Fromson ticks off the warning signs: verbally abusive behavior, tardiness, unexcused absences, inappropriate sexual behavior. The signs of strain tend to come first in a doctor's personal life. "When things happen at the workplace," he says, "usually they have been going on for a long time." Even then, he says, the problem may not be confronted, because most doctors are self-employed and only loosely supervised, and hospital management is often hesitant to call doctors on questionable behavior for fear that they will take their patient base to a hospital across town.
All of this means a doctor's substance abuse problem can go unchecked and then trigger a downward spiral.
And if the drug of choice is crystal meth, or speed as it's also known, the narcotic at the center of Arndt's charges, the spiral can move at dizzying speeds. In his job with the San Francisco Department of Public Health, Grant Colfax has done some pioneering research documenting the prevalence of speed in the gay community. "For many gay men, crystal meth has just completely destroyed them," he says. "People bottom out. It's a question of how far down you've fallen, and if you can get back up."
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