How Should Doctors Learn Wellbeing? Perspectives from Early-Career General Practitioners Across Europe

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is very relevant research. Although you are talking about a 'soft' competency, it is a very important, even essential one. This study can be - as you mention it yourself - a first step for a mental shift and a shift in curricula and how curricula are built. I have some comments to improve the manuscript.

Introduction

• Line 64 & 65: I think you should mention/refer here already to the manuscript of Junge
• Line 74: I think this should be curriculA and not curriculAR

Materials/methods

• you should explain first what EYFDM is; it will not be clear for all readers
• participants --> I feel this part is not stating clear enough what all the 'terms' mean. E.g. it is not clear what EYFDM cohort means: line 99 says that it are the Council members + workshop participants, but in line 113: it is also refers to Junge's study. I would advice to have a new look at this section and try to re-clarify this.
• Figure 1: there is a lot of information in it and can it be that it is a mix of methodology and results? - I do not have the feeling that the figure is clear enough for me

Author Response

 

Revision

Dear Ms. Chu Xu and Reviewers,

Thank you for your structured and insightful work on our paper. It has been instrumental in revising and presenting our work to the best possible extent. Changes to text passages in the manuscript have been marked in yellow. On behalf of all authors, we would like to thank you for your support.

Enclosed you will find our statements and comments on the concrete steps that were taken to incorporate your feedback into the revision.

 

Reviewer 1: General comments

This is very relevant research. Although you are talking about a 'soft' competency, it is a very important, even essential one. This study can be - as you mention it yourself - a first step for a mental shift and a shift in curricula and how curricula are built. I have some comments to improve the manuscript.

Thank you very much for encouraging comment and your suggestions you provided to strengthen our work.  

Reviewer 1: Specific comments

• Line 64 & 65: I think you should mention/refer here already to the manuscript of Junge

Thank you for this helpful suggestion. We agree that an earlier reference to the work by Junge et al. strengthens the contextual framing of the introduction. We have therefore added a reference to Junge et al. see lines 64–65 to highlight the prior identification of wellbeing as a key competency among early-career GPs.

• Line 74: I think this should be curriculA and not curriculAR.

Thank you for pointing this out. We have corrected the wording from “curricular” to “curricula” on line 78.

• you should explain first what EYFDM is; it will not be clear for all readers

Thank you for your advice. The initial explanation of EYFDM can be found in the introduction on line 65.

• participants --> I feel this part is not stating clear enough what all the 'terms' mean. E.g. it is not clear what EYFDM cohort means: line 99 says that it is the Council members + workshop participants, but in line 113: it also refers to Junge's study. I would advise to have a new look at this section and try to re-clarify this.

Thank you for this important comment. We agree that the terminology used in the Participants section was not sufficiently clear and may have led to confusion. We have revised this section (see lines 103-111) to clearly define all participant groups, to distinguish between participants in the present study and those referenced from Junge et al.’s study (line 118), and to ensure consistent use of terminology throughout the manuscript.

• Figure 1: there is a lot of information in it, and can it be that it is a mix of methodology and results? - I do not have the feeling that the figure is clear enough for me

Thank you for this helpful comment. We have revised Figure 1 to focus exclusively on the workshop structure and data collection process. Content related to anticipated benefits, challenges, implementation preferences, and role modelling outcomes has been removed from the figure and is now reported in the methods and results section. This revision improves readability and ensures a clear distinction between methodology and findings.

 

Reviewer 2: General comments

Dear authors,

This mixed-methods study addresses the topic of wellbeing and its integration in GPs training. Based on the findings from Junge et al., the opinion of young physicians was captured qualitatively during a three-stage workshop as part of EYFDM 2023 in Belgium. The Workshop was followed by two consultation rounds with relevant stakeholders. Similar to the teaching of other soft skills such as communication, the need for integration wellbeing in the curricula in all its facets in GP’s training has been identified. A potential approach for integration could be a targeted role-model strategy accompanied by a flexibly usable toolbox. The findings should be viewed as a first step toward the field of medical wellbeing education research. Further research should follow.

The article deals with a highly topical issue in medical education and fits the scope of the journal. The chosen method is appropriate for investigating the research question. The article is clearly written, well structured, and the results are depicted graphically in a vivid manner. The results are discussed in the context of current literature.

We would like to thank you for this positive evaluation of our manuscript. We appreciate the recognition of the relevance of the topic, the choice of the mixed-methods approach, and the clarity of the manuscript structure and graphical presentation. We are particularly grateful for the acknowledgement of the study’s positioning as an initial step in the emerging field of medical wellbeing education research. We have carefully considered your specific comments and have revised the manuscript accordingly to further improve clarity, methodological transparency, and the distinction between methods and results.

Reviewer 2: Specific comments

• In the Paper from Junge et al. wellbeing had in the end no consensus for a LoA in the list of competences. Although the authors use the article as basis for their work, I miss references to this rather important fact either in the Introduction or discussion. Why was the topic wellbeing addressed despite the limited agreement in Junge's article? I assume that the multifaceted but non-consented discussions on the topic were the trigger for the choice. Please clarify.

Thank you for highlighting this important point. The discussion during data collection by Junge et al. showed that specifically doctors´wellbeing as a competence had not previously been mentioned in the literature as equally important to patients wellbeing. This was a new element. Also it triggered discussions, as people found it relevant, but as you righly point out, many found it difficult to imaging how this was going to be implemented. This was why the LoA was not maximised and triggered a major discussion within the cohort. Please also bear in mind, that only the top competencies were mentioned in the Junge et al. study. Therefore it was indeed one of the top competencies, but with a higher level of variation in its rating. Despite discrepancies, it ranked third among the affective competences, demonstrating the relevance of the new learning activity. Junge et al. also pointed out the difficulty of establishing new affective learning objectives in learning activities, as discussed during data collection. We took this as the starting point for our research to find out what suggestions and ideas young general practitioners have for drawing attention to this learning activity and the needs of the younger generation, in line with the call to action by EURACT in 2019. We have clarified this rationale in the Introduction section of the revised manuscript (see lines 66-70). We hope it is to your agreement.

• Line 74: it should read “curricula”.

 

Thank you for your advice. We have corrected the word into „curricula“ on line 78.

 

• Line 110: there is an extra character at position one.

 

Thank you for noting this. The extra character at the beginning of the sentence on line 112 has been removed, and the sentence has been corrected accordingly.

 

 

 

Reviewer 3: General comments

Thank you for the opportunity to review this manuscript, which addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). This manuscript addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). However, the manuscript, in its current form, presents several methodological and theoretical limitations that, in my view, significantly affect the validity and generalizability of its findings.

We are deeply grateful for the time and effort you have devoted to providing such detailed feedback. We appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honored by the chance to address your concerns. 

Reviewer 3: Specific comments

• The manuscript fails to articulate a clear theoretical framework to guide the study. Specifically, there is no explicit reference to established conceptual models in occupational well-being or medical education. Without a theoretical framework, the rationale for exploring specific learning activities is less robust. In addition, a theoretical model would help explain the mechanisms by which certain interventions are expected to influence well-being, thereby contributing to a better understanding of the results.

We are very grateful for this thoughtful and important comment. We agree that a clear theoretical framework is essential to strengthen the rationale of our study and to support the interpretation of our findings. While we did not explicitly label a theoretical framework in the original manuscript, our study is grounded within an established educational framework, namely the EURACT Educational Agenda, operationalised through the WONCA tree. The WONCA tree provides a widely accepted conceptual model for defining competencies in general practice, including affective competencies, and has been used as a reference framework in prior work by Junge et al. In this context, wellbeing lacked curricular operationalisation. Our study builds on this framework by exploring how this emerging competency could be translated into concrete learning activities from the perspective of early-career GPs. Our focus is not whether the learning activities are all valid, but rather what GPs in training contribute as ideas. This is an important piece in the conversation that will of course need to be met with curricular expertise by educators. Additionally, we have added a sentence see lines 95-96 to explain our theoretical background.

 

 

• The sampling strategy raises significant concerns. Reliance on a very small convenience sample drawn from a pre-conference workshop severely limits the generalizability of the findings to GPs “across Europe” and is also open to bias. More critically, this sampling method introduces a high risk of selection bias (or volunteer bias). The participants likely represent a self-selected cohort that already has a high level of engagement with the topic of well-being. These individuals are likely more motivated, more aware of the challenges, or more proactive in seeking solutions than the broader, “average” target population.

 

We thank you for your insightful comment. We acknowledge that the initial workshop was based on a small convenience sample. To broaden perspectives and enhance representativeness, we complemented the workshop with two rounds of online stakeholder consultation within the EYFDM network. The suggestions generated during the Brussels workshop were subsequently presented to a wider group of participants, increasing the total number of contributors from 22 to 52 across multiple European countries. We recognise that highly engaged general practitioners are more likely to participate in such initiatives, which is an inherent limitation of participatory research. Nevertheless, we made concerted efforts to ensure inclusive participation and transparent reporting of this limitation. We have listed your valuable concern under limitations see lines 309-313.  Thank you for pointing this out. We feel that nevertheless the voice of young GP’s ought to be heard.

 

• The study’s stated focus is on “early-career GPs”. However, including senior GPs and medical students in the stakeholder consultation process introduces heterogeneity, blurring this focus. The authors should provide a more explicit rationale for this mixed cohort.

 

Thank you for your helpful comment. We acknowledge that the incorporation of diverse voices has resulted in a certain degree of heterogeneity, which, nevertheless, aligns with the participatory ethos of the EYFDM Special Interest Group.

It was our intention to include every participant involved in our stakeholder consultations. We believe that even medical students—those in the early stages of their training—have important perspectives to share regarding their future working environment and doctors’ wellbeing. It demonstrates that the absence of wellbeing is not a general medicine concern, but rather a concern that is specific to the field of medicine. This suggests that the cultural challenges specific to medicine do not merely emerge during general medical training but rather are present from the initial stages of medical school. Consequently, its implementation should be initiated at the earliest stage. General practice, as a postgraduate subject, cannot resolve this issue alone; rather, it necessitates comprehensive consideration throughout the medical training curriculum.

Also, comments from older GPs or medical students were analysed separately, to minimise the influence thereof. This concept was incorporated into the 'Strength and Limitations' section of the discussion, given that the qualitative diversity of our data is both a strength and a limitation (see lines 324-328). With reference to methods and participation section, we have mentioned senior or medical students separately. Otherwise, we are referring to the majority of early career GPs.

 

• Many of the core qualitative themes identified—such as the desire for self-reflection, peer exchange, and mentorship—are well-established concepts in the broader literature on professional development and physician well-being. The manuscript’s contribution thus appears largely confirmatory. Consequently, the assertion in the Discussion section that “This study is the first to explore the perspectives…” may be an overstatement.

 

Thank you for this valuable comment. It is true that some of the key ideas have been previously mentioned in the existant literature. However, this study gives young doctors a voice and explicitly listens to their opinions about further training and support, with concrete ideas on how to address this issue. It is therefore the first study to reflect the wishes of young, motivated doctors in Europe, focussing on doctors wellbeing.In order to address your concerns, we have revised the text (see lines 309, 335, 346354-357, 360 and 377).

 

• The definition of well-being is currently presented in an info box in the Introduction section. To enhance the argumentative flow, the Authors should integrate this definition directly into the Introduction.

 

Thank you for your advice. We agree to your suggestion and we leave this at the editor’s discretion. It was mentioned that this might be a more suitable place for the definition. Please let us know what is preferred. We are open to both options.

 

• In the Introduction, the authors state that stand-alone interventions like “resilience training” have shown minimal efficacy. Beyond merely noting their limited efficacy, the Introduction would benefit from a brief reflection on why such approaches are often ineffective.

 

This is an important point and would need additional studies. From exchanges within the community and literature research, the explicit compulsory nature of the learning activity could be a major reason, additionally to time constraints. We have added your suggestion in the introduction see lines 90-91.

 

• In section 3.1. Demographics, the mean age (34.4 years) and range (24 to 64) are reported. The standard deviation (SD) is absent. Why did the authors not report this data?

 

We felt, it may not add additional data to the manuscript. We have added it for your kind consideration on line 182.

 

Reviewer 4: General comments

The manuscript addresses an important topic on integrating wellbeing into GP training, but several major issues require attention before publication. In summary, the manuscript explores an important area but requires major revision to improve conceptual clarity, methodological transparency, and integration of findings. These changes are necessary to strengthen the scientific rigor and credibility of the work.

Dear Reviewer, we sincerely apologize for any shortcomings in our initial submission and are deeply grateful for the time and effort have devoted to providing such thoughtful and detailed feedback. We truly appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honoured by the chance to address your concerns. We have carefully considered each of your comments, and we humbly acknowledge the areas where our work did not fully meet expectations. Revisions have been made with great care and respect for your guidance, with the hope that the updated manuscript better aligns with your standards. We remain truly thankful of your support and the opportunity to improve our work.

Reviewer 4: Specific comments

• On page 2, lines 44–52, the definition of wellbeing is presented broadly, yet the study does not explain how this concept was operationalized for participants. Without a shared definition, responses may reflect inconsistent interpretations, which limits validity and comparability.

 

We appreciate your observation. While we provided a broad definition in the manuscript to introduce the concept, we also presented our specific definition to participants prior to the workshop and obtained their consent on this definition. This ensured that all participants had a shared understanding of wellbeing, and responses were collected based on this agreed-upon framework. Therefore, the definition of wellbeing served as the foundation and starting point of our data collection, improving the validity and comparability of participants’ responses. We have included an explanation in the text (line 123-124).  You rightly said it was difficult to understand this issue from our initial manuscript

 

• On page 3, lines 95–104, the sampling strategy relies on voluntary participation at a conference workshop. This introduces strong selection bias because participants likely had a pre-existing interest in wellbeing. The paper acknowledges the limited sample size but does not sufficiently discuss how this affects generalizability.

 

Thank you for sharing your valuable concerns. We agree that the voluntary recruitment at a conference workshop introduces selection bias, as participants were likely to have a pre-existing interest in wellbeing. Consequently, the findings are not statistically generalisable to all European GPs or GP trainees. The aim of this study was exploratory rather than representative (quantitative). It sought to capture perspectives, experiences, and ideas regarding the integration of wellbeing into GP training, rather than to estimate prevalence or effect sizes. As common in social study research-qualitative quality criteria need to be applied. For this purpose, a participatory approach involving engaged early-career and senior GPs is appropriate and aligns with established qualitative research principles. (Transferability of findingsà by providing rich background and methodology and discussing it in the social context of GPs, we believe we have done that criteria justice.  We have broadened perspectives and enhance representativeness via two rounds of online stakeholder consultations within the EYFDM network. In this context, suggestions explored in Brussels workshop were re-evaluated and validated by a wider group of participants to articulate a more coherent position on behalf of the European community. We have expanded the discussion of selection bias and its implications for transferability in the revised manuscript (lines 319-323).

 

• On pages 3–4, lines 105–132, the description of data collection lacks clarity. It is not clear whether subgroup discussions were fully transcribed or whether researcher notes were used. The process for preserving anonymity during peer-sourced questions also needs more detail to ensure transparency and reproducibility.

 

Thank you for this comment. We have revised the Methods section (Data Collection) to clarify the data collection procedures in more detail. Subgroup discussions were audio-recorded and complemented by researcher notes. Based on these recordings and notes, participant contributions were pseudonymised by assigning quote identifiers in chronological order within each subgroup. We also clarified how anonymity was preserved for peer-sourced questions and how qualitative data were documented and processed. These clarifications are now explicitly described in the revised manuscript (see lines 134-145).

 

• On page 4, lines 142–150, quantitative analysis is mentioned, but the results section does not report any statistical measures beyond simple percentages. For example, on page 6, lines 174–176, percentages are given without confidence intervals or any indication of variability. This limits the strength of quantitative claims.

Thank you for your valuable comment. Given the small sample size and the exploratory nature of this mixed-methods study, we intentionally restricted the quantitative analysis to descriptive statistics. The reported percentages were not intended for inferential interpretation, but to provide contextual insight into the descriptive data and to complement the qualitative findings. We have clarified this in the revised manuscript to avoid any implication of statistical inference or correlation (see lines 161-162).

• Although the study claims a concurrent mixed-methods design, integration of qualitative and quantitative findings is weak. Pages 6–10 present results in parallel rather than synthesizing them to provide deeper insights. The discussion section on pages 10–11, lines 285–337, overstates the novelty and generalizability of findings. Statements such as describing the study as a valuable starting point for integrating wellbeing into GP training should be tempered given the small, self-selected sample and exploratory nature of the work.

Thank you for this important comment. We agree that in the initial version, qualitative and quantitative findings were presented largely in parallel. We have revised the Results section to more explicitly integrate both data strands by highlighting how qualitative findings help explain quantitative patterns (see lines 271-273). In addition, we have tempered the language in the Discussion and Conclusion to better reflect the exploratory nature, limited generalisability, and conceptual rather than generalisable contribution of the study (see lines 309, 315-216, 335-337, 346-348, 354- 357, 360 and 377). This study should be interpreted in light of its exploratory design and self-selected (convenience) sample. While the findings are not statistically generalisable to all GP trainees or general practitioners, they offer conceptually transferable insights into how wellbeing is understood and prioritised by engaged early-career GPs. As such, the results may inform further research and support reflective discussion on the role of wellbeing in GP training rather than serve as definitive curricular guidance.

 

• The role modeling concept described on pages 9–10, lines 251–270, raises practical and ethical concerns. Ideas such as a matching platform similar to dating apps are mentioned without addressing privacy, consent, and professional boundaries. These issues need to be considered before proposing such strategies.

Thank you for raising these important practical and ethical considerations. We fully agree that issues such as privacy, consent, and professional boundaries are essential to address when implementing role modelling–based learning activities. In this study, however, we aimed to report and synthesize ideas and perspectives expressed by young general practitioners rather than to propose or evaluate specific implementation strategies. Assessing feasibility and ethical safeguards would need further research, and input from educationalists and curriculum designers. We have clarified in the revised manuscript (see lines 363-366) that these suggestions should be understood as participant-generated concepts and that ethical and practical considerations would need to be carefully addressed during any subsequent implementation phase.

 

• The introduction on pages 2–3, lines 54–88, cites relevant literature but does not critically engage with conflicting evidence, such as the limited impact of resilience training. A more nuanced synthesis is needed to justify the study’s approach.

Thank you for this important point. As the extant literature also points out, individual stand-alone interventions are not addressing the underlying systematic stress factors. This information has now been incorporated into the introduction (see lines 90-91).

 

• Figures and Table 1 on pages 5–8 are insufficiently explained in the text. Table 1 lists categories and quotes but does not indicate frequency or prioritization, which makes interpretation difficult.

 

Thank you for your comment. We have revised the manuscript by explicitly linking to Figure 1, and then providing a further explanation of the subsequent workshop phases in the text (see line 113). We have also clarified Figure 1, as suggested by Reviewer 1. We have provided a more detailed explanation of Table 1 see lines 200-202. Our study is based on a mixed-methods design, incorporating quantitative (descriptive) and qualitative date. Frequencies and priorisation is a difficult metric in qualitative elements. Our aim was to capture the range, depth, and contextual richness of participants’ perspectives rather than to quantify prevalence. Table 1 is therefore intended to provide an overview of the main qualitative categories and illustrative quotes, highlighting the diversity of ideas and concepts expressed by participants rather than their relative frequency. We have added a explanation into the manuscript.

• Finally, ethical considerations on page 4, lines 134–140, are briefly mentioned, but the manuscript should clarify how confidentiality was maintained during group discussions and online consultations. This is particularly important given the participatory nature of the study.

 

Thank you for this helpful comment. We were able to ensure the confidentiality of the data during the subgroup discussions by pseudonymising individuals within the audio recording based on group classification and comments only prior to data coding. Pseudonymisation was also carried out via Slido. The audio transcription and structured notes taken during the discussion were only available to the researchers. These clarifications are now explicitly described in the revised manuscript (see lines 134-144). During the online consultations, the researcher was unable to draw any conclusions about the identity of the participant, as only descriptive answers about age, country of origin and professional status were provided. We have added this explanation into ethical considerations (see lines 154-157).

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

This mixed-methods study addresses the topic of wellbeing and its integration in GPs training. Based on the findings from Junge et al., the opinion of young physicians were captured qualitatively during a three-stage workshop as part of EYFDM 2023 in Belgium. The Workshop was followed by two consultation rounds with relevant stakeholders. Similar to the teaching of other soft skills such as communication, the need for integration wellbeing in the curricula in all its facets in GP’s training has been identified. A potential approach for integration could be a targeted role-model strategy accompanied by a flexibly usable toolbox. The findings should be viewed as a first step toward the field of medical wellbeing eduaction research. Further research should follow.

The article deals with a highly topical issue in medical education and fits the scope of the journal. The chosen method is appropriate for investigating the research question. The article is clearly written, well structured, and the results are depicted graphically in a vivid manner. The results are discussed in the context of current literature.

I have three specific comments on the article:

1. In the Paper from Junge et al. wellbeing had in the end no consensus for a LoA in the list of  competences. Although the authors use the article as basis for their work, I miss references to this rather important fact either in the Introduction or discussion. Why was the topic wellbeing addressed despite the limited agreement in Junge's article? I assume that the multifaceted but non-consented discussions on the topic were the trigger for the choice. Please clarify.

2. Line 74: it should read “curricula”.

3.Line 110: there is an extra character at position one.

Author Response

 

Revision

Dear Ms. Chu Xu and Reviewers,

Thank you for your structured and insightful work on our paper. It has been instrumental in revising and presenting our work to the best possible extent. Changes to text passages in the manuscript have been marked in yellow. On behalf of all authors, we would like to thank you for your support.

Enclosed you will find our statements and comments on the concrete steps that were taken to incorporate your feedback into the revision.

 

Reviewer 1: General comments

This is very relevant research. Although you are talking about a 'soft' competency, it is a very important, even essential one. This study can be - as you mention it yourself - a first step for a mental shift and a shift in curricula and how curricula are built. I have some comments to improve the manuscript.

Thank you very much for encouraging comment and your suggestions you provided to strengthen our work.  

Reviewer 1: Specific comments

• Line 64 & 65: I think you should mention/refer here already to the manuscript of Junge

Thank you for this helpful suggestion. We agree that an earlier reference to the work by Junge et al. strengthens the contextual framing of the introduction. We have therefore added a reference to Junge et al. see lines 64–65 to highlight the prior identification of wellbeing as a key competency among early-career GPs.

• Line 74: I think this should be curriculA and not curriculAR.

Thank you for pointing this out. We have corrected the wording from “curricular” to “curricula” on line 78.

• you should explain first what EYFDM is; it will not be clear for all readers

Thank you for your advice. The initial explanation of EYFDM can be found in the introduction on line 65.

• participants --> I feel this part is not stating clear enough what all the 'terms' mean. E.g. it is not clear what EYFDM cohort means: line 99 says that it is the Council members + workshop participants, but in line 113: it also refers to Junge's study. I would advise to have a new look at this section and try to re-clarify this.

Thank you for this important comment. We agree that the terminology used in the Participants section was not sufficiently clear and may have led to confusion. We have revised this section (see lines 103-111) to clearly define all participant groups, to distinguish between participants in the present study and those referenced from Junge et al.’s study (line 118), and to ensure consistent use of terminology throughout the manuscript.

• Figure 1: there is a lot of information in it, and can it be that it is a mix of methodology and results? - I do not have the feeling that the figure is clear enough for me

Thank you for this helpful comment. We have revised Figure 1 to focus exclusively on the workshop structure and data collection process. Content related to anticipated benefits, challenges, implementation preferences, and role modelling outcomes has been removed from the figure and is now reported in the methods and results section. This revision improves readability and ensures a clear distinction between methodology and findings.

 

Reviewer 2: General comments

Dear authors,

This mixed-methods study addresses the topic of wellbeing and its integration in GPs training. Based on the findings from Junge et al., the opinion of young physicians was captured qualitatively during a three-stage workshop as part of EYFDM 2023 in Belgium. The Workshop was followed by two consultation rounds with relevant stakeholders. Similar to the teaching of other soft skills such as communication, the need for integration wellbeing in the curricula in all its facets in GP’s training has been identified. A potential approach for integration could be a targeted role-model strategy accompanied by a flexibly usable toolbox. The findings should be viewed as a first step toward the field of medical wellbeing education research. Further research should follow.

The article deals with a highly topical issue in medical education and fits the scope of the journal. The chosen method is appropriate for investigating the research question. The article is clearly written, well structured, and the results are depicted graphically in a vivid manner. The results are discussed in the context of current literature.

We would like to thank you for this positive evaluation of our manuscript. We appreciate the recognition of the relevance of the topic, the choice of the mixed-methods approach, and the clarity of the manuscript structure and graphical presentation. We are particularly grateful for the acknowledgement of the study’s positioning as an initial step in the emerging field of medical wellbeing education research. We have carefully considered your specific comments and have revised the manuscript accordingly to further improve clarity, methodological transparency, and the distinction between methods and results.

Reviewer 2: Specific comments

• In the Paper from Junge et al. wellbeing had in the end no consensus for a LoA in the list of competences. Although the authors use the article as basis for their work, I miss references to this rather important fact either in the Introduction or discussion. Why was the topic wellbeing addressed despite the limited agreement in Junge's article? I assume that the multifaceted but non-consented discussions on the topic were the trigger for the choice. Please clarify.

Thank you for highlighting this important point. The discussion during data collection by Junge et al. showed that specifically doctors´wellbeing as a competence had not previously been mentioned in the literature as equally important to patients wellbeing. This was a new element. Also it triggered discussions, as people found it relevant, but as you righly point out, many found it difficult to imaging how this was going to be implemented. This was why the LoA was not maximised and triggered a major discussion within the cohort. Please also bear in mind, that only the top competencies were mentioned in the Junge et al. study. Therefore it was indeed one of the top competencies, but with a higher level of variation in its rating. Despite discrepancies, it ranked third among the affective competences, demonstrating the relevance of the new learning activity. Junge et al. also pointed out the difficulty of establishing new affective learning objectives in learning activities, as discussed during data collection. We took this as the starting point for our research to find out what suggestions and ideas young general practitioners have for drawing attention to this learning activity and the needs of the younger generation, in line with the call to action by EURACT in 2019. We have clarified this rationale in the Introduction section of the revised manuscript (see lines 66-70). We hope it is to your agreement.

• Line 74: it should read “curricula”.

 

Thank you for your advice. We have corrected the word into „curricula“ on line 78.

 

• Line 110: there is an extra character at position one.

 

Thank you for noting this. The extra character at the beginning of the sentence on line 112 has been removed, and the sentence has been corrected accordingly.

 

 

 

Reviewer 3: General comments

Thank you for the opportunity to review this manuscript, which addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). This manuscript addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). However, the manuscript, in its current form, presents several methodological and theoretical limitations that, in my view, significantly affect the validity and generalizability of its findings.

We are deeply grateful for the time and effort you have devoted to providing such detailed feedback. We appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honored by the chance to address your concerns. 

Reviewer 3: Specific comments

• The manuscript fails to articulate a clear theoretical framework to guide the study. Specifically, there is no explicit reference to established conceptual models in occupational well-being or medical education. Without a theoretical framework, the rationale for exploring specific learning activities is less robust. In addition, a theoretical model would help explain the mechanisms by which certain interventions are expected to influence well-being, thereby contributing to a better understanding of the results.

We are very grateful for this thoughtful and important comment. We agree that a clear theoretical framework is essential to strengthen the rationale of our study and to support the interpretation of our findings. While we did not explicitly label a theoretical framework in the original manuscript, our study is grounded within an established educational framework, namely the EURACT Educational Agenda, operationalised through the WONCA tree. The WONCA tree provides a widely accepted conceptual model for defining competencies in general practice, including affective competencies, and has been used as a reference framework in prior work by Junge et al. In this context, wellbeing lacked curricular operationalisation. Our study builds on this framework by exploring how this emerging competency could be translated into concrete learning activities from the perspective of early-career GPs. Our focus is not whether the learning activities are all valid, but rather what GPs in training contribute as ideas. This is an important piece in the conversation that will of course need to be met with curricular expertise by educators. Additionally, we have added a sentence see lines 95-96 to explain our theoretical background.

 

 

• The sampling strategy raises significant concerns. Reliance on a very small convenience sample drawn from a pre-conference workshop severely limits the generalizability of the findings to GPs “across Europe” and is also open to bias. More critically, this sampling method introduces a high risk of selection bias (or volunteer bias). The participants likely represent a self-selected cohort that already has a high level of engagement with the topic of well-being. These individuals are likely more motivated, more aware of the challenges, or more proactive in seeking solutions than the broader, “average” target population.

 

We thank you for your insightful comment. We acknowledge that the initial workshop was based on a small convenience sample. To broaden perspectives and enhance representativeness, we complemented the workshop with two rounds of online stakeholder consultation within the EYFDM network. The suggestions generated during the Brussels workshop were subsequently presented to a wider group of participants, increasing the total number of contributors from 22 to 52 across multiple European countries. We recognise that highly engaged general practitioners are more likely to participate in such initiatives, which is an inherent limitation of participatory research. Nevertheless, we made concerted efforts to ensure inclusive participation and transparent reporting of this limitation. We have listed your valuable concern under limitations see lines 309-313.  Thank you for pointing this out. We feel that nevertheless the voice of young GP’s ought to be heard.

 

• The study’s stated focus is on “early-career GPs”. However, including senior GPs and medical students in the stakeholder consultation process introduces heterogeneity, blurring this focus. The authors should provide a more explicit rationale for this mixed cohort.

 

Thank you for your helpful comment. We acknowledge that the incorporation of diverse voices has resulted in a certain degree of heterogeneity, which, nevertheless, aligns with the participatory ethos of the EYFDM Special Interest Group.

It was our intention to include every participant involved in our stakeholder consultations. We believe that even medical students—those in the early stages of their training—have important perspectives to share regarding their future working environment and doctors’ wellbeing. It demonstrates that the absence of wellbeing is not a general medicine concern, but rather a concern that is specific to the field of medicine. This suggests that the cultural challenges specific to medicine do not merely emerge during general medical training but rather are present from the initial stages of medical school. Consequently, its implementation should be initiated at the earliest stage. General practice, as a postgraduate subject, cannot resolve this issue alone; rather, it necessitates comprehensive consideration throughout the medical training curriculum.

Also, comments from older GPs or medical students were analysed separately, to minimise the influence thereof. This concept was incorporated into the 'Strength and Limitations' section of the discussion, given that the qualitative diversity of our data is both a strength and a limitation (see lines 324-328). With reference to methods and participation section, we have mentioned senior or medical students separately. Otherwise, we are referring to the majority of early career GPs.

 

• Many of the core qualitative themes identified—such as the desire for self-reflection, peer exchange, and mentorship—are well-established concepts in the broader literature on professional development and physician well-being. The manuscript’s contribution thus appears largely confirmatory. Consequently, the assertion in the Discussion section that “This study is the first to explore the perspectives…” may be an overstatement.

 

Thank you for this valuable comment. It is true that some of the key ideas have been previously mentioned in the existant literature. However, this study gives young doctors a voice and explicitly listens to their opinions about further training and support, with concrete ideas on how to address this issue. It is therefore the first study to reflect the wishes of young, motivated doctors in Europe, focussing on doctors wellbeing.In order to address your concerns, we have revised the text (see lines 309, 335, 346354-357, 360 and 377).

 

• The definition of well-being is currently presented in an info box in the Introduction section. To enhance the argumentative flow, the Authors should integrate this definition directly into the Introduction.

 

Thank you for your advice. We agree to your suggestion and we leave this at the editor’s discretion. It was mentioned that this might be a more suitable place for the definition. Please let us know what is preferred. We are open to both options.

 

• In the Introduction, the authors state that stand-alone interventions like “resilience training” have shown minimal efficacy. Beyond merely noting their limited efficacy, the Introduction would benefit from a brief reflection on why such approaches are often ineffective.

 

This is an important point and would need additional studies. From exchanges within the community and literature research, the explicit compulsory nature of the learning activity could be a major reason, additionally to time constraints. We have added your suggestion in the introduction see lines 90-91.

 

• In section 3.1. Demographics, the mean age (34.4 years) and range (24 to 64) are reported. The standard deviation (SD) is absent. Why did the authors not report this data?

 

We felt, it may not add additional data to the manuscript. We have added it for your kind consideration on line 182.

 

Reviewer 4: General comments

The manuscript addresses an important topic on integrating wellbeing into GP training, but several major issues require attention before publication. In summary, the manuscript explores an important area but requires major revision to improve conceptual clarity, methodological transparency, and integration of findings. These changes are necessary to strengthen the scientific rigor and credibility of the work.

Dear Reviewer, we sincerely apologize for any shortcomings in our initial submission and are deeply grateful for the time and effort have devoted to providing such thoughtful and detailed feedback. We truly appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honoured by the chance to address your concerns. We have carefully considered each of your comments, and we humbly acknowledge the areas where our work did not fully meet expectations. Revisions have been made with great care and respect for your guidance, with the hope that the updated manuscript better aligns with your standards. We remain truly thankful of your support and the opportunity to improve our work.

Reviewer 4: Specific comments

• On page 2, lines 44–52, the definition of wellbeing is presented broadly, yet the study does not explain how this concept was operationalized for participants. Without a shared definition, responses may reflect inconsistent interpretations, which limits validity and comparability.

 

We appreciate your observation. While we provided a broad definition in the manuscript to introduce the concept, we also presented our specific definition to participants prior to the workshop and obtained their consent on this definition. This ensured that all participants had a shared understanding of wellbeing, and responses were collected based on this agreed-upon framework. Therefore, the definition of wellbeing served as the foundation and starting point of our data collection, improving the validity and comparability of participants’ responses. We have included an explanation in the text (line 123-124).  You rightly said it was difficult to understand this issue from our initial manuscript

 

• On page 3, lines 95–104, the sampling strategy relies on voluntary participation at a conference workshop. This introduces strong selection bias because participants likely had a pre-existing interest in wellbeing. The paper acknowledges the limited sample size but does not sufficiently discuss how this affects generalizability.

 

Thank you for sharing your valuable concerns. We agree that the voluntary recruitment at a conference workshop introduces selection bias, as participants were likely to have a pre-existing interest in wellbeing. Consequently, the findings are not statistically generalisable to all European GPs or GP trainees. The aim of this study was exploratory rather than representative (quantitative). It sought to capture perspectives, experiences, and ideas regarding the integration of wellbeing into GP training, rather than to estimate prevalence or effect sizes. As common in social study research-qualitative quality criteria need to be applied. For this purpose, a participatory approach involving engaged early-career and senior GPs is appropriate and aligns with established qualitative research principles. (Transferability of findingsà by providing rich background and methodology and discussing it in the social context of GPs, we believe we have done that criteria justice.  We have broadened perspectives and enhance representativeness via two rounds of online stakeholder consultations within the EYFDM network. In this context, suggestions explored in Brussels workshop were re-evaluated and validated by a wider group of participants to articulate a more coherent position on behalf of the European community. We have expanded the discussion of selection bias and its implications for transferability in the revised manuscript (lines 319-323).

 

• On pages 3–4, lines 105–132, the description of data collection lacks clarity. It is not clear whether subgroup discussions were fully transcribed or whether researcher notes were used. The process for preserving anonymity during peer-sourced questions also needs more detail to ensure transparency and reproducibility.

 

Thank you for this comment. We have revised the Methods section (Data Collection) to clarify the data collection procedures in more detail. Subgroup discussions were audio-recorded and complemented by researcher notes. Based on these recordings and notes, participant contributions were pseudonymised by assigning quote identifiers in chronological order within each subgroup. We also clarified how anonymity was preserved for peer-sourced questions and how qualitative data were documented and processed. These clarifications are now explicitly described in the revised manuscript (see lines 134-145).

 

• On page 4, lines 142–150, quantitative analysis is mentioned, but the results section does not report any statistical measures beyond simple percentages. For example, on page 6, lines 174–176, percentages are given without confidence intervals or any indication of variability. This limits the strength of quantitative claims.

Thank you for your valuable comment. Given the small sample size and the exploratory nature of this mixed-methods study, we intentionally restricted the quantitative analysis to descriptive statistics. The reported percentages were not intended for inferential interpretation, but to provide contextual insight into the descriptive data and to complement the qualitative findings. We have clarified this in the revised manuscript to avoid any implication of statistical inference or correlation (see lines 161-162).

• Although the study claims a concurrent mixed-methods design, integration of qualitative and quantitative findings is weak. Pages 6–10 present results in parallel rather than synthesizing them to provide deeper insights. The discussion section on pages 10–11, lines 285–337, overstates the novelty and generalizability of findings. Statements such as describing the study as a valuable starting point for integrating wellbeing into GP training should be tempered given the small, self-selected sample and exploratory nature of the work.

Thank you for this important comment. We agree that in the initial version, qualitative and quantitative findings were presented largely in parallel. We have revised the Results section to more explicitly integrate both data strands by highlighting how qualitative findings help explain quantitative patterns (see lines 271-273). In addition, we have tempered the language in the Discussion and Conclusion to better reflect the exploratory nature, limited generalisability, and conceptual rather than generalisable contribution of the study (see lines 309, 315-216, 335-337, 346-348, 354- 357, 360 and 377). This study should be interpreted in light of its exploratory design and self-selected (convenience) sample. While the findings are not statistically generalisable to all GP trainees or general practitioners, they offer conceptually transferable insights into how wellbeing is understood and prioritised by engaged early-career GPs. As such, the results may inform further research and support reflective discussion on the role of wellbeing in GP training rather than serve as definitive curricular guidance.

 

• The role modeling concept described on pages 9–10, lines 251–270, raises practical and ethical concerns. Ideas such as a matching platform similar to dating apps are mentioned without addressing privacy, consent, and professional boundaries. These issues need to be considered before proposing such strategies.

Thank you for raising these important practical and ethical considerations. We fully agree that issues such as privacy, consent, and professional boundaries are essential to address when implementing role modelling–based learning activities. In this study, however, we aimed to report and synthesize ideas and perspectives expressed by young general practitioners rather than to propose or evaluate specific implementation strategies. Assessing feasibility and ethical safeguards would need further research, and input from educationalists and curriculum designers. We have clarified in the revised manuscript (see lines 363-366) that these suggestions should be understood as participant-generated concepts and that ethical and practical considerations would need to be carefully addressed during any subsequent implementation phase.

 

• The introduction on pages 2–3, lines 54–88, cites relevant literature but does not critically engage with conflicting evidence, such as the limited impact of resilience training. A more nuanced synthesis is needed to justify the study’s approach.

Thank you for this important point. As the extant literature also points out, individual stand-alone interventions are not addressing the underlying systematic stress factors. This information has now been incorporated into the introduction (see lines 90-91).

 

• Figures and Table 1 on pages 5–8 are insufficiently explained in the text. Table 1 lists categories and quotes but does not indicate frequency or prioritization, which makes interpretation difficult.

 

Thank you for your comment. We have revised the manuscript by explicitly linking to Figure 1, and then providing a further explanation of the subsequent workshop phases in the text (see line 113). We have also clarified Figure 1, as suggested by Reviewer 1. We have provided a more detailed explanation of Table 1 see lines 200-202. Our study is based on a mixed-methods design, incorporating quantitative (descriptive) and qualitative date. Frequencies and priorisation is a difficult metric in qualitative elements. Our aim was to capture the range, depth, and contextual richness of participants’ perspectives rather than to quantify prevalence. Table 1 is therefore intended to provide an overview of the main qualitative categories and illustrative quotes, highlighting the diversity of ideas and concepts expressed by participants rather than their relative frequency. We have added a explanation into the manuscript.

• Finally, ethical considerations on page 4, lines 134–140, are briefly mentioned, but the manuscript should clarify how confidentiality was maintained during group discussions and online consultations. This is particularly important given the participatory nature of the study.

 

Thank you for this helpful comment. We were able to ensure the confidentiality of the data during the subgroup discussions by pseudonymising individuals within the audio recording based on group classification and comments only prior to data coding. Pseudonymisation was also carried out via Slido. The audio transcription and structured notes taken during the discussion were only available to the researchers. These clarifications are now explicitly described in the revised manuscript (see lines 134-144). During the online consultations, the researcher was unable to draw any conclusions about the identity of the participant, as only descriptive answers about age, country of origin and professional status were provided. We have added this explanation into ethical considerations (see lines 154-157).

 

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript, which addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). This manuscript addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). However, the manuscript, in its current form, presents several methodological and theoretical limitations that, in my view, significantly affect the validity and generalizability of its findings.

Point 1. The manuscript fails to articulate a clear theoretical framework to guide the study. Specifically, there is no explicit reference to established conceptual models in occupational well-being or medical education. Without a theoretical framework, the rationale for exploring specific learning activities is less robust. In addition, a theoretical model would help explain the mechanisms by which certain interventions are expected to influence well-being, thereby contributing to a better understanding of the results.

Point 2. The sampling strategy raises significant concerns. Reliance on a very small convenience sample drawn from a pre-conference workshop severely limits the generalizability of the findings to GPs “across Europe” and is also open to bias. More critically, this sampling method introduces a high risk of selection bias (or volunteer bias). The participants likely represent a self-selected cohort that already has a high level of engagement with the topic of well-being. These individuals are likely more motivated, more aware of the challenges, or more proactive in seeking solutions than the broader, “average” target population.

Point 3. The study’s stated focus is on “early-career GPs”. However, including senior GPs and medical students in the stakeholder consultation process introduces heterogeneity, blurring this focus. The authors should provide a more explicit rationale for this mixed cohort.

Point 4. Many of the core qualitative themes identified—such as the desire for self-reflection, peer exchange, and mentorship—are well-established concepts in the broader literature on professional development and physician well-being. The manuscript’s contribution thus appears largely confirmatory. Consequently, the assertion in the Discussion section that “This study is the first to explore the perspectives…” may be an overstatement.

Point 5. The definition of well-being is currently presented in an info box in the Introduction section. To enhance the argumentative flow, the Authors should integrate this definition directly into the Introduction.

Point 6. In the Introduction, the authors state that stand-alone interventions like “resilience training” have shown minimal efficacy. Beyond merely noting their limited efficacy, the Introduction would benefit from a brief reflection on why such approaches are often ineffective.

Point 7. In section 3.1. Demographics, the mean age (34.4 years) and range (24 to 64) are reported. The standard deviation (SD) is absent. Why did the authors not report this data?

Author Response

 

Revision

Dear Ms. Chu Xu and Reviewers,

Thank you for your structured and insightful work on our paper. It has been instrumental in revising and presenting our work to the best possible extent. Changes to text passages in the manuscript have been marked in yellow. On behalf of all authors, we would like to thank you for your support.

Enclosed you will find our statements and comments on the concrete steps that were taken to incorporate your feedback into the revision.

 

Reviewer 1: General comments

This is very relevant research. Although you are talking about a 'soft' competency, it is a very important, even essential one. This study can be - as you mention it yourself - a first step for a mental shift and a shift in curricula and how curricula are built. I have some comments to improve the manuscript.

Thank you very much for encouraging comment and your suggestions you provided to strengthen our work.  

Reviewer 1: Specific comments

• Line 64 & 65: I think you should mention/refer here already to the manuscript of Junge

Thank you for this helpful suggestion. We agree that an earlier reference to the work by Junge et al. strengthens the contextual framing of the introduction. We have therefore added a reference to Junge et al. see lines 64–65 to highlight the prior identification of wellbeing as a key competency among early-career GPs.

• Line 74: I think this should be curriculA and not curriculAR.

Thank you for pointing this out. We have corrected the wording from “curricular” to “curricula” on line 78.

• you should explain first what EYFDM is; it will not be clear for all readers

Thank you for your advice. The initial explanation of EYFDM can be found in the introduction on line 65.

• participants --> I feel this part is not stating clear enough what all the 'terms' mean. E.g. it is not clear what EYFDM cohort means: line 99 says that it is the Council members + workshop participants, but in line 113: it also refers to Junge's study. I would advise to have a new look at this section and try to re-clarify this.

Thank you for this important comment. We agree that the terminology used in the Participants section was not sufficiently clear and may have led to confusion. We have revised this section (see lines 103-111) to clearly define all participant groups, to distinguish between participants in the present study and those referenced from Junge et al.’s study (line 118), and to ensure consistent use of terminology throughout the manuscript.

• Figure 1: there is a lot of information in it, and can it be that it is a mix of methodology and results? - I do not have the feeling that the figure is clear enough for me

Thank you for this helpful comment. We have revised Figure 1 to focus exclusively on the workshop structure and data collection process. Content related to anticipated benefits, challenges, implementation preferences, and role modelling outcomes has been removed from the figure and is now reported in the methods and results section. This revision improves readability and ensures a clear distinction between methodology and findings.

 

Reviewer 2: General comments

Dear authors,

This mixed-methods study addresses the topic of wellbeing and its integration in GPs training. Based on the findings from Junge et al., the opinion of young physicians was captured qualitatively during a three-stage workshop as part of EYFDM 2023 in Belgium. The Workshop was followed by two consultation rounds with relevant stakeholders. Similar to the teaching of other soft skills such as communication, the need for integration wellbeing in the curricula in all its facets in GP’s training has been identified. A potential approach for integration could be a targeted role-model strategy accompanied by a flexibly usable toolbox. The findings should be viewed as a first step toward the field of medical wellbeing education research. Further research should follow.

The article deals with a highly topical issue in medical education and fits the scope of the journal. The chosen method is appropriate for investigating the research question. The article is clearly written, well structured, and the results are depicted graphically in a vivid manner. The results are discussed in the context of current literature.

We would like to thank you for this positive evaluation of our manuscript. We appreciate the recognition of the relevance of the topic, the choice of the mixed-methods approach, and the clarity of the manuscript structure and graphical presentation. We are particularly grateful for the acknowledgement of the study’s positioning as an initial step in the emerging field of medical wellbeing education research. We have carefully considered your specific comments and have revised the manuscript accordingly to further improve clarity, methodological transparency, and the distinction between methods and results.

Reviewer 2: Specific comments

• In the Paper from Junge et al. wellbeing had in the end no consensus for a LoA in the list of competences. Although the authors use the article as basis for their work, I miss references to this rather important fact either in the Introduction or discussion. Why was the topic wellbeing addressed despite the limited agreement in Junge's article? I assume that the multifaceted but non-consented discussions on the topic were the trigger for the choice. Please clarify.

Thank you for highlighting this important point. The discussion during data collection by Junge et al. showed that specifically doctors´wellbeing as a competence had not previously been mentioned in the literature as equally important to patients wellbeing. This was a new element. Also it triggered discussions, as people found it relevant, but as you righly point out, many found it difficult to imaging how this was going to be implemented. This was why the LoA was not maximised and triggered a major discussion within the cohort. Please also bear in mind, that only the top competencies were mentioned in the Junge et al. study. Therefore it was indeed one of the top competencies, but with a higher level of variation in its rating. Despite discrepancies, it ranked third among the affective competences, demonstrating the relevance of the new learning activity. Junge et al. also pointed out the difficulty of establishing new affective learning objectives in learning activities, as discussed during data collection. We took this as the starting point for our research to find out what suggestions and ideas young general practitioners have for drawing attention to this learning activity and the needs of the younger generation, in line with the call to action by EURACT in 2019. We have clarified this rationale in the Introduction section of the revised manuscript (see lines 66-70). We hope it is to your agreement.

• Line 74: it should read “curricula”.

 

Thank you for your advice. We have corrected the word into „curricula“ on line 78.

 

• Line 110: there is an extra character at position one.

 

Thank you for noting this. The extra character at the beginning of the sentence on line 112 has been removed, and the sentence has been corrected accordingly.

 

 

 

Reviewer 3: General comments

Thank you for the opportunity to review this manuscript, which addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). This manuscript addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). However, the manuscript, in its current form, presents several methodological and theoretical limitations that, in my view, significantly affect the validity and generalizability of its findings.

We are deeply grateful for the time and effort you have devoted to providing such detailed feedback. We appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honored by the chance to address your concerns. 

Reviewer 3: Specific comments

• The manuscript fails to articulate a clear theoretical framework to guide the study. Specifically, there is no explicit reference to established conceptual models in occupational well-being or medical education. Without a theoretical framework, the rationale for exploring specific learning activities is less robust. In addition, a theoretical model would help explain the mechanisms by which certain interventions are expected to influence well-being, thereby contributing to a better understanding of the results.

We are very grateful for this thoughtful and important comment. We agree that a clear theoretical framework is essential to strengthen the rationale of our study and to support the interpretation of our findings. While we did not explicitly label a theoretical framework in the original manuscript, our study is grounded within an established educational framework, namely the EURACT Educational Agenda, operationalised through the WONCA tree. The WONCA tree provides a widely accepted conceptual model for defining competencies in general practice, including affective competencies, and has been used as a reference framework in prior work by Junge et al. In this context, wellbeing lacked curricular operationalisation. Our study builds on this framework by exploring how this emerging competency could be translated into concrete learning activities from the perspective of early-career GPs. Our focus is not whether the learning activities are all valid, but rather what GPs in training contribute as ideas. This is an important piece in the conversation that will of course need to be met with curricular expertise by educators. Additionally, we have added a sentence see lines 95-96 to explain our theoretical background.

 

 

• The sampling strategy raises significant concerns. Reliance on a very small convenience sample drawn from a pre-conference workshop severely limits the generalizability of the findings to GPs “across Europe” and is also open to bias. More critically, this sampling method introduces a high risk of selection bias (or volunteer bias). The participants likely represent a self-selected cohort that already has a high level of engagement with the topic of well-being. These individuals are likely more motivated, more aware of the challenges, or more proactive in seeking solutions than the broader, “average” target population.

 

We thank you for your insightful comment. We acknowledge that the initial workshop was based on a small convenience sample. To broaden perspectives and enhance representativeness, we complemented the workshop with two rounds of online stakeholder consultation within the EYFDM network. The suggestions generated during the Brussels workshop were subsequently presented to a wider group of participants, increasing the total number of contributors from 22 to 52 across multiple European countries. We recognise that highly engaged general practitioners are more likely to participate in such initiatives, which is an inherent limitation of participatory research. Nevertheless, we made concerted efforts to ensure inclusive participation and transparent reporting of this limitation. We have listed your valuable concern under limitations see lines 309-313.  Thank you for pointing this out. We feel that nevertheless the voice of young GP’s ought to be heard.

 

• The study’s stated focus is on “early-career GPs”. However, including senior GPs and medical students in the stakeholder consultation process introduces heterogeneity, blurring this focus. The authors should provide a more explicit rationale for this mixed cohort.

 

Thank you for your helpful comment. We acknowledge that the incorporation of diverse voices has resulted in a certain degree of heterogeneity, which, nevertheless, aligns with the participatory ethos of the EYFDM Special Interest Group.

It was our intention to include every participant involved in our stakeholder consultations. We believe that even medical students—those in the early stages of their training—have important perspectives to share regarding their future working environment and doctors’ wellbeing. It demonstrates that the absence of wellbeing is not a general medicine concern, but rather a concern that is specific to the field of medicine. This suggests that the cultural challenges specific to medicine do not merely emerge during general medical training but rather are present from the initial stages of medical school. Consequently, its implementation should be initiated at the earliest stage. General practice, as a postgraduate subject, cannot resolve this issue alone; rather, it necessitates comprehensive consideration throughout the medical training curriculum.

Also, comments from older GPs or medical students were analysed separately, to minimise the influence thereof. This concept was incorporated into the 'Strength and Limitations' section of the discussion, given that the qualitative diversity of our data is both a strength and a limitation (see lines 324-328). With reference to methods and participation section, we have mentioned senior or medical students separately. Otherwise, we are referring to the majority of early career GPs.

 

• Many of the core qualitative themes identified—such as the desire for self-reflection, peer exchange, and mentorship—are well-established concepts in the broader literature on professional development and physician well-being. The manuscript’s contribution thus appears largely confirmatory. Consequently, the assertion in the Discussion section that “This study is the first to explore the perspectives…” may be an overstatement.

 

Thank you for this valuable comment. It is true that some of the key ideas have been previously mentioned in the existant literature. However, this study gives young doctors a voice and explicitly listens to their opinions about further training and support, with concrete ideas on how to address this issue. It is therefore the first study to reflect the wishes of young, motivated doctors in Europe, focussing on doctors wellbeing.In order to address your concerns, we have revised the text (see lines 309, 335, 346354-357, 360 and 377).

 

• The definition of well-being is currently presented in an info box in the Introduction section. To enhance the argumentative flow, the Authors should integrate this definition directly into the Introduction.

 

Thank you for your advice. We agree to your suggestion and we leave this at the editor’s discretion. It was mentioned that this might be a more suitable place for the definition. Please let us know what is preferred. We are open to both options.

 

• In the Introduction, the authors state that stand-alone interventions like “resilience training” have shown minimal efficacy. Beyond merely noting their limited efficacy, the Introduction would benefit from a brief reflection on why such approaches are often ineffective.

 

This is an important point and would need additional studies. From exchanges within the community and literature research, the explicit compulsory nature of the learning activity could be a major reason, additionally to time constraints. We have added your suggestion in the introduction see lines 90-91.

 

• In section 3.1. Demographics, the mean age (34.4 years) and range (24 to 64) are reported. The standard deviation (SD) is absent. Why did the authors not report this data?

 

We felt, it may not add additional data to the manuscript. We have added it for your kind consideration on line 182.

 

Reviewer 4: General comments

The manuscript addresses an important topic on integrating wellbeing into GP training, but several major issues require attention before publication. In summary, the manuscript explores an important area but requires major revision to improve conceptual clarity, methodological transparency, and integration of findings. These changes are necessary to strengthen the scientific rigor and credibility of the work.

Dear Reviewer, we sincerely apologize for any shortcomings in our initial submission and are deeply grateful for the time and effort have devoted to providing such thoughtful and detailed feedback. We truly appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honoured by the chance to address your concerns. We have carefully considered each of your comments, and we humbly acknowledge the areas where our work did not fully meet expectations. Revisions have been made with great care and respect for your guidance, with the hope that the updated manuscript better aligns with your standards. We remain truly thankful of your support and the opportunity to improve our work.

Reviewer 4: Specific comments

• On page 2, lines 44–52, the definition of wellbeing is presented broadly, yet the study does not explain how this concept was operationalized for participants. Without a shared definition, responses may reflect inconsistent interpretations, which limits validity and comparability.

 

We appreciate your observation. While we provided a broad definition in the manuscript to introduce the concept, we also presented our specific definition to participants prior to the workshop and obtained their consent on this definition. This ensured that all participants had a shared understanding of wellbeing, and responses were collected based on this agreed-upon framework. Therefore, the definition of wellbeing served as the foundation and starting point of our data collection, improving the validity and comparability of participants’ responses. We have included an explanation in the text (line 123-124).  You rightly said it was difficult to understand this issue from our initial manuscript

 

• On page 3, lines 95–104, the sampling strategy relies on voluntary participation at a conference workshop. This introduces strong selection bias because participants likely had a pre-existing interest in wellbeing. The paper acknowledges the limited sample size but does not sufficiently discuss how this affects generalizability.

 

Thank you for sharing your valuable concerns. We agree that the voluntary recruitment at a conference workshop introduces selection bias, as participants were likely to have a pre-existing interest in wellbeing. Consequently, the findings are not statistically generalisable to all European GPs or GP trainees. The aim of this study was exploratory rather than representative (quantitative). It sought to capture perspectives, experiences, and ideas regarding the integration of wellbeing into GP training, rather than to estimate prevalence or effect sizes. As common in social study research-qualitative quality criteria need to be applied. For this purpose, a participatory approach involving engaged early-career and senior GPs is appropriate and aligns with established qualitative research principles. (Transferability of findingsà by providing rich background and methodology and discussing it in the social context of GPs, we believe we have done that criteria justice.  We have broadened perspectives and enhance representativeness via two rounds of online stakeholder consultations within the EYFDM network. In this context, suggestions explored in Brussels workshop were re-evaluated and validated by a wider group of participants to articulate a more coherent position on behalf of the European community. We have expanded the discussion of selection bias and its implications for transferability in the revised manuscript (lines 319-323).

 

• On pages 3–4, lines 105–132, the description of data collection lacks clarity. It is not clear whether subgroup discussions were fully transcribed or whether researcher notes were used. The process for preserving anonymity during peer-sourced questions also needs more detail to ensure transparency and reproducibility.

 

Thank you for this comment. We have revised the Methods section (Data Collection) to clarify the data collection procedures in more detail. Subgroup discussions were audio-recorded and complemented by researcher notes. Based on these recordings and notes, participant contributions were pseudonymised by assigning quote identifiers in chronological order within each subgroup. We also clarified how anonymity was preserved for peer-sourced questions and how qualitative data were documented and processed. These clarifications are now explicitly described in the revised manuscript (see lines 134-145).

 

• On page 4, lines 142–150, quantitative analysis is mentioned, but the results section does not report any statistical measures beyond simple percentages. For example, on page 6, lines 174–176, percentages are given without confidence intervals or any indication of variability. This limits the strength of quantitative claims.

Thank you for your valuable comment. Given the small sample size and the exploratory nature of this mixed-methods study, we intentionally restricted the quantitative analysis to descriptive statistics. The reported percentages were not intended for inferential interpretation, but to provide contextual insight into the descriptive data and to complement the qualitative findings. We have clarified this in the revised manuscript to avoid any implication of statistical inference or correlation (see lines 161-162).

• Although the study claims a concurrent mixed-methods design, integration of qualitative and quantitative findings is weak. Pages 6–10 present results in parallel rather than synthesizing them to provide deeper insights. The discussion section on pages 10–11, lines 285–337, overstates the novelty and generalizability of findings. Statements such as describing the study as a valuable starting point for integrating wellbeing into GP training should be tempered given the small, self-selected sample and exploratory nature of the work.

Thank you for this important comment. We agree that in the initial version, qualitative and quantitative findings were presented largely in parallel. We have revised the Results section to more explicitly integrate both data strands by highlighting how qualitative findings help explain quantitative patterns (see lines 271-273). In addition, we have tempered the language in the Discussion and Conclusion to better reflect the exploratory nature, limited generalisability, and conceptual rather than generalisable contribution of the study (see lines 309, 315-216, 335-337, 346-348, 354- 357, 360 and 377). This study should be interpreted in light of its exploratory design and self-selected (convenience) sample. While the findings are not statistically generalisable to all GP trainees or general practitioners, they offer conceptually transferable insights into how wellbeing is understood and prioritised by engaged early-career GPs. As such, the results may inform further research and support reflective discussion on the role of wellbeing in GP training rather than serve as definitive curricular guidance.

 

• The role modeling concept described on pages 9–10, lines 251–270, raises practical and ethical concerns. Ideas such as a matching platform similar to dating apps are mentioned without addressing privacy, consent, and professional boundaries. These issues need to be considered before proposing such strategies.

Thank you for raising these important practical and ethical considerations. We fully agree that issues such as privacy, consent, and professional boundaries are essential to address when implementing role modelling–based learning activities. In this study, however, we aimed to report and synthesize ideas and perspectives expressed by young general practitioners rather than to propose or evaluate specific implementation strategies. Assessing feasibility and ethical safeguards would need further research, and input from educationalists and curriculum designers. We have clarified in the revised manuscript (see lines 363-366) that these suggestions should be understood as participant-generated concepts and that ethical and practical considerations would need to be carefully addressed during any subsequent implementation phase.

 

• The introduction on pages 2–3, lines 54–88, cites relevant literature but does not critically engage with conflicting evidence, such as the limited impact of resilience training. A more nuanced synthesis is needed to justify the study’s approach.

Thank you for this important point. As the extant literature also points out, individual stand-alone interventions are not addressing the underlying systematic stress factors. This information has now been incorporated into the introduction (see lines 90-91).

 

• Figures and Table 1 on pages 5–8 are insufficiently explained in the text. Table 1 lists categories and quotes but does not indicate frequency or prioritization, which makes interpretation difficult.

 

Thank you for your comment. We have revised the manuscript by explicitly linking to Figure 1, and then providing a further explanation of the subsequent workshop phases in the text (see line 113). We have also clarified Figure 1, as suggested by Reviewer 1. We have provided a more detailed explanation of Table 1 see lines 200-202. Our study is based on a mixed-methods design, incorporating quantitative (descriptive) and qualitative date. Frequencies and priorisation is a difficult metric in qualitative elements. Our aim was to capture the range, depth, and contextual richness of participants’ perspectives rather than to quantify prevalence. Table 1 is therefore intended to provide an overview of the main qualitative categories and illustrative quotes, highlighting the diversity of ideas and concepts expressed by participants rather than their relative frequency. We have added a explanation into the manuscript.

• Finally, ethical considerations on page 4, lines 134–140, are briefly mentioned, but the manuscript should clarify how confidentiality was maintained during group discussions and online consultations. This is particularly important given the participatory nature of the study.

 

Thank you for this helpful comment. We were able to ensure the confidentiality of the data during the subgroup discussions by pseudonymising individuals within the audio recording based on group classification and comments only prior to data coding. Pseudonymisation was also carried out via Slido. The audio transcription and structured notes taken during the discussion were only available to the researchers. These clarifications are now explicitly described in the revised manuscript (see lines 134-144). During the online consultations, the researcher was unable to draw any conclusions about the identity of the participant, as only descriptive answers about age, country of origin and professional status were provided. We have added this explanation into ethical considerations (see lines 154-157).

 

Author Response File: Author Response.docx

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript addresses an important topic on integrating wellbeing into GP training, but several major issues require attention before publication. On page 2, lines 44–52, the definition of wellbeing is presented broadly, yet the study does not explain how this concept was operationalized for participants. Without a shared definition, responses may reflect inconsistent interpretations, which limits validity and comparability.

On page 3, lines 95–104, the sampling strategy relies on voluntary participation at a conference workshop. This introduces strong selection bias because participants likely had a pre-existing interest in wellbeing. The paper acknowledges the limited sample size but does not sufficiently discuss how this affects generalizability.

On pages 3–4, lines 105–132, the description of data collection lacks clarity. It is not clear whether subgroup discussions were fully transcribed or whether researcher notes were used. The process for preserving anonymity during peer-sourced questions also needs more detail to ensure transparency and reproducibility.

On page 4, lines 142–150, quantitative analysis is mentioned, but the results section does not report any statistical measures beyond simple percentages. For example, on page 6, lines 174–176, percentages are given without confidence intervals or any indication of variability. This limits the strength of quantitative claims.

Although the study claims a concurrent mixed-methods design, integration of qualitative and quantitative findings is weak. Pages 6–10 present results in parallel rather than synthesizing them to provide deeper insights. The discussion section on pages 10–11, lines 285–337, overstates the novelty and generalizability of findings. Statements such as describing the study as a valuable starting point for integrating wellbeing into GP training should be tempered given the small, self-selected sample and exploratory nature of the work.

The role modeling concept described on pages 9–10, lines 251–270, raises practical and ethical concerns. Ideas such as a matching platform similar to dating apps are mentioned without addressing privacy, consent, and professional boundaries. These issues need to be considered before proposing such strategies.

The introduction on pages 2–3, lines 54–88, cites relevant literature but does not critically engage with conflicting evidence, such as the limited impact of resilience training. A more nuanced synthesis is needed to justify the study’s approach. Figures and Table 1 on pages 5–8 are insufficiently explained in the text. Table 1 lists categories and quotes but does not indicate frequency or prioritization, which makes interpretation difficult.

Finally, ethical considerations on page 4, lines 134–140, are briefly mentioned, but the manuscript should clarify how confidentiality was maintained during group discussions and online consultations. This is particularly important given the participatory nature of the study.

In summary, the manuscript explores an important area but requires major revision to improve conceptual clarity, methodological transparency, and integration of findings. These changes are necessary to strengthen the scientific rigor and credibility of the work.

Author Response

 

Revision

Dear Ms. Chu Xu and Reviewers,

Thank you for your structured and insightful work on our paper. It has been instrumental in revising and presenting our work to the best possible extent. Changes to text passages in the manuscript have been marked in yellow. On behalf of all authors, we would like to thank you for your support.

Enclosed you will find our statements and comments on the concrete steps that were taken to incorporate your feedback into the revision.

 

Reviewer 1: General comments

This is very relevant research. Although you are talking about a 'soft' competency, it is a very important, even essential one. This study can be - as you mention it yourself - a first step for a mental shift and a shift in curricula and how curricula are built. I have some comments to improve the manuscript.

Thank you very much for encouraging comment and your suggestions you provided to strengthen our work.  

Reviewer 1: Specific comments

• Line 64 & 65: I think you should mention/refer here already to the manuscript of Junge

Thank you for this helpful suggestion. We agree that an earlier reference to the work by Junge et al. strengthens the contextual framing of the introduction. We have therefore added a reference to Junge et al. see lines 64–65 to highlight the prior identification of wellbeing as a key competency among early-career GPs.

• Line 74: I think this should be curriculA and not curriculAR.

Thank you for pointing this out. We have corrected the wording from “curricular” to “curricula” on line 78.

• you should explain first what EYFDM is; it will not be clear for all readers

Thank you for your advice. The initial explanation of EYFDM can be found in the introduction on line 65.

• participants --> I feel this part is not stating clear enough what all the 'terms' mean. E.g. it is not clear what EYFDM cohort means: line 99 says that it is the Council members + workshop participants, but in line 113: it also refers to Junge's study. I would advise to have a new look at this section and try to re-clarify this.

Thank you for this important comment. We agree that the terminology used in the Participants section was not sufficiently clear and may have led to confusion. We have revised this section (see lines 103-111) to clearly define all participant groups, to distinguish between participants in the present study and those referenced from Junge et al.’s study (line 118), and to ensure consistent use of terminology throughout the manuscript.

• Figure 1: there is a lot of information in it, and can it be that it is a mix of methodology and results? - I do not have the feeling that the figure is clear enough for me

Thank you for this helpful comment. We have revised Figure 1 to focus exclusively on the workshop structure and data collection process. Content related to anticipated benefits, challenges, implementation preferences, and role modelling outcomes has been removed from the figure and is now reported in the methods and results section. This revision improves readability and ensures a clear distinction between methodology and findings.

 

Reviewer 2: General comments

Dear authors,

This mixed-methods study addresses the topic of wellbeing and its integration in GPs training. Based on the findings from Junge et al., the opinion of young physicians was captured qualitatively during a three-stage workshop as part of EYFDM 2023 in Belgium. The Workshop was followed by two consultation rounds with relevant stakeholders. Similar to the teaching of other soft skills such as communication, the need for integration wellbeing in the curricula in all its facets in GP’s training has been identified. A potential approach for integration could be a targeted role-model strategy accompanied by a flexibly usable toolbox. The findings should be viewed as a first step toward the field of medical wellbeing education research. Further research should follow.

The article deals with a highly topical issue in medical education and fits the scope of the journal. The chosen method is appropriate for investigating the research question. The article is clearly written, well structured, and the results are depicted graphically in a vivid manner. The results are discussed in the context of current literature.

We would like to thank you for this positive evaluation of our manuscript. We appreciate the recognition of the relevance of the topic, the choice of the mixed-methods approach, and the clarity of the manuscript structure and graphical presentation. We are particularly grateful for the acknowledgement of the study’s positioning as an initial step in the emerging field of medical wellbeing education research. We have carefully considered your specific comments and have revised the manuscript accordingly to further improve clarity, methodological transparency, and the distinction between methods and results.

Reviewer 2: Specific comments

• In the Paper from Junge et al. wellbeing had in the end no consensus for a LoA in the list of competences. Although the authors use the article as basis for their work, I miss references to this rather important fact either in the Introduction or discussion. Why was the topic wellbeing addressed despite the limited agreement in Junge's article? I assume that the multifaceted but non-consented discussions on the topic were the trigger for the choice. Please clarify.

Thank you for highlighting this important point. The discussion during data collection by Junge et al. showed that specifically doctors´wellbeing as a competence had not previously been mentioned in the literature as equally important to patients wellbeing. This was a new element. Also it triggered discussions, as people found it relevant, but as you righly point out, many found it difficult to imaging how this was going to be implemented. This was why the LoA was not maximised and triggered a major discussion within the cohort. Please also bear in mind, that only the top competencies were mentioned in the Junge et al. study. Therefore it was indeed one of the top competencies, but with a higher level of variation in its rating. Despite discrepancies, it ranked third among the affective competences, demonstrating the relevance of the new learning activity. Junge et al. also pointed out the difficulty of establishing new affective learning objectives in learning activities, as discussed during data collection. We took this as the starting point for our research to find out what suggestions and ideas young general practitioners have for drawing attention to this learning activity and the needs of the younger generation, in line with the call to action by EURACT in 2019. We have clarified this rationale in the Introduction section of the revised manuscript (see lines 66-70). We hope it is to your agreement.

• Line 74: it should read “curricula”.

 

Thank you for your advice. We have corrected the word into „curricula“ on line 78.

 

• Line 110: there is an extra character at position one.

 

Thank you for noting this. The extra character at the beginning of the sentence on line 112 has been removed, and the sentence has been corrected accordingly.

 

 

 

Reviewer 3: General comments

Thank you for the opportunity to review this manuscript, which addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). This manuscript addresses a topic of increasing relevance and urgency in medical education: the well-being of General Practitioners (GPs). However, the manuscript, in its current form, presents several methodological and theoretical limitations that, in my view, significantly affect the validity and generalizability of its findings.

We are deeply grateful for the time and effort you have devoted to providing such detailed feedback. We appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honored by the chance to address your concerns. 

Reviewer 3: Specific comments

• The manuscript fails to articulate a clear theoretical framework to guide the study. Specifically, there is no explicit reference to established conceptual models in occupational well-being or medical education. Without a theoretical framework, the rationale for exploring specific learning activities is less robust. In addition, a theoretical model would help explain the mechanisms by which certain interventions are expected to influence well-being, thereby contributing to a better understanding of the results.

We are very grateful for this thoughtful and important comment. We agree that a clear theoretical framework is essential to strengthen the rationale of our study and to support the interpretation of our findings. While we did not explicitly label a theoretical framework in the original manuscript, our study is grounded within an established educational framework, namely the EURACT Educational Agenda, operationalised through the WONCA tree. The WONCA tree provides a widely accepted conceptual model for defining competencies in general practice, including affective competencies, and has been used as a reference framework in prior work by Junge et al. In this context, wellbeing lacked curricular operationalisation. Our study builds on this framework by exploring how this emerging competency could be translated into concrete learning activities from the perspective of early-career GPs. Our focus is not whether the learning activities are all valid, but rather what GPs in training contribute as ideas. This is an important piece in the conversation that will of course need to be met with curricular expertise by educators. Additionally, we have added a sentence see lines 95-96 to explain our theoretical background.

 

 

• The sampling strategy raises significant concerns. Reliance on a very small convenience sample drawn from a pre-conference workshop severely limits the generalizability of the findings to GPs “across Europe” and is also open to bias. More critically, this sampling method introduces a high risk of selection bias (or volunteer bias). The participants likely represent a self-selected cohort that already has a high level of engagement with the topic of well-being. These individuals are likely more motivated, more aware of the challenges, or more proactive in seeking solutions than the broader, “average” target population.

 

We thank you for your insightful comment. We acknowledge that the initial workshop was based on a small convenience sample. To broaden perspectives and enhance representativeness, we complemented the workshop with two rounds of online stakeholder consultation within the EYFDM network. The suggestions generated during the Brussels workshop were subsequently presented to a wider group of participants, increasing the total number of contributors from 22 to 52 across multiple European countries. We recognise that highly engaged general practitioners are more likely to participate in such initiatives, which is an inherent limitation of participatory research. Nevertheless, we made concerted efforts to ensure inclusive participation and transparent reporting of this limitation. We have listed your valuable concern under limitations see lines 309-313.  Thank you for pointing this out. We feel that nevertheless the voice of young GP’s ought to be heard.

 

• The study’s stated focus is on “early-career GPs”. However, including senior GPs and medical students in the stakeholder consultation process introduces heterogeneity, blurring this focus. The authors should provide a more explicit rationale for this mixed cohort.

 

Thank you for your helpful comment. We acknowledge that the incorporation of diverse voices has resulted in a certain degree of heterogeneity, which, nevertheless, aligns with the participatory ethos of the EYFDM Special Interest Group.

It was our intention to include every participant involved in our stakeholder consultations. We believe that even medical students—those in the early stages of their training—have important perspectives to share regarding their future working environment and doctors’ wellbeing. It demonstrates that the absence of wellbeing is not a general medicine concern, but rather a concern that is specific to the field of medicine. This suggests that the cultural challenges specific to medicine do not merely emerge during general medical training but rather are present from the initial stages of medical school. Consequently, its implementation should be initiated at the earliest stage. General practice, as a postgraduate subject, cannot resolve this issue alone; rather, it necessitates comprehensive consideration throughout the medical training curriculum.

Also, comments from older GPs or medical students were analysed separately, to minimise the influence thereof. This concept was incorporated into the 'Strength and Limitations' section of the discussion, given that the qualitative diversity of our data is both a strength and a limitation (see lines 324-328). With reference to methods and participation section, we have mentioned senior or medical students separately. Otherwise, we are referring to the majority of early career GPs.

