Table 3 Statements indicating health professionals’ lack of clinical equipoise in CONTRACT

Surgery as standard care:

“I’ve been doing surgery now for 15 years, so appendicitis equals an operation and it’s quite difficult to change your mindset.” (Int_Surgeon54)

Experience of antibiotics as effective:

“You watch some patients get better with antibiotics and it’s really, really tempting to just not sort of bother with the trial and just offer patients antibiotics occasionally, which I haven’t done. But, you know, it’s quite hard to sort of, you know, keep your own personal views under control as you see it unfold.” (Int_Surgeon17)

Patient perceived as more poorly leading to doubts about eligibility:

“How they look and if they obviously look pretty sick, then I think you’ll be more reluctant to do something that doesn’t feel standard… He was definitely eligible, for sure. But… he looked like he had appendicitis which, which is not entirely well.” (Int_Surgeon37)

Patient perceived as less poorly leading to doubts about eligibility:

“We do agree that for the selected group of patients [antibiotics] would work… The irony is that sometimes we have selected certain people that we think ‘oh, they definitely, it’s more the early appendicitis type and not the complicated appendicitis and would definitely do well’, but … sometimes you feel sad that someone that looked really well and would do really well with antibiotics alone, is then randomised to having an operation.” (Int_Surgeon11)

Avoiding contributing towards antibiotic resistance:

“You could argue that more [families] than not will go towards the antibiotics rather than surgery. Unless of course you have more scare stories about how antibiotic resistance is coming in… that may well influence how people decide in the longer term.” (Int_Surgeon12)

Fewer surgical training opportunities:

“You take away these straightforward… training operations which can become useful … for people building basic skills... In the longer term you … have to become more inventive or find different ways … for people to gain their surgical experience and that could be a counter risk going forward.” (Int_Surgeon12)