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I don't have any further comments.
1. Check the grammar in the sentence on line 70: "As future physicians it is logical to see what they think..." I couldn't figure out what you wanted to say.
2. I suggest to change the sentence in lines 201-203 in the following way: "The environment in which clinicians teach is not always conducive to high ideals of doctor-patient relationship that the students are taught in lecture theatres."
3. Please, check the reference on Grilo 2014 (line 269), it seems incorrectly presented (Nursing Education Today is the journal title, not a part of the article title; and what does YNEDT stands for?).
4. Table 1 - there is no need for abbreviations if the ters are used only once in the table, so you can delete all the abbreviations from this table
5. Table 2 - please, explain also the PPOS abbreviation
You adequately addressed some, but not all of the comments of the reviewers. I would ask you to revise your manuscript again, taking into account the following:
1. Comment 2 of the Reviewer 2 is valid, but you chose not to accept it. I insist that you revise your manuscript to address the comment. To assist you in this revision, I am giving you two suggestions how to change the wording :
„Patients are increasingly aware“ instead of „With each passing day, patients are getting more and more aware...“
„future physicians“ instead of „healers of tomorrow“/„healers of the future“
In the same way, change or remove the overly poetic expressions and metaphors such as: „A chain is only as strrong as its weakest link“; „Like clay that is cast in a mould...“, „When a cast of clay comes out of a mould... it is shaped forever in the way that mould was designed“; „Nip the evil in the bud“; „incorporate much more space in the mould of medical education“.
2. Comment 4 of the Reviewer 2 about the sweeping (or unsubstantiated) statements is only partially addressed. There are couple of more instances of such statements, such as:
„the doctor-patient relationship is the weak link which bears the weight of all the advances of health care system and its delivery to the patient“.
„to fight hidden curriculum both the curriculum designers and college administration would have to act to mitigate its toxic effects on the development of doctor-patient relationship“.
„The environment they teach in is contradictory to the ideal, students are taught in lecture theatres“.
All of these claims are very strong, but not substantiated with any arguments or literature. Perhaps the doctor-patient relationship is a strong link in modern medicine, and perhaps hidden curriculum does not have only negative, but also positive effects on doctor-patient relationship and therefore should not be called „toxic“. Also, teaching in lecture theatres is not bad in it self – even in the best medical schools in the world part of the teaching is in lecture theatres. Please, revise your statements to address this.
3. Please, try to update the literature in the introduction section – there are too many articles which are older than 10, 15, and even 20 years. There must have been some more recent developments and research in this field.
4. Three sentences in the second paragraph of the Introduction (lines 62-69) are not clearly related and do not clearly follow one from another. Please revise the text to make the link more clearly.
5. line 104 - Explain the rationale for choosing the particular set of demographic characteristics (why, for example, residence or relationship – why would that affect attitudes towards doctor-patient relationship?). Also, explain what the offered categories mean, for example „In a relationship“. What does that mean (having a boyfriend/girlfriend)? 5.1% of the students in a relationship seems very low – is it culturally specific?
6. From the description of the instrument it is not clear how the „sharing“ and „caring“ subscales translate to „patient centered“ vs. „doctor centered care“. Please explain that in more detail.
Other minor comments:
Line 34: Explain the abbreviation PPOS when you first use it. Add the range of the PPOS scale (1- strongly agree to 6-strongly disagree) to allow better understanding of the numerical results presented in the abstract.
Line 121: Add the producer of the SPSS software. I think I gave you the same comment for your previous manuscript in PeerJ.
Line 132: Actually, there was 1181, not 783 participants in the research (in the „Study Sample“ you stated that 1181 students responded (although not all of them provided the completely filled out questionnaires).
Line 149: The word „taboo“ was here incorrectly used. Please, check the dictionary for the exact meaning of this word and rephrase.
Line 183: „These findings“... Not clear to which findings this refers to. Sentences previous to this one describe differences between students in inpatient vs. outpatient rotations. How could these differences be explained by the introduction of Behavioral sciences in clinical years?
Line 184: Was the subject of Behavioural sciences introduced in more than one (all?) Pakistani medical schools or only in the UHS (as suggeste in the lines 236-237).
Line 186: Even if you have not collected the exact data about the origin of foreign students, please provide at least some assessment of this population. Your statement in the lines 186-187 implies that foreign students in Pakistani medical schools are not of Asian origins – is this a plausible statement? If yes, from which countries do they actually come – Africa, America, Europe?
Line 226: I wouldn't say we (or anyone, for that matter) „produces healers“. We perhaps teach students/future physicians, we help them develop and learn, but we do not „produce“ them.
Tables 1 and 2: explain the abbreviations (AIMC, CMH, OPD)
Please, try to address all of the reviewers' comments. Reviewer 2 has suggested a major revision, so please try to address major concerns expressed by that reviewer, especially in relation to style of writing and presentation of results.
The standards of reporting followed in the manuscript is very good.
The experiental design has been well described though there are some clarifications which I have mentioned in my specific comments. The authors have used a validated instrument.
The findings in my opinion are valid.
Dr P Ravi Shankar
24th April 2015
The authors must be congratulated on a well conducted and clearly written study. I enjoyed reading the manuscript. However, the manuscript needs a few revisions before it can be considered for publication. The revisions are mentioned below.
There are a few punctuation and spacing issues in a few places in the manuscript
Page 5, lines 69 to 71. While this may be broadly true it does not take into account the fact that students play an important role in what they learn and how they learn it.
Page 5, paragraph 2: The authors can briefly mention the aims and objectives of the study towards the end of the paragraph.
Page 6, line 95. Are students provided with opportunities for early clinical exposure during the preclinical years as this has been shown to influence their attitudes towards the patient-doctor relationship?
Page 6, line 99. What is the total number of students at each institution?
Page 7, line 120. Was the ethics committee of the Government medical college also informed about the study?
Page 9, line 168. What was the nationality of the foreign students?
Page 10, line 200. The authors can briefly describe what exactly they mean by consent and confidentiality in the manuscript.
Page 11, line 214. The authors can mention about the introduction of behavioral sciences in the curriculum earlier in the Discussion section.
Page 12, line 246. JAMA should be capitalized
Page 12, line 249. The author names should be in sentence case like other references
Page 13, line 268. Certain journal titles do not follow the proper case
Page 13, line 270. The name of the journal seems to be missing
Page 13, line 290. Journal details seems to be missing
Page 14, Table 1. What percentage of male and female students actually participated in the study? This can be mentioned in the Results.
Page 14, Table 1. As mentioned previously nationality of the foreign students may be informative
Page 15, line 303. This can be mentioned earlier in the manuscript
I have also mentioned these comments in the annottaed manuscript.
The manuscript is not well prepared. There were multiple spelling and grammatical errors. The style of writing is also unconventional for a scientific paper. Interesting metaphors such as "weakest link in a chain" and "moulding of clay" were used but they were over-extrapolated to the point it looses its relevance to the issue being discussed. The use of language was not precise. For example the authors used "total" "average" and "mean" inappropriately during the description of the scores of the PPOS instrument. There were various sweeping statements in the manuscript. For example line 63 which said that patient autonomy was "never considered in prior times". There were also unusual terms used such as in line 92 "non-problem based learning".
The explanation of results were not comprehensible. Line 126 referred to a Table 3 which could not be found and presumably was dropped during the submission. This is consistent with the general lack of precision which was reflected in the reporting of results and in the discussion as well. This is a fatal flaw in scientific writing.
I am unable to benefit from this very commendable effort in understanding the attitudes of medical students towards doctor patient relationship. This is a pity as the authors had obviously put much effort into the study. I think they need to review their data more carefully and come up with a more effective report of their effort.
The tool chosen was appropriate.
Unfortunately the characteristics of the students chosen were not well thought through. The analysis was weak and simplistic. Perhaps this was because the hypothesis was unclear in the beginning.
The analysis was weak and the results were not well reported. Based on what that could be understood, the conclusions were not valid.
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