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Three months in, D.C.’s medical marijuana regime is not where it’s supposed to be. As of Oct. 21, medical marijuana licenses had been obtained by only 59 District residents—patients who are expected to keep D.C.’s three new medical dispensaries and three fledgling cultivation centers afloat. “We were anticipating in the first couple of months to be in the hundreds of patients,” says Feseha Woldu, the senior deputy director of the Department of Health’s Health and Regulatory Licensing Administration, which oversees medical marijuana in D.C. “Currently the number of patients that we have is very low. We are trying to see if there are some unintended obstacles.”

One of the biggest obstacles to D.C.’s medical marijuana program may be the very people who are supposed to serve as its gatekeepers: doctors. There are 2,900 physicians actively practicing in the District, but only 37 of them have recommended that their patients receive medical marijuana, according to statistics from the Department of Health. Just 67 doctors have requested the required forms, which are not available online, to recommend a patient for the medication.

Doctors’ reluctance to participate in the program likely has more to do with the attitudes of federal regulators than of local ones. To the feds, medical marijuana is a Schedule I illegal drug, with various felonies attached to its possession, use, and sale. Beyond that, marijuana is not approved as medication by the federal Food and Drug Administration, which means doctors can “recommend” it but not prescribe it. Plus, unlike every other municipality that’s legalized medical marijuana, D.C. laws must be approved by Congress—one reason D.C.’s program was designed to be among the most restrictive in the country.

In order to pass congressional muster, the D.C. law contains several unique checks on abuse that could deter doctors from participating. The Department of Health maintains confidential records on doctors who participate in the system and audits the recommendations of doctors who refer more than 250 patients to dispensaries. Like anyone, doctors don’t want to get in trouble or hurt their careers; several people involved with D.C. medical marijuana program suggest doctors are concerned they could lose a federal grant or harm their reputations. (From a legal standpoint, doctors probably don’t need to worry, since their ability to recommend marijuana—as opposed to prescribing an FDA-approved medication—is a First Amendment right, according to the Supreme Court.)

“It makes them feel like they are doing something wrong,” says Steph Sherer, the executive director of Americans for Safe Access, a national advocacy organization that’s been at the front of the fight to legalize medical marijuana in the District.

The program in D.C., according to Woldu, is designed so that no doctor just becomes a pot doctor, one who writes recommendations for any and every patient who comes through his door. That’s why doctors could be subject to an audit if they recommend a suspicious numbers of patients for the program, and why there are provisions in place to ensure that doctors don’t have any relationships with the distribution or cultivation centers.

And it’s also why there’s a somewhat vague provision in the law that says doctors and patients must have a “bona fide” relationship to qualify for medical marijuana, which is meant to ensure that patients don’t flock to certain doctors for pot recommendations. “We are the nation’s capital, we want to make sure that people don’t exploit us,” Woldu says. But if doctors aren’t willing to recommend medically qualifying patients, it could threaten to paralyze the whole program. Without doctors, even the most eligible patients—the patients who the program was created to help—can’t access medical marijuana.

None of the doctors at Whitman-Walker Health, D.C’s largest community-based provider of HIV services, for instance, has recommended marijuana to patients. Currently HIV, which afflicts about 20,000 District residents, is one of only four conditions that qualify for treatment in the city. (The others are glaucoma, cancer, and severe muscle spasms.)

Whitman-Walker played a key role in pushing for the legalization of medical marijuana back in 1998, when D.C. voters first approved the initiative. But 15 years later, Chip Lewis, deputy director of communications at Whitman-Walker, says the center is still reviewing its policies, and with so many more treatments now available, “the vast majority [of HIV patients] will benefit more from other medications that are currently available.”

“The need for the medical marijuana option is not as great now as it was 15 years ago,” Lewis writes. “We would [recommend] medical marijuana based on specific beneficial results found in clinical trials.” Medical marijuana, he says, helps AIDS patients with wasting syndrome by increasing appetites and decreasing nausea, so Whitman-Walker would potentially recommend the drug in those instances.

For now, Whitman-Walker patients who want medical marijuana are likely out of luck unless they have a “bona fide” relationship with another doctor who’s willing to write a recommendation. (It’s unclear how strict this provision is; DOH says it hasn’t rejected any complete applications.)

The Institute of Multidimensional Medicine, a one-M.D. firm that practices “integrative medicine,” says its has no problem recommending medical marijuana to patients, and has had patients inquire about the treatment. “It’s been a tremendous step forward for the Department of Health to even make the program available,” said Ahmad Mines, the chief operating office of the practice. “A lot of the doctors that I spoke to just had a lack of knowledge of the program and what they had to do to get involved.”

Scott Morgan, the communications director at Capital City Care, says prospective patients have told him they’re struggling to obtain recommendations. “I hear from patients whose doctors were reluctant or unwilling to prescribe medical marijuana,” he says. “Even the most supportive doctors have wanted to limit their involvement with the program.”

At a D.C. Council health committee roundtable Monday, more than a dozen activists, distribution and cultivation center owners, residents whose ailments do not qualify them for medical marijuana, and an actual medical marijuana patient spoke. But there were no doctors, and there didn’t even appear to be a curious doctor in the audience. After some questioning from committee chair Yvette Alexander, Woldu said the Department of Health has yet to establish a training program for physicians, as is required by the medical marijuana law. The agency has participated in a handful of workshops and sent out a few blast emails to doctors. Woldu said the department needs to “work toward” establishing the training program, but didn’t give a timeline.

Which means that D.C.’s medical marijuana industry will have to be patient. “It’s a learning process,” Morgan says of expanding the number of doctors willing to recommend medical marijuana. “It’s going to take a little time for everyone involved to learn the ropes of the program.”

Illustration by Carey Jordan