Placed strategically between the soothing Mediterranean scenes in the waiting room of Foris Surgical Group in Frederick are life preservers bearing a discordant message: "Save Our Doctors."
Inside each preserver ring is a notice that the practice will close Jan. 1 "due to the overwhelming burden of skyrocketing liability insurance costs."
The Maryland doctors are hardly alone in pursuing such tactics to counter rising premiums for malpractice coverage. While many doctors avoid such terms as "job action," physicians around the country are increasingly taking a page out of manuals written by labor organizers and other protest movements. They've resorted over the past few years to tactics that include mass marches, limiting treatment to emergencies or suspending service altogether.
Although the doctors haven't always been successful in gaining the insurance reforms they've sought, many industry experts and political analysts say the pressure exerted by the medical profession has helped move the issue to the forefront of the political agenda.
In threatening to lay down their scalpels, the Frederick surgeons joined efforts by other Maryland doctors to galvanize support for changing how state courts judge fault and award damages in malpractice cases. Last month, 50 or so doctors in Prince George's County declined non-emergency cases for a day. A similar number in Washington County refused to schedule non-emergency appointments for a week.
The doctors have helped generate the pressure that led Gov. Robert L. Ehrlich Jr. and legislative leaders to call an extraordinary holiday-week special session of the legislature, set to convene Tuesday.
"There hasn't been a single state that's enacted major tort reform without physician job action," said Dr. Manuel A. Casiano, a Foris member who has been practicing in Frederick for more than 15 years.
In the past few years, for example:
All the general and cardiac surgeons around Wheeling, W.Va., - about a dozen - took "leaves of absence" as higher malpractice premiums came due, halting most surgery at three local hospitals.
As many as 70 percent of New Jersey's 22,000 doctors, according to estimates by the state medical society, closed their offices, some for up to a week, to rally in Trenton, the state capital, for tort reform.
Hundreds of doctors in Florida stopped elective surgery, shut offices or cut back office hours as a four-day special legislative session convened on tort reform.
Surgeons in Nevada, angered by rising malpractice premiums, declined to sign up to be on call at the state's only trauma center, forcing it to shut down for 10 days.
Though hard to measure precisely, physician activism "has become progressively more widespread" as managed care has squeezed doctors' reimbursements and made it harder to pass on higher costs, said Randall Bovbjerg , a researcher at the Urban Institute who follows malpractice issues.
While protests over malpractice insurance bubbled up periodically in the 1970s and 1980s, doctors in the past had more leeway to raise rates to cover higher premiums. Now they are constrained by contracts with insurers. "It's quite clear the pain is worse this time," Bovbjerg said.
Those in the profession say doctors - who traditionally have stuck to their medical practice and left the lobbying to professionals - have little choice but to resort to direct action, especially as the influence of the American Medical Association has declined.
Dr. Gregory Saracco, a Wheeling surgeon, said that before taking action, doctors in West Virginia had been making little headway in getting the attention of state officials.
"The governor wouldn't talk to us for a month, " said Saracco, then president of the Ohio County Medical Society. "The day the leaves of absence started, I was in his office that very afternoon." The governor quickly put together a reform package, and the surgeons began returning to work after two to three weeks.
The surgeons did handle some emergency cases during the "leaves of absence," Saracco said; he came into the hospital, for example, to repair a ruptured colon. Other patients went to Pittsburgh, about 80 miles away, or elsewhere for care.
Joined against judge
Saracco said doctors in the Wheeling area first began organizing in 2000, when they worked, successfully, to defeat a local judge they considered unfair to doctors in liability cases. More than 300 doctors and their supporters switched their party registration from Republican to Democrat, he said, so they could vote against the incumbent judge in the primary election.
Another shutdown came in Las Vegas in July 2002, as most of the 67 participating surgeons stopped signing up to be on call for the University Medical Center trauma center.