Q&A with Dr. Steven Balt, Part 2: Physician discipline should be better targeted

Last week Antidote introduced you to Dr. Steven Balt, the rare physician to have the courage to open up about his personal experiences with the physician discipline system. The first part of our interview was posted last week. The last part is below. It has been edited for space and clarity.

Q: You say that you are damn good psychiatrist. What tells you that?

A: My own experience has informed me tremendously. I have learned far more about treating patients from my own personal experience than I ever learned in a text book or a lecture. And that's absolutely true. Psychiatry is the one field in medicine where I feel that can be said. I can't say I would be a good oncologist because I went through cancer treatment or a good surgeon because I've had a hernia repair. But, with psychiatry, now I am approaching patients the way I want to be approached. I'm not approaching them like they are a collection of symptoms.

In addiction therapy, there is a huge emphasis on finding the drug to take the place of the drug that is causing the addiction. That works to a point, but it doesn't change the addiction. So, what I try to do is not just put a patient on high dose of Prozac to curb their cravings. I try to find a way to treat the underlying disease.

Q: What do you mean by that?

A: Addictions are lifestyle diseases, spiritual diseases. They need to be treated with that in mind. They go beyond the purely psychological. I try to take it upon myself to find out what is causing their suffering right now and try to treat it. I can't tell you how many patients I have had who have said, "You actually listened to me. The last three or four psychiatrists I have seen didn't listen. They just told me to take this drug, and so I did. But I'm not any better."

One of the things I like about what you have written is that you write a lot about doctors who overprescribe. I'm very sympathetic to the whole anti-psychiatry movement because I see plenty of patients who have just been handed drugs and told to come back when they need another prescription. It's shocking how low the quality is of some of the psychiatry that's practiced out there.

Q: Let's go back to your residency at Stanford for a minute, because it gets to what you're doing now. You weren't able to complete your residency because you had another shoplifting incident, right in October 2006?

A: It was a day when I had patients who had cancelled that morning, and that rarely happened. So I decided to pass some time at a local bookstore. In the store, I just had this impulse to steal some books, four books. I didn't need them. It just made me feel good, in a way. I can't say in any concrete way how. It made me feel good, and so it just happened.

Q: It was just for the thrill of it?

A: In some strange way, that was the highlight of my day. To be able to do something like that and get away with it. I've done a lot of therapy on this, so I think I understand it better now. It gave me something, something that I had obtained for myself when in fact I'd been trying for years to obtain things that were kept out of my reach.

 I had been struggling through medical school and residency and had seen very poor practices on the part of some of my classmates and peers. They would skip classes, complain about the workload and just generally cut corners, sometimes impacting patient care. Here I was trying to stay above it all and doing quite well, even with the pressures the board was putting on me, but I was getting no positive recognition, other than from patients. That lack of positive feedback really took a toll on me, and, in some bizarre way, being able to get something for nothing was appealing.

Q: You quit residency and stayed in diversion? Were you forced to quit because of another arrest?

A: When I was arrested, I knew it was going to be a bigger deal because it had happened before. I spent the night in the Santa Clara County jail, and I was telling myself, "This is the end of my medical career." I actually thought that if I lost my license that would be a good thing. "Tomorrow, my new life starts, and I need to figure out what I do with it." But, surprisingly, the next day I found out that Stanford would keep me but only under a very strict hospital probation.

Q: So why didn't you just do that?

A: Because I also knew that I needed help. This is actually very important. It was my decision to go into treatment again, but to be willing to take my life in a completely new direction.  I didn't go to satisfy the Board, or Stanford, or because I was a raging alcoholic or kleptomaniac, but to rediscover a new life for myself. I found a program that was longer term and specifically for men who have had difficulty staying clean. It was the Prescott House in Arizona. Stanford said if I did that and stayed a resident it would be a violation of my probation. So I resigned. That was a very positive decision and allowed me to come back on my own terms.

I wasn't sure how the medical board would react, but I found out that the medical board allowed me to keep my license. I still wasn't sure if I would return to psychiatry after treatment, but at the end of 2007, I felt much better about myself. It had been a welcome sabbatical, and I thought, "Maybe I can make this work." I was under the delusion that I could get right back into a residency program, but it turned out to be much more challenging. It wasn't until this November that I found a residency program that would take me.

For three years, I contacted every residency program in the state, writing letters, sending emails and making phone calls. The first year, I interviewed in Bakersfield, and they were very interested in hiring me but decided not to because I was still in diversion. Then I interviewed in San Diego, but they said they couldn't hire me because the medical board still had this investigation hanging over my head and hadn't taken any disciplinary action, so there was a concern that I might go through residency only to lose my license midway. The next year I looked at Bakersfield, UCLA, and California Pacific and interviewed at each. At this point, I was on probation with the medical board, and they decided they didn't want to take a risk.

Q: That had to be very discouraging.

A: It was. I was fortunate to know the co-founder of a drug and alcohol treatment center in San Rafael. So I went to work there for a while. I started out as a drug and alcohol counselor, which I was overqualified for. Then in the summer of 2009, I started working as a psychiatrist there. I was placed on a malpractice policy at the clinic and started managing detox.

Q: How could you work as a practicing psychiatrist without finishing your residency?

A: There's nothing to keep me from practicing medicine. I do have a medical license and a DEA license and can prescribe medications. But, to work in most settings, you have to have malpractice coverage or be board-certified or board-eligible. At this clinic, I was able to get onto their malpractice policy.

Q: Where did you finally get into residency?

A: I looked around the Midwest and up and down the East Coast. I interviewed at a program in the Midwest and was offered a residency that will start in July next year. I would rather not be specific about where because everything has not been finalized yet. It will be my fourth year of residency, and when I finish that, I will be board-eligible. Then everything will be done. Right now, it's up to me. I don't know if I will come back to California or not, but I will be much more employable.

Q: Do your patients ever ask about your past?

A: Some of them do know about my history. I don't hide it from anybody. Some of them do ask.

Q: How do they know about your history?

A: Through searching for me online. I don't know if anybody has gone to the medical board to look at my information, but certainly a casual Google search will pick up your article and one other blog post that came up last summer.

Q: You clearly are focused on making sure patients get the right treatment tailored to them. What could the boards do better to monitor the kind of revolving door of prescriptions that you describe?

A: It's tough question because I have seen patients who have to take high doses of drugs, and if they don't they will be wandering around on the highway or end up in a hospital. But I also have seen patients who are as healthy as you or me who are taking the same high doses of medications because someone thought it would be helpful for sleep or anxiety or "stress" and nobody told them about the side effects. So simply looking at prescribing patterns won't work.

A lot of doctors would be resistant to any board knocking on their door and saying, "Please explain to me why you are prescribing so many antipsychotics to patients." You can't just look at the volume of patients, either. In Oakland, I see a lot of patients, and I try to provide as responsible care as I can in the 15 or 20 minutes that I can, but I also recognize that I can't do much in that time. I'm not going to overly medicate and assume that the drugs will do everything, but I also can't say that I am going to cure them in one visit.

I'd have to say the patients themselves are a good measure. Ask them whether the doctor is doing a good job.

Q: From your perspective, as a doctor who is featured in public records and, as you have said, is only shown in a negative light, is it fair to doctors for the medical boards to be as transparent as many of them are?

A: Is it fair? Well, I have read everything that the board has put out there about me, and it is accurate. I actually felt your article was quite supportive of me. Your take seemed to be that this guy has done some bad things and had a rough time and been ill and was monitored but what is he going to do now that diversion is going away. That's a fair characterization of my case. So, in that sense, I wouldn't say that it's unfair for the board to provide that kind of information about me.

I will say it's unfair that the information has been used as a basis for hiring or determining my insurance premiums. I think that there are plenty of examples of bad doctoring that don't reach the point of criminal behavior, and those doctors don't face the same scrutiny. I see that so frequently. I'm not going to name names, but this type of bad medicine happens. I really wish more of those cases came to light because they aren't about a doctor's personal problems, they directly impact patient care.

Let patients choose to see the doctors who have the good bedside manner and are able to work with patients to get them to collaborate on a treatment plan that they understand. And thank goodness that some of these cases are coming to light, especially with stories about doctors who are in the pocket of drug companies. I think the work you and other reporters are doing will eventually change the way medicine is practiced, but it's going to take some time.

Q: If you were in Kansas or Mississippi or another state, you would have nothing written about you that was easily accessible to the public. Does it seem unfair that just because you were licensed in California, your history is there for everyone to see?

A: In my case, I do think it would be better if it were not so easily available. It was my personal life. If I smoked pot on the weekends or cheated on my wif,e these would be questionable character behaviors that you probably don't want your doctor to do, but that don't really affect patient safety. I compare my stuff to that. The DUI was a wakeup call, and I wish I had been able to deal with everything I needed to without the spotlight. I think that the spotlight that was then trained upon me was very demoralizing. People who never met me are able to make decisions based on what has been printed about me.

In my particular case, I would have been much happier and more successful and probably healthier if this had been left to my therapist and to me and not put out for everyone to see.  In fact, the most helpful intervention of the last seven years was my decision to go to treatment on my own. But, that said, I am in California, and I have had to deal with this higher level of exposure, so I am happy to talk with you about it.

Q: When you talk about private matters, where do you place an affair with a patient? This is a common problem, particularly with psychiatrists. Should that be cause for action by a board?

A: Something like that has to come out, absolutely. Again, I don't care what a doctor does in his or her personal life, but once it crosses that boundary between home and office and begins to impact their care, that's something that needs to become public.

Q: What about something violent that happened in a doctor's personal life? I wrote about a doctor who attacked his wife, for example.

A: If it becomes a criminal case, you can find the records if you know where to look. Does it have to be something that the medical board announces to everyone? I don't think so. If I choose this doctor, I don't care if he mistreated his wife. That may sound harsh, but I don't. I care if he is going to give me the right treatment for my problems. If he has a clean record as a physician and takes care of patients in a responsible manner, I don't see why that should come to light if his patients and colleagues know him to be an excellent gastroenterologist or cardiologist.

If this experience has taught me anything, I have learned that people do bad things. They do bad things and can still compartmentalize parts of their life and be quite good in their medical practice. I don't want to judge anything someone did in their personal life. Do I care whom my doctor voted for in the last election? No. I'll just go see him. And the proof is in how he treats me and in the outcome.

Q: One more question. What do you think about "Doctors Behaving Badly"?

A: I appreciate the work you are doing. Even though I‘ve been somewhat targeted by it. Overall, I think what you're doing is good for the field. It takes someone like you to bring to light the worse behaviors of what is happening in the medical field.

Questions or thoughts? Add them to the comments below or write me at askantidote@gmail.com

Related Posts:

Q&A with Dr. Steven Balt, Part 1: Separating personal struggles from clinical success

Doctors with addictions left hanging as diversion program dies