Guest Commentary: It’s Not About the Marijuana

It’s no secret that a number of our colleagues have been cited by our Board as a result of medical marijuana (MMJ) authorizations. Here is some background and tips to avoid being dragged into the disciplinary system.

History

Most of these cases followed a pattern where the naturopathic physician was employed by a company that specializes in medical marijuana authorizations and pays the doctor a small fee for each one written. The patient visits lasted on the average about 10 minutes, a boiler plate SOAP note with preprinted diagnoses directly out of the medical marijuana law was signed and the authorization granted for anywhere from 6 months to lifetime.

The disciplinary actions were based on 2 legal points:

  1. The doctor did not meet the standard of care for a naturopathic physician and
  2. The doctor did not comply with the law controlling medical marijuana authorizations

While we are all required to obey the law as written, the driving issue in these cases was standard of care.

Many patients were seen for the first time presenting with serious complaints such as severe pain, MS and cancer with little or no current substantiating diagnostics. After a brief interview, authorizations were given. In some cases a longer authorization or an authorization with no records could be obtained by paying extra.

Standard of Care

The standard of care issue is this: If the patient had a condition that could be cured or managed now but could put them in a wheelchair or worse if neglected, it is expected that a naturopathic physician would be diligent enough to figure that out directly or by affirmative referral. Sending the patient home with just MMJ and no follow-up did not meet the standard of care. The prescription could have been marijuana, white will bark, valerian or oxycodone and the standard of care finding would have been the same.

In many of these cases the doctor claimed that the clinics employing them were calling the shots including how long they could spend with patients and the authorization duration that needed to be issued.

The issue here is that the doctor always has the final word and responsibility when it comes to the provision of care. This was a tough and confusing issue for many docs since it’s difficult to push back against the person who is providing your livelihood especially when they claim to understand the law and standards governing our practice.

Tips for writing authorizations

So here are a few tips for staying out of the disciplinary system:

  1. Medical marijuana provision is unrelated to recreational marijuana. It’s a mistake to just give out an authorization because the patient can get it easily without one. Medical marijuana, by law, is another treatment that can be used by the doctor for an established, ongoing patient who meets the details of the law. When a patient visits a naturopathic physician the expectation is that physician level care will be provided regardless of where the patient is seen.
  2. Treat every patient as a non-marijuana patient to start. Use the same diagnostics and care you would with any patient and only after reaching your final assessment decide if MMJ is appropriate.
  3. Pay attention to contraindications. If the patient suffers from anxiety, for example, MMJ may do more harm than good. It’s a drug with benefits and risks like all others.
  4. No one can overrule your medical judgment. If a clinic wants to hire you to see 30 new patients a day who want MMJ prescriptions, consider if this meets your personal standards and the naturopathic standard of care.
  5. If you get called up by the Board, immediately hire a lawyer familiar with this area of law. Not everyone who has a complaint lodged against him/her is guilty and a good lawyer can get that settled more quickly than you can on your own. If you’re in trouble a lawyer can find the shortest path to put this behind you. Doctors in disciplinary cases who represent themselves, it’s called pro se, frequently lose much more than the attorney’s fee by not understanding the legal system. It’s an unfortunate fact of the practice environment we live but we need a lawyer even when innocent.
  6. Follow the law. The MMJ statute can be found here. All of the originating complaints that started these cases cited a part of the law. I suggest that you read it thoroughly before writing authorizations.

These cases have implications for all of us, not just the doctors that got snagged. A Seattle Times editorial noted that all of the doctors disciplined over the medical marijuana statute were naturopathic physicians but did not mention that some were dual licensed since the doctors issued authorizations under their ND license. As we fight for equitable treatment in the new healthcare payer model it’s more important than ever that we maintain a positive public presence. None of us likes big brother looking over our shoulders but, as an outsider with plenty of political and regulatory experience, I can tell you that it is a good thing that our Board is acting on these cases. Painful, but necessary.

My personal position is that I write MMJ authorizations when I think they are appropriate. I also believe that adults should be able to do whatever they wish with marijuana as long as they don’t adversely affect the rest of us. Now that there is big money in this business, however, there are many medical claims and statements about MMJ that aren’t even remotely defensible. Some come in the form of “medical research reports” but when you read the whole story you find that the “research” is nothing more than a report created by someone tied to the sale of marijuana and/or an abstract that’s an exaggeration of the data to put it mildly. So we all need exercise additional due diligence if we are to be the experts. The fact is that no one has more training or experience with botanicals than naturopathic physicians but we can’t take information on face value.

Finally, many of these doctors got caught up in this mess because our graduates still struggle to make a living and frequently have few choices as they pay back large education loans. Our profession has come a long way since Les Griffith and I and others successfully fought to undo the sunset (deregulation) of our profession in the 1980’s, but our dream of every new doctor having to decide between offers from well-paying, legitimate healthcare entities is still not here despite a lot of sacrifice from a lot of our colleagues.

The WANP is the avenue by which we can be reimbursed and respected as physicians. Our choices are to stay neutral and let things continue as they are (bad choice) or to get involved with the association with our ideas, our energy and a few bucks even if it’s just dues. We are at a critical juncture where we will be a vital part of the new healthcare delivery model or left on the outside, and the decision will be more political than rational. It’s time that our new doctors don’t have to look to marijuana mills to put food on the table. This is an achievable goal.

I have been a nonstop member of the WANP for over 29 years including some years when I thought the association was making errors but the fact remains that it is our organization and the only reasonable path for us to move forward so I hope you will each consider raising your participation in the association at least one notch.

To your good health and success!

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