January 05, 2005
Vrinda Normand , Metro Newspapers
TWENTY YEARS of experience as a physician's assistant didn't prepare Karen Berman (not her real name) for a short-lived stint writing medical marijuana recommendations. In the summer of 2004, she responded to a lively ad on the PA World website (www.paworld.net). 'San Jose non-profit needs PA's immediately!' it said. 'We have a huge demand and will be hiring an estimated 85 PA's by the end of the year.'
The ad didn't specify the nature of the work, but stated, 'We offer informational programs for patients who are suffering from a wide variety of symptoms.Our team of professionals will design specific plans to alleviate the discomforts associated with their symptoms.' Berman admits that she was skeptical at first, but Donye Mitchell, the owner of the Suffering Patients clinic in Santa Clara, reassured her that he was a lawyer and knew everything there was to know about Proposition 215, the state law passed in 1996 which allows people with certain medical conditions the private use of marijuana if approved by a physician.
But the broadly worded proposition left a void that advocates and state agencies have been scrambling to fill with specific guidelines. For many, it is still unclear what standards physicians must follow in recommending the drug.
Berman crossed this shaky territory with raised eyebrows, and her story suggests that Mitchell may be pushing the boundaries of medical marijuana too far. After many phone calls and emails, the owner of Suffering Patients could not be contacted for this article. Several other parties questioning him about his practices have also failed to contact him, although his website (www.sufferingpatients.com) and answering machine say that the clinic on Stevens Creek Boulevard is still accepting patients.
In mid-September, Berman was hired as the only PA at the small Santa Clara clinic (Mitchell has two other locations in Salinas and Venice), which she says was run more like a business office than a nonprofit medical facility. She saw patients in a room behind the reception area that lacked an exam table and a blood pressure console, among other things necessary for a proper physical examination. In the same room, Mitchell kept computers where he and another employee would have discussions while Berman was seeing patients. She demanded that Mitchell at least put up a curtain for some privacy.
Berman soon found out that 'designing specific plans' for patients really meant conducting two- to three-minute consultations and sending them on their way with medical marijuana recommendations that were pre-signed by Dr. Jordan Paul Weiss, who lives in Southern California. Berman says she never met Dr. Weiss, but spoke to him once or twice on the phone for a couple of minutes when she questioned if someone was eligible for medical marijuana. Other than that, she does not know if the doctor reviewed the patient charts. She never sent them to him.
A $150 visit with the PA at Suffering Patients consisted of answering a few questions: What health problems do you have and why do you want a recommendation for medical marijuana? Berman would write notes on the back of the patient questionnaire, and the closest she ever came to conducting a physical exam was asking someone to show her their scar if they said they had a surgery. Sometimes she asked patients to bring in documentation of their condition.
Because she could not thoroughly assess their needs, Berman told patients, 'This may or may not help you, but if you have a serious medical condition, you need to see a doctor. This is not a substitute for medical care.' In the month that she worked there, she never saw a patient more than once, and says she never intended to, despite her understanding that follow-up is a standard of medical marijuana care. 'This was totally different than what I was used to,' she says. 'It was not clinical medicine.'
As unorthodox as the office setting was, Berman faced even more challenging conditions at the raves, or electronic music festivals, where Mitchell had her conduct consultations. Two Saturdays last October, Suffering Patients set up a booth at the Love Parade and Cyberfest in San Francisco. A few photos on the Suffering Patients website show crowds of young people cheering around a banner that boasts, '1-877-CANABUS.'
The 50-year-old PA was surrounded by entertainment booths and booming music. She saw patients in a curtained-off area by the booth, though 'the noise level was tremendous.' In one night at a rave, she saw at least 20 patients, whereas she might only see five in a day at the clinic. The environment may have been conducive to business, but not to medicine. Berman says that at one point she stopped asking questions because there was no way to guarantee patient confidentiality. 'The conditions were not appropriate,' she says. 'How could I help people there?'
During the time that she worked for Suffering Patients, Berman refused a recommendation only once. At the Love Parade, a young man under 18 requested a consultation and she told him he needed to get his parents' permission. She 'made a big stink' about that incident and told Mitchell she wasn't going to put her license on the line. Eventually she felt her work at Suffering Patients was too risky. 'An undercover police operation would have been catastrophic,' she says.
Five weeks into the assignment, Berman called Mitchell from out of town and quit without notice. She admits that should have given him more time but his behavior after that point has only infuriated her more, and has resulted in a small claims suit for back pay. As alleged in the suit, Berman's second paycheck for $1,500 bounced, and when she called Mitchell about the money, they had a screaming fight. He refused to pay her for her last four days (which fell outside the second pay period) and told her she could come into the office to pick up her second paycheck. Fearing he might 'go ballistic,' she said she wanted him to send it to her. By November she hadn't received it. He told her to stop calling him, that she was using up his phone time. While these complaints are detailed in the filing for the small claims suit, Berman has not yet been able to locate Mitchell in order to serve him the court documents.
After she quit her job, Berman contacted the PA World webmaster, where Mitchell's ad was still posted, and told him of the problems she had with her employment. The webmaster says he tried to verify this complaint by sending three emails to Mitchell. He never received a reply, so he posted a cautionary note next to the ad.
Many of the claims Mitchell makes about himself and his business are questionable. The ad he posted online says he runs a nonprofit, but Suffering Patients is not registered with the California secretary of state as such. He told his employees and several inquirers that he is a lawyer, but his name could not be found in the California Bar Association, or in the American Bar Association.
Moreover, the home page for the Suffering Patients website dated Oct. 7, 2004, boasts, 'We've seen over 300 patients so far and are still growing strong. We have received a tremendous amount of support from doctors, physicianassistants [sic], co-ops, dispensowries [sic], city agencies, and law enforcement.' Lt. Jim Buchanan of the Santa Clara Police Department says he was not aware of the clinic until contacted for this article, and has since discovered that it is operating without a business license and use permit. In addition, prominent medical marijuana advocates in the South Bay along with a dispensary owner in Hayward have certainly not lent their support to this clinic, and after trying to learn more about Mitchell's operation, have only come away frustrated and concerned.
In September, the Hayward Patients Resource Center, a medical marijuana dispensary, received two recommendation letters from Suffering Patients. Owner Jane Weirick says the letters immediately caught her eye because the doctor's signatures on them were identical, as if they had been photocopied from an original. She started the verification process, as she does with every letter she gets, and things just got 'hankier and hankier.' First, she called the number for the clinic and reached Mitchell. He told her he was a lawyer, and when she started questioning him about some of the procedures he was using, he became very defensive. Weirick says he called her a racist white lady who was trying to keep the black man down. 'I was like, what!' she exclaims, baffled. 'Where are you getting this from?'
From this conversation, Weirick discovered that the patients were seeing a PA instead of a doctor. In eight years of verifying recommendation letters for cannabis, this is the first time she has encountered such an arrangement. Weirick also believes that some of the patients were under the false impression that they had seen a doctor at this clinic. Weirick had never heard of Suffering Patients or Dr. Weiss before, so she asked a woman who submitted a recommendation to her dispensary about the doctor. The woman was convinced that she had seen a female doctor, when the signature on the letter is that of a male physician.
In relation to this, the answering machine for Suffering Patients prompts the caller, 'If you would like to make an appointment to see the doctor,' even though, according to Berman, the doctor is never on site and never sees the patients. Berman says she always told patients that she was a PA, and maybe some were confused because, 'A lot of people just don't know what a PA is.' She often explains that a physician's assistant is between a nurse and a doctor.
Weirick says more red flags popped up during the verification process. She called the separate verification number listed on the recommendation letter, and it was also answered by Mitchell, who pretended that he hadn't just spoken with her. On both her attempts, she only reached the owner, a source she didn't consider reliable for her medical verification purposes. 'Ultimately, I want to talk to whoever signed that letter. The more people they put in my way, the more suspicious I'm going to be,' she says.
Weirick has since rejected over 40 letters from Suffering Patients. Shortly after her disturbing encounter with Mitchell, she contacted a chain of medical marijuana advocates in the South Bay, including Dennis Umphress and Jim Lohse, a medical marijuana patient and caregiver in Santa Clara who started the patient advocacy group Area 420 last year.
Curious about a recommendation service an in an area where they say most doctors won't write letters for medical marijuana, Lohse and Area 420 coordinator Chuck (who declined to give his last name) paid a visit to the Suffering Patients clinic. They met the receptionist and the PA, and when Lohse asked about the doctor's whereabouts, the two 'clammed up' but assured him that the owner was a lawyer. Lohse was able to contact Mitchell by phone, and he says they had a very 'contentious' conversation, in which Mitchell accused Lohse of racist intentions and became very defensive in response to his inquiries. The clinic owner contended that using the PA model for medical marijuana was perfectly legal because it was outlined in SB 420, the state Senate bill passed in 2003 that provides more specific regulations on how to implement Proposition 215.
Lohse says he knows the Senate bill 'like the back of his hand' and nowhere does it mention anything about PAs. While PAs are often used in doctor's offices, there is some question as to whether or not they can be used in the process of writing recommendations for medical marijuana.
Richard Wallinder Jr., the executive officer with the Physician Assistant Committee of the California Medical Board, confirms that the law surrounding medical marijuana doesn't say anything about PAs. Proposition 215 stated physicians could recommend the drug, and the Health and Safety Code was updated in 2003 to clarify that doctors of osteopathy could also write such letters.
Even if this case didn't involve medical marijuana, Wallinder says he 'would have some questions about the standards that are being used' (although he could not give a firm assessment of the clinic without conducting an official investigation). Some of the medical practices reported by Berman don't hold up to the guidelines adopted by the Medical Board in May of 2004, which, according to the official website, are the same as any 'reasonable and prudent physician would follow when recommending or approving any other medication.'
The physician must conduct a good-faith examination of the patient, develop a treatment plan with objectives, discuss the side effects, conduct periodic reviews at least annually, and keep proper records that support the recommendation. A secondary physician may recommend marijuana but is responsible for consulting with the patient's primary physician or obtaining the appropriate medical records that confirm the patient's diagnosis and prior treatment history.
The biggest missing piece in the Suffering Patients case is the physician. The California Medical Board website listed a Dr. Jordan Paul Weiss in Irvine. Calls to his answering service there were never returned. Lohse says he also tried to contact the doctor and had no luck. Incidentally, Dr. Weiss has an accusation filed against him by the executive director of the Medical Board for sexual misconduct, gross negligence and incompetence. The report details the testimonies of two patients who describe Dr. Weiss using a self-invented 'Psychoenergetic Healing' technique that involved fondling their private parts. The hearing of this case is set for March 1, 2005, at which time Dr. Weiss could have his license suspended or revoked.
While Dr. Weiss faces accusations unrelated to prescribing cannabis, other California medical practitioners have come under fire for their involvement in the controversial field. In April of 2004, Dr. Tod Mikuriya of Berkeley weathered a Medical Board hearing that set the current standards for recommending the drug. Mikuriya has written over 10,000 pot recommendations since 1996, and according to a recent East Bay Express article, Mikuriya believes he is the victim of a government-run witch hunt.
But the state attorneys who prosecuted Mikuriya say his case was really about the standards of patient care that he used. Investigators located 50 people who had caught the attention of law enforcement for using marijuana after they had obtained recommendations from Mikuriya. After studying Mikuriya's files for 47 of these patients, the Medical Board concluded that he had inadequately examined 16 of them. He was found guilty of gross negligence on all accounts and is now practicing under a five-year probation.
In a recent phone interview regarding Suffering Patients, Mikuriya is quick to point out that nowhere in the law does it say PAs can't see patients for recommending medical marijuana. He sees himself as a consultant (and psychiatrist), not a primary physician. 'A physical exam is irrelevant,' he says. One just needs to ask, 'Does this person in my judgment qualify for the provisions of Proposition 215?'
Mikuriya also stresses the importance of following up on patients, and says that he has known some of his for 10 years. 'I can't count the number of times I've gone to court on their behalf because of some malicious prosecutor or ignorant lawyer,' he adds. He also offers a sliding scale for patients who can't afford treatment. San Jose resident Christine Flora says she has been seeing 'Dr. Tod' since 1998 and has only paid a couple of times. She is re-examined at least once a year and usually has lengthy phone follow-ups in between those exams.
One San Francisco doctor who recommends marijuana offered information about her patient-care practices only under the condition that she remains anonymous because she fears attracting attention from the federal government or the Medical Board. With 25 years of experience behind her, she conducts thorough exams and consultations for medical marijuana. She wants to make sure her patients' marijuana use is safe and responsible, so she asks them detailed questions about their personal lives: their occupation, their activities, how they should explain their medicine to their children. 'I want to know everything about my patients,' she says.
In her office, which smells of essential oils, an exam table and stethoscope are clearly visible. She conducts physical examinations if she deems them necessary, although she spends less time with patients who have obvious physical conditions and ample documentation of their condition. If a patient doesn't already have a primary-care physician, she will often make them go to one for a checkup because she considers herself a secondary doctor. She also gives nutritional advice and addresses other health concerns like weight-loss and blood pressure. Sometimes she only writes a recommendation for three months if she needs to monitor a patient's progress.
As with Mikuriya, other doctors have been prosecuted under the vagueness of the law surrounding medical marijuana, and many advocates are quick to defend the legitimacy of their practices. Bill Kahn, a caregiver who runs a Central California delivery service, says all of the physicians that he has worked with have been excellent. 'They are very skilled and they are risking everything they've got because of what they believe in,' he says.
But when told of Berman's description of conditions at Suffering Patients, particularly regarding the fact that Berman conducted consultations at raves, Kahn says, 'I don't believe those kind of people are helping my industry. There are some people who are just looking for a quick nickel, and I don't want to know them.'
Because of the controversial nature of medical marijuana, Umphress points out, 'All it takes is one operator to give the whole scene a bad name.'