PONE-D-21-19528Transformative Learning of Medical Trainees during the COVID-19 Pandemic: A cross sectional surveyPLOS ONE

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Muhammad Shahzad Aslam, Ph.D.,M.Phil., Pharm-D

Academic Editor

PLOS ONE

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2. Thank you for stating the following financial disclosure: "Funding for this study was awarded (BV) through a Penn State Department of Medicine (https://med.psu.edu/medicine) Inspiration Pilot Grant for COVID-19 Related Research (INSPIREVIP2020).  The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

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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

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: I thought this study was well designed and well done. Here are some thoughts that I have for your study:

1. The sample size was ultimately quite small. Out of around 1300 trainees, only 33 participants took your survey. This makes it hard to make a substantial inference about the whole trainee experience during COVID-19 at your institution.

2. Negative change was the majority. This was an interesting finding that worthwhile sharing since it shows the stress that this population was under while also learning to be professionals.

3. You reference the "hidden curriculum" in your discussion without a citation. Can you either explain this or provide a reference that would explain it? I'm a medical trainee and understand this clearly, but it may not be clear to all readers.

4. I liked the discussion about why your learners didn't have a TL experience because of the pandemic. I think that in hindsight many years from now they may see this as a valuable learning experience.

5. Supplemental Table 1 - Do you have a reference for this information you can include?

Good luck with getting this published!

Reviewer #2: The manuscript titled “Transformative Learning of Medical Trainees during the COVID-19 Pandemic” utilized the Transformative Learning Survey approximately 6 months after the start of the pandemic in September and October 2020, to evaluate three process domains and four outcome subdomains, as well as coding two open-ended questions. Only 22 students (3.2%) and 11 residents/fellows (1.7%) responded, but the authors note they reached qualitative saturation. Of the four outcomes, Self-Awareness was the most prominent, and for the processes, Cognitive Rational and Social Critique were more prominent than Extrarational. Transformative learning through Social Critique was significantly more likely to be used by students than residents/fellows. For the qualitative analysis of the open-ended questions, negative changes were the most common and found significantly more in students than residents/fellows. Negative changes included education stressors, social isolation, and changes in daily life, while positive changes included more time with family and improved work-life balance.

A major concern is the very small sample size and how it can be representative of the pool. However, this is a very well-written and interesting manuscript, and can contribute to the field, particularly if a follow-up study is planned as only 8.4% of reported changes were defined as transformative and the authors believed that not enough time had elapsed since the start of the pandemic for adequate critical reflection, and the location of the study had a relatively low volume of COVID-19 positive patients. Listed below are suggestions and comments to help clarify some points and to potentially improve the utility of this manuscript.

Abstract:

• Background: The phrase “coronavirus disease 2019 pandemic” could be taken as 2019 pandemic, so it may be more clear to state “coronavirus disease 2019 (COVID-19) pandemic”

• Methods: Would be helpful to add the months of survey administration for context

• Results: perhaps listing some of the qualitative coding instead of just “negative changes were most common”

Methods:

• Study design, participants and procedure: It states that medical and PA students were grouped together for analysis given similarities in training structure – do both students have similar pre-requisites? What is the training structure? Perhaps a comparison of some demographics to show they are similar enough to combine?

• Data analysis, quantitative data: It states that if a significant difference was found in a process or outcome of TL between groups, then the same statistical tests were used to examine differences at the subdomain level – would it be possible that there were significant differences in the subdomain level that “canceled out” and wouldn’t be detectable at the higher levels?

Results:

• Demographic characteristics: PA students are divided into clinical and preclinical, but the medical students are not – please clarify. It would also be helpful to list the composition of the 22 students – PA vs medical, clinical vs preclinical.

• Demographic characteristics: The very poor response rate is unfortunate. Is there a way to compare the demographics of the participants vs the pool to be able to comment about it being representative?

• Quantitative results for transformative learning, Overall results: Supplementary Table 1 is stated, but it should refer to Supplementary Table 2.

• Quantitative results for transformative learning, Subgroup comparisons: The first set of numbers regarding Social Critique are not necessary because they are already in the table. I could not find the second set of numbers regarding sub-processes in any of the tables. Please list the results of data analysis in a table.

• Qualitative results for transformative learning, overall results: The inductive coding scheme does not seem to be Supplemental Table 1 – is it the first column of Table 4? And could you add p values to Table 4?

• Qualitative results for transformative learning, Positive change, shift or perception: The quotes at the top and middle of page 14 are not related to the sentences just prior to them that mention local politics and outdoor activities, respectively, so it doesn’t read as smooth.

Discussion:

• Implications for practice: A team-based fitness tracking program by the Department of Medicine was implemented after recruitment for the study was completed. Is there anything that was implemented because of the results of this study?

• Implications for practice: It states that not enough time had elapsed since the disorienting dilemma to truly allow for adequate critical reflection as the survey was completed relatively early in the pandemic when the large academic health center had a relatively low volume of COVID-19 positive patients – it would be interesting to repeat this study and compare – there may be an increase in transformative changes and a difference in Extrarational process

References:

• Unable to access reference #10 – the link did not work, and the name of the journal was not listed (Journal of Transformative Education).

Tables and Figures:

• Table 1: Please define graduate degrees – Masters, PhD and MDs? 5 of the students have graduate degrees.

• Table 2: The note implies that one can compare outcomes to processes, but I don’t think that is the intent. If so, perhaps the note should state, “All measures are grouped so that line items can be compared with other line items within the same heading”

• Table 3: Why are the housestaff boxes so much wider? Would be helpful to have asterisks on those that are significant.

• Table 4: Could you add p values?

• Supplemental Table 1: I am not sure this was referenced in the article. There were references to Supplemental Table 1 that did not seem to be correct – either Supplemental Table 2 or Table 4.

• Missing table? Under Quantitative results for transformative learning, Subgroup comparisons, there were a set of data regarding sub-processes that I couldn’t find.

Reviewer #3: Dear Authors,

It was a pleasure to review this manuscript. The authors have presented a timely and important topic. The following comments are attached to improve this study.

Authors presented ‘Each of these three processes of TL can be further differentiated into more specific subdomains’ suggest authors present a more clear description of subdomains.

Same for ‘Per institutional policy for education research implemented after COVID-19’ please elaborate more. Also, a brief description about how the learning and teaching opportunities were provided during the pandemic? What were the responsibilities of PA, staff, and others?

In the text, I could not see the transformative activities in the medicine program. How participants were informed about the different domains of TL? Please address more.

Sample size and sampling technique are missing.

The authors used a tool consisting of 90 items. It might be helpful for the authors to provide a brief overview of how they ensure the validation of responses? This might be one of the limitations of the low response rate. Please address more.

Few references are incorrect, please follow journal style.

Ethical Dimension - It clearly stated that the authors sought IRB approval, which is a good practice.

Once again, a valuable investigation but it may require some minor changes as discussed.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-21-19528R1Transformative learning of medical trainees during the COVID-19 pandemic: a cross sectional surveyPLOS ONE

Dear Dr. Vipler,

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. 1- Please clarify the study design inside the title. I believe its a mix method cross-sectional study, So, please change the title of manuscript.

Transformative learning of medical trainees during the COVID-19 pandemic: A mix method study.

Although you have explain the limitation of study, yet i request to justify your sample size inside the methodology.

2-Please prepare the checklist and attached it as supplementary file

https://journals.sagepub.com/doi/10.1177/1558689819875832

Please submit your revised manuscript by Oct 06 2022 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 rebuttal 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,

Muhammad Shahzad Aslam, Ph.D.,M.Phil., Pharm-D

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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: (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 #2: Yes

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

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 #2: 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 #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 #2: Thank you for the revisions of this manuscript. This reviewer (#2) also greatly appreciates the analysis done (to satisfy the reviewer’s curiosity) on the group differences for each measure in the other domains to find there was no statistically significant differences between the groups for the scales from the other process domains. The majority of comments were addressed except for the following:

It was suggested to add the months of survey administration and listing some of the qualitative coding within the abstract. The authors may have misunderstood this as their response was pointing out where they are located in the manuscript body. Perhaps there is a word limit to the abstract, but if possible, adding “We used the Transformative Learning Survey in September/October 2020…” would provide context for readers who are skimming the abstract to know that this occurred early in the pandemic.

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Reviewer #2: No

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Transformative learning of medical trainees during the COVID-19 pandemic: a mixed methods study

PONE-D-21-19528R2

Dear,

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,

Muhammad Shahzad Aslam, Ph.D.,M.Phil., Pharm-D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: