-->PONE-D-25-58696-->-->Comparing Diagnostic Accuracy of Acute Vertigo Between General Practitioners and Medical Students: A Cross-Sectional Study-->-->PLOS One

Dear Dr. Maquet,

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: 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

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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:  This manuscript reports a cross-sectional comparison of vignette-based diagnostic performance in acute vertigo between general practitioners (GPs) and final-year medical students, using Script Concordance Tests (SCTs) and Key Feature Problems (KFPs). The topic is relevant to primary care education, and the use of validated assessment tools is a strength. However, important methodological and interpretative limitations substantially weaken the clinical implications of the findings. In its current form, the manuscript overextends its conclusions beyond what the data can robustly support.1. Misclassification of the study as “diagnostic accuracy”

The manuscript repeatedly refers to “diagnostic accuracy,” yet no real patients, reference clinical diagnoses, or patient outcomes are included.The study assesses performance on educational assessment tools, not diagnostic accuracy in the clinical sense.SCTs and KFPs evaluate clinical reasoning under uncertainty, not bedside diagnostic competence.

Recommendation:

Reframe the study consistently as an educational assessment of diagnostic reasoning, not a diagnostic accuracy study. The title, abstract, and conclusions should be modified accordingly.

Reviewer #2:  This manuscript addresses an important and under-studied issue in primary care and medical education: diagnostic reasoning in acute vertigo, comparing general practitioners and final-year medical students using validated assessment tools. The study is methodologically sound, ethically conducted, and clearly reported, and the conclusions are, to a great extent, supported by the data.

The work is appropriate for publication by PLOS ONE as an observational study that has been rigorously conducted and has clearly reported its methodology. However, I believe that the use of some of the conceptual clarification, methodological refinement, and presentation issues will strengthen the interpretability, reproducibility, and balance of the conclusions drawn.

I have provided comments and actionable recommendations on a section-by-section basis.

1. Abstract

Strengths

• Clear structure with standard PLOS ONE headings.

• Objectives, methods, and main findings are accurately reported.

• Effects, estimates, and p-values are appropriately reported.

Issues & Recommendations

1. Interpretive language should be slightly tempered

o The conclusion attributes the superior performance of students mainly to ‘’ recent targeted training. ‘’While plausible, this inference is not directly tested.

o Recommend softening to:

o ‘’…possibly reflecting more recent theoretical exposure.’’

2. Clarify clinical vs. Test-based performance

o Readers may interpret ‘’ diagnostic accuracy’’ as real-clinical accuracy

o Suggest adding ‘’ in vignette-based assessments’’ to the conclusion sentence.

2. Introductory

Strengths

- The introduction contains an appropriate epidemiological context.

- The introduction states the importance of vertigo for primary care practitioners.

- The paper correctly identifies and names structured clinical tests (SCTs) and knowledge and feedback protocols (KFPs) using citation support.

Issues & Recommendations

1. Provide clarification of the educational paradox earlier in the introduction.

- The statement on the unexpected hypothesis (students have superior diagnostic skills to GPs) appears relatively late in the introduction.

2. As a way of clarifying what the authors mean by "educational paradox," the authors may want to include the following statement in the final paragraph of the introduction: "This study looks at the balance between a student's academic preparation and the clinical experience of a GP when conducting structured clinical tests (SCTs)."

3. Materials and Methods

3.1 Study Design and Population

Strengths

- The study had clearly defined eligibility criteria.

- The recruitment approach was transparent.

- There were appropriate ethical considerations in the project.

Issues and Recommendations

- Response rate bias was an issue.

- The physician response rate (approximately 10%) is discussed later in the paper; it should have been addressed earlier in the paper.

- Include a brief statement addressing the potential for selection bias.

- There is an imbalance between how many times students and doctors were exposed to this study's content.

- Students only participated in completing the diagnostic section of this study.

- Clarify if this difference in exposure may lead to differences in levels of fatigue or engagement when participating.

3.2 Design of the Questionnaire

Strengths

The questionnaire's use of validated tools (the SCT and KFP) is a significant strength. In addition, there is a good description of how the expert panel was developed, as well as the way in which the expert panel's scoring was carried out. There are also good supporting materials.

Issues & Recommendations

Explain how the scores were aggregated to obtain the total score.

Clarify if the SCT and KFP scores are equally weighted in the total score.

This would provide more transparency and reproducibility.

Confidence Assessment

The confidence question is binary (yes/no), which may oversimplify the perception of the participant. This limitation should be explicitly mentioned.

3.3 Statistical Analysis

Strengths

- Univariate and multivariable analysis methods were appropriate to the study's objectives.

- The regression model was reported, including reporting of coefficients and confidence intervals.

- The software used and the threshold for significance were reported.

Minor Recommendations

- Briefly describe why linear regression was used as the analysis method. (normality of residuals or robustness of the regression analysis).

4. Results

Strengths

Logical connection of client attributes to results from performance.

The tables provided are organized with clarity and are all labelled appropriately, informing the reader about their content.

The rates of effect size associated with the tables are consistently presented throughout the text.

Issues & Recommendations

Clinical vs. Statistical Significance.

The absolute difference in percentages between groups (~7%).

Add a single sentence explaining whether this statistic can be considered educationally meaningful.

Do not over-analyze or conclude.

The written results section is primarily objective; thus, it should not include any type of causal terminology.

5. Discussion

Strengths

Both systemic and educational Elements are equally accounted for.

Knowledge Decay and Continuing Education Resources were cited and included in the literature review.

Limitations were noted.

Issue & Recommendations

Assessment Format Bias

In the discussion, students may be advantaged by school-type assessments.

Suggest further expansion on the limits of Construct Validity.

Confidence vs. Competence

Discussion of the confidence-calibration concept is well thought out.

Suggest reiterating that confidence is an educational target and not the endpoint of education.

Figure 1 Interpretation

The legend for Figure 1 describes the figure's findings using interpretative terminology (ie, "appears to promote better management").

Suggest using terminology consistent with PLOS ONE to label this finding, for example, "Higher Diagnostic Scores are associated with these Factors."

6. Conclusion

Strengths

The findings of this report are concise and establish a solid connection to the findings.

A clear request was made for continued medical education.

Recommendation

In regard to recommendations, there will be recommendations to replace residual phrases regarding causation with phrases of association and to clarify that these findings relate to performance on diagnostic reasoning, not performance on clinical care.

7. Ethics, Data Availability, and Transparency

Minor Note: The ethics approval numbers appear to be somewhat inconsistent between these sections; please align them to maintain continuity.

8. Language and Presentation: English was written in a clear and professional tone without errors in grammar or style. A few minor typographical and stylistic corrections and adjustments, such as spacing, hyphenation, etc., have been suggested. I suggest that light editorial revisions prior to acceptance be made.

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Reviewer #1: Yes:  Sergio Carmona

Reviewer #2: No

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Assessment of diagnostic reasoning in acute vertigo using vignette-based tools: a cross-sectional comparison between general practitioners and final-year medical students

PONE-D-25-58696R1

Dear Dr. Maquet,

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.

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Kind regards,

Renato S. Melo, PhD

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 #2: 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

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: 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 #2: (No Response)

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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 #2: 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: The issue is not only that vignette-based tools do not reflect real-life performance, but that in acute vestibular syndrome, diagnostic reasoning is inseparable from bedside examination (e.g., oculomotor findings). Therefore, vignette-based assessments may lack construct validity for this specific clinical domain, limiting the interpretability of comparisons between learners and practitioners

Reviewer #2: I’d like to take a moment to thank you for the opportunity to comment on this revised version of the manuscript. I see that the authors have very effectively addressed many of the comments from the previous review cycle, especially those comments related to issues of interpretive overreach, construct validity, and clarifying the definition of what is and is not being measured.

Abstract and Title:

The authors have revised the abstract and title to more accurately reflect the vignette-based nature of the assessment of diagnostic reasoning and less on how accurately it can diagnose clinically. The author's interpretive language has been toned down, and the conclusions drawn in the study now reflect the design of the study.

Introduction:

The authors nicely frame the educational context by explaining that an “educational paradox” exists when there is more emphasis placed on theoretical content versus what has been gained through experience. The hypothesis of the study is presented in a more appropriate position and provides a more cohesive rationale for the decision to use SCTs and KFPs.

Methods:

I can now see that the authors have provided detailed descriptions of the study population, how the questionnaires were constructed, and how the Expert Panel was created. By including detailed explanations of how the scores were aggregated and equally weighed between the SCT and KFP scores, the authors have increased the amount of transparency and reproducibility of the methods. The authors appropriately acknowledge that selection bias may have occurred as a result of response rates or different levels of exposure to the subjects.

Statistical Analysis:

The statistical methods employed by the authors appear to be appropriate and are clearly articulated. Including an additional explanation of the rational of using linear regression modeling provides more clarity in respect to the design and methodology of the study. The reporting of information is consistent with the expectations outlined in PLOS ONE.

Results:

In my opinion, the results presented by the authors were objectively presented. The authors utilized non-causal, descriptive language when discussing the results of the study. The authors acknowledged that although statistically significant differences were found to exist in between groups, the magnitude of these differences may not be significant enough to have an impact from an educational standpoint or from a clinical standpoint.

Discussion:

The Discussion section of the manuscript is very well balanced and thought out by the authors. The authors provide clear discussions on potential sources of assessment-format bias, limitations to construct validity, and the differences between confidence and competence. In addition to the previous comment, the manuscript continues to reinforce that the findings of the study should not be generalized to the real-world clinical outcomes but rather to performance on vignette-based tasks for diagnostic reasoning.

Conclusion:

The conclusion of the manuscript is concise, accurate, and presented in a moderately reserved fashion. The authors have removed any residual causal language that may still be present.

Ethics, Data Availability, and Transparency:

The authors have appropriately completed, communicated, and were compliant with all PLOS ONE guidelines regarding these sections.

Overall Assessment:

This revised manuscript has been written in accordance with the methodological, ethical, and reporting requirements of PLOS ONE, and the authors have effectively responded to the review comments and have greatly enhanced the clarity, rigor, and interpretability of their study. I would recommend that the manuscript be accepted for publication.

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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: Yes:  Sergio Carmona

Reviewer #2: No

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