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. 2023 Jun 23;18(6):e0287388. doi: 10.1371/journal.pone.0287388

A compassion-based program to reduce psychological distress in medical students: A pilot randomized clinical trial

Blanca Rojas 1, Elena Catalan 1,2, Gustavo Diez 3, Pablo Roca 4,5,*
Editor: Samuel Yeung-shan Wong6
PMCID: PMC10289411  PMID: 37352295

Abstract

Objectives

Physicians and medical students are subject to higher levels of psychological distress than the general population. These challenges have a negative impact in medical practice, leading to uncompassionate care. This pilot study aims to examine the feasibility of Compassion Cultivation Training (CCT) to reduce psychological distress and improve the well-being of medical students. We hypothesize that the CCT program, as compared to a waitlist control group, will reduce psychological distress (i.e., stress, anxiety, and depression) and burnout symptoms, while improving compassion, empathy, mindfulness, resilience, psychological well-being, and emotion-regulation strategies after the intervention. Furthermore, we hypothesize that these improvements will be maintained at a two-month follow-up.

Methods

Medical students were randomly assigned to an 8-week CCT or a Waitlist control group (WL). They completed self-report assessments at pre-intervention, post-intervention, and a 2-month follow-up. The outcomes measured were compassion, empathy, mindfulness, well-being, resilience, emotional regulation, psychological distress, burnout, and COVID-19 concern. Mixed-effects models and Reliable Change Index were computed.

Results

Compared with WL, CCT showed significant improvements in self-compassion, mindfulness, and emotion regulation, as well as a significant decrease in stress, anxiety, and emotional exhaustion component of burnout. Furthermore, some of these effects persisted at follow-up. No adverse effects of meditation practices were found.

Conclusions

CCT enhanced compassion skills while reducing psychological distress in medical students, this being critical to preserving the mental health of physicians while promoting compassionate care for patients. The need for institutions to include this type of training is also discussed.

Introduction

The practice of medicine and the training to become a physician are associated with high levels of stress (e.g. patient death, treatment failures, difficult interactions with patients and families, and excessive cognitive demands) [1, 2]. Constant stress experienced by physicians can lead to psychological distress, attrition, and burnout syndrome [3, 4]. A striking concern is that the aforementioned problems may start in medical schools. Medical students are often overloaded with academic activities and burdened with constant stress and a sense of competition [5]. Furthermore, they are exposed, unlike other college students, to the particular stress associated with caring for others. As a result, medical students often experience high levels of psychological distress [6] and higher rates of depression, burnout, and even suicide, than in the general population [7].

Psychological distress harms not only individuals’ well-being but also impedes their professional performance. Anxiety and burnout can increase medical errors [8], decrease empathy and thus foment dehumanization [9], diminish compassionate care [10], and lead to suboptimal patient outcomes [11]. Similarly, during their training, medical students become more frustrated and emotional distanced from patients, undergoing rising levels of cynicism, and becoming less empathic and compassionate [12], which in turn may degrade caretaking and optimal medicine practice [13, 14].

In view of the harmful effects of medical training and practice on both the practitioner’s mental health as well as professional performance, the implementation of strategies and interventions to ameliorate the situation is vital. An alternative would be the practice of compassion. Several medical associations include compassion in their codes of ethics [15, 16], underscoring the importance of compassion [17] and compassionate patient care [18], and thus recognizing compassion as a pillar of medicine.

A growing body of evidence associates compassionate care with beneficial outcomes not only for patients [19] and doctor-patient relationships [20], but also for health-care providers and administrative institutions [21]. In fact, patients, families, clinicians, and policy makers consider compassion to have a greater healing effect than expertise alone [22], viewing compassion as the foundation of quality healthcare [22, 23]. However, compassion is a crosscutting competency in the medical curriculum, and it is usually not specifically addressed in any subjects or training.

Fortunately, evidence from the so-called Compassion-Based Interventions (CBIs) suggests that CBIs improve mindfulness, self-compassion and well-being, while reducing anxiety and depression symptoms [24, 25]. Also, in contrast with Mindfulness-Based Interventions (MBIs), CBIs have shown larger socio-emotional changes (i.e. common humanity and empathic concern) [26, 27], core skills in compassionate clinical practice. Furthermore, a recent literature review has shown that CBIs can increase physician empathy and compassion, medical students constituting the population with highest success rates [19].

Among the CBIs, the Compassion Cultivation Training (CCT) [28] is one of the programs that has shown promising results in recent years [26, 27, 29–31]: increases in compassion (both for self and others), empathy and mindfulness skills, reductions of psychological distress (stress, anxiety and depression) and burnout, improvements in well-being and emotion regulation, among others. Furthermore, the CCT program has also shown promising results in medical-school students, helping students to address major stress associated with academic and clinical responsibilities [32].

Most CCT studies have focused on the general population, with few examples in health-care workers [31, 33]. Only one study available has examined the application of CCT on medical students [32], conducting a qualitative analysis of self-reported experiences after the program without a comparison group or longitudinal measures. The present study aims to examine the effects of CCT on psychological outcomes in a sample of medical students. We hypothesize that the CCT program, as compared to a waitlist control group, will reduce psychological distress (i.e., stress, anxiety, and depression) and burnout symptoms, while improving compassion, empathy, mindfulness, resilience, psychological well-being, and emotion-regulation strategies after the intervention. Furthermore, we hypothesize that these improvements will be maintained at a two-month follow-up.

Materials and methods

Study design

The present study is a pilot two-arm randomized controlled trial, in compliance with CONSORT statements for pilot trials [34] (see S1 Table in S1 File for more details). Participants were randomly assigned in a 1:1 ratio to the Compassion Cultivation Training or the Waitlist control group. Randomization was performed using a Random Number Generation Function and was blind to the data scientist. Furthermore, randomization was performed after the baseline assessment to preserve adequate allocation concealment. Participants assigned to CCT were assessed before the intervention, at the end of the intervention, and in a 2-month follow-up. Participants assigned to WL were assessed at the same time points: pre-waitlist assessment, post-waitlist assessment, and follow-up-waitlist assessment. Participants in the WL received the CCT program following the follow-up-waitlist assessment.

Participation in the study was voluntary and participants gave their written informed consent prior to their inclusion in the study (all were of legal age). Recruitment was carried out between December 2020 and September 2021. The study protocol was approved by the hospital ethics committee prior to participant recruitment (Ref. 20/742-EC_X) and was conducted in compliance with the Declaration of Helsinki, and good clinical practice. Furthermore, the trial was pre-registered at ClinicalTrial.org (ID: NCT04690452).

Participants

A total of 44 medical students (first to sixth year university students) were randomly assigned to an 8-week CCT program or WL. We used the G *Power (v. 3.1) to estimate sample size a priori to test mixed models (i.e., Group as within-subjects factor and Time as between-subjects factor). With a medium effect size of 0.40 [26, 30], and an alpha of .05, we would need at least 44 participants to detect significant effects at 95% power. We estimated a sample loss of less than 5%, and the final attrition rate was 5.5% in CCT and none for the WL.

Fig 1 illustrates the participation flow diagram. Four participants assigned to CCT withdrew before starting the intervention due to incompatibilities in their academic calendar. Finally, we analyzed the data of 40 participants: 18 participants in CCT group, and 22 in WL group. The participants, of which 60% were single and 92.5% were women, had a mean age of 23.4 (SD = 5.59). The CCT and WL groups did not differ at baseline in age (t(38) = -.27, p = .79), gender (χ2(1) = .18, p = .67), nationality (χ2(1) = .18, p = .67), marital status (χ2(1) = 1.36, p = .24), prior meditation experience (χ2(1) = .04, p = .84), or weekly formal meditation (t (12) = 1.17, p = .27).

Fig 1. Study CONSORT diagram.

Fig 1

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Note. CCT: Compassion Cultivation Training; WL: Waitlist.

Eligibility criteria were: 1) being ≥ 18 years of age; 2) being enrolled as a medical student during the academic year 2020–2021; 3) having language fluency to understand the program and the evaluation; 4) providing written informed consent; 5) having internet access to attend the CCT sessions and online assessments; and 6) making a commitment to program attendance. Participants were excluded if they: 1) were diagnosed with a severe mental disorder in the active phase (e.g., schizophrenia, bipolar disorder); 2) were under the influence of alcohol and other substances during the weekly sessions (determined by the CCT instructor); 3) withdrew before starting the intervention; or 4) participated in any other meditation program during the study period.

Procedure

Participants were invited to join the study at the beginning of the academic year (September 2020) on the university’s official website. Eligible individuals received information about the study and gave their written informed consent prior to their inclusion. Then, all participants completed online assessments during the week before starting the program (i.e., pre-intervention assessment), during the week after the completion of the program (i.e., post-intervention assessment), and in the two-month follow-up (i.e., follow-up assessment). Afterwards, participants were randomized to either CCT or WL. The CCT was administered online (in a group format) due to the social-distancing measures during the COVID-19 pandemic. Participants received course credits and a book as a reward for their participation in the study.

Intervention description

CCT is an 8-week standardized, secular, meditation program aimed at cultivating compassion and empathy toward oneself and others, which in turn reduces psychological distress and promotes well-being. CCT was developed by Geshe Thupten Jimpa in collaboration with a group of clinical psychologists and scientists supported by the Centre for Compassion and Altruism Research and Education at Stanford University [28]. The CCT aimed at cultivating compassion and empathy toward oneself and others, including insights and techniques from psychology, neuroscience, and contemplative practice. The program was conducted in a group format and consists of weekly 2-hour online sessions. The sessions combined pedagogical instruction with active group discussions, together with in-class practical exercises, and guided group meditations. In addition, participants engaged in 30 minutes of daily home practice (i.e., formal practice), as well as real-world assignments for practicing compassionate thoughts and actions (i.e., informal practice). At the end of each session, participants received a set of pre-recorded audio files and a workbook to help with their daily practices. One of the authors (BR), a medical doctor certified as instructor by the Compassion Institute, taught the program. The CCT program comprises six sequential steps (see Table 1): 1) learning to focus and settle the mind; 2) experiencing compassion and loving-kindness for a loved one; 3) experiencing compassion and loving-kindness for oneself; 4) experiencing compassion towards others, premised in common humanity and interconnectedness; 5) experiencing compassion towards all beings; and 6) “active compassion” practice (Tonglen).

Table 1. Compassion Cultivation Training protocol.

Week Contents
1 Step 1. Settling and focusing the mind
Introduction of basic skills to still and focus the mind through breath focused meditation. This step is considered foundational for all subsequent practices in the program.
2 Step 2. Loving-kindness and compassion for a loved one 
Learning to recognize how the experiences of love and compassion feel when they occur naturally. Meditation and practical exercises aim to help practitioners recognize the physical and physiological feelings of warmth, tenderness, concern, and compassion. 
3 Step 3a. Compassion for oneself.
Learning to develop self-acceptance, tenderness, non-judgment, and caring in self-to-self relations. Connecting with one’s own feelings and needs and relating them with compassion is the basis for developing a compassionate stance toward others.
4 Step 3b. Loving-kindness for oneself.
Learning to develop qualities of warmth, appreciation, joy, and gratitude in self-to-self relations. While the previous step focused on self-acceptance, this step focuses on developing appreciation for oneself.
5 Step 4. Embracing shared common humanity and developing appreciation of others
Establishing the basis for compassion toward others by recognizing our shared common humanity. Appreciating the kindness of others and how human beings are deeply interconnected. 
6 Step 5. Cultivating compassion for others
Based on the previous step, participants begin to cultivate compassion for all beings by moving progressively from focusing on a loved one, to a neutral person, difficult person, and finally, all beings.
7 Step 6. Active compassion practice
This step explicitly evokes the altruistic wish to alleviate others’ suffering. This involves a visualization practice where the practitioner imagines taking away the suffering of others and giving them what is beneficial in oneself. This practice is known as tonglen or “giving and taking” in Tibetan Buddhism. 
8 Integrated practice 
The core elements of all six steps are combined into an “integrated compassion meditation practice” that can be practiced daily by participants who choose to adopt it.
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Note. Adapted from Brito-Pons, Campos & Cebolla, 2018.

Measures

The online assessment included a set of scales evaluating different domains related to compassion practice: [26, 30, 31, 35–37] compassion (both for others and oneself), empathy, Mindfulness, psychological well-being, resilience, psychological distress, burnout, and concerns about COVID-19. Furthermore, we also assessed program acceptability and satisfaction. Table 2 offers a brief description of the scales, as well as the reliability found in this study (see S1 File).

