White Coat Underground

Two recent posts raised some ethical questions about the practice of a very public doctor who has proclaimed himself (on the front page of his website) to be an expert on testosterone replacement therapy.

Leading TRT expert Dr. Crisler is now available for consultations, lectures, advanced physician training, conference hosting, interviews, and more.

Well, Dr Crisler was apparently not happy with my critique. He was kind enough to drop by and leave several comments explaining why, the first and longest I will reprint here. He has also sent me a great deal of traffic from his own message board which is hosted at musclechatroom.com (a somewhat ironic name given Crisler’s avowed opposition to the use of anabolic steroids).

Anyway, it would only be polite of me to elevate his response to its own thread (with commentary of course).

While I have been the subject of Internet attacks over the years–from nitwit steroid users to Doper Doctors I have gone after–I have yet to see one as vicious as this. It’s amazing what people will post, hiding behind their computer monitors, under an assumed name. What troubles me is that it is from someone who is supposed to be a colleague. If you just would have called me, I would have been happy to clear up your misconceptions–before you libeled probably the most anti-steroid doctor in the country.

I wasn’t aware that my posts constituted “vicious attacks”, but everyone is entitled to his own opinion. I do not necessarily consider myself a “colleague” of Dr. C., but the most useful critiques are generally those one receives from one’s peers, so I’m not sure what his point is. Am I supposed to be a part of some medical “conspiracy of silence”, a medical omerta? As to the “assumed name”, I, like many bloggers, write under a pseudonym but I am not anonymous. My profile links to my real name in several different ways, but keeps it a click or two away to cut back on spam. It’s a common practice. Also, whining about the identity of a critic does not constitute a valid argument.

First, the comments posted here insulting Osteopathic physicians are mind-numbingly ignorant, especially in this day and age. They say lots about the individuals posting them, and absolutely nothing about the Osteopathic profession.
Osteopathic medical students learn all their allopathic counterparts must learn–plus about 25% more. Their board exams are twice as long. And while I refuse to disparage my MD brothers and sisters, Osteopathic physicians not only practice every specialty of medicine, we also regularly score much higher when compared to MD’s for patient satisfaction. Perhaps that is because we tend to practice in a more holistic and family-oriented manner. We are also more likely to seek cures, and less to simply write prescriptions. But there are certainly good physicians, and bad ones, on both sides.

In the United States over the last 20 years or so, osteopathic medicine has ceased to be an alternative and has more or less merged with the MD community. Many if not most DOs complete MD residencies and take MD boards. Crisler is quite correct that to disparage DOs as a class is ignorant and unfair. The rest of his statements about satisfaction, etc. are not meaningful.

Everything we do at my office has been rigorously scrutinized by legal counsel and regulatory body. Therefore there is absolutely nothing unethical, immoral or illegal about anything we do. My profile is far too high to be doing anything I shouldn’t.
For the record, I have never prescribed an anabolic steroid, not even once. Further, I am proud of the fact you could not produce example of a physician doing more to fight the spread of anabolic steroids over the years. There are literally tens of thousands of words published by me on the Internet, portions of every lecture I have given, and countless hours counseling patients regarding the hidden dangers of excessive hormonal manipulation. I also regularly assist Law Enforcement as they crack down on dopers and Doper Doctors. That is why this blog is so profoundly ridiculous.

I am happy to hear that Dr. Crisler has not prescribed any anabolic steroids (other than testosterone, I assume). The rest of this statement is meaningless. Ethics are not determined by legal counsel and regulatory bodies but by a profession as a whole. But if Dr. Crisler has put himself out there on muscleboards.com and other venues as strongly anti-steroid, that’s very commendable.

And very single patient I have has either been seen by me personally, or served on a consultation basis, as is done every day all over the country. Some of the verbiage from my website is meant merley to facilitate that process, whether you understand it, think it’s “weird” or not. By the way, thinking something is “weird” is certainly not excuse for libel.

I’m not sure what this means. When I send a patient to a consultant, the patient sees the consultant—in person. That is the standard which as far as I know all doctors follow. I may from time to time curbside a colleague to ask them a question about a patient, but this is not a consult and cannot be billed as such. And the fact that your practice appears—in my opinion based on what you as a public figure has put out there on the internet—to vary considerably enough from most other doctors’ practice to constitute something “weird” is not libelous but a matter of opinion.

Do you treat patients for the COPD and emphysema that smoking brings? Well then, by your logic, you support tobacco use! These steroid guys will one day finally quit. And on that day I want them to be in the best state of health possible. That way they will be less a drain on our precious medical resources. Of note, while I do not care if a single steroid user ever darkens my door again, I only have a small handful of patients using these days (again, with Controlled Substances not of my doing). In fact, it was precisely the clinical experience gained treating those guys which taught me how the Endocrine system works, as one must come to know the excesses of a thing to truly understand its middle ground.

I have no idea what you are talking about.

I have never called myself an “expert”. That is for others to decide. I am but a simple country doctor. So I am not an Endocrinologist, but I have personally trained literally hundreds of them, from all over the world. I consult for them on a regular basis. And I have a large number of physicians as patients. Hey, I must be doing something right! LOL

When I wrote that you were a self-proclaimed expert, I based that on the statement on your website that, “Leading TRT expert Dr. Crisler is now available for consultations, lectures, advanced physician training, conference hosting, interviews, and more.” Perhaps I read it wrong.

When you say that you have personally trained “hundreds” of endocrinologists, I searched in vain to find what endocrine fellowship program you have been leading or taking a leading role in. Endocrinologists are medical specialists who, after completing a residency program, then complete a 2-3 year fellowship in endocrinology.

Not to disparage Endocrinologists [hundreds of whom you've trained? --ed], but my colleagues who think they should be relied upon to expertly treat hypogonadism are in for an eye-opening experience. For it seems the Endocrinologists are the least likely to properly manage sex hormones. For instance, ask one how to properly manage estrogen in men. You response is likely “estrogen is not important in adult males”. The truth is estrogen is part and parcel of nearly everything that kills a man, outside of trauma. That I why simply optimizing the 40 or so estrogens in our bodies can turn a man’s life around. The evidence is out there, in droves. So why do they jealously maintain the position they do?

Do you have any evidence to support your blanket condemnation of the profession of endocrinology and all those who practice it? If so, I’d love to see it.

That is why they don’t know how to use aromatase inhibitors, such as Arimidex (anastrozole), stating it is “only for female breast cancer patients. So why are there between 100 and 1,000 times more men than women on it? Astra Zeneca is laughing all the way to the bank. They also will not use HCG to its best advantage, even though minimal thought is required to understand same. Or they will prescribe it at 10 times the effective dose, which is counterproductive in several important ways.
For any of you wishing to see just a portion of the 20,000 scientific studies supporting what we do, I invite you to the American Academy of Anti-Aging website www.WorldHealth.net

Once again, I have no idea what you are talking about. If you are in a position to present some great new medical knowledge that would revolutionize our practice, where are you papers, where is your research? Show us the data! And as to the anti-aging stuff, well, that’s fringe and has not managed to get the rest of the medical community to give it recognition yet. There is a reason the American Board of Medical Specialties is a bit picky about accepting any group coming along claiming a new medical specialty.

So what is an “expert”? Is it the head of some mucky-muck medical department? Those of us within the field notice those positions do not come from superior medical technique; but rather as reward for proficiency in paper-pushing and meeting-calling. Some of the finest clinicians I have seen are so because they exclusively value the health and happiness of their patients. It is their commitment to perfecting their art which brings their increased success rates. It’s what they do with their patients, not some shingle on the wall.

…wait for it…

Students of medical history know it was the top “experts” of their day who bled our first president to death, because blood was considered poisonous. And Dr. Joseph Lister was attacked by the top Surgeons of his time for daring suggest they wash their hands, and change their blood-soaked gowns between procedures. Remember when medical “experts” told everyone to stop eating margarine, because saturated fats clearly increase the risk of cardiovascular disease, and to eat margarine instead? They NEVER gave a thought to what trans fatty acids do to us. We now know they are literally toxic to our bodies.

In my second year of practice I had the honor of delivering a lecture at The Royal College of Physicians, in London. The topic was my TRT protocols. In the museum portion of the building was a display case, for the purpose of poking fun at physician ignorance and arrogance. There was a lock of Dr. William Jenner’s hair, the physician credited with inventing the vaccination. Included were letters from some of the top “experts” of the day, demanding Dr. Jenner not only dismissed from the Academy, but drawn and quartered as well!

Bingo! “Medicine has been wrong before!” “They denied Galileo and Semmelweiz!”

Look…dude…a negative argument about others does not constitute an affirmative argument about your own practice. It’s rhetorical smoke and mirrors.

Patients are much more interested in being healthy and happy than they are the shingles on a doctor’s wall. That is why a patient sitting in front of my desk may have already been to half a dozen other doctors, including Urologists and several Endocrinologists. They know I will solve their case, and so I do. It’s a matter of knowledge and experience, and I probably have as much experience in this area as any physician in the world. It’s all about being able to deliver effective medical treatment. Hey, if simple country doctor can figure this stuff out, why can’t everyone else?

I would agree with you that patients just want to be well, or at the very least be listened to. Once again, you haven’t actually made an affirmative argument for your methods.

The host of this blog obviously has no idea how low the Standard of Care is with respect to, for instance, treatment of adult male hypogonadism. That is why, even with the increased risk of cardiovascular disease, cancer, diabetes, osteoporosis, depression, dementia, and sexual dysfunction low (even low-normal) testosterone levels bring, half of them put on TRT go off from it. The physician simply does not know how to manage it properly. So when he asks why anyone would travel to see me, when there are perfectly good doctors in their own area, it just show he knows nothing about the state of the art in treating this insidious and rampant (about half the men over the age of fifty) disease. Maybe this is why I have patients in 48 states and 20 foreign countries?
There are perfectly good Heme/Onc and Cardiologists all over the country. So why do patients travel to the Mayo or Cleveland clinics, or M.D. Anderson? Ummm…is that “weird” too?

Peer-reviewed, validated guidelines for the treatment of male hypogonadism do in fact exist. Whether you and your patients feel that your unpublished results are better is largely irrelevant to the greater world.

This profound ignorance of how TRT works also leads many physicians to deny their patients the testosterone they need and deserve, because , for instance, “TRT will cause prostate cancer”. Find ONE shred of evidence to support that position! And where is it okay for doctors to tell patients things which are exactly the opposite of the truth–purposefully damaging the patient in the process? Rest assured, those opposed to TRT WILL be getting on board. The literature is so abundant it will become malpractice in the future to NOT screen testosterone levels. And its ability to turn around a patient’s life means the patients will demand it (or come to me). I suppose when physician income is damaged their ignorance will cease.

To claim that one is on the cutting edge is nice, but once again, your own opinion of your greatness is lacking any objective support. You may, in fact, be onto something very important, but without validating it with objective studies your knowledge is useless to the rest of the world. No reputable physicians, academic, or medical organizations make treatment recommendations based on the unpublished experiences of a single self-proclaimed expert.

As for myself, I sit on the Speaker’s Bureaus of both BigPharma companies that make T gel, the Medical Advisory Board of the Life Extension Foundation, Advisory Board of the Men’s Health Network, and serve on the faculty of my alma mater. My lectures are nearly always packed (you can watch one for free on my website), whether delivered in Las Vegas or the Michigan Osteopathic Association annual convention (where I have taught TRT three times). In fact, I was supported by both BigPharma companies AND an excellent compounding pharmacy–for the same lecture! I donated all proceeds to the MOA, and financed a statewide radio talk show from there, which I co-hosted, spreading the good word about Osteopathic medicine.

Yes, and…? What is the point of this statement? It sounds like an appeal to an irrelevant authority.

As for our office protocols, patients may get their medications wherever they wish. That is pure Consumer Protection, as it should be. We provide the convenience of ordering their compounded medications for them, and have them delivered at exactly the same price as if they took the time and expense of ordering them themselves. And I do not know where the host of this blog practices, but it is extremely common these days for physicians to impose fees to encourage script writing that the time of the office visit.

I will take you on your word that your current prescribing practices are much more ethical than your literature seems to imply. Physicians who accept insurance are usually forbidden from extra fees such as fees for phone calls or prescription writing. As someone who chooses not to accept insurance, you are free to impose whatever fees you wish, both legally and ethically. But to claim that it is normal practice and that the service would cost just as much elsewhere is probably not entirely consistent with current reality.

I cannot tell you how many gentlemen I have labored to save from the Internet Doper Doctors. Kindly do not lump me into that cesspool. In fact, it would be nice to receive some encouragement for this often thankless task.
Finally, I shall place my trust in the Lord as to the state of my soul.

I am happy to hear that you have helped men get off of anabolic steroids. That’s commendable. Of course, lots of docs can do that, so that’s not a unique service as far as I know. Whether your task is “thankless” or not isn’t anyone’s problem but your own. Medicine is practiced for the benefit of the patient, not for the good feelings of the doctor—the latter is a nice bonus when it happens.

As for the immortal soul, mind-body dualism isn’t my thing. I’m more concerned with, as the title said, the “medical soul”.

Comments

#1 Tsu Dho Nimh
January 13, 2010

it just show he knows nothing about the state of the art in treating this insidious and rampant (about half the men over the age of fifty) disease

Classic quack technique … redefine a normal process as “disease” and sell the remedy to the desperate.

And I love the way you try to imply that you are in the same class as Lister. Nice “Galileo Gambit” doc, but we’ve heard it before. When you want to play with the science bloggers, you will be expected to provide data to back up your assertions.
#2 LL
January 13, 2010

@PalMD

You can reply point by point, but you are still going to come up short every time in an argument with Dr. Crisler.

From the look of your picture above it appears that simply paddling a canoe is a challenge for you, LOL.
#3 MonkeyPox
January 13, 2010

Yo, LL, u in some sort of cult or something?
#4 PalMD
January 13, 2010

FYI, Crisler’s message board has switched over to mandatory registration.
#5 Calli Arcale
January 13, 2010

One thing jumped out at me that wasn’t addressed by your response:

Dr Crisler:

Osteopathic medical students learn all their allopathic counterparts must learn–plus about 25% more.

Dr Crisler is evidently not aware that he is, himself, an “allopathic” physician. The term was invented to mean “doctor who isn’t a homeopath”, and osteopaths are definitely not homeopaths. (Certainly someone prescribing testosterone replacement therapy is not a homeopath.) The term is not truly meaningful, of course; etymologically it means “disease caused by difference” as opposed to “disease caused by same”, and real medicine (osteopathic or otherwise) is far more complex than that.

I dispute the “25% more” figure, which he appears to have pulled out of thin air. In my experience, the training is nearly identical between MDs and DOs. It’s a bit like the difference between a physicist who started out with a BA, and one who started out with a BS. There is a difference, but it’s not really significant to how qualified or knowledgeable they are.

I also have to clarify one other thing for Dr Crisler, though it is not really meaningful with respect to his argument, as the reference is itself not actually relevant:

Students of medical history know it was the top “experts” of their day who bled our first president to death, because blood was considered poisonous.

Clearly, Dr Crisler has not studied medical history. That’s okay; it’s not really necessary for the practice of modern medicine to understand how wacky some practices were (though it is a useful exercise in seeing how easy it is to trick oneself). During this period, based on Classical texts, doctors mostly believed that disease was caused by an imbalance of the four humors which they believed drove the body. Those humors were blood, phlegm, yellow bile, and black bile. An excess or deficiency of any one would cause disease, and so most treatments were aimed at correcting this imbalance. Certain foods or herbs were thought to affect various humors (wine was considered “choleric” for instance, because it appeared to have a choleric effect on drinkers), and would be prescribed if physicians thought it appropriate. More extreme methods were sometimes practiced. The most famous practice related to this was bloodletting, in which excess blood could be drained off, allowing the body to regain its balance (or so the theory went). Purging was another method for adjusting the humoral balance, as was cupping. Purging and cupping remain common alternative health practices today, with most practitioners ignorant of their humoral origins.

Humorism had a profound influence on our language. Even today, we talk of people being sanguine, choleric, melancholic, and (rarely, as the term is fading) phlegmatic. Each of these refer to an excess of one of the humors. It was not a practice restricted to “the West”; the practice probably started in Egypt, was codified by the Greeks, was widely used in the Islamic kingdoms, and thereby made its way to India, where it is actually still practiced today.
#6 Calli Arcale
January 13, 2010

LL — actually, that attitude is normal for paddling a canoe by yourself. Canoes are weird.
#7 Prometheus
January 13, 2010

#5 Calli Arcale

That was a very nice survey of Galenic medicine.

Thank you.

Unfortunately the history of Osteopathy is a far shorter proposition that begins with a looney.

Andrew Taylor Still was delightfully nuts and wandered around the first osteopathic college waiving a stick and wearing hip boots so the snakes wouldn’t get him.

He was part of a post civil war medical looney boom in the American Midwest. The world has us to thank for chiropractors as well.

*Sigh*
#8 Karl Withakay
January 13, 2010

@LL @ 2

“From the look of your picture above it appears that simply paddling a canoe is a challenge for you, LOL.”

We are LOL’ing at you LL, and not with you, as regular readers of this blog were been educated by PalMD as to the proper way to row a canoe when he added that picture. Your comment on a topic on which you are uninformed is amusingly illustrative; thanks for the laugh.
#9 Katharine
January 13, 2010

LL, I was not aware that a comment about PalMD’s weight constituted an argument.

Also, please elaborate. ‘Every time’? In what instance does Pal’s commentary about Dr. Crisler’s response not make Crisler look completely foolish?
#10 Cassandra Yorgey
January 13, 2010

“If you just would have called me, I would have been happy to clear up your misconceptions–before you libeled probably the most anti-steroid doctor in the country.”

It would seem Dr. Crisler struggles with some truthiness issues. As it so happens, I DID contact him and his office and offer them a chance to speak out, since James Ray’s prescriptions were from several different doctors it seems plausible some of them may not have known the full list of drugs James Ray was taking. It would appear Crisler did though, so your article seems simple statement of logical explanation for that particular combo of meds.

I don’t know much about recreational steroid use, but I thought guys took steroids to get a better physique… Can you explain why James Ray didn’t get all buff taking those drugs? Is he just too old for steroids to be that effective?
#11 Karl Withakay
January 13, 2010

I may need to apologize to LL for my comment @8. It may have been a little OTT as a reply to LL’s comment after I re-read it.

Upon rereading @2 I may have inferred the wrong meaning for LL’s comment.

LL, if your intention was to point out that it is pointless to refute Dr Crisler point by point with reason and well supported arguments, and not that Pal’s points were all inferior to Dr Crisler’s, I apologize. Otherwise, you can ignore this and stick with @8.
#12 Calli Arcale
January 13, 2010

Unfortunately the history of Osteopathy is a far shorter proposition that begins with a looney.

Andrew Taylor Still was delightfully nuts and wandered around the first osteopathic college waiving a stick and wearing hip boots so the snakes wouldn’t get him.

He was part of a post civil war medical looney boom in the American Midwest. The world has us to thank for chiropractors as well.

In defence of Dr Still, quite a few non-osteopathic doctors of the period were raving mad as well, and as you so eloquently put it, there was a medical looney boom going on. I doubt there was a field unaffected. On a positive note, though, this “looney boom” coincided with a boom in more systematic research to figure out what actually worked and, more importantly, *why*. The changes in medical practice during the 19th Century can only be described as revolutionary; what was being done in 1899 was radically different from what was being done in 1799. The Civil War had some influence on this, mostly because it provided doctors with such a steady stream of patients. Huge advances were made in the 20th Century as well, particularly the invention of antibiotics, but they would not have been possible had not the very mentality changed so much during the 19th Century.

The same climate that allowed quacks to blossom also allowed medicine to blossom. Mostly, the fashion for “classical” education and knowledge was finally breaking, and people were free to make their own discoveries for a change.
#13 Karl Withakay
January 13, 2010

A very well constructed followup, Pal.
#14 Chris
January 13, 2010

(Just an off topic comment: I would love to be in the same room listening to both Calli Arcale and Tsu Dho Minh having a conversation. It would be fascinating and I would learn lots.)
#15 Dangerous Bacon
January 13, 2010

I can’t speak to what wonderful things Dr. Crisler may or may not be doing in his practice, but his response to your earlier posting raises all sorts of red flags.

“Osteopathic physicians not only practice every specialty of medicine, we also regularly score much higher when compared to MD’s for patient satisfaction. Perhaps that is because we tend to practice in a more holistic and family-oriented manner. We are also more likely to seek cures, and less to simply write prescriptions.”

This is straight out of the woo playbook. No, doc, “holistic” is not defined as “using unproven medicine”. And it’s most commonly woo-ists and outright quacks who emote about how they are providing “cures”, while nasty allopaths merely treat symptoms. When hard evidence is requested, it’s funny how those “cures” evaporate into thin air.

“Everything we do at my office has been rigorously scrutinized by legal counsel and regulatory body. Therefore there is absolutely nothing unethical, immoral or illegal about anything we do.”

If lawyer(s) “rigorously” scrutinize everything you do at your office, one wonders exactly what it is that you do and why you have to have the legal profession go through it with a fine-toothed comb.

“So I am not an Endocrinologist”

…but I play one on my website (?)

“The truth is estrogen is part and parcel of nearly everything that kills a man, outside of trauma.”

Has this guy had some bad experiences with women?

Crisler sneers at the “mucky-muck(s)”, prides himself on being a “simple country doctor”, but then makes a point of telling us about all his pharma and other affiliations and that “In my second year of practice I had the honor of delivering a lecture at The Royal College of Physicians, in London (England? Kentucky?).”

So who’s putting on airs now?

I’ve heard of various physicians styling themselves as experts in dubious “bioequivalent” hormone therapy for women. I was unaware that self-proclaimed experts in unproven hormonal therapy were targeting men on the Internet as well.
#16 Dangerous Bacon
January 13, 2010

Fixed (hopefully) link from last post.
#17 neurospasm
January 13, 2010

I suspect that musclechat suddenly went all-registration because of embarrassment about the threads there.

I was wondering if anyone could lend some insight on the pathology/psychology of commenters here and on the previous post who feel so compelled to blindly defend someone who clearly has delusions of grandeur. There’s kind of an icky, Jim Jones feeling that I’m getting.

btw, if anyone’s “world-famous,” it’s PalMD. PalMD is one of the most beloved and admired physician bloggers in the international medical blogosphere. Dr. Crisler should feel honored to have drawn his attention.
#18 PalMD
January 13, 2010

He’s world-famous in Poland!

To Be or Not to Be, Mel Brooks
#19 Katharine
January 13, 2010

Dr. Crisler has some weird-ass ideas about estrogen, considering the fact that there’s plenty of cancers that have nothing to do with androgens, for one, and indeed, there are also infectious diseases.

Also, men need estrogen too.

I’m almost inclined to think Dr. Crisler may have a bit of a sexist streak.

“simple country doctor”

You’re not friggin’ Dr. McCoy!
#20 Micawber
January 13, 2010

Dangerous Bacon, the point of that article seems to be that licensed pharmacists should not be allowed to do what my grandfather (as a licensed pharmacist) and his father practiced for decades: mixing medications themselves; and futhermore, that only the huge conglomerate pill-pushing pharmaceutical companies should be allowed to do so. Why this is so is never stated.

The rest of that piece is just pointless drivel by two uninformed journalists.

Nice find otherwise though.
#21 Katharine
January 13, 2010

“In Australia and the USA, there has been a recent proliferation of compounding chemists who have taken advantage ofpostmenopausal women’s need for and anxiety about conventional HRT and the loopholes in current legislation in these countries. These compounding pharmacies are now manufacturing ‘bioidentical’ hormonal mixtures and delivery systems in such proportions that they have effectively become a large, inadequately regulated pharmaceutical industry. It is time for the international drug regulatory authorities to regulate this industry, which is based on false promise, pseudo science and pecuniary interest without responsibility for the interests and health of the consumer.”

Is this what you were referring to, Micawber?

I don’t think it’s ‘mixing medications’ that’s the problem. It’s the fact that some unscrupulous ones are mixing one that is hazardous. The ‘huge conglomerate pill-pushing pharmaceutical companies’ are somewhat more liable for their manufacturing than pharmacists, and staffed by pharmacists and pharmacologists themselves.

Also, ‘pointless drivel’? How is it ‘pointless’?
#22 Snuggie is a robe worn backwards
January 13, 2010

@ #10 cassandra

“I don’t know much about recreational steroid use, but I thought guys took steroids to get a better physique… Can you explain why James Ray didn’t get all buff taking those drugs? Is he just too old for steroids to be that effective?”

no one is too old for steroids to be effective, but he probably wasn’t taking steroids.

it’s virtually impossible to get any kind of steroid effect from the amount of hormones you get from prescriptions. 1 bottle of testosterone cypionate that lasts a patient 3 months is two injections for someone who is using steroids as a bodybuilder.

The foundation for this isn’t steroids for supraphysiological physique building but this concept of “anti-aging”. That you can give yourself the same levels of hormones, (testosterone, growth hormone, etc) that you had in your teens or early 20′s and in turn have the same vitality. He was most likely just trying to give himself growth hormone and testosterone levels in the upper normal or high areas of the reference range.

People abusing steroids use 10, 20 times or more what anyone uses for this purpose.
#23 leigh
January 13, 2010

all Crisler has are a plethora of anecdotes, with no analysis and no controls. this does not make for data.

i am a simple country pharmacologist [hahaha, that looks as funny as i expected] with significant exposure to neuroendocrine pharmacology. i did spend plenty of time searching the published (scientific, not playboy) literature for evidence regarding the validity of such pharmacologic manipulation. the simple fact is that evidence is lacking.
#24 qetzal
January 13, 2010

@leigh (#23):

Maybe you neglected to review such prestigious medical venues as Healthy and Fit Magazine or Will Carroll’s Baseball Prospectus Talk Show? Or perhaps Channel 6 News or The Big Show.

