The Society of Cannabis Clinicians (SCC)is a project of the
California
Cannabis
Research Medical Group (CCRMG)
SCC was formed in the Autumn of 2004 by the
member physicians
of CCRMG to aid in the promulgation of voluntary standards for
clinicians
engaged in the recommendation and approval of cannabis under
California
law (HSC §11362.5).
As the collaborative effort continues to move
closer
to issueing guidelines, this site serves as a public venue for
airing
and discussing these guidelines.
Following are the practices of one physician
that could
serve as a model for others contemplating recommending and
approving
cannabis to their patients.
Practitioner’s Perspective
By Frank H. Lucido, M.D.
Medical-Legal Consulting
Protecting Patients and Doctors
Due to cannabis’s excellent safety profile, and the wide
variety
of illness for which cannabis can alleviate symptom distress,
making
cannabis recommendations safely and effectively is a skill
that can
be achieved quite readily. However, due to law enforcement’s
institutional bias against cannabis, knowledge of the
medical-legal
aspect of cannabis consultations is at least as important as
the medical
knowledge, both to protect the patient, and to protect the
doctor.
Caution Against Doctor/Dispensary Cross-Referrals
The extent to which physicians offices or free-standing cannabis
clinics may
work with and cross-refer to and from dispensaries is very unclear,
and an
issue that threatens to lose for recommending physicians, (and any
employee
physicians or practitioners), the full protection of the Conant
decision.
I consider this to be very thoughtless and short-sighted, and perhaps
unethical.
My 2 concerns are:
1. How does this close association between dispensaries and
recommending physicians
impact the quality of the legal protection that is at the heart of a
pure medical-legal
consultation? Will patients have a harder time defending their medical
use
in court, and/or be brought to court more often when a prosecutor can
rely
on his or her ability to discredit sloppy medical consultation work?
2. What should be the reaction of the hard-working pioneers
of medical
cannabis consultation, who have taken the biggest initial
risks with
the Medical Board and law enforcement, when patients seek out
the “convenience” of
dispensary-associated clinics and/or providers whose practice
standards
are so lax as to be open to criticism about the bona fide
medical relationship
between themselves and their patients?
When these questions were discussed at a meeting of medical
cannabis
activists, most could understand the reasons for my concern.
One good friend, and one of the heroes of the movement,
absolutely
supported these practices as a sign of healthy marketplace
competition.
He expressed the general feeling of many that doctors charge
too much
for their services, and patients would benefit if physicians
were to
have a price war.
I pointed out that there are two important purposes for a medical
cannabis
consultation: to give the patient competent evaluation and advice,
and to
provide the patient with the legal protection of the California
Compassionate
Use Act. If either of these is not accomplished, the price of the
visit is
no longer the important factor. A $50.00 visit is no bargain if the
recommendation
is indefensible, If a patient with deficient documentation gets
arrested,
the cost of attorney’s fees and court appearances will more than
cancel
out this kind of savings.
My standards for recommending medical cannabis, requiring
documentation
that the patent is seeing their primary doctor for the serious
illness
or symptoms that they medicate with cannabis, are geared to
making
the recommendation as "bullet-proof" as possible and avoiding
this kind of expense and inconvenience.
It has been my experience that, on the occasions when law
enforcement
calls to verify a recommendation and I am able to say: 'Not
only did
the patient consult me about his/her illness, but he/she sees
his/her
primary doctor regularly for this serious problem,” I almost
always receive a polite reply along the lines of "Thank you,
we
just wanted to make sure it was a valid recommendation". The
big
saving for patients is in not having to hire an attorney or go
to court.
One activist pointed out that some doctors or clinic chains
do not
make anyone available to testify for patients anyway!
Since there seem to be varied expectations of what a medical
cannabis
recommendation should include, perhaps it would be useful to
present
the services I provide to my medical cannabis patients at this
time:
Included in my fee are the following:
Consultation (45 minute first appointment; 30 minute yearly follow-up
re-evaluation)
Recommendation for up to one year (if the patient’s use of medical
cannabis
is appropriate under the California law and the patient has met all my
other
requirements, which are described at the time of scheduling the
appointment).
Brief telephone conferences with law enforcement, attorneys, employee
health
officers, etc, as needed, to verify validity of the recommendation.
(While
this is not my favorite thing, those of us who are experienced are
good at
it).
Adequate knowledge of the medical and legal aspects of cannabis so as
to be
able to testify in support of my patient in a court of law, and the
willingness
to do so.
NOT included in my fee:
Travel to and testifying in court or any other legal proceedings.
Written reports, disability evaluations.
This listing is not meant to be exhaustive, nor the “right
way”.
This is just the way my practice has evolved at this time, and
I welcome
your comments.
Protecting Doctors
I have now reviewed three cases of doctors under investigation by the
Medical
Board (MBC).
Most recently, I was asked by Americans for Safe Access to review a
case
of a doctor who was investigated for having recommended medical
cannabis to
a young adult, whose mother complained to the Board that she found
this inappropriate.
The doctor was ultimately charged with five “simple departures” and
one
“ extreme departure” from the standard of care, and was scheduled
for a
settlement conference prior to a full hearing before an administrative
law
judge (ALJ).
I reviewed all of the patient’s records, and the MBC expert’s report
and
accusations. As usual, the expert appeared to be a reasonably
competent
doctor, but completely inexperienced in the actual standard of care
appropriate
for a limited medical-legal consultation.
I refuted the expert’s charges in a six-page declaration, which was
presented
to the
Board’s prosecutor and the ALJ. The issues raised in my declaration,
and excellent counsel by ASA attorney Joe Elford, resulted in
acceptance by
the doctor of one “simple departure” (with no license restriction),
so as to avoid further legal costs.
Two factors make it more difficult to defend doctors investigated for
recommending cannabis:
1. Inadequate documentation of diagnosis.
2. Providing cannabis recommendations in connection with dispensaries
or clinics
associated with dispensaries, as discussed above.
Although I am willing and able to try to defend doctors in both of
these situations.
it will be much less expensive for the doctor to avoid these two
pitfalls.
Choosing a Consultant
How does one choose a doctor for a medical cannabis consultation?
Here are some qualities that I would suggest patients look for:
1. A good track record: physicians with substantial experience and a
high
level of comfort with medical cannabis.
2. Ability and willingness to testify in court for you should the
patient’s
medical use of cannabis be questioned.
3. Willingness to confirm the legitimacy of the cannabis
recommendation if
contacted by law enforcement (this may save the patient considerable
expense
for fees for providing court testimony)
4. Adequate and accessible medical record keeping, including
supporting
documentation from other providers. The physician who requires
documentation of ongoing care of the patient’s illness by his or her
treating physician, has the easiest time defending that patient to law
enforcement.
What patients can do to help their doctors (as well as themselves):
1. Have a primary care provider with whom you consult at least once a
year
regarding the serious illness or symptoms for which you use medical
cannabis.
2. Bring records covering the last 12 months to your medical cannabis
re-evaluation each year.
Frank Lucido, M.D. is in private practice in Berkeley,
California