April 26th, 2010
Editorial Board Members and Manuscript Reviewers
BMC Medical Education
BioMed Central Ltd
Floor 6 236 Gray's Inn Road
London WC1X 8HL United Kingdom
Dear Editorial Board Members and Manuscript Reviewers,
I am writing on behalf of the authors of the manuscript entitled “Attitudes of US medical
trainees towards neurology education: ‘Neurophobia’ – a global issue” that we submitted
for publication in BMC Medical Education.
Thank you very much for taking the time to review our manuscript and for the
constructive comments.
We have made the requested changes to the manuscript and hope that these changes
have addressed your concerns and comments. Please see below for the specific edits
and the attached, revised manuscript. All the reviewers felt the paper was interesting
and important and we thank them for their enthusiasm. We recognize and agree that the
main limitations of this work is that it was performed in a single center. Interestingly,
both medical students and medical residents (the vast majority did not attend this
institution) were consistent in their rating of Neurology as a difficult specialty. This
suggests that the issue is of importance and is consistent with work performed in
Europe. We have stressed this limitation in our discussion.
In addition, as requested by reviewer 1, please find attached the Survey Instrument used
in the study.
Finally, as requested, the name of the review board granting the approval for the study is
listed below:
University of Connecticut Health Center Institutional Review Board.
We thank you again for your consideration and look forward to hearing from you.
Sincerely,
Dr. Louise McCullough
The changes to the manuscript are listed below in red and highlighted in red in the
revised manuscript. We hope that we addressed your concerns and comments.
Response to Reviewer: Anil K Nair.
Major Compulsory Revisions:
1. The following changes were made in the Conclusions section of the Abstract to
address the concerns regarding the generalizability of our findings:
Medical students and residents at this US medical university found neurology difficult.
Although this is consistent with prior reports from Europe and Asia, we agree that
studies in other universities are needed to confirm generalizability of our findings. We
have softened our conclusions and stressed these limitations in the discussion.
2. Introduction and Discussion references.
Appropriate references were added in the Introduction and Discussion Sections for
sentences in which statements were made either:
A. Not based on the data in this study
B. Not presented as potential reasonable explanations based on the findings (words
such as may, could etc. were used in such instances).
Please see text of the above sections highlighted in red.
Minor Essential Revisions:
1. Low response rate.
We agree that the response rate was lower than expected in the residents and would
have liked greater participation from the students and residents. Although it would have
been very valuable to include this survey as part of our required residency program or
medical school course feedback surveys, ours was an educational research study, and
not part of the official medical school or residency curriculum. Thus participation was
voluntary. The nature of such voluntary participation unfortunately often limits the
response rate. In addition, the low response rate was noted as an issue by reviewer 3.
Unfortunately this is often an issue in survey studies. The residents (especially in Year 2
and 3) had lower response rates, and the reviewer expressed concern that this may
have been due to fear of recrimination. The survey was performed in a blinded,
anonymous fashion, with one return location. The more likely explanation is that the
residents, especially in their later years rotate through several different hospitals and are
often away on electives and fellowship interviews.
At this time, studies are planned to assess the impact of the interventions listed in the
Discussion section of this paper on the perceptions of neurological education and
trainee’s comfort with the subject at the University used in this work. Strategies are
being developed to improve participation in future surveys. A required Neurology
clerkship will begin in late 2010 and we will reassess student’s comfort with Neurology in
two years.
2. Further detail on selection of the significance levels for statistical analysis.
The significance level selected for standard mean comparisons was a conventionally
used alpha level of 0.05. However, as mentioned in the Methods section, the
significance level was adjusted using a Bonferoni correction (please see reference
below) if multiple comparisons were made. This correction is based on the principle that
if an experimenter is testing n hypotheses on a set of data, then one way of maintaining
the familywise error rate is to test each individual hypothesis at a statistical significance
level of “1/n” times what it would be if only one hypothesis were tested (alpha = 0.05). In
this case, the significance level becomes alpha divided by n.
Abdi, H (2007). "Bonferroni and Šidák corrections for multiple comparisons". in N.J.
Salkind (ed.). Encyclopedia of Measurement and Statistics. Thousand Oaks, CA: Sage.
Methods section on statistical analysis was thus edited as below (changes are
highlighted in red):
General linear model multivariate analysis was used to compare the means of overall
(student and resident) responses. A standard alpha level of 0.05 was used. A
Bonferroni correction for multiple comparisons (alpha divided by n, where n is the
number of comparisons being made) was used and the significance threshold for each
comparison is presented along with the results.
Response to Reviewer: Tracey Cho
Major Compulsory Revisions: none
Minor Essential Revisions:
1. Limitation of this being a single center study not explicitly mentioned in
Discussion.
The authors agree that since this is a single center study, it is difficult to
generalize the findings to remaining medical schools and residency programs in
the US. We also agree that a multi-site survey would be the best way to assess
whether findings in our study can be generalized to other medical schools and
residency training programs. The following changes were made to clarify the
single center nature of the study and implication of this to the discussion and
conclusions presented in the paper.
Abstract Conclusion section:
Medical students and residents at this US medical university found neurology
difficult. Although this is consistent with prior reports from Europe and Asia,
studies in other universities are needed to confirm generalizability of these
findings.
Discussion section:
Another important limitation is related to the fact that this study was
performed at a single medical institution, thus our findings may be difficult
to generalize to other medical schools in the US, where variability in
curricula and teaching faculty may lead to different results. It is notable
however, that similar trends were found in Europe and Asia, suggesting
that issues identified in this work may be true across educational
establishments [4,6,11,12], and similar results were found in medical
students (trained at this one institution) and in residents (most of which
went to medical school elsewhere). Nonetheless, studies at additional US
medical centers are needed to confirm that the data presented here can be
generalized to other medical training programs in the US.
Conclusions section:
Both students and residents at the institution studied report significant difficulty
and low confidence when working with patients with neurological complaints.
This is especially concerning in the face of the rising number of patients with
neurological disorders that are managed in many primary care settings. Although
it is difficult to generalize these findings based on a single center study to the
remainder of the US medical educational institutions, our findings are consistent
with reports from diverse educational settings in Europe and Asia.
Discretionary Revisions: Survey Instrument Attached as requested.
Response to Reviewer: Jonathan Miller
Major Compulsory Revisions: none
Response to comment topics:
1. Regarding difficulty with generalization of the findings to other US institutions:
The authors agree that since this is a single center study, it is difficult to
generalize the findings to remaining medical schools and residency programs in
the US. We agree that a multi-site survey would be the best way to assess whether
findings in our study can be generalized to other medical schools and residency
training programs. The following changes were made to clarify the single center
nature of the study and implication of this to the discussion and conclusions
presented in the paper.
Abstract Conclusion section:
Medical students and residents at this US medical university found neurology
difficult. Although this is consistent with prior reports from Europe and Asia,
studies in other universities are needed to confirm generalizability of these
findings.
Discussion section:
Another important limitation is related to the fact that this study was performed at
a single medical institution, thus our findings may be difficult to generalize to
other medical schools in the US, where variability in curricula and teaching faculty
may lead to different results. It is notable however, that similar trends were found
in Europe and Asia, suggesting that issues identified in this work may be true
across educational establishments [4,6,11,12]. Nonetheless, studies at additional
US medical centers are needed to confirm that the data presented here can be
generalized to other medical training programs in the US.
Conclusions section:
Both students and residents at the institution studied report significant difficulty
and low confidence when working with patients with neurological complaints.
This is especially concerning in the face of the rising number of patients with
neurological disorders that are managed in many primary care settings. Although
it is difficult to generalize these findings based on a single center study to the
remainder of the US medical educational institutions, our findings are consistent
with reports from diverse educational settings in Europe and Asia.
2. Clarification regarding the methods used by trainees to learn medicine as part of
their responses to Part 2 of the survey.
The authors agree with the observation that since there is a significant difference
in trainees’ perceptions of neurology in comparison to other specialties, it is
important to specify in Part 2 of the survey whether the ways by trainees best
learn are applicable to learning medicine or neurology specifically. The survey
instrument used a question of “How useful do you find each of the below methods
in learning medicine?” A change to the Methods section regarding Part 2 of the
survey was made to reflect this wording within the survey (see below).
Unfortunately since the differences of trainees’ perceptions of neurology and
other areas of medicine were not elucidated until after data analysis, the
distinction between best ways to learn medicine in general versus neurology
could not be made in the survey instrument at the onset of the study without
singling out neurology and potentially biasing the responses further. The authors
had elected to assess the methods by trainees learned medicine in general with a
goal of capturing how trainees best learn general medical information.
Application to neurology education in this case is an interpolation of these
results.
In Part 2, participants were asked to rate the how useful they find various methods
for learning medicine.
Again, thank you all for your helpful comments. We hope this manuscript is now suitable
for publication.