PONE-D-23-40801Difficulties in Teacher-Student Communication During Family Medicine Residency: A Qualitative StudyPLOS ONE

Dear Dr. López-Ortiz,

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.

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Federica Canzan

Academic Editor

PLOS ONE

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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: Partly

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

Reviewer #1: Yes

Reviewer #2: N/A

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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

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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

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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: Thank you for inviting me to review this study, I want to begin by commending Geovani López-Ortiz and team on a fantastic effort on this paper. They have worked on an important area in medical education, specifically trainer-trainee communication, and they leverage strong methodology to reach promising results. Here are some recommendations that would improve their paper further:

Title and manuscript:

Perhaps, consider changing ‘difficulties’ to ‘challenges’, the latter might be a term that is better suited for this paper.

Abstract:

Overall perspective – well-written, concise and impactful

1. Deficiencies in communication among healthcare professionals have been acknowledged, with potential negative impacts on medical education, and various professional environments.

This is the opening sentence, seems a bit verbose, I would simplify this. Also, please clarify ‘acknowledged’ by whom, and what constitutes various professional environments.

2. “The main problems identified were abuse of power in communication, lack of communication skills, and the absence of institutional communication channels.” – this is actually a result, which does not appear in the results section and instead shows up for the first time in the conclusion. I would move this to the results section (which may need to be shortened) and make the conclusion as the overarching message/takeaway for your paper.

Introduction:

Overall – clear and articulate.

Major

Before adding the second sentence about lack of studies from Mexico, you should add details about existing studies globally. Use the funnel approach to first introduce global literature before moving more specifically to Mexico. Here are recommendations for studies you should cite as global literature on the topic.

• Myerholtz, L. (2014). Assessing family medicine residents' communication skills from the patient's perspective: evaluating the communication assessment tool. Journal of Graduate Medical Education, 6(3), 495-500.

• Merchant, A. A. H., Shaikh, N. Q., Afzal, N., Noorali, A. A., Abdul Rahim, K., Ahmad, R., ... & Haider, A. H. (2023). Disparities in patient-resident physician communication and counseling: A multi-perspective exploratory qualitative study. Plos one, 18(10), e0288549.

• Leung, K. K., Wang, W. D., & Chen, Y. Y. (2012). Multi-source evaluation of interpersonal and communication skills of family medicine residents. Advances in health sciences education, 17, 717-726.

Minor

- Medical residency is pivotal in “specialists” training – the phrase should be specialists’ training (apostrophe after s)

- “often sidelining the development of complementary skills” – can be better phrased as “often deprioritizing’. Sideline means there is absolutely no attention to it, deprioritize indicates that the amount of attention paid to it is reduced.

Methods

Overall – draws on practices from literature and used good methodological practices, certain areas need more elaboration.

Major

- The section on sampling needs more details. “From May 17th to October 11th, 2022, professors and third-year residents in the Family Medicine specialty from the Mexican Republic were invited via e-mail to a Zoom session.” Questions to answer: why were only third year residents chosen, which hospitals were included – single center or multi-center, were all of them full professors or range (assistant, associate, full)

- Consent: Was the consent acquired after the introductory session? It says that the consent was in writing – when and where was this administered. Was it informed consent? Were benefits and risks detailed, and participants clearly informed that they had a right to withdraw, and that this was voluntary participation.

- Exclusion criteria for critical incident forms: “while poorly reported, insufficient, incomplete, or duplicate formats were excluded.” How many were excluded? Who determined that certain forms were “insufficient”?

- “Discrepancies were resolved through multiple rounds of discussion using researcher triangulation.” Elaborate on this further – how were these discussions on resolution of disparities structured – what was the methodology?

Minor

- This is not a complete sentence “Qualitative study, the present research was app..”

- Research team: The research team comprised specialists in family medicine, teaching experts, communication specialists, and doctors in sciences, and education. Please be more specific – you can add the initials of the authors to clarify which author brought what level of expertise to the table.

Results:

Overall – great attempt, but there are some deficiencies and areas of overlap between subcategories.

Major:

- “50 out of 214 residents 23.36% agreed to participate” – this needs some reflection in the limitations section under discussion. What could be reasons why >3/4th of the residents did not agree to participate? This has been reported later, please see my note below in the limitations section.

- “assertiveness was evident in active listening, empathy, and clarity in message delivery” are you sure if assertiveness is the right word that refers to these attributes, specifically empathy? Assertiveness is more about the level of confidence (https://dictionary.cambridge.org/us/dictionary/english/assertive) , which relates better with - “clarity in message delivery” but not the other two.

The section on organizational communication (theme) has been written well, explains different components and perspectives with supporting quotations. Well done.

- For the section on “effective communication”, there is strong overlap between the subcategory “message understanding” and the subcategory for theme 2 which is “Clarity in the message”. Consider combining the two.

Minor:

“80 (63%) incidents were reported by women, and 47 (37%) by men” – gender differences in the number of critical incidents reported. Given this, you should highlight which comments came from which gender. Add the gender of the participant in the brackets when you mention the participant number.

Discussion:

Overall - Well-articulated, starts strong.

Major:

“In Mexico, it has been estimated that 3 out of 4 complaints against physicians, and health institutions are associated with ineffective communication [36].”

I would also add some global literature where you refer to effective/ineffective communication. Here are some citations to include:

- Turner, J. W., Robinson, J., Morris, E., Oberkircher, K., Rios, R., & Roett, M. (2020). Resident reflections on resident-patient communication during family medicine clinic visits. Patient education and counseling, 103(3), 484–490. https://doi.org/10.1016/j.pec.2019.09.011

- Shahbaz, H., Noorali, A. A., Inam, M., Qadeer, N., Merchant, A. A. H., Khan, A. A., Afzal, N., Abdul Rahim, K., Munaf, I., Ahmad, R., Tariq, M., & Haider, A. H. (2022). Developing a communication-skills training curriculum for resident-physicians to enhance patient outcomes at an academic medical centre: an ongoing mixed-methods study protocol. BMJ open, 12(8), e056840. https://doi.org/10.1136/bmjopen-2021-056840

- Jansen, K. L., & Rosenbaum, M. E. (2016). The State of Communication Education in Family Medicine Residencies. Family medicine, 48(6), 445–451.

Limitations and missing demographics table:

- There is mention of one possible reason for the low resident turnout “may have omitted information due to fears or inhibitions” – do you think this was the sole reason – that the data collectors were professors, leading to fear. What could be other reasons? Additionally, do you think that the data collectors being the residents’ own professors could have impacted the responses of those who did participate? Maybe they were also hesitant? Comment on this.

- Were there any gender-based differences? More women reported incidents, but is that because of a higher tendency to report, or because of a higher number of women in the study sample. If it is the former, what are some reasons why – these could be explored in the discussion.

- A table of overall participant demographics needs to be added. You can include gender/biological sex, age, level of training/professor-ship, how many reported 1 incident and how many >1.

- I would also be interested in seeing if there are any differences in those that agreed to respond and those who did not respond – is there a selection bias there? For example: out of all women who were sent the email, a higher proportion responded, compared to all men who were sent the email. This difference in response/no response does not need to be added to the paper, but I would like to review it in your response letter, to see if there was any selection bias, which would then need to be added as a limitation.

Conclusion: Very brief, I would add a couple of sentences on takeaway thoughts and overarching picture/perspective. What is the key message and big picture that you want the readers to leave with? Additionally, what are some directions for future studies.

Overall, your team has done a great job and I would be happy to support this manuscript further pending revisions. Best of luck!

Reviewer #2: Thank you for the opportunity to revise this interesting manuscript that talk about a never-ending issue in clinical practice.

However, some information are missing to fully understand the methods used.

Introduction

Reference to Mexico is not contextualized and the reader could have difficulties to understand why you are citing the country

Communication is explored under several perspectives (with patients, with the team, with the teachers) and is not clear which one is relevant for the study

Differences among the terms students, teachers and residents could not be clear to the reader, needing of specify what do you mean

Previous research findings on this topic are missing

Gap in research is missing

The aim of the study could be more defined

Methods

Why did you choose to investigate the phenomenon from the perspective of critical incidents?

How did you recruit participants?

Inclusion criteria?

From the sentence “Participants received Word-format…”, you could move the paragraph under data collection

What sociodemographic data did you collect? Did you collect work experience data?

How should participants report information? Were the answers provided as open questions? I’m concerned about differences in reporting among participants. You could have missed important data on events.

What did you mean with “poorly reported/insufficient/incomplete etc?” which were the criteria?

How did you evaluate if the critical incidents reported by participants was pertinent to your research question? Which criteria did you adopted?

How did you analyze the data? Content analysis? Thematic analysis? The method of data analysis could be better described.

Given the missing information in the method section, I have some difficulties to judge the results and discussion at the moment.

However, these sections seem written well and are understandable. I suggest removing “theme” from the title of the subheadings.

In the discussion section, more emphasis should be given to training on communication skills among the team and other strategies to prevent communication issues between teachers and residents, such as training and continuing education for teachers.

I hope that suggestions could help to improve the manuscript.

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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

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PONE-D-23-40801R1Challenges in Teacher-Student Communication During Family Medicine Residency: A Qualitative StudyPLOS ONE

Dear Dr. López-Ortiz,

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.

Please submit your revised manuscript by Sep 26 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). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Federica Canzan

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.

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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

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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: Yes

**********

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

Reviewer #1: 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: 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

**********

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: Thank you for reviewing all recommendations/suggestions and incorporating most of them. I also appreciate the clarifications where you did not incorporate suggestions - such as the response on why you felt using assertiveness was appropriate.

The overall manuscript looks in excellent shape now and is close to publication. I am submitting a recommendation to accept the manuscript rather than a minor revision, so that it saves you time and another revision is not required. However, there were two comments that were not addressed, and the response letter stated that these changes have been incorporated.

The first one is a grammatical improvement: https://www.merriam-webster.com/grammar/what-happens-to-names-when-we-make-them-plural-or-possessive

The second one is just a change of phrasing to make it more palatable.

You are welcome to incorporate these changes or retain the original, but I would recommend making sure that the grammar sounds right (in the first one).

Other than that, great work and best of luck for getting this important work published soon!

_____

Copied below from response letter - I did not find these changes in the revised version/track changes.

- Medical residency is pivotal in “specialists” training – the phrase should be specialists’ training (apostrophe after s)

- “often sidelining the development of complementary skills” – can be better phrased as “often deprioritizing’. Sideline means there is absolutely no attention to it, deprioritize indicates that the amount of attention paid to it is reduced.

Thank you for highlighting these aspects. The suggested changes have been implemented and can be seen in the Revised Manuscript with Track Changes.

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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

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[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.

Challenges in Teacher-Student Communication During Family Medicine Residency: A Qualitative Study

PONE-D-23-40801R2

Dear Dr. López-Ortiz,

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. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Federica Canzan

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: