Daniel Altstatt had been in Brownwood, Texas, just two weeks when 71-year-old Ruby Collier came to his office with urinary problems.

Nurses had diagnosed her with a bladder infection. But the problem wasn't that simple.

"He said, 'Ma'am, you don't have a bladder infection, you have kidney cancer,' " Ms. Collier recalled.

Now, nine months after Dr. Altstatt removed her cancerous kidney, Ms. Collier is fine. "He's a marvelous doctor," she said.

He's also a doctor who wouldn't have been there to treat her if not for the state's 2003 cap on malpractice damages.

"I wouldn't be in Texas if it weren't for tort reform," Dr. Altstatt said.

Before Dr. Altstatt came to Brownwood, the town had no urologist; the nearest was 67 miles away, in Abilene.

Dr. Altstatt – who's 38, a native of Tennessee, a graduate of Pennsylvania State University and a father of two – considered job offers from Pennsylvania to Mississippi after finishing his residency.

The fact that Brownwood, population 19,000, is small was a plus, he said. The doctor grew up in a town of 500.

But as a businessman, he also didn't ignore the bottom line.

For one thing, the Brownwood job offered a salary 13 percent higher than the one in Mississippi.

Second, Dr. Altstatt said, he would have paid $60,000 in yearly malpractice insurance in Mississippi, which has a $500,000 cap on noneconomic damages. In Texas, he expects to pay less than $2,000 this year.

Folks in Brownwood feel lucky he's there.

"Recruiting specialists in a rural community is difficult – always has been difficult," said Matt Maxfield, chief executive of Brownwood Regional Medical Center. He's still searching for an orthopedist, obstetrician and radiologist.

Only five of every 100 orthopedists, for example, will move to a community of fewer than 50,000 people, Mr. Maxfield said.

Brownwood is short on incentives to lure big-city talent – there is no symphony or five-star restaurant – but malpractice limits help, he said.

In wooing Dr. Altstatt, the hospital administrator offered a set salary until he could build a patient roster large enough to cover the overhead.

But at the end of the day, "someone has to want the quality of life offered in a small community," Mr. Maxfield said.

Luckily for Ms. Collier, Dr. Altstatt did.

She was in intensive care for three days after the doctor removed her kidney. Now she sings Dr. Altstatt's praises.

"She thinks I walk on water," he said. "But honestly, it's nothing any other urologist wouldn't do."

If you can find one.

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THE GRIEVING FAMILY:
Convinced hospital caused woman's death, relatives found limit on damages left few options

By ERIC TORBENSON / The Dallas Morning News
etorbenson@dallasnews.com

Naydene Lambert's family was ready to sue the hospital when she died after a routine colonoscopy last June.

The Gordonville woman developed a blood clot in her lungs. She didn't get blood-thinning medicine, despite a history of the problem and obvious varicose veins signaling potential clotting problems, her daughters say.

"We're not sue-happy people at all, but they killed our mother," daughter Patsy Wertz said.

But because Ms. Lambert, 73, didn't earn any money, they couldn't ask for lost wages.

That left pain and suffering – a claim that requires lots of costly experts and, because of the $250,000 damage cap, holds zero hope of a substantial award.

After expenses and attorney fees, the family would probably end up with nothing from a lawsuit, even if they won, lawyers told the family.

Ms. Wertz sat in the law offices of Van Wey & Johnson in Dallas recently, as attorney and registered nurse Maria Wormington delivered the bad news.

"She was so alive – she had mowed her own lawn the day before – and they took her away from us," Ms. Wertz said. "And we can't touch these people."

The hospital involved, the Wilson N. Jones Medical Center in Sherman, denied there was any malpractice.

"We are aware of this case and extend our sympathies to the family at the loss of their loved one. The care of this patient has been carefully reviewed, and it was determined that good quality treatment was provided to her," the hospital said in a prepared statement.

Ms. Lambert was told all went well after her colonoscopy. Two weeks later, she collapsed and was admitted to the hospital, bleeding internally, her daughters said.

Through nine days of treatment, the family watched their mother's condition grow worse and a series of treatments fail. She died June 12, 2006, after her body temperature suddenly fell to 92 degrees and the blood clot stopped her heart.

Blood clots are one of the most common causes of death in hospitals, Ms. Wormington said. Without the threat of a lawsuit, hospitals might not make the changes that could prevent other deaths, she said.

But to make Ms. Lambert's case work, Ms. Wormington would have needed testimony from at least three experts. Under the 2003 tort reform law, such testimony is required before a lawsuit can proceed.

The cost of gathering that testimony probably would run $80,000 or more, she said.

After Ms. Lambert's death, the hospital's doctor sent a sympathy card addressed to her husband and made two calls to the home to console him.

But that was just another mistake, the family says. Their father had been dead for 14 years.

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THE PLAINTIFF'S LAWYER:
Malpractice caps forced attorney to shift business, but he says it's the patients who really lose out

By ERIC TORBENSON / The Dallas Morning News
etorbenson@dallasnews.com

John Collins tried his last medical malpractice lawsuit last month.

In a Dallas courtroom, Mr. Collins was able to get a doctor to admit that he probably misdiagnosed the patient. Still, the jury found no negligence.

"We got goose eggs," said Mr. Collins, who practices with Burleson, Pate & Gibson in Dallas. "Even when you have a very meritorious case, there's always a risk."

Now that risk is tied to a much lower potential reward. Texas has capped damages for pain and suffering at $250,000.

Mr. Collins used to take two or three malpractice cases a year, but he's moving on to other areas of civil law now.

He's not bitter about the shift. Instead, he worries about the patients who get bad medical care and then can't get a lawyer to take their case.

The hurdles for pushing medical malpractice suits through Texas' legal system were frustrating even before the damage limits, plaintiff's lawyers say. Lawyers turned down hundreds of cases before trying to move one forward. And insurers seemed to figure that even if they lost at trial, they'd win on appeal. So they had little incentive to settle, Mr. Collins said.

Now, even when a Texas jury returns a big award, victims get less. A Nueces County jury decided in April that Richard Vela, a retired welder, was entitled to $1.53 million for poor care he received at a San Antonio hospital.

But after the new caps on pain and suffering were applied, the amount was cut to $397,716, and the medical center plans to appeal that, according to VerdictSearch, a national publication that tracks notable verdicts.

Any money Mr. Vela receives is likely to be cut substantially by legal costs.

The new law requires plaintiffs to file a medical experts' report just to get a lawsuit started. Gathering those experts means thousands of dollars must be invested before the suit can proceed.

Once that hurdle is jumped, defense attorneys often spit out court filings to "run up the bill" as the plaintiff's side files in response, lawyers say. That makes it even less likely that a damage award will cover the legal costs.

"It's always been tough for us," said Mr. Collins; now, coming out ahead on a malpractice case is even harder.

Those who supported the $250,000 limit happily point to data showing that the number of lawsuits against doctors has been cut in half. They applaud the lower medical malpractice insurance rates and the new doctors attracted to Texas.

But attorneys like Mr. Collins say the new caps have shut the courthouse doors to patients who have nowhere else to turn.

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THE GRATEFUL PATIENT:
His spinal infection needed treatment from a specialist – and fortunately, hospital had just hired one

By JASON ROBERSON / The Dallas Morning News
jroberson@dallasnews.com

George Rodriguez heard something pop in his back while cleaning out the dugouts after a minor league baseball game in August 2004. Only slightly alarmed, he called it a night and went home to rest.

When the 43-year-old Robstown man woke up later that night, he couldn't feel his legs. A spinal infection was paralyzing his lower body.

Paramedics rushed him into an operating room at nearby Corpus Christi Medical Center at 2 a.m.

Dr. Mathew Alexander – at the time, a 33-year-old in his first assignment as Corpus Christi's newest surgeon – decided that if Mr. Rodriguez didn't have surgery within the hour, he could be paralyzed forever.

A year earlier, a neurosurgeon might not have been available.

For four years, Corpus Christi medical officials had tried unsuccessfully to recruit such a specialist. Dr. Alexander was their first hire after malpractice caps went into effect, according to the Christus Spohn Health System, which owns the hospital in Corpus Christi.

Dr. Alexander, 35, had a stack of job offers when he finished his residency at a Wisconsin hospital. He said he chose Corpus Christi because his brother, Thomas, is a cardiologist there – and because of Texas' lawsuit limits.

The new doctor spent much of the next three days trying to mend Mr. Rodriguez. The first night, Dr. Alexander treated the spinal infection and worked to relieve pressure on nerves in his lower body.

Two days later, Dr. Alexander again went into Mr. Rodriguez's back to stabilize his spine with rods and screws, administering a series of shots to his legs at the same time.

Today, Mr. Rodriguez walks with a cane and considers himself blessed.

"I'm a fighter," the former amateur boxer explained.

He talked recently of his record from his younger days – 30 wins and 10 losses.

"I was never knocked out," Mr. Rodriguez was quick to point out. "They were all by decision."

He playfully reminds his sons, 16 and 14, that Dad is still stronger and quicker than they are, even in his condition.

Mr. Rodriguez is one of the state's 5.5 million uninsured residents. He receives no company benefits in his job as a maintenance man. But he said he got the best care money could buy on that August night, from one of Texas' newest doctors.