Internist's Relapse Into Drug Use Undetected

Cheney's press secretary, Kevin Kellems, would not comment on when the vice president learned about Malakoff's problems but said Cheney had no concerns about the care he received.

Several doctors and medical administrators said Malakoff's story is emblematic of a larger problem of the difficulties doctors face in applying the tough love their impaired colleagues need.

"My experience over the last 30 years is that in any setting, physicians are very cautious and conservative about correcting and monitoring their fellow colleagues," said Thomas W. Chapman, former chief executive at the medical center and now president of the HSC Foundation, which helps special-needs children. "It's a very important thing obviously, because you're dabbling around with someone's career. It's a very thin line. It's complicated."

Several doctors suggested that GWU's medical center is in a particularly difficult position because of its affiliation with the White House -- a relationship that adds significantly to its reputation and which the medical center has not been shy about.

"It's the president's hospital," said Robert Stillman, medical director at the Shady Grove Fertility Reproductive Science Center in Rockville and a former director of GWU's fertility program. "You parlay that in the community, and it's an appropriate thing to do. You say, 'Who trusts us? Well, the president of the United States and the Secret Service.' "

But the flip side, doctors said, is that GWU's medical center has more to lose from an open admission of wrongdoing by a staff physician.

"Remember all those men in their white coats at the Cheney news conference with their chests all pumped up? They knew that if they blew the whistle on Gary, it would hurt the center," said a physician with close ties to the case who spoke on the condition of anonymity out of fear of repercussions. As a result, the physician said, overseers either intentionally or unconsciously "turned a blind eye to someone in need of help."

Malakoff is not the first doctor caught in this dilemma at GWU's medical center, which prides itself on its Capitol Hill clientele. In D.C. Superior Court papers filed in 1999 relating to a different doctor also under treatment for drug abuse, that doctor's attorney explicitly sought to seal the court record "by virtue of the status of his many prominent patients."

Center spokeswoman Barbara Porter declined to answer questions about how the institution deals with impaired doctors. "We have decided not to have any further comment on the story," she said.

Malakoff continued to treat patients from the fall of 1999 -- when he was first caught using other doctors' names to prescribe drugs for himself -- until this May, when the medical society determined he was failing to stay clear of drugs and insisted he stop practicing or face possible action by the District's medical licensing board.

For several weeks, Malakoff has been in "intensive therapy" at an inpatient treatment program, Cohen said.

Much in Malakoff's treatment record supports the view that his doctors were not inclined, at least initially, to define him as addicted and were less than aggressive about finding out whether he was truly off drugs, as he said he was.

In an April 2000 retrospective he wrote as part of his treatment, describing his drug habits leading up to being caught in 1999, Malakoff wrote: "The medication made me feel better and I kept using more. . . . I found myself trying to do anything to avoid interrupting taking and getting the medication. . . . Daily use of the medication became necessary."

Yet according to a deposition by GWU's chief of medicine, Alan Wasserman, an initial evaluation of Malakoff by the medical center's then-chief of psychiatry David Mrazek concluded that Malakoff "did not have an addiction problem" but rather had a problem of "self-medicating."