Ten years of graduates: A cross-sectional study of the practice location of doctors trained at a socially accountable medical school

John C. Hogenbirk; Roger P. Strasser; Margaret G. French

doi:10.1371/journal.pone.0274499

Peer Review History

Original SubmissionMarch 3, 2022
11 Apr 2022 Decision Letter - Muhammad Shahzad Aslam, Editor PONE-D-22-06414Ten years of graduates: a cross-sectional study of the practice location of doctors trained at a socially accountable medical schoolPLOS ONE Dear, 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 26th May 2022. 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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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 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 ****** 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 ****** 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 is an excellent study and most helpful to those who are interested in learning which factors weigh most heavily toward recruitment of primary care into rural and underserved settings. One additional limitation: I understand that Canada manages their residency slots, and this helps produce a higher percentage of family physicians. It may be worth adding this since not all countries will have this in place. This certainly adds to the literature on the need for rural/underserved exposure during medical school. If not referenced, consider reviewing some of the recent literature out of Australia that also supports this. Reviewer #2: Comments (L = Line) L51: Put a reference at the end of the paragraph. L162: Table 1 needs to be re-organized in a better way. L163: The total calculation should be either in a form of ‘row’ or ‘column’ total, but the authors have calculated the percentages out of the grand total. L170 and downwards: There are a lot of explanations and definitions that can be mentioned in the methods section rather than putting them under the table. L191-196: Table 2 is not accepted in this format. The text contains details like p values and percentages that are not present in the table. The authors should calculate a row percentage and should put the percentage (%) between brackets next to each frequency, and in the last column they should mention the p value. ****** 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: 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. Attachments Attachment Submitted filename: Comments.docx https://doi.org/10.1371/journal.pone.0274499.r001
Revision 1
10 Jun 2022 Author Response Please refer to the uploaded file "response to reviewers" Attachments Attachment Submitted filename: Response to reviewers and editors PLOS One 2022-06-10.docx https://doi.org/10.1371/journal.pone.0274499.r002
11 Jul 2022 Decision Letter - Muhammad Shahzad Aslam, Editor PONE-D-22-06414R1Ten years of graduates: a cross-sectional study of the practice location of doctors trained at a socially accountable medical schoolPLOS ONE Dear Dr. Hogenbirk, 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 Aug 25 2022 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: https://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, Muhammad Shahzad Aslam, Ph.D.,M.Phil., Pharm-D 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 Editor Comments : Please complete the corrections according to reviewer comments otherwise the manuscript does not proceed further [Note: HTML markup is below. Please do not edit.] 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 #2: (No Response) ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes ****** 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 #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 #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 #2: Dear authors: Plz respond positively to my previous note L191-196: Table 2 is not accepted in this format. The text contains details like p values and percentages that are not present in the table. The authors should calculate a row percentage and should put the percentage (%) between brackets next to each frequency, and in the last column they should mention the p value. Regards ****** 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 #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. Attachments Attachment Submitted filename: Comments.docx Attachment Submitted filename: Comments_version2.docx https://doi.org/10.1371/journal.pone.0274499.r003
Revision 2
3 Aug 2022 Author Response This response was first submitted and uploaded as a separate file on May 26, 2022. Re-submitted/uploaded on June 10, 2022 with minor changes. Re-submitted/uploaded on August 3, 2022 with additional details on the structure of Table 2. Thank you for the opportunity to reply to the reviewers’ comments. The comments and our responses are documented below. Reviewer #1. Abstract: some of the strongest data, in my opinion, is the aOR of 45 for FPs practicing in northern Ontario who completed UG and PG at NOSM vs. rural background aOR = 5 Would recommend adding this to the abstract. We have revised the abstract to include the adjusted odds ratios and their 95% confidence intervals. Line 21 “We used a cross-sectional study to measured, …” Is the word “measured” necessary? It first appears to be a typo (e.g. to measure) Our thanks for identifying these and other typos. The abstract was revised to include the above suggestion and the typo was resolved. Line 47-48 “NOSM selects students from underserved and economically deprived regions of Canada with a focus on northern Ontario.” This can be strengthened with some data, such as “____% of matriculating students at NOSM are from….” We’ve revised this paragraph to add information on matriculating students. Line 60 typo “with most of the these” Fixed, thanks. Lines 269-270. “Completing both UG and PG at NOSM had the highest aOR of 45.7.” Since there is a lot of data, would recommend qualifying this statement, “Completing both UG and PG at NOSM had the highest aOR of 45.7 for FPs practising in northern Ontario.” We have revised the relevant sentences to read…” FPs who completed both UG and PG at NOSM had highest magnitude adjusted odds ratio (aOR) of practising in northern Ontario relative to those FPs who only completed their UG at NOSM. This aOR of 46 was three-times the magnitude of the aOR for completing just the PG at NOSM and almost nine-times the magnitude for having a northern Ontario background.” Line 280-282 “The overall percentage was nearly twice that of the 49% (508/1047) of doctors who graduated 1973 – 2008 from the Memorial University of Newfoundland (MUN) and did at least some of their PG training at MUN and were practising in MUN’s service region in 2014.[27]” Intriguing. A very nice comparator. For those not familiar, what is the rationale for using MUN as a comparator? Are they similarly situated? We have added information on how MUN compares with NOSM. Lines 326-334 seem out of place for this manuscript [“Recent increases in the use of virtual care…”] Our rationale for including this paragraph is that virtual care offers an alternative to physically locating physicians in regions of need. We argue that, at least, physicians should be trained to care for patients in underserved regions if they are to provide effective virtual care. We also suggest that it is better still to have physicians locate their practice in underserved areas. We have added text to flesh out our arguments. Line 347 It’s fair to say the following, yes? The second, and more influential factor in our study, is to provide undergraduate and postgraduate medical education immersed in the regions, whereby students and trainees are living and learning in the community and in the clinical settings where they are expected to practice in the future. We added the suggested clause to this sentence. Many are going to be interested in this conclusion because while we recognize the value of admitting students from rural backgrounds into medical school, and we recognize the role of the medical school educational environment, we do not know which is more influential. This study appears to help answer that. This is an excellent study and most helpful to those who are interested in learning which factors weigh most heavily toward recruitment of primary care into rural and underserved settings. We thank the reviewer for these kind comments One additional limitation: I understand that Canada manages their residency slots, and this helps produce a higher percentage of family physicians. It may be worth adding this since not all countries will have this in place. We have added some information to the Methods section on medical education in Canada and on residency matching to provide readers with the necessary context. This certainly adds to the literature on the need for rural/underserved exposure during medical school. If not referenced, consider reviewing some of the recent literature out of Australia that also supports this. We have added more references including some very recently published studies from Australia. Reviewer #2 L51: Put a reference at the end of the paragraph. We have revised the paragraph and have included the appropriate reference. L162: Table 1 needs to be re-organized in a better way. Table 1 has been reorganized. L163: The total calculation should be either in a form of ‘row’ or ‘column’ total, but the authors have calculated the percentages out of the grand total. We have calculated percentages in the revised Table 1 to best illustrate the point that we wish to make. We used the percentage of the total in the part of the Table that presents rural or urban hometown vs hometown region because we don’t wish to prioritize rurality (row) over region (column). L170 and downwards: There are a lot of explanations and definitions that can be mentioned in the methods section rather than putting them under the table. We have added to the existing material in the Methods section and have removed most of the Table notes. L191-196: Table 2 is not accepted in this format. The text contains details like p values and percentages that are not present in the table. The authors should calculate a row percentage and should put the percentage (%) between brackets next to each frequency, and in the last column they should mention the p value. [Authors’ reply was updated August 3, 2022, elaborating on the reply that was uploaded May 26 and June 11.] Table 2 contains detailed data that were collapsed in different ways in the text to test for differences among the three specialty groups in rural-urban practice location or in practice region. We have added text to the manuscript to better describe the specific values that we extract from Table 2, which are used in these exact tests. August 3, 2022 tracked changes in the manuscript are highlighted in yellow. We deliberately presented only the counts and not percentages in Table 2 to avoid confusion. We suggest that Table 2 would become too cluttered and complex if we were to place the percentages (calculated on column totals within each specialty for one comparison and calculated on row totals within each specialty for the other comparison), plus display p-values and highlight the desired comparisons in Table 2. The current structure of Table 2 also helps with data disclosure requirements, by allowing the reader to extract counts and run customized analyses (provided the data that they extract are mutually exclusive and complete). For example, the reader could conduct exact tests within a specialty group (e.g., within the FP group), run a hierarchical log-linear model with specialty group (n=3) by rurality (n=2) by region (n=3), or collapse some categories and run additional tests. We also suggest that it is accepted practice to extract a subset of data from a larger table and test pre-defined hypotheses as we have done in our manuscript. The explanatory text added to the manuscript on August 3, 2022, should help clarify our approach and justify the current structure of Table 2. If there are residual concerns about Table 2, then one alternative is to create two separate and collapsed Tables to reflect the two comparisons and repurpose the detailed Table 2 as a supplement. This alternative seems unnecessarily redundant and hence we prefer to use Table 2 as is, with additional explanation in the text. We trust that we have addressed the major concerns expressed by the reviewers and editor(s). Please contact us should you have any further questions. Respectfully submitted, John C. Hogenbirk, Roger Strasser, Margaret French Attachments Attachment Submitted filename: Response to reviewers PLOS One 2022-08-03.docx https://doi.org/10.1371/journal.pone.0274499.r004
30 Aug 2022 Decision Letter - Muhammad Shahzad Aslam, Editor Ten years of graduates: a cross-sectional study of the practice location of doctors trained at a socially accountable medical school PONE-D-22-06414R2 Dear, 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, Muhammad Shahzad Aslam, Ph.D.,M.Phil., Pharm-D 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 #3: All comments have been addressed ******** 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 #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes ****** 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 #3: 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 #3: 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 #3: The paper has been improved according to the reviewers' suggestions. Now the manuscript can be accepted for publication. ****** 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 #3: No ******** https://doi.org/10.1371/journal.pone.0274499.r005
Formally Accepted
6 Sep 2022 Acceptance Letter - Muhammad Shahzad Aslam, Editor PONE-D-22-06414R2 Ten years of graduates: a cross-sectional study of the practice location of doctors trained at a socially accountable medical school Dear Dr. Hogenbirk: 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. Muhammad Shahzad Aslam Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0274499.r006

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