PONE-D-21-20456

Inattentional blindness in Anesthesiology: a gorilla is worth one thousand words.

PLOS ONE

Dear Dr. De Cassai,

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Dylan A Mordaunt

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

I agree with the reviewer, this study injects some humour into a serious issue and adds novelty in a similar way to Christmas BMJ. I intend to accept this submission but I would like the reviewers to go away and expand the discussion to include semantically similar concepts to inattentional blindness in their discussion. They have cited the one previous simulation study but for the authors' own benefit and for the benefit of increased future impact, I think they could expand to discuss similar/relevant concepts such as situational awareness, as they have been studies in anaesthetics, peri-operative or critical care circumstances. Have some examples as follows- https://blog.oup.com/2015/01/perceptual-errors-inattenional-blindness/ and https://pubs.asahq.org/anesthesiology/article/118/3/729/13561/Situation-Awareness-in-AnesthesiaConcept-and (NB: these are not self-references). Situational blindness is a critical concept in human factors studies and I also think it's something you'll find has highly relevant military and aviation links. I look forward to reading the response, the intention is not to get you to completely rework the paper, just to consider adding some generalisability and additional value. Kind regards,

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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

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

Reviewer #1: 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

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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

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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: The authors present a wonderful piece of research: they raise attention for a very serious topic with a highly entertaining method, and thus succeed in making the reader both think and smile.

Inattentional blindness is, as pointed out in their discussion, a major topic for health care providers, especially in but definitely not limited to perioperative care. The authors confronted anaesthesiologists with medical cases, in which a gorilla face was hidden in a chest-x-ray. Only one third spotted the gorilla.

Of course, the study can be criticized, as biases in the selection of the sample and the response rates are not completely transparent, (as the authors mention in their discussion) but this does not weaken the fundamental statement that a large proportion of experienced clinicians were not aware of the gross conspicuity.

I congratulate the authors for their work! Thank you!

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Reviewer #1: No

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PONE-D-21-20456R1

Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.

PLOS ONE

Dear Dr. De Cassai,

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 Oct 15 2021 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. 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,

Dylan A Mordaunt

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments (if provided):

Although human factors psychology is an important part of healthcare safety sciences, and in particular areas like anaesthesia, there were relatively few individuals available to review the manuscrupt. With this in mind, I sought input from an academic specialist in human factors psychology. This expert's recommendation was to reject the article on the basis of what you can see in the reviewer's responses. The first issue was a perceived lack of new findings- whilst the suggestion is that this is similar to previous work, I think the difference is that it's applied to this specific scenario (i.e. anaesthetic safety) and whilst the approach may be similar, it doesn't appear to be either direct duplication nor replication of previous work- so though perhaps iterative or redundant from a human factors psychology perspective, I think it offers value to the health safety sciences community. With that in mind, both reviewer 2 and 3's comments should be considered as I think they have the potential to add value to the manuscript. I will leave it to the authors to decide which they agree with and to respond to those which they don't, but they do increase the bar for re-review to major. It may be worth considering whether the authors make greater reference to the phenomena of inattentional blindness in other fields, and the wider implications for other areas of healthcare.

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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: (No Response)

Reviewer #3: (No Response)

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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: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: 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: Yes

Reviewer #2: Yes

Reviewer #3: 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: No

Reviewer #3: 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: The authors present a revised version of their manuscript. They included satisfying responses all issues raised.

Reviewer #2: The manuscript is incomplete and not ready for the review.

1. I don't see any new findings in this study.

2. Instead of a general remark (ever-growing attention is deemed necessary to improve patient safety.), more specific suggestions should be provided.

3. This study analyzed only incidence rates. How about diagnostic accuracy for each case?

4. Each section should consist of paragraphs, but some sections do not have paragraphs. In addition, some sentences have grammatical errors.

5. The conclusion consists of only one sentence.

When simulated tasks are used, it is essential to ensure their validity. Discuss their validity.

1. Are simulated tasks valid in terms of image size, resolution, visual angle, task time, etc?

2. How seriously would the respondent consider each case?

3. How confidently would the respondent answer each question?

4. How similar were the five cases to the actual cases in terms of workload?

For each simulated case, explain in detail where to look at for a typical diagnosis.

Describe how the developed survey meets the BRUSO criteria.

If laboratory tests, chest radiography and electrocardiogram are the same for the first several cases, without pathological findings, it is very unlikely to pay attention to these data for the remaining cases, thus more likely to miss the gorilla.

How did you conclude whether the gorilla was (was not) spotted by respondents? I don't see a direct question on this.

The abstract should be rewritten.

1. The abstract should be one paragraph without any subsections.

2. An online survey was spread on Facebook (Facebook, Inc., Menlo Park, California, United States) between May 1, 2021 and May 31, 2021.

: Too much information is provided.

3. The survey consisted of simulated cases.

: More information is needed. (The survey consisted of five simulated cases.)

4. There are no meaningful findings/implications.

In the introduction, the nature of anaesthesia-related tasks should be described in detail for readers without medical information. For example, what types of attention (focused, selective, divided, and sustained) are relevant to anaesthesia-related tasks ? How many and what data channels are involved? and what is a typical procedure involved in diagnosis?

The statistical analysis section should be described more in detail.

Reviewer #3: Inattentional blindness is a serious concern that is somewhat lacking attention in the public and in serious workplaces. I agree with the previous reviewer and editor, the authors do a good job bringing light to this topic using humility that will attract a wide audience to a serious topic. I also agree that there are some pitfalls to this paper and study; however, I agree with the previous reviewer that they do not affect the overall statement of the paper.

Despite that, I do have a few minor comments regarding grammar:

1) Although not significant, the rate at which the gorilla was spotted did trend towards decreasing with experience. Please be sure to mention this in your discussion in the topic regarding age and inattentional blindness.

2) Abstract, Materials and Methods - please replace "spreaded" with spread or distributed.

3) Page 7 (Methods, Population of Interest and Survey Distribution Plan - please revise "we initiated to spread the invite to respond to the survey" to "We spread an invite to the survey" or "We began distribution of the survey invitation" or equivalent

4) Page 8 (Results, paragraph 1) - there are two references to figure 2. Please remove one.

5) Page 11 (Discussion, sentence 1) - remove that from "exists in the anesthesia field and that may be far more common than generally thought"

6) Page 13 (discussion) - remove the new line following "our study has some limitations that we would like to discuss"

7) Page 14 (discussion) - reword "using as example a wave analysis model"

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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

Reviewer #3: Yes: Matthew Scott Sherwood

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Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.

PONE-D-21-20456R2

Dear Dr. De Cassai,

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.

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Kind regards,

Dylan A Mordaunt

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: