is to "ramp up" the level of trust and perhaps even the ethical expectations.

Everything about this story stinks and I look forward to hearing about formal investigations into the sweat lodge deaths and the way the medications from Dr. Crisler's pharmacy may have been diverted.

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all the protectionist talk from followers of this dude. thou shalt not raise questions about the practice of teh leading expert doctor!


Protectionism? Really? It's his fucking JOB to dispense sound medical advice such as this. It's called informing, not 'protectionism'.

But whatever. I'm under no Hippocratic oath, so I can just tell you to enjoy the attendant health problems that come with doing something that's medically bad for you.

By Katharine (not verified) on 10 Jan 2010 #permalink

by "this dude" i was referring to Crisler. hence the sarcasm.

leigh, you need a nice /sarcasm tag. I'll let you borrow one of mine.

Ah. I see.

It does raise some intriguing questions, though, about why Arimidex and finasteride aren't approved for testosterone replacement therapy.

By Katharine (not verified) on 10 Jan 2010 #permalink

I wonder if Dr. Crisler is just the tip of the iceberg. A new compounding pharmacy recently opened here that heavily advertises "bioidentical hormones" for both men an women. They seem to be in cahoots with at least a couple of naturopaths who hold "seminars" at the pharmacy on a regular basis. If this can succeed in a small city of 50,000 or so, I wonder how many other such pharmacies and doctors are out there.

Love this "Testimonial":
Dr. John Crisler may very well be the best Testosterone Replacement Therapy specialist in the world. His international reputation is well deserved."

- Nick Delgado, PhD, author of eleven books on health and fitness
Well, I'm the best Ear Wax Eating Therapy [EWET] specialist in the world (probably) (By the way: don't; it's horrid)


I may be misreading my pharmacology here - this is a pretty complex set of drug interactions here. My understanding was that arimidex and finasteride aren't approved for testosterone replacement therapy (oversimplifying here) because they're primarily helpful for reducing the effects of "too much" testosterone, which shouldn't be a problem in real testosterone replacement therapy, because you're trying to get back up to normal levels of testosterone.

FWIW, a few years ago I ordered some prescription medication online, for reasons I'd prefer not to divulge. There was a charge for an "online consultation" in order to get the prescription. This turned out to be a simple form where you just had to tick the right boxes (trivial!) and write about a sentence saying why you needed the medication. At no point was there a consultation with an actual doctor (though supposedly one reviewed what I had written in the form). Wham bam, done.

I was a little disturbed by this :D

By anonymous (not verified) on 11 Jan 2010 #permalink

The "Testimonial" is very well couched. He "may very well be," but then he may not. Notice the good PhD didn't claim he was the best. "His international reputation is well deserved." No doubt it is, but what is the reputation? I'm not calling the good doctor a Nazi, but Adolf Hitler had a well-deserved international reputation. Hint: it wasn't good. Many words used. Little actual meaning conveyed.

By The Gregarious… (not verified) on 11 Jan 2010 #permalink

Words cannot sescribe the revulsion upon reading this. This entire blog post and comment section is an insult to the intelligence of the reader on par with the Stephen Barrett Quackwatch nonsense. You all should be ashamed of yourselves for stooping to the level of slime to smear and defame an excellent physician. You are all repulsive medical fascists, and like all preceding fascist movements, you will neet the same fate.

By voice of reason (not verified) on 12 Jan 2010 #permalink

Are you planning a landing at Normandy?

By MonkeyPox (not verified) on 12 Jan 2010 #permalink

Why do you posts rumors you don't know to be true?

And you're going to talk ethics? WOW.

He does not own his own pharmacy.

He uses a compounding pharmacy in another state if the patient does not have a preferred pharmacy already.

No one has ever read the stupid testimonials on his website but you guys. People learn about his practice through his patients on his and other messageboards. Patients talking to patients, in real-time.

Also, he considers himself an anti-aging doctor, and is very well regarded among the a4m society of anti-aging physicians, and speaks at all their conferences. So contrary to yet another one of the other pieces of slanderous garbage you've stated he is actually regarded as an expert by other experts in his field of anti-aging which I'm sure you feel doesn't count in the end one way or another anyway.

You're preaching ethics and just republishing rumors you heard in a chat room just like TMZ or the enquirer.

"I've heard he owns his own pharmacy and his patients have to use the drugs. I don't know if this is true, but if so, it's disturbing!"

Unfortunately I restated that more concisely than you did but you know as soon as someone reads a rumor like that the damage is done. The seed is planted that there is this scary guy out there up to no good, in fact his practice is so dubious that it's even possible he owns his own steroid lab he deals drugs out of! He's _so_ unethical that's totally feasible and reasonable it could be the case!

That's the impression the reader is left with when you rumor monger. This is how the writers for the new york post page 6 make their living. Creating lasting impressions in the reader based on scant or no evidence or the hint of a possibility.

For someone preaching ethics in medicine you sure have no ethics in journalism.

You go on and on about how hard it is to know if someone is true or not in medicine and how patient reports don't count for a lick yet you'll readily print devastating rumors that will linger in google forever like this based on things you were simply told.

You really strike me as someone who would make a great doctor with all of the care, attention to detail, forethought, and high standard for truth on display here.

By Dazed and Confused (not verified) on 12 Jan 2010 #permalink

Man, I can't count all the fallacies Dr. Crisler's supporters have perpetrated in their attempt to fall all over themselves defending him.

By Katharine (not verified) on 13 Jan 2010 #permalink

i have a question for the healthcare professionals in the readership: is "anti-aging medicine" actually a recognized branch of medical science? i wouldn't know, but to my layman's ears the term sounds fishy. it's not as if aging can be stopped, after all, and we already have a specialty (gerontology) dedicated to treating the ills that come with it, do we not?

By Nomen Nescio (not verified) on 13 Jan 2010 #permalink

There is no field of "anti-aging medicine" that is recognized as a legitimate medical specialty by the usual sources such as the American Board of Medical Specialties.