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.