According to a study published in the June 1, 2005 issue of the Journal of the American Medical Association (JAMA), the practice of defensive medicine is widespread among the 824 Pennsylvania physicians who participated in the study funded by the Pew Charitable Trusts. Study participants were chosen in the specialties most frequently involved in litigation: emergency medicine, general surgery, neurosurgery, obstetrics and gynecology, orthopedic surgery and radiology. Of these, 93 percent reported engaging in defensive medicine—a practice that has been shown to lead to higher costs, lower quality of care and less access to services. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums.