There is a clear need for education for health care professionals on the use of CTP. We report the results of a national survey of Canadian physicians’ perceived knowledge gaps and perceived needs concerning CTP. We found that the largest gaps between current and desired knowledge concerned dosing, the development of treatment plans, and comparisons between cannabis and existing prescription cannabinoids. There was an expressed need for better knowledge of the risks and benefits of CTP. Respondents thought that both specialists and family physicians were capable of authorising CTP; however, overall it was felt that pharmacists or naturopathic doctors should not have this authority. Concerns regarding the recreational use of cannabis masquerading as medical use was common among respondents. Respondents reported that their comfort level in including CTP in their practice would increase with additional education, and reported their educational needs would be best met with focused literature reviews, online, and small group continuing medical education activities.

Ranking perceived knowledge levels on several related topics allows a comparison of ‘what is’ and ‘what should be’ regarding perceived educational needs, and enables the quantification of perceived knowledge gaps. Describing and ranking the perceived knowledge gaps for several CTP subtopics enables a comparison of gaps between topics, and enables the identification of strategies to reduce the gaps [13,14]. Based on our data, Canadian physicians perceive their current knowledge level on CTP to be low, while desiring a high knowledge level, consistent with other reports that physicians desire education on CTP [9,10]. More specifically, we identified the lowest perceived knowledge levels, and largest knowledge gaps, to be regarding hands-on clinically relevant CTP subtopics, including; dosing and treatment plans, comparing between cannabinoids, and Canadian CTP regulations. In contrast, we identified higher perceived current knowledge levels, and smaller knowledge gaps, to be regarding more theory-based CTP subtopics, including; the mechanism of action of cannabis, potential risks, and potential benefits. This suggests that practical hands-on style information should be prioritized.

Two interesting discrepancies emerge from responses about experiences with the clinical use of CTP. Firstly, patients initiate most of the discussions about CTP, and physicians feel they have insufficient information and lack guidance on the topic. Few guidelines exist for CTP [15,16], while Canadian physicians have reported that clinical practice guidelines would be useful or very useful [3]. Secondly, only one third of respondents had signed a patient’s application to possess CTP through the federally regulated program, yet two thirds reported having patients using CTP. It is possible that respondents had patients who had received CTP from another physician. The discrepancy between the prevalence of self reported use of CTP (48%) and the proportion of patients with legal access through Canada’s federal program (32%) has been reported previously in certain populations [17,18].

The highest reported obstacle to CTP was found to be a concern that patients are actually seeking cannabis for recreational purposes, supporting similar results from previous reports [4,9,10]. Patients report experiencing a lack of trust by health care providers, and suggest that it is due to the stigma associated with cannabis as an illegal recreational drug [17]. Such views may be a result of the blurred lines between therapeutic and recreational use reported in the media [19]. Another potential cause for this distrust of patient motivation for CTP use stems from the fact that some of the patient populations in which cannabis may be a potential therapeutic option, such as chronic pain, HIV/AIDS, and mental health issues, are already stigmatized [17]. Canadian patients using CTP have reported the stigma associated with cannabis negatively impacts their relationship with health care providers, creating a barrier to receiving the health care they need, and increased levels of physician education may be a means to decrease the stigma [17]. It may be the case that negative attitudes and values about cannabis in general influence potential therapeutic uses, as has been reported in other controversial therapeutic areas like methadone maintenance therapy [20]. Finally, the demographic overlap (young white males) between medical cannabis users and recreational users also adds to the potential for physician mistrust of the real medical ‘necessity’ for CTP [21,22].

Our survey has several potential limitations. The low number of responses creates a potential selection bias, which affects our ability to generalize findings, and which may not be representative of Canadian physicians overall. A true response rate is impossible to calculate, as the denominator is unknown; we do not know how many different physicians received or saw the survey. The low number of overall responses may be due, in part, to the lack of monetary compensation for participation [23], a large number of similar requests, lack of time, or hesitancy to enter answers into a survey on this topic. Another contributing factor to the low number of responses may be the source of the invitations; other non-medical-college distributed surveys have reported similarly low response rates from Canadian physicians [24], whereas surveys sent by provincial or national medical colleges or associations have reported response rates around 20% or higher [9,10,20,25]. An additional limitation is that a number of recipients of email invitations were based on lists of previous participants in CTP-related continuing medical education programs, or those who had expressed interest in topic of CTP to a variety of sources. This may have selected participants with specific interest in CTP or who had already had some education on this topic. However the number of responses received is similar to other recent physician surveys on CTP including the 607 responses received by the Canadian Medical Association (CMA) [10], and 520 responses to the Colorado physician survey [9]. Finally, this study is limited by the focus on perceived needs and did not include an assessment of unperceived needs; we did not determine whether high levels of perceived knowledge were in fact truly high levels of knowledge based on external evaluation. Triangulating perceived needs with unperceived needs should be the focus of further research.

Our results support the need for further medical education and training on CTP [9]. In alignment with expressed needs for more information on CTP, physicians reported that focused peer-reviewed summaries on specific CTP sub-topics would be helpful in enhancing their knowledge on this area. The preference for online education is consistent with trends towards e-learning in the health professions [26]. Additionally, studies have reported that educational interventions that enhance competencies and skills have a direct influence on improvement of patient outcomes [27].