Medical school was supposed to be the place where he'd get his drinking under control. At least that's what he told himself: It's time to get serious about school now. This is my career. No more late nights in the bars, no more exams taken with a hangover.
But Neil White, a fourth-year student at the University of Southern Alabama School of Medicine, had been drinking beer since high school, and he quickly discovered he couldn't stop for long. "I managed not to drink for the first few months of medical school, but after our first big test, my whole class went out to a bar," White recalled. "By the end of the night, I was the drunkest one there. I quickly found the heavy drinking crowd at school, and we started going out at night."
Soon, White was drinking heavily at least three nights each week. "I couldn't go out and drink just one beer," he recalled. "It was always six or seven. I justified it by telling myself I was working hard and getting good grades . . . and I deserved to go out and get bombed."
His drinking reached a crisis last fall. Although it was time to apply for residency programs, White began having second thoughts about his decision to specialize in surgery. That prompted a five-day binge, during which he missed four days of hospital rotations.
"I got to such a low point that I didn't even know if I wanted to be a doctor any more," he said. "Finally, I tried to kill myself with an overdose of aspirin and Tylenol, but luckily I realized right away I didn't really want to die. I called an ambulance, and when the medical school administrators learned I was in the hospital, they sent a psychologist to see me. Within 10 minutes, he diagnosed me as an alcoholic and said I needed treatment."
As a medical student, White is part of a population that addiction specialists consider particularly vulnerable to alcohol and drug abuse. Between 10 and 12 percent of the general population is chemically dependent, according to the most conservative estimates. Substance abuse experts estimate that the rate among medical students and resident physicians -- doctors in training who work grueling hours and are under intense pressure -- is at least as high.
A 1987 study of an unnamed Midwestern medical school class published in the Journal of the American Medical Association by researchers from Rush-Presbyterian St. Luke's Medical Center in Chicago found that nearly 20 percent of 116 students had drug or alcohol problems. And in another study published last year in JAMA, more than half of a 93-member class of third-year medical students surveyed in 1989 told researchers that they'd observed their classmates abusing alcohol or drugs.
Most medical students are at high risk for addiction or abuse long before their medical training begins, said G. Douglas Talbott, a psychiatrist who is a recovering alcoholic and runs a substance abuse treatment program for physicians. Talbott said he has treated about 150 impaired medical students and 2,700 doctors since 1978.
Nearly three quarters of the medical students and residents he has treated come from dysfunctional families, according to Talbott. Many were physically or emotionally abused or neglected by a parent. At least half of the impaired students had at least one parent who was addicted to alcohol or drugs. "The fact that they're children of alcoholics or drug addicts means they're predisposed to substance abuse from Day One," Talbott said.
In some ways, said Robert Booher, a physician who treats impaired medical students in Maryville, Tenn., medical school is a logical place for some children from dysfunctional families. "People who grow up in these families often gravitate toward the helping profession. They want to take care of everyone and cure the world," said Booher, who has been in recovery for 10 years from an amphetamine addiction.
They may also feel at home in medical school, which reinforces some of the same values they learned growing up: to compete and achieve and not to talk about or acknowledge their feelings.
"Medical school is a very dysfunctional system itself," Booher said. "In order to survive there, you're taught to work long hours and deny your feelings if you lose a patient. It's not okay to cry, because doctors are supposed to be above that. So you continue to stuff your anger and frustration, just like you learned to do at home. It's a real set-up to become addicted," and some students turn to drugs or alcohol to relieve the pressure or to escape.
A medical student's psychological training, with its subliminal message of omnipotence and invulnerability, may contribute to what Talbott calls the "Titanic syndrome," a reference to highly-publicized claims that the mammoth ship was unsinkable. Medical students, told for four years that they're invulnerable or should be, start to believe that alcoholism and drug addiction are diseases that can't affect them, he said.
The standard image of the alcoholic or addict often feeds this perception. For a while, that reassurred Neil White. "My idea of an alcoholic was a bum, someone who sleeps on the street," he said. "I kept telling myself that if I could get into medical school and do well, then there was no way I could be an alcoholic. I was just someone who liked to drink."
More than half of the 150 medical students Talbott has treated since 1978 began using drugs, mostly marijuana or alcohol, in medical school. "Alcohol is the No. 1 drug of choice here," said John Peterson, a third-year medical student at Stanford University School of Medicine and a co-chair of that school's program for addicted students. "Stanford's problems mirror society's problems."
But most people don't have the kind of access to prescription drugs that a medical student in a hospital, and especially a resident, does. A 1987 study of 1,785 residents indicated that 66 percent of those who used tranquilizers regularly began during medical school or residency, when the availability of drugs increased. "Anyone in medicine who's chemically dependent can figure out how to get drugs," said Jon Lieberman, a fourth-year surgery resident in Knoxville, Tenn., who sought treatment in 1987 for an addiction to the powerful narcotic painkiller Demerol. "Most can get away with it for a while, but they'll get caught sooner or later."
Identifying the addiction is only the first step toward coping with it. The next is formal treatment, preferably in a program or with a counselor prepared to deal especially with the specific issues health professionals face.
When residents and interns arrive at the Realization Center, a private outpatient addiction clinic in Manhattan that specializes in treating physicians, Marilyn White, the center's founder and director, first works to curtail their drug use. Next, she encourages them to talk about their fears.
"Medical school and hospitals can be very, very frightening environments, and these residents never talk about that until they come into treatment," said White, who is not related to Neil White, a certified addiction counselor who has taught a course in alcoholism and addiction to residents at St. Vincent's Medical Center in Manhattan. Classroom work doesn't necessarily translate into effective emergency-room practice, and students and residents often buckle under the awesome responsibilities of making life-and-death decisions about other peoples' lives, she said.
Through the Realization Center's outpatient program, residents also work individually and in groups to shatter the myths associated with medicine. They come to accept that medical students and doctors aren't infallible -- the Titanic, after all, did sink -- but this process can be a slow one. "In their hearts, these residents think they should have known better," said White, "because society tells them they should have known better. But . . . circumstance and availability of drugs and family history all play their parts."
The typical treatment process for health professionals, including medical students and residents, lasts a minimum of three months. "I had to be in treatment long enough to completely disassociate from my work," said Lieberman, the Tennessee resident. "I had to be able to say, 'I am not a resident. I am a human being who has a problem.' " He took off six months to go through in-patient treatment at a Tennessee hospital and begin an aftercare recovery program.
A three-to-six-month leave of absence from school may sound threatening to students who fear their graduation or academic progress will suffer irreparably, but as more medical schools begin to view alcoholism and drug addiction as a disease rather than a sign of moral weakness, administrators are seeking ways to guide their impaired students into treatment and then back into school.
Of the 126 medical schools associated with the American Association of Medical Colleges, approximately 20 percent now have an Aid to Impaired Medical Students program designed to identify impaired students and recommend them to treatment programs. At the University of Tennessee College of Medicine in Memphis, students identified by the impaired students' council as chemically dependent receive a three-or-four-month medical leave of absence for treatment. The University of Southern Alabama gave Neil White a leave of absence plus partial credit for the three and a half months he spent in treatment. He hopes to graduate in June, on time.
Most students who complete a treatment program also finish medical school, though a few are encouraged to drop out. Students who go through Talbott's program in Atlanta are evaluated and placed in one of three categories: those who can re-enter medical school immediately after treatment; those who should stay out of school for an additional year or two to concentrate full-time on recovery; and those who should never return to school. A five-year unpublished study by Talbott of University of Georgia medical students indicated these evaluations appeared to be accurate predictors. Students who were advised to drop out but returned to school nonetheless had high incidences of relapse and continued drug use, Talbott said.
Avoiding a relapse can mean the difference between graduation and dismissal. Students who return to school after treatment must agree to continue their recovery programs, including involvement with 12-step support groups such as Alcoholics Anonymous and, at some schools, to submit to random urinalyses.
In some states, programs for impaired physicians monitor their recovery after graduation. The names of residents who return to their hospitals after completing treatment are reported to the state board, and they are expected to attend 12-step Alcoholics Anonymous meetings on a weekly basis.
Some say the transition is not as hard as they had feared. "My first day back was a little bit awkward, but by and large, my colleagues were receptive to my recovery," Lieberman recalled. "By the time I'd been back for a month, nobody really gave a damn any more about why I'd been gone. There was a job to do, and we all had to get it done."
White, who's now seriously considering a career as an addiction specialist, says he returned to medical school with a new set of priorities. Graduation ranks high, but maintaining his sobriety is at the top of his list. "I got to such a low point before I went into treatment," he said. "Whenever I feel the urge to drink now, I remember what it felt like then, and I won't do it. I never want to be back at that point again."
Hope Edelman is a writing instructor at the University of Iowa.