Audit Says Doctor Sees 11,800 Patients a Year- Waiting Rooms Still Full

LARA has just released the results of an audit of medical marijuana certification doctors.  As always, they are making a big play that less that 25 doctors have seen some 56% of all certification patients in Michigan and one doctor (gasp) saw 11,800 patients in 2015.  First, let me make it clear, that one doctor was not me, though I wish it was and so does my checking account.  I think a good number of attorneys wish it was me as well, because my certifications are pretty easy to defend and use for Section 8 hearings due to our high standards and procedures.  But as an experienced primary care doctor, I think I should put some of these numbers in perspective.

First, the quote we are seeing that the ‘average’ doctor sees 11-20 patients a day is nonsense.  That volume may be at the ‘peak’ of the bell curve, but it is a pretty wide bell curve.  Problems with this average is that it seems to be the answer to ‘how many do you want to see’ rather than how many do you actually see.  Second there is no breakdown between doctors that are paid by the hour and those in private practice that are paid by the patient.  When I was in private practice in Internal Medicine, I worked from 8-5 or later every day.  Assuming an hour for breaks, food, bathroom, or whatever, that is a good 8 hours a day.  I averaged about 5 patients an hour, or 40 per day.  Some had simple problems and only took 5 min, other were more complicated and took an hour.  Each got as much time as they needed.  Of note, when I worked for the VA, my ‘full load’ was 8-12 patients a day.  With 1/2 a day off on Thursdays to do ‘administrative paperwork’.  Volumes depend on the setting and need.

Five patients an hour is 12 min a patient.  Is that enough?  Actually, yes for an organized and experienced doctor.  My first full history and physical in medical school took 5 hours.  My last hospital H&P took 20min, but the patient had quite a few problems.  Second, I don’t greet the patient at the door to the office, get their clipboard and paperwork together, help them fill it out, see them, and check them out.  That whole process may take an hour.  That’s why I have staff.  Trained staff.  They get the patient and paperwork together, I meet the patient and evaluate them/answer questions, the staff then helps them with the nuts and bolts of the application and gets signatures, etc.  We all do our part to give the patient a comprehensive visit.  In Internal Medicine, I saw between 30 and 45 patients a day, and I was on the LOW end of the volume in my town.  Plus 10-15 in the Hospital after work.  As a small town doctor, I worked 7 days a week for months at a time, and when not seeing patients, was required to be within 45 min of the hospital.

A typical, but busy, primary care doctor such as me seeing a typical patient load of 35 patients a day and working a 5 day week would see 9,100 patients a year.  Note that isn’t even at ‘full capacity’ of 40 patients per day, nor does it account for weekends (recall I had a hospital load of 10-15 per day, weekends included, and I didn’t count that in the numbers for my outpatient office practice).  So to get real for a moment, the headline of ‘One Doctor Saw 11,800 Patients’ is only abnormal because it was ‘presented’ as abnormal.  I would present it as a ‘light load’ for a small town solo practitioner.

Are There Problems with Certification Clinics?

Are there problems with certification clinics?  OF COURSE THERE ARE.  The Main Problem is that they are needed at all.  When 63% of Michigan Voters approved the MMMA in 2008, there was an implied understanding that, once approved, qualified patients would be able to see their primary care doctors and get their certification.  Unfortunately, this did not occur.  In fact, many patients are now AFRAID to discuss it with their doctors.  First, we see many offices post signs in their (full) waiting rooms instructing patients not to even ask about medical marijuana.  Second, many doctors not only refuse to look into medical marijuana, they dismiss or cut off pain medication when they discover their patient has a card.

This is something that really concerns me as a physician.  In order to properly treat my patients, I need them to feel comfortable telling me their secrets.  I need to know about the state of their health, their complaints, and what they are doing about it.  I need to know their vices and marital infidelities, so I know to look for things.  I need to know if they find something that helps them, not only because I want to know about what they are doing, but because it may help my other patients.

That is how my patients working through narcotic withdrawals got me interested in medical marijuana (which was helping them greatly with withdrawal).  If the average primary care physician learned that they had several patients reduce their need for narcotic pain medicine by 50% simply by eating celery, how long would it be before they recommended celery to all their pain management patients?  Not long at all, because doctors don’t like writing narcotics.  Yet change celery to medical marijuana, and they lose their freaking minds and start punishing patients by cutting them off, putting them in withdrawal and dismissing them from their practice.  How do you reconcile that with ‘Do No Harm’???  Don’t even get me started on lawyers (judges and prosecutors) demanding people be taken off ‘celery’ and put back on hard narcotics and ulcer causing NSAID’s.

Where to from here?

Without getting into legalization and decriminalization, what should we do with the current certification system?  First, since primary care doctors are not participating, we will have certification clinics and doctors that spend most of their time doing certifications.  It is not unexpected that there are relatively low numbers of doctors in this field.  Hospitals and large clinics generally do not allow their doctors to do certifications, either does the VA.  As a result only private practice doctors (especially solo providers) are the only ones that can really become certification doctors, and there are relatively few available.  Many already have busy practices, don’t know much about the field, or simply don’t wish to be known as ‘pot doctors’.  But there were 55 doctors doing most of the certifications in 2011 (the last time a number was reported), now we are fewer than 25.  Patient numbers are higher than ever.  Our waiting rooms are full, and we are seeing the patients.

Using patient numbers to imply improper certifications or to label individual doctors as ‘problem doctors’ is not accurate.  Assuming physicians are following the law- Seeing patients in person (not on Skype or through the mail), reviewing records and doing follow ups, more power to them.  They found a market and are meeting the needs of that market in a professional way.  If I were LARA, I would concentrate on doctors that don’t do certifications correctly.  Doctors that do renewals through the mail, or see patients on Skype.  Doctors that have been to court and have had their certifications overturned.  Was it an isolated ‘bad’ visit or a pattern of cutting corners or ‘signing for dollars’?  That is a question for a LARA investigator to answer.  Perhaps rather than look at a spreadsheet and say a doctor is ‘bad’ because they are busy, they should actually work and identify problems in procedures and those that don’t follow the law.

Bonus Feature!

Do you want to learn more about medical marijuana and the patients that use it?  Have a look at the last 2 years worth of statistics from our practice– Average ages, condition breakdowns, ages by conditions etc.