A comparison of match outcomes between traditional medical degree and dual-degree applicants

Bryce R. Christensen; Chad M. Becnel; Leland P. Chan; Paul D. Minetos; John F. Clarke; Marc J. Kahn

doi:10.1371/journal.pone.0244147

Peer Review History

Original SubmissionOctober 12, 2020
6 Nov 2020 Decision Letter - Leonidas G Koniaris, Editor PONE-D-20-32094 A comparison of match outcomes between traditional medical degree and dual-degree applicants PLOS ONE Dear Dr. Kahn, 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 address comments and suggestions from the reviewer. Please submit your revised manuscript by Dec 21 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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Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No ****** 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: No ****** 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 ****** 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: This study presents residents data from over 100 institutions to examine the characteristics of residents with MD only vs dual degree MD and study the relationship of these degrees with match outcomes. This study is trying to fill the knowledge gap in match competivity by analyzing the data with additional degrees among MDs. There are several methodological and statistical issues that need to be addressed in this study. Please specify the range of years (though this was specified in abstract and conclusion) that the data was achieved from STAR database and the total number of residents when describing your data. It is not clear, if the investigators used the aggregate data or resident level individual data in this study. If they have used an aggregate level data, ecological fallacy might exist and need to account for that. The clarity on the STAR database need to be elaborated together with the types of variables used. The authors have used two-sample t-test to compare means. T-test is a parametric approach. Given the sample size, the central limit theorem might be applicable here. However, it is important to check the assumptions of the parametric approaches before applying t-tests. Please specify the variables that were treated as continuous and those as categorical. There are some discrete variables, for example, programs applied, interviews attended. Treating these as continuous and using t-test might not be correct due to the skewness of the data. Please confirm and provide justification to treat these as continuous variables to apply t-tests. In chi-square tests of proportions, some of the expected proportions are very small (with expected cell count <5). The chi-square tests will not be applicable for such small cell counts; however, you might want to check the significance tests using some exact methods (e.g. Fisher’s exact test). Multiple pairwise comparisons are done here using MD alone as the comparison group. Were p-values accounted for these multiple testing? Please comment. Since no significant difference was seen by degree types, please comment of the power of the tests to rule out any Type II errors. The primary aim of this study was to compare the match rates by single vs dual degrees. It seems that there are several applicant characteristics that are significantly different between the degrees. These characteristics in addition to some baseline characteristics (such as age, gender, race/ethnicity, interest in area of medicine, etc. if any) might confound the relationship between the degrees and match rates. Did the authors see the relationship between the degrees and match rates in multivariable analysis? Did the difference (no difference) exist by the school type (private, public)? Suggestion: You can analyze this by stratified analysis using school types as stratifying variables. I totally understand the feasibility of the length/width of the table to present the actual p-values instead of p<0.05. However, it would be helpful to understand the strength of association is raw p-value is presented as supplement. Since the study is voluntary and survey-based, the missing data might be of another limitation. Please comment on the range of item missing rates. Also comment on what strategies did you use to account for the missing data? ****** 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 [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. https://doi.org/10.1371/journal.pone.0244147.r001
Revision 1
1 Dec 2020 Author Response Editors of PLoS ONE November 25, 2020 Dear Sirs: Thank you for allowing us to resubmit our manuscript. We will address each of the reviewer’s comments as follows: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. The data is from the publicly available Texas STAR database. We have attached a sample data set used for this study. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. We will make the required upload. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ We will make the requested update. The corresponding author’s ORCHID iD is: 0000-0002-9781-9316 Reviewer #1: This study presents residents data from over 100 institutions to examine the characteristics of residents with MD only vs dual degree MD and study the relationship of these degrees with match outcomes. This study is trying to fill the knowledge gap in match competivity by analyzing the data with additional degrees among MDs. There are several methodological and statistical issues that need to be addressed in this study. We thank the reviewer for their comments. Please specify the range of years (though this was specified in abstract and conclusion) that the data was achieved from STAR database and the total number of residents when describing your data. It is not clear, if the investigators used the aggregate data or resident level individual data in this study. If they have used an aggregate level data, ecological fallacy might exist and need to account for that. The clarity on the STAR database need to be elaborated together with the types of variables used. We added text to specify the years of the study data (2017-2019). The total number of residents is also included (18,224). We additionally clarified in the manuscript that this study used individual resident level data, not aggregate data. The authors have used two-sample t-test to compare means. T-test is a parametric approach. Given the sample size, the central limit theorem might be applicable here. However, it is important to check the assumptions of the parametric approaches before applying t-tests. We chose a simple t-test as is easily understood and widely used. Additionally, the variables studied are assumed to be parametric. As an example, the probability characteristics of USMLE scores are distributed according to a normal distribution by design. Because the probability distribution is defined, a parametric method (like the Student’s t-test) is appropriate. Similarly, our other variables are assumed parametric. Please specify the variables that were treated as continuous and those as categorical. There are some discrete variables, for example, programs applied, interviews attended. Treating these as continuous and using t-test might not be correct due to the skewness of the data. Please confirm and provide justification to treat these as continuous variables to apply t-tests. Continuous variables included USMLE scores, honored clerkships, research experiences, programs applied to, interview number and most of the variables in Table 3. Because of the large number of students in the data set (over 18,000) we assumed lack of skewness and a normal distribution. In chi-square tests of proportions, some of the expected proportions are very small (with expected cell count <5). The chi-square tests will not be applicable for such small cell counts; however, you might want to check the significance tests using some exact methods (e.g. Fisher’s exact test). None of the cells had less than a count of 5. Chi-squared analysis is typically used in such comparisons. Multiple pairwise comparisons are done here using MD alone as the comparison group. Were p-values accounted for these multiple testing? Please comment. P-values were accounted for multiple pairwise testing as suggested. Since no significant difference was seen by degree types, please comment of the power of the tests to rule out any Type II errors. The p-values in Table 1 suggest that we can exclude the null hypothesis with less than 95% certainty. For studies of this type, this is typically represented as the groups not being statistically different. Since our study included over 17,000 participants, we feel that the study has the power to rule out Type II errors. The primary aim of this study was to compare the match rates by single vs dual degrees. It seems that there are several applicant characteristics that are significantly different between the degrees. These characteristics in addition to some baseline characteristics (such as age, gender, race/ethnicity, interest in area of medicine, etc. if any) might confound the relationship between the degrees and match rates. Did the authors see the relationship between the degrees and match rates in multivariable analysis? Although interesting questions, the database does not include the additional information suggested by the reviewer. Further, as the data submitted is blinded, additional demographic information could make the data more identifiable. As such, it is not collected by Texas STAR. Did the difference (no difference) exist by the school type (private, public)? Suggestion: You can analyze this by stratified analysis using school types as stratifying variables. This is an interesting question but not one addressed by our current study. I totally understand the feasibility of the length/width of the table to present the actual p-values instead of p<0.05. However, it would be helpful to understand the strength of association is raw p-value is presented as supplement. Actual p-values are presented in Table 1. Since the study is voluntary and survey-based, the missing data might be of another limitation. Please comment on the range of item missing rates. Also comment on what strategies did you use to account for the missing data? We describe missing data in our discussion. Missing data is impossible to collect as participation in the Texas STAR database is voluntary. We thank the reviewers for their thoughtful comments. Sincerely, Marc J. Kahn, MD, MBA Dean and Professor of Medicine UNLV School of Medicine Attachments Attachment Submitted filename: Response letter to PLoS ONE.docx https://doi.org/10.1371/journal.pone.0244147.r002
4 Dec 2020 Decision Letter - Leonidas G Koniaris, Editor A comparison of match outcomes between traditional medical degree and dual-degree applicants PONE-D-20-32094R1 Dear Dr. Kahn, 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, Leonidas G Koniaris, MD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0244147.r003
Formally Accepted
9 Dec 2020 Acceptance Letter - Leonidas G Koniaris, Editor PONE-D-20-32094R1 A Comparison of Match Outcomes Between Traditional Medical Degree and Dual-degree Applicants Dear Dr. Kahn: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Leonidas G Koniaris Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0244147.r004

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