-->PONE-D-25-63882-->-->Who Becomes a Dermatologist? A Cross-Sectional Study on Diversity in the Dutch Dermatology Workforce-->-->PLOS One

Dear Dr. Mulder

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Academic Editor

PLOS One

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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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 study assesses diversity in the Dutch dermatology workforce, focusing on sex, migration background, and socioeconomic status. Data from the BIG register (2005-2023) reveal significant increases in female dermatologists (61.7% in 2023), but ethnic diversity remains stagnant. Regression analyses show that being female, having wealthy or physician parents increases the likelihood of becoming a dermatologist.

This is a timely and relevant paper.

Minor comments:

- The paper touches on socioeconomic status and family background but could expand on intersectionality: how socioeconomic and ethnic backgrounds intersect to impact dermatology career progression.

- The lack of data for small groups (<5 individuals) in some regression models limits the analysis. Please briefly discuss how this was dealt with.

Some spelling mistakes (" recruitmenent, microdataconducting, sociaal-economic etc.). Please revise.

Reviewer #2: This manuscript addresses an important and timely issue regarding workforce diversity in Dutch dermatology. The use of nationwide registry data spanning nearly two decades is a clear strength, and the analytical approach is appropriate for the research questions posed. The topic is highly relevant for health workforce research and for ongoing discussions about equity in medical specialties. That said, several aspects of reporting and interpretation would benefit from refinement.

With respect to the abstract, it is generally clear and structured, but it could better align with reporting recommendations for observational studies (STROBE). First, the study design should be explicitly stated early in the abstract. At present, the data source and analytical approach are described, but the design is not clearly identified as a nationwide repeated cross-sectional study. Including this explicitly would immediately clarify the methodological framework. Second, the comparison group in the regression analysis should be more clearly defined. It would improve transparency to specify that dermatologists were compared with the broader physician workforce registered in the national registry. Third, the Results section of the abstract summarizes regression findings narratively; if space allows, including at least one adjusted odds ratio with its confidence interval would strengthen quantitative reporting. Finally, the concluding sentence should be moderated slightly to avoid implying causal effects on patient care, given the cross-sectional design. Framing the implications as potential or exploratory would enhance scientific precision.

Beyond the abstract, the overall methodology is sound and the statistical analyses are appropriately conducted, including assessment of multicollinearity. The use of parental asset percentiles and parental profession as socioeconomic indicators is thoughtful and yields interesting findings. However, the interpretation of these associations should be more cautious. The study identifies demographic characteristics associated with being registered as a dermatologist, but it does not include data on residency applications, acceptance rates, specialty preferences, or academic performance. As such, it cannot determine whether observed disparities reflect structural barriers, self-selection, intergenerational professional transmission, or other mechanisms. The Discussion occasionally moves beyond the data in suggesting inequitable access or exclusion; these statements should be tempered and clearly framed as hypotheses requiring further study.

Similarly, while the manuscript raises important concerns about potential implications for equitable dermatologic care, the study does not evaluate patient outcomes, diagnostic accuracy, or access to care in the Netherlands. Extrapolations from international literature are informative, but conclusions about clinical impact should be presented as areas for future research rather than direct consequences of the findings.

The policy recommendation for a centralized residency selection system is thought-provoking but currently exceeds the direct evidence provided by the analyses. As the study does not examine selection procedures themselves, these recommendations should be presented more cautiously.

Conceptually, a brief expansion on the limitations of using “migration background” based on parental country of birth would strengthen the theoretical framing, as this classification may not fully capture lived cultural or linguistic experience.

Overall, this is a valuable and well-executed study that contributes meaningful national data to an underexplored European context. The primary revisions required concern clarity of reporting in the abstract and greater interpretive restraint in the Discussion. With these adjustments, the manuscript would be considerably strengthened and well suited for publication.

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Reviewer #1: Yes:  Mahdi Salih

Reviewer #2: Yes:  Gabriel Lazzeri Cortez

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Who becomes a dermatologist? A repeated cross-sectional study on diversity in the Dutch dermatology workforce

PONE-D-25-63882R1

Dear Dr. Mulder

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,

Gisele Viana de Oliveira

Academic Editor

PLOS One

Additional Editor Comments (optional):

The authors carefully revised the manuscript to address all reviewer and editorial comments. They corrected language and formatting issues throughout the paper, clarified methodological points, and expanded the discussion on intersectionality and demographic disparities. They also added clearer explanations about limitations related to small subgroup analyses and the use of “migration background” as a proxy measure.

Discussion and Conclusions were rewritten in a more cautious and balanced way. Claims that could imply causation were softened, clinical implications were reframed as hypotheses requiring further research, and policy recommendations were presented more carefully.

The abstract was strengthened by explicitly stating the study design, clarifying the comparison group, and including adjusted odds ratios with confidence intervals.

Finally, the authors fully updated the manuscript to comply with PLOS ONE requirements, including formatting, tables, supplementary files, financial disclosure, data availability statements, figure specifications, and reference checks. They also clarified concerns regarding overlap with related publications from the same broader research project.