 

• Many of the core qualitative themes identified—such as the desire for self-reflection, peer exchange, and mentorship—are well-established concepts in the broader literature on professional development and physician well-being. The manuscript’s contribution thus appears largely confirmatory. Consequently, the assertion in the Discussion section that “This study is the first to explore the perspectives…” may be an overstatement.

 

Thank you for this valuable comment. It is true that some of the key ideas have been previously mentioned in the existant literature. However, this study gives young doctors a voice and explicitly listens to their opinions about further training and support, with concrete ideas on how to address this issue. It is therefore the first study to reflect the wishes of young, motivated doctors in Europe, focussing on doctors wellbeing.In order to address your concerns, we have revised the text (see lines 309, 335, 346354-357, 360 and 377).

 

• The definition of well-being is currently presented in an info box in the Introduction section. To enhance the argumentative flow, the Authors should integrate this definition directly into the Introduction.

 

Thank you for your advice. We agree to your suggestion and we leave this at the editor’s discretion. It was mentioned that this might be a more suitable place for the definition. Please let us know what is preferred. We are open to both options.

 

• In the Introduction, the authors state that stand-alone interventions like “resilience training” have shown minimal efficacy. Beyond merely noting their limited efficacy, the Introduction would benefit from a brief reflection on why such approaches are often ineffective.

 

This is an important point and would need additional studies. From exchanges within the community and literature research, the explicit compulsory nature of the learning activity could be a major reason, additionally to time constraints. We have added your suggestion in the introduction see lines 90-91.

 

• In section 3.1. Demographics, the mean age (34.4 years) and range (24 to 64) are reported. The standard deviation (SD) is absent. Why did the authors not report this data?

 

We felt, it may not add additional data to the manuscript. We have added it for your kind consideration on line 182.

 

Reviewer 4: General comments

The manuscript addresses an important topic on integrating wellbeing into GP training, but several major issues require attention before publication. In summary, the manuscript explores an important area but requires major revision to improve conceptual clarity, methodological transparency, and integration of findings. These changes are necessary to strengthen the scientific rigor and credibility of the work.

Dear Reviewer, we sincerely apologize for any shortcomings in our initial submission and are deeply grateful for the time and effort have devoted to providing such thoughtful and detailed feedback. We truly appreciate the opportunity to revise our manuscript on accordance with your suggestions, and we are honoured by the chance to address your concerns. We have carefully considered each of your comments, and we humbly acknowledge the areas where our work did not fully meet expectations. Revisions have been made with great care and respect for your guidance, with the hope that the updated manuscript better aligns with your standards. We remain truly thankful of your support and the opportunity to improve our work.

Reviewer 4: Specific comments

• On page 2, lines 44–52, the definition of wellbeing is presented broadly, yet the study does not explain how this concept was operationalized for participants. Without a shared definition, responses may reflect inconsistent interpretations, which limits validity and comparability.

 

We appreciate your observation. While we provided a broad definition in the manuscript to introduce the concept, we also presented our specific definition to participants prior to the workshop and obtained their consent on this definition. This ensured that all participants had a shared understanding of wellbeing, and responses were collected based on this agreed-upon framework. Therefore, the definition of wellbeing served as the foundation and starting point of our data collection, improving the validity and comparability of participants’ responses. We have included an explanation in the text (line 123-124).  You rightly said it was difficult to understand this issue from our initial manuscript

 

• On page 3, lines 95–104, the sampling strategy relies on voluntary participation at a conference workshop. This introduces strong selection bias because participants likely had a pre-existing interest in wellbeing. The paper acknowledges the limited sample size but does not sufficiently discuss how this affects generalizability.

 

Thank you for sharing your valuable concerns. We agree that the voluntary recruitment at a conference workshop introduces selection bias, as participants were likely to have a pre-existing interest in wellbeing. Consequently, the findings are not statistically generalisable to all European GPs or GP trainees. The aim of this study was exploratory rather than representative (quantitative). It sought to capture perspectives, experiences, and ideas regarding the integration of wellbeing into GP training, rather than to estimate prevalence or effect sizes. As common in social study research-qualitative quality criteria need to be applied. For this purpose, a participatory approach involving engaged early-career and senior GPs is appropriate and aligns with established qualitative research principles. (Transferability of findingsà by providing rich background and methodology and discussing it in the social context of GPs, we believe we have done that criteria justice.  We have broadened perspectives and enhance representativeness via two rounds of online stakeholder consultations within the EYFDM network. In this context, suggestions explored in Brussels workshop were re-evaluated and validated by a wider group of participants to articulate a more coherent position on behalf of the European community. We have expanded the discussion of selection bias and its implications for transferability in the revised manuscript (lines 319-323).

 

• On pages 3–4, lines 105–132, the description of data collection lacks clarity. It is not clear whether subgroup discussions were fully transcribed or whether researcher notes were used. The process for preserving anonymity during peer-sourced questions also needs more detail to ensure transparency and reproducibility.

 

Thank you for this comment. We have revised the Methods section (Data Collection) to clarify the data collection procedures in more detail. Subgroup discussions were audio-recorded and complemented by researcher notes. Based on these recordings and notes, participant contributions were pseudonymised by assigning quote identifiers in chronological order within each subgroup. We also clarified how anonymity was preserved for peer-sourced questions and how qualitative data were documented and processed. These clarifications are now explicitly described in the revised manuscript (see lines 134-145).

 

• On page 4, lines 142–150, quantitative analysis is mentioned, but the results section does not report any statistical measures beyond simple percentages. For example, on page 6, lines 174–176, percentages are given without confidence intervals or any indication of variability. This limits the strength of quantitative claims.

Thank you for your valuable comment. Given the small sample size and the exploratory nature of this mixed-methods study, we intentionally restricted the quantitative analysis to descriptive statistics. The reported percentages were not intended for inferential interpretation, but to provide contextual insight into the descriptive data and to complement the qualitative findings. We have clarified this in the revised manuscript to avoid any implication of statistical inference or correlation (see lines 161-162).

• Although the study claims a concurrent mixed-methods design, integration of qualitative and quantitative findings is weak. Pages 6–10 present results in parallel rather than synthesizing them to provide deeper insights. The discussion section on pages 10–11, lines 285–337, overstates the novelty and generalizability of findings. Statements such as describing the study as a valuable starting point for integrating wellbeing into GP training should be tempered given the small, self-selected sample and exploratory nature of the work.

Thank you for this important comment. We agree that in the initial version, qualitative and quantitative findings were presented largely in parallel. We have revised the Results section to more explicitly integrate both data strands by highlighting how qualitative findings help explain quantitative patterns (see lines 271-273). In addition, we have tempered the language in the Discussion and Conclusion to better reflect the exploratory nature, limited generalisability, and conceptual rather than generalisable contribution of the study (see lines 309, 315-216, 335-337, 346-348, 354- 357, 360 and 377). This study should be interpreted in light of its exploratory design and self-selected (convenience) sample. While the findings are not statistically generalisable to all GP trainees or general practitioners, they offer conceptually transferable insights into how wellbeing is understood and prioritised by engaged early-career GPs. As such, the results may inform further research and support reflective discussion on the role of wellbeing in GP training rather than serve as definitive curricular guidance.

 

• The role modeling concept described on pages 9–10, lines 251–270, raises practical and ethical concerns. Ideas such as a matching platform similar to dating apps are mentioned without addressing privacy, consent, and professional boundaries. These issues need to be considered before proposing such strategies.

Thank you for raising these important practical and ethical considerations. We fully agree that issues such as privacy, consent, and professional boundaries are essential to address when implementing role modelling–based learning activities. In this study, however, we aimed to report and synthesize ideas and perspectives expressed by young general practitioners rather than to propose or evaluate specific implementation strategies. Assessing feasibility and ethical safeguards would need further research, and input from educationalists and curriculum designers. We have clarified in the revised manuscript (see lines 363-366) that these suggestions should be understood as participant-generated concepts and that ethical and practical considerations would need to be carefully addressed during any subsequent implementation phase.

 

• The introduction on pages 2–3, lines 54–88, cites relevant literature but does not critically engage with conflicting evidence, such as the limited impact of resilience training. A more nuanced synthesis is needed to justify the study’s approach.

Thank you for this important point. As the extant literature also points out, individual stand-alone interventions are not addressing the underlying systematic stress factors. This information has now been incorporated into the introduction (see lines 90-91).

 

• Figures and Table 1 on pages 5–8 are insufficiently explained in the text. Table 1 lists categories and quotes but does not indicate frequency or prioritization, which makes interpretation difficult.

 

Thank you for your comment. We have revised the manuscript by explicitly linking to Figure 1, and then providing a further explanation of the subsequent workshop phases in the text (see line 113). We have also clarified Figure 1, as suggested by Reviewer 1. We have provided a more detailed explanation of Table 1 see lines 200-202. Our study is based on a mixed-methods design, incorporating quantitative (descriptive) and qualitative date. Frequencies and priorisation is a difficult metric in qualitative elements. Our aim was to capture the range, depth, and contextual richness of participants’ perspectives rather than to quantify prevalence. Table 1 is therefore intended to provide an overview of the main qualitative categories and illustrative quotes, highlighting the diversity of ideas and concepts expressed by participants rather than their relative frequency. We have added a explanation into the manuscript.

• Finally, ethical considerations on page 4, lines 134–140, are briefly mentioned, but the manuscript should clarify how confidentiality was maintained during group discussions and online consultations. This is particularly important given the participatory nature of the study.

 

Thank you for this helpful comment. We were able to ensure the confidentiality of the data during the subgroup discussions by pseudonymising individuals within the audio recording based on group classification and comments only prior to data coding. Pseudonymisation was also carried out via Slido. The audio transcription and structured notes taken during the discussion were only available to the researchers. These clarifications are now explicitly described in the revised manuscript (see lines 134-144). During the online consultations, the researcher was unable to draw any conclusions about the identity of the participant, as only descriptive answers about age, country of origin and professional status were provided. We have added this explanation into ethical considerations (see lines 154-157).

 

Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

I would like to thank the authors for submitting the revised manuscript. The changes have significantly enhanced the overall quality of the paper

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript has been thoroughly revised in response to all reviewers’ comments. Revisions focused on improving conceptual clarity, methodological transparency, and consistency throughout the text. The theoretical background has been clarified, key definitions integrated more clearly into the introduction, and the rationale for the study strengthened. The Methods section was expanded to better describe participant selection, data collection, analysis procedures, and ethical considerations, while limitations related to sampling and generalisability were explicitly acknowledged. Figures and tables were revised for clarity and better alignment with the text, and the Results and Discussion sections were refined to more accurately reflect the exploratory nature of the study and its contribution to the existing literature. Overall, the revisions have substantially strengthened the manuscript in terms of clarity, rigor, and coherence.