Enhancing Final-Year Medical Students’ Clinical Examinations Performance via a Transdiagnostic ACT-Based Intervention

Round 1

Reviewer 1 Report

• The authors say that the students were randomly assigned, so why do you still call it a quasi-experimental design?

• When selecting a questionnaire or scale, the readers should be informed of the choice of use, such as the popularity of the questionnaire or scale in the field, reliability indicators, validity evidence from existing studies, etc.

• The results obtained from such a small sample size are hardly generalizable, and the authors need to think about the issue of sample representativeness. To avoid misleading your readers, be careful with the wording of your research conclusions and do not exaggerate the conclusions drawn from an unreliable result. In addition, this limitation needs to be highlighted in the discussion.

• Does such a small sample size satisfy the computational requirements of ANOVA? If not, it should try to use some non-parametric methods.

Author Response

• The authors say that the students were randomly assigned, so why do you still call it a quasi-experimental design?

This has been rectified thank you.

• When selecting a questionnaire or scale, the readers should be informed of the choice of use, such as the popularity of the questionnaire or scale in the field, reliability indicators, validity evidence from existing studies, etc.

We have added validity and reliability indicators both from existing studies and from internal analysis of the in-study data.

• The results obtained from such a small sample size are hardly generalizable, and the authors need to think about the issue of sample representativeness. To avoid misleading your readers, be careful with the wording of your research conclusions and do not exaggerate the conclusions drawn from an unreliable result. In addition, this limitation needs to be highlighted in the discussion.

We have re-highlighted this limitation again, thank you.

• Does such a small sample size satisfy the computational requirements of ANOVA? If not, it should try to use some non-parametric methods.

According to the literature, as long as we have fulfilled the normality criteria using either graphical displays or assessment of distributional properties, ANOVA is acceptable. There are also specific statistical tests of normality (eg, Kolmogorov‐Smirnov, Shapiro‐Wilk) but these would only produce any meaningful results in a larger sample size, hence creating a chicken and egg situation. In this study we have assessed skewness and kurtosis of all study variables and they fall below +/-2, hence there should be no obstacles in utilising ANOVA.

Reviewer 2 Report

The article is well structured. Hence the subject is relatively new, it is a good idea to emphasize the aim after the introduction. The manuscript brings value added to the research. Below some recommendations to the authors:

• The authors should elaborate more on how the consent from the participants was obtained and how their personal data are protected. The study involves participants on a voluntarily basis, therefore data protection and free consent are required. 
• The dicussion section should elaborate a bit on comparing this kind of intervention with other interventions such as Cognitive Based Psychotherapy. 

Author Response

• The authors should elaborate more on how the consent from the participants was obtained and how their personal data are protected. The study involves participants on a voluntarily basis, therefore data protection and free consent are required. 

Data protection information has been included thank you.

• The dicussion section should elaborate a bit on comparing this kind of intervention with other interventions such as Cognitive Based Psychotherapy. 

We have included thess comparisons, thank you.

Reviewer 3 Report

The authors examined the effectiveness of Acceptance and Commitment therapy (ACT) on psychological wellbeing (depression, anxiety, stress) and cognitive variables (flexibility, fusion and, mindfulness) among a small group of medical students in an experimental design. The authors found some differences between the experimental and control groups and concluded the effectiveness of the ACT (reduced psychopathology and enhanced the mindfulness).

I understand this article is a brief report. However, readers need to know more about ACT. From the discussion, it seems that some studies have examined the ACT and psychological wellbeing in a college setting (line 237-241). However, none of these studies were mentioned in the introduction. what are the differences between the previous studies and the current one on the “mindfulness” approach – adding the commitment?

More importantly, what did the authors do for the intervention. “5 sessions during the one-day intervention” were completed. What did the authors (or therapists) do in each session. What is “being present, being open, being committed…”? Please provide details of each session on ACT.

Please add the reliability score for each questionnaire.

“Qualitative feedback obtained” line 224. What are these feedbacks?

Another major concern is the sample size. Although the authors discussed it as a limitation, it is not a legitimate excuse because the authors can recruit participants from other universities online. There was no power analysis, so I wonder if the significant results were due to type I error. 11 participants in each group seems an unreasonably small sample. Also, any gender differences?

Author Response

The authors examined the effectiveness of Acceptance and Commitment therapy (ACT) on psychological wellbeing (depression, anxiety, stress) and cognitive variables (flexibility, fusion and, mindfulness) among a small group of medical students in an experimental design. The authors found some differences between the experimental and control groups and concluded the effectiveness of the ACT (reduced psychopathology and enhanced the mindfulness).

I understand this article is a brief report. However, readers need to know more about ACT. From the discussion, it seems that some studies have examined the ACT and psychological wellbeing in a college setting (line 237-241). However, none of these studies were mentioned in the introduction. what are the differences between the previous studies and the current one on the “mindfulness” approach – adding the commitment?

The difference between mindfulness and ACT-based studies has been addressed in the introduction, thank you.

More importantly, what did the authors do for the intervention. “5 sessions during the one-day intervention” were completed. What did the authors (or therapists) do in each session. What is “being present, being open, being committed…”? Please provide details of each session on ACT.

This has been added in a table

Please add the reliability score for each questionnaire.

This has been added

“Qualitative feedback obtained” line 224. What are these feedbacks?

We have removed this, as it was merely verbal so was not collected in a formal qualitative method.

Another major concern is the sample size. Although the authors discussed it as a limitation, it is not a legitimate excuse because the authors can recruit participants from other universities online. There was no power analysis, so I wonder if the significant results were due to type I error. 11 participants in each group seems an unreasonably small sample. Also, any gender differences?

We were intending for it to be a pilot study, thus we did not include other universities, but will definitely be includdng other universities in a larger scale study, now that we have a reasonable outcome with such a small size. Due to the urgency of running the ACT for performance anxiety intervention, as this batch of students was going for their final exit examinations in two months’ time, we decided to run it as a small pilot in our university setting instead of delaying it till we had a sufficient sample size. We did it as a hybrid intervention – the trainers were online whereby the participants were all face to face. Hence, if we had included other universities, there would have been differences due to the different curriculum, different stressors from other examination systems there, and different levels of disruption in their university education. There were no gender differences.

Round 2

Reviewer 3 Report

The authors have responded to all my comments. 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.