Abstract
Background: Physicians’ ability to guide their patients on the use of medical cannabis can vary widely and is often shaped by their training, experiences, and the regulations and policies of their state. The goal of this qualitative study is to understand how prepared physicians are to certify and advise their patients to use medical cannabis. A secondary goal is to explore how physicians integrate certification into their clinical practices, and what factors shape their decisions and behaviors around certification.
Method: Using semi-structured interviews with 24 physicians authorized to certify patients to use medical cannabis in Pennsylvania, a state with a medical access only program, we explored how physicians are trained and set up their practices. Interviews were analyzed using a blend of directed and conventional, and summative content analysis.
Results: Three main themes emerged from the data around training, system-level factors, and practice-level factors that shaped how physicians are trained and practice medical cannabis certification. Although participants were largely satisfied with their CME training, they noted areas for improvement and a need for more high-quality research. Participants also noted system-level factors that prohibited treating cannabis as a traditional medical therapy, including communication barriers between physicians and dispensaries and confusion about insurance coverage for certification exams.
Conclusion: Physicians require additional training to improve the operation of the medical cannabis program in Pennsylvania. Participants suggested that the program could be improved by reducing communication barriers between them, their patients, and the dispensaries around the product purchase, selection, use, and effectiveness of medical cannabis.
- Cannabis
- Health Policy
- Medical Education
- Medical Marijuana
- Pennsylvania
- Qualitative Research
- Quality Improvement
Introduction
Medical cannabis is an increasingly prevalent part of medical treatment, with more than 5.4 million registered medical cannabis patients in the US.1 Thirty-six states allow for some form of medical cannabis use,2 but implementation of state programs varies widely. For example, Pennsylvania requires physicians to complete 4 hours of continuing medical education (CME) offered by the State before issuing medical cannabis certification to patients, and in Minnesota no CME is required.3,4 Eight state-approved training programs were active as of January 2022.
Despite significant support and acceptance of medical cannabis’s role in clinical practice, most health care providers report low knowledge,5 which is perceived as a main barrier to engaging with patients regarding medical cannabis. Patients are consequently referred to cannabis dispensary staff as cannabis subject experts6,7 despite a lack of requirements for dispensary staff education or an understanding of how patient-dispensary staff interactions operate.8 This lack of preparation poses a public health concern to patient safety3 and is a significant concern among medical cannabis patients.9 There is also a dearth of awareness among health professionals about how medical cannabis programs procedurally operate in their own state.10 Few studies have examined the perceptions of health care providers regarding their knowledge around medical cannabis5,11 and even fewer provide the richness of detail that comes from qualitative studies on these topics.
Some of the challenges around training for indications and usage of medical cannabis products reflect the broad uses and forms of cannabis that are available commercially, of which only a small subset has been rigorously tested in research. Only 4 prescription cannabinoids have FDA approval and therefore have clear evidence for dosing guidelines, indications, and interactions. Nonsynthetic medical cannabis (tinctures, edibles, vaporization cartridges) cannot be prescribed and the composition of approved cannabis products are presented variably, as percentages of an inhaled form to ratios or mg strength if orally ingested. Thus, it is difficult for some providers to adequately educate their patients on specific dosages, dosing schedules, or delivery methods.3,5 There are also concerns about safety in the supply of unregulated products allowed after the Agricultural Improvement Act of 2018 authorized the exclusion of hemp products from the statutory definition of cannabis if products contain less than 0.3% of Δ-9-tetrahydrocannabinol, which may further complicate advising patients about cannabis use.
As legalization and use expand, there is a critical need to understand how the implementation of medical cannabis programs affects clinical practice and what are the most persistent or problematic knowledge gaps among physicians authorizing access to medical cannabis. The present study is among the few studies to use qualitative inquiry to assess physician knowledge gaps and education needs regarding cannabis for therapeutic purposes12 and the only study that we are aware of that examines physician perspectives on the implementation of a medical cannabis program. Given physicians’ major role in patient access to medical cannabis, it is essential to understand what factors shape clinical decisions; this can inform the development of educational resources that increase physicians’ clinical competence and improve patient care.
Methods
Setting
Pennsylvania authorizes physicians to certify patients to use medical cannabis after completion of a 4-hour state-approved training course and registering with the state as an “approved practitioner.” In Pennsylvania 4% (1500 out of 54,681) of physicians are certified to register medical cannabis patients. Patients must have 1 of 23 qualifying medical conditions and details of the certification process are outlined in Figure 1.
Certification process for patients in Pennsylvania to use medical cannabis.
Sample
A convenience sample of 24 physicians who can certify patients to use medical cannabis in the state of Pennsylvania were recruited from participants in a larger statewide survey on clinician attitudes, knowledge, and training about cannabis.5 Participants in the larger survey who granted permission to be contacted for a follow-up interview received an e-mail invitation to participate. E-mails were sent out to 96 people and 24 scheduled interviews for a 25% response rate.
Procedures
Twenty-four semistructured interviews were conducted between March to October 2020. Participants were interviewed by a single interviewer (ELK) using a semi-structured interview guide asking physicians to describe their experiences as certifying physicians, how their training prepared them to certify, and to identify areas of education for patients or providers around certification, purchase, and use of medical cannabis. The interview guide was developed by a research psychologist (ELK) with experience studying substance use and cannabis and a physician (BW) who has conducted multiple projects on medical cannabis and is authorized to certify patients to use medical cannabis in Pennsylvania. The initial protocol was completed with 3 participants, transcribed, and analyzed with process memos, and the interview guide was refined for the remaining 21 interviews. All interviews lasted 15 to 25 minutes, were tape-recorded, and completed over telephone (n = 4) or via Zoom (n = 20) and professionally transcribed. All procedures were approved by the Institutional Review Board of Thomas Jefferson University. Study participation was voluntary and verbal consent was given after reviewing the consent form. No incentives were provided. No identifying information was collected. Data were collected until saturation was achieved.
Analysis
Members of the research coding team included a psychologist with more than 10 years of experience conducting qualitative research (ELK), a medical student (KB), and a research coordinator (SP) with a bachelors in Women and Gender Studies. Data were analyzed using a blend of conventional, directed, and summative content analysis.13 Analysis started with 2 coders who read each transcript, highlighted key points, and noted potential themes and codes (ELK, SP). An initial codebook was iteratively constructed through discussion of these codes with a third coder (KB) in NVivo. Axial coding was used by all 3 coders who collaboratively coded 2 interviews, modified the codebook, and then independently coded the interviews with 2 coders for each transcript using the finalized codebook. Coding disagreements were collaboratively reconciled among the 3 coders. Two coders (ELK, KB) analyzed the data in an iterative process of examining all data within each code through thematic memos. Using a form of summative content analysis13 within the memos, we tracked the number of participants whose responses mapped onto those codes to guide our analysis to the centrality of each theme and subtheme. Through this process, some codes were combined or removed until the central themes and subthemes were consolidated. A senior physician (BW) reviewed and validated the completed findings.
Results
Three main themes emerged about training, the process of becoming a certifying physician, and how physicians approached their roles as certifying physicians due to their perceptions of the health care system’s boundaries, such as state-level rules, and their practice-level concerns (Table 1). Physicians varied widely in the extent they certified patients, with some rarely doing so while maintaining their primary practice (n = 2), some interweaving it with their routine patient panel (n = 18), to those whose full-time practice focused on certifying patients for medical cannabis (n = 4). Most of those whose practices focused only on certifying patients also reported being authorized in other states.
Illustrative Quotes from Main Themes and Subthemes
Training Quality
Most physicians expressed overall satisfaction with the required medical cannabis CME training (n = 12/17, 71%), though 5/17 (29%) were completely unsatisfied. However, even among those who reported satisfaction, most (n = 8/12, 67%) described learning information in limited domains (eg, legal history, basic mechanics of the endocannabinoid system). Those who felt dissatisfied expressed feeling highly unprepared for their role and were uncomfortable providing guidance about use or product selection. Outside of the initial training, participants remarked that up-to-date, peer-reviewed literature, or prior experience were their “go-to resources” when providing guidance to patients, and that conferences and communication with peers were also key to guiding their clinical practices. To address questions on navigating the PA system—either the legalities surrounding medical cannabis certification or navigating the website itself—participants noted the use of informal web sites, use of their own judgment, or the Department of Health website; some (n = 4) participants expressed frustration over the lack of support or bidirectional communication with the state government and medical cannabis regulatory agency to assist clinicians or clarify questions.
Areas for Improved CME Training
Three primary areas were identified as missing or underdeveloped within the required CME modules: information on the dispensary process and experience, guidance on establishing medical cannabis-specific workflows within existing practices, and evidence-based information about how cannabis can and cannot be used medically. Seven participants expressed a desire to learn more about the dispensaries, the product purchase decision process, educate patients on supply availability, or how to manage patient expectations. Some (n = 3) recommended that future CME training encourage similar experiences through visitation or training organizations bringing in working staff or pharmacists from dispensaries to discuss front and back-end processes.
Participants emphasized that training could be improved by up-to-date, high-quality research evidence to guide their clinical recommendations. Fourteen participants wanted more information about cannabis for specific conditions, 9 about dosing guidelines, 6 on interactions with other medications, and 4 on the mechanisms of action. Although all participants agreed that there is limited research on how cannabis should be used to treat specific conditions, 10 recommended that training incorporate more guiding principles for medical cannabis (eg, routes of administration, dosing, formulation, contraindications, and drug interactions).
Communication Divides
Two main gaps in communication were described, which either reflected how the state designed the program to compartmentalize information around cannabis or perceived disconnects of patients’ experience and knowledge of cannabis by patients and dispensary staff. Physicians reported little knowledge of how dispensaries operate, such as how products are selected, guidance offered and by whom, and if a patient’s experience is a part of these discussions. Several (n = 5) described their discomfort with this lack of transparency compared with other prescribed medications, as they would normally be able to see all the details of medications that their patients are using and discuss processes or issues with pharmacists.
Physicians primarily learned about dispensaries from patients or through relationships developed with specific dispensaries (eg, relationships with local dispensary staff). A few (n = 3) learned about the dispensary process by visiting dispensaries (in other states), which they described as invaluable. These physicians emphasized the value of sharing this knowledge to prepare other patients regarding what to expect and how to plan ahead. Some (n = 7) stressed that the lack of communication between dispensaries and physicians impairs patient care, as patients have difficulty describing their products to their physicians, which limits their ability to provide input. Physicians expressed concern that dispensary staff may expect that patients have more knowledge and experience than they actually do and 7 wanted more information about the training and experience of dispensary staff or pharmacists. Although many patients were described as having tried cannabis before to some degree, others may not have. Even experienced patients may not understand how to select and use products clinically with a detailed understanding of how different cannabinoids or terpenes may affect their condition. For example, one physician described concern after a patient with COPD purchased an inhaled (dry leaf) product, which they had specifically advised against.
Physicians wanted patients to have education on practical concerns, such as knowing what expect when they go to a dispensary, how to navigate the state’s website, payment options, expectations for treatment efficacy, and how they initiate and find the correct product or dosage. Three described how patients need to have the tools to become self-advocates. Four expressed concerns about patients’ misconceptions about cannabis as a cure to their conditions and a lack of awareness of other therapies or treatments.
Technical Issues
Patients and physicians must enter information about those applying for certification in an iterative process (see Figure 1). The majority of physicians (n = 18) described difficulties using the state’s website, either themselves or their patients. Participants described difficulties in troubleshooting the myriad of steps created by the back and forth process between the patient, the state, and physician. Physicians described how difficult the state’s website was for patients to enter their information, how issues with the Department of Motor Vehicle’s (DMV) information (as patients with hyphenated names or changes in address can result in information mismatch) causes issues, and how technical assistance from the state required long phone waits. Several (n = 5) physicians expressed concerns about completing registration on the website created barriers for patients with cognitive impairments or lacking technological access or comfort. However, a few (n = 2) participants noted the state had made efforts to update the website, such as removing an extra confirmation step at the end of the certification process frequently missed by patients.
Legal and Ethical Concerns
Legal boundaries and where the PA Medical Program’s legal reach begins and ends were described as unclear to patients and certifying physicians. Physicians perceived health organizations as having inconsistent interpretations of what is legal or not (such as continuing cannabis therapy during hospitalizations), which led them to develop individual interpretations of what is allowable. This led to ethical conundrums for some physicians, who outlined a need to set clear boundaries to protect themselves and their patients. Some (n = 4) physicians described concerns about their roles within the medical cannabis system and expressed a desire for clearer boundaries. One physician attributed other physicians’ hesitancy about providing counseling or becoming a certifying physician to liability and medical malpractice coverage concerns.
Approach Within Practice
Participants incorporated medical cannabis certification into their existing practices in different ways. Although all but 2 (8%) participants agreed that they were consistently certifying patients, the number of patients seen and certified depended on the level to which certification was integrated into their practice, as 8 (33%) certified only those patients within their practice enterprise, a small number (n = 3/24, 13%) accepted patients with a condition related to the physician’s specialty, and 13 (54%) accepted all patients with qualifying conditions. This decision process was highly individualized and based on the volume of patients that they felt comfortable certifying and concerns about impact on their existing practice.
Participants described a wide range of practice workflows that were typically self-developed. Six participants did not describe any difficulty implementing their medical cannabis practices, but also described collaboration or mentorship from colleagues to develop these workflows. Four participants noted difficulty with developing workflows and building infrastructure to process medical cannabis appointments, and recommended development of guides or practice tools for newly authorized physicians.
Participants also discussed their perceived roles in the PA program. Eleven physicians considered cannabis as another tool in their toolbox as health care providers and educated their patients on indications, contraindications, and safety practices, and made recommendations. A smaller subset (n = 6) viewed their role as only to certify patients and encouraged patients to seek out information from dispensaries or online.
Insurance and Payment
Insurance and cost concerns shaped the ways that physicians set up certification exams, follow-up visits, and recertification. Many physicians perceived that the rules around insurance coverage did not allow insurance to cover the costs of certification but some thought that insurance could cover the visit if certification was not the sole purpose of the examination visit or for existing patients. Among the physicians whose practice was solely focused on certification, patients covered the cost of their certification examination out-of-pocket. Among physicians who integrated it into their existing practices, there was a roughly even split among those who charged out-of-pocket (n = 7/15, 47%) and those who had it covered by insurance only (n = 8/15, 53%), though some allowed for a combination of out-of-pocket and insurances coverage. Six of these did so by limiting their certification to those whose conditions matched their specialty or only to their existing patients. One provider, who rarely certified, never charged patients.
Several physicians (n = 5) described their outrage at the costs of certification for patients and a few advocated within their organizations to ensure insurance coverage of visits. Due to physicians’ awareness of the costs of visits, most did not have follow-up visits specifically about their patients’ cannabis use and the majority only saw those who wanted to renew their certifications on an annual basis (n = 14). Routine patients were asked about their experiences with cannabis by their physician on a more frequent basis (n = 7) but for the most part, follow-up visits were considered prohibitively expensive and not required.
Tools and Support
Participants described a wide range of support from staff and use of self-developed tools to guide their practice, with some having none to those who had comprehensive support. Seven had support staff to assist with technical issues (eg, helping patients figure out how to enter their information properly on the website) and providing guidance throughout the whole process. Of the 15 without support staff, 6 (40%) reported that their patients struggled to navigate the online registration and had to assist their patients personally or asked patients to call the state for assistance. Six participants described how they developed their own tools for their patients’ education or to improve internal processes. Among those who certified a high volume of patients, they described building infrastructure to improve patient experiences, including templates for informed consent, screening questionnaires, and even online platforms to disseminate information about cannabis, facilitate payment portals, or telemedicine visits.
Mentorship
All physicians who were asked (n = 22) saw the benefits of mentorship or a shared knowledge network to improve their medical cannabis practice, however, most physicians (n = 12/22, 55%) did not have access to these platforms. Three areas were highlighted as beneficial domains for mentorship: dosing or prescription strategies, setting up practice to incorporate cannabis certification, and clinical perspectives on various scenarios.
