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Methodological letter
Bias in surgery. Do and act, that’s the key
Sesgos en cirugía. Hacer y proceder, esa es la clave
Josep María Garcia-Alaminoa,b, Manuel López-Canoc,
Corresponding author
mlpezcano@gmail.com

Corresponding author.
a Grupo de Investigación Salud Global, Género y Sociedad (GHenderS), Blanquerna-Universitat Ramon Llull, Barcelona, Spain
b Programme in Evidence Based Health Care, University of Oxford, Oxford, United Kingdom
c Unidad de Cirugía de Pared Abdominal, Hospital Universitario Vall d’Hebrón, Universidad Autónoma de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Validity in a surgical article &#40;as in most scientific articles&#41; can be categorised as internal validity&#44; which is the accuracy of the conclusions about the effects of an intervention on a given group of subjects under the specific circumstances of the study design&#44; and external validity&#44; which is the applicability of the study findings or how a clinician can rely on the research findings to apply to patients in their real-world practice beyond the circumstances of the study design&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Validity is compromised by bias &#40;systematic error&#41; which is defined in the dictionary of the Spanish Royal Academy<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> as the &#34;systematic error that may occur when sampling or testing selects or favours some responses over others&#34;&#46; Biases in a study can be &#34;methodological&#34; &#40;in undertaking the study&#41; during data collection&#44; analysis&#44; interpretation&#44; or review&#44; occurring before&#44; during or after the study is conducted&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> or they can be &#34;cognitive&#34; &#40;in applying the results&#41;&#44; i&#46;e&#46;&#44; barriers intrinsic to human nature&#44; and therefore to surgeons&#44; that affect the interpretation and incorporation of evidence in decision making&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">&#8220;Methodological&#8221; biases</span><p id="par0010" class="elsevierStylePara elsevierViewall">This is not exhaustive and covers the most important in our opinion&#58;</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Before the study is conducted</span>&#44; these can be in selecting patients with different characteristics that potentially influence the outcome&#44; the remedy is randomisation&#59; allocation bias when individual prognostic factors influence the allocation of an intervention&#44; the remedy is stratification&#59; ambiguous and poorly defined protocols&#44; the remedy to which is a well-defined protocol and their registration in databases&#44; such as ClinicalTrials&#46;gov<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; surrogate endpoints that may not correlate with clinically useful endpoints&#44; the remedy is that the surrogate endpoints correlate appropriately with clinically useful endpoints&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">While the study is being conducted&#44;</span> these can be&#58; outcome detection bias through non-uniform measurement of outcomes&#44; the remedy is standardisation &#40;uniformity&#41; of measurements or blinding&#59; outcome ascertainment bias with distorted ascertainment of important elements of the study&#44; the remedy may be blinding or pre-randomisation&#59; follow-up bias with differences between groups&#44; the remedy is to homogenise follow-up&#59; non-uniformity bias in the interventions performed&#44; the remedy may be stratification&#44; for example by surgical experience&#44; institution or surgeon&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">After the study has been conducted&#44;</span> perhaps the best known is publication bias&#58; the tendency to publish only studies with positive results&#44; although there may be others such as duplicate publication or incomplete study information&#44; remedies may be to register the paper or follow established standards in conducting studies&#44; such as the CONSORT statement for randomised studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">All the above-mentioned methodological biases produce a classic pyramid graph or hierarchy of evidence that essentially represents the progression &#40;from the bottom to the top&#41; of the strength of confidence of different study designs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">&#8220;Cognitive&#8221; biases</span><p id="par0035" class="elsevierStylePara elsevierViewall">A two-route model of decision-making has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The analytical &#40;reason&#41; and the intuitive &#40;heuristic&#41;&#46; When surgeons judge situations&#44; make decisions and solve problems they&#44; like any other human beings&#44; primarily use mental shortcuts&#44; i&#46;e&#46;&#44; the intuitive route&#46; They make use of tacit knowledge based on experience&#44; on &#34;exchange&#34; with other surgeons&#44; on reading or watching videos made by opinion leaders or experts in a given technique&#46; These cerebral shortcuts are essential for daily practice as they allow a large amount of information to be processed in a short time and under pressure&#46; Obviously&#44; the surgeon must make frequent use of these shortcuts&#44; although this implies a significant number of cognitive biases that hinder the practice of evidence-based surgery&#46; We list the most characteristic of these below&#58;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Action bias</span> or the tendency to favour &#8220;action&#8221; over &#8220;inaction&#8221;&#46; Action is motivated to avoid regretting a missed opportunity&#44; for example&#44; not performing a surgical procedure or performing it late&#44; not ordering a diagnostic test or not prescribing an antibiotic&#46; This type of bias can lead to overuse of certain surgical procedures &#40;overtreatment&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Omission bias</span> or the tendency to favour &#8220;inaction&#8221; to avoid making mistakes or failure&#46; This bias arises whenever either an omission or an action is likely to cause harm&#46; At that point omission may be chosen because the harm this causes could subjectively appear to be less&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Status quo bias</span> or the preference for the status quo&#44; which can be explained as an aversion to loss&#46; This bias may contribute to the surgeon&#39;s inertia to continue using the same technique when there are alternatives with better efficacy or not to discontinue procedures that have not been shown to be effective&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Halo effect bias</span> or the tendency to define a person&#8217;s overall image based on one of their features&#46; If a surgeon is a virtuoso in a particular technique&#44; it is assumed that they will also be a virtuoso in indicating the technique or being ethical in their professional conduct&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Confirmation bias</span> or the tendency to use only information &#40;analytical data&#44; imaging&#44; evidence from studies&#41; that confirms the surgeon&#8217;s pre-existing information and conforms to a prior preconception or hypothesis&#44; ignoring data that runs counter to the surgeon&#8217;s prior conception&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Availability bias</span> or the tendency to overestimate the likelihood of events when they readily come to the surgeon&#8217;s mind&#46; For example&#44; a recent complex case that debuted in a similar way and had a complex or fatal outcome&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Framing bias&#46;</span> This may cause the surgeon to make decisions based on the context and presentation of an option&#46; For example&#44; when the results of a study are shown to them as an absolute effect &#40;relative risk&#41; or relative effect &#40;relative risk reduction&#41; they will interpret the information differently and then also make the decision differently&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Optimism bias</span> or believing that new is better&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rhetoric bias</span>&#44; which refers to using an argument to persuade the surgeon by reading or hearing that argument without making use of quality evidence&#46; It might not be uncommon for surgeons to cite evidence without an actual in-depth analysis of the quality of that evidence&#46; The rhetoric used is persuasive and may show a relevant effect&#44; without solid evidence&#46; This bias may be for or against an intervention or surgical technique and the arguments are opinions&#44; beliefs&#44; or experiences rather than evidence&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hot topic bias&#46;</span> When a topic is in vogue &#40;&#8220;hot&#8221;&#41; researchers &#40;and editors&#41; may be less critical of the research protocol and execution&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conflict of interest bias</span>&#44; when the surgeon&#8217;s opinion on a condition &#40;a surgical technique&#44; validity of research&#41; may be influenced by an extraneous secondary interest &#40;a surgical technique&#44; validity of research&#41; may be influenced by an extraneous secondary interest &#40;financial&#44; personal projection&#44; etc&#46;&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Corollary</span><p id="par0095" class="elsevierStylePara elsevierViewall">It is 25 years since the Lancet published a controversial editorial entitled &#8220;Surgical research or comic opera&#58; questions&#44; but few answers&#8221;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> on surgical publications and research&#44; in which the title spoke for itself&#46; This editorial can obviously be contested from different perspectives&#59; however&#44; 25 years later we must recognise as a surgical community that we need to continuously improve&#44; on the one hand&#44; the quality of our publications by limiting the number of methodological biases&#44; and on the other by identifying&#44; reviewing&#44; and controlling potential cognitive biases that may hamper the implementation of the best available evidence&#46; Perhaps the only way to achieve this is with adequate training in these issues during the degree course and continuous updating throughout the specialty&#46;</p></span></span>"
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Original language: English
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