International medical graduates’ experiences of clinical competency assessment in postgraduate and licensing examinations: A scoping review protocol

Helen Hynes; Anél Wiese; Nora McCarthy; Catherine Sweeney; Tony Foley; Deirdre Bennett

doi:10.1371/journal.pone.0305014

Peer Review History

Original SubmissionMay 27, 2024
25 Jul 2024 Decision Letter - Muhammad Shahzad Aslam, Editor PONE-D-24-19584International medical graduates’ experiences of clinical competency assessment in postgraduate and licensing examinations: a scoping review protocol.PLOS ONE Dear Dr. Hynes, 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. International medical graduates are essential to developed countries and their assessment for practicing in the host country is often under debate. Most assessments focus on competency rather than performance or Entrustable Professional activities, and often do not assess communication and teamwork skills. There is increasing interest in performance-based and programmatic assessments, as well as the publication of composite reliability of workplace-based assessments. This signals a potential shift towards a performance-based approach in the assessment of international medical graduates. Please explain problem statement in couple of paragraph and signify the rational behind the study. Please submit your revised manuscript by Sep 08 2024 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). 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: International medical graduates are essential to developed countries and their assessment for practicing in the host country is often under debate. Most assessments focus on competency rather than performance or Entrustable Professional activities, and often do not assess communication and teamwork skills. There is increasing interest in performance-based and programmatic assessments, as well as the publication of composite reliability of workplace-based assessments. This signals a potential shift towards a performance-based approach in the assessment of international medical graduates. Please explain problem statement in couple of paragraph and signify the rational behind the study. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses? The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable? Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors described where all data underlying the findings will be made available when the study is complete? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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 ****** 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 #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics. You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The manuscript is well-presented, and its objectives are clearly outlined. However, it is not clear whether the authors intend to conduct a global study or if the scope is limited to a specific region. This clarification is particularly pertinent to the scoping of the grey literature search. The authors are to consider specifying whether the grey literature search will cover global "postgraduate training bodies and medical licensing organizations" or be confined to specific regions. Additionally, the authors to consider outlining their approach to mitigating information bias, particularly regarding the translation of non-English papers. Reviewer #2: International medical graduates are vital to all developed countries and are growing in numbers. Their assessment to get a licence to practise in the host country is often subject to much debate. Most assessments are based on competency and not performance or Entrustable Professional activities. Communication and teamwork skills are not assessed. There are models of performance-based assessment and there is a growing interest in programmatic assessment (Nair B , Moonen van Loon J, et al MJA, 2017). Composite reliability of workplace based assessments have been published too . This may be the future of IMG assesmsent ****** 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: No Reviewer #2: Yes: Balakrishnan R Nair ******** [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.0305014.r001
Revision 1
29 Aug 2024 Author Response Dear Dr Aslam, We would like to thank you and the PLOS ONE reviewers for your useful comments. We are very pleased that the reviewers consider the paper to be well presented with clearly outlined objectives. As regards the clarifications and suggestions, we will outline below each of the points made and our responses to same. Reviewer #1: 1. “It is not clear whether the authors intend to conduct a global study or if the scope is limited to a specific region. This clarification is particularly pertinent to the scoping of the grey literature search.” • This is intended as an international study and sources relating to International Medical Graduates (IMGs) practicing in any country will be included. Please see the clarification of this point on lines 206 and 207 of the revised paper (Manuscript). o “This is intended as an international study and sources related to IMGs practicing in any country will be included.” 2. “The authors are to consider specifying whether the grey literature search will cover global "postgraduate training bodies and medical licensing organizations" or be confined to specific regions.” • The grey literature search will cover global stakeholders. We feel this is an important aspect of the study because the phenomenon of doctors migrating is a truly global issue. Please see edit on line 230. o “Sources of unpublished studies or gray literature to be searched include Google, Google Scholar, and reports of relevant stakeholders, such as postgraduate medical training bodies and medical licensing organizations internationally.” 3. “Additionally, the authors to consider outlining their approach to mitigating information bias, particularly regarding the translation of non-English papers.” • We believe that given the international scope of this study, and the fact that international medical graduates originate from and work in a multitude of countries around the world, that to limit the search to papers in the English language would risk information bias. We have therefore decided not to place any language limitations on the sources included in the review. We will make every effort to translate sources which are not in the English language using a combination of online software (Google Translate and DeepL) and the many language resources which are available to us in our university. Please see lines 242-246. o “To minimize information bias, no language restrictions will be applied. From the initial searches, we believe that the number of non-English language papers will be low. If the need arises, the authors will draw on the available resources from their university and or use Google Translate35 and DeepL36 software to translate relevant papers from other languages.” Reviewer #2: 1. “International medical graduates are vital to all developed countries and are growing in numbers. Their assessment to get a licence to practise in the host country is often subject to much debate. Most assessments are based on competency and not performance or Entrustable Professional activities. Communication and teamwork skills are not assessed. There are models of performance-based assessment and there is a growing interest in programmatic assessment (Nair B , Moonen van Loon J, et al MJA, 2017). Composite reliability of workplace based assessments have been published too . This may be the future of IMG assessment.” • We acknowledge the importance of programmatic assessment in postgraduate medical assessment and its potential in the authentic assessment of performance of IMGs. We have added a discussion of programmatic assessment in the introduction section. Please see lines 139-145. o “In recent years there has increasing interest in programmatic assessment which involves the use of multiple different assessment components which build a picture over time to allow a more considered decision regarding the candidate passing or failing; progressing or not. 26 This could include assessment of skills such as teamwork, and professionalism which are difficult to examine using traditional means of assessment. 26 Programmatic assessment offers an authentic way in which to evaluate IMGs. 28 Thus this study will include clinical assessments in simulated and workplace based setting.” Editor: 1. “International medical graduates are essential to developed countries and their assessment for practicing in the host country is often under debate. Most assessments focus on competency rather than performance or Entrustable Professional activities, and often do not assess communication and teamwork skills. There is increasing interest in performance-based and programmatic assessments, as well as the publication of composite reliability of workplace-based assessments. This signals a potential shift towards a performance-based approach in the assessment of international medical graduates. Please explain problem statement in couple of paragraph and signify the rationale behind the study.” • We would like to thank the editor for raising this issue. We believe that programmatic assessment has great potential both in the assessment of postgraduate trainees and also for assessment of IMGs who are already working in a supervised capacity. We have added a brief description of the nature and benefits of workplace based assessment and programmatic assessment of medical practitioners including IMGs. Please see lines 130-145. o “Traditionally, assessment of IMGs for licencing purposes has been based on knowledge based tests (MCQs) and tests of competence such as OSCEs.8,10 While traditional assessments can yield scores which are both reliable and valid 25 they offer a mere snapshot of candidate ability, and performance in real settlings may vary greatly from that observed in structured simulated environments. 26 Postgraduate training assessment often makes use of workplace based assessment (WBA) methods such as mini-CEX, DOPS and evaluation of Entrustable Professional Activities (EPAs)27,28 which aim to evaluate the top level of Miller’s pyramid (Does). 24 In recent years there has increasing interest in programmatic assessment which involves the use of multiple different assessment components which build a picture over time to allow a more considered decision regarding the candidate passing or failing; progressing or not. 26 This could include assessment of skills such as teamwork, and professionalism which are difficult to examine using traditional means of assessment. 26 Programmatic assessment offers an authentic way in which to evaluate IMGs. 28 Thus this study will include clinical assessments in simulated and workplace based setting.” • We have added in the rationale for the study in lines 157-160. o “Therefore, the aim of this study is to document and understand what is known about IMGs’ experiences of clinical competency assessment, and to identify gaps in our knowledge about this topic. The rationale for carrying out this work is to improve fairness and inclusivity for this group of doctors as they transition to working in a new country.” We would like to thank the editors for their thorough review of our manuscript and for the opportunity to publish in PLOS ONE. Your insightful feedback has been very helpful in enhancing the clarity of the protocol. Yours sincerely, Dr Helen Hynes, Senior Lecturer in Medical Education, Director, 5 Year Medical Programme, School of Medicine, University College Cork Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0305014.r002
9 Sep 2024 Decision Letter - Muhammad Shahzad Aslam, Editor International medical graduates’ experiences of clinical competency assessment in postgraduate and licensing examinations: a scoping review protocol. PONE-D-24-19584R1 Dear Dr. Hynes, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. 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Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions? The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field. Reviewer #2: Yes ******** 2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses? The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory. Reviewer #2: Yes ****** 3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable? Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible. Reviewer #2: Yes ****** 4. Have the authors described where all data underlying the findings will be made available when the study is complete? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics. You may also provide optional suggestions and comments to authors that they might find helpful in planning their study. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #2: The authors have revised the paper based on the comments from the reviewers . I am satisfied by the responses . The article reads well now ****** 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: Yes: Balakrishnan R Nair ******** https://doi.org/10.1371/journal.pone.0305014.r003
Formally Accepted
11 Oct 2024 Acceptance Letter - Muhammad Shahzad Aslam, Editor PONE-D-24-19584R1 PLOS ONE Dear Dr. Hynes, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Muhammad Shahzad Aslam Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305014.r004

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