The patient and her psychiatrist flew from Dulles International Airport one steamy June Saturday on an impossible mission: to scour the woman's childhood home in Illinois for proof of events that never occurred.
The 36-year-old woman's therapy sessions with psychiatrist Martin H. Stein had been dominated by horrific "memories" -- that her father, a prominent lawyer who had been dead for more than a decade, was a leader of a racist satanic cult. She told Stein she had been sexually abused by him and other cult members who forced her to kill and eat a baby. She said she stood on the basement steps of her family's house and watched her father shoot numerous black men, among them a handyman who worked for the family.
None of it ever happened, the woman's family said. The Virginia Board of Medicine said Stein used hypnosis, suggestion, massage, psychiatric drugs and the trip to Illinois to evoke the memories -- all of which were uncorroborated or disproved. The handyman, for example, actually died in a hospital after a long illness.
The story of the Fairfax County homemaker -- identified as Patient C in the board's ruling suspending Stein's license -- is the most extraordinary of the 10 cases cited by the board. It highlights the life-altering influence a psychiatrist can exert over a patient and underscores the unusual nature of Stein's practice.
At the time of their 1998 trip, financed from the woman's seven-figure trust fund, Stein was involved in an intense relationship with her, which included "sexually intimate behavior," according to the board. Stein urged the woman to divorce her husband and advised her that spending the inheritance would be "therapeutic," the board found.
Their remarkable 2½-year relationship is chronicled in a 500-page complaint the woman's ex-husband submitted to the medical board in November 1999. The complaint, which includes e-mails, medical records and other documents, became the basis for portions of the consent order Stein signed last year when he surrendered his license. It alleges, in painstaking detail, the destruction of a family and the increasingly precarious condition of a woman with a history of serious mental illness who endangered her children and sacrificed her financial security in a desperate attempt to please her doctor. The woman's two young children also are among the patients cited in the order.
The board found that Stein referred the woman to an Alexandria divorce lawyer who is his friend and diagnosed her as having eight psychiatric disorders for which he prescribed about 30 drugs. It concluded that he gave her financial advice, accepted expensive gifts from her and arranged a meeting with his sister to talk about sexual abuse. The board found that he showed the woman a videotape and discussed the treatment of another patient, identified elsewhere as Ruthann Aron, the Montgomery County politician charged with hiring a hit man to murder her husband. Stein was a key defense witness at Aron's trial.
Stein misdiagnosed Patient C's 4-year-old son and gave the boy and his 7-year-old sister powerful psychiatric drugs that had not been approved for children, the board also found.
"What happened here is that someone who went to a psychiatrist for help comes out of it with her life destroyed," said Walter, the woman's former husband, who spoke on condition that his last name not be published to protect his children's pricy. "I basically lost everything. And my kids? Well, who knows what the long-term damage might be."
Walter said his former wife, whom he sees frequently, has been cautioned by her attorney not to talk about Stein; the attorney confirmed this. In September 2001, Stein agreed to pay the woman about $200,000 to settle a lawsuit in D.C. Superior Court alleging medical malpractice, sexual battery and fraud. All records in the case were sealed by a judge at the request of both parties. Walter estimates that his former wife gave Stein $200,000 to $250,000 in fees and gifts.
Walter said his former wife consulted Stein in September 1997 because she thought she might have attention deficit disorder. A few weeks after their initial meeting, Walter said, Stein summoned the couple to his office. "He told me [she] had bigger problems [than ADD] and started showing me these devices, including a battered metal baby cup, that he said were used by satanic cults."
Stories about ritual sexual abuse by satanic cults -- increasingly fantastic tales about organized devil-worshippers who abused and killed young children -- circulated in mental health and law enforcement circles beginning in the 1980s. The phenomenon had been discredited in mainstream psychiatric circles well before 1992, when a noted FBI behavioral scientist, Kenneth Lanning, issued an influential report saying that despite extensive investigation, there was no evidence of such cults.
Stein disagreed. In 1995, according to a teenage patient and her mother, he kept trying to convince the girl that her estranged father had been a cult member. The patient, now 22, said Stein threatened her with hospitalization if she did not "remember" the abuse.
In November 1997, Walter said, Stein drove Walter's wife to the Psychiatric Institute of Washington, where he had privileges. Walter said Stein told him at the hospital -- where Walter's wife spent nine days -- that Walter's nine-year marriage was over and blamed him for his wife's hospitalization. "I went home, and I didn't know what to do," Walter recalled. "I concluded that she was crazy and that I wasn't going to leave the children."
Within weeks, Walter said, his wife began spending as much time as she could with Stein. She left home at 5:30 a.m. to bring Stein coffee and bagels and returned later than 10 p.m., after she had delivered the psychiatrist's dinner.
Stein billed her $450 for two-hour therapy sessions, which were sometimes as frequent as six days per week, Walter said. The board found that he also allowed her to fill canceled appointments and rented her a room in his office for a daily rate of $100 so she could "hang out." She confided to her sister that she couldn't live without Stein and threatened to kill herself by starving. At one point, records show, the woman, who had a history of anorexia and bipolar disorder, stopped eating and lost 20 pounds. The board found that twice she took overdoses of medication Stein prescribed, yet he failed to send her to an emergency room.
Stein seemed to encourage the patient's dependence: He took her with him when he taught at George Washington University's medical school and accompanied her to doctor's appointments, sometimes going with her into the examining room, according to documents that are part of the complaint.
Six months after she started seeing Stein, a Merrill Lynch vice president handling her brokerage account questioned Stein's fees and expressed amazement at the $60,000 she had given Stein, according to a statement the woman's sister submitted as part of Walter's complaint. The broker warned her that if she did not curtail her expenses, her trust fund, which then substantially exceeded $1 million, would be exhausted in a few years.
At the same time, Walter said he and her siblings, alarmed by her condition, consulted a dozen prominent psychiatrists across the country. Most advised that they obtain a second opinion, a plan that Stein discouraged, the board found.
Stein's attentions were increasingly directed at the woman's children, especially her young son, whom the psychiatrist decided was seriously mentally ill. The medical board found that Stein misdiagnosed both children and continued to be involved in their care over Walter's written objections and in violation of a court order. On one occasion, the board found, Stein bound the boy's feet and ankles with electrical tape in front of his sister because his mother said he was "out of control."
William Stage, a child psychiatrist who treated both children for several months, said he thought at the time that "the kids and their father were okay and [their mother] was making them sick." The board found that several other child psychiatrists failed to find any evidence of the multiple problems Stein diagnosed in the boy other than depression.
In September 1999, a judge awarded both parents joint custody of the children but explicitly barred Stein from involvement in their care, an order the board found Stein violated.
In January 2000, the relationship between Stein and the patient ended abruptly, for reasons that remain unclear. About that time, Walter said, the medical board, which had received two complaints about Stein in 1999, began its investigation.
Walter said that his ex-wife has found a new therapist and that his children are being treated by a child psychiatrist at Johns Hopkins Hospital and seem to be coping well. He said he is trying to put the ordeal, which cost him his marriage and more than $60,000, behind him.
"I lost everything," Walter said, "and I had to basically fight this by myself. Unless you force the board to act, they will protect doctors."
Anita Kratzke hadn't been feeling well in the days before she died. Her body was still in bed, tucked under her comforter, and there were no signs of violence.
So when the Fairfax County detective who had been called to the Reston home to investigate Kratzke's sudden death spotted several bottles of pills near her bed, she called the doctor who had prescribed them.
Martin H. Stein said he was Kratzke's doctor and would sign the 49-year-old woman's death certificate, police reports said. No autopsy was performed.
Police said Stein never explained that he was a psychiatrist treating her primarily for back pain, not for any life-threatening condition.
"Cardiac arrest," Stein wrote on the death certificate. He did not examine the body, nor had he documented a visit with her in eight months.
Stein, once listed among the region's best psychotherapists in Washingtonian magazine, would say later in court papers that he had no idea what killed Kratzke.
