In an accompanying editorial, Bishop and Pesko comment that this study was the “first to substantiate the common assumption that if doctors spend and use more resources they are less likely to be sued.” However, they note that it is not possible to determine whether increased rates of Cesarean section actually represent defensive medicine, or whether they were undertaken for medical reasons, and the increased medical care led to fewer medical errors and adverse events. The researchers did not investigate whether higher spending indeed translated into fewer medical errors and adverse events. Lastly, Bishop and Pesko question whether the physicians in the higher spending categories had been sued prior to the study period. This might have motivated a more defensive medicine on the part of physicians. And a letter to the study authors4 questions the findings on grounds that defensive medicine might be only one reason why physicians might practice “resource intensive medicine.” The “real policy relevant question” might be “whether physicians use fewer resources when the threat of a lawsuit is low.”

Neel T. Shah, MD, MPP, ScB, Assistant Professor at Harvard Medical School and an Obstetrician/Gynecologist at Beth Israel Deaconess Medical Center in Boston, MA, voiced an additional concern. “Medical malpractice may be one of many factors that contribute to higher than necessary spending in healthcare,” he told MPR. “This study suggests that ‘defensive medicine’ may be effective. However, it is important to remember that more tests and treatments are not always better, and doing more than necessary in healthcare can often introduce new risks and harms.”