PONE-D-19-29629

Relationships between Objective Structured Clinical Examination, Computer-based Testing, and Clinical Clerkship Performance in Japanese Medical Students

PLOS ONE

Dear Dr Komasawa,

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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Kind regards,

Conor Gilligan

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

This paper addresses an important topic in medical education but some further detail and justification is needed to strengthen the paper and ensure it makes a valuable contribution. Both reviewers make helpful points which you should take into consideration in preparing a revised version. In particular, I agree that the study needs clearer justification and I would think that further discussion of the theories associated with competency-based assessment and the challenges of teaching and assessment in clinical settings would be an important addition. Also, please provide further detail on the methods including the assessment measures and scoring systems. The discussion will need to change to reflect these changes to other sections.

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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: 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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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 the opportunity to review this paper. It is an interesting piece of work, however, there are issues that need to be addressed and clarified by the authors in different parts of the manuscript.

Introduction

The introduction lacks in depth discussion and information about the relationship between OSCE, written examination and Mini-CEX. The authors have provided the organizational context in the introduction but have failed to highlight what is already known in the literature about the relationship between OSCEs, written examination and Mini-CEX. Some examples of published literature include

• Susan Humphrey-Murto, Mylène Côté, Debra Pugh & Timothy J. Wood (2018) Assessing the Validity of a Multidisciplinary Mini-Clinical Evaluation Exercise, Teaching and Learning in Medicine, 30:2, 152-161, DOI: 10.1080/10401334.2017.1387553

• Rogausch A, Beyeler C, Montagne S, Jucker-Kupper P, Berendonk C, Huwendiek S, Gemperli A, Himmel W. The influence of students’ prior clinical skills and context characteristics on mini-CEX scores in clerkships–a multilevel analysis. BMC medical education. 2015 Dec;15(1):208.

Given that there are published evidence highlighting the relationship between the above variables, the authors need to identify the gap and state the justification for the study.

In addition, some of the references listed such as references, one (1) to four (4) do not reflect the statements written by the authors in the first paragraph. Please use appropriate references.

Methods

Study measures

OSCE content and evaluation

The authors stated that seven aspects were covered in the OSCE. Could the authors state the clinical disciplines that were examined? Was it only one discipline or was the OSCE conducted in all disciplines (Internal Medicine, Pediatrics, Obs and Gyn, Surgery, Family medicine, Emergency, and Anesthesiology)?

How was the overall score calculated?

CBT Content and Evaluation

What content was covered? Were the clinical disciplines assessed? If so, please state it.

Clinical clerkship content and evaluation

The authors have stated that an evaluation sheet based on Mini-CEX and DOPS was used. Could the authors include a copy of the evaluation sheet?

In addition, the authors have stated that the basic clinical clerkship was conducted across all disciplines. How was the average and overall score for the mini-CEX calculated as well as the scores for the different clinical disciplines? Was the form adapted for the different clinical disciplines? If so, please provide the details

Statistical analysis

The statistical analysis should be updated based on the information provided above related to the methods.

Results

As stated in the methods section, the authors need to provide further information on how the average score reported were calculated for the OSCE, CBT and CC. This applies to all sections of the results. Given the above issues, the results reported by the authors cannot be verified.

Discussion

Given the concerns raised about the methodology and results, the discussion needs to be re-written to align with the updated information.

However, the first paragraph in the discussion is a repetition of the first paragraph in the introduction. The authors need to consider how to present the findings of the study in relation to existing evidence.

Other issues

Some references listed in text do not reflect the statements written by the authors. It is important for the authors to use appropriate references.

Reviewer #2: This manuscript is very well written. It looks at the relationship between objective structured clinical exam, computer-based testing and clinical clerkship performance in Japanese medical student. The transition from medical student to practising doctor is a very topical issue in medical education at the moment and hence this manuscript is very welcomed.

Well, the paper has been written very well with good statistical rigour, however, there are a few clarifications that is needed.

1. It would be good to know what teaching was done prior to the test. Did all 94 students attend the session. was it mandatory? was it right before the test or was there a lag period? This was not clear on the manuscript and would have a significant impact on the results. Please clarify.

2. What elements of the examination (head and neck exam; neurological examination etc.) was expected in the five minute OSCE period. So, specifically for the chest exam, was it just the preacordium that was examined in the five minutes? For neurological exam was it all aspects of sensation, proprioception, reflexes for upper and lower limb that was done in the five minutes? Please clarify.

3. Did the 2 examiners scores correlate? An average was achieved. Was examiner training provided to ensure consistency?

4. Typo in paragraph 2 of study measures. 'the examination also strictly checks the identification of students.....'

5. For the computer based testing, were the 320 question standard tested beforehand? If so, was this to the standard of a fourth-year or a 5th year medical student?

6. In addition clarification should be provided as to what aspects of clinical knowledge was tested. Was it all subjects or just acute medicine and acute surgery that is applied during clinical clerkship?

7. It looks like the mini clinical evaluation exercise and the direct observation of procedural skills assessement tools were graded for correlation purposes. Could the grading/marksheets be provided, please. Traditionally these assessments are used for feedback purposes and not usually graded.

Many thanks.

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Reviewer #1: No

Reviewer #2: Yes: Gozie Offiah

[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 to be viewed.]

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PONE-D-19-29629R1

Relationships between Objective Structured Clinical Examination, Computer-based Testing, and Clinical Clerkship Performance in Japanese Medical Students

PLOS ONE

Dear Dr Komasawa,

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.

We would appreciate receiving your revised manuscript by Apr 16 2020 11:59PM. When you are 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

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). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Conor Gilligan

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The authors have attempted to address the reviewers comments but in many cases have done so superficially, resulting in a paper that continues to lack clarity.

1. The conclusion section of the abstract needs to make a stronger ‘so what?’ point.

2. Reviewer 1 suggested a deeper exploration of the topic in the introduction and I do not feel that this has been addressed.

3. On page 3 – ‘assuring basic clinical competency is essential’ – are the authors referring to achieving this prior top CC?

4. On page 4, the authors have added some detail but the writing. Is unclear and includes repetition. The paragraph starting ‘The OSCE…’ needs to be revised.

5. Page 5 please delete ‘We have discussed that’ and begin this sentence with ‘All data’

6. Why were students who did not progress excluded? Might this have introduced bias? Also, I would expect that this group might increase the variance in the findings which would be statistically helpful.

7. On page 6 – what is the statistical justification for having 7 stations – is there evidence that this provides sufficient data for assessment?

8. Also on page 6 the bracketed ‘(i.e chest….’) is not needed as this information has already been provided.

9. Was the training ‘based on common text’ purely written preparation? Is there any assessor standardisation?

10. I am surprised at such high scores, particularly on the CBT – is item analysis available and how is the standard set for this examination? There is very limited variance across all scores – this should be addressed as a limitation in making judgments about the correlations or lack thereof.

11. On page 11, second paragraph there is repetition – the discussion in general is repetitive and offers limited analysis of the findings. I encourage the authors to explore the potential implications more deeply to clarify a ‘so what?’ message.

12. The English grammar at the bottom of page 11 is clumsy and needs revision.

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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 #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 #2: Yes

**********

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

Reviewer #2: 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 #2: Yes

**********

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 #2: 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 #2: Comments:

Revisions well received and efforts made to address initial concerns raised but not there yet for me hence accept with minor changes.

The indepth discussions are useful for this paper to add rigour.

Minor – Typos and grammar need to be corrected.

For example -

Abstract: Although a few studies examined the efficacy of CC

Ethical consideration: rephrase the sentence – It was agreed that as all data were fully anonymised, the ethics committee waived the requirement for informed consent.

Reference 23 and 24 is a duplicate, a thorough review of the references is needed to ensure refrences in the biblography as adeqautely represented in the body of the text.

Overall - satisfied but manuscript needs to be read for grammartical and typo errors and references. Thanks.

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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.

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Reviewer #2: Yes: Gozie Offiah

[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 to be viewed.]

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 us at figures@plos.org. Please note that Supporting Information files do not need this step.

Relationships between Objective Structured Clinical Examination, Computer-based Testing, and Clinical Clerkship Performance in Japanese Medical Students

PONE-D-19-29629R2

Dear Dr. Komasawa,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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Conor Gilligan

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

You have addressed the concerns adequately and I feel that the paper can now be accepted.

Reviewers' comments: