title: Time to be BRAVE: is educating surgeons the key to unlocking the potential of randomised clinical trials in surgery? A qualitative study.
abstract: BACKGROUND
  Well-designed randomised clinical trials (RCTs) provide the best evidence to inform decision-making and should be the default option for evaluating surgical procedures. Such trials can be challenging, and surgeons' preferences may influence whether trials are initiated and successfully conducted and their results accepted. Preferences are particularly problematic when surgeons' views play a key role in procedure selection and patient eligibility. The bases of such preferences have rarely been explored. Our aim in this qualitative study was to investigate surgeons' preferences regarding the feasibility of surgical RCTs and their understanding of study design issues using breast reconstruction surgery as a case study.
  
  
  METHODS
  Semistructured qualitative interviews were undertaken with a purposive sample of 35 professionals practicing at 15 centres across the United Kingdom. Interviews were transcribed verbatim and analysed thematically using constant comparative techniques. Sampling, data collection and analysis were conducted concurrently and iteratively until data saturation was achieved.
  
  
  RESULTS
  Surgeons often struggle with the concept of equipoise. We found that if surgeons did not feel 'in equipoise', they did not accept randomisation as a method of treatment allocation. The underlying reasons for limited equipoise were limited appreciation of the methodological weaknesses of data derived from nonrandomised studies and little understanding of pragmatic trial design. Their belief in the value of RCTs for generating high-quality data to change or inform practice was not widely held.
  
  
  CONCLUSIONS
  There is a need to help surgeons understand evidence, equipoise and bias. Current National Institute of Health Research/Medical Research Council investment into education and infrastructure for RCTs, combined with strong leadership, may begin to address these issues or more specific interventions may be required.
authors.affiliation: Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK. Shelley.Potter@bristol.ac.uk.
authors.forename: Shelley
authors.initials: S
authors.lastname: Potter
authors.forename: Nicola
authors.initials: N
authors.lastname: Mills
authors.forename: Simon J
authors.initials: SJ
authors.lastname: Cawthorn
authors.forename: Jenny
authors.initials: J
authors.lastname: Donovan
authors.forename: Jane M
authors.initials: JM
authors.lastname: Blazeby
mesh_terms: D001291:Attitude of Health Personnel; D032882:Comprehension; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D016462:Mammaplasty / Q000193:education / Q000379:methods*; D018579:Patient Selection; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D011897:Random Allocation; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D012107:Research Design; D015983:Selection Bias; D057212:Therapeutic Equipoise; D006113:United Kingdom