By: Robyn Suriano
The Orlando Sentinel
July 08, 2003

Christine Mills found the lump in her breast in March. But later, when she tried to get an appointment for a mammogram, the 43-year-old Orlando woman was told she would have to wait until September -- nearly four months.

Mills, whose family has a history of breast cancer, knew waiting that long could put her life at risk.

So she worked the phones until she managed to get an appointment in May at a Longwood facility. The tumor proved to be malignant, and Mills had surgery in June.

Her fight for what many consider to be a basic, lifesaving test illustrates a growing trend in Florida, where fewer doctors are doing procedures such as mammograms that carry a high risk of lawsuits.

Physicians also are cutting back on the number of hospitals where they practice, in part to reduce their hectic schedules, but also to decrease the risk of litigation. As a result, hospitals statewide have fewer doctors on call and are struggling to provide certain emergency services and lawsuit-prone procedures.

Health officials are blaming the problem on the soaring cost of medical-malpractice insurance, which they hope will ease when the Legislature meets yet again in Tallahassee on Wednesday to try to enact malpractice reforms.

"We've basically pushed our physicians to the wall with medical malpractice to the point where they're forced to make these very, very difficult decisions," said Dr. Monica Reed, senior medical officer for Florida Hospital. "What you end up with is a balancing act between providing no service for the patient against a reasonable delay in service."

Even today, Mills is baffled by her experience. After all, she works as a clerk in the radiology department of Orlando Regional Medical Center -- a job that might have given her an inside track for an appointment.

"I just kept saying to people, 'You don't understand -- I have a lump in my breast,' " Mills said. "I can't wait."

Malpractice caps sought

Doctors in Florida and many other states are facing huge increases in the premiums they pay for malpractice insurance. Some high-risk specialists, such as neurosurgeons, are being asked to pay $150,000 or more a year. Doctors and hospitals blame the rise on the increasing number of lawsuits and higher payouts.

They are pushing the Legislature to enact a variety of reforms suggested by a task force created by the governor last year. The measures include a $250,000 cap on the amount of money people could collect for pain and suffering, or so-called "noneconomic" damages. There would be no limit on awards for economic damages, such as the cost of medical care and lost wages.

Lawyers and some consumer groups are opposed to the cap, saying it demeans the suffering inflicted by medical malpractice. They say that the legal system is not to blame for the problems, which instead are rooted in insurance-industry mismanagement. Companies kept rates artificially low in the 1990s to attract customers; now they must increase them dramatically to make up for investment losses.

Doctors complain they are at greater risk of litigation when they care for patients in the emergency room. But a February report from a U.S. Senate committee shows that claims filed from ER care are dropping, said Debra Henley, deputy executive director of the Academy of Florida Trial Lawyers in Tallahassee.

Since 1990, the report counted a high in 1997 of 72 closed claims against doctors in emergency-care settings. In 2002, the number of closed claims was 46.

Trouble on the horizon?

Both large hospital chains in Central Florida say they have an adequate number of physicians on staff overall. The hospitals have contracts with some specialty groups to provide core services, such as pathology and radiology.

But the hospitals rely heavily on private doctors to help cover their emergency services. Doctors who earn hospital privileges through a screening process agree to be "on call" at times for emergencies in return for use of the facilities.

Historically, doctors often maintained privileges at several hospitals, but they increasingly are limiting themselves to one or two locations.

Orlando Regional Healthcare, whose largest facility is Orlando Regional Medical Center, counts 1,642 physicians on staff. Florida Hospital -- with Florida Hospital Orlando as its main site -- has 1,849 doctors. Neither hospital could provide data showing how staff size has changed in the past few years.

But Florida Hospital officials said 167 doctors have either relinquished their privileges so far in 2003 or asked for temporary suspensions. Officials with both chains said they are having trouble providing some emergency services at smaller facilities.

They do not claim that medical-malpractice insurance is the sole factor for the difficulties. But the insurance issues are adding to the problem, they say.

"When you get out into the smaller, community hospitals, there are a lot of specialties that are not represented 24 hours a day, seven days a week," said Dr. Arnold Lazar, an obstetrician/gynecologist and vice chief of staff for Orlando Regional Healthcare. "It's just hard to provide that kind of coverage."

For example, Florida Hospital no longer performs emergency general surgeries at its Winter Park Memorial campus. In April, the last group of general surgeons on staff dropped its privileges to consolidate its work at one location. Now Winter Park sends patients with appendicitis, stab wounds, ruptured spleens and other injuries by ambulance to Florida Hospital Orlando.

The group's decision stemmed from many factors, including simply being overburdened by the demands of two different hospitals. The doctors also worried about being busy with an emergency surgery at one hospital while the other summoned for help. Delays in care -- even when caused by work -- might become fodder for a lawsuit.

"It's a significant medical responsibility, but it's a legal responsibility, too," said Dr. Joseph Portoghese. "We just didn't feel like we could continue to do a good job in both places, and the medical-liability issues make it worse. It's not enough to say that you did the best you could do anymore."

Patients deal with delays

In addition to dropping privileges entirely, another trend is that doctors are doing fewer procedures that are considered at high risk of lawsuits.

At Orlando Regional, for example, the number of radiologists willing to examine mammograms has dropped by half during the past 18 months, said Dr. Clarence Brown, president and chief executive officer of M.D. Anderson Cancer Center Orlando.

Even when a woman has a suspicious lump in her breast, she may not get an appointment for months.

"With fewer radiologists, it's becoming increasingly difficult to schedule a diagnostic mammogram," Brown said. "Instead of days, it's weeks now."

There are fewer doctors in the country overall, and it's increasingly difficult to recruit new ones to Central Florida, Florida Hospital's Reed said. At the same time, the aging baby-boomer population is requiring more care.

"This is not sustainable over the long haul," Reed said. "We thought it was bad six or nine months ago, but I feel very comfortable in saying that it is getting worse, and I would almost go so far as saying it is getting worse by the day."

Copyright 2003 (The Orlando Sentinel)
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