Drug use, he said, "never prevented me from staying focused on my work." But he said he became reckless with money, stayed up all night and was always "bone-dead tired." Still, no one at Norfolk Community Hospital knew about his drug use, and "nothing was ever documented" that he harmed a patient, he said.
After he tested positive for drugs in 1990, the Virginia medical board suspended his license for the first time. But it immediately set aside the order, allowing him to keep practicing. If he relapsed, the board could enforce the suspension.
In 1993, a medical board inspector approached him during his 12-hour shift at Norfolk Community Hospital's emergency room and ordered him to stop practicing medicine immediately, Birch said. His license was suspended, she told him, because he had tested positive for cocaine.
"There were people around," Birch recalled. "That was the most humiliating experience of my life."
The cycle continued, with Birch testing positive, losing his license and then regaining it. Birch obtained a Missouri license in 2003 and is on a medical fellowship in the state.
One Chance in Ohio
Some states are less tolerant than others.
In Ohio, for example, "everybody has one chance to screw up," said Lauren Lubow, the senior executive staff attorney for the Ohio Medical Board.
If doctors are impaired, they are evaluated, offered treatment and then allowed to return to practice "without interference from the board," she said. If a relapse occurs, the board takes action, usually a consent agreement immediately removing the doctor from practice, she said. The doctor must meet certain guidelines, including 28 days of treatment, before applying for license reinstatement.
"There is an end to [the board's] patience," Lubow said. "It comes at a point where they are convinced this is not a person who will be able to recover and safely return to practice."
In Massachusetts, an impaired doctor who relapses twice or more must demonstrate at least a year of sobriety before being allowed to return to medicine, according to Nancy Achin Audesse, executive director of the Massachusetts Board of Registration in Medicine. "We give people a couple of chances to get themselves together," she said. "But our primary goal is patient protection."
Maryland, Virginia and the District are more tolerant.
Alexandria psychiatrist Luanne Ruona has been hospitalized for alcohol dependency and been in drug rehab at least nine times since 1991, records show. By her own admission, Ruona relapsed at least 12 times during that period and once tampered with her urine sample so that those who monitored her couldn't detect alcohol, according to Virginia medical board records.
She also has treated patients while under the influence, records show. In March 1999, a patient arrived appearing "distressed" for an afternoon appointment at her home office and was greeted by Ruona at the door, according to records. She suggested that he lie on her couch, then she sat beside him on the floor and held his hands near her face to relax him.
At one point, Ruona excused herself and told him she was going upstairs to phone in a prescription. When she didn't return, the man said, he went upstairs and found her in "lounging attire" asleep across the bed, according to records. He left and reported the incident to another doctor the next day. Five months passed before the board acted, suspending her license for two years, records show.
It was the first time the Virginia medical board took away her license, even though it knew about her alcohol abuse for more than a decade, medical board records show.
In 2001, a physician familiar with her history recommended that the Virginia board allow her to practice again. Another doctor said he "very strongly" recommended reinstatement because "this time, she surrendered to her illness," records show. The board reinstated her license in October 2001. She has relapsed at least three times since then, according to board records.
"I probably over-drank," Ruona, 63, said in an interview. "But I didn't feel like it interfered with my work that much. And it wasn't like I would get up and drink."
After 11 relapses, she was put out of Virginia's Health Practitioners' Intervention Program, which oversees impaired doctors, in March 2004. She surrendered her license in the fall after another relapse and said the board told her that it would return her license in 2006 if she does not drink again.
"They said the ball was in my court this time and told me to come up with a good treatment plan, and if I stayed clean I could get my license back in 18 months," Ruona said. "It's a big relief. I was satisfied and I think the board was, and we all shook hands."
Staff researcher Bobbye Pratt contributed to this report.