Evaluation of the reliability and risks of ChatGPT-4o in answering pediatric cough questions: A comparative analysis between pediatricians and pediatric pulmonologists

Hanife Tuğçe Çağlar; Emine Özdemir Kaçer; Sevgi Pekcan; Fatma Nur Ayman

doi:10.1371/journal.pone.0340007

Peer Review History

Original SubmissionJuly 18, 2025
10 Nov 2025 Decision Letter - Gauri Mankekar, Editor Dear Dr. Çağlar, 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. ============================== ACADEMIC EDITOR: I agree with the reviewer.Strengths of your manuscript:Weakness1. Please submit your revised manuscript by Dec 25 2025 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. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). 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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments (if provided): [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? Reviewer #1: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: Thank you for the opportunity to review this manuscript. The research topic is important and highlights how the interpretation of AI answers differs between specialty doctors and non-specialized doctors. But there are several methodological concerns that significantly limit the strength of the findings. First, an introduction to the abstract is not written. For the methodology: 1- What was the rationale for specifically using the 10 questions presented. 2- The sample size calculation is not mentioned. 3- The used Likert scale was not tested for reliability and validity. Adding the binary question does not justify not testing the reliability and validity. So was the Likert scale validated in another study? 4- Adding the reasons behind "yes" answers for whether there was anything clinically wrong in each ChatGPT-4o response would have given better context to understand, especially the pulmonologist reasons. Having all those statistically significant results without a clear sample size calculation, and without knowing if the study had enough/over power or not, along with not testing the reliability and validity of the Likert scale, means that even if p-values are <0.05, you can’t be sure the scale measured what it was supposed to. ****** 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 ******** [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". 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Revision 1
5 Dec 2025 Author Response Dear Editor and Reviewers, We sincerely thank you for the thoughtful and constructive feedback provided on our manuscript titled “Evaluation of the reliability and risks of ChatGPT-4o in answering pediatric cough questions: a comparative analysis between pediatricians and pediatric pulmonologists.” We carefully considered each comment and revised the manuscript accordingly. Below we provide a point-by-point response, detailing how each concern was addressed. We believe these revisions have substantially strengthened the clarity, methodological rigor, and interpretability of our study. EDITOR COMMENTS Editor Comment 1 “Study design lacks systematic methodology and validation. The design does not include open-ended questions which can help understand the limitations of ChatGPT responses.” Response: We agree with the editor’s concern. We added a justification for not including open-ended items and acknowledged this as a study limitation. Specifically: • Methods → Study Design: We explained that open-ended questions were considered but excluded to minimize participant burden and maintain response rates in a geographically dispersed physician sample. • Discussion → Limitations: We now explicitly state that the absence of qualitative explanations limits interpretation and that future studies should incorporate open-ended follow-up questions. Editor Comment 2 “Authors should discuss why ChatGPT was selected for this study when several AI models exist.” Response: A new paragraph was added in the Methods section explaining why ChatGPT-4o was selected, emphasizing its widespread use, public accessibility, multilingual capacity, and performance in recent medical evaluation studies. Editor Comment 3 “Statistical analysis: The study is underpowered to detect small differences. Suggest adding effect sizes for all comparisons; report power analysis; include 95% CIs; include boxplots for Likert ratings.” Response: All recommended improvements were implemented: • Effect sizes (r) and 95% confidence intervals were added for all Mann–Whitney U analyses (Tables 1 and 2). • A post hoc power analysis using GPower 3.1 was conducted and reported in the Statistical Analysis section. • Boxplots illustrating the distribution of Likert ratings for both specialties were added as Figure 1. Editor Comment 4 “Discussion: Discuss pulmonologists’ responses and whether associated with case complexity; discuss study limitations such as subjective Likert ratings.” Response: We expanded the Discussion to include: • A detailed explanation of why pediatric pulmonologists provided more critical ratings (complex cases, rare presentations, greater sensitivity to nuance). • An explicit acknowledgment of Likert-scale subjectivity and the absence of formal psychometric validation. • An addition on content/face validity established through expert review. REVIEWER COMMENTS Reviewer Comment 1 “An introduction to the abstract is not written.” Response: We revised the abstract to include a clear introductory sentence that establishes the rationale behind the study. Reviewer Comment 2 “What was the rationale for specifically using the 10 questions presented?” Response: We added a statement explaining that the selected questions consistently appeared across repeated unbiased Google searches and represent the most common parent-driven concerns in pediatric respiratory practice. Reviewer Comment 3 “The sample size calculation is not mentioned.” Response: A post hoc power analysis was conducted and added as recommended, showing adequate power (>80%) for the observed effect sizes. Reviewer Comment 4 “The Likert scale was not tested for reliability and validity.” Response: We now provide a detailed methodological explanation: • The four Likert items intentionally measured distinct constructs, so internal consistency metrics (e.g., Cronbach’s alpha) were not appropriate. • However, content and face validity were ensured through expert review by two pediatric pulmonologists. • The absence of formal psychometric validation is explicitly discussed as a study limitation. Reviewer Comment 5 “Adding the reasons behind ‘yes’ answers would have given better context.” Response: We fully agree. We explicitly acknowledged this as a limitation and clarified that lack of qualitative explanations restricts interpretability. We also recommended including open-ended follow-ups in future research. We thank the editor and reviewers for their valuable feedback. We believe the revisions have substantially improved the quality, methodological transparency, and clarity of the manuscript. We hope the revised version meets your expectations and look forward to your favorable consideration. Sincerely, The Authors Attachments Attachment Submitted filename: Response to reviewersR1.docx* https://doi.org/10.1371/journal.pone.0340007.r002
15 Dec 2025 Decision Letter - Gauri Mankekar, Editor Evaluation of the reliability and risks of ChatGPT-4o in answering pediatric cough questions: a comparative analysis between pediatricians and pediatric pulmonologists PONE-D-25-38006R1 Dear Hanife Tuğçe Çağlar, 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. For questions related to billing, please contact billing support . 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, Gauri Mankekar, MD,PhD,FACS Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> 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 Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: (No Response) ****** 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 ******** https://doi.org/10.1371/journal.pone.0340007.r003
Formally Accepted
Acceptance Letter - Gauri Mankekar, Editor PONE-D-25-38006R1 PLOS One Dear Dr. Çağlar, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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. Gauri Mankekar Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0340007.r004

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