Abstract
The legalization of recreational cannabis across Canada has revealed the importance of medical education on cannabis-related topics. A recent study has indicated that Canadian physicians report a significant gap in current versus desired knowledge regarding the therapeutic use of cannabis. However, the state of education on cannabis has never been studied in Canadian medical schools. This article presents the preliminary findings of a survey conducted to understand the perceptions of Quebec’s medical students regarding cannabis-related teachings in their current curriculum. Overall, students reported very low to low levels of exposure to, knowledge of, and comfort levels with cannabis-related subjects. The majority of students reported that they felt that their medical curricula did not prepare them to face cannabis-related issues in their future practices. Strategies need to be developed for improving medical school curriculum regarding cannabis-related issues. These findings provide potential key strategies to improve curricula.
Keywords: Cannabis, Cannabinoids, Cannabis legalization, Knowledge transfer, Medical education
With the recent legalization of recreational cannabis in Canada, physicians face many new challenges and concerns when discussing cannabinoids with their patients. A recent study has shown a concern prevalent among Canadian family physicians that patients will begin substituting medical cannabis for recreational cannabis (1). Furthermore, physicians expect an increase in emergency room visits due to recreational cannabis use after the legalization of cannabis, as it has been observed in other countries such as the USA (2). Whether or not these concerns will actually translate in the real-world setting is still unknown, but physician education remains critical to ensure appropriate patient management. This is particularly true for paediatric care providers considering that adolescents are among the most prevalent cannabis users in Canada (3), and due to specific age-related risk associated with early cannabis use (4).
Some evidence suggests that Canadian physicians feel there is a significant gap in current versus desired knowledge regarding the dosage, development of treatment plans, and comparisons between cannabis and existing prescription cannabinoids (5). Physicians have reported that they would be more comfortable discussing cannabis for therapeutic purposes (CTP) with patients if they had more knowledge about it (5). To our knowledge, only one study has focused on the education levels on cannabis-related topics during medical school and it was conducted in the USA (6). Of all the medical schools surveyed, 66.7% reported that their graduates were ‘not at all prepared’ to prescribe cannabis. Almost 90% of residents and fellows felt ‘not at all prepared’ to prescribe medical cannabis, and more than one third of them did ‘not feel at all prepared’ to answer questions related to this subject.
Due to the paucity of literature, it remains unclear whether physicians across North America are adequately equipped to address the questions that they face regarding CTP and recreational cannabis use. Thus, we conducted a survey which aims to provide preliminary evidence on the perceptions of Quebec’s medical students regarding cannabis-related teachings in their current curriculum, their level of knowledge, and comfort with cannabis-related topics. Additionally, this study sought to understand how students prefer to see cannabis-related teachings integrated in the medical curriculum.
METHODS
A cross-sectional survey was sent to medical students registered in an undergraduate medical school program in Quebec between the months of November 2018 and April 2019 via e-mail and Facebook. Two reminders were sent via e-mail. The survey took less than 30 minutes to complete; no incentive was offered. The questionnaire consisted of 39 items including demographics, cannabis-related training, level of knowledge, level of comfort, rating of medical curriculum on cannabis-related subjects, and preferred strategies to improve their curriculum. Participants were asked if they had received training/a course during their medical school curriculum on 14 different subjects. Participants were asked to rate their level of knowledge on 10 cannabis-related subjects and to specify their level of comfort to deal with cannabis-related issues in their future practice by using a 5-point Likert scale (very low to very high). They were also asked to rate their medical school curriculum in its capacity to prepare them to face cannabis-related issues in their future practice, and to assess which educational methods they believed would improve their curriculum regarding cannabis-related subjects. Finally, students were presented with six commonly used educational methods and asked to indicate which ones they preferred for education about cannabis.
RESULTS
A total of 235 students responded (response rate = 5.6%) to the survey and completed at least the demographics section. The average age of participants was 23.06 years (SD 2.93). Among the total number of medical students enrolled in Quebec, Université de Montréal (39.6%) was overrepresented and McGill University was underrepresented (12.8%), while the University of Sherbrooke and Université de Laval represented 25.1% and 22.6%, respectively, which are similar to their representation of the Quebec medical student population.
Our preliminary findings indicate that medical students have low levels of exposure to cannabis topics at each year of medical school in Quebec. As shown in Table 1, across all years of medical school, the majority of students did not have a course on most cannabis-related issues questioned, except courses on cannabis use and its effects on cognition and mental health, and on cannabis use disorder (CUD). Most students rated their level of knowledge regarding cannabis-related issues surveyed as very low to moderate (Table 2). The topic with the lowest rated level of knowledge among participants was ‘good practices on how to prescribe cannabis, and/or other cannabinoids’ with 66.5% of participants rating their level of knowledge as very low. The topics with the highest rated level of knowledge were on cannabis use and its effects on mental health (20.6% high level of knowledge, 2.6% very high level of knowledge), and CUD (17.0% high level of knowledge and 5.7% very high level of knowledge).
Table 1.
Training or a course received during medical school on cannabis-related topics
| First year respondents | Second year respondents | Third year respondents | Graduating year respondents | Total | |
|---|---|---|---|---|---|
| n=59 | n=47 | n=48 | n=49 | n=203 | |
| n (%) | n (%) | n (%) | n (%) | n (%) | |
| The endocannabinoid system and the role it plays in brain physiology? | 45 (76.3%) | 28 (59.6%) | 31 (64.6%) | 33 (67.3%) | 137 (67.5%) |
| Cannabis (the plant) and its contents? | 47 (79.7%) | 33 (70.2%) | 31 (64.6%) | 38 (77.6%) | 149 (73.4%) |
| Cannabis use and its effects on cognition? | 45 (76.3%) | 29 (61.7%) | 20 (41.7%) | 27 (55.1%) | 121 (59.6%) |
| Cannabis use and its effects on physical health? | 46 (78.0%) | 31 (66.0%) | 31 (64.6%) | 36 (73.5%) | 144 (70.9%) |
| Cannabis use and its effects on mental health? | 47 (79.7%) | 24 (51.1%) | 22 (45.8%) | 24 (49.0%) | 117 (57.6%) |
| Cannabis use disorder (abuse, dependence, addiction)? | 44 (74.6%) | 14 (29.8%) | 13 (27.1%) | 16 (32.7%) | 87 (42.9%) |
| The management of cannabis intoxication and/or withdrawal? | 46 (78.0%) | 25 (53.2%) | 32 (66.7%) | 34 (69.4%) | 137 (67.5%) |
| The therapeutic effects of cannabis and cannabinoids? | 50 (84.7%) | 41 (87.2%) | 38 (79.2%) | 34 (69.4%) | 163 (80.3%) |
| The medical indication and prescription modalities of cannabis and/or other cannabinoids? | 57 (96.6%) | 46 (97.9%) | 45 (93.8%) | 40 (81.6%) | 188 (92.6%) |
| The resources available to physicians regarding the therapeutic effects of cannabis and its medical uses? | 55 (93.2%) | 45 (95.7%) | 45 (93.8%) | 45 (91.8%) | 190 (93.6%) |
| The resources available to physicians regarding the effects of cannabis consumption, cannabis use disorder, and other health problems related to cannabis consumptions? | 50 (84.7%) | 42 (89.4%) | 42 (87.5%) | 38 (77.6%) | 172 (84.7%) |
| The resources available to patients who use cannabis for therapeutic purposes? | 55 (93.2%) | 46 (97.9%) | 47 (97.9%) | 48 (98.0%) | 196 (96.6%) |
| The resources available to patients who present with cannabis use disorder or other health problems related to cannabis use? | 52 (88.1%) | 38 (80.9%) | 42 (87.5%) | 41 (83.7%) | 173 (85.2%) |
| The regulations surrounding the legalization of cannabis in Canada and/or your province? | 57 (96.6%) | 44 (93.6%) | 41 (85.4%) | 41 (83.7%) | 183 (90.1%) |
n=Number of ‘No’ responses. %=Percent total of ‘No’ responses.
Table 2.