Discussion
The results of present study highlight the numerous barriers to integrated care created by the murky legal status of cannabis. Physician training is hampered by numerous perceived and actual barriers. In the present study, physicians stressed the lack of evidence-based research to support clinical decision making, including establishing clinical workflows and making dosing or product-type recommendations. Training gaps were partly filled by seeking out anecdotal evidence from peers, mentors, or patients, but not all physicians had access to people who could provide guidance. In the absence of evidence-based research or guidance from the state regulations, physicians self-directed their practices, which sometimes led to very limited guidance being offered to patients. This led several physicians to express deep concerns about their role as authorizing medical cannabis and the impacts of cannabis on their patients. The current lack of standardized care is perceived by physicians as reducing the efficacy of cannabis treatment for patients who would otherwise see a positive benefit. There is a clear need for continued CME training with updated research findings and clear policy guidance to improve care quality.5,14
Similar to previous survey research,4 system-level issues of insurance, payment, equitable access, and barriers to communication were frequently raised by participants, as they created ethical, practical, and legal dilemmas for physicians. If cannabis certification is for medical purposes, the systematic carve out of insurance coverage for this certification creates access disparities among patients. Second, many (n = 7) physicians were unaware or had trepidations about possible audits if they charged insurance for an examination so the majority required patients to pay out-of-pocket for certification exams. However, an office visit for patient seen by any physician providing ongoing care for a medical condition is a billable visit. Under that umbrella, certification can be covered as a billable service with ICD-10 codes denoting the medical condition. Clarifying the rules around insurance coverage of appointments for exams and follow-up visits should be better addressed within the initial training programs. The perceived lack of insurance coverage for visits meant that physicians, who are acutely aware of the high costs for patients, were reluctant or disincentivized to schedule follow-up visits to monitor their patients’ responses to cannabis and to provide ongoing recommendations. Another unfortunate by-product is that the high costs of medical cannabis certification and products are prohibitive for lower income patients and constitute a significant health equity issue. The online patient registration system also drives health inequity; physicians commented that many patients describe difficulties with the state website, and internet access is a known contributor to health disparities for communities with those with limited access to internet or electronic devices, limited health or digital literacy, or other disabilities.15,16
Physicians reported barriers to communication with dispensaries3 and concerns about whether their recommendations are followed. Several expressed frustrations that they cannot inquire about individuals’ purchases and communicate with dispensary staff. This information can be acquired if they know which dispensaries their patients make purchases at and call them directly. However, this is prohibitive logistically and in a practical sense ensures that this information is not shared. Greater transparency between physicians and dispensaries may alleviate the informational divide that uniquely separates physicians from understanding what products their patients are using and how they are guided into making those selections. Unlike discussions and treatment decisions that physicians and pharmacists have with prescription medications, pharmacists or dispensary staff were perceived as having unique expertise or excessive leverage over the choices of patients within dispensaries. There is some evidence that these fears are well-founded. In a national survey of dispensary employees,17 60% of respondents indicated using personal use to advise customers and only 40% reported taking into account physician recommendations, which lends credence to physician reservations about the qualifications and motives of dispensary staff.
Conflicting state, federal, and insurance regulations and policies around the role of cannabis in medical treatment create ethical conundrums for physicians who must make important decisions about the care of their patients with limited information and resources. Physicians urgently need guidance on how to navigate the systems that patients must operate in while obtaining and using cannabis as well as rigorous scientific studies to guide their patients in treating specific conditions. 4,11,14,18 The results of this study likely generalize to the experiences of physicians in other states due to the overall federal policies and restrictions that limit information about the safety and effectiveness of the vast number of products available.
Limitations
Data are limited by collection within a single state and being drawn from participants already involved in a larger research project about medical cannabis. No demographic information was collected about participants so no statements about their representativeness are possible, though the larger study was representative of certifying physicians state-wide.5 However, the range of ways that physicians included cannabis certification in their practices suggests that we were able to recruit a broad cross-section of physicians. Similar studies may be conducted in separate US regions and states to offer a comparison of physicians’ attitudes toward training, system- and practice-level concerns, and if particular conditions are particularly challenging to certify for or to provide counseling.
Conclusions
State and federal policies only partially sanction the use of medical cannabis, which has led to a fragmented system of care that creates ethical and financial dilemmas for physicians and patients, as well as significant confusion about the rules about certification, counseling, and information sharing. The lack of rigorous research to guide the selection and use of products creates significant ethical concerns for physicians. There is an urgent need for high quality medical research so that physicians can better guide patients about the conditions that can be best treated or managed with cannabis.
Acknowledgments
The authors thank Emily Hajjar and Greg Garber, who helped them to develop this project.
Notes
This article was externally peer reviewed.
Funding: This work was supported by a grant from Ethos Cannabis, LLC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict of interest: The authors have no conflict of interest.
To see this article online, please go to: http://jabfm.org/content/36/4/670.full.
- Received for publication September 6, 2022.
- Revision received January 31, 2023.
- Accepted for publication March 20, 2023.
