In the field of obstetrics, the number of doctors who deliver babies and provide care to the mother has dropped by 9 percent to 146 statewide in the past two years, according to the Hawai'i chapter of the American College of Obstetricians and Gynecologists.

Moreover, 42 percent of Hawai'i OB-GYNs plan to quit obstetrics, with 29 percent planning to stop delivering babies in the next five years, according to a Hawai'i ACOG survey conducted last year. On the Neighbor Islands, the situation is more critical: 67 percent plan to quit by 2009. The majority cited the risk of getting sued as the main reason.

Dr. Michele Shimizu is the only physician delivering babies in the North Shore-Kahuku-La'ie area — and she's not sure how long she'll last. As a family practitioner doing obstetrics, her malpractice insurance is four times higher than family practitioners who don't do it. She continues to practice obstetrics because her insurance costs remained level this year.

"Prior to this year, I thought I would have to stop because it wouldn't be cost effective," she said. "If (the cost of malpractice insurance) becomes too high, I would have to stop."

Over the past five years, malpractice insurance for OB-GYNs has risen by 53 percent to $62,500, said Paula Arcena, executive director of the Hawaii Medical Association. Premiums are higher than for other fields because babies are involved; if something goes awry, insurers have to pay for the care of infants for the rest of their lives.

Meanwhile, the median take-home pay for obstetricians has dropped 17 percent over the same period of time, said Dr. Nathan Fujita, ACOG's Hawai'i section chairman.

One reason doctors' pay is dropping is because health insurance companies are cutting the amount they reimburse doctors for certain procedures.

Dr. Linda Rasmussen, an orthopedist who works the emergency room at Castle Medical Center, is facing not only increases in malpractice costs but also a decline in reimbursements from insurance companies. Richard Ambo • The Honolulu Advertiser

But lawsuits are the main concern. The average practitioner is sued 2.6 times during a career, according to a national ACOG survey.

As a result, "doctors are giving up obstetrics. It may come to a crisis before (the Legislature) will do something," Fujita said.

For instance, there are no doctors who deliver babies anymore on Moloka'i, he said. Midwives, whose malpractice insurance is paid by the state, are doing the job. If a mother suddenly needs a Caesarean section, she has to be flown to Honolulu, which could take two hours. In cases of fetal distress, where the baby's heart is in trouble, such a delay can be risky.

The Kona Coast also faces a shortage, Fujita said. The area has three doctors doing obstetrics, down from six about a decade ago, but the population continues to grow. Hilo has found it difficult to attract new OB-GYNs and refers high-risk patients to Honolulu.

In Maui, it takes two to three months to get an appointment with an obstetrician. The two who take Quest (lower-income) patients are being overwhelmed, Fujita said in testimony sent to the Senate Health Committee.

Orthopedic emergency room work is also considered high risk by malpractice insurance companies because the doctors usually don't know a trauma victim's medical history, increasing the chances that mistakes could be made in treatment.

At Kapiolani Medical Center for Women and Children, there are no orthopedic surgeons taking ER calls on a regular basis. Castle Medical Center in Kailua has coverage for only half the week.

Pat Oda, a spokeswoman for Kapiolani Medical Center for Women and Children, said the hospital can call in pediatric orthopedic surgeons for emergencies. Castle Medical spokesman David Earles said the hospital is working on ways to boost coverage.

At The Queen's Medical Center, the state's lone trauma center that takes cases too complex for regular emergency rooms to handle, only two orthopedic surgeons are on call daily to cover major cases. That means they're essentially on call every other night, according to the Hawaii Medical Association.

It's worse on the Neighbor Islands. "It is a time bomb that's waiting to explode," said Maui Mayor Alan Arakawa. "It's the most critical issue in the state right now."

At Hilo Medical Center, for instance, one surgeon is on call for eight days a month, leaving three weeks without surgical care coverage for victims with bone injuries, said hospital director Ron Schurra.

In the past two years, Hilo Medical has tried and failed to recruit more orthopedic surgeons and other specialists. It offered an annual salary of $250,000 to $350,000, Schurra said, but that's 10 percent to 20 percent lower than on the Mainland.

Patients are forced to wait for orthopedic care, or board an air ambulance flight to O'ahu, which could take hours.

Delaying treatment runs the risk of creating additional medical problems.

"Every hour that surgery is delayed increases your chances of complications, especially blood clots," said Dr. Linda Rasmussen, past president of the Hawaii Orthopedic Association.

It used to be "standard" for orthopedic surgeons to take ER and trauma calls, Arcena said. But that was when there was a bigger pool of surgeons in Hawai'i.

Overall, the number of orthopedic surgeons in the state has dropped 29 percent over the past decade to 48 today.

Rasmussen said her malpractice insurance costs rose by 33 percent last year. She said she's also taking a hit from the health insurance companies. In the past 10 years, for instance, her reimbursement for knee surgeries has dropped to $1,400 from $4,000. She said she could quadruple her income by relocating her practice to the Mainland.

Since 2001, the average malpractice insurance premium for orthopedic surgeons has risen 45 percent to as much as $59,000, Arcena said, citing figures from the Medical Insurance Exchange of California, which insures a third of Hawai'i physicians.

"They've got to start paying the providers a just reimbursement," said Rich Meiers, president of the Healthcare Association of Hawai'i, a trade group for Hawai'i hospitals. "They've got to start paying for the care we provide. Reimbursements have been cut back and hospitals are barely able to hold on. It's a very serious issue."