Comparative Impact of ChatGPT and Conventional Search Tools on Clinical Reasoning Performance: A Randomized Crossover Study in Preclinical Medical Students [Response to Letter]

Abstract

We thank Kalra for the thoughtful comments regarding our article.We appreciate the opportunity to clarify the interpretation of our findings and to place the study's limitations in appropriate context.First, we agree that carryover effects are an important consideration in crossover educational studies.In this setting, a washout period cannot fully remove learning once it has occurred.For that reason, our 60-minute washout period should be interpreted as a practical measure to reduce immediate recall and tool-related priming, rather than as a guarantee of complete elimination of residual learning effects.We therefore agree that carryover cannot be fully excluded.However, this does not invalidate the study.Rather, it means the findings should be interpreted cautiously as short-term, within-learner comparisons in a structured educational setting.This interpretation is consistent with published guidance for randomized crossover trials, which emphasizes transparent acknowledgment of period and carryover effects rather than assuming that any washout period can fully resolve them. 1 Second, we agree that the single-institution setting and modest sample size limit generalizability.This was an educational study conducted within one authentic classroom cohort, and we do not claim broad external validity.At the same time, the randomized crossover design was chosen precisely because it improves internal efficiency by allowing participants to serve as their own controls.In that context, the design remains appropriate for an initial study of shortterm educational performance, even though confirmation in larger and multicenter cohorts is still needed. 1hird, we agree that the eight-point rubric would be strengthened by additional psychometric evidence.Clinical reasoning is a complex construct, and rubric-based assessment should ideally be supported by broader validity evidence and reliability reporting.At the same time, the use of a structured rubric is not, in itself, a methodological weakness.On the contrary, rubric-based assessment is a recognized approach in medical education when grounded in relevant domains and applied transparently.Our intention was to use a practical structured measure aligned with the objectives of casebased learning, not to claim that this single rubric fully captures the entire construct of clinical reasoning.Future work should expand this by including formal inter-rater reliability and broader validity evidence. 2ourth, regarding statistical analysis, we agree that repeated comparisons in crossover studies should be interpreted carefully.For that reason, our findings should not be read as proof of cumulative superiority across phases without reservation.However, we respectfully disagree that the statistical approach was inappropriate.Paired analysis is a reasonable method for within-subject comparisons in this educational design, and effect sizes were reported to complement p-values.The main point of our results was not to make an inflated confirmatory claim, but to show that

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