Nearly all states have confidential rehab programs that let doctors continue practicing as long as they stick with the treatment regimen. Nationwide, as many as 8,000 doctors may be in such programs, by one estimate.
These arrangements largely escaped public scrutiny until last summer, when California's medical board outraged physicians across the country by abolishing its 27-year-old program. A review concluded that the system failed to protect patients or help addicted doctors get better.
Opponents of such programs say the medical establishment uses confidential treatment to protect dangerous physicians.
"Patients have no way to protect themselves from these doctors," said Julie Fellmeth, who heads the University of San Diego's Center for Public Interest Law and led the opposition to California's so-called diversion program.
Most addiction specialists favor allowing doctors to continue practicing while in confidential treatment, as does the American Medical Association.
Supporters of such programs say that cases in which patients are harmed by doctors in treatment are extremely rare, and would pale next to the havoc that could result if physicians had no such option.
"If you don't have confidential participation, you don't get people into the program," said Sandra Bressler, the California Medical Association's senior director for medical board affairs.
California's program ends June 30. If no alternative program is adopted, the rules could revert back to the zero-tolerance policy in place before 1980, when doctors who were found by the medical board to have drug or alcohol problems were immediately stripped of their licenses.
No other state has followed California's lead. But the president of California's medical board, Dr. Richard Fantozzi, said that behind the scenes, regulators nationwide share his ambivalence toward such programs.
"To hide something from consumers, something so blatant ... it's unconscionable today," Fantozzi said.
Between 10 percent and 15 percent of physicians nationwide will have a substance abuse problem at some point in their lives, a rate similar to that of the general population, according to widespread estimates. An estimated 7,500 to 8,000 practicing doctors are probably in confidential treatment, or about 1 percent of all physicians practicing in the U.S., said Dr. Greg Skipper, head of Alabama's program and a leader of an upcoming study on the issue.
Opponents of such programs are unable to cite any documented cases in which doctors who were confidentially undergoing treatment botched operations while drunk or high. But they say the very secrecy of the programs makes it hard to assess the risks.
Nevertheless, some doctors have been accused of harming patients while they were in treatment.
In Montana, a patient accused a doctor enrolled in the state's treatment program of not following up on her abnormal test results, delaying her cancer diagnosis by more than a year. Montana revoked Dr. Robert Schure's license last year after he flunked out of treatment six times since 1994, according to board documents. The patient's suit was settled for an undisclosed sum.
A North Carolina surgeon enrolled in the state's program for alcoholism charged patients for one type of gastric bypass and then performed a shortcut procedure that led to serious complications, including stomach ulcers and vomiting, according to patients and a medical board investigation.
It wasn't until Dr. Steven Olchowski lost his license in 2005, years after many of the incidents occurred, that his participation in North Carolina's program became publicly known.
Opponents of California's program have focused on the case of Dr. Brian West, a Long Beach plastic surgeon who has been accused of negligence by the state medical board and is fighting to keep his license.
In 1999, West performed a double mastectomy and breast reconstruction surgery on Becky Anderson. The procedure left her with gaping, infected wounds that wouldn't close and, ultimately, a grotesque lump the size of a melon caused by organs spilling through an unhealed hole in her abdomen.
Weeks before performing his final, futile procedure on her, West was arrested for a drunken-driving accident.
After his conviction, West entered the diversion program for alcoholism. A year later he performed a tummy tuck on a 37-year-old woman that also healed poorly.
West ultimately flunked out of the treatment program after investigators uncovered a pattern of relapses, binge drinking and doctored urine tests that "demonstrate that he is a physician who has been long and chronically impaired by alcohol," according to a 2005 medical board complaint.
West's supporters say he has been made a scapegoat, asserting that he is not to blame for his patients' complications and that the severity of his drinking problem has been exaggerated by investigators. "I have no information from any of my investigations that Dr. West has ever cared for patients while under the influence of alcohol," said his attorney, Dominique Pollara.
West admitted no fault in settling Anderson's malpractice lawsuit for $250,000, Pollara said. The tummy-tuck patient lost her malpractice case.
Without the assurance of confidentiality, some say, addicted doctors will go underground and continue to practice without getting any treatment at all.
Jim Conway, a Venice, Calif., drug and alcohol counselor, said that before confidential treatment programs, doctors would do whatever they could to hide their addiction for fear they would lose their licenses.
At a Pomona hospital where Conway worked, an alcoholic obstetrician came to work and delivered a baby while "dead drunk," he said. In the process, the doctor severed the newborn's spine.
"And that's how it will be if they just do a punitive approach," Conway said.
Dr. Jason Giles, a Malibu physician, completed California's program in 2004 after five years in treatment for alcoholism and addiction to prescription drugs.
"I was never intoxicated taking care of patients. It didn't get to that - but would have if I didn't avail myself of that rope dropped from the helicopter," he said.
His experience in rehab was so transformative, he said, that he quit practicing anesthesiology and opened the drug treatment center he now runs.
Giles said allowing physicians to continue to practice while in rehabilitation is crucial to the success of the treatment.
"Working actually helps them get better," he said.