Tutors Matter: The Relationship between Medical Students’ Satisfaction from Their Tutor and Their Overall Satisfaction from Clinical Rotations

Round 1

Reviewer 1 Report

Dear Authors,

Thank you for the opportunity to review this paper, please find my comments below:

1) The relationship between student satisfaction with their clinical rotations and teachers tutoring them during these rotations is quite straightforward and not surprising. It seems quite obvious that the teaching quality (as a concept assessed by students) weighs predominately on the quality of the teaching process as conducted by a teacher and only to lesser extent on other factors like “hospital organization and department facilities, geographical distance from home, working hours” mentioned by you. The topic was also already covered in numerous previous publications, which brings me to my other comment – the literature review conducted before the study seems very limited (only 6 references are cited, mostly very old – the most recent is almost 10 years old!). Maybe following a more detailed literature review the Authors could take steps to enrich their paper – especially the Introduction and Discussion parts.

2) Please provide the copy of the questionnaire/ a list of questions.

3) As the Likert scale was used during the study (ordinal scale), the Pearson correlation and Student t-tests should not be used. In case of the ordinal scale, it is better to use Spearman’s correlation and non-parametric tests (Wilcoxon signed-rank test, Mann–Whitney U test, Kruskal–Wallis test or Friedman test – depending on whether the samples are dependent or not and the number of compared groups).

4) The process in which the Perceived satisfaction with the tutor was evaluated seems very troubling and arbitrary. For example, “if tutors receiving both positive and negative feedbacks then they obtained a “good” score” – for me, a good score should be applied when the positive feedback was more often than negative. When a teacher obtained both positive and negative feedback, shouldn’t it be neutral or average? For this reason, I am inclined to suspect that the scale was skewed towards the ”good” score. Wouldn’t it be easier to simply ask students to assess the quality of the teacher again on a 1-5 Likert scale. It would make the direct comparison with classes evaluation much easier. In its present form I have very limited confidence in this scale, and consequently all comparisons involving it.

5) Correlation of satisfaction of clinical rotation and satisfaction of tutor – apart from the statistical test used issue, I also uphold my opinion from the comment No. 1. Therefore, the use of word “remarkably” seems kind of awkward. In fact, this relationship seems very obvious.

6) The quality of the Discussion is very low. The findings of the study are barely summarized. No comparison with the literature is offered.

7) No limitations section is provided.

Author Response

Dear Reviewer,

Thank you for providing comments. Below is a point-by-point response (in blue).

Thank you,

The authors

 

Reviewer 1

Dear Authors,

Thank you for the opportunity to review this paper, please find my comments below:

1) The relationship between student satisfaction with their clinical rotations and teachers tutoring them during these rotations is quite straightforward and not surprising. It seems quite obvious that the teaching quality (as a concept assessed by students) weighs predominately on the quality of the teaching process as conducted by a teacher and only to lesser extent on other factors like “hospital organization and department facilities, geographical distance from home, working hours” mentioned by you. The topic was also already covered in numerous previous publications, which brings me to my other comment – the literature review conducted before the study seems very limited (only 6 references are cited, mostly very old – the most recent is almost 10 years old!). Maybe following a more detailed literature review the Authors could take steps to enrich their paper – especially the Introduction and Discussion parts.

--> We thank the reviewer for this comment, and have added references from the past three years in the introduction:

To assess teaching skills at our Faculty, students are constantly surveyed using satisfaction questionnaires (Barash, Alon, et al. "Summing up 10 years in a new medical school: Per aspera ad astra." The FASEB Journal 36 (2022)).   Based on such student surveys, several studies have characterized important markers for successful teaching, mentoring, and tutoring.  One study shows that the optimal duration of clinical rotations is around 7 weeks, based on students’ satisfaction (González‐García, Alberto, et al. "The relationship between clinical placement duration and students' satisfaction with the quality of supervision and learning environment: A mediation analysis." Nursing & Health Sciences 23.3 (2021): 688-697.). Another study shows that student satisfaction is associated mostly with the clinical learning environment, but less with the ward premises, the ward manager, and the pedagogical atmosphere,  (Adam, Alhassan Basour, et al. "Nursing and midwifery students’ satisfaction with their clinical rotation experience: the role of the clinical learning environment." Nursing Research and Practice 2021 (2021)).  In contrast, another study shows that student satisfaction is correlated equally with the clinical learning environment, the ward premises, the ward manager, the pedagogical atmosphere, and last but not least the relationship with the supervising tutor (i.e. mentor) (Alatawi, Abeer, et al. "Nursing Students’ Satisfaction of the Clinical Learning Environment in Saudi Arabia." International Journal of Nursing Didactics 10.06 (2020): 09-17. ). The students satisfaction with the tutor-student relationship has been shown to contribute most to instruction rating (Neufeld, Adam, and Greg Malin. "How medical students’ perceptions of instructor autonomy-support mediate their motivation and psychological well-being." Medical teacher 42.6 (2020): 650-656.). Likewise, the majority of students reported that the rotation was a useful educational experience and that the tutoring coach was one of the most valuable aspects of clinical rotation ( Sigler R, Roberts E, Welford E, Keehner J, Wooten D. Evaluation of an Infectious Diseases Elective for Early Clinical Medical Students on Their Internal Medicine Clerkship. Open Forum Infect Dis. 2022 Mar 9;9(5):ofac120.)

2) Please provide the copy of the questionnaire/ a list of questions.

-->We thank the reviewer for this comment and have added a copy of the questionnaire in the supplementary section. This is also reflected in the text of the materials section: “A copy of the questionnaire is shown in the supplementary materials (Table S1).”

3) As the Likert scale was used during the study (ordinal scale), the Pearson correlation and Student t-tests should not be used. In case of the ordinal scale, it is better to use Spearman’s correlation and non-parametric tests (Wilcoxon signed-rank test, Mann–Whitney U test, Kruskal–Wallis test or Friedman test – depending on whether the samples are dependent or not and the number of compared groups).

-->We apologize for the typographical mistake, and indeed we did not use the Pearson correlation and Student t-test. Rather we used the Spearman correlation coefficient.   This is now reflected in the material section as follows: “In this study, we attempted to correlate the perceived satisfaction of clinical rotations and of tutors using the Spearman coefficient factor, and the Kruskal–Wallis test was used for comparisons in more than two groups. Descriptive statistics were used to display the distribution of perceived tutor characteristics, and perceived rotation satisfaction from the questionnaires. Student t-tests were used to compare questionnaire scores between the different clinical rotations and tutors. All p values were two-sided, and only p values less than 0.05 were considered statistically significant.”

4) The process in which the Perceived satisfaction with the tutor was evaluated seems very troubling and arbitrary. For example, “if tutors receiving both positive and negative feedbacks then they obtained a “good” score” – for me, a good score should be applied when the positive feedback was more often than negative. When a teacher obtained both positive and negative feedback, shouldn’t it be neutral or average? For this reason, I am inclined to suspect that the scale was skewed towards the ”good” score. Wouldn’t it be easier to simply ask students to assess the quality of the teacher again on a 1-5 Likert scale. It would make the direct comparison with classes evaluation much easier. In its present form I have very limited confidence in this scale, and consequently all comparisons involving it.

--> We thank the reviewer for this comment, and in compliance with it, we have renamed the scores to: “Good feedback only”, “Neutral feedback”, and “Bad feedback only”.  This is now reflected in the text, table 1, and figures 2 and 3. 

In the questionnaire, the tutor was not rated on a Likert scale, and the written comments were used to calculate a score. This is now reflected in the result section as follows: “The reported performance for the 40 tutors of the 102 clinical rotations was evaluated based on the written assessments of the questionnaires, and were translated into a numerical scale, as tutors were not rated using Likert scale ”. As the questionnaire was performed many years ago, we do not have access to the students anymore. One of the outcomes of this study is that, all tutors have been rated using a Likert scale in subsequent student satisfaction questionnaires.

5) Correlation of satisfaction of clinical rotation and satisfaction of tutor – apart from the statistical test used issue, I also uphold my opinion from the comment No. 1. Therefore, the use of word “remarkably” seems kind of awkward. In fact, this relationship seems very obvious. 

--> We thank the reviewer for this comment, and have omitted the word remarkably.  The sentence now read: “A positive, high, and significant correlation was found between the tutor score and the perceived satisfaction of clinical rounds (rs = 0.78 , p < 0.01).”

6) The quality of the Discussion is very low. The findings of the study are barely summarized. No comparison with the literature is offered.

--> We thank the reviewer for this comment, and have revised the discussion with a summary of the findings, as following: “In this study, we find that the student satisfaction of clinical rotations is positively and significantly correlated with the student satisfaction of the tutor. We do not find any correlation with hospital organization, department facilities, department heads, distance from home, working hours, student gender and age.  One of the outcomes of this study is that, all tutors have been rated using a Likert scale in subsequent student satisfaction questionnaires. Our findings are in agreement with earlier findings showing that tutors matter most in the satisfaction of clinical rotations  (Neufeld, Adam, and Greg Malin. "How medical students’ perceptions of instructor autonomy-support mediate their motivation and psychological well-being." Medical teacher 42.6 (2020): 650-656.)( Sigler R, Roberts E, Welford E, Keehner J, Wooten D. Evaluation of an Infectious Diseases Elective for Early Clinical Medical Students on Their Internal Medicine Clerkship. Open Forum Infect Dis. 2022 Mar 9;9(5):ofac120.).  Our findings are in partial agreement with earlier reports showing that other confounders matter less, such as the department premises (rs = 0.51), the department director (rs = 0.34), and the pedagogical atmosphere (rs = 0.38) (Alatawi, Abeer, et al. "Nursing Students’ Satisfaction of the Clinical Learning Environment in Saudi Arabia." International Journal of Nursing Didactics 10.06 (2020): 09-17. ).), but contrast another report showing that the aforementioned factors matter equally (Adam, Alhassan Basour, et al. "Nursing and midwifery students’ satisfaction with their clinical rotation experience: the role of the clinical learning environment." Nursing Research and Practice 2021 (2021).  In all cases however the tutor matters. As a result, tutors are now rated using a Likert scale in all student satisfaction questionnaires of clinical rounds.”

 

7) No limitations section is provided.

-->We thank the reviewer for this comment, and have added a limitation section, as follows:” As a potential limitation of this study, we did not take into account confounding factors such as tutor acclamation, based on the number of papers published, tutor years of experience, tutor age, and gender.  These factors could all be important contributors to the success of clinical rotation, however, they are out of scope. Another potential limitation is that only 40% of students responded to the questionnaires, and that their opinions do not reflect the majority view.  Finally, one of the potential limitations to this study is that verbal assessment is not easily translated into numbers, and that  only about 75% of the students provided verbal comments.”

 

Author Response File: Author Response.docx

Reviewer 2 Report

The article deals with an interesting topic with implications in the more general area of the Faculty Development. The research design is clear and the object of investigation and the conclusions are consistent with the literature in the field. 

 

However, the arguments are conducted in a very concise manner and the contents could be deepened, also with regard to the theoretical premises and the methodological part.

Two considerations:

1. In the light of what is indicated in the conclusions, it is advisable to make explicit which idea of "good tutors" (what is meant by “good tutors”) can possibly refer to which profile and which are characterising competences

From a methodological perspective: even if the essential variable demonstrated by the research is the role of tutor-teacher, and consistent with the evidence-based pedagogical literature, it is not clear how the authors intend to explain and/or possibly further investigate the role of the other potential variables (factors) that are recognised in the Discussion as "important contributors to the success of clinical rotation". 

 

 

Author Response

Dear Reviewer,

Thank you for providing comments. Below is a point-by-point response.

Thank you,

The authors

 

Reviewer 2

The article deals with an interesting topic with implications in the more general area of the Faculty Development. The research design is clear and the object of investigation and the conclusions are consistent with the literature in the field. 

However, the arguments are conducted in a very concise manner and the contents could be deepened, also with regard to the theoretical premises and the methodological part.

Two considerations:

1. In the light of what is indicated in the conclusions, it is advisable to make explicit which idea of "good tutors" (what is meant by “good tutors”) can possibly refer to which profile and which are characterising competences.

--> We thank the reviewer for this comment, and have added a new sentence summarizing and classifying  the good feedback of tutors: “Good feedback included praiseworthy clinical knowledge (e.g. informed, familiar, proficient), and skills (qualified, accustomed, capable), as well as academic rhetorics (teacher, speaker, lecturer, explainer, orderly, explain in details, charismatic, motivational), personal attachment (caring, giving, engaging, available, pleasant, present, patient, professional, etc).”

From a methodological perspective: even if the essential variable demonstrated by the research is the role of tutor-teacher, and consistent with the evidence-based pedagogical literature, it is not clear how the authors intend to explain and/or possibly further investigate the role of the other potential variables (factors) that are recognised in the Discussion as "important contributors to the success of clinical rotation". 

--> We thank the reviewer for this comment, and as such we have deleted that sentence, Instead, the sentence now reads: “In this study, we find that the perceived student satisfaction of clinical rotations is positively and significantly correlated with the student satisfaction of the tutor. We do not find any correlation with hospital organization, department facilities, department heads, distance from home, working hours, student gender and age”.

Author Response File: Author Response.docx

Reviewer 3 Report

The topic of this paper is of interest (importance of the tutor in student satisfaction), but it seems to me that the presentation does not capture all the dimensions of the context. The authors probably collected many more data in the time period of interest but their report seems only a very succinct summary. At least these aspects must be addressed:
- how many students were invited and what was the response rate?

- when reporting their work, the authors should at least attempt to organize their presentation addressing the consolidated criteria to report qualitative research (COREQ: https://www.equator-network.org/reporting-guidelines/coreq/)

- previous training and experience of tutors should also be considered
- since several years were covered, was any time trend captured?

- the discussion should at least address in which ways a faculty development program can be started on the basis of these findings

- the authors infer that factors other than tutor’s ability had minor influence on student satisfaction, but this statement is not supported by data presented in this manuscript. Can the authors provide specific support using the already collected data?

- English style can be improved.

Author Response

Dear Reviewer,

Thank you for providing comments. Below is a point-by-point response.

Thank you,

The authors

 

Reviewer 3

The topic of this paper is of interest (importance of the tutor in student satisfaction), but it seems to me that the presentation does not capture all the dimensions of the context. The authors probably collected many more data in the time period of interest but their report seems only a very succinct summary. At least these aspects must be addressed:

- how many students were invited and what was the response rate?

--> We thank the reviewer for this comment, and have added the following sentence describing the number of students in the results section: “The number of students that responded to the questionnaires were 282 in 2014, 219 in 2015, and 209 in 2016.”

In addition, the following sentence was added in the discussion as a potential limitation: “Another potential limitation is that only ~40% of students responded to the questionnaires, and that their opinions could not reflect the majority view.  ”       

 

- when reporting their work, the authors should at least attempt to organize their presentation addressing the consolidated criteria to report qualitative research (COREQ: https://www.equator-network.org/reporting-guidelines/coreq/)

--> We thank the reviewer for this comment, and have attempted to organize the presentation of data addressing the consolidated criteria to report qualitative research. In addition, the text has undergone English editing.

- previous training and experience of tutors should also be considered

--> We thank the reviewer for this comment, but we do not have information about all tutor previous training. However, based on a partial estimate, the age, experience, and gender of the tutor does not affect satisfaction.  This is now reflected in the discussion, as following: “Nevertheless, based on partial data, we estimate that tutor experience, tutor age, and tutor gender do not affect student satisfaction.”

- since several years were covered, was any time trend captured?

--> We thank the reviewer for this comment, and did not capture a time trend.  This now reflected in the result section as follows: “The histogram distribution is almost identical for each year of the three year period, and no time trend was captured”

 

- the discussion should at least address in which ways a faculty development program can be started on the basis of these findings

--> We thank the reviewer for this comment, and have added the following Faculty development, in the discussion: “In all cases however the tutor matters. As a result, tutors are now rated using a Likert scale in all student satisfaction questionnaires of clinical rounds.”

 

- the authors infer that factors other than tutor’s ability had minor influence on student satisfaction, but this statement is not supported by data presented in this manuscript. Can the authors provide specific support using the already collected data?

--> We thank the reviewer for this comment, and have added the following statement in the result section: “The perceived satisfaction of a rotation was not correlated with perceived satisfaction of the other clinical teachers, department heads, hospital organization, department facilities, geographical distance from home, working hours, student gender, and student age (p>0.01, data not shown).”

In addition, the following sentence was added in the discussion: “As a potential limitation of this study, we do not take into account confounding factors such as the hospital prestige and tutor acclamation, based on the number of papers published, tutor salary, and tutor native tongue.  These factors could all be important contributors to the success of clinical rotation however, they are out of scope. Nevertheless, based on partial data, we estimate that tutor experience, tutor age, and tutor gender has little or no effect on student satisfaction (p>0.01, data not shown).”

- English style can be improved.

--> We thank the reviewer for this comment, and the text was reviewed by an English editor.

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Following my previous comments, for the paper to be publishable, it still requires some work. 

I have noticed some new literature positions added. However, given the abundance of papers on the topic, I still do not think that the paper' literature review is sufficient for an original article. Both Introduction and Discussion are extremely short and underdeveloped. 

What exactly was calculated using Kruskal-Wallis test? Because I only see mentions of correlation results in the Results section.

Please provide better examples in the Table 1. Some of the "neutral examples" do not seem neutral rather negative - e.g. “In my opinion, the tutor could also have been present during physical examinations.” Issues like this, still limit my confidence in findings in this regard. A clear procedure should be provided how this was assessed to leave no place for doubts for the reader. How many researchers assesed this. What was their inter-coder reliability/agreement between them? How disputes were decided? What was the main deciding factor in case of doubts if the feedback was positive vs. neutral, or neutral vs. negative?

Reviewer 3 Report

None