Exploring the Plastic Surgery Related Experiences, Needs, Confidence and Knowledge Gaps of Foundation Year Doctors

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear colleague, hello!

 

I have read your manuscript with great attention and would like to express my gratitude for the scientific satisfaction I have experienced from the work.

The study is well planned, the results are supported by reliable processing methods, but some points raise questions that I think you can remove

 

1. I would like to see a broader description of the limitations and exclusion criteria

2. The list of references should be expanded and updated with newer works, since it is the list of references that allows you to make "Relevance" modern. In your case, there are articles that are more than 10 years old, which raises concerns about the modernity of effective reasoning

Author Response

Thank you for the kind comments. Below please find the amendments done as requested:

Comments 1:

I would like to see a broader description of the limitations and exclusion criteria

Response 1: The inclusion and exclusion criteria has been clarified in Section 2: Participants and procedure. The following text was added:

The inclusion criteria included:

• FY2 trainee doctors currently enrolled in the Malta Foundation Training Programme (MFTP). 

The exclusion criteria consisted of:

• Doctors with significant previous exposure to plastic surgery that is not normally available at an FY level e.g locum/paid jobs/internships in plastic surgery (excludes student electives or exchanges). 
• Staff grade doctors employed at the FY doctor grade but not enrolled in the MFTP. 

 

Concerning limitations, this has also been improved and clarified, with the following text added in the 'Limitations and Potential Bias and Further Research Section':

4.2 Limitations and potential bias

Selection bias was present as recruitment was limited to those who volunteered and were available to participate. Volunteers who responded to the class representative's email may have had a particular interest in or strong opinions about the subject matter. This could skew the findings towards those with more extreme or passionate views about the need for plastic surgery education in the FY curriculum.

This study focused on experiences and perceptions from the point of view of an FY, and may not represent or be representative of the sentiment of more senior doctors.

The sample size of eight participants may limit the generalisability of the findings to the wider FY doctor population. While within this sample saturation of meaning, in line with phenomenology principles, was achieved, the experiences and insights gathered may not fully represent the views of all FY doctors, particularly those with different cultural or educational backgrounds, or those practicing in diverse healthcare settings. Therefore, the qualitative nature of the study, while providing rich, in-depth data, may limit the ability to draw definitive conclusions about the broader educational needs of all FY doctors.

 

4.3 Further research

Future studies with a larger and more diverse participant pool could further enhance the applicability of the findings of this study. Quantitative studies measuring actual knowledge, skills, and outcomes could complement these findings and provide a more comprehensive picture of the educational requirements for plastic surgery competencies in early medical practice. 

Future research could potentially explore insights from more senior doctors and plastic surgery educators to gain a more comprehensive understanding of the educational system.

Future research may further explore the effect on plastic surgery patient care as a result of FY preparedness and competence. Studies focused on optimising educational strategies e.g. innovative teaching methods, and curriculum integration to address FYs specific needs in plastic surgery are recommended.

Comment 2:. The list of references should be expanded and updated with newer works, since it is the list of references that allows you to make "Relevance" modern. In your case, there are articles that are more than 10 years old, which raises concerns about the modernity of effective reasoning

Response 2:

Thank you for your feedback regarding the list of references and the need to ensure the modernity of the study. I understand the concern about including older references, and I would like to clarify my reasoning for including some of them.

While a few of the references cited are over 10 years old, they were selected because they remain foundational and unique within the field. For instance, foundational methodological works such as Braun & Clarke’s (2006) paper on thematic analysis continue to be widely recognised and applied in qualitative research, whilst the 1984 work by Kolb concerning ‘Kolb’s Learning Theory’ is a cornerstone of educational theory, which is still relevant and referenced in modern papers. Their work remains a key reference for medical education studies and studies employing thematic analysis, and their inclusion is important to support the methodology used in my research.

Moreover, older works such as that of Wade and Clarke (2013) and Gorman et al. (2012) are highly relevant as they are unique in the insights that they contribute, and are still applicable today. These studies address critical areas in medical education that have not been extensively explored in more recent literature. Given the under-researched nature of the topic—particularly regarding the training experiences of FY doctors—these references provide essential background and context that support the need for further investigation.

Finally, given the limited research available on this topic, the publication of this study is especially important to contribute further to the ongoing discussion and address the gaps in the literature. I believe this research adds valuable insights and helps build a stronger foundation for future work in this under-explored area.

I agree, however, that incorporating more recent literature can enhance the contemporary relevance of the study, and therefore the following have been added:

• Nurunnabi, A.S.M.; Rahim, R.; Alo, D.; Mamun, A.; Kaiser, A.; Mohammad, T.; Sultana, F. Experiential learning in clinical education guided by Kolb’s experiential learning theory. Int. J. Hum. Health Sci. 2022, 6, 155-160. doi: 10.31344/ijhhs.v6i2.438.
• Monrouxe, L.V.; Bullock, A.; Gormley, G.; Kaufhold, K.; Kelly, N.; Roberts, C.E.; Mattick, K.; Rees, C. New graduate doctors' preparedness for practice: a multistakeholder, multicentre narrative study. BMJ Open 2018, 8, e023146. doi: 10.1136/bmjopen-2018-023146.
• Burridge, S.; Foster, K.; Jones, M. A qualitative analysis of junior doctors’ journeys to preparedness in acute care. BMC Med. Educ. 2020, 20, 1-12. doi:10.1186/s12909-020-1929-8.
• Weurlander, M.; Lönn, A.; Seeberger, A.; Hult, H.; Thornberg, R.; Wernerson, A. Emotional challenges of medical students generate feelings of uncertainty. Med. Educ. 2019, 53, 1037-1048. https://doi.org/10.1111/medu.13934.
• Burgess, A.; van Diggele, C.; Roberts, C.; Mellis, C. Facilitating small group learning in the health professions. BMC Med. Educ. 2020, 20 (Suppl 2), 457. https://doi.org/10.1186/s12909-020-02282-3.

 

Thank you again for your constructive input.

Reviewer 2 Report

Comments and Suggestions for Authors

1. The study explores the experiences, confidence, knowledge gaps, and needs of foundation year (FY) doctors related to plastic surgery. It aims to identify how these gaps impact patient care and the well-being of FY doctors.

2. The topic is both original and relevant. It addresses a specific gap in the field of medical education regarding the limited plastic surgery training provided to junior doctors. The study fills a need for more research on the firsthand experiences of FY doctors managing plastic surgery cases, an area often overlooked in medical curricula.

3. This research provides qualitative insights into the challenges FY doctors face in plastic surgery-related tasks. Unlike other studies that focus on the lack of formal education, this work delves into the personal experiences, emotional impact, and coping mechanisms of junior doctors, emphasizing the importance of incorporating plastic surgery training into the curriculum.

4. The study uses semi-structured interviews and reflexive thematic analysis, which is appropriate for qualitative research. However, expanding the sample size and including FY doctors from diverse geographical locations could increase the study’s generalizability. Additionally, including feedback from senior doctors or plastic surgery educators might offer a more comprehensive understanding of the educational gap.

5. The conclusions are consistent with the evidence presented. They align with the main question by highlighting the importance of improving plastic surgery education for FY doctors to enhance patient care and doctor wellbeing.

6. The references are relevant and comprehensive, covering a range of sources that discuss the current state of plastic surgery education and the roles of FY doctors.

7. The tables and figures effectively illustrate the study’s findings. Table 1 provides clear demographic information about participants, while the thematic diagrams help visualize the main themes and subthemes identified in the research.

Overall, the paper is well-structured, and the findings provide valuable insights into the need for enhanced plastic surgery training in medical education.

Author Response

 Thank you very much for your kind and encouraging comments. I am very pleased to hear your appreciation for my work.

Regarding the following comments for suggested improvement:

Comment 1: However, expanding the sample size and including FY doctors from diverse geographical locations could increase the study’s generalizability..

Response 1: While I appreciate the suggestion to expand the sample size and include FY doctors from diverse geographical locations, it is important to note that the objective of this study was to explore the specific, lived experiences of FY doctors within a particular healthcare system, using a phenomenological approach. Qualitative research, in this case, phenomenology, focuses on in-depth understanding rather than broad generalisability. Furthermore, phenomenology applies the principle of ‘saturation of meaning’,  allowing the researcher to stop conducting further interviews once no new information is obtained from the participants. In this case, no new information was elicted after 8 interviews and therefore, by applying the principle of saturation of meaning, it is unlikely that further interviews would have revealed new information.

This was clarified in the ‘Participants and procedure section' with the addition of the following text:

‘Eight interviews were conducted until saturation of meaning was achieved, in line with qualitative research and phenomenology principles. This indicated that further interviews are unlikely to yield additional information, indicating the adequacy of the sample size for the study's goals.’ 

The decision to limit the study to one geographical location allowed for a more detailed and contextualized exploration of the experiences within that specific environment. Adding participants from other regions could have diluted the depth of analysis by introducing additional variables that were outside the intended scope of this study.

Comment 2: Additionally, including feedback from senior doctors or plastic surgery educators might offer a more comprehensive understanding of the educational gap

Response 2: The suggestion to include feedback from senior doctors or plastic surgery educators could indeed provide a broader view. However, the primary aim of this research was to capture the first-hand experiences of FY doctors, who are at the forefront of the educational and healthcare system. Including senior doctors or educators would have shifted the focus from the lived experiences of these junior doctors to more generalised perceptions of the educational and healthcare system. However, I appreciate this feedback and have added it to the potential future research as described in the ‘Future Research’ sections by adding the following text:

‘Future research could potentially explore insights from more senior doctors and plastic surgery educators to gain a more comprehensive understanding of the educational system.’

Ultimately, this study contributes a focused and detailed understanding of FY doctors’ experiences, which can provide a foundation for future studies. Expanding the participant pool or including other stakeholder perspectives could indeed be a direction for subsequent research, potentially building on the insights gained from this initial, in-depth exploration.

 

Thank you once again for your time and kind comments

Reviewer 3 Report

Comments and Suggestions for Authors

The authors address a very important topic. While it is widely accepted that basic knowledge of the speciality is of relevance to non-plastic surgery doctors, the field of plastic surgery is underrepresented in the curriculum of aspiring physicians. The authors state that poor understanding of the scope of plastic surgery among non-plastic doctors can result in a delay

in proper patient management and also impact patient safety.

The study reveals how plastic surgery features the work life of young doctors and participants expressed a need for enhanced training and modification of the existing curriculum.

 

Remarks:

As much as I agree with the authors concerning the need for enhanced training in the field of plastic surgery, a study population of n=8 is hardly enough to endorse significant changes to a national curriculum.

I recommend rolling out this study to more FY doctors over the next months.

 

 

 

 

Author Response

Thank you very much for your positive comments, I am very pleased to read your appreciation for my work.

Regarding the following comments for suggested improvement:

Comment 1: As much as I agree with the authors concerning the need for enhanced training in the field of plastic surgery, a study population of n=8 is hardly enough to endorse significant changes to a national curriculum. I recommend rolling out this study to more FY doctors over the next months.

I fully recognize that the current sample size of eight participants may not be sufficient to endorse national curriculum changes directly. The intent of this study was exploratory, aiming to uncover rich, in-depth insights into the experiences of FY doctors as a starting point for further research and reflection. The objective of this study was to explore the specific, lived experiences of FY doctors within a particular healthcare system, using a phenomenological approach. Qualitative research, in this case, phenomenology, focuses on in-depth understanding and therefore this study sought to achieve saturation of meaning rather than broad, statistical generalisability.

Furthermore, phenomenology applies the principle of ‘saturation of meaning’,  allowing the researcher to stop conducting further interviews once no new information, themes or insights are obtained from the participants. This is a key marker in qualitative research that signifies the adequacy of the sample size for the study's goals. In this case, no new information was elicited after 8 interviews and therefore, by applying the principle of saturation of meaning, it is unlikely that further interviews would have revealed new information in this particular context. 

This was clarified in the ‘Participants and procedure section' with the addition of the following text:

‘Eight interviews were conducted until saturation of meaning was achieved, in line with qualitative research and phenomenology principles. This indicated that further interviews are unlikely to yield additional information, indicating the adequacy of the sample size for the study's goals.’ 

Ultimately, this study contributes a focused and detailed understanding of FY doctors’ experiences, which can provide a foundation for future studies. Expanding the study to include a larger sample size, as you suggest, would indeed be a valuable next step in broadening the findings and potentially offering a more comprehensive view of the educational gaps, as has now been further discussed in the ‘Limitations and potential bias’ and ‘Future Research’ Section.

Limitations and potenital bias section:

The sample size of eight participants may limit the generalisability of the findings to the wider FY doctor population. While within this sample saturation of meaning, in line with phenomenology principles, was achieved, the experiences and insights gathered may not fully represent the views of all FY doctors, particularly those with different cultural or educational backgrounds, or those practicing in diverse healthcare settings. Therefore, the qualitative nature of the study, while providing rich, in-depth data, may limit the ability to draw definitive conclusions about the broader educational needs of all FY doctors.

Future research section: Future studies with a larger and more diverse participant pool could further enhance the applicability of the findings of this study. Quantitative studies measuring actual knowledge, skills, and outcomes could complement these findings and provide a more comprehensive picture of the educational requirements for plastic surgery competencies in early medical practice. 

For this initial phase, however, the goal was to provide contextual depth and detail rather than breadth, and I believe the study successfully highlights the key FY concerns required for consideration of further discussion in this area of medical education.

Thank you once again for your time and kind comments

Reviewer 4 Report

Comments and Suggestions for Authors

This study does not have wide applicability, given the way doctors are trained in the specialty in various countries.

The batch is far too small to draw conclusions. In addition, the opinions of 8 people, even if they are good, cannot be taken into account to change a system.

Author Response

Thank you for taking the time to read my work and writing your comments.

Comment 1: ‘This study does not have wide applicability, given the way doctors are trained in the specialty in various countries.

Response 1:

I appreciate your concern regarding the wide applicability of the study, given the variations in how doctors are trained in different countries.

This study was intentionally designed as a context-specific exploration of FY doctors’ lived experiences within the particular healthcare system being studied. The goal was not to generate findings that could be universally applied across all medical training systems, but rather to provide a deep, detailed understanding of the specific challenges and experiences faced by FY doctors in their work environment. In qualitative research, and especially in phenomenological studies, the emphasis is on the depth of insight rather than generalisability.

While the structure of medical training varies internationally, many of the themes and insights identified in this study—such as the need for better preparation in specific specialties—can still offer valuable reflections for readers working in similar healthcare settings. The findings contribute to a broader understanding of junior doctor training and may inspire further research in other contexts to explore how these issues manifest in different healthcare systems.

Additionally, the study’s transferability allows readers to consider how the results might resonate with or apply to their own contexts. By providing detailed descriptions of the participants’ experiences and the environment in which they work, I hope that others in similar healthcare systems can find relevant takeaways from the research, even if the exact training structures differ.

In conclusion, while the study may not offer universal applicability, it provides essential insights that can inform discussions about the education and work-life balance of junior doctors in comparable systems.

 

Comment 2:

‘The batch is far too small to draw conclusions. In addition, the opinions of 8 people, even if they are good, cannot be taken into account to change a system’

Response 2: I fully recognise that the current sample size of eight participants may not be sufficient to endorse national system changes directly. The intent of this study was exploratory, aiming to uncover rich, in-depth insights into the experiences of FY doctors as a starting point for further research and reflection. The objective of this study was to explore the specific, lived experiences of FY doctors within a particular healthcare system, using a phenomenological approach. Qualitative research, in this case, phenomenology, focuses on in-depth understanding and therefore this study sought to achieve saturation of meaning rather than broad, statistical generalisability.

Furthermore, phenomenology applies the principle of ‘saturation of meaning’,  allowing the researcher to stop conducting further interviews once no new information, themes or insights are obtained from the participants. This is a key marker in qualitative research that signifies the adequacy of the sample size for the study's goals. In this case, no new information was elicited after 8 interviews and therefore, by applying the principle of saturation of meaning, it is unlikely that further interviews would have revealed new information in this particular context. 

This was clarified in the ‘Participants and procedure section' with the addition of the following text:

‘Eight interviews were conducted until saturation of meaning was achieved, in line with qualitative research and phenomenology principles. This indicated that further interviews are unlikely to yield additional information, indicating the adequacy of the sample size for the study's goals.’ 

Ultimately, this study contributes a focused and detailed understanding of FY doctors’ experiences, which can provide a foundation for future studies. Expanding the study to include a larger sample size, as you suggest, would indeed be a valuable next step in broadening the findings and potentially offering a more comprehensive view of the educational gaps, as has now been further discussed in the ‘Limitations and potential bias’ and ‘Future Research’ Section.

For this study, however, the goal was to provide contextual depth and detail rather than breadth, and I believe the study successfully highlights the key FY concerns required for consideration of further discussion in this area of medical education.

Thank you again for your thoughtful feedback.

 

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Sufficient revision of the article.

Reviewer 4 Report

Comments and Suggestions for Authors

The requirements were not fully met. The subject of the need for more intensive training of young doctors is not new, and as long as the study does not come up with concrete solutions, on a significant sample, I do not think that this study brings improvements to the specialized literature or medical practice.