Table 2. Summary of measures.

Changes measured Scale used for assesement α
Primary outcomes
Compassion to others Compassion Scale Pommier (CSP) [38], 24-item [39]. .83
Self-compassion Self-Compassion Scale, Short Form (SCS-SF) [39], 12-item .90
Empathy Interpersonal Reactivity Index (IRI) [40], 28-item. .76
Psychological distress Depression Anxiety Stress Scales (DASS-21) [41], 21-item. .85
General well-being Pemberton Happiness Index (PHI) [42], 11-item. .95
Secondary outcomes
Mindfulness Five-Facet Mindfulness Quest Short (FFMQ) [43], 20-item. .83
Burnout Maslach Burnout Inventory-Student (MBI-SS) [44], 15-item. .75
Emotion Regulation Difficulties in Emotion Regulation Scale (DERS) [45], 28 item. .95
Resilience Brief Resilience Scale (BRS) [46], 5-item. .86
Concerns COVID-19 A single item. -
Acceptability/satisfaction Adaptation of Based on Mindfulness-based Teaching Assessment Criteria (MBI-TAC) [47] and home practice. -
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α: Cronbach’s α (reliability) found in the current study

Data analysis

Chi-square test for categorical data and independent Student’s t test for continuous data were performed to confirm that there were no baseline differences between CCT and WL groups. Missing data were also explored, revealing that there were only 6.1% of overall missing values completely at random (Little MCAR test: χ2 (632) = 225,265, p = .99). Only one drop-out case was found in the CCT group. Given that imputation of missing values is not necessary before performing longitudinal mixed-model analysis [48], we did not impute the missing data.

Mixed-effects models were conducted to analyze the effects of the CCT program, using the lmer function from the lme4 R-package [49]. R version 4.0.2 was used for the analyses [50]. Analyses were conducted via Restricted Maximum Likelihood estimation (REML) [51, 52], which provides a less-biased estimate of variance components with smaller sample sizes and missing data [51, 53, 54]. Variance across participants was modelled as a random effect in the model to account for individual differences in the dependent variable. Group (i.e., CCT vs WL) and Time (i.e., pre, post, and 2-month follow-up) were modelled as fixed effects. We used the WL and pre-intervention as reference categories in the analysis. Fixed-effect parameters were interpreted as the regression weights in the linear regression models [55], in which parameter estimates reflect changes in the mean of the dependent variable between the contrast and reference groups. Furthermore, the effect sizes of each model were presented as the model-derived fixed-effect parameter regression weights [56]. Tukey-corrected post hoc comparisons were computed to determine which interactions are responsible for the significant differences.

To improve individual-level analysis and the detection of potential adverse effects of the intervention, we also computed the Reliable Change Index (RCI) [57, 58] on pre-post scores for the main clinical outcomes (i.e., stress, anxiety, depression, emotional exhaustion, and cynicism). Participants were classified into four different categories based on their cut-off and RCI scores: (1) No change: when post-intervention scores did not reach the functional cut-off and the change was not reliable; (2) Improved: when the change was reliable but post-intervention scores did not reach the functional cut-off level; (3) Recovered: when post-intervention scores were located within the range of the functional cut-off distribution and the change was reliable; and 4) Deteriorated: when post-intervention scores were worse than the pre-intervention.

Results

Fig 2 shows fixed-effect parameter estimates, and their corresponding 95% confidence interdentals for each dependent variable (see also S1 Fig in S1 File).

Fig 2. Fixed-effect parameter estimates (standard error), and their corresponding 95% confidence interdentals for each dependent variable.

Fig 2

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Compassion measures

Significant differences were found between CCT and WL in self-kindness, common humanity, and mindful self-compassion after the program was completed (i.e., a significant Group x Time2 interaction). Tukey-corrected post hoc comparisons showed a significant increase of these measures after the CCT (i.e., self-kindness p = .003; common humanity p < .001; mindful self-compassion p = .005), whereas no changes were found in WL (i.e., self-kindness p = .884; common humanity p = .840; mindful self-compassion p = .962). Furthermore, significant differences also appeared between CCT and WL in self-kindness at follow-up (i.e., a significant Group x Time3 interaction). Post hoc comparisons showed that improvements in self-kindness in CCT persisted at follow-up (p < .001), whereas no changes were detected in WL (p = .847). However, no significant differences between groups were found in compassion to others and empathic concern.

Psychological distress and burnout measures

Significant differences were found between CCT and WL after the program in all the measures evaluated (i.e., a significant Group x Time2 interaction for stress, depression, anxiety, and emotional exhaustion, and cynicism). Post hoc comparisons indicated significantly lower scores in stress (p < .002), depression (p = .041), anxiety (p = .003), and emotional exhaustion (p < .001) after the CCT, whereas no changes were found in WL (i.e., stress p = .935; depression p = .451; anxiety p = .395; emotional exhaustion p = .533). Furthermore, significant differences also appeared between CCT and WL in anxiety, emotional exhaustion, and cynicism at follow-up (i.e., a significant Group x Time3 interaction). Post-hoc comparisons showed that the decreases in anxiety (p = .013) and emotional exhaustion (p < .001) in CCT group remained at follow up, whereas no changes were found in WL (i.e., anxiety p = .567; emotional exhaustion p = .792). The case of cynicism was atypical, because significant differences between groups appeared at baseline (where CCT participants showed significantly higher cynicism levels), but these differences disappeared after the intervention.

Psychological well-being measures

No significant differences between groups were found in psychological well-being, resilience, or academic effectiveness (i.e., the Group x Time interactions were not significant).

Mindfulness measures

Significant differences were found between CCT and WL in observing, non-reactivity to inner experience, and non-judging after the program (i.e., a significant Group x Time2 interaction). Tukey-corrected post hoc comparisons showed a significant increase of these facets after the CCT (i.e., observing p = .004; non-reactivity p < .001; non-judging p < .001), whereas no changes were found in WL (i.e., observing p = .885; non-reactivity p = .954; non-judging p = .951). In addition, CCT and WL significantly differed in observing and non-reactivity at follow-up (i.e., a significant Group x Time3 interaction). Post hoc comparisons showed that improvements in observing (p = .004) and non-reactivity to inner experience (p < .001) were maintained in the CCT group at follow-up, whereas no changes were found in WL (i.e., observing p = .917; non-reactivity p = .873). No significant differences between groups were found in describing and acting with awareness factors.

Emotional-regulation measures

Significant differences appeared between CCT and WL after the program in emotional inattention, emotional confusion, emotional lack of control, and emotional rejection (i.e., a significant Group x Time2 interaction). Tukey-corrected post hoc comparisons indicated a significant decrease in all these non-adaptive emotional-regulation strategies after the CCT (i.e., inattention p = .008; confusion p < .001; lack of control p < .001; and rejection p < .001), whereas no changes were found in WL (i.e., inattention p = .176; confusion p = .745; lack of control p = .077; and rejection p = .688). Furthermore, significant differences were also detected between CCT and WL in emotional inattention, confusion, and lack of control at follow-up (i.e., a significant Group x Time3 interaction). Post hoc comparisons showed that decreases in emotional confusion (p = .007) and emotional lack of control (p = .005) in CCT persisted at follow-up, whereas no changes were found in WL (i.e., confusion p = .561; lack of control p = .999). However, no significant differences appeared between groups in emotional life interference.

Regarding concern about the impact of COVID-19, a significant Group x Time interaction was found at follow-up, but not after the CCT. No significant differences between groups were found after the intervention, but these differences emerged at follow-up, where the CCT significantly reduced concern about COVID-19 impact (p < .001), but no changes were found in WL (p = .899).

Significance of clinical improvements

Fig 3 shows the RCI for the main clinical outcomes. The RCI analyses indicated significant differences between CCT and WL in clinical change regarding stress (χ2(3) = 7.98, p = .04), where CCT showed higher recovery rates whereas WL showed a higher number of deteriorated participants. Similarly, there were significant differences between CCT and WL in clinical change in anxiety (χ2(3) = 11.03, p = .01), where CCT showed higher recovery and improvement rates whereas WL showed a higher number of participants registering no change and deteriorated. However, no significant differences were found in depression symptoms (χ2(3) = 5.50, p = .14). Regarding burnout measures, significant differences between CCT and WL in clinical change were found in emotional exhaustion (χ2(3) = 11.73, p < .01) and cynicism (χ2(3) = 8.56, p = .04), where CCT displayed a higher number of improved participants whereas WL showed a higher number of participants with no changes.

Fig 3. Reliable Change Index for the main clinical outcomes.

Fig 3

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Note. CCT: Compassion Cultivation Training; WL: Waitlist. *p < 0.05; **p < 0.01.

Program acceptability and satisfaction

Regarding program satisfaction, all the participants stated that they would recommend the CCT to a friend. The average score of the participant’s overall satisfaction was very high (rated 8.76 out of 10). A large proportion of the participants considered that the goals of the program had been reached (rated 8.11 out of 10), and they perceived strong relevance of the contents of each session to achieve the program goals (rated 9.36 out of 10). Participants were also very satisfied with the instructor’s work and the materials provided, with average scores above 9. Furthermore, 94% of participants claimed they will continue practicing meditation after CCT had finished. In terms of perceived usefulness, participants found the meditations to be very helpful (8.1 out of 10). The most valued formal practices were attention to breathing (M = 9: SD = 1.06) and loving-kindness meditation (M = 8.88: SD = 1.22). Furthermore, participants perceived a high degree of applicability of the program’s contents in their daily lives (rated 8.22 out of 10).

Discussion

The mental health and well-being of physicians and medical students is a current issue of concern [5, 59]. Therefore, the aim of this study was to examine the effects of a Compassion-Based Intervention on psychological outcomes in medical students.

Based on previous studies [26, 27, 31, 36], we hypothesized that CCT would improve compassion levels, both for oneself and for others. Our results showed that CCT significantly improved self-compassion after the program (i.e., self-kindness, common humanity, and mindful self-compassion). The changes in self-compassion are broadly consistent with previous work in the field, both with CCT in general population [31, 60] and other CBIs [61], extending previous findings to a sample of medical students. The improvements in self-compassion in this population are crucial for several reasons. Firstly, improvements in awareness of their own suffering in the present moment could help them to regulate their negative thoughts and emotions in a preventive way [37, 62], helping them to reduce over-identification or to recognize their own psychological distress. Secondly, self-kindness would act as a protective factor against excessive self-criticism and self-judgment [61], helping them to accept that they are not perfect and will sometimes make mistakes in their medical work. Thirdly, common humanity improvements after the program would reduce the sense of isolation [26, 63], helping them to realize that suffering is part of the shared human experience. Furthermore, training self-compassion not only leads to improvements at a personal level, but could also enhance professional skills necessary for optimal medical practice [64].

In contrast to previous studies [26, 27, 36], we found no significant changes in compassion to others and empathic concern. The lack of changes in these variables might be explained by sample characteristics. For instance, medical students might be exerting a ceiling effect, having higher levels of compassion and empathy at baseline than in the general population. Furthermore, unlike physicians who have been practicing for years, medical students have not yet been exposed to large doses of daily suffering, so that their compassion levels to others are still preserved [65]. The fact that the intervention was delivered online during the COVID-19 pandemic (drastically reducing interpersonal interactions) could explain the lack of improvements in empathy and compassion to others.

The results of the present study also showed a significant decrease in psychological distress (i.e., stress, anxiety, and depression) after the CCT, whereas no changes were found in WL. These results are in line with those found in previous studies [26, 27, 30, 66], showing that CCT is an effective intervention to improve mental health in the general population. Given the high level of psychological distress in physicians and medical students [6, 67], the positive effects of CCT on mental-health outcomes make it a promising program to be included in hospitals and medical school curriculum. The lack of maintenance of significant changes in stress and depression at follow-up may suggest the importance of introducing maintenance sessions throughout the academic year to sustain the effects of intervention and to support continued meditation practice.

Furthermore, we also found a significant decrease of burnout symptoms (i.e., emotional exhaustion) after the CCT program. This reduction is consistent with earlier studies showing that MBIs reduce burnout symptoms in healthcare providers [68, 69], extending previous findings to CBIs. In fact, self-compassion and mindfulness changes might be important mechanisms of change that explain the effects of CCT on psychological distress [27] and burnout symptoms [70–72].

Contrary to the results of previous studies [26, 31, 66], we found no significant changes in well-being variables after the CCT (i.e., psychological well-being, resilience, and academic effectiveness). A plausible explanation could be that CCT is focused mainly on “suffering”. In the CCT, compassion is defined as the feeling that arises in witnessing the suffering of others and oneself, prompting a desire to reduce this suffering. Therefore, the program teaches skills to approach this suffering in a healthier and less avoidant way, but it does not have modules specifically aimed at enhancing positive affect. Importantly, participants showed high levels of satisfaction with the program, all of them would recommend the program to others, they perceived a high applicability of the program’s contents in their daily lives, and most of them expressed intentions to continue practicing compassion meditation after the intervention.

Consistent with our hypothesis, mindfulness skills significantly improved after CCT (specifically the facets of observing, non-reactivity to inner experience, and non-judging of inner experience). Similar results have been found in previous studies in the field [30, 31, 66]. This is a noteworthy finding, given that CCT is focused primarily on compassion skills. However, mindfulness plays an important role as a foundation of compassion and prosocial practices [73]. For instance, mindfulness is formally trained in the early sessions of CCT as a foundation for subsequent practices [74]. Future studies should compare the differential effect of mindfulness and compassion-based programs in this population.

In line with previous studies examining the effects of CBIs [27, 37, 60, 66], there was a significant reduction of most maladaptive emotion-regulation strategies after the CCT (i.e., emotional inattention, emotional confusion, emotional rejection, and lack of emotional control). These skills are crucial in medical population, continually exposed to the suffering of their patients, which generates intense emotions that should be regulated, instead of ignoring and accumulating them, as this increases the risk of developing mental-health problems [2, 75]. Furthermore, we also found a significant decrease in concerns involving COVID-19 impact in the CCT group at follow-up, which is an important feature considering the reported negative impact of COVID-19 pandemic on clinicians’ mental health [76].

Finally, to further test the efficacy of CCT, we used the RCI as a means of improving the individual-level analysis and the detection of potential adverse effects. The RCI revealed differences between CCT and WL in terms of clinically significant changes in stress, anxiety, emotional exhaustion, and cynicism. Generally, CCT showed higher recovery and improved rates, whereas WL showed higher number of participants with no changes or deteriorated. It bears noting that only a tiny fraction of participants showed a deterioration from baseline in CCT, which is an important result considering the potential adverse effects of meditation practice, such as increases in anxiety, depression or negative thinking [77].

Strengths, limitations, and future directions

Our study shows certain strengths in that we have tried to overcome major limitations in this field [78], implementing some of the main recommendations for compassion interventions [25]. That is, the present study is a pilot randomized control trial with a waitlist control group, following CONSORT statements for pilot trials. Another noteworthy strength of this study was the inclusion of a follow-up assessment, an exception more than a rule in empirical compassion studies. Furthermore, although CCT was originally designed as an in-person program, we found that the positive effects remains despite being offered as an online intervention in the context of the second wave of COVID-19 pandemic.

Our study shows certain limitations. First, as a pilot study, the sample size was moderate, although it is in line with previous studies on CCT in medical students [32]. Since the final sample comprised fewer participants than expected, that may have reduced the statistical power of the trial. Second, we used a waitlist control group instead of an active control comparison. Third, the nature of CCT precludes blind participants from the intervention. Finally, we included only self-reported measures, although this is the most common and validated method for measuring psychological variables. Future studies should replicate our results with a larger sample size, an active control condition (e.g., a mindfulness training or a relaxation program), and measurements of biological variables (e.g., cortisol levels, heart-rate variability, and brain activity).

In view of the above, future studies should replicate our results with a larger sample size to extrapolate information about the efficacy of the program, an active control condition (e.g., a mindfulness training or a relaxation program), and measurements of biological variables (e.g., cortisol levels, heart-rate variability, and brain activity). Furthermore, some post-intervention changes persisted at follow-up (i.e., self-kindness, observing, non-reactivity, anxiety, emotional exhaustion, and some emotional-regulation factors), whereas others had vanished. Thus, future research should include longer longitudinal designs (e.g., one-year follow-up) while exploring the role of continued meditation practice after completion of the program as a mediator of follow-up effects. Future research should also compare our results with other compassion-based interventions (e.g., Compassion Focused Therapy), in order to examine whether other compassion programs could enhance the measures that did not improve with CCT. It would be informative also to analyze the effectiveness of the program in physicians working at hospitals as well as in medical students diagnosed with anxiety, depression, and/or burnout syndrome. Furthermore, given that universities are also responsible for sustainable human-resource development, these kinds of programs could also be applied to other university employees in order to improve their skills related to well-being. Finally, there could be cross-cultural differences in the importance of compassion in the medical curriculum, so futures studies should explore these potential differences.

Conclusions

For all the above, the CCT appears to be an effective intervention to enhance compassion skills in a profession where compassion is such a vital and fundamental attribute. In addition, CCT also proves to be an effective intervention to reduce stress, anxiety, depression, and burnout symptoms, while reducing the maladaptive emotion-regulation strategies in a population particularly vulnerable to developing mental-health problems. This makes the CCT an excellent program to be included in hospital and medical-school training. Medical schools should aim not only for academic excellence, but also for training healthier and more compassionate professionals.

Supporting information

S1 Checklist. CONSORT 2010 checklist of information to include when reporting a randomised trial*.

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Acknowledgments

The present work is part of an Innovation Teaching Program at Complutense University (2020-2021/139) and partially supported by Nirakara-lab. The authors want to thank all participants for their generosity in voluntarily participate in the study. We also thank Lilly Foundation, Maria Teresa García Antón, and Elena María Vara Ameigeiras for their help and inspiration throughout the project.

Data Availability

The data are already available at https://github.com/nirakara-lab/CCT-medical-students.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Dario Ummarino, PhD

11 Apr 2023

PONE-D-23-02561A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trialPLOS ONE

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Reviewer #2: Yes

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Reviewer #1: Important note: This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ [like medical importance, relevance of the study, ‘clinical significance and implication(s)’ of the whole study, etc.] are to be evaluated [should be assessed] separately/independently. Further please note that any ‘statistical review’ is generally done under the assumption that (such) study specific methodological [as well as execution] issues are perfectly taken care of by the investigator(s). This review is not an exception to that and so does not cover clinical aspects {however, seldom comments are made only if those issues are intimately / scientifically related & intermingle with ‘statistical aspects’ of the study}. Agreed that ‘statistical methods’ are used as just tools here, however, they are vital part of methodology [and so should be given due importance]. I look at the manuscript in/with statistical view point, other reviewer(s) look(s) at it with different angle so that in totality the review is very comprehensive. However, there should be efforts from authors side to improve (may be by taking clues from reviewer’s comments). Therefore, please do not limit the revision only (with respect) to comments made here.

COMMENTS: I noted (i.e., in my opinion) that your ABSTRACT is well drafted, but is ‘assay type’. It is preferable [refer to item 1b of CONSORT checklist 2010: Structured summary of trial design, methods, results, and conclusions] to divide the ABSTRACT with small sections like ‘Objective(s)’, ‘Methods’, ‘Results’, ‘Conclusions’, etc. which is an accepted practice of most of the good/standard journals [including this one, though ‘The PLoS One Guidelines to Authors’ did not specify an Abstract format, it is desirable]. It will definitely be more informative then, I guess, whatever the article type may be [including a pilot randomized clinical trial].

A very small correction: meaning/longform of CCT [Compassion Cultivation Training] is given in the ‘abstract’ itself but on second time use of the term, whereas, it is a general convention to give it at first time use of the term. Of course, it a very minor correction suggested. It is stated in ‘abstract’ that “This pilot study aims to examine the effectiveness of Compassion-Based Interventions (CBIs) in preventing psychological distress” [is not ‘Interventions’ plural?] but next sentence “We hypothesize that the CCT program, as compared to a waitlist control group” indicates that this study deals with only one intervention namely CCT program. Is not that so? It is pardonable if it is by oversight/typing mistake, however, please clarify.

It seems that this ‘Clinical Trial’ is not register as desired. If it is, then why the number {ClinicalTrial.org (ID: XXX)} is not specified? This study being ‘pilot’ in nature, sample size is not a big issue. However, [though many things are ignored (loosely looked at / evaluated)] in case of ‘pilot studies’, methodological issues need to be very rigorous followed {like in case of clinical trial, CONSORT guidelines are to be strictly observed/followed}. Then the term ‘CONSORT’ is a very vital term [but surprisingly it appears only once in ‘Strengths, limitations, and future directions’ section]. Even important items of/in CONSORT checklist are not found [since your article type is ‘Clinical Trial’, you are supposed to cover these items in the report (& note that CONSORT for Pilot trial is/are also available).

According to document on CONSORT for Pilot trial “Formal hypothesis testing for effectiveness (or efficacy) is not recommended. The aim of a pilot trial is not to assess effectiveness (or efficacy) and it will usually be underpowered to do this” (check your aim stated). In addition, please note that any regression techniques [including Mixed-effects models which are conducted here to analyze the effects of the CCT program] are not basically/originally developed for any sort of [between or within group(s)] comparison(s). Using ‘Mixed-effects models’ is definitely not wrong; however, some head-to-head comparison is expected. Further, it may be noted that

Though the measures/tools used are appropriate [refer table-2], most of them are likely to yield data that are in ‘ordinal’ level of measurement [and not in ratio level of measurement for sure {as the score two times higher does not indicate presence of that parameter/phenomenon as double (for example, a Visual Analogue Scales VAS score or say ‘depression’ score)}]. Then application of suitable non-parametric test(s) is/are indicated/advisable [even if distribution may be ‘Gaussian’ (also called ‘normal’)]. Agreed that there is/are no non-parametric test(s)/technique(s) available to be used as alternative in all situation(s) [suitable / most desired/applicable], but should be used whenever/wherever they are available. Therefore, in short use suitable non-parametric test(s)/technique(s) while dealing with data that are in ‘ordinal’ level of measurement even if [despite that] the distribution may be ‘Gaussian’. Testing ‘normality’ in sample [by using any normality test(s)} is not required/desired while dealing with data that are in ‘ordinal’ level of measurement [as most of the normality tests are not valid for ‘ordinal’ data].

I request authors to check contents of references 77,78. Because in my knowledge, at least article 77 concludes as follows:

Conclusions: Engagement in MBSR is not predictive of increased rates of harm relative to no treatment. Rather, MBSR may be protective against multiple indices of harm. Research characterizing the relatively small proportion of MBSR participants that experience harm remains important.

Moreover, it may please be noted that “Absence of evidence is not evidence of absence” [Altman DG, Bland JM. BMJ volume 311, 1995, p 485 (Reprinted: Australian Veterinary Journal 1996;74, 311)]. {Even when P-value is not significantly lower that is null hypothesis of no difference / no association is not rejected, (in short, result is not significant), that does not amount to evidence of absence i.e., it does not imply that there no difference / no association. It only implies that there is no (i.e., these samples do not provide) [say enough] evidence to prove (rather indicate with certain specified confidence level) the difference / association}. Therefore, conclusion(s) from any study [in which result(s) is/are not significant], should be drawn in the light of this fact. Particularly look at (due consideration of) the hypothesis in each of the study quoted in reference 78.

Although the ‘Intervention description’ is indeed very good and useful, [as pointed out in ‘important note’ above] note that “This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ should be assessed separately/independently [one should carefully consider/look at the clinical implications of the study].

In my opinion, to rescue this article (which is quite possible and easy), a small amount of re-vision (re-drafting) may be needed. However, please do not limit the revision only (with respect) to comments made here. More improvement is expected. Recommending minor revision.

Reviewer #2: Thanks for allowing me to review the present manuscript. This is an interesting research report on the effectiveness of a Compassion-Based Intervention (CCT) in reducing distress in medical students. The study is a randomized-controlled trial. I think this is an important topic and a well-written manuscript that should be accepted for publication.

Reviewer #3: “A compassion-based program to reduce psychological distress in medical students: a

pilot randomized clinical trial”

The present study aims to investigate the impact of Compassion Cultivation Training on psychological outcomes in a sample of medical students. The topic is exciting, and the contribution that the current study could provide to scientific literature is influential and essential.

Following this, I reported a series of suggestions to help authors improve the manuscript.

Background:

Since there are other types of Protocol Intervention, CBT-oriented focused on increases in

“Compassion, empathy and mindfulness skills, reductions of

psychological distress (stress, anxiety, and depression) and burnout, improvements in

well-being and emotion regulation, among others” I suggest that authors explain better why they chose this specific training and not others.

Materials and Methods:

The number of the study protocol approved by the Ethical Committee and the pre-registration at ClinicalTrial.org need to be included.

Participants:

I kindly ask the authors to specify the background related to the decision to set a medium effect size to estimate sample size, also considering that this field is novel and not extensively investigated, it should be expected to have a sample composed of a higher number of participants to extrapolate information about efficacy in a pilot study.

Discussion:

Since the final sample comprised fewer participants than expected, I suggest that authors better explain the implication of this fact on the outcome interpretation. I suggest adding this part to the conclusion section.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Susanna Pardini

**********

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PLoS One. 2023 Jun 23;18(6):e0287388. doi: 10.1371/journal.pone.0287388.r002

Author response to Decision Letter 0

29 May 2023

We thank the reviewers for their constructive comments and suggestions that have markedly improved our manuscript. Please see below our responses to each comment.

Reviewer #1

1.1. I noted (i.e., in my opinion) that your ABSTRACT is well drafted, but is ‘assay type’. It is preferable [refer to item 1b of CONSORT checklist 2010: Structured summary of trial design, methods, results, and conclusions] to divide the ABSTRACT with small sections like ‘Objective(s)’, ‘Methods’, ‘Results’, ‘Conclusions’, etc. which is an accepted practice of most of the good/standard journals [including this one, though ‘The PLoS One Guidelines to Authors’ did not specify an Abstract format, it is desirable]. It will definitely be more informative then, I guess, whatever the article type may be [including a pilot randomized clinical trial].

We thank the reviewer for this suggestion. We have adapted the abstract according to the item 1b of the CONSORT checklist 2010, which is also reflected in the CONSORT checklist for pilot studies (see point 1.5 below).

1.2. A very small correction: meaning/longform of CCT [Compassion Cultivation Training] is given in the ‘abstract’ itself but on second time use of the term, whereas, it is a general convention to give it at first time use of the term. Of course, it a very minor correction suggested.

Done!

1.3. It is stated in ‘abstract’ that “This pilot study aims to examine the effectiveness of Compassion-Based Interventions (CBIs) in preventing psychological distress” [is not ‘Interventions’ plural?] but next sentence “We hypothesize that the CCT program, as compared to a waitlist control group” indicates that this study deals with only one intervention namely CCT program. Is not that so? It is pardonable if it is by oversight/typing mistake, however, please clarify.

We thank the reviewer for this observation. Indeed, the CCT is one of the many Compassion-Based Interventions that have been developed. We selected it because it is one of the programs with the most empirical evidence in this field. To avoid any confusion in the abstract, we have replaced CBIs with the CCT (p. 2), which is the program we have evaluated in this study.

1.4. It seems that this ‘Clinical Trial’ is not register as desired. If it is, then why the number {ClinicalTrial.org (ID: XXX)} is not specified?

Clinical Trial ID was intentionally hidden to maintain the anonymity during the review process. The ID (NCT04690452) is now included in the Study Design section (p. 6).

1.5. This study being ‘pilot’ in nature, sample size is not a big issue. However, [though many things are ignored (loosely looked at / evaluated)] in case of ‘pilot studies’, methodological issues need to be very rigorous followed {like in case of clinical trial, CONSORT guidelines are to be strictly observed/followed}. Then the term ‘CONSORT’ is a very vital term [but surprisingly it appears only once in ‘Strengths, limitations, and future directions’ section]. Even important items of/in CONSORT checklist are not found [since your article type is ‘Clinical Trial’, you are supposed to cover these items in the report (& note that CONSORT for Pilot trial is/are also available).

We thank the reviewer for rising this. The CONSORT checklist for pilot studies (Eldridge et al., 2016) is now available as a table in the Supplementary Materials. Furthermore, the adhesion to the CONSORT recommendations for pilot studies is now mentioned in the Study Design (p. 5) and Discussion (p. 19) sections.

6.1. According to document on CONSORT for Pilot trial “Formal hypothesis testing for effectiveness (or efficacy) is not recommended. The aim of a pilot trial is not to assess effectiveness (or efficacy) and it will usually be underpowered to do this” (check your aim stated).

Following CONSORT recommendations, we have changed “effectiveness” to “feasibility” as the aim of the study (p. 2).

7.1. In addition, please note that any regression techniques [including Mixed-effects models which are conducted here to analyze the effects of the CCT program] are not basically/originally developed for any sort of [between or within group(s)] comparison(s). Using ‘Mixed-effects models’ is definitely not wrong; however, some head-to-head comparison is expected.

We thank the reviewer for this suggestion. As can be seen in Table 2, we analyzed between and within groups differences, including Group and Time main effects and the interactions. Furthermore, we computed post-hoc comparisons (adjusted by Tukey) to determine which Group X Time interactions are responsible for the significant differences. However, we neglected to mention these comparisons in the Data Analysis plan, and they were described in little detail in the results. Therefore, we have improved the explanation in Data Analysis (p. 10) and Results (p. 11) sections.

8.1. Though the measures/tools used are appropriate [refer table-2], most of them are likely to yield data that are in ‘ordinal’ level of measurement [and not in ratio level of measurement for sure {as the score two times higher does not indicate presence of that parameter/phenomenon as double (for example, a Visual Analogue Scales VAS score or say ‘depression’ score)}]. Then application of suitable non-parametric test(s) is/are indicated/advisable [even if distribution may be ‘Gaussian’ (also called ‘normal’)]. Agreed that there is/are no non-parametric test(s)/technique(s) available to be used as alternative in all situation(s) [suitable / most desired/applicable], but should be used whenever/wherever they are available. Therefore, in short use suitable non-parametric test(s)/technique(s) while dealing with data that are in ‘ordinal’ level of measurement even if [despite that] the distribution may be ‘Gaussian’. Testing ‘normality’ in sample [by using any normality test(s)} is not required/desired while dealing with data that are in ‘ordinal’ level of measurement [as most of the normality tests are not valid for ‘ordinal’ data].

Although the questionnaires used in our study are ordinal at the item level, they are quantitative at the factor level (i.e., sum scores), which makes them suitable to be analyzed by means of parametric tests. This is a very common practice in areas such as psychology, where they use procedures very similar to those used in our manuscript (e.g., González-Robles et al., 2022; Romero-Ferreiro et al., 2022).

González-Robles, A., Roca, P., Díaz-García, A., García-Palacios, A., & Botella, C. (2022). Long-term Effectiveness and Predictors of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Emotional Disorders in Specialized Care: Secondary Analysis of a Randomized Controlled Trial. JMIR Mental Health, 9(10), e40268.

Romero-Ferreiro, V., García-Fernández, L., Aparicio, A. I., Martínez-Gras, I., Dompablo, M., Sánchez-Pastor, L., ... & Rodriguez-Jimenez, R. (2022). Emotional Processing Profile in Patients with First Episode Schizophrenia: The Influence of Neurocognition. Journal of Clinical Medicine, 11(7), 2044.

9.1. I request authors to check contents of references 77,78. Because in my knowledge, at least article 77 concludes as follows: “Conclusions: Engagement in MBSR is not predictive of increased rates of harm relative to no treatment. Rather, MBSR may be protective against multiple indices of harm. Research characterizing the relatively small proportion of MBSR participants that experience harm remains important”. Moreover, it may please be noted that “Absence of evidence is not evidence of absence” [Altman DG, Bland JM. BMJ volume 311, 1995, p 485 (Reprinted: Australian Veterinary Journal 1996;74, 311)]. {Even when P-value is not significantly lower that is null hypothesis of no difference / no association is not rejected, (in short, result is not significant), that does not amount to evidence of absence i.e., it does not imply that there no difference / no association. It only implies that there is no (i.e., these samples do not provide) [say enough] evidence to prove (rather indicate with certain specified confidence level) the difference / association}. Therefore, conclusion(s) from any study [in which result(s) is/are not significant], should be drawn in the light of this fact. Particularly look at (due consideration of) the hypothesis in each of the study quoted in reference 78.

We thank the reviewer for this observation. We used reference 77 as an example of the debate about the potential adverse effects of meditation programs, which is well covered in its introduction and discussion. However, we agree with the reviewer that it might be confusing given its results. Therefore, we have replaced these references with Baer et al. (2019) study, which best fits the content of the sentence (p. 19).

Baer, R., Crane, C., Miller, E., & Kuyken, W. (2019). Doing no harm in mindfulness-based programs: conceptual issues and empirical findings. Clinical psychology review, 71, 101-114.

10.1 Although the ‘Intervention description’ is indeed very good and useful, [as pointed out in ‘important note’ above] note that “This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ should be assessed separately/independently [one should carefully consider/look at the clinical implications of the study]. In my opinion, to rescue this article (which is quite possible and easy), a small amount of re-vision (re-drafting) may be needed. However, please do not limit the revision only (with respect) to comments made here. More improvement is expected. Recommending minor revision.

Once again, many thanks to the reviewer for these very helpful comments and suggestions!

Reviewer #2:

Thanks for allowing me to review the present manuscript. This is an interesting research report on the effectiveness of a Compassion-Based Intervention (CCT) in reducing distress in medical students. The study is a randomized-controlled trial. I think this is an important topic and a well-written manuscript that should be accepted for publication.

We are glad that the reviewer enjoyed the manuscript and recognized the importance of the topic it addresses.

Reviewer #3

The present study aims to investigate the impact of Compassion Cultivation Training on psychological outcomes in a sample of medical students. The topic is exciting, and the contribution that the current study could provide to scientific literature is influential and essential. Following this, I reported a series of suggestions to help authors improve the manuscript.

3.1. Since there are other types of Protocol Intervention, CBT-oriented focused on increases in “Compassion, empathy and mindfulness skills, reductions of psychological distress (stress, anxiety, and depression) and burnout, improvements in well-being and emotion regulation, among others” I suggest that authors explain better why they chose this specific training and not others.

We thank the reviewer for this suggestion. There are several reasons to explain why we chose CCT among all compassion-based programs: 1) CCT has shown promising results in improving the targets that we were interested in (e.g., psychological distress, emotion regulation, mindfulness…); 2) the CCT was developed at Stanford University with a duration and format well adapted to university settings. Furthermore, the CCT have shown promising results in medical students (Weingartner et al., 2019); and 3) a member of our research team is certified by the Compassion Institute to apply the CCT, which enhanced the feasibility of the project. We have now explained these reasons in more detail in the Introduction (p. 4) and Method (p. 8) sections.

3.2. The number of the study protocol approved by the Ethical Committee and the pre-registration at ClinicalTrial.org need to be included.

We thank the reviewer for this observation. Clinical Trial ID and the Ethical Committee ID were intentionally hidden to maintain the anonymity during the review process. Both are now included in the Study Design section (p. 6).

3.3. I kindly ask the authors to specify the background related to the decision to set a medium effect size to estimate sample size, also considering that this field is novel and not extensively investigated, it should be expected to have a sample composed of a higher number of participants to extrapolate information about efficacy in a pilot study.

We thank the reviewer for the suggestion. We used a medium effect size because previous studies using the CCT have found effects around .40 in the same variables that we are using in our study (e.g., Brito-Pons et al., 2018; Roca et al., 2021). Furthermore, as mentioned by Reviewer #1 in point 1.5, our study is pilot in nature, so sample size is not a major concern. However, we have now explained better this rationale in the Method (p. 6), including a reflection in the Discussion on the need to increase the sample size in future studies to extrapolate information about efficacy of the program (p. 20).

3.4. Since the final sample comprised fewer participants than expected, I suggest that authors better explain the implication of this fact on the outcome interpretation. I suggest adding this part to the conclusion section.

Following the reviewer’s suggestion, we have included a limitation in the Discussion section about how the sample size may have reduced the statistical power of the trial (p. 20).

---

We thank you for your constructive comments that have markedly improved our manuscript.

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Decision Letter 1

Samuel Yeung-shan Wong

5 Jun 2023

A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trial

PONE-D-23-02561R1

Dear Dr. Roca,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Samuel Yeung-shan Wong

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The authors have adequately addressed my comments raised in the previous round of review and I feel that this manuscript is acceptable for publication.

Reviewer #3: (No Response)

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: Yes: Susanna Pardini

**********

Acceptance letter

Samuel Yeung-shan Wong

12 Jun 2023

PONE-D-23-02561R1

A compassion-based program to reduce psychological distress in medical students: a pilot randomized clinical trial.

Dear Dr. Roca:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Samuel Yeung-shan Wong

Academic Editor

PLOS ONE

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