Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper addresses an important topic—the assessment and management of undifferentiated criticality in medical education.  The detailed breakdown of clinical processes provides a strong framework for understanding the clinical management of undifferentiated patients. This focus on practical, actionable steps is useful for both students and educators. However, clear clarifications and justifications on key issues are required to enhance the quality of the paper. My detailed comments are presented below:

·       The title of the paper should be revised to ensure that it is clear and accurately conveys the focus of the paper. 

·       The purpose and rationale for the paper should be presented at the end of the introduction and NOT as an opening statement.

·       The title of the paper indicates that it focuses on review and recommendation. However, the authors have only focused on the recommendations

·       The Introduction needs more detailed information. The paper moves into clinical tasks immediately, it does not adequately provide a review of existing literature on student learning and current training in critical care. This limits the paper’s ability to critically analyse what has been done and what gaps exist in current educational practice.

·       Furthermore, the authors need to provide practical advice for medical schools on how to integrate these skills into their existing curricula.

·       Finally, while the paper presents clinical processes well, it would benefit from a concluding discussion on future directions for both curriculum design and research. For example, how can we measure the long-term impact of these interventions on clinical outcomes? What are the challenges in implementing these changes?

Author Response

Please see attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The review is a good summary of the process that, not only medical students, but all critical care trainees should follow in their routine assessments.  It would have improved the paper of the authors would have described in the paper aspects of communication skills, active listening, the role of the parent in a child presentation and a structured hand over tool (ISBAR).

Dr Hyde and Brown’s paper offers a novel approach in medical education by focusing on an often-overlooked aspect, how students can learn to assess patient criticality in an undefined situation? Their proposal is of a new strategy based on a structured and algorithmic model that is less commonly seen in published educational research in this field.

The paper aims to equip students with the necessary tools to accurately assess patient criticality and manage care, accordingly, ensuring that they can manage both critical and non-critical patients effectively.

The paper explores this by proposing a structured methodology that complements existing teaching methods, emphasizing the importance of accurately determining and managing patient criticality in real-time clinical setting.

By dividing the process into three main steps—Primary Survey, Secondary Survey, and Plan and Treatment—the methodology provides a clear framework that is accessible to students regardless of their clinical experience. The Primary Survey, which involves forming a general impression of the patient and assessing the ABCDEs (Airway, Breathing, Circulation, Disability, and Exposure), is a particularly strong component. It ensures that students can quickly and accurately determine patient criticality, thereby setting the stage for appropriate subsequent care. This method is not only practical but also aligns well with the existing clinical education, offering an easy adjunct to traditional methods while emphasizing the importance of criticality in patient management.

However, the methodology could benefit from further refinement in certain areas. While the algorithmic approach is commendable for its clarity and accessibility, it may oversimplify complex clinical scenarios where patient presentations do not fit neatly into "Critical" or "Non-Critical" categories.

The binary classification system could lead to challenges in cases that require more nuanced decision-making, particularly for less experienced students. Additionally, the reliance on experiential gestalt in the Primary Survey might pose difficulties for preclinical students who have not yet developed this intuitive skill set.

Undergraduate medical and adult education requires for a combination of flexible structured algorithmic learning that incorporates communication skills and situational awareness.

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors I have reviewed the revised manuscript but I do not think that the authors adequately addressed the issues raised. The changes made were not highlighted. The following issues have not been adequately addressed.

• The purpose and rationale for the paper should be presented at the end of the introduction and NOT as an opening statement.
• The Introduction needs more detailed information. The paper moves into clinical tasks immediately, it does not adequately provide a review of existing literature on student learning and current training in critical care. This limits the paper’s ability to critically analyse what has been done and what gaps exist in current educational practice.

Author Response

Comment 1: The changes made were not highlighted

Response 1: We apologize for this oversight and understand how frustrating it must have been to try to perform the review without them. This is the first submission for both authors to this journal, and it was a procedural point that we overlooked. For the purposes of this review, changes related to Reviewer 1's comments are highlighted in yellow.

Comment 2: The purpose and rationale for the paper should be presented at the end of the introduction and NOT as an opening statement.

Response 2: We appreciate the stylistic direction. We had hoped by moving the "purpose" statement from its location at the beginning of the section (line 39) to its current position (starting at line 69) that structurally the paragraph would flow a little more towards the intentions highlighted by this comment. However, additional background will be added to address Reviewer 1 Comment 3 that should provide a broader background prior to engaging the clinical concepts of the paper. 

Comment 3: The Introduction needs more detailed information. The paper moves into clinical tasks immediately, it does not adequately provide a review of existing literature on student learning and current training in critical care. This limits the paper’s ability to critically analyse what has been done and what gaps exist in current educational practice.

Response 3: We were a little confused by this comment. We feel that we have offered a literature review of current educational methods that are currently in use through citing articles related to critical care instruction methods (Al Ansari et al 2021 and Rogers et al 2000 and 2001), ABCDE instruction (Drost-de Klerck et al 2020 and Thim et al 2012), and current physical diagnostic methods (Bates 13th ed). Summaries of these citations are accompanied by analysis related to gaps in learning relevant to this paper. However, in the context of a formal literature review, these six sources provide a rather anemic offering to the reader, so we added some additional sources and analyses in an attempt to fulfill the spirit of Reviewer 1's Comment 3. These additions also provide the benefit of helping to address Reviewer 1's Comment 2 by adding some distance between the beginning of the introduction and the purpose statement. 

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have adequately addressed all the issues raised.