I would like to tell you about the most embarrassing thing that has ever happened to me in my years of working as a palliative care physician. This happened a couple of years ago. I was asked as a consultant to see a woman in her 70s -- retired English professor who had pancreatic cancer. I was asked to see her because she had pain, nausea, vomiting ... When I went to see her, we talked about those symptoms and in the course of that consultation, she asked me whether I thought that medical marijuana might help her. I thought back to everything that I had learned in medical school about medical marijuana, which didn't take very long because I had learned absolutely nothing. And so I told her that as far as I knew, medical marijuana had no benefits whatsoever. And she smiled and nodded and reached into the handbag next to the bed, and pulled out a stack of about a dozen randomized controlled trials showing that medical marijuana has benefits for symptoms like nausea and pain and anxiety. She handed me those articles and said, "Maybe you should read these before offering an opinion ... doctor."
Gustaríame contarlles a cousa máis embarazosa que me pasou nestes anos traballando como médico de coidados paliativos. Isto aconteceu hai un par de anos. Pedíronme que consultara a unha muller que tería sobre uns 70 anos. Unha profesora de inglés retirada que tiña cancro de páncreas. Pedíronme que a consultara porque tiña dores, náuseas, vómitos... Cando fun vela falamos sobre eses síntomas e durante a consulta preguntoume se pensaba que a marihuana medicinal lle podería axudar. Intentei lembrar todo o que aprendera na universidade sobre marihuana medicinal. Non me levou moito xa que non aprendera nada en absoluto. Polo tanto, díxenlle todo o que sabía: que a marihuana medicinal non tiña ningún beneficio. Ela sorriu, asentiu e colleu o bolso que tiña ao lado da cama e sacou unha morea de ensaios aleatorizados controlados que mostraban que a marihuana medicinal é beneficiosa para síntomas como as náuseas, a dor ou a ansiedade. Ela pasoume eses artigos e dixo: "Quizais debería ler isto antes de dar unha opinión... doutor".
(Laughter)
(Risos)
So I did. That night I read all of those articles and found a bunch more. When I came to see her the next morning, I had to admit that it looks like there is some evidence that marijuana can offer medical benefits and I suggested that if she really was interested, she should try it. You know what she said? This 73-year-old, retired English professor? She said, "I did try it about six months ago. It was amazing. I've been using it every day since. It's the best drug I've discovered. I don't know why it took me 73 years to discover this stuff. It's amazing."
E fíxeno. Esa noite lin os artigos e atopei moitos máis. Cando volvín vela á mañá seguinte tiven que admitir que parecía que si que había probas de que a marihuana pode ofrecer beneficios médicos e suxerín que se ela estaba realmente interesada debería probala. Saben o que dixo? Esta profesora de inglés retirada de 73 anos? Dixo: "Xa a probei hai seis meses. Foi xenial. Estouna consumindo dende aquela. É o mellor remedio que descubrín. Non sei como me levou 73 anos descubrila.
(Laughter)
É xenial". (Risos)
That was the moment at which I realized I needed to learn something about medical marijuana because what I was prepared for in medical school bore no relationship to reality.
Nese momento decateime de que precisaba aprender algo sobre a marihuana medicinal porque a formación que me deran na facultade non tiña nada que ver coa realidade.
So I started reading more articles, I started talking to researchers, I started talking to doctors, and most importantly, I started listening to patients. I ended up writing a book based on those conversations, and that book really revolved around three surprises -- surprises to me, anyway. One I already alluded to -- that there really are some benefits to medical marijuana. Those benefits may not be as huge or as stunning as some of the most avid proponents of medical marijuana would have us believe, but they are real. Surprise number two: medical marijuana does have some risks. Those risks may not be as huge and as scary as some of the opponents of medical marijuana would have us believe, but they are real risks, nonetheless. But it was the third surprise that was most ... surprising. And that is that a lot of the patients I talked with who've turned to medical marijuana for help, weren't turning to medical marijuana because of its benefits or the balance of risks and benefits, or because they thought it was a wonder drug, but because it gave them control over their illness. It let them manage their health in a way that was productive and efficient and effective and comfortable for them.
Entón comecei a ler máis artigos e a falar con investigadores. Comecei a falar con doutores e o máis importante: comecei a ouvir aos pacientes. Acabei escribindo un libro sobre esas conversas. E ese libro centrábase sobre todo en tres sorpresas. Sorpresas para min, polo menos. Sobre unha xa falei. Que realmente hai algúns beneficios na marihuana medicinal. Pode que eses beneficios non sexan tan grandes nin sorprendentes como a maioría dos defensores da marihuana medicinal nos farían crer. Pero son reais. Sorpresa número dúas: a marihuana medicinal ten algúns riscos. Pode que eses riscos non sexan tan grandes nin aterradores como a maioría dos opositores da marihuana medicinal nos farían crer. Non obstante, son riscos reais. Pero foi a terceira sorpresa a máis... sorprendente. Moitos dos pacientes cos que falei recorreran á marihuana medicinal en busca de axuda. Non recorreran a ela polos seus beneficios ou o equilibrio entre riscos e beneficios ou porque pensaran que era unha droga marabillosa. Senón porque lles daba control sobre a súa enfermidade. Permítelles xestionar a súa saúde de forma produtiva, eficiente e cómoda para eles.
To show you what I mean, let me tell you about another patient. Robin was in her early 40s when I met her. She looked though like she was in her late 60s. She had suffered from rheumatoid arthritis for the last 20 years, her hands were gnarled by arthritis, her spine was crooked, she had to rely on a wheelchair to get around. She looked weak and frail, and I guess physically she probably was, but emotionally, cognitively, psychologically, she was among the toughest people I've ever met. And when I sat down next to her in a medical marijuana dispensary in Northern California to ask her about why she turned to medical marijuana, what it did for her and how it helped her, she started out by telling me things that I had heard from many patients before. It helped with her anxiety; it helped with her pain; when her pain was better, she slept better. And I'd heard all that before. But then she said something that I'd never heard before, and that is that it gave her control over her life and over her health. She could use it when she wanted, in the way that she wanted, at the dose and frequency that worked for her. And if it didn't work for her, then she could make changes. Everything was up to her. The most important thing she said was she didn't need anybody else's permission -- not a clinic appointment, not a doctor's prescription, not a pharmacist's order. It was all up to her. She was in control.
Para amosárllelo falareilles doutra paciente. Robin tiña sobre 40 anos cando a coñecín. Pero semellaba que tiña máis de 60. Sufrira de artrite reumatoide durante os últimos 20 anos. Tiña as mans tortas pola artrite. A columna vertebral encurvada. Dependía da cadeira de rodas para desprazarse. Víase débil e fráxil. E supoño que fisicamente o era. Mais emocionalmente, cognitivamente e psicoloxicamente era unha das persoas máis fortes que xamais coñecín. Cando sentei ao seu lado nun dispensario de marihuana medicinal en California para preguntarlle por que recorrera á marihuana medicinal, que fixera por ela e como lle axudara, comezou contándome cousas que xa lles escoitara a moitos pacientes. Axudoulle coa ansiedade. Axudoulle coa dor. Cando a dor mingua dorme mellor. Todo iso xa o escoitara. Pero logo dixo algo que nunca escoitara antes: que lle dera control sobre a súa vida e sobre a súa saúde. Podía consumila cando quixera, como quixera, a dose e frecuencia que lle viña mellor. E se non lle ía ben podía facer algúns cambios. Ela podía decidir. O máis importante era que non precisaba o permiso de ninguén nin unha cita médica, nin unha receita nin un pedido do farmacéutico. Era ela a que decidía. Era ela quen tiña o control.
And if that seems like a little thing for somebody with chronic illness, it's not -- not at all. When we face a chronic serious illness, whether it's rheumatoid arthritis or lupus or cancer or diabetes, or cirrhosis, we lose control. And note what I said: "when," not "if." All of us at some point in our lives will face a chronic serious illness that causes us to lose control. We'll see our function decline, some of us will see our cognition decline, we'll be no longer able to care for ourselves, to do the things that we want to do. Our bodies will betray us, and in that process, we'll lose control. And that's scary. Not just scary -- that's frightening, it's terrifying. When I talk to my patients, my palliative care patients, many of whom are facing illnesses that will end their lives, they have a lot of be frightened of -- pain, nausea, vomiting, constipation, fatigue, their impending mortality. But what scares them more than anything else is this possibility that at some point, tomorrow or a month from now, they're going to lose control of their health, of their lives, of their healthcare, and they're going to become dependent on others, and that's terrifying.
E se iso parece pouco para alguén con unha doenza crónica non o é en absoluto. Cando nos enfrontamos a unha doenza crónica sexa artrite reumatoide, lupus, cancro, diabetes ou cirrose perdémo-lo control. E decátense de que digo "cando", non "se". Porque nalgún momento das nosas vidas sufriremos unha doenza crónica seria que nos fará perder o control. Veremos como as nosas funcións diminúen. Algúns verán como a cognición diminúe. Non poderemos coidarnos a nós mesmos. Facer as cousas que queiramos. Os nosos corpos traizoarannos e nese proceso, perderémo-lo control. E iso mete medo. Non so mete medo, senón que é temible. É aterrador. Cando falo cos meus pacientes de coidados paliativos, moitos dos cales se enfrontan a doenzas que acabaran coas súas vidas, teñen moito que temer: dores, náuseas, vómitos, estrinximento, canseira, a súa inminente mortalidade. Pero o que os aterra máis que nada é a posibilidade de que nalgún momento, ben sexa mañá ou dentro dun mes, van perder o control sobre a súa saúde, a súa vida, a súa atención sanitaria, e volveranse dependentes doutra persoa, e iso é aterrador.
So it's no wonder really that patients like Robin, who I just told you about, who I met in that clinic, turn to medical marijuana to try to claw back some semblance of control. How do they do it though? How do these medical marijuana dispensaries -- like the one where I met Robin -- how do they give patients like Robin back the sort of control that they need? And how do they do it in a way that mainstream medical hospitals and clinics, at least for Robin, weren't able to? What's their secret? So I decided to find out.
Por iso non é sorprendente que pacientes como Robin, da que lles acabo de falar, e a quen coñecín nesa clínica, recorrera á marihuana medicinal para tentar recuperar un pouco de control. Pero como o fan? Como estes dispensarios de marihuana medicinal como aquel en que coñecín a Robin, lles devolven aos pacientes coma ela o tipo de control que precisan? E como o fan dunha forma na que hospitais e clínicas convencionais polo menos para Robin, non foron capaces? Cal é o seu segredo? Decidín achalo.
I went to a seedy clinic in Venice Beach in California and got a recommendation that would allow me to be a medical marijuana patient. I got a letter of recommendation that would let me buy medical marijuana. I got that recommendation illegally, because I'm not a resident of California -- I should note that. I should also note, for the record, that I never used that letter of recommendation to make a purchase, and to all of you DEA agents out there --
Fun a unha clínica con mala fama en Venice Beach, California e conseguín unha recomendación que me permitiría ser un paciente de marihuana medicinal. Conseguín unha carta de recomendación que me permitiría comprar marihuana medicinal. Conseguina de forma ilegal porque non son residente en California. Debería mencionalo. Tamén debo facer constar que nunca a usei para facer unha compra. E a todos os axentes da DEA que andan por aí...
(Laughter)
(Risos)
love the work that you're doing, keep it up.
adoro o traballo que fan. Sigan así.
(Laughter)
(Risos)
Even though it didn't let me make a purchase though, that letter was priceless because it let me be a patient. It let me experience what patients like Robin experience when they go to a medical marijuana dispensary. And what I experienced -- what they experience every day, hundreds of thousands of people like Robin -- was really amazing. I walked into the clinic, and from the moment that I entered many of these clinics and dispensaries, I felt like that dispensary, that clinic, was there for me. There were questions at the outset about who I am, what kind of work I do, what my goals are in looking for a medical marijuana prescription, or product, what my goals are, what my preferences are, what my hopes are, how do I think, how do I hope this might help me, what am I afraid of. These are the sorts of questions that patients like Robin get asked all the time. These are the sorts of questions that make me confident that the person I'm talking with really has my best interests at heart and wants to get to know me.
Aínda que non me permitira facer unha compra esa carta era valiosísima porque me permitía ser un paciente. Permitíame pórme na pel de pacientes coma Robin cando van a un dispensario de marihuana medicinal. E o que experimentei, o que eles experimentan cada día, centos de miles de persoas coma Robin foi asombroso. Entrei na clínica e dende o momento en que entrei en moitas desas clínicas e dispensarios sentín que ese dispensario, esa clínica estaba aí para min. Ao comezo había preguntas sobre quen era, cal era o meu traballo, con que fins buscaba receitas de marihuana medicinal, ou produtos, cales eran os meus obxectivos, as miñas preferencias, cales eran as miñas esperanzas, como pensaba ou esperaba que me ía axudar, que temía... Este é o tipo de preguntas que pacientes coma Robin reciben todo o tempo. Este é o tipo de preguntas que me fan confiar en que a persoa coa que estou falando pensa nos meus mellores intereses e quere coñecerme.
The second thing I learned in those clinics is the availability of education. Education from the folks behind the counter, but also education from folks in the waiting room. People I met were more than happy, as I was sitting next to them -- people like Robin -- to tell me about who they are, why they use medical marijuana, what helps them, how it helps them, and to give me advice and suggestions. Those waiting rooms really are a hive of interaction, advice and support.
A segunda cousa que aprendín nestas clínicas é a dispoñibilidade da educación. Educación das persoas ao outro lado do mostrador. Pero tamén das persoas na sala de espera. Coñecín persoas que estaban encantadas, cando eu sentaba á súa beira, xente coma Robin, de contarme quen eran e por que consumían marihuana medicinal, en que lles axudaba e como, e de darme consellos e suxestións. Esas salas de espera son coma unha colmea de interacción, consello e apoio.
And third, the folks behind the counter. I was amazed at how willing those people were to spend sometimes an hour or more talking me through the nuances of this strain versus that strain, smoking versus vaporizing, edibles versus tinctures -- all, remember, without me making any purchase whatsoever. Think about the last time you went to any hospital or clinic and the last time anybody spent an hour explaining those sorts of things to you. The fact that patients like Robin are going to these clinics, are going to these dispensaries and getting that sort of personalized attention and education and service, really should be a wake-up call to the healthcare system. People like Robin are turning away from mainstream medicine, turning to medical marijuana dispensaries because those dispensaries are giving them what they need.
E o terceiro, a xente de detrás do mostrador. Estaba asombrado por como esa xente estaba disposta a estar unha hora ou máis explicando os matices entre distintas cepas, entre fumala e vaporizala, entre comestibles e tinturas. E recorden, todo isto sen eu ter intención de facer compra ningunha. Pensen na última vez que foron a un hospital ou clínica e alguén estivo unha hora explicándolles ese tipo de cousas. O feito de que pacientes coma Robin vaian a estas clínicas e dispensarios e reciban este tipo de atención personalizada e educación e servizo debería ser unha chamada de atención para o sistema sanitario. Xente coma Robin está rexeitando a medicina convencional, e acudindo a dispensarios de marihuana medicinal porque estes ofrécenlles o que precisan.
If that's a wake-up call to the medical establishment, it's a wake-up call that many of my colleagues are either not hearing or not wanting to hear. When I talk to my colleagues, physicians in particular, about medical marijuana, they say, "Oh, we need more evidence. We need more research into benefits, we need more evidence about risks." And you know what? They're right. They're absolutely right. We do need much more evidence about the benefits of medical marijuana. We also need to ask the federal government to reschedule marijuana to Schedule II, or to deschedule it entirely to make that research possible. We also need more research into medical marijuana's risks. Medical marijuana's risks -- we know a lot about the risks of recreational use, we know next to nothing about the risks of medical marijuana. So we absolutely do need research, but to say that we need research and not that we need to make any changes now is to miss the point entirely. People like Robin aren't seeking out medical marijuana because they think it's a wonder drug, or because they think it's entirely risk-free. They seek it out because the context in which it's delivered and administered and used, gives them the sort of control they need over their lives. And that's a wake-up call we really need to pay attention to.
