What a first consultation actually involves.

The first two appointments are with a specialist consultant: an initial consultation, then a review two to four weeks later to see how the patient is getting on. Between them they set the tone for everything that follows. The medicines are mostly unlicensed, patients have often waited years and tried a great deal, and the sector is watched closely by regulators who want to see that decisions are careful. Get those first appointments right and everything downstream is easier.

What happens before the patient sees the doctor?

A screen, usually led by a nurse. Often the consultation starts before the consultant is involved. A nurse, or a well-trained coordinator with a nurse behind them, has already gathered the diagnosis, the treatment history, the GP summary, current medicines, mental health history and any cannabis use, and has run the standard screening tools. In my experience that means a cannabis use disorder questionnaire and a mental health risk screen for every patient as standard, not just when clinically indicated.

The point of the screen isn't to keep people out. It's to make sure the doctor's time is spent deciding, not fact-finding, and to catch the small number of patients for whom this isn't safe: an untreated psychotic illness, an unstable heart, a pregnancy, a dependency that needs a different conversation first.

What should the history cover?

Everything a normal specialist history covers, plus three extra threads. A specialist consultation for a cannabis-based medicine is a normal specialist consultation with those three threads running through it. The first is the treatment story: what has been tried, for how long, at what dose, and what happened. Most clinics require that conventional treatments have been tried and haven't given enough benefit, and it needs to be documented. The second is the patient's own relationship with cannabis, asked without judgement: whether they use it now, how much, in what form, what it does for them and what it costs them. Plenty of patients arrive already self-medicating, and being honest about previous self-medication means the doctor will have a better understanding of what to prescribe. The third is what the patient is actually hoping for. Pain scores are useful; "I want to get back to walking the dog" is more useful.

The honest conversation

This is the part I'd teach first. A cannabis-based medicine is not a miracle and not a menace. It helps some people and not others, and nobody can promise which. Side effects are usually mild and dose-related but they're real: drowsiness, dizziness, dry mouth, a foggy head, and for some people a worse mood. The consultation has to cover the things patients get caught out by: driving law and the medical defence, workplace drug policies, travel, the fact that it's a private prescription with a monthly cost, and that products change and go out of stock. It works best when all of this is said plainly, and the patient is then asked what they think.

What happens if the doctor thinks it's appropriate?

The doctor proposes a starting product and a plan. Start low, go slow: a low starting dose, with clear instructions on how to increase it and when to stop and call. The plan should include who the patient will speak to next and when. A first prescription without a named follow-up is one of the commonest gaps I see.

Then, in most clinics, the case goes to the multidisciplinary team before the prescription is written. Most of these medicines are unlicensed, a second set of eyes on the decision is good practice, and inspectors will ask how you check your own decisions.

From the patient's side

They were listened to. Nobody was surprised by anything in their records because it was gathered in advance. They understood what they were being offered and what it would cost. They left with a plan, a name and a date. And they knew they could ring someone if the first week went badly.

If you're a patient reading this

Bring a copy of your GP summary or ask the clinic how to get one, a list of your current medicines, a list of what you've tried, and your questions written down. Be honest about any cannabis you already use. And if you leave the consultation without knowing who you'll speak to next, ask.