Almost all surgeries were canceled at four West Virginia hospitals beginning Wednesday as more than two dozen surgeons began a protest of the high cost of malpractice insurance.

On Wednesday, at least one patient was transferred 90 miles to another hospital for an operation.

A similar walkout was averted in Pennsylvania with a promise of a plan to trim the skyrocketing insurance costs.

The West Virginia general, orthopedic and heart surgeons complain that their state has done too little to address their rising insurance costs.

Their protest was in the form of leaves of absence rather than a strike.

At least 18 of 19 surgeons at Wheeling Hospital are beginning 30-day leaves of absence, and 11 others have asked for leave from Weirton Medical Center. Two other hospitals said surgeons there were taking leave, but it was unclear how many.

All four hospitals are keeping emergency rooms open. But with the exception of plastic surgeons, they have almost no emergency surgeons available, meaning most patients will have to be transferred 90 miles away to Morgantown or to hospitals in neighboring Ohio and Pennsylvania.

Dr. Gregory Saracco, 49, a general surgeon who started leave Wednesday, said he had to borrow money twice last year to pay $73,000 a year for malpractice insurance -- $40,000 for a state plan and $33,000 to a private carrier. Those costs will go up next year to $100,000, he said.

"This is not a strike -- I'm not protesting anything," Saracco said. "I'm taking time to look at other options. But if I don't get some help to offset my premium costs, I can't operate in this state."

Saracco echoed hospital administrators in saying he and other surgeons would return to the operating room in an emergency.

"My job is to help people -- I couldn't drive past an accident on the road and not stop," Saracco said. "I don't know any doctor that could."

The West Virginia Medical Association is remaining neutral, saying the issue must be decided by local doctors.

One patient needing emergency surgery Wednesday was transferred to Ruby Memorial Hospital in Morgantown, said Donald Hofreuter, Wheeling Hospital's chief executive officer. He wouldn't give details on the patient.

Officials at the three other hospitals said Wednesday afternoon that no patients had been transferred but they were prepared to do so.

The surgeons want the state to make it harder to file malpractice lawsuits, which they say would eventually lower insurance premiums. They also want the state to seek help from insurance companies and other third parties to pay a larger share of their medical costs.

State Insurance and Retirement Services Director Tom Susman met Wednesday with surgeons at Wheeling General but could not work out an immediate solution.

In Pennsylvania, surgeons backed off their threat to close their practices Wednesday after Gov.-elect Ed Rendell promised to fight for $220 million in aid for doctors.

Still, the threat of doctor walkouts in Pennsylvania is far from over.

Dr. Seth Krum, an orthopedic surgeon at Warminster Hospital outside Philadelphia, said he is considering leaving the area for a state where insurance costs would be lower, and has already interviewed at out-of-state medical facilities.

"I've had my wife in tears for months," Krum said. "I've developed a great practice. My kids are 1 and 4 years old. I don't want to leave. But this just can't continue."

Despite concerns in Pennsylvania, Saracco said West Virginia Gov. Bob Wise should seek a deal similar to the one proposed by Rendell.

"We see what Governor Rendell is offering to get from third-party payers, and our costs would be a lot lower than $220 million, I can assure you," Saracco said.

Susman said the governor would offer details of a malpractice insurance plan in his State of the State address Jan. 8.