A compassion-based program to reduce psychological distress in medical students: A pilot randomized clinical trial

Blanca Rojas; Elena Catalan; Gustavo Diez; Pablo Roca

doi:10.1371/journal.pone.0287388

Peer Review History

Original SubmissionFebruary 8, 2023
11 Apr 2023 Decision Letter - Dario Ummarino, PhD, Editor PONE-D-23-02561A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trialPLOS ONE Dear Dr. Roca, 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 three reviewers, and their comments are available below. The reviewers appreciate the importance of your study, but also raised a number of concerns, such as clarification on methodological aspects of the study and the interpretation of the results. Could you please revise the manuscript to carefully address the concerns raised? Please submit your revised manuscript by May 26 2023 11:59PM. 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Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. 4. Please include a separate caption for each figure in your manuscript. 5. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes Reviewer #3: 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 Reviewer #3: 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 Reviewer #3: 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: Important note: This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ [like medical importance, relevance of the study, ‘clinical significance and implication(s)’ of the whole study, etc.] are to be evaluated [should be assessed] separately/independently. Further please note that any ‘statistical review’ is generally done under the assumption that (such) study specific methodological [as well as execution] issues are perfectly taken care of by the investigator(s). This review is not an exception to that and so does not cover clinical aspects {however, seldom comments are made only if those issues are intimately / scientifically related & intermingle with ‘statistical aspects’ of the study}. Agreed that ‘statistical methods’ are used as just tools here, however, they are vital part of methodology [and so should be given due importance]. I look at the manuscript in/with statistical view point, other reviewer(s) look(s) at it with different angle so that in totality the review is very comprehensive. However, there should be efforts from authors side to improve (may be by taking clues from reviewer’s comments). Therefore, please do not limit the revision only (with respect) to comments made here. COMMENTS: I noted (i.e., in my opinion) that your ABSTRACT is well drafted, but is ‘assay type’. It is preferable [refer to item 1b of CONSORT checklist 2010: Structured summary of trial design, methods, results, and conclusions] to divide the ABSTRACT with small sections like ‘Objective(s)’, ‘Methods’, ‘Results’, ‘Conclusions’, etc. which is an accepted practice of most of the good/standard journals [including this one, though ‘The PLoS One Guidelines to Authors’ did not specify an Abstract format, it is desirable]. It will definitely be more informative then, I guess, whatever the article type may be [including a pilot randomized clinical trial]. A very small correction: meaning/longform of CCT [Compassion Cultivation Training] is given in the ‘abstract’ itself but on second time use of the term, whereas, it is a general convention to give it at first time use of the term. Of course, it a very minor correction suggested. It is stated in ‘abstract’ that “This pilot study aims to examine the effectiveness of Compassion-Based Interventions (CBIs) in preventing psychological distress” [is not ‘Interventions’ plural?] but next sentence “We hypothesize that the CCT program, as compared to a waitlist control group” indicates that this study deals with only one intervention namely CCT program. Is not that so? It is pardonable if it is by oversight/typing mistake, however, please clarify. It seems that this ‘Clinical Trial’ is not register as desired. If it is, then why the number {ClinicalTrial.org (ID: XXX)} is not specified? This study being ‘pilot’ in nature, sample size is not a big issue. However, [though many things are ignored (loosely looked at / evaluated)] in case of ‘pilot studies’, methodological issues need to be very rigorous followed {like in case of clinical trial, CONSORT guidelines are to be strictly observed/followed}. Then the term ‘CONSORT’ is a very vital term [but surprisingly it appears only once in ‘Strengths, limitations, and future directions’ section]. Even important items of/in CONSORT checklist are not found [since your article type is ‘Clinical Trial’, you are supposed to cover these items in the report (& note that CONSORT for Pilot trial is/are also available). According to document on CONSORT for Pilot trial “Formal hypothesis testing for effectiveness (or efficacy) is not recommended. The aim of a pilot trial is not to assess effectiveness (or efficacy) and it will usually be underpowered to do this” (check your aim stated). In addition, please note that any regression techniques [including Mixed-effects models which are conducted here to analyze the effects of the CCT program] are not basically/originally developed for any sort of [between or within group(s)] comparison(s). Using ‘Mixed-effects models’ is definitely not wrong; however, some head-to-head comparison is expected. Further, it may be noted that Though the measures/tools used are appropriate [refer table-2], most of them are likely to yield data that are in ‘ordinal’ level of measurement [and not in ratio level of measurement for sure {as the score two times higher does not indicate presence of that parameter/phenomenon as double (for example, a Visual Analogue Scales VAS score or say ‘depression’ score)}]. Then application of suitable non-parametric test(s) is/are indicated/advisable [even if distribution may be ‘Gaussian’ (also called ‘normal’)]. Agreed that there is/are no non-parametric test(s)/technique(s) available to be used as alternative in all situation(s) [suitable / most desired/applicable], but should be used whenever/wherever they are available. Therefore, in short use suitable non-parametric test(s)/technique(s) while dealing with data that are in ‘ordinal’ level of measurement even if [despite that] the distribution may be ‘Gaussian’. Testing ‘normality’ in sample [by using any normality test(s)} is not required/desired while dealing with data that are in ‘ordinal’ level of measurement [as most of the normality tests are not valid for ‘ordinal’ data]. I request authors to check contents of references 77,78. Because in my knowledge, at least article 77 concludes as follows: Conclusions: Engagement in MBSR is not predictive of increased rates of harm relative to no treatment. Rather, MBSR may be protective against multiple indices of harm. Research characterizing the relatively small proportion of MBSR participants that experience harm remains important. Moreover, it may please be noted that “Absence of evidence is not evidence of absence” [Altman DG, Bland JM. BMJ volume 311, 1995, p 485 (Reprinted: Australian Veterinary Journal 1996;74, 311)]. {Even when P-value is not significantly lower that is null hypothesis of no difference / no association is not rejected, (in short, result is not significant), that does not amount to evidence of absence i.e., it does not imply that there no difference / no association. It only implies that there is no (i.e., these samples do not provide) [say enough] evidence to prove (rather indicate with certain specified confidence level) the difference / association}. Therefore, conclusion(s) from any study [in which result(s) is/are not significant], should be drawn in the light of this fact. Particularly look at (due consideration of) the hypothesis in each of the study quoted in reference 78. Although the ‘Intervention description’ is indeed very good and useful, [as pointed out in ‘important note’ above] note that “This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ should be assessed separately/independently [one should carefully consider/look at the clinical implications of the study]. In my opinion, to rescue this article (which is quite possible and easy), a small amount of re-vision (re-drafting) may be needed. However, please do not limit the revision only (with respect) to comments made here. More improvement is expected. Recommending minor revision. Reviewer #2: Thanks for allowing me to review the present manuscript. This is an interesting research report on the effectiveness of a Compassion-Based Intervention (CCT) in reducing distress in medical students. The study is a randomized-controlled trial. I think this is an important topic and a well-written manuscript that should be accepted for publication. Reviewer #3: “A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trial” The present study aims to investigate the impact of Compassion Cultivation Training on psychological outcomes in a sample of medical students. The topic is exciting, and the contribution that the current study could provide to scientific literature is influential and essential. Following this, I reported a series of suggestions to help authors improve the manuscript. Background: Since there are other types of Protocol Intervention, CBT-oriented focused on increases in “Compassion, empathy and mindfulness skills, reductions of psychological distress (stress, anxiety, and depression) and burnout, improvements in well-being and emotion regulation, among others” I suggest that authors explain better why they chose this specific training and not others. Materials and Methods: The number of the study protocol approved by the Ethical Committee and the pre-registration at ClinicalTrial.org need to be included. Participants: I kindly ask the authors to specify the background related to the decision to set a medium effect size to estimate sample size, also considering that this field is novel and not extensively investigated, it should be expected to have a sample composed of a higher number of participants to extrapolate information about efficacy in a pilot study. Discussion: Since the final sample comprised fewer participants than expected, I suggest that authors better explain the implication of this fact on the outcome interpretation. I suggest adding this part to the conclusion section. ****** 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 Reviewer #3: Yes: Susanna Pardini ******** [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: renamed_45aaa.docx Attachment Submitted filename: ref.docx https://doi.org/10.1371/journal.pone.0287388.r001