Se é unha chamada de atención para o sistema sanitario, é unha chamada que moitos dos meus compañeiros non escoitan ou non queren escoitar. Cando falo cos meus compañeiros, en particular con doutores, sobre marihuana medicinal din: "Precisamos máis probas. Precisamos máis estudos sobre os beneficios e máis probas sobre os riscos". E saben que? Teñen razón. Toda a razón. Si que precisamos moitas máis probas sobre os beneficios da marihuana medicinal. Tamén debemos pedirlle ao goberno federal que modifique as restricións da marihuana para facer posible ese estudo. Tamén precisamos máis estudos sobre os riscos da marihuana medicinal. Os riscos da marihuana medicinal... Sabemos moito sobre os do uso recreativo pero non sabemos nada sobre os da marihuana medicinal. Por iso precisamos investigar, pero dicir que precisamos investigar e non dicir que precisamos facer cambios agora non ten sentido ningún. Xente coma Robin non busca marihuana medicinal porque a consideren unha droga marabillosa ou porque pensen que non ten ningún risco. Búscana porque o contorno no que se vende, administra ou usa dálles o control que precisan sobre as súas vidas. E esa é unha chamada de atención á que lle temos que facer caso.
The good news though is that there are lessons we can learn today from those medical marijuana dispensaries. And those are lessons we really should learn. These are often small, mom-and-pop operations run by people with no medical training. And while it's embarrassing to think that many of these clinics and dispensaries are providing services and support and meeting patients' needs in ways that billion-dollar healthcare systems aren't -- we should be embarrassed by that -- but we can also learn from that. And there are probably three lessons at least that we can learn from those small dispensaries.
O bo é que hai leccións que hoxe podemos aprender dos dispensarios de marihuana medicinal. E son leccións que deberiamos aprender. Estes son normalmente pequenos negocios familiares xestionados por xente sen formación médica. E aínda que é vergoñento pensar que moitas destas clínicas e dispensarios están ofrecendo servizos e apoio e cubrindo as necesidades dos pacientes dun xeito que os millonarios sistemas sanitarios non fan --debería darnos vergoña--, tamén podemos aprender diso. E hai polo menos tres leccións que podemos aprender deses pequenos dispensarios.
One: we need to find ways to give patients more control in small but important ways. How to interact with healthcare providers, when to interact with healthcare providers, how to use medications in ways that work for them. In my own practice, I've gotten much more creative and flexible in supporting my patients in using drugs safely to manage their symptoms -- with the emphasis on safely. Many of the drugs I prescribe are drugs like opioids or benzodiazepines which can be dangerous if overused. But here's the point. They can be dangerous if they're overused, but they can also be ineffective if they're not used in a way that's consistent with what patients want and need. So that flexibility, if it's delivered safely, can be extraordinarily valuable for patients and their families. That's number one.
Unha: precisamos atopar formas de darlles máis control aos pacientes en cousas pequenas pero importantes. Como conversar con profesionais médicos, cando conversar con eles, como usar os medicamentos de forma que funcionen para eles. No meu caso volvinme moito máis creativo e flexible apoiando aos meus pacientes para que usen os medicamentos de forma segura para xestionar os síntomas pondo énfase na seguridade. Moitos dos medicamentos que prescribo son opioides ou benzodiacepinas que poden ser perigosos se se consomen en exceso. Mais esta é a cuestión. Poden ser perigosos se se usan en exceso, pero poden ser ineficaces se non se usan de xeito consistente co que os pacientes queren e precisan. Polo que esa flexibilidade, se se ofrece de forma segura pode ser moi valiosa para os pacientes e as súas familias. Esa é a número un.
Number two: education. Huge opportunities to learn from some of the tricks of those medical marijuana dispensaries to provide more education that doesn't require a lot of physician time necessarily, or any physician time, but opportunities to learn about what medications we're using and why, prognoses, trajectories of illness, and most importantly, opportunities for patients to learn from each other. How can we replicate what goes on in those clinic and medical dispensary waiting rooms? How patients learn from each other, how people share with each other.
Número dous: educación. Grandes oportunidades para aprender algúns trucos deses dispensarios de marihuana para ofrecer máis formación que pode non requirirlle a un médico moito máis tempo, ou ningún, senón oportunidades para aprender sobre que medicamentos usan e por que, prognoses, traxectoria da doenza, e o máis importante, oportunidades para os pacientes de aprender uns doutros. Como podemos imitar o que pasa nas salas de espera desas clínicas ou dispensarios médicos? Como os pacientes aprenden uns doutros, como a xente comparte.
And last but not least, putting patients first the way those medical marijuana dispensaries do, making patients feel legitimately like what they want, what they need, is why, as healthcare providers, we're here. Asking patients about their hopes, their fears, their goals and preferences. As a palliative care provider, I ask all my patients what they're hoping for and what they're afraid of. But here's the thing. Patients shouldn't have to wait until they're chronically seriously ill, often near the end of life, they shouldn't have to wait until they're seeing a physician like me before somebody asks them, "What are you hoping for?" "What are you afraid of?" That should be baked into the way that healthcare is delivered.
E por último, pór aos pacientes primeiro, igual que fan os dispensarios. Facer que os pacientes sintan de verdade que o que eles queren, o que precisan é a razón pola que estamos aquí como profesionais médicos. Preguntarlles sobre as súas esperanzas, temores, metas e preferencias. Como provedor de coidados paliativos pregúntolles a todos os meus pacientes que esperan e que temen. Pero esta é a cuestión: Eles non deberían ter que esperar ata sufriren unha doenza crónica, a miúdo ao final das súas vidas. Non deberían ter que esperar a ver un doutor coma min antes de que alguén lles pregunte: "Cales son as súas esperanzas? E os seus temores?" Debería ir implícito na forma na que se ofrece o servizo sanitario.
We can do this -- we really can. Medical marijuana dispensaries and clinics all across the country are figuring this out. They're figuring this out in ways that larger, more mainstream health systems are years behind. But we can learn from them, and we have to learn from them. All we have to do is swallow our pride -- put aside the thought for a minute that because we have lots of letters after our name, because we're experts, because we're chief medical officers of a large healthcare system, we know all there is to know about how to meet patients' needs.
Podemos facelo. De verdade que si. Os dispensarios e clínicas de marihuana de todo o país están logrando resolvelo. Están logrando resolvelo mentres os sistemas sanitarios máis grandes e convencionais se están quedando anos atrás. Pero podemos aprender deles e temos que facelo. Só temos que tragar o orgullo e deixar de pensar por un minuto que como temos moitas letras detrás do noso nome, somos expertos, ou somos directores médicos dun gran sistema sanitario xa o sabemos todo sobre como cubrir as necesidades dos pacientes.
We need to swallow our pride. We need to go visit a few medical marijuana dispensaries. We need to figure out what they're doing. We need to figure out why so many patients like Robin are leaving our mainstream medical clinics and going to these medical marijuana dispensaries instead. We need to figure out what their tricks are, what their tools are, and we need to learn from them. If we do, and I think we can, and I absolutely think we have to, we can guarantee all of our patients will have a much better experience.
Debemos tragar o orgullo. Temos que visitar algúns dispensarios de marihuana medicinal. Temos que comprender o que fan. Temos que descubrir por que moitos pacientes coma Robin abandonan as clínicas convencionais e acoden aos dispensarios de marihuana medicinal. Temos que descubrir cales son os seus trucos e as súas ferramentas e precisamos aprender deles. Se o facemos, e penso que podemos, e por suposto penso que debemos, podemos garantir que todos os pacientes terán unha mellor experiencia.
Thank you.
Grazas.
(Applause)
(Aplausos)