The Healer’s Art

6/24/2013 Testosterone Supplementation: the Good, the Bad…the Facts!

There is an advertising frenzy in the US in marketing of testosterone supplements…a multi-billion dollar business. To observers outside the US it must seem that all American men have Low T and suffer from sexual dysfunction, low energy, brittle bones, depression and obesity. Well, the obese part has some truth….the Centers for Disease Control tell us that more than 35% of US adults are obese with medical costs related to obesity amounting to over 147 billion dollars….more on this in a bit. No doubt about it, low serum testosterone also referred to as Low T, Hypogonadism and Andropause, is a real entity affecting over 40% of men 40 years and older. In fact, as men age the incidence of low testosterone goes up. The real issue however is: who should be treated? Men with breast cancer (yes men, although rare, do get breast cancer too) and those men with diagnosed, but not yet treated, prostate cancer should definitely not take testosterone supplements. To this group, I would add those men interested in maintaining their fertility (or ability to conceive a child) since testosterone and androsterone (collectively called androgens) will significantly decrease, or completely stop, sperm production. In fact, 10 to 20% of these men might not re-start sperm production after stopping testosterone therapy. In addition, many of the men that had been placed on testosterone therapy will not return to their pre-therapy production of sperm! So who might benefit from testosterone therapy? Well-respected professional societies, such as the American Urological Association, American Society for Andrology, American Society for Reproductive Medicine and the Endocrine Society, offer guidelines on who should receive testosterone supplementation. In my practice, as a Urologist specializing in male reproduction and sexual medicine, I consider treatment in men with a low serum testosterone level and at least one symptom of low testosterone that significantly affects the patient’s quality of life. Also, men with a decreased bone density and a low serum testosterone may benefit from supplementation. For men interested in fertility, non-testosterone options exist that will raise their testosterone and preserve, and possibly increase, their sperm production. …and yes, overweight men often do have a low testosterone. However, the best way to treat them is by lifestyle changes, not supplementation. By that, I am indeed referring to diet and exercise, leading to an improvement in serum testosterone by 15% in one recent study!

“With all the rights, privileges and responsibilities” . . . Hippocrates and the Practice of Medicine – Part 3

For many of us, using unproven techniques, unless as part of an approved research protocol, is not even a consideration. However, many good and caring physicians continue to be drawn in by the hype surrounding these techniques. These new techniques may, in fact, prove to be valuable and worthy of widespread implementation. However, we must insist—no, we must demand— that these nonstandard approaches are performed only under clinical research protocols until data on efficacy, safety, and cost-effectiveness can be provided to our patients. As a modern version of the Hippocratic Oath instructs, “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”

Often in the practice of Medicine, the lack of specific regulation require us to accept the responsibility to self-regulate. We must always respect the patient’s rights to be completely informed of the treatment they are to undergo. Specifically, they must be apprised of the reason for the treatment, the expected results, the duration of treatment, potential side effects, and the total cost of treatment. Our patients, our colleagues, and the regulatory authorities hold us, as physicians to a higher level. We need to define what is and what is not standard treatment . . . or it will be defined for us. Nonstandard treatment may, in fact, be better then standard treatment, but we need to validate efficacy in approved protocols that protect the patient and the patient’s rights. From this, we cannot waiver. It is our responsibility. It is our Oath.

As I listened to the recitation of the Hippocratic Oath and reveled in the euphoria I shared with these new graduates, I realized that by upholding its doctrine to “ . . . respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow” that we will continue to answer a higher calling, serve and protect the needs of others, and maintain the responsibility we have as healers.

Bruce R. Gilbert MD PhD

“With all the rights, privileges and responsibilities” . . . Hippocrates and the Practice of Medicine – Part 2

I regard our independence to practice our craft as one of the principal rights we have as physicians and surgeons. We are given this right not by the university that granted us our degree, nor by local, state, or federal authorities, but by our patients. Our patients lay bare their bodies and souls to us, often times complete strangers, without a written or verbal contract but with unstated expectations. They enter this covenant with the hope, and yes, the expectations, that we are equipped both intellectually and ethically to cure or at least ameliorate their ills. Therein lies the sometimes overwhelming responsibility we have as healers. “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.” Implicit in this classical translation of a portion of the Hippocratic Oath is the physician’s vow to maintain the good of the patient as the highest priority. Possibly the most difficult challenge to today’s physician with this portion of the Hippocratic Oath is economics. To practice our art, we have expenses, staff, rent, and supplies. We also have responsibilities to our family, especially our parents, spouse, and children. Our expenses continue to escalate without a parallel increase in our income stream. The conflict emerges when providing optimum care to patients is inversely related to making a living. Therein lies the basis of an ethical dilemma that all physicians must face. Do we use protocols or devices that might yield us great financial rewards, unencumbered by our participation in managed care, even though they have unproven efficacy and an unknown
safety profile? Or should we insist on providing our patients with the appropriate information with which they can make an informed decision?

to be continued…….Bruce R. Gilbert MD PhD

“With all the rights, privileges and responsibilities” . . . Hippocrates and the Practice of Medicine – Part 1

EUPHORIA! A single word encompassed my persona some 25 years ago during my medical school commencement. I had finally achieved my life’s goal of becoming a doctor and was ready to enter my residency with excitement . . . and a bit of trepidation.

As parents, attending graduation ceremonies instills great pride in our children’s accomplishments and provides us the luxury of cogitation and introspection. I recently attended my daughter’s college graduation from Columbia University, a neoclassical urban institution with 3 undergraduate schools, 13 graduate and professional schools, and a school of continuing education, as well as 5 affiliated colleges. Each of these schools has its own graduation followed by a larger combined university ceremony. This year’s attendance approached 40,000 guests including the graduates and their family and friends. My daughter’s impending entrance into medical school made the portion of the program during which the graduating medical school class recited the Hippocratic Oath even more engaging. A revered tradition thought to be written by Hippocrates or one of his students in the fourth century BCE, the Hippocratic Oath marked a physician’s “rite of passage.” At the completion of the recitation, one would transform from a medical student into a Doctor of Medicine, with all the “Rights, Privileges and Responsibilities hereto entrusted.” As these medical student graduates repeated with joined voices the oath passed down by a legacy of physicians, a silence spread throughout the massive audience witnessing the metamorphosis. My eyes welled up, my throat tightened, and my heart raced, just as it did 25 years ago. I also remember feeling at that time, although probably would never have admitted it then, some fear.

to be continued…….Bruce R. Gilbert MD PhD