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Bona Fide Issue Resolved By Mi Board Of Medicine


Yesterday the Michigan Board of Medicine may have ended the discussion regarding what a "Bona Fide" dr/pt. relationship is.  They issued the following memorandum...


The Board of Medicine and the Board of Osteopathic Medicine and Surgery has
adopted the following statement to clarify the standard of care applicable to the
evaluation of an individual for the purpose of certification to use marihuana for any
medical condition:

Generally accepted components of a full medical evaluation to determine
suitabitity and appropriateness for recommending treatment of any kind, including
certification for medical marihuana, include:

- a hands-on physician patient encounter
- full assessment and recording of patient's medical history
- relevant physical examination
- review of prior records of relevant examinations, treatments and treatment
response including substance abuse history
- receipt and review of relevant diagnostic test results
- discussion of advantages, disadvantages, alternatives, potential adverse
effects and expected response to treatment
- development of plan of care with state goals of therapy
monitoring of the response to treatment and possible adverse effects
- creation and maintenance of patient records documenting the information
above
- communication with patient's primary care physician when applicable

The Boards expect that these medical encounters would be completed at permanent
locations that enable the patient to retum for follow-up, consultation or assistance as
needed.

A physician failing to meet generally accepted standards of practice when certifying a
patient to use marihuana for a medical condition may be found to be practicing below
the acceptable standard of care and therefore may be subject to disciplinary action.


18 Comments

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ScottKelley
Feb 04 2012 09:11 AM
Well Here We Go

This was sent to me from Dr. Bob and there is a link to the wording to what the board sent out to all doctors. I myself have asked my primary doc to sinz zee papers, he wouldn't. My buddy with no legs asked his doc to sign the papers, he would not, but offered him oxi for his pain. So it is a moral political debate. And if your doc does not believe in it, guess what it is in your power to find another doc. Which isn't easy as it sounds.

The State Board of Medicine has released a new standard for the 'bona fide' doctor/patient relationship for medical marijuana certifications. I want to assure all my patients that I have met those standards at all my live clinics all along, and met all but the requirement for a physician face to face meeting between the doctor and patient on my Skype telemedicine certifications. Though telemedicine is widely used in medicine, certifications have been separated out from other specialty exams under these new standards. The question is not why they were separated out, but what we are going to do about it. At the very least, I think for the protection of patients that I will simply stop doing them for new certifications simply to assure there is no kink in the defense of my patients and no reason to question my certifications either in court with the patients or with the board for me. It is just wise to follow the recommendation. Here is the letter all Michigan physicians received:

http://dl.dropbox.com/u/28101571/lara.pdf

Review of the letter shows that there are two parts. The first is basically a desire that certifications be issued by a primary care doctor. As many of you know, I've always said the very best certification you could get was from your primary care doc, and in fact wrote a guest article for the Lansing State Journal last July talking about just that. I asked the state to put me out of a job by encouraging primary care doctors to participate in the program, free of restrictions by their practice, hospital, and insurance administrators. At the time only 1 in 15 Michigan physicians had written even one certification, and the major reason for that was that many primary care doctors were not allowed by their hospitals and other administrators to write certifications, even for very qualified patients. The second reason was because most primary care doctors did not know what was expected of them with certifications, or how to show they met the 'standard of care' if questioned in court
or by the Board. There was no cut and dried 'standard of care' only the vague term requiring them to have a 'bona fide' relationship.

The result was the rise of the 'certification clinic'. While some practices such as mine and several others throughout the state took the standard to mean that we had to follow good medical practice, require records, see the patient, etc (see 'what you need for an evaluation' on the main menu of the my website), others popped up as a marketing tool and tried to figure out the very minimum they could get away with. Well folks, the very minimum was a license and the ability to sign your name and the type of professionalism that let you say 'It was adequate in my opinion' even though they never reviewed records, examined the patient, or in some cases even had contact with the patient. Affidavits, renewal by mail in exchange for money, presigned certifications, and a host of questionable activities by sales agents masquerading as 'certification clinics' followed. Most were designed to get just enough information from the patient to give the clinic some 'deniability' of fraud while
leaving the patient hanging in the wind if they were ever charged and had to defend their use of cannabis. I am personally aware of one court that requires card holding patients to bring their actual medical records to court for the judge to review before he considered the card valid. This was due to the number of patients in his district going to 'mills'.

The result was the second part of the letter, an actual list of standards for doctors to follow, both as a guideline for the good doctors and to weed out the bad ones. Reviewing them, they are pretty common sense. See the patient, require records of their care to prove the condition, keep records, advise them of the advantages and disadvantages of the treatment plan, and follow up with them. Meet the requirements and you have done your job and can defend your decisions if questioned the board indicates. Vary from that standard and you could still be fine, but you will have to justify the variation.

Now primary care doctors have a standard to follow, their corporate lawyers and administrators no longer have uncertainty and have reduced their risk. This hopefully will encourage primary care doctors to participate in the program. Even if we go from 1 in 15 to 2 in 15, we have to remember we have around 140,000 patients at the current level, and if we can double participation, we can double that level. Double it again and we will be at the 4% of the population holding cards like the other states that have been doing this for awhile. As for the mills, it is a good time for you to take up another line of work and leave this field to the professional physicians that put patient safety, not patient money, first. There are plenty of us out there.

As for my practice, my live clinics will not change in any way, they were already fully compliant. We have fixed base offices in Mt. Pleasant, Saginaw, Cadillac, Traverse City, and are getting ready to open in Muskegon. I will continue to travel to clubs, and will have an active circuit of travel clinics. For the most part, I will no longer do telemedicine for new patients. I am deciding if I will do recertifications for my existing patients via Skype. My professional reputation and credentials, history of sound standards, and procedures are 'good' enough in my opinion to justify an occasional Skype- especially for clear cut conditions like cancer, crohn's, or hep c that are quite clear and don't have physical findings. The fact that the majority of of practice is in rural N. Michigan will also come into play in my decision, but Skypes will be on a case by case basis and will have to be justified as to why they were done that way vs a personal meeting. I am also considering
more traditional telemedicine in some of the larger remote clinics with a licensed professional on both ends of the link.

While the new standards do disrupt my practice to some extent, small changes will handle that as I was doing a pretty good job in the first place. Like most professionals, I welcome them and the transition should be seamless. I believe more primary care doctors will participate, and my goal this year was to increase the familiarity of primary doctors with the program (see my call to action for 2012). There are plenty of patients out there, and these standards go a long way towards erasing the image of the typical marijuana patient as an '18 year old with a stubbed toe' who got his ticket punched by a quack in a hotel room. Doctors will see the new standards and realize that real doctors are becoming serious about the field. In addition to the standards, I am currently preparing the largest study on patient demographics done to date and hope to publish it to give doctors an idea of the 'true face' of medical marijuana in Michigan.

Thanks for your support and I'll keep you posted.

Dr. Bob
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bobandtorey
Feb 13 2012 11:48 AM
WOW! it's no wonder the THC-F has left town
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AlternativeSolutionsPlus
Feb 14 2012 09:29 AM
What is a bonafide relationship? In our opinion why would they issue an opinion; one that is clearly a double standard with marijuana and not other prescribed medications; the opinion is absurd and comical. This opinion is a clear reflection of just how powerful an influence large pharmaceutical companies have over certain parts of the political landscape.
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AlternativeSolutionsPlus
Feb 14 2012 09:34 AM
Think about it...a physician can not legally prescribe marijuana, yet they can prescribe highly toxic chemotherapeutic drugs, dangerously addicitive narcotics, and radiation treatments...and not be held to the same standards as someone wanting to be certified for marijuana!
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AlternativeSolutionsPlus
Feb 14 2012 09:36 AM
"More than a thousand people die from aspirin-induced bleeding each year in the United States." Compare that to the number of reported deaths from cannabis...ZERO!
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AlternativeSolutionsPlus
Feb 14 2012 09:37 AM
The value of cannabis is especially clear when overall quality of life is considered for the patient. Too bad marijuana is a political issue, not a mere medical matter.
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AlternativeSolutionsPlus
Feb 14 2012 10:16 AM
"current" Republican Attorney General Bill Schuette is forcing patients to break the law; when all they want to do is provide for their own medical needs.
While across the country and with increasing frequency, public opinion polls show that support for medical marijuana is popular and steadily rising — and cuts across demographic and party lines. There has never been a better time for legalization than now. :abe:
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sissybryant
Feb 20 2012 12:50 PM
Why does the process of getting "It all together," when it comes to "understanding the Varied Properties in Marijuana associated with its effects when utilizing its Medical Properties for many Symptoms, Diseases, Syndromes, Viruses, Etc., to help in the aid of;
#1). Relieving Pain,
#2). Relieving Symptoms,
#3). Relieving Stress,
#4). Relieving Anxieties,
#5). Relieving Hyperventilation,
#6). Relieving Effects of Glaucoma,
#7). Relieving Effects of Cancers,
#8). Relief for Nausea (Generally),
and so on . . .
And to add to the Benefits List;
--------------------------------
It is NOT addictive,
It is beneficial and NOT harmful,
It is a NATURAL Herb born from the earth not a Laboratory,
Most, if any, side-effects will probably occur due to an individual not being responsible/abusive behavior issues/lack of respect for others. Like anything else, eventually, someone somewhere can make anything look bad by their behavior being the cause of attention.
Marijuana, in my opinion, "if the use of it is made illegal for Medical Purposes, our medical professionals are not considering, the best interest of the Individual. It certainly cannot be prescribed to just anyone for any reason of course, but it certainly should be prescribed to Individuals who definitely can benefit by its use considering their history of medical issues and the known benefits it can produce to aid in the Well-Being and Care for many.

Unlike the 'days of old,' marijuana no longer is a product of the earth growing wild. yes, it is still of the earth, but it
has been taken to a science of science. Now, the Science of Producing Marijuana, is a big business, just as the science of the many ways to grow or produce it has. Today, it is all Hybrid Strains so Scientific, the beneficial factor known as THC in Marijuana can be Identified and labeled as such. In fact, it is being grown to serve the Medical Needs of those who are receiving the Medical Verifications for its use. There are so many different strains of the Stativa (SP?) and Indica seeds/clones and the understanding of them is certainly not complicated.
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AlternativeSolutionsPlus
Feb 22 2012 10:31 AM
How ridiculous is it that a helpful, harmless, and innocuous "plant" cannot be prescribed by doctors or bought over the counter like aspirin.
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sunflower265
Feb 26 2012 12:52 PM
"monitoring of the response to treatment and possible adverse effects"

Does anyone know. Other than interference from law enforcement, has there been any adverse effects from the use of medicinal marijauna? Are people dropping dead? being hospitalized? addicted and turning to a life of crime? I don't know for sure, but I doubt it. It kills me that they want to monitor and mess with the current law when it is working just fine. I have been using MM for Rhuematoid Arthritis since the law passed. Family intact. Still employed at full time job. No longer taking dangerous drugs such as Humera ($800 shot/ 2 times month), the wonderful chemotherapy drug that destroys your liver, methotrexate, and steroids. It has truly been a miracle and probably saved my life!I am terrified, however, that they are going to make it impossible for me to get.
How many dx and doctor appointments is acceptable. When it's chronic pain and you tell your doctor it's working is a annually or every six months, it's still flakey. My doc I'm seeing every six months for follow up but am sending him my documentation after a successful month using peanut oil. My doc knows I know my body and he knows I want what is best. After the first rally I decided to go off opoids and try medical marijuana, it has taken awhile...opoid free for six months...no more poison and I feel like my old self, just older. Thanks to all the ppl who have helped me to find a way to manage pain without opoids. Gersh Avery help so much...and my family is so supportive...marijuana doesn't lead to higher drugs it helps you get away from them..:))
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AlternativeSolutionsPlus
Feb 29 2012 08:08 AM
"More than a thousand people die from aspirin-induced bleeding each year in the United States." Compare that to the number of reported deaths from cannabis...ZERO!
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AlternativeSolutionsPlus
Feb 29 2012 08:09 AM
The value of cannabis is especially clear when overall quality of life is considered for the patient. Too bad marijuana is a political issue, not a mere medical matter.
this whole fiasco is a waste of time and resources. Cannibus needs to be decriminalized---taxed and governed by laws the same as liquor
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AlternativeSolutionsPlus
Mar 07 2012 08:34 AM
:goodjob: :thumbsu:
Sisbryant hit the issue right on the Head,

"...the best interest of the Individual."


It seems, somehow We are tolerating our Political Representatives (Senators and Reps) who put THIER interests above that of the Patient or Constituent and ignore the Voters!
This is a sick perversion of the System that our Fore-Father's fought, and Died for -- Washington, Madison, Jefferson, and the List goes on fought and obtained there rights for us.
We sully them when We do not demand their enforcement.


Doctors, good Doctors, put the Patient first !
Politicians do what their Bosses (the Voters) say !


If Doctors did not put the Patient first, what Doctor would go into a War Zone to treat the Injured?
What Doctor would treat infectious diseases as it is clear they Could get it themselves? And the List goes on that good Doctors treat the patient.
But now we have the Doctor's Bosses telling them what NOT to do - do NOT sign a form about medical use of Marijuana. So Patients go to Doctors
that Will, and What happens, the Court, three or four Judges, call into question the Doctor Patient relationship and go outside the Law and assert on NO FACTS
whatsoever (invading the privacy of medical information) and start questioning the aliment the person suffers from -- We must stop this as it is a slippery, slippery slope.


Where our supposed "Representatives" are doing is putting their interests above the Patient, the Voter and Society because they object to Marijuana.


They must be removed by Vote (which they will then try to ignore that as well) as this perversion could spell the end of the Country -- this cannot be tolerated.
"....that government of the people, by the people, for the people, shall not perish from the earth." Clearly this is what is at stake Here in Michigan where People
opposed to what you, and I, put in our Bodies, are violating the Will, and Vote of the People and it is just as Serious an issue as Lincoln saw back at Gettysburg but
in the Political realm rather than the Battlefield.


Until We demand better it will continue and accelerate for the Worsen.
Already We are witnesses to the Worst this Country has where Constitutional Rights are being eviscerated every day.
The NDRA makes it possible to incarcerate without trial, or evidence. Now a Law was passed that makes protesting illegal as they
did not like Occupy movement ! Soon they will be carting away everyone that "they" do not like to private prisons where you have no rights and no advocate.


Powers that own Large Hospitals and Health Care Organizations TELL their Doctors what to do - and what NOT to do, such as simply signing the most
innocuous statement possible -- that Marijuana "might" help -- that is a pretty low standard and a just one -- it might Help, it might not, but you have the RIGHT to try it. Taking Rights away
seems to be the flavor of this Government and it will take everyone to stand up and say NO YOU WON'T !


All the hoopla about Marijuana is pure Politics -- make no mistake about it -- Do not lower yourselves to their level.


If you have a Registry Card, that should be it and enough. Explaining more is a waste of time. Doing anything other than demanding the Initiative be enforce is a waste of time.


In Drunk driving Law or perlance We in Michigan have a "Per Se" State, meaning if you have ANY amount of THC *11-nor-9-Carboxy-THC* in your Body, are "per se" guilty of drunk or drugged driving
(without any proof whatsoever of impairment). It is somehow assumed your impaired (even though the evidence establishes most people with some metabolites of THC in them are actually
safer drivers -- which just blows their minds)!

We need to argue "Per Se" enforcement of the Initiative #1 of 2008 --- just like the Initiative says, if you have went through the steps to obtain a Doctor's Certification and a MM Registry Card (Patient

or Caregiver), you are "Per Se" in compliance, and immune from arrest for the possession of the amounts noted in the Initiative. Period. No arguing abotu other side-issues to detract fron the issue at hand.
Did you have a Registry Card and below the amounts in Sect. 4 -- Yes, dismiss any charges. It will not take long for LEO to sto arresting people if the Courts enforce the Law as written. And this is what a Civil Action must
demand, enforcement AS WRITTEN. Nothing else matters. Enforce the Law.


All this "Bonafide" relationship stuff is Judge created OUTSIDE the language of the Initiative -- no where does it say any of that and this is outside the Law. All Doctors seeing patients are in a
Bonafide Doctor Patient relationship (and if not the Doctors police themselves). If the Doctor is breaking the Law, go after the Doctor, not the patient !


It is amazing when people try to heal themselves with a Plant that was given to this Earth and used medically for Thousands of Years, We now have to go through this. Sadly, no one
group has stepped forward and FORCED enforcement of the Law through Civil Action as California has done. What is it about Us here in Michigan where we cannot find 100 or 1000 people
to get together and fund a suit against LARA?


My 2 cents,
M10
my surgeon for my leg didnt even want to give me copys of my medical records to take to my certification physician. so i told him he would be hearing from my lawyer he pulled my file and dropped it on the counter and told me dont come back to his office. so i took my files to my certification physician she reviewed them asked me why i wanted to use the medical cannabis i explained to she that i had a problem with pain pills in the past and did not want to put my self or my family through that again she examined my leg where the steel rod still remains asked me what causes the pain so i gave her a list of the work duties that i do and im in the cold outside during the winter mnts she understood and certified me. Now that the state want a bonafide dr/pat relationship now i have one because she reviewed the files and did a examination of my leg and back that is considered a bonafied dr / pat interaction or relationship...
All meds. come from a sort of PLANT form, THE POPPY,ummm,the gov has vast amounts put aside ! Cannasbis is not as strong as others. OPium, another ! Mary,don't have a BAD record,but, all your other pain killers do, so, whats the problem ?