PONE-D-20-23258

Medical Students in Distress:

The Impact of Gender, Race, Debt, and Disability

PLOS ONE

Dear Dr. Nikhil Rajapuram,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

In particular, please review the comments from Reviewer 1 and make appropriate revisions.

Please submit your revised manuscript by Oct 18 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Yuka Kotozaki

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this paper, I found the approach and results quite interesting.

I commend the authors on their novel investigation and aim of identifying risk factors for distress. Validation of their survey, the MSWS (portions not included in the MS-WBI) was not addressed. No information about the piloting of these questions was given. A copy of the survey was not available. These are critical to understanding the validity of the assessment, which is central to the validity of the findings.

Self-selection bias is a major limitation of this study and the approach using a liaison was poorly defined, for example, how many liaisons agreed to distribute the survey?Finally, variables added to the regression model are noted in the introduction, with the exception of disability, which is not discussed until the methods and results. Having a solid framework for choosing all variables is important. I would add this reasoning to the background/introduction alongside the others.

Reviewer #2: Despite the limitations you recognize (eg. response rate), this study offers significant contributions to conversations about medical schooling conditions that deserves wide dissemination in the public sphere as well as to the medical community. Foremost, this study identifies a need for "course correction" in the ways that medical schools & the profession address student well-being. As you state: "Our data suggest that changes to the underlying structural components of medical education are likely to yield more substantial results to improve medical student well being than continued focus on individuals." This recommendation to attend to structure is critical. Further, this study reveals that debt is a significant factor in students distress. Again, this is something, as the authors' indicate, that needs to be addressed at the structural level. For future studies and/or in disseminating and explaining the significance of these findings (op-eds, medical school leadership, undergrad institutions), I would encourage the authors to look at studies addressing the effects of student debt in education (outside of medical context) (eg Hormel & McAlistair) and those that show that small amounts of debt - as little as $5,000 are an effective deterrent for students of color and under-represented students in the pursuit of graduate or first professional school (Millet). Since this study does have demographic information, I wonder if there are additional findings around what the authors point to as "demographic changes" and their findings about stress that could be highlighted. The authors do state that their data show more work is needed to understand the links between disability and documented increased stress levels that were indicated by their data. As medical schools seek to diversify, they will need to address not only recruitment and cost, but retention and completion - taking into account the importance of well-being in that equation. The "fixes," as this study suggests, cannot just be individual, but must be structural. A different kind of conversation needs to take place and this study is a very important step in that direction - to think about the increased stress and its unequal distribution (and I am guessing the unequal distribution of other causal factors like debt) on people with disabilities, women, and students of color.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Jeanne Scheper

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-20-23258R1

Medical Students in Distress:

The Impact of Gender, Race, Debt, and Disability

PLOS ONE

Dear Dr. Nikhil Rajapuram,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 26 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Yuka Kotozaki

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have done a commendable job addressing the feedback. I would suggest accepting with minor revisions.

A few notes:

While the authors are correct that their findings are novel and add to the literature, they fail to mention the disability finding in the conclusion portion of the abstract.

Consider adding more updated citations for student depression/suicidal ideation.

Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta‐analysis. Medical education. 2016 Apr;50(4):456-68.

Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. Jama. 2016 Dec 6;316(21):2214-36.

The authors should add disability status to this paragraph under novel questions:

The validated MS-WBI questionnaire was administered within the survey with permission from the authors. Novel questions were created based on foundations established from previously validated wellbeing survey methods [27-29]. Changes in students’ physical, emotional, and social domains of wellbeing since entering medical school were assessed on a five-point Likert scale. Additionally, respondents were asked about their frequency of participation in activities known to be protective against distress and burnout, such as exercise, meditation/mindfulness practices, healthy eating, hobby participation, and connecting with a loved one [30-33]. Frequency of actual participation in protective activities was compared against students’ self-reported ideal participation frequency.

I’m not sure this needs to be included (could be removed for word count)

We first contacted the Association of American Medical Colleges (AAMC). However, the AAMC administers a national survey that targets second-year and graduating medical students only, does not include the MS-WBI and would not allow for individual response tracking. We also contacted several Medical School Deans who voiced concern that respondents were asked to identify their medical school.

In this paragraph I would mention that these numbers are higher than the latest findings (the implication being that students may not feel protected/well supported in disclosing to their schools.

We found that nearly 10% of survey respondents identified as having a disability and that

disability status nearly doubled the risk of severe distress (OR 1.81). Self-reporting of disability

in medical school has risen substantially over the last three years, specifically for psychological

and chronic health issues [41]. Little is currently known about the additional stressors faced by

students with disability and to what degree accommodations from medical schools are being

offered and utilized. Understanding this topic more thoroughly may prove pivotal for guiding

314 medical schools in designing interventions to support this vulnerable group.

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Medical Students in Distress:

The Impact of Gender, Race, Debt, and Disability

PONE-D-20-23258R2

Dear Dr. Nikhil Rajapuram,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Yuka Kotozaki

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The revisions to this article strengthen the authors presentation and sufficiently address the prior feedback. The authors should be commended for this work and the novel addition of disability status to the discussion of wellbeing.

Reviewer #2: Author's had previously addressed my concerns and recent revisions were to address the concerns of other readers. While the study has limitations (not a large or perfect sample), it still has sufficient data to highlight an important and neglected area. This research will stimulate further work, hopefully, to map and address these concerns.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No