***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Objective : To examine the use of evidence based leaflets on informed choice in maternity services . Design : Non-participant observation of 886 antenatal consultations . 383 in depth interviews with women using maternity services and health professionals providing antenatal care . Setting : Women 's homes ; antenatal and ultrasound clinics in 13 maternity units in Wales . Participants : Childbearing women and health professionals who provide antenatal care . Intervention : Provision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use . Main outcome measures : Participants ' views and commonly observed responses during consultations and interviews . Results : Health professionals were positive about the leaflets and their potential to assist women in making informed choices , but competing dem and s within the clinical environment undermined their effective use . Time pressures limited discussion , and choice was often not available in practice . A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of “ right ” and “ wrong ” choices rather than “ informed ” choices . Hierarchical power structures result ed in obstetricians defining the norms of clinical practice and hence which choices were possible . Women 's trust in health professionals ensured their compliance with professionally defined choices , and only rarely were they observed asking questions or making alternative requests . Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy . The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced . Conclusions : The way in which the leaflets were disseminated affected promotion of informed choice in maternity care . The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice . What is already known on this topic Informed Choice leaflets are widely used in maternity care but little is known about their ability to influence informed choice and decision making High quality information is essential for promoting informed choice but is insufficient by itself What this study adds Time constraints and other pressures on health professionals result ed in a lack of discussion of the content of the leaflets Fear of litigation , power hierarchies , and the technological imperative in maternity care limited the choices available Health professionals promoted normative practice s rather than choice , and as women valued their opinions this led to the promotion of informed compliance rather than informed OBJECTIVE To examine the causal effects of doctor-patient relations and the severity of a medical outcome on medical patient perceptions and mal practice intentions in the event of an adverse medical outcome . DESIGN R and omized between-subjects experimental design . Patients were given scenarios depicting interactions between an obstetric patient and her physician throughout the patient 's pregnancy , labor , and delivery . PARTICIPANTS One hundred twenty-eight postpartum obstetric patients were approached for participation , of whom 104 completed the study . Main outcome measures Patients ' perceptions of physician competence and intentions to file a mal practice cl aim . RESULTS Positive physician communication behaviors increased patients ' perceptions of physician competence and decreased mal practice cl aim intentions toward both the physician and the hospital . A more severe outcome increased only patients ' intentions to sue the hospital . CONCLUSION These results provide empiric evidence for a direct , causal effect of the doctor-patient relationship on medical patients ' treatment perceptions and mal practice cl aim intentions in the event of an adverse medical outcome BACKGROUND Informed consent forms should document and reflect the goals of informed consent and shared decision making . We conducted this study to examine the extent to which informed consent for procedure forms meet accepted informed consent st and ards , how well state informed consent statutes correlate with these st and ards , and whether existing forms can enhance the interactions between patients and physicians or other health care providers . HYPOTHESIS Informed consent forms do not meet accepted st and ards . A different format may be more useful for patient-physician interactions . DESIGN A content analysis was conducted of  hospital informed consent for procedure forms from a r and om selection of hospitals in the 1994 American Hospital Association membership directory . Forms were examined for evidence of the basic elements of informed consent ( nature of the procedure , risks , benefits , and alternatives ) and items that might enhance patient-physician interactions and encourage shared decision making . UNIT OF ANALYSIS : From 157 hospitals nationwide , 540 hospital informed consent for procedure forms were examined . MEASUREMENTS AND MAIN RESULTS Ninety-six percent of forms indicated the nature of the procedure , but risks , benefits , and alternatives were found less often . Only 26 % of forms included all 4 basic elements , 35 % included 3 of 4 elements , 23 % had 2 of 4 elements , 14 % had only 1 element , and 2 % had none of the elements . Forms appear to authorize treatment ( 75 % ) or protect hospitals and caregivers from liability ( 59 % ) rather than clarify information about procedures ( 40 % ) or aid patients in decision making ( 14 % ) . Forms from states with statutes that require that all 4 elements be provided were no more likely than other states to include them ( Fisher exact test = 1.000 ) . Fewer than 40 % of forms supported models of shared decision making . CONCLUSIONS The content of most forms did not meet accepted st and ards of informed consent or patient-physician interactions . We propose a form that more fully supports the models of ideal informed consent and shared decision making to enhance the applicability of informed consent in the clinical setting OBJECTIVE To ascertain general practitioners ' perceptions of medicolegal risk when screening for prostate cancer , and explore the potential impact of three national guidelines on perceptions and clinical practice . DESIGN Postal survey in August 1997 . PARTICIPANTS 219 r and omly selected GPs in New South Wales ( 65 % response rate ) . MAIN OUTCOME MEASURES Response to case scenarios ; perceptions of medicolegal risk and protection afforded by national guidelines before and after reading extracts of three national guidelines ; ratings of current and potential strategies to increase GPs ' sense of medicolegal protection . RESULTS 90 % ( 95 % CI , 86.5%-94.3 % ) would screen an asymptomatic male patient