PONE-D-25-55463Musculoskeletal Surgeons Use Mixed Reasoning Rather Than Pure Bayesian Strategies in

Clinical PracticePLOS One

Dear Dr. Ring,

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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Ismail Tawfeek Abdelaziz Badr, M.D.

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

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: 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

Reviewer #3: Yes

Reviewer #4: 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: • Did you perform any test to determine the appropriate sample size?

Given the sensitivity of the study, please revise the manuscript to include complete details on sample size justification.

• Please provide the full text of all eight scenarios, including the four response options for each scenario, as well as the detailed normative Bayesian justification (priors, likelihoods, posteriors, and the criteria used to rank options from non-Bayesian to fully Bayesian).

Only Scenarios 1, 2, 4, and 5 appear to be included; the full set of eight scenarios is not visible.

• In the section on “other relevant findings,” the references to Scenario 1 (Table 3) and Scenario 2 (Table 4) appear inaccurate.

Please review and correct the scenario numbering and corresponding table references.

• How were the scenarios and their Bayesian rankings developed and validated?

Please indicate whether you conducted:

- Expert panel review

- Pilot testing

- Cognitive interviews

- Interrater agreement assessments for the Bayesian ranking criteria

• Given that the primary outcome is ordinal, why did you choose linear models instead of ordinal or mixed-effects ordinal models?

Please provide justification for this choice and report sensitivity analyses using an ordinal mixed-effects model with random effects for both surgeon and scenario.

• Could unmeasured covariates explain the observed regional effect?

Please clarify whether additional variables—such as country, subspecialty, prior training in EBM/Bayesian reasoning, or native language—were considered or included in extended models.

• PLOS ONE requires open data.

The statement “Data available on request” is not compliant and conflicts with the declaration “No – some restrictions will apply.”

Please clarify:

- What specific restrictions you intended

- How these restrictions align with PLOS ONE’s open-data policies

- How the dataset will be made publicly available

•Additional demographic details appear to be missing.

For example, surgeons with 15 years of practice experience may differ significantly depending on age or career stage, and it is unclear whether responses differed by gender.

Please provide all relevant demographic variables and describe whether they influenced the results.

• Please report the results of normality testing.

Since means and standard deviations (SD) should not be used for non-normally distributed data, include the outcomes of normality tests and consider presenting medians and IQRs if appropriate.

• Scoring validity:

Please provide the explicit normative Bayesian calculations (priors, likelihoods, posteriors, and decision thresholds) used to justify the ranking of the response options.

If the ranking is based on qualitative Bayesian principles rather than exact numerical calculations, specify the criteria used to determine which options are “more Bayesian.”

Reviewer #2: Technical Soundness & Data Support

The manuscript is technically sound, and the presented data robustly support the conclusions. The experimental design and methodology are appropriate for the research objectives.

Statistical Analysis

The statistical analysis has been performed appropriately and rigorously. The methods are well-described, and the results are presented with sufficient detail to validate the findings.

Data Availability

The authors have made all underlying data fully available, ensuring transparency and reproducibility of the study.

Clarity & Language

The manuscript is well-structured, clearly written in standard English, and presented in an intelligible manner. The logical flow enhances readability.

Overall Recommendation:

The manuscript meets the expected scientific and editorial standards for publication.

Reviewer #3: General comment

1. This study is important and novel in the field of surgical decision-making. However, some methodological transparency issues must be addressed to meet the journal’s standard.

2. Are the musculoskeletal surgeons limited to only orthopaedic surgeons? Additionally, how are the distributions of subspecialties or fellowships among surgeons? Would this affect the answer to a specific scenario based on their subspecialty?

3. Some grammatical errors are found in the text. Please proofread and edit your manuscript before submission. Numbers below 11 should be written in text, not numerically.

4. Missing the tables of Scenario 6, 7, and 8. Furthermore, please number the scenarios in the table consecutively.

5. Missing citation in line 342.

6. Please complete the proper citation of citation no. 16.

7. 12/33 references were outdated; please use more valid references for the study.

Methods

1. How would the partial responders affect the validity of the study? A sensitivity analysis restricted to complete responders would help demonstrate that the main findings are robust.

2. Describe more of the scoring rubric used in this study. Please be transparent on how the author validated the ranking of responses from 1 to 4.

3. How did the author curate and validate the scenarios? Please explain more to make it reproducible.

Results

1. Please clarify the writing of “95% CI: 2.82, 2.94” in lines 183-184.

2. The author should highlight the significance of the result of the association of the region of practice more (i.e., “significantly lower”), in lines 197-199.

3. Please include the original survey results, the scoring rubric, and any analysis code (Stata files) in the appendix. The data-availability statement should be added.

Discussion

1. Lacking discussion in comparing the current study with previous or similar studies

2. Please elaborate further on the sample’s generalizability, as the sample in this study is drawn from a single group.

3. Consider adding a concise narrative or table summarising key prior studies (population, clinical domain, task type, main outcome, and typical proportion of Bayesian-consistent responses), and clearly state how the present findings align with or diverge from those patterns.

4. For further implication, provide concrete examples of how Bayesian concepts could be integrated into orthopaedic training (e.g., structured case conferences emphasising priors and likelihood ratios, incorporation into fracture conference, use of decision aids for imaging and surgery thresholds.

Overall, the manuscript requires major revision to be considered for publication in this journal.

Reviewer #4: This manuscript addresses an important topic in clinical decision-making and presents a carefully designed scenario-based assessment of Bayesian reasoning among musculoskeletal surgeons. The study is generally well conducted and clearly reported, and the findings provide useful insight into the context-dependent nature of clinical reasoning under uncertainty. However, several aspects of the study designand interpretation would benefit from further clarification, as outlined below.

1.Based on the research team's theoretical framework, the author assigned scores ranging from 1 to 4 to each response option. However, it remains unclear whether inter-rater reliability (IRR) was formally assessed. Furthermore, could the author clarify if this specific scoring rubric is substantiated by extant literature or established validation studies?

2.The authors report significant variations in reasoning patterns across different clinical scenarios. However, it remains unclear whether these discrepancies stem from genuine shifts in reasoning strategies or are artifacts of scenario-specific factors, such as task difficulty, situational familiarity, or relevance to specific subspecialties. Please clarify whether the equivalence of the scenarios was established during the study design. Furthermore, please specify if, and how, potential confounding effects, such as the 'difficulty effect' or 'familiarity bias,' were controlled for or mitigated.

3.The authors report statistically significant disparities in Bayesian reasoning scores across different regions; however, a concrete explanatory framework for these findings is currently absent. The authors are requested to clarify whether such variations might reflect regional differences in training systems, clinical guidelines, or the contextual relevance of the scenarios. Furthermore, please address whether the scenarios maintain equivalent representativeness across the various geographical regions included in the study.

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Reviewer #1: Yes: Sameh Eldaly

Reviewer #2: No

Reviewer #3: Yes: Ismail Hadisoebroto Dilogo

Reviewer #4: No

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PONE-D-25-55463R1Musculoskeletal Surgeons Use Mixed Reasoning Rather Than Pure Bayesian Strategies in Clinical PracticePLOS One

Dear Dr. Ring,

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 May 07 2026 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 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,

Ismail Tawfeek Abdelaziz Badr

Academic Editor

PLOS One

Journal Requirements:

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.

[Note: HTML markup is below. Please do not edit.]

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: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

Reviewer #7: (No Response)

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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: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: (No Response)

Reviewer #7: Yes

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

Reviewer #1: No

Reviewer #3: N/A

Reviewer #4: Yes

Reviewer #5: N/A

Reviewer #6: (No Response)

Reviewer #7: 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 #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: (No Response)

Reviewer #7: 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: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: (No Response)

Reviewer #7: 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: (No Response)

Reviewer #3: • Please provide more information about the participant characteristics in the abstract, such as the regions and years of experience.

• Please clarify how the responses were obtained from the study subjects. Was it through an online questionnaire or a multicenter study?

• How were younger musculoskeletal surgeons represented in this study? Most of the participants seem to have several years of experience in their field, which creates an imbalance between junior and senior surgeons. This may introduce a bias in the study.

• Please add an explanation regarding the partial responses. Could these affect the results and introduce bias? Or address this in the study limitations.

• Please include citations for lines 225 to 248.

• Please explain how your findings compare with previous studies in the literature.

• Were there any regional differences in the findings among orthopaedic surgeons? Please expand the discussion on these regional variations.

Reviewer #4: (No Response)

Reviewer #5: I found the topic is interesting, original but difficult to interpret and analyze. This study addresses an important and underexplored aspect of surgical decision-making.

The Cronbach alpha of 0.43 suggests low internal consistency. While the authors interpret this as evidence of context-dependent reasoning, it also raises concern that the instrument may not be measuring a unified construct. The manuscript would benefit from deeper discussion of whether “Bayesian reasoning” is being operationalized consistently across scenarios and whether the low alpha reflects measurement limitations rather than cognitive variability.

The central conclusion that surgeons use mixed reasoning rather than pure Bayesian strategies may be overstated. Mixed reasoning could reflect adaptive expertise rather than deviation from a normative ideal. The discussion should more clearly distinguish between cognitive flexibility and suboptimal probabilistic reasoning.

The convenience sample from the Science of Variation Group (predominantly academic, highly experienced surgeons) limits external validity. This limitation should be emphasized more clearly in the Discussion and Conclusions.

Reviewer #6: This study investigates the cognitive logic of 153 senior musculoskeletal surgeons (primarily from North America and Europe) when navigating clinical uncertainty. Through eight simulated clinical scenarios, the authors assessed the extent to which surgeons employ Bayesian reasoning in diagnostic and treatment decisions. The findings suggest that surgical decision-making is not purely probability-driven but rather characterized by "mixed reasoning," which is highly context-dependent. The revised manuscript appropriately introduced mixed-effects modeling to further analyze the heterogeneity across scenarios.

1. Abstract

The authors are encouraged to provide a clearer operational definition of "Mixed Reasoning" within the context of this study. The conclusion should explicitly state the implications of this logical instability for the implementation of clinical guidelines.

2. Introduction

Strengthen the link between "logical flaws" and "adverse clinical outcomes." Adding literature regarding common cognitive biases in orthopaedics (e.g., overdiagnosis or diagnostic anchoring) would better justify the necessity of studying reasoning logic as a tool to prevent over-medicalization or unnecessary surgery.

3. Methods

Please clarify whether "individual surgeon" was treated as a random effect in the mixed-effects model. While scenarios are treated as fixed effects, it is crucial to determine if the model adequately separates variance caused by the scenarios from variance stemming from individual cognitive differences or professional backgrounds.

4. Results

Although the authors view regional differences as potential confounders, providing a subgroup analysis by region (e.g., North America vs. Europe) in the supplementary materials is recommended. Differences in medical education systems regarding statistical literacy may exist; showcasing these trends—even without over-interpretation—offers valuable insights for a global audience.

5. Discussion

Expand the discussion on how "non-Bayesian logic" practically impacts the quality of care. For instance, does failing to follow Bayesian logic in low-prevalence scenarios significantly increase false-positive rates? The manuscript needs to bridge the gap between "abstract logic scores" and "tangible clinical risks."

Provide more actionable recommendations for musculoskeletal education. Given the "context-dependent" nature of reasoning, education should move beyond teaching formulas toward Case-Based Learning (CBL) to correct cognitive biases within specific clinical contexts.

6. Conclusion

Emphasize the finding that "extensive clinical experience does not necessarily equate to logical rigor." This serves as a critical policy reminder for Continuing Medical Education (CME) programs targeting senior clinicians.

7. References

The timeliness of the references is acceptable, but it is recommended to supplement the basic literature on the application of mixed-effects models in cognitive research, as well as the latest studies on surgeon decision preferences (Surgeon preference) in the past two years (2024-2025), in order to demonstrate that this research is at the forefront of the field.

Reviewer #7: Short Formal Peer Review (150–200 words)

This manuscript investigates how musculoskeletal surgeons apply Bayesian reasoning when making clinical decisions under uncertainty. Using a vignette-based survey, a group of 153 musculoskeletal surgeons responded to eight clinical scenarios designed to reflect varying levels of Bayesian reasoning. The results suggest that surgeons use a mixture of Bayesian and non-Bayesian reasoning strategies, with substantial variability across scenarios. The study highlights that surgeons appear capable of Bayesian reasoning but apply it selectively depending on the clinical context.

The topic is relevant and timely, particularly given the increasing emphasis on probabilistic reasoning in medical education and the emergence of AI-supported clinical decision tools. The vignette-based approach provides a practical method for exploring reasoning patterns, and the study offers useful insights into how clinicians interpret evidence and update diagnostic probabilities.

Overall, the manuscript addresses an important aspect of clinical reasoning and contributes valuable observations. I see no issues with this manuscript.

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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: Sameh Eldaly

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #6: No

Reviewer #7: No

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Musculoskeletal Surgeons Use Mixed Reasoning Rather Than Pure Bayesian Strategies in

Clinical Practice

PONE-D-25-55463R2

Dear Dr. Ring,

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,

Ismail Tawfeek Abdelaziz Badr, M.D.

Academic Editor

PLOS One

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