Addicted medical students whose problems are untreated often graduate to become impaired physicians.

With this in mind, administrators and students at the University of Tennessee College of Medicine founded the nation's first Aid to Impaired Medical Students council in 1982. Since then, as medicine's "conspiracy of silence" has dissipated, the interest in campus substance abuse programs has grown.

Currently, 25 American medical schools -- one fifth of the total -- have student-run councils similar to Tennessee's. In the hope of further increasing this number, the American Association of Medical Colleges plans to issue recommendations later this year that provide guidelines for such programs. "It's time to begin wrestling with the issue at the school level," said Bob Beran, the association's assistant vice president for student and educational programs.

The problem is serious, experts say. The Public Citizen Health Research Group, a nonprofit advocacy group in Washington, estimates that more than 100,000 people are injured or killed each year as a result of doctor negligence due to chemical impairment or incompetence. Among the sources Public Citizen cites is the Harvard Medical Practice study published recently in the New England Journal of Medicine.

Most states have rehabilitative programs, usually called Impaired Physicians Programs or Physicians Recovery Programs, which investigate reports of substance abuse and steer addicted doctors into treatment.

The effectiveness of such programs varies. In Oklahoma, which is believed to have one of the most successful programs in the country, 4.5 percent of the doctors in the state -- 222 out of 4,900 -- have gone through formal treatment; their recovery rate after one year is 92 percent, according to program officials who say that compliance is monitored by urine tests and attendance at weekly meetings.

Some programs for impaired medical students are based on the same model. A council, usually made up of two students elected from each class and eight faculty members or local physicians, works with the friends and colleagues of an impaired student. Though students occasionally approach the council seeking help for themselves, such self-reporting is rare.

More often, a student approaches the council to express concern about a friend's drinking or drug use. Then one or two council members investigate by questioning other students or faculty members and looking for further evidence of drug or alcohol abuse. The questioning is done as informally as possible, and efforts are made to keep names confidential. If enough evidence is amassed to verify problem alcohol or drug use, a council member, with several of the impaired student's friends, will approach the student through an "intervention," a rehearsed confrontation, and recommend a treatment program.

"An intervention is the end of a very, very long process," said Stacey Mackay, a third-year student at the University of Virginia School of Medicine and a member of the council. "We have to prove beyond the shadow of a doubt that a student has a problem, and this is difficult, because we prefer legal documentation, such as an arrest for driving while intoxicated or being drunk in public. One person saying, 'This person has a drug problem' isn't enough."

Because it raises fundamental questions about privacy, this approach is not universally embraced. Medical students at Stanford rejected the Tennessee program, balking at what one program leader called its "policing" element. "Students here felt that council members were going to wear raincoats and stand in corners at parties, watching for people who drank too much," said John Peterson, a third-year Stanford student.

Stanford instead adopted a modified program that works exclusively with the student who reports a friend's problem; it provides information and resources but stays out of the intervention process.

Council programs, most still in their initial phases of development, have yet to achieve their long-range goals. "We assume that between at least 10 and 15 percent of our medical students have problems with drugs and alcohol," said Mackay of the University of Virginia, "and {ours} is well below those statistics. We're not identifying or performing interventions on 10 percent of the students here."

In the seven years since the Tennessee program was founded, only 20 students -- fewer than three per year -- have been identified and treated. One reason these numbers are low, administrators say, is because other services on campus may be reaching students before an addiction becomes entrenched. At the University of Tennessee, the council program is considered the last step in a process that includes student-faculty advisory groups and peer counselors who are trained to recognize addictive behaviors in their early stages.

But at most campuses, the most formidable obstacle that such programs must face is the difficulty of identifying impaired students. "The bottom line is that you don't know who they are because they're very good at hiding it, even from themselves," said Lori Aronson, a second-year student at Case Western Reserve School of Medicine.

To reach more students who need help, program coordinators are expanding their outreach efforts and their focus. Most medical schools devote a portion of their pharmacology curriculum to alcohol and drug addiction, but the emphasis is most often on biological, not psychosocial, effects.

At the University of Virginia, council members, with the help of a grant from the National Institutes of Health, will implement a pilot drug and alcohol education program for medical students. "We want more of them to recognize drug and alcohol addiction for what it is, a disease, and then bring their concerns to us," Mackay said.