and 61 % ( 95 % CI , 54.2%-67.2 % ) indicated GPs would be at risk if they did not screen . Although significant changes in responses were found after respondents had read guideline extracts , 46 % ( 95 % CI , 39.5%-52.7 % ) continued to perceive medicolegal risk if screening was not performed . About two-thirds ( 65 % ; 95 % CI , 59.9%-72.5 % ) supported a clear statement about the legal status of guidelines in a court of law to increase their sense of medicolegal protection . CONCLUSIONS Even when made aware of national evidence -based guidelines against prostate cancer screening , GPs in our survey perceived limited hypothetical medicolegal protection Decision aids are evidence -based sources of health information that can help patients make informed treatment decisions . However , little is known about how decision aids affect health care use when they are implemented outside of r and omized controlled clinical trials . We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State . Consistent with prior r and omized trials , our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries , 38 percent fewer knee replacements , and 12 - 21 percent lower costs over six months . These findings support the concept that patient decision aids for some health conditions , for which treatment decisions are highly sensitive to both patients ' and physicians ' preferences , may reduce rates of elective surgery and lower costs OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity BACKGROUND The current literature does not provide an answer to the question , " What prompts patients to sue doctors or hospitals ? " Not all adverse outcomes result in suits , and threatened suits do not always involve adverse outcomes . The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care . This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a mal practice cl aim . METHODS This study is a descriptive series review of a convenience sample of 45 plaintiffs ' depositions selected r and omly from 67 depositions made available from settled mal practice suits filed between 1985 and 1987 against a large metropolitan medical center . Information extracted from each deposition included the alleged injury ; the presence of the question , " Why are you suing ? " and , if present , the answer ; the presence of problematic relationship issues between providers and patients and /or families and , if present , the discourse supporting it ; the presence of the question , " Did a health professional suggest maloccurrence ? " and , if yes , who . Using a process of consensual validation , relationship issues were organized into groups of more generalized categories suggested by the data . Answers to the questions , " Why are you suing ? " and " Who suggested maloccurrence ? " are described . RESULTS Problematic relationship issues were identified in 71 % of the depositions with an interrater reliability of 93.3 % . Four themes emerged from the descriptive review of the 3787 pages of transcript : deserting the patient ( 32 % ) , devaluing patient and /or family views ( 29 % ) , delivering information poorly ( 26 % ) , and failing to underst and the patient and /or family perspective ( 13 % ) . Thirty-one plaintiffs were asked if health professionals suggested maloccurrence . Fifty-four percent ( n = 17 ) responded affirmatively . The post outcome -consulting specialist was named in 71 % ( n = 12 ) of the depositions in which maloccurrence was allegedly suggested . CONCLUSIONS In our sample , the decision to litigate was often associated with a perceived lack of caring and /or collaboration in the delivery of health care . The issues identified included perceived unavailability , discounting patient and /or family concerns , poor delivery of information , and lack of underst and ing the patient and /or family perspective . Particular attention should be paid to the postadverse-event consultant-patient interaction OBJECTIVE To examine the relationship between prior physician mal practice experience and patients ' satisfaction with care . DESIGN Women were interviewed using a question naire that contained structured and open-ended questions . PARTICIPANTS Mothers of all stillborn infants , infant deaths , and a r and om sampling of viable infants drawn from 1987 Florida Vital Statistics were sorted into four groups based on the mal practice cl aims experience of their obstetricians between 1983 and 1986 . Interviews were completed with 963 of 1536 women , most by telephone , 53 by in-person interview . MAIN OUTCOME MEASURES Mothers ' responses to closed-ended and open-ended questions about their perceptions of the care they received during their pregnancy , labor , and delivery . RESULTS Even though none of the women actually filed a cl aim , a consistent pattern of differences emerged when comparing women 's perceptions of care received . Patients seeing physicians with the most frequent numbers of cl aims but without high payments were significantly more likely to complain that they felt rushed , never received explanations for tests , and were ignored . In response to the open-ended question , " What part of your care were you least satisfied with ? " women seeing physicians in the High Frequency mal practice risk group offered twice as many complaints as those seeing physicians who had never been sued . Problems with physician-patient communication were the most commonly offered complaints . CONCLUSION Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide even by their patients who do not sue 
    Output:
    
The analysis confirms the absence of empirical data necessary to determine whether or not shared decision-making promoted in the clinical encounter can reduce litigation .
Three out of five included studies provide retrospective and simulated data suggesting that ignoring or failing to diagnose patient preferences , particularly when no effort has been made to inform and support underst and ing of possible harms and benefits , puts clinicians at a higher risk of litigation .
Simulated scenarios suggest that documenting the use of decision support interventions in patients ’ notes could offer some level of medico-legal protection .
Our analysis also indicated that a sizeable proportion of clinicians prefer ordering more tests and procedures , irrespective of patient informed preferences , as protection against litigation .
Conclusions Given the lack of empirical data , there is insufficient evidence to determine whether or not shared decision-making and the use of decision support interventions can reduce medical mal practice litigation .