Postgraduate General Practice Training Under Early Clinical Responsibility: A Narrative Review on System-Based Supervision and the Supportive Role of Artificial Intelligence

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I believe the authors need to make some improvements to the article. These are:
1- What was the main motivation that led the authors to conduct this study?
2- What exactly are the research question(s)? Please reflect this in the article.
3- Please state the contributions this study will make to the literature. Maximum 4 points.
4- When reviewing the literature, it is considered that research published in recent years may have been overlooked. Please expand the literature by prioritizing studies conducted in 2024-2025.
5- If supervisors have limited time, shouldn't some tasks be delegated to AI? Other studies in the literature indicate that AI performs better than experts in disease diagnosis. In this context, it should be explained in a short sentence which AI tool can perform which tasks, or which datasets it can perform better on, or in which situations it can only be used to support the physician. I believe this will eliminate confusion.
6- In this study, the authors have attempted to address AI tools from a discourse perspective rather than a technical one. This has been observed to obscure the issue. Please clarify the findings related to AI.
7- Why can't AI tools replace a supervisor, as briefly mentioned in the study? Why do they act as an auxiliary element, or facilitate tasks, helping to systematize them? Please elaborate on this point by providing evidence and reflecting this evidence in the article.
8- Is it necessary to generalize the findings of the study beyond Italy using a multi-center approach? If this is deemed necessary, please consider it in the study.
9- The limitations of the study are not clear. Please elaborate.
10- It has been observed that "GP, general practitioner" is written twice in the caption of Figure 2. Please correct this.
11- It has been observed that Table 1 and Table 2 have the same title. Table names should not be the same. Please correct this and rename them.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript addresses a policy-relevant issue concerning the transformation of postgraduate general practice training within evolving primary care systems, using the Italian reform and South Tyrol as an illustrative case. The integration of system-based supervision models and artificial intelligence into postgraduate education is conceptually strong. However, aspects related to conceptual clarity, methodological transparency, evidentiary balance, and practical implementation require further refinement to strengthen the manuscript.

1. The central research question and objectives of the review should be stated more explicitly at the outset to clearly frame the scope and intent of the manuscript.
2. The rationale for selecting South Tyrol as a case study should be expanded, including discussion of its representativeness or uniqueness within the broader Italian primary care reform context.
3. The narrative review methodology requires clearer description, particularly regarding inclusion criteria, study selection, and how policy documents were weighted relative to empirical studies.
4. The use of SANRA-guided interpretive analysis should be explained in more detail to clarify how rigor and bias control were ensured.
5. The manuscript should more clearly distinguish between evidence derived from empirical studies and normative or policy-driven arguments.
6. The discussion of early clinical responsibility would benefit from a more balanced analysis of potential risks alongside reported educational benefits.
7. Greater clarity is needed regarding what constitutes “system-based supervision,” including its core components, governance structures, and operational requirements.
8. The concept of entrustment criteria and competency frameworks should be elaborated, with examples relevant to postgraduate general practice training.
9. The role of organizational culture and team-based care in mediating training quality should be discussed more explicitly.
10. The section on artificial intelligence would benefit from clearer categorization of AI tools (e.g., decision support, learning analytics, assessment support) and their current maturity levels.
11. Claims regarding the benefits of AI-supported educational tools should be more cautiously framed, given the limited empirical evidence in postgraduate training contexts.
12. Ethical, legal, and data governance considerations related to AI use in education and patient care should be expanded.
13. The manuscript should more clearly articulate criteria for determining whether community care hubs are suitable as training environments.
14. Comparative insights from other international primary care training models could strengthen the generalizability of the conclusions.
15. Limitations of the narrative review approach, including potential selection and interpretation bias, should be explicitly acknowledged.
16. The conclusions should more clearly separate evidence-supported findings from forward-looking recommendations.
17. The subsequent studies should be evaluated and integrated into the manuscript’s literature review.  https://doi.org/10.3390/jtaer20030231, http://doi.org/10.4018/JOEUC.336284

 

 

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

The manuscript addresses a relevant and timely topic. The paper is well structured and covers an important gap in literature. Below, I provide detailed comments:

Title

The title does not indicate the type of article. I recommend explicitly stating the study design in the title (e.g., “A Narrative Review”).

Abstract

The abstract exceeds the journal’s recommended length.

The keywords do not correspond to MeSH terminology. Terms such as Community Centers, Ministerial Decree 77/2022, South Tyrol, or primary care reform are not MeSH descriptors. I suggest revising the list to align with MeSH terms where possible.

Introduction

The introduction provides a solid overview of the pressures on primary care and the limitations of traditional apprenticeship models.

However, the specific knowledge gap motivating the review could be articulated more explicitly. For example:

What exactly remains underexplored about early clinical responsibility in the Italian context?

How does the intersection of DM 77/2022, system‑based supervision, and AI create a novel analytical space?

I suggest adding one or two references that situate the review within existing debates on supervision reform or AI‑supported medical education, to strengthen the theoretical positioning.

Methods

I have some doubts regarding this section. Several clarifications would enhance methodological rigor.

- I recommend clarifying the evidence base used in the review. Although the search strategy is described, it is not clear which documents were actually selected, how many sources were included, or what criteria guided the selection. Without this information, it is difficult to understand the foundation of the analysis. Perhaps a table would help.

- I also recommend adding methodological references to justify the chosen design and analytical strategy. The narrative review approach is appropriate, but the rationale for selecting this design should be explained (e.g., heterogeneity of sources, emerging nature of the topic).

- The search strategy would benefit from greater detail, including inclusion/exclusion criteria, how policy documents were integrated with scientific literature, and how relevance was assessed.

- The use of SANRA is mentioned, but it would be helpful to describe how it informed the synthesis (e.g., structuring, quality appraisal). Likewise, the role of Consensus AI in the search process should be contextualized to avoid confusion with AI‑supported analysis.

- Finally, since the review includes a case study (South Tyrol), I recommend explaining how this case was selected and how it contributes to the interpretive analysis.

Results

The results section is well organised. However, I recommend clarifying the conceptual boundaries between some subsections (e.g., early clinical responsibility, CdC implications), as they occasionally blend descriptive content with interpretive commentary.

I suggest expanding Table 1 to clarify what “Emerging GP training” entails beyond the Italian context and adding a brief explanation in Table 2 of how the representative references were selected.

The section on AI is well developed, but I recommend making the limitations of current evidence more explicit (e.g., lack of validation studies, ethical considerations, and the need for human oversight).

Discussion

The manuscript could more clearly articulate its unique contribution, especially regarding the conceptualization of system‑based supervision in the context of DM 77/2022, and the nuanced role of AI as an augmentative, not substitutive, tool.

The Italian case is compelling, but I suggest a more explicit comparison with international models to highlight what is generalizable and what is context‑specific.

The policy implications could be more tightly linked to the evidence presented in the results.

Finally, I recommend strengthening the Discussion by adding a clearer comparison with previous studies.

Conclusions

The conclusions are aligned with the findings, but I suggest adding a short section on practical implications for training institutions and policymakers, and recommendations for future research, particularly regarding empirical evaluation of system‑based supervision and AI‑supported tools.

References

This section is ok

I hope this helps.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors fulfilled all the requests made of them and reflected this in the article.

Reviewer 2 Report

Comments and Suggestions for Authors

All comments resolved. Thank you

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,
Thank you very much for your responses and for the modifications made to the manuscript. I believe that you have adequately addressed the comments raised.   Best regards,