Seriously, though, if Crisler is really as committed to better treatment for hypogonadism as he claims, it’s awfully curious that he’s made no apparent attempt to publish any of his ‘remarkable’ results in any reputable medical journal.
#25 leigh
January 13, 2010

@qetzal (#24)

but… if he’s The Anointed One With Teh Answerz, the business is all his.
#26 Snuggie is a robe worn backwards
January 13, 2010

What your guy’s angle on this at this point?

What’s the current agenda?

What would you realistically like to see happen or change from this point going forward?

Why do you even care about this guy like this?
#27 Katharine
January 13, 2010

leigh and qetzal, you win the thread.
#28 Warren
January 13, 2010

So this is how all this strikes me:

It’s as if the first thousand people with fractured legs found a country doctor who first discovered how to “reset” the bone. All the other doctors demanded proof it worked. The thousand running around again didn’t matter. They refused to set the bones of their own patients until peer-reviewed studies came around – such studies never came because doctors so ridiculed the practice; ignored the plain evidence in front of their eyes; jealously assassinated the character of this country doctor; and, in the end, hurt the very patients they claimed they were “fighting for.”

Moral of the story sheeple: open your minds & use reason and your critical faculties. Ask questions – forcefully, directly, but also politely and respectfully. Stop the small minded stuff that’s all-too-apparent here.
#29 Joshua
January 13, 2010

@Cassandra Yorgey #10

“I don’t know much about recreational steroid use, but I thought guys took steroids to get a better physique… Can you explain why James Ray didn’t get all buff taking those drugs? Is he just too old for steroids to be that effective?”

Yes, people do take exogenous androgens in high doses that we call “steroid” doses for the purpose of obtaining higher than normal muscle growth.
The key here is that TRT aims to replace androgens to standard physiologic levels, IE what a healthy person should have. By that logic, somebody who is taking testosterone for the purpose of restoring physiologic levels should have the ability to generate muscle to a strength and mass of a healthy person of the same age.
Please know that just by taking a steroid doesn’t mean that you’re going to be instantly ‘big’; even body builders who are on abusive doses of androgens and other steroids need to put in a ridiculous level of hard work to get their physiques.
#30 Joshua
January 13, 2010

@Dangerous Bacon #15

“If lawyer(s) “rigorously” scrutinize everything you do at your office, one wonders exactly what it is that you do and why you have to have the legal profession go through it with a fine-toothed comb.”

Heck, if I was so frequently prescribing a drug/hormone that has the ramifications to be abused in high doses, of which such a use is highly illegal, I’d be wanting to be scrutinised to make sure that I’m working within the law. Wouldn’t you?

I commend the fact that he states he has been checked over by medical boards.
#31 leigh
January 13, 2010

when it comes to pharmacology, there is this thing called the placebo effect that has absolutely nothing to do with the pharmaceutical intervention. perhaps you have heard of it.

there are plenty of other effects. for one, the small group of participants in this weak collection of anecdotes are not representative of the general population (which is highly variable in genetics, age, environmental exposures, lifestyle, eating habits, work conditions, etc) and are not sufficient to demonstrate that the described therapy does what it is purported to do.

there are also long-term effects that we do not know of. just look at the women’s hormone replacement therapy results. it took a large, properly controlled study to determine the long-term effects of estrogen replacement therapy.

in short, the sheeple are the ones bleating their way along behind the prophet with no supporting evidence, refusing to ask for such evidence or question the leader. if this d00d wants the respect of the scientific and medical community, and his primary interest is improving protocol for hypogonadism therapy, then he would subject his own protocol for analysis and scrutiny, potential improvement, and wider use should it prove effective.

simply put, by publishing in his current venues, he is advertising to a wider public client base without contributing to science. a shame, if he is as miraculous as so many here say he is.
#32 Warren
January 13, 2010

@ Leigh

Serious question: how would you construct a peer review study for a “protocol” that is by its very nature tailored to each individual person on an ongoing basis.

BTW, your thing about the placebo effect has some merit; but when so many of his patients have experienced measurable results (BP down/regularized; weight down; lipid profile dramatically improves, etc…) I’d say that it’s time to sit up and pay attention.
#33 Kristen
January 13, 2010

@28

It’s as if the first thousand people with fractured legs found a country doctor who first discovered how to “reset” the bone. All the other doctors demanded proof it worked. The thousand running around again didn’t matter. They refused to set the bones of their own patients until peer-reviewed studies came around

What a terrible analogy. There is no possible drawback to setting a bone, and the benefit is quite obvious (almost immediate and beneficial to 100% of patients) to any observer. Prescribing a potent drug is quite different, that should have lots of proof before it is practiced.
#34 Warren
January 13, 2010

Kristin: 1. there is a massive amount of peer-reviewed proof that TRT is effective and safe; 2. “There are no drawbacks to setting a bone” – that’s a bit of a chronological provincialism; NOW you know that; however, in my in-the-past metaphorical example, how would you know? Irrational fear is irrational fear – whether in the middle ages or now. 3. The benefits of TRT are immediate and hugely beneficial – and there are long-term benefits too.
#35 Warren
January 13, 2010

Also Kristin: I’m assuming by “drug” you mean something not natural to one’s body; testosterone, DHEA, Pregnenelone, etc.. are not drugs.
#36 leigh
January 13, 2010

as a scientist, your references of improvement say to me that we have a basis for formal investigation, not that it works for sure. if you’re honestly interested in how a study could be conducted to ask whether this is a valid protocol, by all means.

i presume the protocol is intended to reach a target serum testosterone/estradiol level, yes? presuming that target is generally within a defined range, and that range can be reliably achieved: we recruit a whole lot of hypogonadic men, randomize them into separate treatment groups, and have them undergo differing treatment regimens.

ideally there would be several treatment groups: if i were designing the study, i would include a placebo group (saline injection rather than testosterone, sugar pill for the arimidex), TRT alone at perhaps a low and high target range (testosterone injection, sugar pill for the arimidex), and TRT + arimidex to reach a low and high target T and low and lower E2 range (you guess the conditions). arimidex alone might also be considered. of course, all of this would be approved by a proper human subjects study review to ensure proper clinical practice and ethical guidelines have been met. and as a pharmacologist, i like to see dose-response effects.

during the course of the study, serum hormone levels (presumably T and E2, yes?) would be monitored, and several other measurable outcomes- you mentioned weight, BP, lipids (which have been investigated in small studies in the past, with mixed results over placebo) and whatever others are relevant (bone mineral density? cognitive function?), perhaps subjective scores of libido, feelings of well-being, etc. and in case it is not implied, i am not a TRT specialist and not even a human researcher myself, i just read and evaluate a lot of clinical pharmacology.

long-term studies of course would be needed as well- look how long it took us to look at female HRT and the changes made as a result of sufficiently large studies.

in short, we’re asking which treatment gives the greatest benefit? are any better than placebo? are there significant negative results associated with any of them? we could also look at stratified age groups. perhaps it’s only effective in men of certain ages. in men with certain medical histories. you get the idea.

unfortunately, without asking these questions and demonstrating the answers with reliable data from a properly designed clinical study, you’re not going to drive any change in standard protocol, because it’s not real until it’s been investigated. if you want to play with pharmacological tools, you get to play by the same rules as the rest of us in the discipline.
#37 A. Noyd
January 13, 2010

Warren (#28)

Moral of the story sheeple: open your minds & use reason and your critical faculties.

Yes, we’re doing that. You seem to be a little confused as to how that works, exactly. Considering how every woo-peddler under the sun uses the “evil skeptics ridiculed the miracle worker, keeping him from showing objectively how awesome his treatment is” sob story, if we were “open minded” enough to forgive Dr. I Shit Rainbows and Fluffy Bunnies his as-yet lacking credibility, then we’d have to offer the same courtesy to every guy or gal with a dubious cure and lots of blithering sycophants.

Ask questions – forcefully, directly, but also politely and respectfully. Stop the small minded stuff that’s all-too-apparent here.

Don’t tell me how to comment on someone else’s blog.
#38 Joshua
January 13, 2010

I’d be happy with a placebo effect!
After trying dozens of different therapys, some alternative, why would TRT have the sudden placebo effect that I was seeking? Is it because it was better sold to me by my physician, where as the sales people of other therapies weren’t up to task? Just a thought.
#39 Kristen
January 13, 2010

@Warren

“There are no drawbacks to setting a bone” – that’s a bit of a chronological provincialism; NOW you know that

Please inform me what the drawbacks would be of setting one of the bones of the leg (with examples/references). I dislike being insulted now you know that.

I know there are benefits to TRT, I was speaking of the unproven reasons for which this Dr. is administering the hormones.
I don’t pretend to be a doctor, I am certainly not as learned as some who have commented here, but I am not stupid. I also don’t mind being corrected when warranted.

TRT can consist of natural hormones, but it is still considered a drug because it is controlled by the FDA. The definition of drug does not preclude natural substances, but perhaps medication would have been a better word to use.
#40 Snuggie is a robe worn backwards
January 13, 2010

#36 @leigh

actually leigh he does a full hormone profile every time he tests a patient until they hit their “sweet spot” of symptom relief and subjective wellness

for instance he will use any of the below if he feels it’s necessary based on each patients clinical response and test results:

thyroid hormones
pregnenolone
testosterone
arimidex
hcg
dhea
cortisol
ghrp-6

rather than just looking at testosterone each time, or just looking at estrogen this time because it was the only hormonal problem last month, he always does a complete panel of all relevant hormones to make sure they’re all optimal and looks for conflicts to see if treating one or several hormone deficiencies is having a negative affect on other hormones in the process

he doesn’t do a standardized formula where everyone gets targeted for the same spot in the reference range. he goes by how the patient responds (symptoms, subjective relief) and how their overall numbers look in their complete hormone profile. some guys feel their best at low-normal, some normal-high, some high.

He also will use different administration methods, gels, creams, shots, all depending on how well the patient is responding.

When symptoms are alleviated and there’s no red flags in the serum or urine test data it’s considered “hitting their sweet spot” and a success, regardless of where they end up in the ranges.

So, a meaningful test based on his complete clinical practice would be significantly more difficult than just targeting a range for total testosterone and estradiol, even with only those two the doses and administration type may be different in each person to reach the desired point on the reference range even if you set out to do it that way. Some guys can’t seem to raise their testosterone at all through the topicals, and some guys have a energy crash by the end of the week on shots. Topicals raise estradiol more than shots do, etc. It gets complicated and there are a lot of variables to account for. There’s probably a way to mine all of the treatment variables to pluck out a few core things that could be isolated and studied to a reasonable degree one way or another, but I don’t think it’s very easy.
#41 leigh
January 13, 2010

the point is that science is not easy. excuses mean nothing.
#42 MonkeyPox
January 13, 2010

Leigh, how can you talk so callously about science taking time when my nuts are shriveling to raisins???!!!111!??
#43 Calli Arcale
January 13, 2010

Warren:

Also Kristin: I’m assuming by “drug” you mean something not natural to one’s body; testosterone, DHEA, Pregnenelone, etc.. are not drugs.

It might be helpful to agree upon a definition of “drug”. The legal definition is any substance administered to prevent, treat, cure, or diagnose a disease or condition. It doesn’t much matter how it’s obtained; if it’s administered exogenously (i.e. not made by the body), it’s a drug.

Testosterone is made by the bodies of both men and women. But if additional testosterone is injected, that additional testosterone is being used as a drug. I should also note that this testosterone is definitely not produced in the human body; there are several ways to obtain these hormones for pharmaceutical use, but extracting them from living humans is neither ethical nor practical. I’m not sure where pharmaceutical testosterone comes from. I know pharmaceutical estrogen comes from horse urine. Pharmaceutical insulin (another human hormone) comes from genetically engineered bacteria. Synthroid is thyroid hormone that has actually been synthesized in an industrial chemical setting. There are also “bio-identical” hormones touted by the supplement industry, such as soy extract (which contains phytoestrogens, chemicals which happen to mimic estrogen fairly well). So there are a range of sources for replacement hormones.
#44 Warren
January 13, 2010

@39: I didn’t insult you. I was saying that NOW – in our present time – we know that setting a leg has no other consequences. Human history is fraught with irrational fears about such things; and it is a chronological snobbery to think that those irrational fears are no longer with us. Also, you people are really sensitive. And incidentally, that’s often a sign of elevated e2. Kidding, kidding…
#45 Snuggie is a robe worn backwards
January 13, 2010

leigh, why do you care about any of this again?
#46 leigh
January 13, 2010

what does my interest have to do with it? science is science. like i said earlier, if you wanna play with pharmacological tools, you can follow the same rules that the rest of the field does.
#47 Snuggie is a robe worn backwards
January 13, 2010

i’m just curious why a physician, who is using the same tools as everyone else in evidence based medicine, is getting his balls busted to this degree by you and others. i could see if he claimed he was curing hypogonadism with pyramids. why does it bother you so much that he and his patients claim good outcomes?
#48 Chris
January 14, 2010

I usually find that the “why are you here asking questions” come from folks who finally realize they don’t have anything to argue with.

You are playing with the strawman. It does not bother anyone that his patients claim good outcomes, what is bothersome is the lack of evidence. For all we know that only one quarter of his patients claim good outcomes, and the rest are not and don’t hang around his forum.
#49 leigh
January 14, 2010

if there were evidence, you wouldn’t need to be so defensive.
#50 Kristen
January 14, 2010

“There are no drawbacks to setting a bone” – that’s a bit of a chronological provincialism; NOW you know that; however, in my in-the-past metaphorical example, how would you know?

According to the dictionary provincialism means: “narrowness of mind or outlook; lack of sophistication.” Your above sentence must have been written in haste, because it is not very clear. I think now I understand what you mean, but before I was confused.

I wasn’t talking about the past, and in your original example you never mentioned the middle ages. The emphasis on now made it sound like you were ‘schooling’ me. But thank you for the clarification.
#51 Snuggie is a robe worn backwards
January 14, 2010

@chris #48

I usually find people that object to the question of why have finally realized they don’t have anything to argue with, or a reason for doing so.

@leigh #49

I usually find people who say “you’re being defensive” have finally realized they don’t have anything to argue with.

again, i ask, what has he done wrong that requires any scrutiny and/or evidence of his clinical practice?

why aren’t you walking around to every physician in your town, knocking on the door, and demanding evidence of good patient outcomes?

perfectly valid question: why the witch hunt?

so far you guys have stated multiple things which were untrue, yet you continue to pursue a line of reasoning that “something” is wrong but aren’t identifying it and demanding things from a physician for no apparent reason. that’s all.
#52 neurospasm
January 14, 2010

I still can’t figure how a doctor who spouts off about being world-famous can have such a shitty website with 2nd grade graphics and hyperlink dysfuncationality as well as spelling errors (such as his repeated “reccomendations” at cardiofuel). Judging from the level of intellect of the trolling here, these people appear to be compensating for something and it may not just be lack of testosterone.

One theory is that the doctor and his minions are just a bunch of neuronally-challenged oafs whose only validation in life comes from the reacharound circlejerk they’ve got going.

Just take a look at his long-standing war with Harvard and MIT graduate Dr. Michael Scally. That’s a name certain to send the good doctor into fits.
#53 NMD
January 14, 2010

“Physicians who accept insurance are usually forbidden from extra fees such as fees for phone calls or prescription writing.”

This is patently false. There is nothing forbidden for cost except for certain Medicare/Medicaid requirements. Phone calls, depending upon the reason, are often billed out as consults. The fees imposed are usually NOT REIMBURSED by insurance, but it is merely at their discretion. There is no legal ‘forbidding’ of the fees.

Believing that simply having a patient in front of you makes the process of patient care somehow ‘responsible’ ignores the fact that I would rather my physician spend an hour on the phone with me in discussion, than simply spend 5 minutes in front of me, reading a chart.

I am a physician, and I agree, Crisler’s methods and practice is ‘not the norm’. However, I see no evidence, that its simple variance from the way in which you practice medicine, diminishes his care of patients to a greater degree.
#54 qetzal
January 14, 2010

NMD wrote:

I am a physician, and I agree, Crisler’s methods and practice is ‘not the norm’. However, I see no evidence, that its simple variance from the way in which you practice medicine, diminishes his care of patients to a greater degree.

I am not an MD, but I generally agree. Some of Crisler’s activities strike me as rather self-aggrandizing, while others seem to be rather unabashed self-marketing, but those don’t show diminished care, IMO. They don’t really show anything about quality of care.

My own interest was more in his (and his patients’) claims that he provides superior care. So far, there seems to be no evidence for that either. Only assertions, testimonials, and vague claims that there is “abundant” literature, without actually referencing any of it, much less showing how it supports the superiority of Crisler’s approach.

I’m always dubious of people who claim to have superior treatments but who are unable or unwilling to back up their claims with any reliable evidence.
#55 leigh
January 14, 2010

the physicians i personally have seen don’t claim to be world-famous simple country doctors who are out to save the world from [pick a disease] against the will of BigPharmaBigMedicineZOMGComplex while demonstrating nothing more than self-interest and profit motivation.

frankly, what i’m seeing here is anecdotal evidence that this particular therapy regimen imposes some kind of cognitive impairment.
#56 Calli Arcale
January 14, 2010

Snuggie is a robe worn backwards @ 47:

i’m just curious why a physician, who is using the same tools as everyone else in evidence based medicine, is getting his balls busted to this degree by you and others. i could see if he claimed he was curing hypogonadism with pyramids. why does it bother you so much that he and his patients claim good outcomes?

There are a few things which give cause for concern:

1) Are his patients really getting good outcomes? They believe they are, but the evidence is abundant that reality is not always coincident with our own impressions of it.

2) Just because some of his patients are being treated well does not mean they all are. It is not unheard of (nor, unfortunately, unusual) for a doctor to use legitimate treatment of real issues as a cover for dubious treatment of dubious or even nonexistent issues. While the former is ethical, the latter is predatory and could lead to considerable harm. One of the more widespread examples is chelation therapy. A quack will diagnose lead poisoning in order to bill insurance for chelation therapy which is actually intended to reduce atherosclerosis or treat autism — despite the fact that the procedure has significant risk and absolutely no scientific evidence that it helps either condition. (Anecdotes, though, exist aplenty.)

3) TRT is, in many ways, analogous to the hormone replacement therapy many women have undergone. It was considered pretty standard not too long ago, but long-term trials have revealed that it has bigger risks than anybody knew. It seems reasonable that the same could be true of testosterone replacement therapy. I hope Dr Crisler follows his patients carefully and consistently so that the data obtained will be comparable in a useful way.

4) Even if he is treating his patients correctly, the legal disclaimers he’s put out are concerning. They are not normal documents. This raises questions — why is he so concerned with preventing him from being sued, and with disclaiming a connection to anabolic steroid use? To paraphrase the Bard, “methinks he doth protest too much.” It could be there’s nothing to it, that he’s just got some really overzealous lawyer, but it looks bad.

5) He has an established relationship with a pharmacy, which although he doesn’t require you use it, he appears to strongly encourage use of it. This is another red flag, because it suggests a financial conflict of interest. While he may not mean any harm, most doctors who do this are doing it for kickbacks from the pharmacy, and so it does raise some concern.

As far as #1, I don’t want to claim that you or anyone else may not have had a good outcome. Good outcomes are good. We all want that. I will take you at your word that you had a good outcome. I’m just cautious of generalizing that to, say, my male relatives having a good outcome if they try the same protocol. I know there have been examples of therapies where users enthusiastically touted their good results, even though it was later demonstrated that they could not possibly have had any real effect from the treatment.

And “male issues” are one of the classic areas of fraud. People have hawked things with these sorts of claims for centuries. One of the more colorful examples in recent times (relatively) was Dr John R Brinkley. He’s an interesting one to read about. He, too, had many satisfied customers who had sought his unique treatment which was billed as essentially a sort of testosterone replacement therapy. He was transplanting goat testicles into men. It’s a very interesting story. It’s also part-and-parcel with the story of the border blasters (powerful radio stations in Mexico to evade US broadcast regulations). Brinkley was so heavily into quackery and fraud that he himself had a huge influence on regulation of both medicine and broadcasting, by so eloquently demonstrating the need for such regulation. It’s a fascinating story; google it sometime.
#57 JohnV
January 14, 2010

“He was transplanting goat testicles into men.”

This is the part of the story where I imagined a record scratching sound and a narrator voice over began speaking.
#58 Snuggie is a robe worn backwards
January 14, 2010

Calli, thanks for the earnest response, I will definitely read about john brinkley, I am fascinated by quackery and supernatural scams and love stories like that.

I realize the bar for meaningful evidence is very high, and anecdotes and testimonials count for nothing as far as clinical evidence.

However that being said, as a small piece of anecdotal data: these “testimonials” and “outcomes” claimed are from patients actively participating on both the messageboard crisler runs and other messageboards he’s not connected to or has any control over.

You could say well, if he received criticism about his treatment outcomes on his own messageboard, it could have just been deleted. But peoples experiences are just as positive virtually everywhere. Mike Scally sits on the bodybuilder messageboards and flames crisler all day long. Anyone could post anything negative they wanted about him on any messageboard who was unsatisfied. The few posts I’ve seen where a patient wrote something negative or said they quit his practice, they didn’t complain about their treatment, but that they thought he was an asshole. Some of these guys as you’ve seen can be… temperamental. They have hormone issues, lol.

Until there is the equivalent of the women’s health initiative for men, we will have no way of knowing the true safety profile of testosterone or the other possible forms of hormone manipulation in men.

On the pharmacy thing, he has used multiple compounding pharmacies over the years, I believe he has only been using anewrx for something like a year or less. He claims to be impressed by their superior knowledge and compounding techniques and that he’s been able to get involved with the technical aspect with them to ensure the highest level of quality control for his prescriptions. He prefers to use inexpensive bioidenticals for hormone replacement, and says he just wants to be sure people are using a reputable compounder for this purpose. He also says in his lectures androgel is “wonderful”, and likes testim, so he’s not steering guys away from “bigpharma” with fear tactics or anything. It’s just that it costs $300 and his compounder is $20.

As far as whether outcomes are real or imagined, any hormone manipulation you do is directly measurable through serum and urine testing. When you give someone a 100mg testosterone injection once a week for 6 weeks and their testosterone goes from 250 to 725, you can’t call a placebo, or imagined response. If they can’t get an erection and you bring their estradiol down from 75 to 23 and they get consistant nighttime erections for the first time in years and have a normal sex life, without changing their testosterone dose, it’s reasonable to assume the arimidex is probably having the desired effect. It gets increasing complex and harder to isolate the more medications you add and hormones you address, but this is still ultimately 50% evidence based in the form of lab work, isn’t it?

He’s still only using the same medications all evidence based practitioners use, not goat testicles, he didn’t invent his own compounds. He just claims to be taking whats already out there, and putting it to better, and more careful, use.
#59 A. Noyd
January 14, 2010

leigh (#55)

frankly, what i’m seeing here is anecdotal evidence that this particular therapy regimen imposes some kind of cognitive impairment.

I don’t think that’s the “obvious” conclusion you were supposed to draw, but it’s sooooo true. *snicker*

~*~*~*~*~*~

Calli Arcale (#56)

Seriously excellent post.
#60 DLC
January 14, 2010

And they say men aren’t vain.
Sorry, but a lot of this seems like Vanity gone wild.
#61 JohnV
January 15, 2010

Reading about that John Brinkley guy was … interesting.
#62 Calli Arcale
January 15, 2010

That’s not even the whole story; there are several accounts available on the web which tell more. Wikipedia’s the easiest to find. It’s an important story for other reasons, as it was instrumental in prompting greater regulation of both medicine and broadcasting.

However that being said, as a small piece of anecdotal data: these “testimonials” and “outcomes” claimed are from patients actively participating on both the messageboard crisler runs and other messageboards he’s not connected to or has any control over.

That doesn’t increase their level of quality. I’m not alleging any fraud in them; I’m pretty certain that the people posting these testimonials are doing so because they believe are they true, not because they have been paid. I certainly don’t believe there’s any “sockpuppetry” going on. Those are things I won’t believe without a good bit of evidence.

One of my major areas of interest lately for quackery has been autism. You can find glowing, unsolicited testimonials for all sorts of things. Chelation therapy. Lupron. Hyberbaric oxygen therapy. The gluten-free/casein-free diet. Dietary supplements. Steroids (corticol, not anabolic). A wide range of psychotropic medications, some of which may work, some which probably do not. Herbal treatments. Homeopathy. If people will write an unsolicited and glowing endorsement of homeopathy for autism, then I have to take all such medical endorsements with a grain of salt. Maybe it works. Maybe it doesn’t. But if the measure is at all subjective, it’s very easy to fool oneself, and so while the endorsements are interesting and certainly they sound happy, they’re not enough.

That’s all.

I am encouraged by your statement that his relationship with this particular pharmacy is relatively recent, but it’s still a bit of a red flag for me. Is he shopping around for a better deal for himself? Or is there some other reason? I’ve never met a doctor who recommended a particular pharmacy, with the sole exception that in hospitals, you are generally obliged to use the hospital pharmacy for reasons of practicality. But then, I’ve never had need of a compounding pharmacy. My pharmaceutical needs have always been met by Target or Walgreens. I do know that some compounding pharmacies are unethical; they have means of skirting a lot of FDA regulations, and so the quacks and charlatans have been attracted to that business. That doesn’t mean they’re all shady, but it does mean one needs to be more careful in picking a good one. That also could explain why Dr Crisler recommends a particular compounding pharmacy; perhaps he’s simply found this one to be ethical. I just don’t know.
#63 Micawber
January 15, 2010

Calli,

Dr. Crisler refuses to patronize any services that evidence unethical practices.

For example, the various blood/saliva testing (“self-serve” and no script required) services, which foster a “I read the interwebs and I’ll treat myself, attitude. These he frowns upon and avoids.

Dr. Crisler is very impressed with this particular compounding pharmacies practices, their extremely high quality control, and their strict ethical practices – all of which, again, he demands.

As to why compounding pharmacies – besides being cheaper than standard preparations, a doctor can more closely tailor medications (transdermal test, for example) to the patient. I’m sure there are many other reasons.
#64 Snuggie is a robe worn backwards
January 15, 2010

Hey Calli,

Yeah, dr crisler has a list of a handful (i think 5 or so) compounding pharmacies outside of the default one he uses that he will send a prescription to if you’re need compounding, outside of these compounding pharmacies he has personal knowledge of and approves he won’t allow someone to use one.

You’re probably also thinking of “research chemical” pharmacies. These guys use a loophole to create liquid versions of common drugs (such as viagra, but also peptides and things of this nature) which are for “animal use only”. Then they sell them online after you tick a box claiming you’ll use it for it’s intended purpose. Anyone who has come on crislers messageboard saying they use liquid arimidex or something like that has been banned or publicly warned that he won’t tolerate discusion or use of “gray area” medications and the post left up for a day or two for everyone to see it before it is deleted.
#65 Snuggie is a robe worn backwards
January 15, 2010

I forgot to mention… as to why he uses compounders you have a lot of flexibility in formulation very cheaply.

For instance, instead of there being a one or two dose version of a testosterone cream, say 5mg or 10mg, if he has a patient who has poor absorbability for whatever reason and needs to use twice the normal amount of cream to get his levels up he can have a 20mg formulation made for the same cost rather than the guy having to buy twice as much medication as most people each month.

Another example is he considers oral DHEA inferior to transdermal, so he can add a small amount of dhea to a persons testosterone formula thereby reducing the number of medications they need to remember to take as well. Same goes for pregnenolone… etc. He’s working with generic compounds and this just gives him a lot of flexibility in tailoring therapy for maximum benefit and in some cases simplicity.
#66 gaiainc
January 15, 2010

I recommend Costco pharmacies out here in the PNW because they tend to have the cheapest prices on meds (warehouse store and by state law have to open their pharmacies to everyone even without a membership). I even recommend that patients call up Costco, find out the price there, and then call their local pharmacy to see if they will match the price. More often than not, they will. I also spend time perusing the Target/Walmart/Kroger $4 lists because that what my patients need. Honestly, I don’t care where they go, just that they get their meds. The exception is that I have ONE compounding pharmacy within a 30 mile radius, so I have to use them.

To re-iterate, if Dr. Crisler is really doing such a marvelous, wonderful, bang-up job, and he has the data, PUBLISH IT. Show the rest of us how great his treatment is. Then I might believe him. Until then, yeah… not so much. If I’m going to ask my patient to spend several hundred dollars a month, I’d like more evidence than just some testimonials and anecdotes.

A book on Brinkley called “Charlatan” is a fascinating read and a reminder to me over and over again that deregulation of the medical field is not a good thing.
#67 Snuggie is a robe worn backwards
January 15, 2010

Gaiainc, what costs hundreds per month?

Brand name arimidex is $50 per month. Generic arimidex is $15. Testosterone injections are $20 per month. Transdermal is about $40. All of his medications are in this price range aside from viagra and cialias and things of that nature

I’ve never been charged more than $60 to review my lab results with him even if it went as long as 20+ minutes.

Just being clear as a lot of false assumptions keep being piled on that will confuse undiscerning readers.
#68 Calli Arcale
January 15, 2010

You’re probably also thinking of “research chemical” pharmacies. These guys use a loophole to create liquid versions of common drugs (such as viagra, but also peptides and things of this nature) which are for “animal use only”.

No, I’m thinking of compounding pharmacies. There are many reasons to use compounding pharmacies (and indeed, in the old days, those were the only kinds that existed). Again, most of my knowledge in the area relates to autism quackery, so that does color my impressions.
#69 Micawber
January 15, 2010

Callie,

The impression I get from all of this is that the Woo Seekers keep jumping around from criticism to criticism, hoping something will stick.

The efficacy of TRT/HRT is well-founded both in practice and peer-reviewed research. Check.

Dr. Crisler’s practice is rigorously above board on ethical and legal matters. Check.

Dr. Crisler has a veritable army of happy patients willing to defend him (how many doctors can say that?? LOL). Check.

Other than these things, are you (or anyone else here) able to say what exactly your problem is. I know I’m really dumb (or so I’m told! LOL), but I still don’t understand what, exactly, is at issue.

I suspect it’s that the website (muscle-whatever) and the focus of his practice (to say that testosterone gets a really bad name is a bit of an understatement) that has the Woo Seekers all riled up; to be sure: that, ironically, it’s not the allegedly “unscientific” nature of his practice, but rather a whole set of cultural stereotypes that has really attracted so much anger.

Peace.
#70 Calli Arcale
January 15, 2010

If you scroll up a bit, I went into considerable detail on what my concerns are. I’m speaking as somebody without a dog in the fight; I just find medical ethics interesting.

I agree that the efficacy of hormone replacement therapy in general is known, though I would disagree if you went so far as to say it’s well studied. I think it could use a great deal more study. And I’m not just talking about testosterone here. My mom is dependent on thyroid hormone replacement, as she has a non-functional thyroid gland. This is rather more dire than testosterone replacement; without her Synthroid, she will actually die. I get the impression that we do not understand the full action of these hormones adequately, and though I absolutely feel it’s important to treat people’s suffering before we have all the answers (for humanitarian reasons if nothing else), I also think we need to accept the limitations of what we know. It was many years before estrogen replacement therapy was shown to be hazardous in many cases; I would not be surprised if something similar were found with testosterone replacement therapy. That doesn’t mean guys should just abandon it; there is certainly suffering, and that suffering needs to be relieved if at all possible. (And for those who snicker, I strongly believe that sexual health problems deserve proper treatment. It’s not just macho BS, and all the jokes about raisin-sized balls are really not appropriate in my opinion.) It just means we all need to be aware of the limitations of what is known. Just look at how much oral contraceptives have changed since their invention, as more was learned about them.

I am still not convinced that Dr Crisler’s practice is rigorously above board on ethical and legal matters. It may be, but I still see red flags which have not been adequately answered. His “you’re not allowed to sue me” agreement is strange indeed, and reminds me a lot of a Microsoft EULA. It’s probably not enforceable in court, and if I’m right about that, then it would mean he’s got some issues in the legal department. (I don’t mean he’s doing anything illegal; I mean he may need to get better legal advice so that his legalese is stronger.)

The army of happy patients doesn’t really tell me anything. The worst quacks have armies of happy patients, and you rarely see the unhappy ones. Dr Brinkley had armies of happy patients too, and his care was about as bad as it gets. (His medical board first became suspicious because so many of his patients were dying.) If he could get patient satisfaction, anybody can. It doesn’t tell us anything, good or bad.

The only reason I bother to express my concerns is because I have a peculiar interest in questionable medical practices, so when I hear of a possible one, I get curious. Beyond that, I don’t think it’s any of my business what doctor you see for what complaint. That’s your business, and yours alone.
#71 Kristen
January 15, 2010

I started coming here when the quacks were telling me their is something wrong with my(autistic) son and he needed to be cured of what makes him him.

I don’t know if Pal is always right, noone is. But he brings a rationality to my world I don’t get anywhere else.

Unfortunately I don’t know Dr Crisler, except through his decidedly unfortunate comments. I think you would agree with me (if you think of it objectivly) that some of the comments made on allthingsmale were not apropriate.

I went to that message board (I registered) I know you all love Dr Crisler very much for the help he has given you. I have studied nutrition and was impresses by some of the advice there.

I have had lots of fun with this discussion, it is a welcome diversion from the regulars who insist there is something inherenty wrong with my child. I did appreciate Micawber’s considerate and sensitive statement when he struck a raw nerve with me.

I do not come with preconcieved notions about what kind of people you are, just that I think the anger has reached a fever pitch, and doesn’t do any of us justice.

Pal is a great blogger, and he gives me a chance to be in touch with other people of like mind as me. We feel every bit as protective of him as you do your doctor.
#72 Dazed and Confused
January 15, 2010

Calli arcale,

Right on, good post, I think most would agree with you 100%.

However, I feel the womens health initiative is often cited without full context, and is actually a better example of the difficulties of epidemiology and the complexity of creating reliable evidence in medicine in _general_ rather than specifically pertaining to anything to do with hormone therapies or their potential outcomes exclusive to other forms of treatment.

Please see my response to kristin over on the other thread:
http://scienceblogs.com/whitecoatunderground/2010/01/nobody_knows_the_trouble_ive_s.php
#73 Dazed and Confused
January 15, 2010

Kristen, you seem very kind and reasonable

Thank you… and good luck with your son.
#74 Comrade PhysioProf
January 16, 2010

Crisler is quite correct that to disparage DOs as a class is ignorant and unfair.

Tough shit. DOs are fuck-ups who couldn’t get into a real medical school. Period. Their patients are “more satisfied” because they feed them a load of bullshit.
#75 B
January 16, 2010

@73

You obviously know nothing about which you speak.
#76 B
January 16, 2010

Kristen, I also have a family member (cousin) who is autistic. Though I don’t know what it would be like if it were my own child, I can somewhat relate to how you feel about that. I would like to wish you and your son the very best in health and happiness.
#77 Calli Arcale
January 18, 2010

Thanks, Dazed and Confused, for the kind words!

My mention of my mother wasn’t meant as a reference to the women’s health initiative; my mother’s hormone replacement has nothing to do with sex hormones, and addresses a problem which men can have too. She had Grave’s Disease, an autoimmune disorder in which the immune system attacks the thyroid. In response, the thyroid actually ends up growing and producing more thyroid hormone. Untreated, it can be fatal. She tried thryoid-suppressing hormones for a while, but these were ineffective. In the end, she had to take radioactive iodine tablets which killed off her thyroid. This makes her profoundly hypothyroid, a condition which, untreated, would also prove fatal. So she takes synthetic thyroid hormone. She will be on it for her entire life. It’s a different ball of wax, really, than low testosterone, but the side effects are always obvious, and the fact that taking it is, for her, a life-and-death decision means that she cannot choose to discontinue it just in case. So if there *are* any adverse effects, it would be good to know in advance. Synthroid is a good simulacrum for human thyroid hormone, but it is not identical.

I actually read your post in the other thread too, responding to Kristin. I agree that the women’s health initiative has a larger context. But we can learn some things from it, and one of them is the lesson (which we all should have known already, but usually can stand to learn again) that there can be unforseen side effects to these things. That’s why the idea of estrogen replacement at age 50 is controversial; if it’s just to satisfy a woman’s vanity, or delay the inevitable with respect to menopausal symptoms, is it worth risking the side effects? We *know* there’s stuff we don’t know about how these hormones actually work. Consider oxytocin; this hormone is associated with orgasm in both sexes, and with both labor and lactation in women. But what it actually *does* isn’t entirely clear. Oh, in labor it’s clear, and induced labor demonstrates that fact pretty unambiguously. But what exactly does it do with respect to orgasm? The popular media has latched onto the idea of it being an “attachment hormone”, promoting bonding, but this appears to be overly simplistic and may even be entirely wrong. It seems reasonable to expect that there may be similar knowledge gaps with other hormones.

That doesn’t mean low testosterone should never be treated. There are clearly times where its needed. It just means there needs to be surveillance, and an open dialog between patients and their doctors so that if things go wrong, it can be caught and addressed promptly.

Sidenote: testosterone is something that comes up a lot in autism quackery, but not in the context of a deficiency. Rather, some autism quacks (notably the Geiers) believe that testosterone is implicated in autism. They based this partly on Simon Baron-Cohen’s description of autism as “male brain”. He meant an excessively male brain. Other autism researchers have had mixed feelings about that, believing it to be an overly simplistic view of the situation. (I tend to agree with his critics on that one.) He’s been horrified at his work being used by the Geiers as support. The other thing they based their “excessive testosterone” notion on was the finding that, in test tubes, testosterone can react with mercury. They leaped from that to the conclusion that testosterone might form sheets of mercury in the brain, thereby trapping “vaccine toxins” in the brain, and also making it impervious to chelation. (Left unexplained is how they felt it could be impervious to chelation and also dangerous to nerve cells.) So they claim you must reduce testosterone before you can chelate an autistic child and actually get the mercury out and “recover” them. Their solution? Lupron. During preadolescence and through what should be puberty (but might not be because they’re taking Lupron). They bill it as treatment of precocious puberty so insurers will pay, but it’s not. And there is a very real risk of suppressing puberty altogether (thus creating a new generation of Michael Jacksons, potentially). That’s MUCH scarier than anything I’ve seen suggested for male hormone replacement therapy.

One last sidenote, becuase I forgot to address it earlier in this post: I don’t think we need a men’s health initiative analogous to the women’s health initiative. I’d rather we did away with the women’s health initiative and started believing that surveillance of these things would be the norm rather than an exception. One problem with stuff like breast cancer awareness and all is that people start thinking that there are neat buckets for all of these health problems, and they also start taking attention away from other problems. They can be useful at first, but long-term, if we need to rely on such initiatives, to me it seems like we’ve got a bigger problem that ought to be solved.
#78 Scott
February 2, 2010

You know what is sad?
A doctor that wants to help others, and happens to be very successful in doing so, which by the way is mostly by word of mouth with a fantastic track record, gets a slap in the face from others that have little knowledge of subject at hand, and suggests he is not doing this to help but for profit.
Why make such a fuss?
If he makes men feel better, this is a bad thing?

There are some endocrinologists that are very well known in this world like Dr. Eugene Shippen, even Dr. John Cristler.
I have seen first hand men that have been on steroids for some time come off, they crash, they go to their own endo doctor and what is the fix?
They put them on TRT.
Dr. John is one of few that can return endogenous testosterone levels without having to put men on TRT for life.
He (in some men) is treating the cause and not the symptom.

If I go to my doctor and have high cholesterol, he might immediately put me on statin drugs. But if diet and lifestyle were to change and one was to bring cholesterol within range, this is preferred correct?

I don’t expect the women on this thread to understand what it is like to have testosterone levels of a girl, but it isn’t pretty. I had that, and could not get an erection with either Viagra or any type of good looking chick for the life of me. Sad when a young man can’t have an erection, is depressed, and can’t even think clearly.
What is the fix?
In my case resetting my hormones, but my endo wanted to put me back on testosterone.
Just like the Statin drugs for lowering cholesterol, I went on TRT.
Good at first, then bad.
Not till my HPTA was reset I felt normal.
Some doctors would have put me on anti-depressants and that again is treating the symptom not the cause.

One day if any of you haters get a problem with low testosterone, I hope you remember this doctor as you will see fist hand his magic he does.
Oh and the chick that talked about placebo, that does not work for men with low testosterone levels, wont do a thing for nocturnal erections or morning wood…..lol
Works good for depression though, but when your man cant get an erection for you and is low in testosterone, you might sing another tune.
This stuff is real folks, just because you cant taste it, touch it, smell it, does not mean it isn’t true, and you don’t need clinical studies to suggest otherwise.
#79 MonkeyPox
February 2, 2010

This stuff is real folks, just because you cant taste it, touch it, smell it, does not mean it isn’t true, and you don’t need clinical studies to suggest otherwise.

And God bless you, as well!
#80 Helpy.Helperson
July 15, 2010

Most doctors want nothing to do with diagnosing or treating male hypogonadism no matter what the cause. That includes most endocrinologists and urologists. Some go so far as to refuse to show you the lab report or tell you what your testosterone measurement is. They will simply insist that you are “fine” and “everything is normal” no matter what your testosterone level is. Unfortunately I know this from personal experience. I actually had a doctor lie to me to my face about my blood testosteone level. Yes, this “doctor” did a male hormone profile at my request, then lied to me and said my levels were “normal”, although she refused to show me the lab report or tell me what the number was. When I pressed her, she still refused to show me the report but said my T level was 580. This was an outright lie. The true number was about 225. I suspected I was being lied to, so I did follow-up blood work at 2 independent labs that confirmed that my T levels were well below the bottom of the normal range. Yes, some doctors DO lie to thier patients, especially when it comes to lying to thier male patients about testosterone replacement therapy. To let men suffer needlessly when they can easily be treated is unacceptable and a complete shame and a black eye on the entire worldwide medical community. My advice to any man seeking help for this condition is this: You must become your own doctor. Request blood work not only for total T but also free or bioavailable T, FSH, LH, and estrodoil. If the physician comes back after the results are in and says “everything is normal”, insist on seeing the lab report for each measurement in your hormone profile. That is your right no matter how upset the doctor gets. And whatever you do, don’t give up. Physicians like Dr Crisler do exist, but they are incredibly hard to find because there are very, very few of them out there. {By the way I’ve never met Dr Crisler nor am I a patient of his.} It is your body, your health, and your future. It is very unhealthy for a man to be androgen deficient. His mental and emotional health will suffer, and he will be much more prone to osteoporosis, type II diabetes, and heart and blood vessel disease. God Bless.