From his perch atop the dais, surgeon Anthony Coletta looked out over a billowing sea of white coats.

The assembly at the Valley Forge Convention Center had the look and feel of a political convention, with placards bobbing and signs waving. But this was no gathering of straw-hatted, cigar-smoking ward leaders, no coalition of locked-out insurgents.

Far from it. Most of the people in the rambunctious crowd of 2,000 were physicians - among the wealthiest and most privileged professionals in the nation, people whom others view as charter members of the American elite.

On this day in late April, the doctors, most of whom had never protested anything in their careers, were rocking the convention center with the roar of their voices. Many had closed their offices for the day, determined to express their fury over malpractice insurance and a health-care system they believe has gone out of control.

The hall pulsated to the beat of old rock anthems, such as Thunderclap Newman's "Something in the Air," with its dated calls to social revolution, and the perennial local rouser, the theme from Rocky.

Coletta watched approvingly from the stage as these modern revolutionaries grew angry in their protests. One placard pictured Gov. Rendell on the ace of spades, the same villainous rank that U.S. military searchers had assigned to Iraqi dictator Saddam Hussein. Another chided U.S. Sen. Arlen Specter, whose son, Shanin, is a prominent Philadelphia malpractice lawyer.

"They say that organizing doctors is like herding cats," Coletta began. "Well, welcome to the cattery."

As a call to arms, the demonstration was unique for its participants, unusual for its tenor, and more than a little odd. Here were some of the more eminent people in society, professionals who enjoy more education and higher pay than almost all other Americans. Yet they felt themselves forced into the streets, parading in public to articulate a single, heartfelt conviction: that they - and by extension their patients - are being mistreated.

Ask doctors how they're enjoying their work, and you'll get an earful: frustration, indignation, pain, resentment, accusation. If there were such a thing as a misery index for doctors, it would now stand at 10. And that isn't good for patients.

"I honestly think the stress is about as high as I have ever seen it," says Daniel Duffy, executive vice president of the American Board of Internal Medicine.

"This is the worst that I've seen," adds Richard Wender, chair of the department of primary care at Jefferson Medical College in Philadelphia.

The American health-care system is a vast and often capricious enterprise, beset by spiraling costs, untold waste, and a troubling rate of error. Each of the major players - insurers, hospitals, government, pharmaceutical companies and physicians - faces its own specific stresses and turmoil.

Among these groups, physicians are reaching a pivotal moment, crossing a historical fault line when their prestige, privilege and pay are beginning to crumble, experts say.

Evidence of that decline shows in their attitudes. Last year, when the Kaiser Family Foundation asked doctors what they thought of their jobs, you might have thought they were polling migrant mushroom workers.

BB Nearly 90 percent said morale had dropped in the last five years. Only 1 percent said it had gone up.

BB Nearly half said they would not recommend the medical profession as a career for a young person.

BB Three-quarters said the time they should be spending with patients was being devoured by paperwork.

BB Most crucial for care, less than half felt they had the authority to make clinical decisions that were best for their patients.

What's driving doctors crazy is the same thing that exasperates people who write software, edit newspapers, and build cars: The bean counters have taken over.

Money is no longer just part of the equation. Too often, it's the deciding factor.

Physicians are especially vulnerable to their pinstriped overlords because, unlike most businesses, they can't simply raise their prices when their costs go up. Payments to doctors are set by the government or frozen in insurance contracts. By comparison, if an attorney faxes a document, advises a client on the phone, or thinks about a court case in front of his shaving mirror, he can bill the client for his time. Doctors can't do that.

As malpractice insurance premiums have soared, zooming about 50 percent in each of the last two years, doctors have had to pay the added cost out of their own pockets. Some can no longer find an insurer to write them a policy. Many are now being lumped with bad drivers, having to enroll in Pennsylvania's Joint Underwriting Association, the state-run malpractice insurer of last resort.

Even doctors who aren't losing money are losing something that many cherish even more: autonomy. Today, insurers often tell them how to practice, whom to test, and what drugs to prescribe. Many doctors now work under productivity requirements that force them to see more patients and send them running from room to room, scurrying like hamsters in a wheel. Increasingly, doctors are using their precious office hours to lobby patients, handing out literature and asking people to phone legislators to help save the healing profession.

Meanwhile, a new patient-safety movement is measuring doctor performance more closely than ever before. In Massachusetts, doctors see their malpractice suits posted on a state-run Web site; officials in Pennsylvania and New Jersey are considering similar sites.

"It's not the halcyon days of the past, when they really didn't answer to anybody," says John Zamzow, an Independence Blue Cross vice president who oversees physician contracts.

Before managed care took hold in the 1980s, doctors and patients shared the same goal: Patients wanted to get sophisticated care. And doctors wanted to give it to them, without regard to cost. But that changed as HMOs instituted procedures that held down expenses by limiting care. Those measures have driven a wedge into the traditional doctor-patient relationship, rewarding physicians for doing less and making some patients question their doctors' decisions.

It's hard to overstate the bitterness that doctors harbor toward the managed-care companies. More than three-quarters told the Kaiser Foundation that the firms had hurt their ability to tailor treatment to patients' personal circumstances. Almost all say managed care has increased their paperwork. It has definitely sapped the joy from their work.

"It's not as much fun as it used to be," Haddonfield gynecologist Joseph A. Riggs says.

Doctors might not be so bitter had they been raised in a previous era, when physicians were less valued. But beginning in the early 1900s, doctors began to consolidate and expand their authority. For the last 50 years, the prospect of becoming a physician - or marrying one - was the grandest of dreams. Doctors were respected, honored members of their communities, men and women - mostly men - whose opinion was the last word on any subject. They were less MDs than MDeities.

Yet today, many health and insurance publications don't even grant the courtesy of calling them doctor. Now they're grouped in with "care providers."

They shouldn't be surprised. More than 20 years ago, Princeton University professor Paul Starr predicted the slide of the profession in his classic book The Social Transformation of Medicine.

The time when doctors could rule with "economic power and cultural authority" was passing, he wrote. "The last decades of the 20th century are likely to be a time of diminishing resources and autonomy for many physicians."

Eliot Freidson, a professor emeritus of sociology at New York University who has studied the profession, believes doctors' current turmoil is only a preview. The future will hold an ever-increasing focus on cost. Shorter appointments for patients. Shrinking salaries for doctors.

"Their expectation of what their practice is going to be is based on things that have already disappeared," Freidson says. "The great time when they were self-employed, and they could choose their patients, bill and decide what to charge - these things are largely gone."

To outsiders, Family Practice Associates of Upper Dublin looks to be another flourishing business in a prosperous Montgomery County suburb. The eight-doctor practice has added 1,000 new patients in each of the last four years - without spending a dime on advertising.

Normally, such strong annual growth is the hallmark of a booming enterprise.

But not in medicine.

The reality is that rising costs, flat payments and an excess of paperwork have put the practice on shaky ground. The doctors took pay cuts - they earn 15 percent less than they did in 1994 - and the practice has contributed to their retirement plans only once in the last six years.

The practice is $50,000 in the red.

"We're pedaling harder and losing ground," says David J. Badolato, the managing physician. His long-term diagnosis? "The end is in three years if I do nothing."

Badolato, 53, is a fanatic for details, and he has tracked the practice's performance with the zeal of someone who, after 25 years, remains passionate about healing. He can tell you how many patients each doctor sees a day, the reimbursement fees paid by different insurers, even the number of phone calls his staff handles each year - 81,000, four times the number answered by the Upper Dublin Police Department.

In March, Badolato was asked to lecture colleagues from across the nation on the challenge of maintaining high-quality health care in today's marketplace. For years, he has compiled charts showing how the practice exceeds the quality standards recommended for diabetes, heart disease and other illnesses. Yet, in the inverse world of modern medicine, quality hasn't helped the practice's bottom line. In fact, it may be hurting it.

He and his colleagues say their efforts to comply with an unwieldy sprawl of health-care regulations have mostly succeeded in choking their office with paperwork. The practice now employs four staff members to support every doctor - up from three a decade ago. The doctors complain that their work has become as much secretarial as medical, that an outside bureaucracy isolates them from patients and forces them to spend hours performing arcane administrative dances to reorder drugs and gain approval for routine procedures.

"The biggest problem, day to day, is everything competing for our time," says Adam T. Turk, a physician in the practice. "As we are bombarded by new things we have to do - mostly unreimbursed - we have less time to perform our mission."

In the old days, when a patient needed a prescription, the doctor would write a script to be filled at a drug store. Now, a vast apparatus aimed at slowing the rising cost of drugs has been created to look over the doctor's shoulder. Many prescription-drug insurance plans now come with formularies, lists of preapproved drugs. If the doctor prescribes a drug that's not on the list, the insurer may not pay for it.

Insurance companies don't like to pay for newer, higher-priced brand-name drugs, preferring that doctors try to substitute older medicines or lower-cost generics.

And, because different health plans often have conflicting formularies, doctors frequently find themselves scrambling to find a compromise drug. Badolato and his colleagues estimate that 20 percent of their prescriptions are rejected for one reason or another. Something that used to be simple has now become burdensome.

Insurance executives say the restrictions are sorely needed, because doctors showed no interest in restraining costs. Doctors view the formularies as an intrusion, saying the drug that emerges from this negotiation may not be best for the patient.

"It's no longer ((about)) what I believe is good for you," says Ira Z. Gerstman, a doctor who helps Badolato manage the practice.

In many ways, Upper Dublin Associates is a microcosm of the state of family practice - which has long been recognized as the front line of medical care, but is now threatened with extinction. Young doctors don't want to hear about 15 percent pay cuts. So they're pursuing other specialties. Nationally, the percentage of medical-school graduates who enter family practice has dropped for six straight years.

"If things continue as they are, you'll see the family doctor disappear," says James C. Martin of San Antonio, Texas, president of the American Academy of Family Physicians. "If trends continue, there probably won't be family practice 30 years from now. That should be frightening to everybody."

The Upper Dublin doctors speak angrily about how outside agencies have grafted a multitude of trivial, tangling duties onto their practice. Near the top of that list is what's known as a "pre-cert."

When doctors order a sophisticated treadmill stress test or a magnetic resonance imaging scan for an HMO patient, they often must apply to the insurer for a pre-certification. That's a document that says the insurance company has reviewed the request and agreed that the procedure is necessary.

Doctors say the process is often an empty exercise. The tests are nearly always approved - after time is spent on additional faxes or phone calls.

"There seems to be no rationale for doing it, so why are we doing it?" asks Colleen Devinney, another physician in the Upper Dublin practice.

In the face of these rising demands, Badolato says, the practice has struggled to keep the average patient visit at a full 15 minutes, believing a shorter time would compromise the quality of care.

"You can't hear about depression or erectile dysfunction in seven minutes," Badolato says. "You just can't crunch it down too much. The day I have to do that, I'll quit."

That day may be coming. Badolato recently learned that his malpractice insurance company will be leaving the state. It looks as if his $10,000-per-doctor rate will more than double.

"Those are devastating numbers," he says. "It basically means that either you quit or you take it again out of the doctor's salary. Where else does it come from?"

It's hard to feel sorry for doctors, mostly for one reason: They pull down salaries the typical working stiff can only dream about.

Any discussion of rising malpractice-insurance costs or dwindling reimbursements must also consider pay - and doctors earn more than most people.

When a rookie assembly-line foreman shows up for work at a plant in Akron, Ohio, he can expect to earn $30,612, according to data compiled by the Wall Street Journal. In San Francisco, a new assistant director at an art gallery will earn about $50,276, and a librarian in Peoria, Ill., will start at $20,453.

But the general practitioner - the lowest-paid and least-specialized of doctors - can expect to start at $125,000 a year, according to the National Association of Physician Recruiters. Specialists will earn as much as $200,000 in their first year.

Moreover, within three years the doctors' salaries will soar: To an average of $279,000 for cancer doctors, $300,500 for cardiologists, and $559,000 for cardiovascular surgeons.

"Before managed care, physicians were paid more to do more, and all the fat in the health-care system went to physicians' salaries - to the tune of an average 10 to 15 percent salary increase per year," University of Pennsylvania bioethics professor Glenn McGee wrote on MSNBC.com.

Many people don't begrudge doctors' their high pay - who better to earn a good salary than the person making life-and-death decisions? And doctors point out that everything is relative - their best-paid brethren earn a fraction of the $116 million that Tenet Healthcare Corp. paid former C.E.O. Jeffrey C. Barbakow last year. Tenet is the for-profit company that owns eight area hospitals.

Doctors in the Philadelphia region say they're underpaid compared with their colleagues elsewhere, because the economic trends that bedevil medicine are more pronounced here. That makes it hard for practices to hire young doctors or find replacements for those who leave.

And doctors point out that those big beginning salaries come tethered to a weight that people in other jobs don't bear: a ton of debt. Medical school costs a fortune, and the loans accumulated there will follow a doctor for years.

Last year, at the moment the typical med-school student collected his or her diploma, he owed $104,000 in loans, according to the American Medical Association. In interviews, several local doctors asserted that the number was far too low, that the actual debt is closer to $200,000.

After graduation, new doctors generally spend three years training as residents, usually at a hospital, where they work for peanuts - 12 to 18 hours a day for $30,000 to $50,000 a year. By the end of their residency, the average debt will have grown by about 15 percent, according to the AMA.

It's the lower-paid family practice doctors who have the hardest time repaying those loans.

"Our medical debt exceeds the mortgage of our house," says Upper Dublin's Devinney, whose husband is also a physician. "We are living week to week."

Last summer, when G. Fred DiBona attended a casual dinner party at a friend's oceanfront home in Margate, N.J., he was looking forward to enjoying the fresh sea breezes.

It wasn't long before a storm blew in. As DiBona tells it, half the 80 guests were doctors, and when they found out who he was, many began circling him like seagulls over a fish.

Because DiBona, as president of Independence Blue Cross, has considerable say in how much doctors are paid for providing care to their patients. Doctors view IBC as a prime source of their misery, a callous corporate machine that holds monopoly power over the Philadelphia market. And DiBona is its public face.

That night, as the questioning grew hotter, the hostess' daughter fled to the kitchen, fetching her mother to rescue DiBona. The hostess called him the next morning - in tears - to apologize.

"My comment was, 'That was easy stuff,' " DiBona recalls. " 'You should come in on a Monday morning.' "

If you did walk into DiBona's 45th-floor office, the first thing you would notice is the industrial-size jar of Tums on his desk. The antacids were placed there only half-jokingly, a symbol of the pressures he's facing.

DiBona says he's the man in the middle, caught between doctors who demand higher reimbursements and employers who insist on reasonable premiums.

"You feel as though you're in a vise," DiBona says. "You want to do the right thing for everyone. You want to be fair-handed. Every time you increase a physician reimbursement, you increase the cost for your customer."

Moreover, he and other Blue Cross officials say doctors' feverish descriptions of dwindling reimbursements are only partly accurate. True, reimbursements hardly rose during the 1990s. But since August 2001, the company says, fees to doctors have gone up 21 percent.

"You'll never hear them say, 'IBC doesn't pay us enough, even though they've come up 21 percent recently,' " says Zamzow, the Independence vice president.

Independence Blue Cross' total medical expenses have doubled in the last four years. That's created real hardship for employers who have to pay higher premiums, and for employees who have to forgo pay raises or even give up their coverage.

People in this region have unusually good access to health care, including teaching hospitals that offer the latest technological advances, and they take full advantage of it. One measure of health-care use is the total number of days per year that insured patients spend in the hospital. Nationally, the average is 682 days per 1,000 members. Here, it's 846 - almost 25 percent higher. That's a lot of extra patients and extra care - and extra cost, DiBona points out.

Still, he says, there's no question the health-care industry has been rough on physicians.

"If I had the power to simply write blank checks for them, I would," DiBona says. "But I have a whole different constituency to address."

And that means DiBona is likely to face more dinner-party inquisitions. "To a person who would be observing it for the first time, they would probably say, 'Wow.' For me it wasn't 'Wow,' " DiBona says. "It's more of a sense that this is really a tough business."

It's a clear and sunny Monday, the start of the workweek, but at midmorning Stephen Emanuel is not at his office treating patients. He's hunched over his kitchen table, drinking coffee.

"I'm retired. I'm out. That's it," he says flatly. His former patients' medical records fill several filing cabinets in his garage.

He wishes it were different. But Emanuel, a 66-year-old ob-gyn, says he's been forced out of medicine, compelled to give up the work he loves because of the spiraling cost of malpractice insurance. In many ways his story is that of modern obstetrics - great personal satisfaction and terrible legal risk.

For most of 35 years, Emanuel delivered babies and performed surgery, maintaining a two-office practice with privileges at Lankenau Hospital in Wynnewood. He cared about his patients, he says, and they cared about him.

Malpractice rates intruded on that relationship. Emanuel's insurance, which cost $100 in his first year, would have hit $89,000 two years ago, had he been able to afford it.

At the same time, reimbursements were dropping. In the early 1980s, insurers paid him $2,500 to provide seven months of care to a pregnant woman - prenatal services, delivery, and postpartum follow-up. By the end, he says, that fee had dropped to $1,500. (The fee has since rebounded to $2,000, according to Independence Blue Cross.)

Among specialists, obstetricians bear tremendous legal liability, because they're responsible not just for births but for any illness that could be traced to the deliveries for the next 23 years, Emanuel says.

That's why annual rates for some obstetricians have reached $150,000 in Philadelphia.

Emanuel bailed out long before it reached that level.

By 1997, his insurance was costing him $46,200 a year, an unaffordable drain on his solo practice. The next year, he tried to save money by lessening his coverage, switching from what is known as "occurrence" insurance to what is called "claims made." The first covers all claims, whenever they may be filed, while the second covers only those filed during the period of the policy.

That lowered his bill to about $37,300. But within two years, it had crept back up to $46,200. Worse, his new bill alerted him that in 2001 his premium would be $89,000.

So in February 2001, Emanuel stopped performing surgery and delivering babies. By eliminating those risky procedures, he sliced his bill to $29,750. About the same time - already dissatisfied with low HMO reimbursements - he stopped accepting insurance and asked his patients to pay cash. Some patients stopped coming.

In early 2002, he reduced his practice further, to part-time, bringing his insurance bill down to $18,500.

Emanuel estimates that, at that point, he wasn't even covering his expenses. He didn't mind. He was secure financially, owning a home in Broomall with his wife, Beverly S. Emanuel, who heads the Human Genetics Division at Children's Hospital of Philadelphia.

"It was a hobby," he says.

Then, in March 2002, his malpractice insurer delivered the final blow - a notice that he'd been undercharged and owed an additional $13,000. In May 2002 he closed his doors.

"It's hard not to be angry," says Mary Ann Tyler, his office manager for 18 years. "It was really painful to have to stop, because it was really out of our control. . . . We're not trying to buy him another Lexus. We're trying to keep the business open."

Now, 13 months into retirement, Emanuel says he'd like to volunteer somewhere, to provide free care to women. But that would require an insurance rider costing about $85,000, he says, and what nonprofit group can afford that?

He hates for it to end this way. His father was a doctor, practicing in Philadelphia for more than half a century, beginning with house calls during the deadly influenza epidemic of 1918-19. Emanuel grew up knowing he wanted to be a doctor, too. Today, his children have followed him, his daughter a radiologist in Allentown, his son a urologist in Washington.

"All my colleagues said, 'Why did you let them go into it?' " he says. "I guess they're like me. I enjoyed it. They watched me enjoy it. And they watched me get angry."

Contact staff writers Karl Stark and Jeff Gammage at 215-854-5363 and 215-854-2810, respectively.