Toward improvement of knowledge of financial conflicts of interest in a large medical school in France

J. F. Alexandra; D. Roux; H. Maisonneuve; B. Chousterman; P. Ruszniewski; D. Dreyfuss

doi:10.1371/journal.pone.0285894

Peer Review History

Original SubmissionDecember 21, 2022
31 Jan 2023 Decision Letter - Alberto Molina Pérez, Editor PONE-D-22-34803Toward improvement of knowledge of financial conflicts of interest in a large medical school in FrancePLOS ONE Dear Dr. alexandra, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but requires some clarifications and revisions to 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: Both reviewers’ comments are helpful to improve the quality of the article. In particular, they indicate some issues that require further clarification, with a special attention on their comments regarding the methods section. In addition, I recommend that you thoroughly review the manuscript for typos and errors. It is often useful to have the text proofread by someone else who can see it with new eyes. Please submit your revised manuscript by Mar 17 2023 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'. 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Kind regards, Alberto Molina Pérez, Ph.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. You indicated that ethical approval was not necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on why your study is exempt from the need for approval and confirmation from your institutional review board or research ethics committee (e.g., in the form of a letter or email correspondence) that ethics review was not necessary for this study? Please include a copy of the correspondence as an ""Other"" file. 3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. [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: Thank you for the opportunity to review this paper. I enjoyed reading it and it reports on a useful and important study. I have made some suggestions for how its clarity could be improved. Most importantly, there is confusion about what the study actually entailed. As an initial comment, Charte is Charter (rather than chart) In the introduction you say there is a quasi-complete lack of academic policy, but in the next sentence you introduce the Charter. This seems contradictory. Do you mean that there is policy that is not implemented? Or that despite agreeing to the Charter no policy actions have been taken? This needs a bit of clarity. The methods section is confusing. Were items 1-4 part of the study or would they have happened anyway as part of professional training? Here they seem to be presented as part of the experiment but up to this point the paper doesn’t suggest this. My reading of the paper is that the survey of the students is the study, to see whether training their instructors on the Charter led to change in practice or had any sort of trickle down effect to students. If this is the case, the info from 1-4 could go into the introduction. I agree that it is important information but it is not a study method. If the activities in 1-4 were done for the specific purpose of this study then that needs to be made much clearer up front and ideally methodologically justified. Would you have expected that working with instructors would sensitise students to COI? Were instructors asked to train students on COI? Per number 5, was it compulsory? The response rate in the results suggests not but the wording in 5 suggests yes. Perhaps reword 5 in the methods. Per number 6, it’s unclear why there are 4 responses to the questions because they are all essentially y/n questions and you subsequently report the results as y/n in each category. Can you talk about why you set up the questionnaire like this? How did you decide the questions? Are the questions relevant to the Charter? Do they test particular aspects of the Charter? Discussion: The second paragraph repeats the information in the introduction and should be removed. In this paragraph you use ref 8 to note that students are unaware of the harms that COI might pose. This would be useful info to have in the introduction (where you use ref 8 to make a very different point). In para 3 of the discussion you need to include more information about FORMINDEP if you’re going to talk about survey response. Perhaps at the beginning of this para you could say that the survey measures schools’ performance on COI policy. As it was I wasn’t sure what the numbers referred to and it needed some reading between the lines. P8 “The lack of knowledge of these issues…” – which issues? Is it that they lack knowledge about COI? About the importance of policies mitigating against COI? or don’t care or haven’t made it a priority or something else? Also p8 you make it sound like items 1-4 in the methods were in fact part of the study? Again, confusing. P8 is the first place that you mention Charter expectations (eg that teachers should declare at the beginning of each class), though you say you alluded to it. I note in the text that you included the Charter as an appendix but it did not show up in my review. If it is short enough it would be great to include it (or a summary) in a box in the manuscript. It is unlikely that most readers will take the trouble to find an appendix before reading the paper and the paper makes less sense without knowing the contents or even the gist of the Charter. The pitfall section: The sentence about not taking the potential influence of partnership between teachers and industry into account is confusing. Into account how? Perhaps you mean that you only studied the Charter and its implementation and not COI that are not covered in the Charter? Some clarity here would be beneficial. Reviewer #2: Thank you for conducting this study, the results of which seem very important to me. I just have a few minor suggestions to further improve the quality of the paper. I will make my recommendations by mentioning systematically and in order the number of the page to which I refer. Page 3: "This association aims at both to promotion of evidence-based medicine and prevention of the influence of economic interests of industry on patients, doctors, medical students, and public decision-makers" -> The sentence does not sound good. It could be something like : « This association aims both to promote evidence-based medicine and to prevent the influence of industry's economic interests on patients, physicians, medical students and public policy makers. » Page 4: You refer to an appendix but I have not been able to find it. Methods, point 3: "Implementation of the Chart" -> It is strange to have a specific title for this point and not for the others, it should be harmonized Page 5: Methods: In my opinion, only points 5 and 6 really constitute the methodology of the survey presented in the study. The previous points seem to me to be more contextualizing elements. Also, it would be interesting to know a bit more about the creation of the questionnaire: how the 10 items were decided, when exactly the questionnaire was submitted, how did you analyze the results, etc. Page 7: Discussion: "the first taking directly in account students’" -> "I would add "on this specific subject" or "in France" because there are many international studies that directly take into account the opinions of medical students on their interactions with industry, the issue of independence and their perceptions. For example: " ext-link-type="uri" xlink:type="simple">https://doi.org/10.1186/s12909-018-1394-9" Page 9: First, the rather good response rate shows the feasibility of this survey. - « of this kind of survey » ? ----- As you can see, my main point is about the presentation of the survey methodology. This section could be reworked in order to better present the different steps that led to the creation of the study. For the rest, it is a very good paper on a fundamentally important topic. ****** 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: Yes: Lucas Bechoux ******** [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.0285894.r001
Revision 1
23 Mar 2023 Author Response We wish to thank both Editor and Reviewers for their helpful comments that helped improving our manuscript. Editor’s comment You indicated that ethical approval was not necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on why your study is exempt from the need for approval and confirmation from your institutional review board or research ethics committee (e.g., in the form of a letter or email correspondence) that ethics review was not necessary for this study? Please include a copy of the correspondence as an ""Other"" file. Thank you for raising this point. French law on research involving human subjects applies only to research involving patients and to surveys involving health data. It therefore does not apply to an anonymized survey of medical student feeling about their medical school policy. No personal data was involved. In a study like ours, no IRB approval is required by French law. Obviously students were informed of the purpose of the survey and were perfectly free to refuse it (see response to Reviewer 1). We have clarified the issue in the revised version (page 6). Responses to reviewers’ comments Reviewer #1: Thank you for the opportunity to review this paper. I enjoyed reading it and it reports on a useful and important study. I have made some suggestions for how its clarity could be improved. Most importantly, there is confusion about what the study actually entailed. Thank you very much for your positive appreciation As an initial comment, Charte is Charter (rather than chart) We wrongly thought that both “chart” and “charter” could be used as translation of the French word “charte” Thank you for your comment. The word “chart” has been replaced by “charter” throughout our manuscript. In the introduction you say there is a quasi-complete lack of academic policy, but in the next sentence you introduce the Charter. This seems contradictory. Do you mean that there is policy that is not implemented? Or that despite agreeing to the Charter no policy actions have been taken? This needs a bit of clarity. Thank you for allowing us to clarify this point: there was a lack of policy action or a lack of their evaluation (probably both) in French medical schools, including ours. The purpose of our study is to describe the issue in our medical school. We have modified this sentence page 3 . The methods section is confusing. Were items 1-4 part of the study or would they have happened anyway as part of professional training? Here they seem to be presented as part of the experiment but up to this point the paper doesn’t suggest this. My reading of the paper is that the survey of the students is the study, to see whether training their instructors on the Charter led to change in practice or had any sort of trickle down effect to students. If this is the case, the info from 1-4 could go into the introduction. I agree that it is important information but it is not a study method. If the activities in 1-4 were done for the specific purpose of this study then that needs to be made much clearer up front and ideally methodologically justified. The reviewer is right. The text has been modified and point 1-4 no longer appear in the Methods section but in the introduction. Would you have expected that working with instructors would sensitise students to COI? Were instructors asked to train students on COI? The Reviewer raises an important point. One can imagine that working with instructors (this was not the case in our study) would sensitise students. According to their question, we now mention at the end of the paper that our next survey should investigate how students are sensitised to COI by the mandatory course Per number 5, was it compulsory? The response rate in the results suggests not but the wording in 5 suggests yes. Perhaps reword 5 in the methods. This is an important point. Responses were anonymized and students were free to answer or not as mentioned in revised manuscript page 5 Per number 6, it’s unclear why there are 4 responses to the questions because they are all essentially y/n questions and you subsequently report the results as y/n in each category. Can you talk about why you set up the questionnaire like this? How did you decide the questions? Are the questions relevant to the Charter? Do they test particular aspects of the Charter? We explain our choice in the revised manuscript page 5: The questions took into account every point of the charter summary. One to 4 scale was chosen in order to allow nuanced analysis. Discussion: The second paragraph repeats the information in the introduction and should be removed. In this paragraph you use ref 8 to note that students are unaware of the harms that COI might pose. This would be useful info to have in the introduction (where you use ref 8 to make a very different point). Thank you for this pertinent suggestion. We have moved this paragraph from the discussion to the introduction in order to mention the two points addressed in ref 8 In para 3 of the discussion you need to include more information about FORMINDEP if you’re going to talk about survey response. Perhaps at the beginning of this para you could say that the survey measures schools’ performance on COI policy. As it was I wasn’t sure what the numbers referred to and it needed some reading between the lines. Thank you for allowing us to clarify this issue. We have modified the text according to your recommendation (page 8) P8 “The lack of knowledge of these issues…” – which issues? Is it that they lack knowledge about COI? About the importance of policies mitigating against COI? or don’t care or haven’t made it a priority or something else? Also p8 you make it sound like items 1-4 in the methods were in fact part of the study? Again, confusing. Thank you very much for this comment. We have clarified this confusing point and modified the entire paragraph (page 8) P8 is the first place that you mention Charter expectations (eg that teachers should declare at the beginning of each class), though you say you alluded to it. I note in the text that you included the Charter as an appendix but it did not show up in my review. If it is short enough it would be great to include it (or a summary) in a box in the manuscript. It is unlikely that most readers will take the trouble to find an appendix before reading the paper and the paper makes less sense without knowing the contents or even the gist of the Charter. We are sorry that you could not access the Charter. We have made sure that the summary of the charter is uploaded in appendix The pitfall section: The sentence about not taking the potential influence of partnership between teachers and industry into account is confusing. Into account how? Perhaps you mean that you only studied the Charter and its implementation and not COI that are not covered in the Charter? Some clarity here would be beneficial. The Reviewer is right. We have clarified this point by mentioning that our study focused only on students’ perception of the charter implementation Reviewer #2: Thank you for conducting this study, the results of which seem very important to me. I just have a few minor suggestions to further improve the quality of the paper. I will make my recommendations by mentioning systematically and in order the number of the page to which I refer. Thank you very much for your positive appreciation. Page 3: "This association aims at both to promotion of evidence-based medicine and prevention of the influence of economic interests of industry on patients, doctors, medical students, and public decision-makers" - The sentence does not sound good. It could be something like : « This association aims both to promote evidence-based medicine and to prevent the influence of industry's economic interests on patients, physicians, medical students and public policy makers. » Thank you for suggesting a better formulation that is now used in our manuscript. Page 4: You refer to an appendix but I have not been able to find it We are sorry that you could not access the Charter. We have made sure that the summary of the charter is uploaded in appendix Methods, point 3: "Implementation of the Chart" - It is strange to have a specific title for this point and not for the others, it should be harmonized The Reviewer is right. We have removed this title Page 5: Methods: In my opinion, only points 5 and 6 really constitute the methodology of the survey presented in the study. The previous points seem to me to be more contextualizing elements. Also, it would be interesting to know a bit more about the creation of the questionnaire: how the 10 items were decided, when exactly the questionnaire was submitted, how did you analyse the results, etc. Both Reviewers rightly make the same point. Point 1-4 are no longer present in the study method and appear in the introduction Page 7: Discussion: "the first taking directly in account students’" - "I would add "on this specific subject" or "in France" because there are many international studies that directly take into account the opinions of medical students on their interactions with industry, the issue of independence and their perceptions. For example: https://doi.org/10.1186/s12909-018-1394-9" The Reviewer is perfectly right: the sentence has been modified accordingly and the reference to the paper of Saito and al added (page 8). Page 9: First, the rather good response rate shows the feasibility of this survey. - « of this kind of survey » ? We have made this change ----- As you can see, my main point is about the presentation of the survey methodology. This section could be reworked in order to better present the different steps that led to the creation of the study. Thank you for pointing this. We have modified the text according to your suggestion (pages 4-5) For the rest, it is a very good paper on a fundamentally important topic. Once again, we thank the Reviewer for their positive appreciations https://doi.org/10.1371/journal.pone.0285894.r002
11 Apr 2023 Decision Letter - Alberto Molina Pérez, Editor PONE-D-22-34803R1Toward improvement of knowledge of financial conflicts of interest in a large medical school in FrancePLOS ONE Dear Dr. alexandra, Thank you for submitting your manuscript to PLOS ONE. Before a final decision can be made, we invite you to submit a revised version of the manuscript that addresses the remaining points raised by reviewer 2. Please submit your revised manuscript by May 26 2023 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-emailutm_source=authorlettersutm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Alberto Molina Pérez, Ph.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. [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 #1: All comments have been addressed Reviewer #2: 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 #1: (No Response) Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) 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 #1: (No Response) 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 #1: (No Response) 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 #1: (No Response) Reviewer #2: Thank you for this revised version and for incorporating the comments made earlier. I still have a few minor comments. Throughout the manuscript, the use of the term "charter" instead of "chart" should be harmonized: there are still quite a few passages where the word "chart" is used. Page 7: "This questionnaire was also sent to the Conference of the Deans who did not answer it..." -: I think that the use of ellipsis is not very common in scientific articles. Page 7-8: In the paragraph "The accuracy of results of previous studies is beyond doubt... his amendment occurred after our survey was conducted." - to me, here there are two different ideas: the limitations of the Formindep study and the tools put in place to limit COI. The paragraph should be split in two in order to maintain coherence. Page 9: "Last, we did not investigate the behavior of the teachers, but they probably share responsibility for the poor results with the students." - I don't understand what you mean here. From the turn of phrase, it is understood that the students would share some responsibility for the poor results of the study. I think that needs to be clarified because the responsibility for the low knowledge of the charter does not lie with them at all. Thank you for your attention to my comments and congratulations on the great work done on this article. ****** 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 #1: Yes: Jane Williams Reviewer #2: Yes: Lucas Bechoux ******** [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.0285894.r003
Revision 2
17 Apr 2023 Author Response We thank the Reviewer for his positive appreciation of our work and for his helpful suggestions that have all been followed in the manuscript. Throughout the manuscript, the use of the term "charter" instead of "chart" should be harmonized: there are still quite a few passages where the word "chart" is used. Done Page 7: "This questionnaire was also sent to the Conference of the Deans who did not answer it..." -: I think that the use of ellipsis is not very common in scientific articles. We agree. We have suppressed the suspension points and slightly changed the sentence. Page 7-8: In the paragraph "The accuracy of results of previous studies is beyond doubt... his amendment occurred after our survey was conducted." - to me, here there are two different ideas: the limitations of the Formindep study and the tools put in place to limit COI. The paragraph should be split in two in order to maintain coherence. We have followed the Reviewer’s suggestion and modified the paragraph accordingly. Page 9: "Last, we did not investigate the behavior of the teachers, but they probably share responsibility for the poor results with the students." - I don't understand what you mean here. From the turn of phrase, it is understood that the students would share some responsibility for the poor results of the study. I think that needs to be clarified because the responsibility for the low knowledge of the charter does not lie with them at all. The Reviewer is perfectly right. We have modified the unfortunate sentence. Thank you for your attention to my comments and congratulations on the great work done on this article Many thanks again for your very insightful review. Attachments Attachment Submitted filename: response to reviewers 14-04-23.docx https://doi.org/10.1371/journal.pone.0285894.r004
4 May 2023 Decision Letter - Alberto Molina Pérez, Editor Toward improvement of knowledge of financial conflicts of interest in a large medical school in France PONE-D-22-34803R2 Dear Dr. alexandra, 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, Alberto Molina Pérez, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0285894.r005
Formally Accepted
9 May 2023 Acceptance Letter - Alberto Molina Pérez, Editor PONE-D-22-34803R2 Toward improvement of knowledge of financial conflicts of interest in a large medical school in France Dear Dr. Alexandra: 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. Alberto Molina Pérez Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0285894.r006

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