A Hypogonadism Consult

I had an interesting consult the other  day. Again, one of the many, hordes in fact, of men coming in for a testosterone prescription. And I admit I'm jaded and I've begun the stereotype. This was the classical young man, meathead type with biceps bigger than a treetrunk. He could have been a body double for the incredible hulk. Proud that he bench presses 200 lbs.

And yet, feels that he needs to be on testosterone. Admits he 'juices' up frequently too (a word I learnt not too long ago) with crazy shit he was getting from his gym- androgens, to which they often add aromatase inhibitors to prevent gynecomastia, and HCG to prevent the resultant testicular shrinkage. What a crazy world.

Anyway, like many before him, this chap refuses to accept that his blood test showed his testosterone to be normal. And so he was here for  some 'medical testosterone'.

"I'm young. I should be on the higher range of normal!".

They all say that. Never mind that the total T was in the 600s already.

And he was most convinced of this for two reasons. That he has peaked with his weightlifting. And that he has 'erectile dysfunction'.

As an endocrinologist, I do go into a bit of detail when taking a history of ED. So I asked him what that meant to him. He was very concerned because a few years ago he could have sex about 5 times. And now it's only about twice.

A. SINGLE. DAY.

Talk about feeling inferior. This chap's definition of normal was having sexual intercourse 5 times a day. And he is concerned that he is now only interested or able to do it 2 times a day.

I wasn't sure if I should laugh, cry, hit my head on the wall, or go on my knees and kowtow to him. 5 times a day??? Teach this padawan, O Master.

I was professional and held my composure. And did all I could to explain to him the normal endocrine physiology of the reproductive system, the risks of unnecessary testosterone use and the medical guidelines. I'm pretty sure he left unconvinced.

In the meantime, I feel like I need to go to the gym more.

The Nonbelievers

I have to admit, I have an inherent bias.

And how it came to this I don't know. After all, I hated Evidence-Based Medicine (EBM) in medical school. I had a bully of a mentor, a lab-based cardiac physiologist with minimal people skills, who bluntly told me, "Your question was so stupid I'm not even going to try to answer it...." (digression: I'm not a model teacher- but I swore I would never speak to a student/resident like that ever. Words do scar). Anyway, I spent all of medical school fearing the word 'research', and hating everything EBM.

I went into residency with the same sentiments, feeling stupid, ignorant and inferior when you are in the company of the world's medical greats. The world-famous researcher clinicians whom patients travel the world over to see. Classmates who compare not only how many publications you have but what impact factor the journal that accepted your manuscript carried.

Research. Ugh.

And then something kinda slowly happened. After all, you do get brainwashed training at the same institution for six years. And not that I consider myself a brilliant researcher, but at least I learnt some of the ropes. I learnt what it takes to write a paper, analyze a study, even perform experiments (I got to play with human orbital fibroblasts, yay!). And I popped my publication cherry. And became a scientist. I still consider myself one- after all, a doctor is a person of science, and as dynamic as science can be, we too need to evolve and learn, don't we? And so, it's interesting how I went from that hater of EBM in 1999, to one who looks at The Evidence, to guide his clinical judgments. Not only the conclusions of the study, but also to try to pick apart the study to see if he agrees with the findings. After all, the goal of an author is to get the study published, and one often learns to present the data in the most compelling way; so you can't always take things at face value. And so, yes, I'm a believer of EBM, I think we all should be.

That being said, I've realize that the world doesn't see things that way. For some, EBM remains a bad word, one that is controlled by Big Pharma who makes things up to fool doctors and ultimately patients, all in the name of making money. And I've realized that once a person chooses to not believe, there is no amount of data you present that will be accepted, that they always will view things with a generous serving of skepticism. That big pharma bought you/CDC/FDA over- never mind that the basic concept of EBM is that you learn to critically appraise and make your own decisions.

This is perhaps more worrisome when the person you're trying to convince is a medical professional. I ran into this situation when discussing a case with a surgeon, when he (in my opinion) was over treating a patient with an unjustified therapy based on an unproven diagnostic test (which incidentally enough, is something he owns too).

And so sometimes, there is only so much you can do. And sometimes, you just have to take a step back, and agree to disagree. But secretly you hope the patient takes your side, because the data really doesn't show that that treatment is necessary.

Patient Satisfaction

There is much talk about the importance of patient satisfaction. Of how some hospitals and physicians are reimbursed in part based on how satisfied patients are, the much-hated Press-Ganey surveys. After all, we do want our patients satisfied, don't we?

Do we?

Proponents say, patients are clients, customers. Keeping them happy should be a priority.

But is this truly the relationship physicians and patients should have? After all, in situations like this, the 'customer' isn't always right; the patient doesn't have the background knowledge to know that's best for him or her. Studies have shown that higher patient satisfaction is associated with more adverse outcomes.

I'm sure this is a struggle all physicians across all specialties face. I hear this coming from ER and primary care colleagues of how patients leave disappointed if they are not prescribed antibiotics for a viral syndrome, or opiates for pain.

This week alone I encountered three situations myself where patients left obviously disappointed and upset.

Two patients with no background of thyroid problems who were upset because I would not prescribe thyroid hormone treatment for their fatigue and inability to lose weight despite claiming to be on a diet and exercising. One already had a TSH that was undetectable while on exogenous Levothyroxine, refusing to discontinue treatment.
Another patient, a woman, who left upset because I would not prescribe Testosterone treatment for her dry skin! Because according to her extensive research (on Google) skin dryness if from Testosterone deficiency; after all if a person makes too much, you get oily skin, acne, right?

I have to say, a part of me blames the referring physician. It gets my blood boiling, wondering where how the heck these people got their medical degrees. It's not surprising that a patient leaves unhappily, when your GP promises that this hormone specialist will fix your problems, and gives you the impression that your troubles are indeed from a hormonal imbalance. And then you wait 2 months to see this person, who then says no to treatment but bills you for the visit.

So, no. I do wish to try to satisfy my patients, but my view is a patient is not a customer in the classic sense; he/she does not have the medical background to really know what's best for his or her health.

As how my patient ominously ended my session with her after I counselled her on the risks of unnecessary hormonal treatment: "I'd rather have a stroke than continue to be fat..."

Is this going to be the future of healthcare?