'One-third of patients in the current medical malpractice environment do not get the right care,' said William Sage, a doctor who teaches at Columbia Law School and contributed to the Pennsylvania study.

It's called "defensive medicine" -- an extra X-ray here, an additional blood test there. And it can involve surgeons refusing to do the riskiest operations or to treat the sickest patients.

Ninety percent of physicians in high-risk specialties such as emergency medicine and neurosurgery practice defensive medicine, according to a survey of Pennsylvania doctors released Tuesday in the Journal of the American Medical Association.

Insurance Rates Lower

Pennsylvania has among the nation's highest malpractice insurance premiums, and it also has more medical lawsuits than most states. Doctors there see California's law limiting payouts in malpractice suits as a way to cut insurance premiums and curb defensive medicine.

California physicians say the state's malpractice law has helped keep insurance rates lower here. But still, the fear of litigation has dramatically changed medicine in the state, many say.

"I have been sued. You will not find a doctor who has not been sued," said Allan Siefkin, chief medical officer at UC Davis Medical Center in Sacramento. "It has changed the specialties physicians choose, where they do residencies, where they end up practicing, and what they do within a specialty."

Siefkin was just starting his career in internal medicine when California's Medical Injury Compensation Reform Act of 1975 was passed. The state law, known as MICRA, capped jury awards for pain and suffering in malpractice suits to $250,000. It did not limit economic damages for lost wages or medical bills.

While Siefkin and other physicians credit the law with reducing lawsuits and lowering premiums, doctors still see many common instances of defensive medicine in California:

Family physicians ending labor and delivery services because litigation is too common for infants with complications or birth defects.

Hospital internists refusing to put patients with severe lung disease on ventilators to open airways, fearing a lawsuit if the patient never breathed again without help from the machine.

Emergency physicians running a full battery of tests to rule out brain tumors or cerebral blood clots when patients complain of headaches.

Defensive Medicine

In 2003, California had 48 medical malpractice awards of more than $1 million, while the average payout was about $300,000, according to the California Medical Association.

"California still has defensive medicine, but it is significantly less than in places where physicians are fearful of frivolous lawsuits," said Jack Lewin, chief executive officer of the California Medical Association, which represents doctors.

For general surgery, annual malpractice premiums in 2003 for general surgeons in Los Angeles were $43,000. That compares to $226,000 in Miami, $97,000 in Detroit, and $73,000 in Philadelphia, studies show.

The survey of 824 Pennsylvania physicians in high-risk medical specialties found nearly all -- 92 percent -- ordered extra tests. Many -- 42 percent -- had restricted their practices to exclude the riskiest patients and procedures.

"One-third of patients in the current medical malpractice environment do not get the right care," said William Sage, a doctor who teaches at Columbia Law School and contributed to the Pennsylvania study.

In one respect, California benefits from the medical malpractice crisis brewing in other states. Kaiser Permanente now employs many doctors who once worked for the top hospitals on the East Coast, said Robert Pearl, executive director and chief executive officer of The Permanente Medical Group, which employs the doctors who work at Kaiser.

They came, he said, because of the culture of medicine rooted in clinical evidence at Kaiser and the low risk of career-ending lawsuits in California, he said.

"I fear that physicians across the nation still feel so personally vulnerable, they are held to an impossible standard. If you do 10,000 things for a critically ill patient and one thing of all those things is problematic, there can still be a legal problem."