Q&A with Dr. Steven Balt, Part 1: Separating personal struggles from clinical success
When I wrote in 2009 about the death of the Medical Board of California's diversion program, some medical board staffers expressed disbelief that I would say anything nice about a program that had been so controversial. After all, in 2002 I co-authored series of stories called "Doctors Without Discipline" at The Orange County Register that prompted a state investigation of the board and, ultimately, resulted in diversion being discredited and then dismantled.
Dr. Steven Balt, a psychiatrist, was one of the doctors caught in the fallout, and I featured him in my post about diversion. When diversion died, Balt was left without a viable option for him to continue fighting his addictions while he practiced medicine. One of Balt's friends sent Antidote a note about Balt. I wrote asking whether Balt might agree to an interview. Fortunately for fans of Antidote, he did.
What follows is a fascinating and rare look at the physician discipline process through the eyes of a self-described "damn good psychiatrist" who has struggled with his own demons.
I reached him at his home in Northern California. The interview has been edited for space and clarity. Here is the first part of our interview, with the second coming next week.
Q: Tell me a little bit about your experience in medical school and in your residency. I take it that some of the pressure of that experience contributed to your later problems?
A: I finished medical school in 2003, graduating from Cornell, and started residency in summer 2003 at Stanford Hospital in the psychiatry program. I enjoyed medical school and found it challenging, but there was nothing that was overwhelming or incredibly difficult or stressful. I did take on a lot of work, though, because I was going to graduate school along with medical school.
However, I had been suffering from bulimia starting in high school, and that became particularly bad when I was in college, from 1989 through about 1995. Then when I moved to New York, a couple years into my medical school program, I started taking my bulimia seriously, going into therapy and starting on medications to treat it. I also started drinking socially at that time. I had not drank or used any drugs at that point. Looking back at my whole experience, bulimia was really something that set everything on a course.
Q: Your eating disorder is even cited by the Medical Board of California as one of the issues you were facing. You say that you took it seriously starting in medical school. What changed?
A: It had gone completely untreated through my undergraduate years. Then I had a couple of leg injuries and my orthopedist noticed that I had weak bones. One thing led to another and I ended up in therapy. It persisted at a lower level for the next several years, but it was under control.
Q: And what about your drinking?
A: I would drink on weekends but it was nothing that was out of the ordinary compared to my peers, and I never used drugs.
Q: What do you mean by "compared to my peers?" Do you think other med school students were more heavily into drugs and drinking?
A: I saw a lot of that going on in medical school. One of the ongoing themes of my professional life is my observation of questionable behavior on the part of doctors, mostly around drugs and alcohol. I've seen bad behavior in terms of their medical practice, too. I don't think that anyone is a perfect person, myself included. For me, it was the luck of the draw that things happened the way they did. I'm not saying that I was innocent of what I did, but there were plenty of other examples of doctors behaving badly, so to speak, where the doctors were never caught.
Q: What was the difference with your case, do you think?
A: I think it goes back to the bulimia. If I had to do it over again, I would have addressed that much earlier on. Nobody around me really recognized the bulimia, and it proved to be my undoing.
Q: Your parents never recognized the bulimia?
A: My parents did, but there were some difficulties at home, too, so it was hard to be open about any personal problems. Before I went off to college they took me in to see a child psychiatrist, but it ended up being useless because I was just longing to leave home and figured that my disease would resolve itself. Instead it just went underground when I went to college, and I was a very isolated person in college. I didn't have any good friends.
Q: And, yet, you were clearly doing something right. You had made it into a great school, for one. Were you with friends when you ended up being cited for a DUI?
A: No. I was by myself. I was fully conscious and aware, and to this day I'm still not sure why I was pulled over, but I was. But I had been drinking, so that was it. I didn't get a lawyer or think about trying to fight it. I just thought, "I made a mistake, and now I have to pay for it." I kept it to myself because I thought it was something that happened in my personal life and that I would deal with it on my own. But the stress from that and some complicated aspects of a relationship I had at the same time created a lot of pressure. That stressful period contributed to the theft around that same time.
Q: By the thefts, you mean the petty theft incidents in January and March 2005. Neither the DUI nor the shoplifting incidents were reported to the medical board right away, right?
A: Right. Nothing was reported to the board. I didn't know how legal actions or criminal actions get reported to the board. I had the DUI and didn't even think about notifying the hospital or the medical board because it wasn't work-related. I only learned later that apparently counties have the responsibility to report matters like this to licensing boards for doctors, lawyers, nurses and so forth.
Q: When you have to renew your license, there's a question on there about criminal actions, and so you would have had to report those yourself. But let's step back for a minute. How did the bulimia and the pressure from this relationship lead up to the theft?
A: By the time of the thefts, I was in residency at Stanford, and work was going quite well. I enjoyed what I did, and I was quite successful at Stanford. It didn't take me long to become a very accomplished resident who had a very good reputation with patients. That's something that is a longstanding issue, too. Nothing that I have done in my personal life has ever spilled over into my clinical work. I've never been drunk on the job, never binged and purged at work, never stolen anything from work. I knew I had issues going on in my personal life that I had to deal with, but I just thought I could deal with them apart from my work.
As for the relationship, I was in a complicated relationship where my girlfriend didn't know about the DUI or that I was bulimic. I had kept so much of my life secret, and it was sort of falling apart. I had a lot of friends at that point, but I wasn't really happy. The high point of my life was truly practicing medicine and helping others. Then, in May 2005, I got a call from the medical board saying they'd like to talk to me about these events of the past few months.
Q: Meaning the DUI and the shoplifting?
A: Right. So I had an interview with the investigation unit. I didn't have a lawyer or anything, which perhaps was naïve on my part. I was given the option of enrolling in the diversion program.
Q: Did the investigator bring up diversion? Had you even heard about it before then?
A: No, I knew nothing about it. It came up during this hour-long interview with an investigator, who said "We have a couple of ways we could go. We could initiate a disciplinary action against you or you can enroll in diversion."
Q: So what did you say?
A: Diversion is for substance use or mental health problems. At that point, it did not appeal to me because I honestly didn't know if my issues were severe enough to qualify. But the investigator pointed out, "You do have a mental illness, that being bulimia, so let me see if that qualifies." So I signed up.
Q: How did the board find out about the thefts and the DUI?
A: Santa Clara County reported it to the board.
Q: To me this is just so rare. So few cases that go criminal seem to result in anything with the medical board, in California or elsewhere. It seems that the boards are often the last to find out.
A: I'm glad you pointed this out. I talked with a criminal attorney about whether the fact that I'd been arrested twice in the space of two months would result in tougher penalties from the court, and he said, "I'm more concerned about the effect it might have on your medical license." He did not recommend I notify the board, but he did recommend that I notify the hospital where I was in residency. So I did go to the Stanford Hospital Well Being Committee and discussed my case with them.
In retrospect, I think I would have done a lot better for myself personally and professionally if I had come clean at that point, gone to the medical board and voluntarily entered diversion. But the committee did not let me know that I could have pursued diversion to stay a step ahead of the board. Instead, I knew nothing about diversion and so I was on the defensive when the board finally did contact me.
Q: But Stanford didn't take away your privileges or kick you out of your residency, so, in a way, the hospital was quite supportive, right?
A: Absolutely. But I didn't get the sense that the committee was there for anything other than to satisfy the Joint Commission's requirements. It was a name-only kind of thing. I had a faculty monitor who was outside of my department and outside of my specialty. He was a neurologist, and I never met with him.
Q: Wasn't it your responsibility to follow up with him?
A: Yes, it was. But there was no follow-through by anyone saying, "Dr. Balt, are you doing what you should be doing and meeting with the people you should? Are you in therapy?" Or even, "How is your work going?" Only on paper was I being monitored, and academically, things were going quite smoothly
Q: You went into diversion in June 2005, right? What was that like?
A: I was in diversion from that point all the way through November 2006, a year and a half. I was referred for treatment in August 2005. This is a component of diversion that I was quite angry about at the time. They wanted to ship me off to a treatment program when at this point I had been sober for two months and was working full-time and everything was going well. It seemed unnecessary at that point to force me to quit working. I didn't meet criteria for inpatient treatment. Still, they forced me to go. So, for a five-week program, I was at the Meadows.
Q: And Stanford allowed you to go?
A: They did, but Stanford also expected me to start work on my first day back, which I did. But halfway through my first meeting with a patient, I got a call from the medical board saying, "You can't work. We need to review your treatment first." That took four months, so I was kept out of work for four more months.
Q: What took the board so long?
A: It was just the process. I needed to appear in front of a diversion committee of three doctors who met every month to review my treatment and discuss whether it was acceptable for me to return to practice. In December 2005, they said I could work but only for 24 hours a week. So, in January 2006, I had to balance my schedule so I didn't work for more than 24 hours a week.
That's when things got ridiculous. There are certain requirements and obligations I had to meet as a resident. If I had been in private practice, it would have been far easier to change my schedule around in that way. But I felt like I was put in this impossible position of trying to keep the board happy and at the same time keep my employer happy. Stanford was not too thrilled with all these requirements that the board levied upon me, but they were able to help me out.
Q: It seems like Stanford was really bending over backwards.
A: I think they felt obligated. But right from the start, and even to this day, everything that has been reported about me, either to the board or to the public, has been about my faults. It seemed that nobody ever expressed any interest or recognition in the fact that I was a damn good psychiatrist, or that there were ways to deal with my personal difficulties that didn't have to impact my professional life. That has made the whole experience very demoralizing. My personal issues have not interfered with my work. In fact, I think they have helped my work in a large way. That has not been recognized or acknowledged by anyone who is supposedly helping me, and Stanford was no exception.
Next week: Balt talks about career rehabilitation and ways to improve physician discipline
Related Posts:
Q&A with Dr. Steven Balt, Part 2: Physician discipline should be better targeted
Doctors with addictions left hanging as diversion program dies