Perceived level of knowledge on cannabis-related topics
| Total N=194 (all years confounded) | Very low | Low | Moderate | High | Very high |
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | |
| The endocannabinoid system and the role it plays in brain physiology? | 46 (23.7%) | 85 (43.8%) | 53 (27.3%) | 9 (4.6%) | 1 (0.5%) |
| Cannabis (the plant) and its contents? | 37 (19.1%) | 72 (37.1%) | 60 (30.9%) | 18 (9.3%) | 7 (3.6%) |
| Cannabis use and its effects on cognition? | 22 (11.3%) | 57 (29.4%) | 85 (43.8%) | 23 (11.9%) | 7 (3.6%) |
| Cannabis use and its effects on physical health? | 27 (13.9%) | 76 (39.2%) | 69 (35.6%) | 18 (9.3%) | 4 (2.1%) |
| Cannabis use and its effects on mental health? | 22 (11.3%) | 43 (22.2%) | 84 (43.3%) | 40 (20.6%) | 5 (2.6%) |
| Cannabis use disorder (abuse, dependence, addiction)? | 21 (10.8%) | 46 (23.7%) | 83 (42.8%) | 33 (17.0%) | 11 (5.7%) |
| The management of cannabis intoxication and/or withdrawal? | 54 (27.8%) | 66 (34.0%) | 51 (26.3%) | 21 (10.8%) | 2 (1.0%) |
| The therapeutic effects of cannabis and other cannabinoids? | 53 (27.3%) | 82 (42.3%) | 42 (21.6%) | 14 (7.2%) | 3 (1.5%) |
| Good practices on how to prescribe cannabis, and/or other cannabinoids? | 129 (66.5%) | 45 (23.2%) | 16 (8.2%) | 2 (1.0%) | 2 (1.0%) |
| The regulations surrounding the legalization of cannabis in Canada and in your province? | 32 (16.5%) | 67 (34.5%) | 66 (34.0%) | 22 (11.3%) | 7 (3.6%) |
n = number of respondents.
Along with the reported low levels of exposure to cannabis-related subjects, and lack of perceived knowledge on these subjects, student comfort levels with cannabis-related issues in their future practice was generally low as well. By graduating year, over 60% of students report very low to low levels of comfort with all of the topics asked in the survey (Figure 1).
Figure 1.
Perceived comfort level among graduating students.
The majority of participants rated their medical school’s cannabis-related curriculum and its capacity to prepare them to face cannabis-related issues in their future practices as very low or low, i.e., 31.8% and 44.1%, respectively. Formal didactic lectures were deemed the most necessary method of teaching by the participants (88.2%), with 45.5% reporting this as their preferred choice. The methods reported most often as necessary were ‘increased clinical exposure in therapeutic settings where cannabis can be used for therapeutic purposes’ and ‘case-based learning’. For complete results, see Table 3.
Table 3.
Necessary and most preferred educational methods
| N=178 | Methods deemed necessary * | % | Most prefered method | % (most important) |
|---|---|---|---|---|
| n | n (most important) | |||
| Formal Lectures | 150 | 88.24% | 81 | 45.5% |
| Case-Based learning | 109 | 64.12% | 37 | 20.8% |
| Increased clinical exposure in clinical settings where cannabis use disorder and cannabis- related problem are treated | 103 | 60.59% | 18 | 10.1% |
| Increased clinical exposure in therapeutic settings where cannabis can used for therapeutic purposes | 128 | 75.3% | 27 | 15.2% |
| Direct contact with community members who have had experiences with cannabis use and its consequences on health | 78 | 45.88% | 7 | 3.9% |
| Direct contact with community members who have had experiences with cannabis for therapeutic purposes | 91 | 53.53% | 8 | 4.5% |
*More than one response possible.
DISCUSSION
This study reports on Quebec’s medical students’ perceived levels of knowledge, comfort regarding various cannabis-related topics, and desired strategies to integrate cannabis training in medical education. The majority of medical students surveyed had been minimally exposed to cannabis-related issues throughout their medical curricula. Most rated their knowledge and comfort with cannabis-related issues as very low to low, while desiring that their curricula be improved on topics pertaining to cannabis. Moreover, our preliminary findings highlight a specific lack of exposure and level of comfort with topics associated with the therapeutic uses of cannabinoids. This too is particularly relevant for paediatric care providers considering the growing evidence for the indication of cannabinoids for specific conditions, such as paediatric epilepsy. These results are unsurprising considering the lack of cannabis-related specific objectives among the Licentiate of the Medical Council of Canada examination (7) and the Committee on Accreditation of Canadian Medical Schools’ learning objectives for Canadian medical schools (8). This concern has already been shared by the Canadian Federation of Medical Students of Canada, who have recently recommended to create a ‘longitudinal evidence-based cannabis course that will be integrated into undergraduate medical education’ (9).
Students’ preference for formal didactic lectures may indicate that students feel a need to learn the fundamentals of cannabis and its role in medicine in the classroom before being exposed to the topics in the clinical setting. The lack of medical education on topics related to addiction medicine is not a new problem (10). Though drug- and substance-related addiction represents a significant societal health care burden, many physicians fail to identify and treat substance-related disorders, which have been suggested to at least partially result from a suboptimal training in addiction medicine-related topics (11). Lessons can be learned from the opioid and pain management curriculum (12), which was created in response to the opioid crisis. There was also a lack of formal dedicated hours to pain management in medical curricula across Canada (13). In response, the Association of Faculties of Medicine of Canada (AFMC) adopted the accreditation standards to include objectives on pain management, responsible opioids prescription and risk assessment of substance use disorder (5). A similar model could be implemented for cannabis-related medical training.
Cannabis is now legal for recreational use, while it has been used for therapeutic purposes for almost 20 years in Canada. Considering its legal status, physicians and medical students may now, more than ever, be required to comfortably discuss and manage cannabis-related issues in their practices. The perceived lack of exposure to various cannabis-related topics does actually translate to low levels of comfort with these topics among medical students in Quebec. Students are interested in being exposed to these topics, and therefore curricula should be updated accordingly for future physicians. Strategies need to be developed to improve medical school curriculum regarding cannabis-related topics and to integrate additional training in Quebec’s medical schools. Although the results presented in this study are fairly consistent, this preliminary study has numerous limitations, including a relatively low response rate. Still, its timing is relevant, as some faculties, such as Université de Montréal, have started putting together a specific training initiative on cannabis-related issues, and the results from this survey may provide useful information to ensure that such endeavours match students’ needs. This survey also highlights the need for additional, in-depth assessment of students’ needs in regard to cannabis and other related topics.
ACKNOWLEDGEMENTS
Funding: There are no funders to report for this submission.
Potential Conflicts of Interest: Dr. Jutras-Aswad reports non-financial support from Insys Therapeutics outside the submitted work. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest: Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References
- 1. Shah R. Recreational Cannabis’ Impact on Physicians’ Practice | Health & Pharmaceutical Marketing Research | MD Analytics Inc. 2018. https://www.mdanalytics.com/2018/08/20/recreational-cannabis-infographic/ (Accessed June 10, 2019). [Google Scholar]
- 2. Gummin DD, Mowry JB, Spyker DA, Brooks DE, Osterthaler KM, Banner W. 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila) 2018;56(12):1213–415. [DOI] [PubMed] [Google Scholar]
- 3. Government of Canada SC. Prevalence of cannabis use in the past three months, self-reported 2019. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310038301 (Accessed October 23, 2019).
- 4. Hosseini S, Oremus M. The effect of age of initiation of cannabis use on psychosis, depression, and anxiety among youth under 25 years. Can J Psychiatry 2019;64(5):304–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Ziemianski D, Capler R, Tekanoff R, Lacasse A, Luconi F, Ware MA. Cannabis in medicine: A national educational needs assessment among Canadian physicians. BMC Med Educ 2015;15:52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Evanoff AB, Quan T, Dufault C, Awad M, Bierut LJ. Physicians-in-training are not prepared to prescribe medical marijuana. Drug Alcohol Depend 2017;180:151–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Examination Objectives Overview | Medical Council of Canada https://www.mcc.ca/objectives/ (Accessed December 10, 2019).
- 8. CACMS | CACMS https://cacms-cafmc.ca/ (Accessed December 10, 2019).
- 9. Hartman M, Lasry D, Khan AU, et al. Canadian Federation of Medical Students Position Statement on Recreational Cannabis Legalization. Halifax, Nova Scotia: Canadian Federation of Medical Students; 2018. [Google Scholar]
- 10. Ram A, Chisolm MS. The time is now: Improving substance abuse training in medical schools. Acad Psychiatry 2016;40(3):454–60. [DOI] [PubMed] [Google Scholar]
- 11. Wood E, Samet JH, Volkow ND. Physician education in addiction medicine. Jama 2013;310(16):1673–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Opioids | AFMC. https://afmc.ca/priorities/ (Accessed December 10, 2019).
- 13. Watt-Watson J, McGillion M, Hunter J et al. A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag 2009;14(6):439–44. [DOI] [PMC free article] [PubMed] [Google Scholar]