PHILADELPHIA - In an era of scattering families, Anthony Clay took a different route. He remained on home turf through college, medical school and residency to become a cardiologist in Philadelphia. He gets to treat families he has known since boyhood. He likes knowing where his patients live, work and shop. All nine of his siblings still live here. He never thought he would leave.
But these days, Clay is engaging his patients in the most difficult of conversations, and not about their medical conditions. He has to tell them he is leaving his practice in Philadelphia this spring because of surging malpractice insurance rates - and starting anew in Delaware, where his insurance costs will drop from roughly $70,000 a year to $8,000.
"It's been terrible," said Clay, 40. "In this field, you've been with the patient, and also the family, in some of their most life-defining moments - in the throes of a heart attack with no blood pressure.
"Wrongly or rightly, the patient credits you with being there when they weren't doing so well. You realize you've created a bond. I take that very seriously."
Pennsylvania is among a dozen states where the soaring cost of malpractice insurance is creating a desperate situation, forcing doctors to leave the state, retire early or abandon high-risk procedures, such as delivering babies.
President Bush used a visit to Scranton last month to call for a $250,000 cap on jury awards in medical malpractice cases, not including lost wages, medical costs and other economic damages. The medical establishment, which backs Bush's proposal, blames huge "pain and suffering" awards for rocketing malpractice insurance costs.
Around the nation, doctors are taking drastic measures to protest the rising premiums. In New Jersey this week, more than 4,000 doctors participated in rallies and a work slowdown in which many withheld non-urgent care. Surgeons in West Virginia and Mississippi, and doctors in Florida, temporarily walked off the job last month. During the Mississippi walkout, four hospitals canceled surgeries while the doctors were gone.
Maryland, which caps jury awards at $620,000 this year - the figure rises $15,000 a year - has so far avoided the crisis, even attracting some doctors fleeing Pennsylvania.
The Pennsylvania problem is compounded by other pressures: For one, the state has one of the lowest rates at which doctors are reimbursed by insurance companies, the result of a near-monopoly among carriers of patient insurance. For the cardiologists in Clay's practice, that means insurance costs alone - roughly $70,000 this year - can consume nearly a third of a doctor's annual income, which in that practice ranges from $220,000 to $320,000.
In addition, many of the companies that wrote malpractice policies have left Pennsylvania or stopped issuing new policies, leaving doctors to scramble for any insurance at all.
The extent of the problem is evident in a list compiled by the state's Medical Society, which lists 919 doctors who have decided to leave the state or have scaled back their practices as premiums spiraled upward over the past three years.
Most affected are specialists who perform high-risk procedures, such as neurosurgeons, orthopedic surgeons and obstetricians, whose departures have left shortages at several hospitals.
Abington Memorial Hospital, in the Philadelphia suburbs, had to send trauma patients to other hospitals for nearly two weeks in December because it had too few surgeons to treat the most severely hurt patients. Late last year, Easton Hospital in the Lehigh Valley went for a month without a neurosurgeon on staff.
In Fayette County in western Pennsylvania, three obstetricians who had been delivering nearly half the county's newborns stopped treating pregnant women after learning that annual premiums for their practice would rise from $150,000 to $400,000, and 75 pregnant women were referred to new doctors. Without obstetrics, the premiums fell to less than $100,000.
State lawmakers, criticized for letting the problems fester for years, have recently lunged into action.
Last month, Pennsylvania's incoming Democratic governor, Ed Rendell, stopped a doctors walkout by proposing a one-time, 50 percent rate break in insurance premiums for a state-run fund that covers catastrophic damages in malpractice suits.
Last year, the Legislature enacted new rules for malpractice cases: Among them, lawsuits are now restricted to the counties where the treatment occurred, preventing plaintiffs from moving their cases to Philadelphia, where juries have a history of handing out multimillion-dollar malpractice judgments.
A group of politically active physicians is urging a compromise that would limit jury awards and regulate the insurance industry.
But serious tort reform, doctors say, continues to be elusive.
"Pennsylvania has a very strong trial lawyers association," said Chuck Moran, spokesman for the Pennsylvania Medical Society, "and they have the ear of very powerful people." The lawyers contribute heavily to politicians in the Legislature, and the elected judiciary.
Mark Phenicie, legislative counsel for the Pennsylvania Trial Lawyers Association, asserts that the malpractice crisis is not the result of large jury awards but rather a poorly managed insurance industry - evidenced by the bankruptcy of several major insurers - and the state's failure to weed out bad doctors.
"For the president and medical society to arbitrarily come in with a cookie-cutter approach, a cap of $250,000, isn't fair, particularly to children and college students who might be faced with a lifetime of blindness or deafness," he said. "How do you put a figure on that? To have the Legislature come in and say, 'I didn't hear any evidence, I didn't see the trial. I didn't see the victim. We're going to supersede the jury.' This totally undercuts the jury system."
The state laws passed last year, Phenicie said, will correct much of the problem as soon as pending cases work their way through the courts.
A brutal equation
But Dr. Andrew Freese, 43, a Philadelphia neurosurgeon schooled at Harvard University and the Massachusetts Institute of Technology and trained at the University of Pennsylvania, isn't waiting around. As soon as he finds the right fit, he plans to move his wife and four children to a state with a friendlier climate for physicians.
Freese, the vice chairman of neurosurgery at Thomas Jefferson University, is overwhelmed with patients, partly because so many neurosurgeons have left the area, partly because others have given up high-risk procedures.
Patients must now wait three to four months for an appointment, some traveling two hours each way. Five years ago, he'd see 30 patients in a typical week. Last week, he saw more than 100. He's working 80 hours a week - 20 just to pay his malpractice insurance, he said.
"It's just ludicrous that I'd have to do that," he said. "It's not appropriate for patient care, for personal job satisfaction or for quality of life. It leads to burnout.
"There's a true sense of desperation on the part of patients and doctors in the state."
In the past five years, Freese's malpractice insurance bill has jumped from about $40,000 to more than $200,000, and is expected to reach about $250,000 by July, he said. A job he's considering in Wisconsin, by contrast, would cost him roughly $15,000 a year in insurance, and his reimbursement rate per surgery would roughly double.
"I can do a very demanding, high-risk operation on someone who might die if it's not done and get $2,000 to $3,000 if it goes well," he said. "If it goes poorly, I can be punished $20 [million] to $30 million. How can that disconnect be justified?
"It comes down to a false pretense that lawyers want to protect their clients, when the reality is they want to maximize their own income," he said.
The added workload has forced Freese, who is also the university's director of neurosurgery research, to give up active participation in a gene therapy program exploring novel treatments for childhood metabolic disease.
"I went in full of idealism, and now I am so pessimistic and negative about the whole process that I've thought about leaving the field of medicine entirely," he said.
The prospect of losing physicians like Freese scares Edna Leifheit, 70, of Cape May, N.J., who was among the patients who had traveled long distances to see him last Wednesday. Leifheit's orthopedic surgeon told her she'd have trouble finding a neurosurgeon in South Jersey to take on the risk of back surgery.
"I think it should be handled on a federal level," she said of the insurance crisis. "The states are not moving quickly enough."
"Two to three years from now," said her husband, Joe, "we might be in a situation where you can't find a doctor for 100 miles. Not everyone can get on an airplane and go somewhere else."
Bush is urging passage of a bill sponsored by Rep. James C. Greenwood, a Pennsylvania Republican, that would cap awards for pain and suffering at $250,000 while covering patients' medical costs and lost wages. The bill is modeled after a 1976 reform in California that is credited with holding down premiums there. Today, an obstetrician who paid about $57,000 in malpractice insurance in California would have to pay more than $210,000 in Florida and more than $116,000 in Pennsylvania, according to the Medical Liability Monitor.
"On the issue of pain and suffering, there are no rules," said Richard Corlin, immediate past president of the American Medical Association. "It's simply an emotional appeal to a jury with an injured person sitting there. Courts are not places where emotion should rule the day. Rules should rule the day."
While reform measures crawl through Congress and state legislatures, countless doctor-patient relationships are being broken apart.
For Clay, the cardiologist, the final squeeze began last fall when the 22 doctors in his practice were told that their insurance carrier was dropping Pennsylvania as of Jan. 1. Researching options for new policies, the doctors found that they faced huge costs or higher risks.
And the headhunters - who are swarming all over Pennsylvania - were at the door. Clay, who is married with three sons, decided to join a practice in Wilmington, Del., remain in his house in suburban Philadelphia and make the 50-minute trip each morning.
The human cost
The effect on his income is only part of the equation, he said. "It has changed the entire way we practice medicine. We've closed offices. Meetings often are about how can we survive rather than offering new therapies or expanding services."
Now, as he looks at his patient list in the morning, he sees the faces in his mind and winces at the thought of telling them he's leaving.
Blanche Mycek, 76, was one of the tough ones. Clay has treated her since she received a diagnosis of congestive heart failure two years ago. Clay took his time trying to find the right medication to avoid an invasive procedure, said her daughter, Eileen Ryan.
"It's exactly like he was treating his own mother," Ryan said. "His bedside manner and patience and kindness were overwhelming."
Mycek cried when Clay told her. The doctor, too, had tears in his eyes.
"I filled up. It was very emotional," Ryan said.
Ryan says she would like to follow Clay and is willing to make the hour-plus drive but fears that her mother's insurance won't allow it. An initial conversation with the carrier did not leave her optimistic. Most importantly, she worries about emergencies.
"She's so distraught over it," Ryan said. "How can you force a woman who's 76 years old with a heart condition to go to somebody else when she doesn't want to go?"