Two weeks ago, my piece, “Cannabinoids are medicine, but patients aren’t getting the care they need,” was published. Since that time, I’ve heard from quite a few physicians who admitted that they did not know card-mills existed or, if they did, how they were different from Cannabis Specialist Physicians. From their collective perspective, pot was pot. I am grateful to have had the opportunity to provide them with information and with education. When the case below presented itself, it seemed a wonderful opportunity to delve a bit deeper and to point out the fact that not only are card-mills inconsistent with good patient care but that they often have significant conflicts of interest.
This past week I was asked to add a new patient to my schedule at the last minute. I was told that she was coming to see me hoping that medical cannabis would offer some relief of chronic migraine headache pain. The patient’s details have been changed to protect her privacy, but the facts remain the same.
Patients don’t always know what is important to share with their physicians and what is not. It is for this reason that physicians are trained to take full medical histories. We ask about current symptoms, past episodes, what makes the symptoms better, and what makes them worse. We ask about medications and tests and family histories and social histories. We learn that when one “hears hoofbeats, they should look for horses, not zebras” – meaning that common things are common. It is only with adequate time and sufficient inquiry that physicians can determine whether the patient in their office is, in fact, presenting with something common.
After the first 30 minutes with my new patient, I was concerned that there was more going on with her than typical migraines headaches. As we got deeper into her history, I became more certain that I needed to examine her medical records. Typically I have the opportunity to do so before new patient appointments. Because she was added to the schedule last minute, I had not had that chance. I told my new patient, who thought she might find relief from her chronic headache pain, that I was concerned about her symptoms – that, perhaps, we were looking at a zebra rather than a horse. I was not at all comfortable potentially masking her symptoms with medical cannabis. I told my patient that I needed to consult with my practice partner and review her primary care physician’s records. I expected her to be disappointed, if not downright angry. Instead, she said, she finally felt hope – that someone was actually listening to her. We agreed that I would call her the following morning with a plan. She understood it was unlikely that I could get all of the information together in less than 24 hours, but she trusted that I would get in touch and that we would move forward together.
It was at this point that I found myself, once again, grateful for having declined the invitations I’ve had to join medical cannabis card-mills. Had this patient presented to me at one of those ever-proliferating establishments, I would have had only the allotted 15 minutes to determine whether medical cannabis would have been an appropriate treatment for her. And, in our initial 15 minutes, it appeared that such treatment would likely have been fine. However, with further discussion, it became apparent that it might not have been fine. In fact, it might actually have been harmful. And, had I had adequate time, I would have been faced with a conflict of interest.
Card-mills pay their physicians approximately $45 to $50 per patient, with patient after patient scheduled for 15-minute slots. They then boast that physicians who work with their companies earn $180 to $190 per hour with no overhead. It is true that these physicians earn such income, but only if they certify patients for medical cannabis cards. If they certify for medical cannabis only when appropriate, they don’t necessarily earn an income; they’re paid only if they certify the patient. That is the very definition of a conflict of interest, isn’t it?
Back to my patient: I looked through her medical records but didn’t see the test I was looking for. I called the office and learned that the patient’s PCP was on vacation, so I spoke with the covering doc. She looked through the records and came to the same conclusion. She told me she would follow up with the patient and make sure the test had been ordered. I called my patient who, tearfully said, “This is the first time I feel like someone has heard me in twenty years.”
I don’t believe this would have occurred at a card-mill.
In my current practice, I have an hour scheduled with each new patient and thirty minutes scheduled for each follow-up. I’m also available via email or telephone, as needed. I am compensated not because of the amount of time I spend nor by the number of medical marijuana cards I give out, but by the patient care I provide.
Once again, I find myself thinking: Don’t real patients deserve real patient care?
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