PONE-D-23-23122The effect of real-time EF automatic tool on cardiac ultrasound performance among medical studentsPLOS ONE

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GE healthcare© provided the POCUS devices used for this study. 

Lior Fuchs declares that he

works as a consultant for GE healthcare. The company had no access to the idea, to the study's primary objective, nor to its design, data analysis or writing. 

The rest of the authors declare that

no competing interests exist."

We note that one or more of the authors are employed by a commercial company: GE healthcare

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was small in both groups)

Additional Editor Comments:

1) Can authors explain if this AI indicator is available/or will be available with other brand of ultrasound machines. Basically can these results be reproduced at other institutions with other brand machines. What is the cost component with this AI indicator.2) As reviewers note. Even for non apical views without AI tool. Intervention group had better scores. Authors proposed a reason stating, indicator can help with probe pressure etc  Can authors propose an alternative reason for this? The mean and median number of extracurricular hours were more in the intervention group in table 1( I understand it was not statistically significant but at the same time, N was small in both groups)3) Whats the main take home point from this study/ or aim. Should we incorporate this specific AI tool in medical school education or should we start using ultrasound companies which have this new AI tool etc ( as reviewer mentions below, we need to go beyond presenting the results, explain what these results mean for the field of medicine in more detail)4) Please see reviewer comments below and address them

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: While the introduction highlights the importance of POCUS and the challenges in integrating it into medical education, it lacks a clear statement of the research problem or hypothesis. What specific aspect are you trying to address or investigate with your study?

The recruitment process for participants could be described in more detail. How were students selected, and what criteria were used for exclusion?

It would be helpful to provide effect sizes or confidence intervals for the statistically significant differences you've identified.

The discussion section lacks depth in analyzing the results and their implications. It's important to go beyond just presenting the results and explain what they mean for the field of medical education, POCUS training, and the use of AI tools.

Reviewer #2: Any reason why only male students were enrolled in the study?

Only one experienced provider has reviewed the result. Study results reviewed by multiple provider might have provided more reliability.

Did the subjects in this study have any cardiac pathologies?

Did case and control groups have same subjects? If subjects differ, which group had more patients with cardiac pathologies?

Reviewer #3: Overall Assessment

The study is well-conceived and addresses an important issue in medical education, specifically focusing on the impact of an AI-based quality indicator tool in teaching cardiac point-of-care ultrasound (POCUS) to 4th-year medical students. The research methodology is sound, and the results are statistically significant, suggesting that the AI-based tool does improve both the performance and image quality in cardiac ultrasound.

Strengths

The topic is relevant to medical education and has implications for better diagnostic performances, especially in point-of-care settings.

The study design is robust, including a control group for comparison.

Detailed statistical analysis strengthens the reliability of the findings, and the authors controlled for multiple covariates.

Areas for Improvement

Long-term Retention: The study's most significant limitation, as pointed out by the authors, is the immediate testing after the academic course. An evaluation of long-term retention of skills would provide a more comprehensive understanding of the tool's effectiveness.

Selection Bias: Another limitation is that over a third of the participants were excluded from the study, potentially causing a selection bias. This needs to be addressed more in the discussion.

Single Institution Study: The study being conducted at a single medical school may not generalize to other settings. Multi-center studies are encouraged.

Tool Availability: The intervention group was tested using the quality indicator, so it is not clear if the skills were internalized enough to maintain performance without the tool. Future studies could look into this.

The study appears to adhere to ethical guidelines, including informed consent and approval by an ethics committee. However, the authors should clarify whether all students were offered the chance to benefit from the AI tool post-study, given its proven efficacy.

Publication Ethics

No concerns about dual publication or publication ethics are apparent from the manuscript.

Reviewer #4: 1. The research involves assessing skills learned within hours which makes it difficult to avoid operator bias, as few students might be better than others or some do better by chance. However the use of the 6 mins test is a better idea to overcome the issue.

2. It is also difficult to see how this will help in long term practice as the operator of POCUS become more experienced the quality of obtaining images is improves. So, hard to justify the absolute necessity of the AI tools but definitely it will help learning at beginners level.

3. Over all good study but practical use ll be limited.

Reviewer #5: I congratulate the investigators. Overall, it is a good study and well-written.

There are some minor revision recommendations.

1. Please provide the supplementary document of the quality assessment.

2. Line number 55-56, please rewrite it; it needs to be clarified.

3. It's better to report the OR rather than the RR.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Naveen Prasath Baskaran

Reviewer #4: Yes: Nihar Jena

Reviewer #5: No

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The effect of real-time EF automatic tool on cardiac ultrasound performance among medical students

PONE-D-23-23122R1

Dear Dr. ARONOVITZ,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Antoine Fakhry AbdelMassih

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 #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Excellent work on your article! It's clear you've thoroughly researched the topic and presented your findings effectively.

Reviewer #3: study's design and implementation are good, providing valuable insights into the effectiveness of real-time feedback mechanisms on learning outcomes. Additionally, addressing potential biases more thoroughly, ensuring data accessibility, and discussing ethical considerations related to AI use in education would further strengthen the manuscript. Overall, the study is a meaningful step towards integrating advanced technologies into medical training, with suggestions provided aiming to refine and enhance its contribution to the field.

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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 #3: No

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