DOCTORS DRIVEN TO DESPERATE TACTICS

Doctors around the country are increasingly using methods popularized by labor unions to gain leverage in their fight against rising premiums for malpractice coverage. Over the past few years, their tactics have included large-scale marches, limiting treatment to emergencies or suspending service altogether. The doctors have not always been successful in gaining insurance changes, but experts say the pressure has helped move the issue up on the political agenda.

Maryland doctors have tried to galvanize support for changing how state courts judge damages in malpractice cases. Last month, about 50 doctors in Prince George's County declined nonemergency cases for a day. A similar number in Washington County refused to schedule nonemergency appointments for a week. In February 2003, most of New Jersey's 20,000 physicians took part in a slowdown for several days, canceling routine checkups and rescheduling elective surgery in one of the nation's largest walkouts ever by doctors. Emergency rooms were inundated with patients, and a rally in Trenton drew 4,000 doctors. About a dozen general and cardiac surgeons took "leaves of absence" in Wheeling, W.Va., in January 2003 as higher malpractice premiums came due, halting most surgery at three local hospitals.

In Maryland, the doctors have helped generate the pressure that led Gov. Robert L. Ehrlich Jr. to call a special session of the Legislature, set to convene on Tuesday. "There hasn't been a single state that's enacted major tort reform without physician job action," said Dr. Manuel A. Casiano, who has been practicing in Frederick for more than 15 years. Randall Bovbjerg, a researcher at the Urban Institute who follows malpractice issues, said physician activism "has become progressively more widespread" as managed care has squeezed doctors' reimbursements and made it harder to pass on their higher costs.

Doctors have traditionally concentrated on their medical practices and left the lobbying to professionals. But doctors say they now have little choice but to resort to direct action, especially as the influence of the American Medical Association has declined. Dr. Gregory Saracco, a surgeon in Wheeling, 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 Dr. Saracco, who was president of the Ohio County Medical Society at the time. "The day the leaves of absence started, I was in his office that very afternoon." The governor quickly put together a package to overhaul the system, and the surgeons began returning to work after two to three weeks.

Doctors are potentially subject to antitrust complications if they are seen to be colluding. They are careful to say they have made their decisions on job actions individually or within their practice. Carlton Carl, director of media relations for the Association of Trial Lawyers of America, a group that opposes doctors over changes in tort law, describes the doctor protests as strikes or job actions. "Clearly, this is an organized effort by the A.M.A. and state medical associations," Mr. Carl said. "It raises serious antitrust issues. And the denial of even nonemergency care is questionable for a doctor."

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