The issue is malpractice, a system by which patients can receive court settlements if a doctor or physician errs in a particular diagnosis, treatment or surgical procedure.

Insurance coverage physicians are required by law to maintain for malpractice has soared through the roof, with rates physicians say consume their overhead costs, affect patient treatment and alter career decisions or planning.

In Enid, where the medical community has prided itself on expanding services and attracting more hard-to-come-by specialists, the situation and consequences are sensitive topic areas among physicians and interns.

"In many states, in your state, the medical malpractice liability system is in crises," Dr. Donald J. Palmisano, president of American Medical Association, the nation's largest doctor's group, said in a national news story. "There is an answer to this. We know what must be done."

Palmisano's statement is significant, said Enid general surgeon David Selby who is an AMA board member and a member of Physicians Liability Insurance Co. (PLICO), which provides insurance coverage for Oklahoma doctors.

"This is the first time the president has come out in favor of reform. Our (AMA) major focus is medical liability reform. Jury awards are killing us," Selby said.

Dr. Jeffrey Jones, an Enid family physician, is a recent, past president of Oklahoma Osteopathic Association. Before he finished his term in April, Jones said much of his and the association's effort was spent addressing the troubling areas of physician liability insurance. They lobbied for tort reform.

"Malpractice suits are seemingly on the increase, and the reasons are more frivolous. This is limiting a patient's access to care," Jones said.

Particular fields that have been hit hard by rate increases are obstetrics and gynecology (OB-GYN), neurosurgery and even specialty practices such as gastroenterology.

Dr. Elaine Davis is a longtime and respected Enid doctor who has served on American OB-GYN and Surgery Board.

She is retiring Jan. 1 after 37 years of practice. Why?

An 81 percent increase in her malpractice insurance premium due on that date is a big factor.

"I'm going to quit because I can," Davis said.

She can't afford $37,000 that includes privileges to do hospital surgeries.

To get extra revenue, Davis said an option would be increasing patient volume - not a very sensible or likely option for doctors going into the twilight of their careers.

What Davis and other physicians talked about over and over to help clear public misunderstanding and perception is they cannot raise their rates for providing medical care.

Health care insurance plans, that most if not nearly all patients have, set fixed rates on standards of care. Doctors and physicians cannot alter or deviate from those rates if they agree to treat patients covered by those plans.

"We have a cap on what we can earn. The insurance plans pay what is allowable," Davis said.

A vaginal hysterectomy, a surgical procedure for the removal of ovaries and Fallopian tubes that many women undergo, is an approximate two-hour surgical procedure that costs about $2,250 and includes an initial office visit, hospital stay and some aftercare examinations and treatment.

Davis showed records of major insurance payment plans that cover vaginal hysterectomies. Their reimbursements range from $1,040 to a maximum of $1,459.

Insurance payment fee schedules or reimbursements for general office visits range from 50 percent to nearly 70 percent in some cases.

A constant stream of under-valuation in reimbursements is forcing specialists to find other means to subsidize and maintain their practices, Davis said.

"To offer the specialty care we have in Enid now, in my words, it's going to be a tough proposition," Davis said.

Obstetrics and gynecology are important fields in medical care. The process of women giving birth to children and the treatments tied to it spawns huge emotions, something that can weigh heavily in a courtroom, Davis said.

An Oklahoma County jury found an OB-GYN specialist guilty of negligence earlier this month and decided a $5 million judgment for the victim.

A doctor in Oklahoma City responded in a letter to the editor that juries cannot be trusted anymore to resist the temptation of "jackpot justice" and are disregarding the consequences of cost that eventually filter down to increased medication, emergency room and health insurance costs or fees.

Dr. David Weaver, another OB-GYN physician, moved from Las Vegas to Enid and began practicing here nearly a year to the date.

He saw malpractice insurance premiums skyrocket nearly 150 percent in a short three-year period in Nevada.

What was about 10 percent of his overhead, soared to 60 percent.

Weaver, like lots of other physicians, went looking for opportunities in other states where malpractice premiums are not so outrageous.

According to AMA, Oklahoma ranks in the middle of states with increased malpractice insurance rates. Nevada is among the 20 states with the highest rates.

"Many people think doctors are making a million bucks. I sure don't see that. This is one of the few professions where costs are going up while incomes remain fixed. This is why people are not going into the medical profession," Weaver said.

It's complicated trying to make up for the widening gap in malpractice insurance premiums, some physicians said.

Increasing patient volume is not an automatic option.

"Our volume is a fairly fixed number of people," said Dr. Charles Cannon, who practices in the field of gastroenterology.

If a physician's or specialist's patient volume does go up, other variables increase, such as adding to staff to handle more people, Cannon said.

Cannon has seen an 80 percent increase in his malpractice insurance rate. He said there is "no end in sight" as to how far it may escalate.

Cannon said he is not thrilled, either, about some of Gov. Brad Henry's appointments to the state's medical licenser board, appointments that include a plaintiff attorney who has represented many clients in malpractice suits.

Neurosurgeon Bruce Pendleton has seen his malpractice insurance premium jump from $25,000 in 2001 to $40,000 in 2002. His latest bill is $75,000 for another year of coverage.

"We have no way to recoup these costs," Pendleton said. "Ours is higher because of the risky surgeries we perform. Even a law suit that seems frivolous still costs money to defend yourself, even if you are successful in getting an acquittal."

It's probable neurosurgeons likely contend more with the thought of curtailing their surgery loads because of the risk factor and consequences involved, Pendleton said.

"The bottom line is to quit and retire early," he said.

Of the 3,500 licensed neurosurgeons in the United States, approximately 300 retired or changed specialties in 2002. And not enough neurosurgeons are coming up the ranks to fill those vacancies.

Up to 150 neurosurgeon residents finished their training a year ago and have entered private practice. Oklahoma is averaging a single neurosurgeon annually who finishes residency training.

"The bottom line is access to medical care," Pendleton said.