Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional study

Jarurin Pitanupong; Katti Sathaporn; Pichai Ittasakul; Nuntaporn Karawekpanyawong

doi:10.1371/journal.pone.0279564

Peer Review History

Original SubmissionMay 13, 2021
16 Feb 2022 Decision Letter - Vanessa Carels, Editor PONE-D-21-15809Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional study PLOS ONE Dear Dr. Sathaporn, 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. The manuscript has been evaluated by two reviewers, and their comments are available below. The reviewers have raised a number of major concerns, and have requested additional information on methodological aspects of the study and analyses. Could you please carefully revise the manuscript to address all comments raised? Please submit your revised manuscript by Apr 01 2022 11:59PM. 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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: No Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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: Dear Authors, I am delighted to see a study on mental health and burnout from Thailand. Appropriate, well-validated (within a North American context) questionnaires were utilized to assess whether there is an association with empathy, broadly speaking, burnout, mental health, as well as what I perceive to be 'control' variables, such as substance use within your demographics questionnaire. In North American studies, what we do find is generally a decrease in empathy (per scale used for that study), and generally a negative relationship between burnout and empathy. However, given that your study focuses on Thai medical students, these constructs may not hold the same sort of validity, or may need to be interpreted differently. Indications for me was 1) high personal achievement despite burnout, which is fairly surprising given the North American literature, and 2) the conflation of all three aspects of empathy to be equally important, when they may be best served as broken apart into cognitive v emotional empathy. There is a great deal of sociological/philosophical literature and debate on the utilization of emotional empathy (see Paul Bloom's Against Empathy) and whether it is even needed within the clinical encounter. I recommend to the authors to do their analysis but breaking both burnout and empathy constructs apart into their three dimensions to better understand the reasons for the differences seen. Merely stating that they are cultural differences without pulling in evidence suggestive of such (in Thai, non medical student samples) is far too speculative. Reviewer #2: Thank you for submitting this manuscript reporting results of your study of three Thai medical school students' self-reported mental health, burnout and empathy. The following comments are meant to help the authors refine their work. I feel these edits will be easy for the authors to make. Abstract At the conclusion of your results and in the conclusions, you suggest that the statistical relationship between the mental health scale with empathy is causal. The analysis indicates there is a positive association between the two measures, but it does not mean that better mental health improves empathy levels. The wording needs to be revised to reflect that. Introduction Line 96-98: I am not entirely convinced this sentence belongs here. It read as something that should be part of the conclusions of your manuscript and not the background. It may be worth discussing amongst yourselves or the editor to decide. Materials and Methods With regard to the administration of the questionnaire, I was curious if there was a plan of who would get the paper questionnaire and who would get the electronic version. The reason I ask is that what if you administer it to a class on paper and the student forgets they did that and completes the electronic version as well. I know it is unlikely, but it is possible. A better explanation of how these two administrations were done and why is needed. For the section on questionnaires, TMHI-15 and MBI need to have a sentence similar to the TEQ that defines item response options and scores. Along those same lines, it would be helpful to have how many questions on MBI and TEQ are included in their subscores. You indicated scores for MBI, but that does not tell us how many questions nor the scale. I also had a question about MBI. Is there an expected correlation between the three subscales? It seems that emotional exhaustion and depersonalization would have a positive correlation and the inverse with personal accomplishment. It may be worth noting what should be expected and if your study found similar results. Results section read nicely. Discussion Some additional limitations that should be addressed include potential bias due to greater number of female respondents and large number of Buddhist respondents. Also, have you considered non-response bias for those students not completing the survey? Conclusion Line 301 should be modified per my comment about the abstract. ****** 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? 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Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0279564.r001
Revision 1
26 Jul 2022 Author Response Dear, editor and reviver team Thank you for your kindly review, comments, and suggestion. Author's Responses to Questions of reviewer Reviewer #1: Dear Authors, Q: I am delighted to see a study on mental health and burnout from Thailand. Appropriate, well-validated (within a North American context) questionnaires were utilized to assess whether there is an association with empathy, broadly speaking, burnout, mental health, as well as what I perceive to be 'control' variables, such as substance use within your demographics questionnaire. In North American studies, what we do find is generally a decrease in empathy (per scale used for that study), and generally a negative relationship between burnout and empathy. However, given that your study focuses on Thai medical students, these constructs may not hold the same sort of validity, or may need to be interpreted differently. Indications for me was 1) high personal achievement despite burnout, which is fairly surprising given the North American literature, and 2) the conflation of all three aspects of empathy to be equally important, when they may be best served as broken apart into cognitive v emotional empathy. There is a great deal of sociological/philosophical literature and debate on the utilization of emotional empathy (see Paul Bloom's Against Empathy) and whether it is even needed within the clinical encounter. A: Thanks for your kindly and useful recommendation. We remove the sentence or wording that may be too speculative or not relate to the evidence of this research as the following This variance might be due to differences in study instruments, population ethnicity, and culture. We add discussion related to Paul Bloom's Against Empathy [reference 42] as following However, empathy and concern other’s mind may be psychologically distinct and empathy may be limited by our moral lives [42]. Q: I recommend to the authors to do their analysis but breaking both burnout and empathy constructs apart into their three dimensions to better understand the reasons for the differences seen. Merely stating that they are cultural differences without pulling in evidence suggestive of such (in Thai, non-medical student samples) is far too speculative. A: We try to do more analysis by breaking both empathy constructs apart and burnout into three dimensions as below. However, three dimensions of burnout (EE, DP, PA) were evaluated to determine if they had an impact on any subgroups of empathy. Data was analyzed using a linear regression for each of only two dimensions of burnout (EE and DP) because of the majority of participants (97%) reported high PA. It was discovered that participants with higher levels of DP had statistically lower scores of demonstrating appropriate sensitivity, altruism, and behaviors engaging higher-order empathic responding (p<0.001, p<0.003, and p<0.014, respectively). Reviewer #2: Thank you for submitting this manuscript reporting results of your study of three Thai medical school students' self-reported mental health, burnout and empathy. The following comments are meant to help the authors refine their work. I feel these edits will be easy for the authors to make. Thanks for your kindness review Abstract Q: At the conclusion of your results and in the conclusions, you suggest that the statistical relationship between the mental health scale with empathy is causal. The analysis indicates there is a positive association between the two measures, but it does not mean that better mental health improves empathy levels. The wording needs to be revised to reflect that. A: We correct the conclusion according your suggestion as Most medical students had below-average empathy levels, and two-thirds of them had high emotional exhaustion levels, yet most of them reported having a high level of personal accomplishment and good mental health. Better mental health resulted a protective factor that improves the level of empathy There was an association between mental health and the level of empathy. Higher levels of depersonalization related to lower scores of demonstrating sensitivity, altruism, and behaviors responding. Introduction Q: Line 96-98: I am not entirely convinced this sentence belongs here. It read as something that should be part of the conclusions of your manuscript and not the background. It may be worth discussing amongst yourselves or the editor to decide. A: We remove all these sentence as suggest. The findings of this study provide useful information for efforts to enhance empathy, promote well-being, and reduce distress among medical students as well as establish educational programs in the medical curriculum geared at boosting medical professionalism. Materials and Methods Q: With regard to the administration of the questionnaire, I was curious if there was a plan of who would get the paper questionnaire and who would get the electronic version. The reason I ask is that what if you administer it to a class on paper and the student forgets they did that and completes the electronic version as well. I know it is unlikely, but it is possible. A better explanation of how these two administrations were done and why is needed. A: We add the more explanation of these issue as “The data were collected in the given classroom following relevant guidelines by using a paper-based or online process. One participant had the right to choose only one way to answer the questionnaire. Before entering the study, all participants were asked whether responded on paper or online questionnaire to prevent double response of completing this study.” Q: For the section on questionnaires, TMHI-15 and MBI need to have a sentence similar to the TEQ that defines item response options and scores. Along those same lines, it would be helpful to have how many questions on MBI and TEQ are included in their subscores. You indicated scores for MBI, but that does not tell us how many questions nor the scale. I also had a question about MBI. Is there an expected correlation between the three subscales? It seems that emotional exhaustion and depersonalization would have a positive correlation and the inverse with personal accomplishment. It may be worth noting what should be expected and if your study found similar results. A: We add the more explanation of the range of each sub-scores in TMHI, MBI Tool as 2) Thai Mental Health Indicator-15 (TMHI-15) consisted of 15 questions. The score of each question ranged from 1 to 4; 1 (never); 2 (rarely); 3 (sometimes); and 4 (always), 3) Thai version of the Maslach Burnout Inventory (MBI) questionnaire [29,30] consisted of 22 items divided into three dimensions: emotional exhaustion (feelings of being emotionally overextended and exhausted by one’s work), depersonalization (unsympathetic and impersonal responses toward the recipients of one’s care or service), and personal accomplishment (feelings of competence and achievement in one’s work with people) [30]. Emotional exhaustion (EE) subscale ranged from 0 (never) to 6 (every day), Cronbach’s alpha coefficient=0.9. Depersonalization (DP) subscale ranged from 0 (never) to 6 (every day), Cronbach’s alpha coefficient=0.7. Personal accomplishment (PA) subscale ranged from 0 (every day) to 6 (never), Cronbach’s alpha coefficient=0.7. Results Q: section read nicely. A: We feel good, thank you so much ^__^ Discussion Q: Some additional limitations that should be addressed include potential bias due to greater number of female respondents and large number of Buddhist respondents. Also, have you considered non-response bias for those students not completing the survey? A: We add the limitation according to suggestion as Additionally, there might have potential bias due to greater number of female respondents and large number of Buddhist respondents. Q: Also, have you considered non-response bias for those students not completing the survey? A: We considered non-response bias for those students who not completing the survey, then we add more explanation in difference of demographic characteristic as Additionally, there was no statistically significant difference in demographic data (gender, religion) between participants and non-participants. Conclusion Q: Line 301 should be modified per my comment about the abstract. A: We correct the conclusion according the suggestion as Better mental health was found to be a significant protective factor for improving the level of empathy. There was the association between mental health and the level of empathy. Higher levels of depersonalization related to lower scores of demonstrating sensitivity, altruism, and behaviors engaging empathic responding. Finally We have sent our “Revised manuscript” for re-checked and re-proofreading the English from the Office of International Affairs of the Faculty of Medicine. Sincerely thanks for every nice, kind comments and suggestion, they are very useful to improve our manuscript. Best regards Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0279564.r002
18 Oct 2022 Decision Letter - Omnia Samir El Seifi, Editor PONE-D-21-15809R1Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional studyPLOS ONE Dear Dr. Sathaporn, 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. ============================== ACADEMIC EDITOR:please respond to the comments to make your research suitable for publicationGrammar revision is requested ============================== Please submit your revised manuscript by Dec 02 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, Omnia Samir El Seifi, Professor Academic Editor PLOS ONE [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 #3: (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 #3: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: No ****** 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: No ****** 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: Major revision is needed One of the objectives is to determine the association between burnout and empathy: So, it is not true to adjust for burnout in logistic regression. Burnout must be included in the model beside mental health. It is not true to make two models (one for personal and one for depersonalization): you should make one logistic regression model that includes mental health, depersonalization and personal exhaustion. I mean the relation between burnout and empathy should be clearly reported in the logistic regression. In your models (table 3 and 4), I noticed that you report one p value; it should be two p values: one for each category as compared with the reference group. Do this for the new model. The sequence of table is not correct: begin with all the descriptive analysis then move to bivariate and then to multivariate: so, table one should include only descriptive statistics. Put the association just before the last table which is the multiple logistic regression. If there are new findings, discuss them and include them in the conclusion. Have you checked for multicollinearity in multiple logistic regression? Your conclusion does not reflect the findings. Please rewrite it. After conclusion, write your recommendation according to your findings. ****** 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: Yes: SAMI ABDO RADMAN AL-DUBAI ******** [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.0279564.r003
Revision 2
9 Nov 2022 Author Response Response to review Comments Title: Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional study. Reviewer #3: Major revision is needed C: One of the objectives is to determine the association between burnout and empathy: So, it is not true to adjust for burnout in logistic regression. Burnout must be included in the model beside mental health. It is not true to make two models (one for personal and one for depersonalization): you should make one logistic regression model that includes mental health, depersonalization and personal exhaustion. I mean the relation between burnout and empathy should be clearly reported in the logistic regression. In your models (table 3 and 4), I noticed that you report one p value; it should be two p values: one for each category as compared with the reference group. Do this for the new model. The sequence of table is not correct: begin with all the descriptive analysis then move to bivariate and then to multivariate: so, table one should include only descriptive statistics. Put the association just before the last table which is the multiple logistic regression. A: We have modified the manuscript and tables as suggested (as table 1 show only descriptive data, and table 2,3 show bivariate and then multivariate, respectively) C: If there are new findings, discuss them and include them in the conclusion. A: The finding is not different from the original or previous results. C: Have you checked for multicollinearity in multiple logistic regression? A: Yes, we check it. Thanks. C: If your conclusion does not reflect the findings. Please rewrite it. A: The finding is the same as the prior results, then the conclusion is the same. C: After the conclusion, write your recommendation according to your findings. A: The finding is the same as the prior results. However, we concern about your valuable suggestion, then we add our recommendation according to our findings in conclusion part “Therefore, medical educators should pay close attention to promoting good mental health among medical students.” Finally, we are grateful for your good wishes and valuable suggestion. This is helpful so much and encourages us to make this manuscript to get better. We wish to have more best wishes from you again. Thanks. Attachments Attachment Submitted filename: response to reviewer V3.docx https://doi.org/10.1371/journal.pone.0279564.r004
12 Dec 2022 Decision Letter - Omnia Samir El Seifi, Editor Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional study PONE-D-21-15809R2 Dear Dr. Sathaporn, 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, Omnia Samir El Seifi, Professor Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0279564.r005
Formally Accepted
16 Dec 2022 Acceptance Letter - Omnia Samir El Seifi, Editor PONE-D-21-15809R2 Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional study Dear Dr. Sathaporn: 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 Professor Omnia Samir El Seifi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0279564.r006

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