Peter J. Cohen, the physician who chairs the Medical Society of D.C. committee that monitored treatment of internist Gary Malakoff, spoke of Malakoff's history and status in a July 8 article only after he was informed that The Washington Post had obtained a copy of the contract Malakoff had signed with the Medical Society. (Published 7/9/04)

For years after Vice President Cheney's personal internist, Gary Malakoff, had supposedly quit abusing prescription painkillers, the team of doctors monitoring his recovery remained oblivious to the fact that the high-profile doctor was still drug-dependent, according to legal papers and medical records obtained by The Washington Post.

Records show that treatment team members at George Washington University Medical Center, who conducted frequent medical and psychiatric examinations to watch for signs of relapse, may even have facilitated Malakoff's problem by their deferential treatment, raising questions about the suitability of having medical center doctors overseeing one of their own.

The psychiatrist and neurologist overseeing care for Malakoff -- then the director of the medical center's internal medicine division -- repeatedly prescribed the drugs the internist was known to have been abusing, medical charts show.

And when the neurologist, Perry Richardson, needed to document Malakoff's progress to the local medical society, he let Malakoff craft the letter, Richardson acknowledged in a deposition.

"I have no concerns about his thought processes or judgment," Malakoff wrote about himself for Richardson's signature. "I truly believe that he is stable enough to see and take care of patients as well as teach our medical students and residents."

The documents, along with interviews of doctors familiar with the case, paint a picture of an insular and ineffective system of oversight in which Malakoff's doctors accepted his assurances of well-being at face value while he continued to order thousands of dollars of drugs on the Internet, repeatedly crashed his car and managed to bamboozle scores of urine tests.

By doing so, the records show, Malakoff's physicians effectively, if unwittingly, protected him from further disciplinary action by the District's medical licensing board.

The Malakoff case also has spotlighted the role of the Medical Society of D.C., the nonprofit physician organization that monitored his treatment.

Peter J. Cohen, the physician who chairs the committee that watches over impaired doctors, said the medical society took immediate steps when it discovered this spring that Malakoff was still using drugs.

"When we found out about this, because we knew his history, we acted very quickly," Cohen said. "The first thing we did was notify the hospital, and he stopped practicing immediately. . . . We did not coddle him. We did not hide him."

It is not clear, however, why earlier periods of ongoing drug use by Malakoff were not picked up by drug tests demanded by the medical society. Malakoff "has had some relapses" during his nearly five years of oversight by the medical society, Cohen said.

One thing that became clear yesterday is that Cheney has known about Malakoff's problems for some time. Jonathan Reiner, director of GWU's cardiac catheterization laboratory, said in an interview that Cheney "has known for years" about Malakoff's drug dependence, although he would not be specific.

"Dr. Malakoff had frank discussions with the vice president for quite a period of time about this," Reiner said. "This was not just recent news. He has kept him apprised."

Reiner said he had "no concern" that Malakoff's problems affected Cheney's care, saying that Malakoff was "a member of a team of doctors" that made collective decisions.

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."

Records, obtained by The Post from a person close to the case who insisted on complete privacy, indicate that in the first years of Malakoff's treatment, when his doctors documented his purported recovery, he spent about $50,000 on bulk orders of Stadol, an opiate; fiorinal, a barbiturate; codeine, a narcotic; Xanax, an anti-anxiety drug; Ambien, a sleeping aid; and other prescription drugs.

Similarly, when Gerald Perman -- the psychiatrist on Malakoff's treatment team -- was told by a lawyer in January 2002 that Malakoff had secretly continued to order large quantities of drugs during treatment in 2001, Perman seemed unalarmed.

"There are many things in the world I don't know about, and there are many things my patients do, I'm sure, that they don't tell me about or that I don't know about," Perman is quoted as saying in legal documents related to Malakoff. He added, "It tells me that he may have felt embarrassed and ashamed about this problem."

Perman said yesterday that he could not talk about Malakoff's case but emphasized that in a situation in which he has suddenly learned that a patient in recovery is still abusing drugs, "My initial reaction would not be to express a strong emotional reaction but to sort things out in a dispassionate way."

Nonetheless, in the deposition Perman appeared less than quick to accept the news: "Even though he ordered these medications, I don't know -- we don't know if he took them or not."

What is known is that in the course of Malakoff's treatment, Richardson, the neurologist, prescribed fiorinal and codeine, two drugs that Malakoff had been abusing, with the stated aim of helping Malakoff deal with headaches and sinus pain. Malakoff's psychiatrist, Perman, added Xanax and Ambien to the mix -- two drugs Malakoff had used heavily during his times of drug dependence.

Perman said yesterday that prescribing drugs that the patient has had trouble kicking can help a physician develop a "relationship" with the patient before gradually discontinuing the drug. But he conceded that others would strongly disagree.

Those prescriptions gave Malakoff plausible deniability for his occasional positive drug tests. The real question, several doctors said, is how Malakoff managed to pass virtually all of those tests -- more than 150 of them in one stretch, according to one doctor who was monitoring his progress.

As it turns out, Stadol -- a synthetic opiate -- does not get detected on standard toxicology screening tests, which detect only naturally occurring morphine derivatives. And fiorinal is so short-acting that people can often clear the substance from their systems in time for a drug test.

Perman said that the medical society orders special tests if there is reason to believe the patient is abusing a drug not on the standard screen. Asked why a Stadol screen was apparently not included in Malakoff's tests until late in the game, when that was the drug he had been abusing from the start, Perman said: "We're fallible."

In the early years of his treatment -- the only period for which records were obtained -- Malakoff had multiple automobile accidents. Repair shop records, citations and other documents indicate he had at least 20 crashes between April 1998 and October 2001. Many of them were on the George Washington Parkway, which he would drive daily from his home in Great Falls, and several involved rental cars he had while his car was in for repairs.

The records indicate that Malakoff attributed many instances of car damage to parking garage incidents.

Staff writers Cheryl W. Thompson, Mike Allen, Henri E. Cauvin and Carol D. Leonnig and research editor Margot Williams contributed to this report.

Gary Malakoff had a drug problem in '99.