Revision 1
29 May 2023 Author Response We thank the reviewers for their constructive comments and suggestions that have markedly improved our manuscript. Please see below our responses to each comment. Reviewer #1 1.1. I noted (i.e., in my opinion) that your ABSTRACT is well drafted, but is ‘assay type’. It is preferable [refer to item 1b of CONSORT checklist 2010: Structured summary of trial design, methods, results, and conclusions] to divide the ABSTRACT with small sections like ‘Objective(s)’, ‘Methods’, ‘Results’, ‘Conclusions’, etc. which is an accepted practice of most of the good/standard journals [including this one, though ‘The PLoS One Guidelines to Authors’ did not specify an Abstract format, it is desirable]. It will definitely be more informative then, I guess, whatever the article type may be [including a pilot randomized clinical trial]. We thank the reviewer for this suggestion. We have adapted the abstract according to the item 1b of the CONSORT checklist 2010, which is also reflected in the CONSORT checklist for pilot studies (see point 1.5 below). 1.2. A very small correction: meaning/longform of CCT [Compassion Cultivation Training] is given in the ‘abstract’ itself but on second time use of the term, whereas, it is a general convention to give it at first time use of the term. Of course, it a very minor correction suggested. Done! 1.3. It is stated in ‘abstract’ that “This pilot study aims to examine the effectiveness of Compassion-Based Interventions (CBIs) in preventing psychological distress” [is not ‘Interventions’ plural?] but next sentence “We hypothesize that the CCT program, as compared to a waitlist control group” indicates that this study deals with only one intervention namely CCT program. Is not that so? It is pardonable if it is by oversight/typing mistake, however, please clarify. We thank the reviewer for this observation. Indeed, the CCT is one of the many Compassion-Based Interventions that have been developed. We selected it because it is one of the programs with the most empirical evidence in this field. To avoid any confusion in the abstract, we have replaced CBIs with the CCT (p. 2), which is the program we have evaluated in this study. 1.4. It seems that this ‘Clinical Trial’ is not register as desired. If it is, then why the number {ClinicalTrial.org (ID: XXX)} is not specified? Clinical Trial ID was intentionally hidden to maintain the anonymity during the review process. The ID (NCT04690452) is now included in the Study Design section (p. 6). 1.5. This study being ‘pilot’ in nature, sample size is not a big issue. However, [though many things are ignored (loosely looked at / evaluated)] in case of ‘pilot studies’, methodological issues need to be very rigorous followed {like in case of clinical trial, CONSORT guidelines are to be strictly observed/followed}. Then the term ‘CONSORT’ is a very vital term [but surprisingly it appears only once in ‘Strengths, limitations, and future directions’ section]. Even important items of/in CONSORT checklist are not found [since your article type is ‘Clinical Trial’, you are supposed to cover these items in the report (& note that CONSORT for Pilot trial is/are also available). We thank the reviewer for rising this. The CONSORT checklist for pilot studies (Eldridge et al., 2016) is now available as a table in the Supplementary Materials. Furthermore, the adhesion to the CONSORT recommendations for pilot studies is now mentioned in the Study Design (p. 5) and Discussion (p. 19) sections. 6.1. According to document on CONSORT for Pilot trial “Formal hypothesis testing for effectiveness (or efficacy) is not recommended. The aim of a pilot trial is not to assess effectiveness (or efficacy) and it will usually be underpowered to do this” (check your aim stated). Following CONSORT recommendations, we have changed “effectiveness” to “feasibility” as the aim of the study (p. 2). 7.1. In addition, please note that any regression techniques [including Mixed-effects models which are conducted here to analyze the effects of the CCT program] are not basically/originally developed for any sort of [between or within group(s)] comparison(s). Using ‘Mixed-effects models’ is definitely not wrong; however, some head-to-head comparison is expected. We thank the reviewer for this suggestion. As can be seen in Table 2, we analyzed between and within groups differences, including Group and Time main effects and the interactions. Furthermore, we computed post-hoc comparisons (adjusted by Tukey) to determine which Group X Time interactions are responsible for the significant differences. However, we neglected to mention these comparisons in the Data Analysis plan, and they were described in little detail in the results. Therefore, we have improved the explanation in Data Analysis (p. 10) and Results (p. 11) sections. 8.1. Though the measures/tools used are appropriate [refer table-2], most of them are likely to yield data that are in ‘ordinal’ level of measurement [and not in ratio level of measurement for sure {as the score two times higher does not indicate presence of that parameter/phenomenon as double (for example, a Visual Analogue Scales VAS score or say ‘depression’ score)}]. Then application of suitable non-parametric test(s) is/are indicated/advisable [even if distribution may be ‘Gaussian’ (also called ‘normal’)]. Agreed that there is/are no non-parametric test(s)/technique(s) available to be used as alternative in all situation(s) [suitable / most desired/applicable], but should be used whenever/wherever they are available. Therefore, in short use suitable non-parametric test(s)/technique(s) while dealing with data that are in ‘ordinal’ level of measurement even if [despite that] the distribution may be ‘Gaussian’. Testing ‘normality’ in sample [by using any normality test(s)} is not required/desired while dealing with data that are in ‘ordinal’ level of measurement [as most of the normality tests are not valid for ‘ordinal’ data]. Although the questionnaires used in our study are ordinal at the item level, they are quantitative at the factor level (i.e., sum scores), which makes them suitable to be analyzed by means of parametric tests. This is a very common practice in areas such as psychology, where they use procedures very similar to those used in our manuscript (e.g., González-Robles et al., 2022; Romero-Ferreiro et al., 2022). González-Robles, A., Roca, P., Díaz-García, A., García-Palacios, A., & Botella, C. (2022). Long-term Effectiveness and Predictors of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Emotional Disorders in Specialized Care: Secondary Analysis of a Randomized Controlled Trial. JMIR Mental Health, 9(10), e40268. Romero-Ferreiro, V., García-Fernández, L., Aparicio, A. I., Martínez-Gras, I., Dompablo, M., Sánchez-Pastor, L., ... & Rodriguez-Jimenez, R. (2022). Emotional Processing Profile in Patients with First Episode Schizophrenia: The Influence of Neurocognition. Journal of Clinical Medicine, 11(7), 2044. 9.1. I request authors to check contents of references 77,78. Because in my knowledge, at least article 77 concludes as follows: “Conclusions: Engagement in MBSR is not predictive of increased rates of harm relative to no treatment. Rather, MBSR may be protective against multiple indices of harm. Research characterizing the relatively small proportion of MBSR participants that experience harm remains important”. Moreover, it may please be noted that “Absence of evidence is not evidence of absence” [Altman DG, Bland JM. BMJ volume 311, 1995, p 485 (Reprinted: Australian Veterinary Journal 1996;74, 311)]. {Even when P-value is not significantly lower that is null hypothesis of no difference / no association is not rejected, (in short, result is not significant), that does not amount to evidence of absence i.e., it does not imply that there no difference / no association. It only implies that there is no (i.e., these samples do not provide) [say enough] evidence to prove (rather indicate with certain specified confidence level) the difference / association}. Therefore, conclusion(s) from any study [in which result(s) is/are not significant], should be drawn in the light of this fact. Particularly look at (due consideration of) the hypothesis in each of the study quoted in reference 78. We thank the reviewer for this observation. We used reference 77 as an example of the debate about the potential adverse effects of meditation programs, which is well covered in its introduction and discussion. However, we agree with the reviewer that it might be confusing given its results. Therefore, we have replaced these references with Baer et al. (2019) study, which best fits the content of the sentence (p. 19). Baer, R., Crane, C., Miller, E., & Kuyken, W. (2019). Doing no harm in mindfulness-based programs: conceptual issues and empirical findings. Clinical psychology review, 71, 101-114. 10.1 Although the ‘Intervention description’ is indeed very good and useful, [as pointed out in ‘important note’ above] note that “This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ should be assessed separately/independently [one should carefully consider/look at the clinical implications of the study]. In my opinion, to rescue this article (which is quite possible and easy), a small amount of re-vision (re-drafting) may be needed. However, please do not limit the revision only (with respect) to comments made here. More improvement is expected. Recommending minor revision. Once again, many thanks to the reviewer for these very helpful comments and suggestions! Reviewer #2: Thanks for allowing me to review the present manuscript. This is an interesting research report on the effectiveness of a Compassion-Based Intervention (CCT) in reducing distress in medical students. The study is a randomized-controlled trial. I think this is an important topic and a well-written manuscript that should be accepted for publication. We are glad that the reviewer enjoyed the manuscript and recognized the importance of the topic it addresses. Reviewer #3 The present study aims to investigate the impact of Compassion Cultivation Training on psychological outcomes in a sample of medical students. The topic is exciting, and the contribution that the current study could provide to scientific literature is influential and essential. Following this, I reported a series of suggestions to help authors improve the manuscript. 3.1. Since there are other types of Protocol Intervention, CBT-oriented focused on increases in “Compassion, empathy and mindfulness skills, reductions of psychological distress (stress, anxiety, and depression) and burnout, improvements in well-being and emotion regulation, among others” I suggest that authors explain better why they chose this specific training and not others. We thank the reviewer for this suggestion. There are several reasons to explain why we chose CCT among all compassion-based programs: 1) CCT has shown promising results in improving the targets that we were interested in (e.g., psychological distress, emotion regulation, mindfulness…); 2) the CCT was developed at Stanford University with a duration and format well adapted to university settings. Furthermore, the CCT have shown promising results in medical students (Weingartner et al., 2019); and 3) a member of our research team is certified by the Compassion Institute to apply the CCT, which enhanced the feasibility of the project. We have now explained these reasons in more detail in the Introduction (p. 4) and Method (p. 8) sections. 3.2. The number of the study protocol approved by the Ethical Committee and the pre-registration at ClinicalTrial.org need to be included. We thank the reviewer for this observation. Clinical Trial ID and the Ethical Committee ID were intentionally hidden to maintain the anonymity during the review process. Both are now included in the Study Design section (p. 6). 3.3. I kindly ask the authors to specify the background related to the decision to set a medium effect size to estimate sample size, also considering that this field is novel and not extensively investigated, it should be expected to have a sample composed of a higher number of participants to extrapolate information about efficacy in a pilot study. We thank the reviewer for the suggestion. We used a medium effect size because previous studies using the CCT have found effects around .40 in the same variables that we are using in our study (e.g., Brito-Pons et al., 2018; Roca et al., 2021). Furthermore, as mentioned by Reviewer #1 in point 1.5, our study is pilot in nature, so sample size is not a major concern. However, we have now explained better this rationale in the Method (p. 6), including a reflection in the Discussion on the need to increase the sample size in future studies to extrapolate information about efficacy of the program (p. 20). 3.4. Since the final sample comprised fewer participants than expected, I suggest that authors better explain the implication of this fact on the outcome interpretation. I suggest adding this part to the conclusion section. Following the reviewer’s suggestion, we have included a limitation in the Discussion section about how the sample size may have reduced the statistical power of the trial (p. 20). --- We thank you for your constructive comments that have markedly improved our manuscript. Attachments Attachment Submitted filename: Compassion_Response to reviewers.docx https://doi.org/10.1371/journal.pone.0287388.r002
5 Jun 2023 Decision Letter - Samuel Yeung-shan Wong, Editor A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trial PONE-D-23-02561R1 Dear Dr. Roca, 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, Samuel Yeung-shan Wong 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 #2: All comments have been addressed 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 #2: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes 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 #2: Yes 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 #2: Yes 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 #2: The authors have adequately addressed my comments raised in the previous round of review and I feel that this manuscript is acceptable for publication. Reviewer #3: (No Response) ****** 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 Reviewer #3: Yes: Susanna Pardini ******** https://doi.org/10.1371/journal.pone.0287388.r003
Formally Accepted
12 Jun 2023 Acceptance Letter - Samuel Yeung-shan Wong, Editor PONE-D-23-02561R1 A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trial. Dear Dr. Roca: 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. Samuel Yeung-shan Wong Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0287388.r004

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