It's a scenario that frightens pregnant women, ailing seniors and anyone else with health concerns: Doctors across South Carolina going on strike.

People needing care would be forced to drive to Augusta, Charlotte or some other out-of-state location for assistance.

Not likely, you say?

It's already happened in Florida, West Virginia and Nevada. Doctors there walked out briefly, leaving all but critically ill patients out of luck.

And it could happen here.

"There's no doubt about it, there will be a strike if necessary," said Harry Metropol, a physician who works out of Palmetto Baptist. "We don't think we'll have to, but we're ready to strike if we need to."

S.C. doctors say they're fed up with rising rates for malpractice insurance, and they've moved to the forefront of a legislative push to dramatically alter civil litigation in the state.

Doctors and businesses nationwide call it "tort reform" -- rules that would limit where people can sue and how much they can collect.

South Carolina last week became the 22nd state whose lawmakers are considering bills to change civil litigation laws. Congress has its own version of a bill, backed by President Bush.

But trial lawyers say it's not "reform" at all.

Billy Nicholson, president of the S.C. Trial Lawyers Association, said changing tort laws will hurt patients -- and won't lower malpractice insurance rates for doctors.

"The people of South Carolina would be giving up a lot of their rights in court for something that's not going to help doctors," Nicholson said.

Nicholson blames the rate hikes on insurance companies. Insurers have boosted premiums sharply the past couple of years to make up for what they've lost in the stock market.

Insurers counter by saying rising jury awards and settlements play a big role in skyrocketing premiums.

Columbia health care analyst Lynn Bailey said tort reform is probably not the key to reducing malpractice rates.

"It's a piece of it, but it's a simple answer to an incredibly complex problem," she said. "It's like giving an aspirin to someone suffering from a coronary."

DOCTORS FEEL THE SQUEEZE

At age 47, Sid Morrison is a relatively young doctor, at least by the standards of a profession that requires at least a decade of college education.

But Morrison, a physician with Surgical Associates of S.C. in Columbia, said on May 1 he will stop performing general surgery because of frustration with the increased threat of litigation. He'll stop handling trauma cases and other emergencies, too.

"If you're taking care of patients on the front line today, you're going to get sued, no matter how good a doctor you are," he said. "It's something that I and many other doctors find very upsetting."

Morrison said he will concentrate solely on colon and rectal surgery beginning this spring.

"I'm just tired of the emotional distress of liability," he said.

Morrison is among a growing number of S.C. doctors who are changing how they do business. Some physicians are threatening to retire early or leave South Carolina.

"I think many obstetricians here are about one to two insurance increases away from hanging it up," said Mark Salley with S.C. OB/GYN Associates in Columbia. "I know there's been talk in our group and in other groups about that, and it's not just idle discussion."

Many physicians say rising malpractice rates are cutting into their incomes and causing them to rethink the services they provide.

The average S.C. family practitioner earned $109,770 in 2001, down 13 percent from 1999 after adjusting for inflation, according to the U.S. Bureau of Labor Statistics. Surgeons averaged $140,440, down 5 percent after inflation.

"If my costs go up, I have to do something," said Lilly Filler, an obstetrician with the Women Physicians Associates and president of the Columbia Medical Association.

"There can be some increases that go on to consumers, but more often what's affected is what I can offer my patients in terms of services and what I can offer my staff in terms of salaries and benefits," she said.

DOUBLE-DIGIT PREMIUM HIKES

Many S.C. physicians pay into the state-run Joint Underwriters Association / Patient Compensation Fund, which sets malpractice rates across the state. There's no question that those rates in South Carolina have jumped sharply in recent years, especially in higher-risk specialties:

• A obstetrician now pays on average of nearly $29,000 a year, up from $7,336 in 1995.

• The average premium for a family practitioner is now $5,745, up from $1,414 in 1995.

• A general surgeon's premiums now top $21,000 on average, up from $6,158 in 1995.

While rates have gone up for many S.C. doctors, malpractice premiums in the Palmetto State remain lower than in other states. Some Florida doctors pay more than $200,000 a year in premiums, while rates in Ohio can top $150,000, for example.

"Doctors are, if anything, coming here because of our rates," said Nicholson, who practices with the firm of Nicholson & Anderson in Greenwood.

But S.C. doctors say they're being pinched on two sides. While malpractice premiums rise, the payments they receive from health insurance companies, Medicare and Medicaid aren't keeping up with inflation.

"We have probably the worst Medicaid system in the nation and pretty much the worst Medicare system in terms of reimbursement," said Rick Hobson, a Greenwood vascular surgeon. "Our rates are among the lowest in the country."

Hobson, who estimated that 60 percent of his revenue comes from Medicare and Medicaid, said more than 10 percent of his revenue now goes to cover malpractice premiums.

Columbia attorney Ken Suggs said he has the "utmost sympathy" for the financial pressure on doctors.

"But none of that has to do with verdicts and injured people," added Suggs, secretary of the Association of Trial Lawyers of America. "It has to do with inflation and the cost of health and the way insurance companies do business."

JACKPOT JUSTICE?

Doctors say unlimited punitive damages have encouraged a "lottery atmosphere" in court, where trial lawyers manipulate juries into awarding huge claims. Doctors -- and many businesses -- want a $250,000 cap on non-economic and punitive damages.

Big judgments and settlements nationwide led malpractice insurer St. Paul Cos. to quit the business in 2002, spokeswoman Andrea Wood said.

"We did not necessarily see a spike in the number of claims, but we did see an increase in the severity of claims, both in jury awards and settlements," she said. "And what that did was drive up the bar for future awards and settlements."

St. Paul ranked second in the volume of malpractice premiums it wrote nationwide and in South Carolina.

"We decided to get out of the market because we didn't see things changing anytime soon," Wood said.

Physicians also complain about lawsuits they say are frivolous, costing them time and money to fight. And they say trial lawyers rely on "venue shopping" -- increasing the likelihood of winning a big claim by moving cases to areas perceived as being sympathetic to plaintiffs.

"We need the ability that if we win in court, the plaintiff's attorneys should have to pay for our legal fees," said Glen Strickland, a Lexington surgeon.

Last year saw a 16 percent increase in the number of lawsuits filed against South Carolina doctors insured by the state's Joint Underwriters Association / Patient Compensation Fund, a shared-risk insurance pool. Some 773 claims were reported in 2002, up from 668 in 2001 and 665 in 2000, according to the S.C. Medical Association.

Doctors say odds are stacked against them in court because trial attorneys manipulate juries who don't have the medical knowledge to make sound decisions.

"The jury system fails because it's not a jury of peers, it's a jury of laypeople that can't determine between a bad outcome and negligence," Hobson said.

Concerned about being hit with malpractice suits, many doctors say they are practicing "defensive medicine." They order more tests and procedures that might not be necessary for the patient's well-being but help reduce liability if something goes wrong and they are sued.

"I can tell you there's a lot more C-sections being done because nobody gets sued for doing a C-section too soon, but there have been a lot of lawsuits when the doctor is thought to have waited too long," said Salley, the Columbia obstetrician.

Defensive medicine drives up costs, which hurts consumers and doctors alike.

Many of the problems facing the health care industry today are systemic, said Bailey, the Columbia health care analyst.

There isn't enough focus or dollars being spent on health care quality, she said. Hospitals are afraid to share information that could save lives, because detailing mistakes could lead to even more lawsuits.

"If we find a problem that can be solved by, say, laying the instruments out differently, that doesn't get transmitted across facilities because there's no clearinghouse for information," Bailey said. "Doctors are afraid they're more likely to be sued."

KEEPING DOCTORS HONEST

Helen Haskell of Columbia said she believes that changing civil litigation laws would be bad for patients -- especially children and the elderly -- who are more vulnerable physically.

Her son, Lewis Blackman, died in 2000 at a Medical University of South Carolina hospital after what hospital officials admit was a series of errors.

"As it is, doctors have very little accountability," she said. "Malpractice lawsuits are very difficult to bring, and this would make it harder."

Doctors say patients who are victims of negligence deserve to be fairly compensated.

"If there is negligence, if there is malpractice, of course the patient ought to sue," Filler said. "But I think people see this as a meal ticket. The thought is, 'Let's go after doctors, because they'll settle and we'll get something out of them.'‘"

Hobson, the Greenwood surgeon, said his malpractice rates have tripled in two years because of greedy attorneys, who stand to collect up to half of a jury's verdict.

"They can win just one of these cases, and it's worth millions of dollars to them," he said.

But trial lawyer Suggs said capping damages, one of the proposals in both South Carolina and federal legislation, hasn't worked in the past.

"The average premium in the 18 states with caps are higher than the 32 states without caps," he said.

SHOWDOWN COMING

South Carolina appears to be at a crossroads in terms of medical care.

Doctors say unless the system changes, more physicians will cut services or find another line of work.

Lawyers and patients-rights groups say major changes to the system could leave consumers out in the cold -- and bad doctors less immune to the pressures of the legal system.

Bailey said the entire health care system is on the precipice of collapse. Difficulties within the civil litigation system are just a small part of a much bigger problem, she said

"Tort reform is important, but what's really needed is to reform the entire health care system," she said. "It's a cliche, but if you fix malpractice, all you're really doing is just rearranging the deck chairs on the Titanic."