More than 2½ years after Anita Kratzke's death on March 19, 2000, the Virginia Board of Medicine ruled that Stein was a danger to public health and that his signing of the death certificate without proper investigation was part of a pattern of negligence. The board's 22-page order details ethical breaches, misdiagnoses and the inappropriate and excessive prescribing of drugs, including narcotics, in the treatment of 10 patients Stein saw between 1991 and 2000.
The board found that Stein had sexual relations with a patient, treated children even though he is not a child psychiatrist and was responsible for the deterioration of several people under his care. Despite the severity of the violations, Virginia's medical board did not revoke Stein's license. Instead, the 63-year-old board-certified psychiatrist signed a consent order last Oct. 11 agreeing to surrender his license for at least a year. He can apply for reinstatement next month. The D.C. Medical Board issued an emergency suspension based on Virginia's order and revoked Stein's license July 9.
Stein's story provides a rare, unusually detailed examination of the failures of a flawed system that purports to protect the public. His case raises questions about the speed and adequacy of discipline meted out by medical boards -- a slow process enveloped in secrecy that critics say harms vulnerable patients by allowing bad doctors to keep practicing -- and about the medical profession's ability to police itself. This report is based on more than 100 interviews with former patients and their families, physicians, hospital officials, lawyers and medical board and law enforcement authorities, and on thousands of pages of documents filed with two medical boards and courts in the area.
Among the patients cited by the board were Anita Kratzke, her husband, Robert, and their youngest son, Chris, whose simultaneous treatment the board called a "clear conflict of interest." The board found that Stein's treatment of Robert Kratzke caused him irreparable brain damage that forced him to retire on disability from his GS-15 engineering job at the Department of Energy. Chris Kratzke got so sick under Stein's care that he was committed to psychiatric hospitals for more than a year. The board also cited Stein for not properly managing more than a dozen medications, including powerful narcotics, he prescribed to Anita Kratzke.
"He totally wiped out my family, and we had to start over," said Robert Kratzke, 52, who pulled up three decades of roots to build a new life in Honolulu for his sons. "Our life was totally destroyed."
Beyond the Kratzkes, the board found that Stein "engaged in sexually intimate behavior" for more than two years with a patient to whom he rented a room in his Arlington office for $100 a day and charged her $200 an hour to go on shopping trips and visit her home. Stein flew with the 35-year-old woman to her home town in Illinois -- at her expense -- to "evoke memories of childhood abuse." Other documents submitted to the board say Stein encouraged the woman to "remember" that her father had been active in a satanic cult that sexually abused her and forced her to kill and eat a baby. The report concluded that Stein misdiagnosed and drugged her 4-year-old son, once binding the boy's ankles with electrical tape after his mother said he was out of control. None of the patients was named in the board's order.
Stein has declined more than a half-dozen requests for comment. One of his attorneys, Geoffrey Gavett, said, "We've reviewed the requests from The Post to comment, and after careful deliberation we've concluded it's not appropriate." In court papers, Stein has denied mistreating his patients and said the care he provided has always been in their best interests. Although Stein agreed not to contest the findings of the board, he did not admit they were true. He has told colleagues and others that he was suffering from undiagnosed bipolar disorder while treating many of the patients cited by the medical board.
Stein was well known to the Virginia board years before his suspension. A 1995 complaint by the father of a teenage patient was closed in 1998 without any action. A 1999 letter by a Northern Virginia internist triggered a second probe that ended more than three years later with his suspension. In the interim, there was no way a patient could have known Stein was under investigation. Board officials say that 85 percent of the approximately 1,500 complaints it receives annually do not result in disciplinary action and must remain confidential. Anyone who checked would have been told that Stein had a clean record. Of the 10 patients cited in the board order, nine consulted him in 1995 or later.
Nor did the board do anything to protect the public by suspending Stein's license while it investigated the complaints. Six malpractice suits have been filed against Stein since 1995; four are pending, one was settled, and one was withdrawn.
Even the doctor who reported Stein to the board was angered by how long the process took. "The board is incapable of getting rid of bad people," the internist said, speaking on condition of anonymity. "I kept calling and calling, and nothing happened. The fact is, the public is not being protected."
Medical board officials say changes are underway and they already have cut the time it takes to resolve complaints from an average of 2.6 years in 1999 to 1.3 years last year.
Stein's case highlights another systemic flaw that imperils patients: a lack of oversight that allows doctors -- especially psychiatrists, who tend to practice alone in an office -- enormous discretion. Physicians are further shielded from scrutiny by what patient advocate Peter Lurie calls "the thin white line" -- the fierce reluctance of physicians to report a colleague they suspect or know is incompetent, impaired or dangerous. Under Virginia law, doctors are required to notify the medical board when they see such conduct, but that rarely happens.
"The medical profession does a really crummy job of policing itself," said a psychiatrist who reported her concerns about Stein to a Washington hospital. "Nobody wants to say anything critical about a colleague, because they don't want to get involved, they're worried about being sued and there's this feeling, 'That could be me.' "
Chris Kratzke was 7 years old when behavioral problems prompted his parents to seek help in 1995. A respected neurologist at Washington's Children's Hospital recommended that they see Stein.
"We always looked for the best care for our family, and that's what we thought he was," Robert Kratzke recalled.
Stein's credentials were impressive: degrees from Harvard and Yale, a 12-year tenure as medical director of a Northern Virginia psychiatric hospital, joint appointments in psychiatry and neurology to the clinical faculty at the George Washington University School of Medicine, and a thriving practice in Arlington.
Supporters and critics describe Stein as bright and outspoken, a risk taker who delights in challenging the orthodoxy of his profession.
But, some doctors and patients say, his rebelliousness breached boundaries psychiatrists are not supposed to cross. From the earliest days of training, doctors -- especially psychiatrists -- are repeatedly warned that they must maintain the proper physical and emotional distance from patients. Stein, though, sometimes hugged female patients or held their hands, according to several doctors and patients.
He loved to talk about himself, revealing intimate details of his life, including his use of antidepressants, according to four former patients. He once entered patient Debra Fink's room at Dominion Hospital in Falls Church, flopped down next to her on a bed and began nibbling a cupcake she had left on her nightstand, according to Fink's friend Stephanie Miller, who witnessed it.
An 11-year-old Stein treated for three years for alleged incest said he stroked her shoulders, commented on her developing breasts and advised her to gain weight to stave off unwanted sexual attention. "He told me so much about his childhood and his family that I felt I knew them," recalled the woman, now 22.
Stein's behavior was no secret among the staffs at the hospitals where he practiced, according to several doctors. It was the subject of frequent comments, especially among the nurses. One psychiatrist said she complained to supervisors at the Psychiatric Institute of Washington that Stein was behaving inappropriately, holding a patient's hand and conducting excessively long therapy sessions in unusual places, such as seclusion rooms. Their response, she said, was, "Marty does things that way." The psychiatrist said she left the hospital soon afterward. Administrators said that they found no record of the complaint and that Stein was never disciplined.
Similar complaints were rare. Medical experts attribute the silence to doctors' unwillingness to criticize a colleague and the value they place on clinical independence. The ability to practice as a doctor sees fit, however unconventional the method or dubious the treatment, reflects medicine's most ferociously defended prerogatives: physician authority and autonomy.
Some physicians fear that blowing the whistle on a colleague will brand them as traitors and subject them to ostracism and retaliation.
"There really is a conspiracy of silence in medicine," said Lurie, a physician and deputy director of the patient advocacy organization Public Citizen Health Research Group. "Doctors protect each other. The whole culture of medicine, going back to the boot camp style of residency, creates a team mentality. There's a tendency to protect people who share so much."
Hospitals are equally reluctant to censure physicians, fearing expensive and time-consuming lawsuits that could earn them bad publicity and the wrath of the medical staff on whom they depend for patients. Since the 1990 inception of the National Practitioner Data Bank, the federal government's confidential repository of malpractice payments and disciplinary actions, about 60 percent of the nation's 6,000 hospitals have never reported disciplining a single doctor. Problems are often handled informally. Sometimes doctors are given a signal that their privileges will not be renewed or are advised to resign to avoid a sanction that will appear on their records.
Howard Hoffman, medical director at the Psychiatric Institute of Washington, where Stein had privileges from 1997 to 1999, said Stein's privileges were not renewed there because "he never completed the re-credentialing process."
In a deposition, Stein said he resigned as medical director from Dominion in 1990 after 12 years to avoid being fired from that post. Hospital records show that he chose not to renew his privileges in 1992, said Brian Dearing, the hospital's chief executive officer.
Professional societies also seem reluctant to root out problems. A complaint against Stein filed with the American Psychiatric Association and its local branch, the Washington Psychiatric Society, in March 2000 by the former husband of a patient ended three years later when Stein resigned from the organizations "during the course of an ethics investigation," according to an APA spokeswoman.
Officials at both groups declined to explain why the resolution took three years.
A key reason Stein practiced so long with so little oversight is psychiatry's elastic standards. Although it is clearly malpractice for a surgeon to cut off the wrong leg, psychiatric malpractice is less clear-cut and harder to prove. Diagnosis and treatment tend to be more subjective, there are rarely witnesses, and the victim, who is being treated for a mental illness, is regarded as inherently less credible.
But Stein's prescribing of unusually high doses of medication, often for unapproved uses and in untested combinations, drew the attention of some of his colleagues. The medical board cited his misuse or overuse of drugs in the cases of all 10 patients.
"He was shameless about using these doses," said one psychiatrist. She recalled one meeting at which Stein announced that he had a patient on 180 milligrams per day of Prozac, double the maximum dose of the antidepressant recommended by the manufacturer.
"The whole room went quiet," she recalled. "But nobody said, 'Marty, are you out of your . . . mind?' " Over the years, she said, she has seen patients of Stein's who "were medicated up and down the wazoo and were completely dysfunctional. I needed to tell these patients, 'Your doctor's a quack,' which patients never want to hear. Generally what I'd say instead is, 'You should get a second opinion,' because there's this whole thing about not bad-mouthing a colleague or picking off someone else's patients."
Although some doctors consider Stein a reckless cowboy, others are vocal in their defense of him as a courageous pioneer.
One of the most ardent is Jonathan H. Pincus, chairman emeritus of neurology at Georgetown. "People hate him because he's pushing the envelope most of the time, and he would mock people within the envelope," said Pincus, chief of neurology at the Veterans Affairs Medical Center in Washington, who said Stein is "one of the most talented and sensitive physicians with whom I've had the pleasure of working." That sentiment is shared by a number of his patients, who spoke privately.
But Pincus noted that his opinion was not widely shared. "Every time his name came up, psychiatrists would roll their eyes," Pincus said. His requests that Stein be granted privileges at Georgetown University Hospital were rebuffed by hospital administrators, who cited the objections of the psychiatry department. He was rejected despite the facts that Pincus was an influential chairman with a national reputation and Stein had referred dozens of patients for neurological workups and brain surgery.
Pincus observed that "some of the things Marty said were just off the wall," such as his diagnosis of epilepsy in patients who showed no symptoms. To Pincus, this showed that his friend was a "provocateur," not that he was impaired or dangerous.
Neurologist Samuel J. Potolicchio, leader of a weekly epilepsy conference at GWU who has treated many of Stein's patients, said he respects Stein's abilities. "If I had a psychiatric problem, I would see him," Potolicchio said. "Dr. Stein took care of very difficult cases. These people would come in, and he was like a god to them."
When William Stage arrived at Dominion Hospital in 1988 after 10 years as medical director of child psychiatry at Washington's St. Elizabeths Hospital, he heard stories about his new boss. He had a favorite "drug of the year" as well as a "diagnosis of the year."
Stage was skeptical -- until he flipped through patients' charts. "I saw he was putting everyone on the same drug, regardless of their diagnosis. One year it was Tegretol," a potent epilepsy drug that can cause a fatal blood disorder.
Stage said he agonized about what to do. He worried that he lacked sufficient evidence of wrongdoing because he hadn't directly witnessed it and that if he spoke up, Stein might sue him. His wife, a clinical psychologist, warned him that blowing the whistle on his supervisor could torpedo his own career.
"What I saw was never quite enough," recalled Stage, who now is in private practice in Alexandria. "Psychiatry is a unique relationship that by its very nature is more intense, more involved and more intimate than any other field of medicine. There are not a lot of clear-cut ethical boundaries. It's very hard to define where the line is between sloppy work and dangerous work. This is a bright man, a charismatic man, who worked hard and had good credentials."
In August 1999, a Northern Virginia internist decided he had to act. One of his patients, a young woman with a history of heroin use, had landed in Fair Oaks Hospital with an arm abscessed from intravenous drug use. She told the internist that Stein had prescribed large amounts of the narcotic painkiller Oxycontin because it alleviated her depression. The internist said he called Stein, who defended his treatment and said antidepressants were not helping her.
In his letter to the medical board, the internist wrote that he had treated other patients who had seen Stein "whom I felt received excessive and inappropriate therapies."
"I wrote such a strong letter they couldn't ignore it," he recalled. "But then I kept calling the board to find out why nothing was happening."
Robert Kratzke said he and his wife were elated when Stein told them he could help their son Chris control the disruptive outbursts that stemmed from his severe learning disabilities. "This is not a big problem," Robert Kratzke recalls Stein telling them in 1995. "He'll be a new boy in a couple of months."
The psychiatrist prescribed escalating doses of powerful drugs for the boy, whom he diagnosed with three serious disorders. Soon he was treating Anita Kratzke's chronic back pain with massive amounts of powerful narcotic painkillers. Robert Kratzke, depressed about his son's worsening condition, became his patient, too.
Paul Applebaum, a Massachusetts psychiatrist and expert in psychiatric ethics who is president of the APA, said psychiatrists rarely treat members of the same family, because it poses a problem of divided loyalties.
Instead of getting better, the family got worse, the board found. Chris became suicidal and explosive and spent more than a year in three mental hospitals -- one five hours away in Lynchburg, Va. His father suffered brain damage from the drugs Stein prescribed, according to the board. His mother died suddenly at 49.
The board did not conclude that Stein's treatment caused Anita Kratzke's death but questioned his signing of the death certificate without examining the body.
After The Washington Post showed Fairfax Commonwealth's Attorney Robert F. Horan Jr. a copy of the board's ruling, he assigned a homicide detective to reopen the investigation into her death. The detective considered having her body exhumed for an autopsy but was told by experts that the embalming process would render inconclusive any toxicology tests. Stein would not talk to the detective, police said.
"In hindsight, there is a lot of indication that an autopsy was called for," Horan said. "The [first] officer didn't know the volume of medication she was supposedly taking. The reality is that without an autopsy, it's difficult . . . to prove actual cause of death. The known evidence would lean toward a drug death."
Stein said in court papers that he was pressured by the funeral home to sign the death certificate. He said he wanted to say the cause of death was unknown, but the funeral home said that was unacceptable.
In a lawsuit against Stein filed in Arlington County Circuit Court, Robert Kratzke alleges that his wife died from taking multiple, addictive pain medications prescribed by Stein that the psychiatrist failed to adequately monitor. In court papers, Stein has denied that and his lawyers speculate that Robert Kratzke may have poisoned his wife.
Fairfax Detective Robert Murphy discounts that theory and said his investigation indicates that Anita Kratzke likely died from an accidental overdose. "I also believe that her overdose was largely due to Dr. Stein's failure to properly monitor her condition and drug regimen," Murphy wrote in an e-mail to Robert Kratzke. "I believe the only way we could have known the truth was with an autopsy, which Dr. Stein thwarted when he signed the death certificate."
Stein's excessive use of numerous medications and his misdiagnoses formed the core of the board's findings involving the Kratzkes. The ruling noted that he prescribed 23 drugs for Chris, including those used to treat epilepsy and psychosis, as well as 160 milligrams per day of Prozac, double the maximum adult dose. At the time, the drug was not recommended for children.
Peter S. Jensen, a professor of child psychiatry at Columbia University and a former official at the National Institute of Mental Health, called Stein's treatment of Chris "just astounding. In my career, I've never seen these kinds of doses before." Jensen, a psychopharmacologist, called the regimen "extremely dangerous because of the risk of using medications in a way we have no information about."
Stein failed to respond to evidence that Chris was "severely deteriorating" and dismissed concerns that his treatment might be responsible, the board found.
Martha B. Denckla, a professor of neurology, pediatrics and psychiatry at the Johns Hopkins University School of Medicine, who had seen Chris for annual evaluations of his severe learning disabilities since he was 5, said she was alarmed by the "marked change" in his condition in 1996 after Stein began treating him. Denckla said she twice warned the Kratzkes that Chris was seriously overmedicated and that she saw no evidence of the psychiatric problems Stein had diagnosed.
"This had been a bright-eyed, bushy-tailed, smart, charming little kid, and he had become very unpredictable, explosive and out of it," Denckla said. After the Kratzkes twice ignored her concerns, she said, she called Stein and told him she was upset by Chris's condition. Denckla said Stein agreed that a child psychiatrist she recommended should consult on the case. He saw Chris briefly, then left for a new job in California; Stein continued treating the boy.
On Chris's 10th birthday, his parents took him, kicking and screaming, to Dominion. He was later moved to a Lynchburg hospital, where he stayed for more than a year. His oldest brother, Robby Kratzke, 33, said Chris often cried on the phone, begging to come home and asking, "Why do I have to be here?"
Robert Kratzke said Stein assured him that many psychiatric problems could be remedied by treating chemical imbalances in the brain. "He said if you're still feeling pain, then your body still needs the drug," Kratzke said. "I found him believable."
In its order, the board found that Stein prescribed "inappropriate and conflicting" medications for Robert Kratzke that resulted in permanent injury. The board also found that Stein did not respond to evidence that Kratzke was abusing alcohol as well as prescription drugs, that he repeatedly passed out behind the wheel, crashing several cars, and that he was so drugged that he fell headfirst down the stairs.
Fifteen months after he became Stein's patient, Kratzke, 47, retired on disability after a 24-year career with the federal government. Stein helped him complete the paperwork.
Even though Stein does not currently have a license, he faithfully attends a weekly epilepsy conference at George Washington University Hospital designed to teach medical students and residents, according to senior doctors in attendance.
On a recent Thursday morning, residents waited expectantly in the hospital's basement auditorium, ready for the 7:45 a.m. event.
Shortly before the start, Stein, wearing a hospital ID badge that said "Martin Stein Neurology," strode through the double doors and headed for a seat down front.
Stein offered frequent observations about a trio of patients presented on videotape, although he can't practice and his teaching appointment at GWU School of Medicine ended in June 2000, according to records.
An official of the D.C. Medical Board said it planned to send investigators to the hospital next week to determine whether Stein was practicing medicine without a license by participating in the conference.
A spokeswoman for GWU Hospital said because the epilepsy conference is open to the public, Stein's participation is permissible. "It does not mean that he is in any way participating in any decision-making about patients," she said.
But she added, "Certainly we're not happy with the fact that he was wearing his badge." She noted that the hospital has three times asked Stein to return it since October 1996, when he last had privileges there.
"I'm appalled that Stein is attending and contributing at conferences that are intended to teach residents and students proper patient care," said Donna Miller Rostant, a lawyer for the Kratzkes. She declined to discuss the Kratzke cases.
The Virginia board could have revoked Stein's license but instead permitted him to surrender it for a year. Deputy Executive Director Karen Perrine declined to discuss Stein's case but said the practical effect of a suspension at the time of the 2002 order was the same as a revocation: loss of his license for a year. In either case, she said, doctors can apply for reinstatement.
Stein's case underscores years-long criticism of the Virginia board that is only beginning to be addressed: that it rarely disciplines doctors, that the process takes too long and that punishment is too lenient, leaving the public vulnerable.
"We see a lot of bad conduct by physicians, but it doesn't get any worse than this," patient advocate Lurie said of Stein. "A year seems like a very short time, given the damage he did -- like less than a slap on the wrist.
"I think it's outrageous that someone would be able to reapply for his license, especially since there's no hoop he has to jump through, no set of clear criteria about what standards he would have to meet to get reinstated," Lurie added.
In August 1999, the Joint Legislative Audit and Review Commission, the Virginia General Assembly's investigative arm, issued a report that found that the board took an average of three years to resolve the most serious cases involving physicians and usually allowed them to continue practicing during an investigation regardless of the severity of allegations -- including the death of a patient.
Until recently, Virginia doctors faced sanctions for substandard care only if they were grossly incompetent or negligent. That threshold was so high -- higher than the standard applied to doctors in nearly every other state and to other health care workers in Virginia, including veterinarians -- that meeting it was extremely difficult. As a result, only 3 percent of cases before the board involved substandard care by doctors.
Earlier this year, the General Assembly passed a law lowering the standard from gross negligence to simple negligence and authorizing the board to revoke a doctor's license for three years, not just one.
William L. Harp, a psychiatrist who is executive director of the board, said Virginia's system is "complaint-driven" and does not attempt to uncover bad doctors. "Unless the board hears that there's a problem, the doctors are expected to be practicing good medicine," Harp said, adding that "the practice of medicine is on the honor system."
That seems to be the philosophy of many state medical boards. In 2002, according to Public Citizen, fewer than 0.5 percent of the nation's doctors -- about 2,800 of nearly 805,000 -- were the subject of serious discipline. "Too many state medical boards . . . still believe their first responsibility is to rehabilitate 'impaired physicians' and to protect them from the public's prying eyes," the group concluded.
Most boards, advocates say, are chronically under-funded, dominated by doctors -- there are 14 on Virginia's 18-member board -- and intimidated by the well-funded legal defenses that are mounted by physicians in trouble.
Physician Joseph A. Leming, who was president of the medical board during the Stein investigation, disagreed and said the board is aggressive in disciplining bad doctors. "I have never seen sympathy for a doctor be an impediment to the removal of a license," he said. "The protection of the public is our paramount concern."
Bureaucratic obstacles, Leming said, prevent a speedy resolution. Cases too often languish for months or longer before board members receive them. "I've seen reports that merited immediate suspension, and I felt the hair on the back of my neck go up, and I've asked, 'Where the hell has this been? This is a damn catastrophe,' " said Leming, whose term expired in June. "That was not uncommon."
One problem, he said, is that investigators do not work directly for the medical board but for the much larger Department of Health Professions. And, he noted, the board has no control over its budget, which is set by the legislature, or its staffing, which is controlled by the governor.
Funding is critical, Harp said. Boards that ferret out bad doctors rather than wait for complaints have many more resources than Virginia's, he said. The scheduled addition of investigators may help, he said, but may be offset by an increase in cases resulting from the lower negligence standard.
Some progress has been achieved, he said. "Resources are the key. . . . [The process] will never move fast enough for me."
Chris Kratzke is not taking medication now, his father said. At 15, he is doing well in school and played defensive tackle on the football team. Recently his artwork took first place in a state competition.
Denckla, who last saw Chris in 2001, said his dramatic improvement "is a tribute to some resilience inside the kid. It's amazing how well he's bounced back."
Robert Kratzke said his primary focus is constructing a new life for Chris and his older brother, Mike, 17. Chris, his father said, is angry and "feels like he lost a good part of his childhood."
Chris says he doesn't recall much about Reston. He remembers how his mother used to make him waffles and cut them into tiny pieces for him when he was little. By contrast, his memories of the mental hospitals remain painfully vivid.
"It was like being in jail when you don't deserve it," he said. His worst moments were the wrenching sadness he felt watching his parents drive away after their visits. "I used to really want to go home. But I couldn't."