PONE-D-21-09730

Burnout among medical students of a medical college in Kathmandu; A cross sectional study

PLOS ONE

Dear Dr. Shrestha,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: I Don't Know

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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: No

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: 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: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: 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: I find the manuscript well written and addresses the burnout in medical undergraduates in Nepal. I have the following comments to make:

1. Methods: Please further elaborate on how the authors got the email addresses of the students. Did the authors collect any identifying information from the students (for e.g., email addresses)? How long was the link to the questionnaire made active? Why did it take so long for the students to respond to the questionnaire? Did the authors contact students to fill up the survey form as they didn't receive the adequate response on time? How did the authors know that no student filled out the survey form more than once? As there are co-authors from third year medical school where the study was conducted, it would be wise to mention that none of the co-authors filled up the questionnaire.

2. Methods: line 93- There is duplication of text. Please remove the sentence at line 74-76.

3. Results: line 139- There is duplication of text. Please delete the text at line 139 and start the sentence with the text beginning at 140.

4. There are some errors in English language, some of which are highlighted below:

a. “cross sectional” is generally written as “cross-sectional”.

b. Line 24 and 192: the prevalence

c. Line 27: “The burnout” be written as “Burnout”

d. Line 27: gender, and year of study

e. Line 66: “physicians is” be replaced as “physicians are”

f. Line 73: the Nepalese

g. Line 77: consent form attached to the form itself.

h. Line 91: 228 and

i. Line 101: depersonalization, emotional exhaustion, and

j. Line 106: patient-related

k. Line 119: use past tense. Replace ‘is’ with ‘was’.

l. Line 119-120: scores of

m. Line 134-135: check spacing

n. Line 140: replace ‘completely filled’ with ‘completed’

o. Line 146-149: use the article ‘the’. For e.g., the disengagement, the total score, the exhaustion

p. Line 151: previous mentioned be written as ‘previously mentioned’

q. Line 152-153: Use article the after under for e.g., ‘under the disengaged group’

r. Line 157-158: for the occurrence

s. Line 169: due to the use of

t. Line 171: due to a multitude of factors

u. Line 173: sentence can be reframed as “Our study found the prevalence of burnout to be considerably higher than previous study conducted in Nepal which…”

v. Line 176: due to the timing

w. Line 177: Still, multiple factors

x. Line 180: significant association of gender with burnout in…

y. Line 199: students were

z. Line 205: exposure to it since

aa. Line 192-199: consider using a hyphen in first year, fourth year etc.

bb. Line 237: performed the

Reviewer #2: Review of

Burnout among medical students of a medical college in Kathmandu: A cross sectional study

1. Reviewer’s Overall Comment:

Research on burnout and emotional exhaustion in Nepal for medical professionals and students is increasing. Nevertheless, there is a gap in the study of burnout among preclinical students. The relevancy of the research is well articulated and explained in the Nepali context. This research, scientifically designed and meticulously carried out after following exact research methods, will support the education and medical institutions to look at the burden of medical education on their students. With minor revisions to be addressed, the reviewer recommends publishing this article.

2. Few comments for adjustment:

- Line 31 – please be specific that the researchers had used the English version of the Oldenburg Burnout Inventory adapted for students. It seems that the tool was not translated and culturally adapted in the research process. Replicate the same in line 105.

- In abstract's result section, line 33, please include the total number of respondents (N = 229).

- Line 78, please describe the sampling process and cite the formula you have used to define the sample size for this research. It would be nice to explain, the reasons for choosing the sample size in that way before straightforwardly putting the formula.

- The data were collected using a google form, was there any record of individual data such as the email of the respondents? Did the participants receive any debriefing note with an explanation of the burnout including exhaustion and disengagement? Did the participant receive any guidance to seek support if they wish?

- Line 136 – how do you explain that the confidentiality and anonymity of the participants were ensured? Kindly explain the process from data collection to data analysis and repository phase of the data.

- Line 173, please mention (N = 651) after % of prevalence and response rate of their study.

- After line 197, it would be worth mentioning that the peer and family pressure to be a medical doctor in Nepali society creates pressure on the students.

• Pokhrel, Khadayat, and Tulachan (2020) outlined other possible causes of higher prevalence of burnout in Medical students – ‘the field of medicine not being one’s first priority, following friends to study medicine, parental wish to study medicine, wrongly choosing the specialty, and being demotivated after learning the reality of medicine. The authors, unfortunately, came across a few circumstances in which some medical students became demotivated after living the reality of medicine. Most of them followed their parents’ wish or dreamt of their higher social status before enrolling into the medical school (p.15).’

The reviewer recommends highlighting such findings in the discussion section.

- Authors have suggested some of the strategies and actions to address the burnout of medical students in the conclusion section. Line 223-225 says, ‘Hence, effective strategies for the mental well-being of future physicians need to be made by relevant authorities such as psychological help desk, mental health support groups, and amendments in the academic curriculum’. It is understandable that this study limits after knowing the prevalence of burnout, nevertheless, it would be great to review secondary literature on effective and efficacious actions for the prevention of burnout in medical students and describe it in the discussion section for future researchers and academia leaders. Here are some of the resources available to similar populations to address burnout of medical students:

• Adhikari (2018) on Compassion fatigue into the Nepali counselors: challenges and recommendations

• Recommendation section of Adhikari (2020) pages – 131 to 134,

• Equally, the study of Adhikari et al. (2017 p.6) mentions, ‘Various solutions to reduce stress like creating a nurturing learning environment, identifying and assisting students, teaching skills for stress management and promoting self-awareness have been proposed. Integration of such programs as a part of medical education with special focus on preclinical students and female students may improve mental health among students’.

 

References

Pokhrel, N. B., Khadayat, R., & Tulachan, P. (2020). Depression, anxiety, and burnout among medical students and residents of a medical school in Nepal: a cross-sectional study. BMC psychiatry, 20(1), 1-18. https://doi.org/10.1186/s12888-020-02645-6

Adhikari, A., Dutta, A., Sapkota, S., Chapagain, A., Aryal, A., & Pradhan, A. (2017). Prevalence of poor mental health among medical students in Nepal: a cross-sectional study. BMC medical education, 17(1), 1-7. https://doi.org/10.1186/s12909-017-1083-0

Adhikari, Y. (2020). Prevalence of Professional Quality of Life (ProQOL) and Its Influence on the Personal Distress of Doctors in Nepal. (Doctor of Philosophy Dissertation, University of Nicosia). https://www.researchgate.net/publication/344397792_Prevalence_of_Professional_Quality_of_Life_ProQOL_and_Its_Influence_on_the_Personal_Distress_of_Doctors_in_Nepal

Adhikari, Y. (2018). Compassion fatigue into the Nepali counselors: Challenges and recommendations. MOJ Public Health, 7(6), 376–379. http://dx.doi.org/10.15406/mojph.2018.07.00271

Reviewer #3: Manuscript is written in important area. Overall flow of content also seems good. Some of my observations are as follows:

Manuscript lacks the clarity while talking about sampling procedure. It is mentioned that there was stratified sampling technique, which is one of the random sampling technique. How could authors made random sampling through google form is not clearly mentioned.

You could add "Model adequacy test (hosmer and lemshw, cox-snell r2" as there is Binary logistic regression.

It would be more appropriate if you make age categories and do multivariate analysis.

No need to keep that many ZERO in Odds ratio.

If your tool supports, it is better to keep your outcome variable into Mild, Moderate and Severe burnout.

Reviewer #4: Authors are more experience of research, Article is current more relevant and Ethical approval letter and Participants consent was obtained. provide a specific recommendation from student side and national medical council level.

Reviewer #5: This is a well written paper that has examined the questions set out in the investigation as well as preformed a rigorous statistical review. The discussion also examines the issues at hand and explains the various factors associated with burnout.

Reviewer #6: This was a very interesting piece to read. The authors have addressed appropriately to the main objective of the study and have also listed all the possible limitations that could have been the cause of the noted higher burnout rates compared to other similar studies.

The authors have referenced a recent similar study published from Nepal, as that was just recently published and had looked at many more variables, I would like the authors to look for any additional data that they might have collected to make this particular study unique.

1) It would be interesting to have a general demographic of the students of each year of study.

2) Line 183 - 'similar/contrary' it would be better to split them in two different sentences.

3) Just curious if the 3 yr, 4th yr and 5th yr students were helping out at a COVID ward, as they would have started clinical rotations and might have been roped in to help out - if do include that too.

Best wishes with your submission.

Reviewer #7: Dear author,

Congratulation for the excellent work and bringing this issue forward. The paper has been written in a nice way with good explanation of methodology and in depth analysis where possible. Few queries

1. You have calculated Cronbach's Alpha for the tool used, which is already a validated tool. Did you have any modification or translation of this tool.

