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.