▁average . ▁After ▁looking ▁at ▁other ▁potential ▁explan ations ▁such ▁as ▁relatively ▁poor er ▁health ▁or ▁medical ▁mal p ract ice , ▁G aw ande ▁concluded ▁the ▁town ▁was ▁a ▁chief ▁example ▁of ▁the ▁over use ▁of ▁medical ▁services . ▁G aw ande ▁concluded ▁that ▁a ▁business ▁culture ▁( phys icians ▁view ing ▁their ▁practices ▁as ▁a ▁re venue ▁stream ) ▁had ▁established ▁itself ▁there , ▁in ▁contrast ▁to ▁a ▁culture ▁of ▁low - cost ▁high - quality ▁medicine ▁at ▁the ▁May o ▁C lin ic ▁and ▁in ▁the ▁Grand ▁J unction , ▁Colorado , ▁market . ▁G aw ande ▁ad vised : ▁ ▁Medical ▁mal p ract ice ▁laws ▁and ▁def ensive ▁medicine ▁ ▁To ▁protect ▁themselves ▁from ▁legal ▁pro sec ution ▁U . S . ▁phys icians ▁have ▁an ▁in cent ive ▁to ▁order ▁clin ically ▁unnecessary ▁tests ▁or ▁tests ▁of ▁little ▁potential ▁value . ▁While ▁def ensive ▁medicine ▁is ▁a ▁fav ored ▁explanation ▁for ▁high ▁medical ▁costs ▁by ▁phys icians , ▁G aw ande ▁estimated ▁in ▁ 2 0 1 0 ▁it ▁only ▁contributed ▁to ▁ 2 . 4 % ▁of ▁the ▁total ▁$ 2 . 3   tr ill ion ▁of ▁U . S . ▁health ▁care ▁sp ending ▁in ▁ 2 0 0 8 . ▁ ▁Direct - to - consum er ▁advert ising ▁ ▁Direct - to - consum er ▁advert ising ▁can ▁encou rage ▁patients ▁to ▁ask ▁for ▁dru gs , ▁devices , ▁di agnostics , ▁or ▁procedures . ▁ ▁Sometimes ▁service ▁prov iders ▁will ▁simply