2. Selection of Target population, N = 560* in sample size calcualtion?? Explain

3. More literature review and more elaborated discussion section from the regional or global literature is expected if there is less literature from Nepal.

4. Explain the reason for choosing only selected variable (years, gender and year of study) for binary logistic regression and its significance.

5. Biases in self administered questionnaires during the use of Likert Scale? Please see

Reviewer #8: Summary of the research

This was the cross-sectional study about burnout of medical student in a medical college in Kathmandu, Nepal. Methodology of the study appears sound and study designs is appropriate for the study. Instrument used was Oldenburg Burnout Inventory adapted for students (OLBI-S) which has been shown to have good internal consistency. As per my (poor) knowledge on statistics, I don’t find any fault in statistical analysis. Results shows high prevalence of burnout among medical students which is mentioned in the conclusion. All data are accessible. References are ok. Title is appropriate and informative.

Major issues observed: None.

Minor issues:

Abstract: Authors should clarify whether it is burden or burnout (line 24) and put a comma or restructure the sentence to make it understandable (line 33/34).

Introduction: Please cross check the spellings (line 68)

Study sample: Authors need to make it clear how many class years were taken as stratum (line 95)

Study instruments: Authors need to focus on the instrument they are using with mention of pros and cons of using it rather than describing about instruments they are not using (line 100-107).

Analytical strategy: internal consistency of the instrument used can be put in the methodology parts rather than in analysis part. (line 129-131)

Conclusion: Can we put it as ‘The prevalence of burnout among medical students in our study was very high’ or something like this? If we write ‘More than expected’, authors may need to clarify what was expected (line 221).

I suggest the authors should hire a professional English language/academic editors to get help in editing the write up.

Review Conclusion:

The study topic is an interesting one. The study is methodologically sound. Conclusions are well presented. However, it needs minor revision in areas of grammars and editing part.

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Reviewer #1: Yes: Alok Atreya

Reviewer #2: Yes: Yubaraj Adhikari

Reviewer #3: Yes: Dr. Kishor Adhikari

Reviewer #4: Yes: Rajesh Kumar Yadav

Reviewer #5: Yes: Dr. Rijen Shrestha

Reviewer #6: No

Reviewer #7: No

Reviewer #8: No

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Attachments

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Submitted filename: Review of Burnout among medical students of a medical college in Kathmandu_A cross sectional study.docx

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Submitted filename: PONE-D-21-09730_reviewer_RKY.pdf

Attachment

Submitted filename: Summary of Comments.docx

PONE-D-21-09730R1

Burnout among medical students of a medical college in Kathmandu; A cross-sectional study

PLOS ONE

Dear Dr. Shrestha,

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 14-June-2021. 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Academic Editor Comments:

- Comments by Reviewer #4 have not been completely addressed in the revised manuscript. Kindly check the attachments for detailed comments made by Reviewer #4 and provide a specific point-to-point response.

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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

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #6: All comments have been addressed

Reviewer #8: 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: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #6: Yes

Reviewer #8: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #6: Yes

Reviewer #8: Yes

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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: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #6: Yes

Reviewer #8: 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: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #6: Yes

Reviewer #8: Yes

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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: (No Response)

Reviewer #2: Authors have addressed all recomendations and revised the paper accordingly. Thanks to authors for incorporation of my comments.

The reviewer has no further comments on the revised paper.

I believe, this paper helps to sensitize the burnout on future doctors and act accordingly to reduce the burden.

Reviewer #3: (No Response)

Reviewer #4: Dear Author,

Everything seems fine. You have addressed all those comments. Best wishes for your publications!!!

Thank you !!!

Reviewer #6: Good work on answering most of the comments and great job on the quick turn around. I have no additional comments.

Reviewer #8: (No Response)

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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: Yes: Alok Atreya

Reviewer #2: Yes: Yubaraj Adhikari, PhD

Reviewer #3: Yes: Dr. Kishor Adhikari

Reviewer #4: Yes: Rajesh Kumar Yadav

Reviewer #6: No

Reviewer #8: Yes: Dr Khagendra Kafle

[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.

Burnout among medical students of a medical college in Kathmandu; A cross-sectional study

PONE-D-21-09730R2

Dear Dr. Shrestha,

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.

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Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE