West 2014.

Study characteristics
Methods	Study design: RCT Study grouping: parallel group Unit of randomisation: individuals Power (power sample size calculation, level of power achieved): Of the 37 participants in each arm of the study, 34 (91.9%) provided survey responses. With this sample size, power was 80% to detect a moderate Cohen f2 effect size of 0.15; no sample size calculation reported Imputation of missing data: no imputation of missing data (information received from authors; West 2017 [pers comm]); per‐protocol analysis (with participants who took part in allocated intervention, i.e. without 2 participants in IG who withdrew consent) and available‐case analysis (with participants for whom outcomes were obtained)
Participants	Country: USA Setting: Department of Medicine at the Mayo Clinic Rochester Age: see Population description; age not specified Sample size (randomised): 74 Sex: 25 women, 49 men Comorbidity (mean (SD) of respective measures in indicated, if available) at baseline: IG had slightly higher rates of high emotional exhaustion and overall burnout (MBI); burnout, n (%): full high depersonalisation: IG = 9 (24.3%), CG = 9 (25.7%); full high emotional exhaustion: IG = 17 (45.9%), CG = 12 (34.3%); full overall burnout: IG = 20 (54.1%), CG = 15 (42.9%); depression, n (%): positive depression screen (2‐question approach): IG = 11 (29.7%), CG = 11 (31.4%) Population description: practising physicians in the Mayo Clinic Department of Medicine Inclusion criteria: not specified Exclusion criteria: not specified Attrition (withdrawals and exclusions): 2/37 (5.4%) in IG withdrew consent and therefore could not be analysed; number who did not complete assessments (information received from authors; West 2017 [pers comm]): pre‐intervention: n = 7; 3‐month follow‐up: 5 ‐ 6 for different outcomes; 12‐month follow‐up: 8) Reasons for missing data: not specified
Interventions	Intervention: small‐group curriculum (n = 37) delivery: face‐to‐face, group sessions (4 small groups of 8 ‐ 10 physicians each) with similar composition by sex and specialty providers: practising internal‐medicine physicians with specific expertise in communication and teaching courses involving small‐group facilitation training: 4‐hour training session specific to the study curriculum before start of the small‐group sessions supervision: 1‐hour, bi‐weekly facilitator meetings to debrief and prepare for the next session duration of treatment period and timing: 19 sessions; 1‐hour meetings occurring once every 2 weeks for 9 months description: topics addressed during these sessions organised into modules entitled “self,” “patient,” and “balance” and included meaning in work, personal and professional balance, medical mistakes, community, caring for patients, and other topics relevant to the work experiences of practising physicians same structure in each session: (1) check‐in and welcome, (2) preparing the environment (e.g. journalling and reflective exercise), (3) facilitated group discussion, (4) learned skills and solutions, and (5) checkout and summary MODULE I: self 1. introduction and overview of curriculum, group development 2. physician well‐being: a. preventive care: e.g., screening, physicians’ physical health practices; b. assessing well‐being (mainly mental side): honesty, reflective practice, mindfulness 3. physician distress: a. physical and psychological distress (illness, disability); b. the wounded healer: moral distress, burnout, fear, anger, (other emotions) 4. meaning in work: part Ia. definitions of meaning: group question – why do you work doing what you do?; b. sources of meaning: influence of personal values, identity 5. meaning in work: Part IIa. protecting meaning: meaning through the professional life cycle; b. promoting meaning: approaches may vary over time, need to be flexible 6. personal resources: a. mindfulness/resiliency (internal resources); b. spirituality/religion, community, friendships, activities (links to external resources) 7. thriving: a. definitions: the spectrum of well‐being, with distress at 1 end, what is on the other end?; b. what is needed to flourish/thrive? MODULE II: patient 8. patient connectedness: a. compassion in the face of personal disengagement; b. deep versus surface acting and empathy 9. barriers to care: part I (patient‐based) a. the challenging patient; b. expectations from patients and families 10. barriers to care: part II (provider‐based) a. physician assumptions and biases (stereotypes, prejudices); b. insight into personal cognitive patterns and how these may represent barriers to the patient‐physician relationship, recognising personal limitations 11. bad news: a. effect of suffering and death on physicians (the grieving healer); b. physician as source of hope 12. medical mistakes and errors: a. experiences of error and reactions from peers/system; b. impact on physicians 13. being present: a. definitions, relevance to practice; b. skills for being present: reflective listening, listening to self and listening to others MODULE III: balance 14. personal/professional balance: a. work‐home interference; b. balancing external pressures (societal and professional expectations) 15. personal/professional identity: a. professional and personal expectations and self; b. the role of choices (intentional or not) 16. personal/professional relationships: a. relationships beyond work and within work (healthy and unhealthy); b. power differentials as a barrier to healthy relationships 17. gender and generational differences: a. male‐female roles at work and home; b. priorities across generations, barriers to communication (e.g., mindfulness and acknowledgment of personal perspectives and biases) 18. resiliency: a. mindfulness/resiliency; b. resiliency skills training 19. closure of curriculum: a. orientation to resources, ongoing relationships; b. closure process (reflections on course) compliance: 35 participants analysed in the intervention arm attended a mean of 11.7 of 19 facilitated small‐group sessions integrity of delivery: not specified economic information: not specified theoretical basis: Building on previous literature, this intervention involved facilitated physician discussion groups organised around a curriculum incorporating elements of mindfulness, reflection, shared experience, and small‐group learning intended to promote collegiality and community at work among participants (Epstein 1999; Krasner 2009; McCue 1991; Rabow 2001; Shapiro 2005; Sood 2011; ; Shanafelt 2003; Warnecke 2011). Control: no intervention; could schedule and use this hour of protected time in any manner they believed was most useful but did not participate in the formal curriculum (n = 37)
Outcomes	Outcomes collected and reported: job satisfaction ‐ PJSS perceived stress ‐ PSS fatigue ‐ single‐item linear analog question ‐ not reported quality of life ‐ single‐item linear analog question engagement, empowerment and meaning at work ‐ EWS overall burnout ‐ MBI burnout, emotional exhaustion ‐ MBI burnout, depersonalization ‐ MBI burnout, low personal accomplishment ‐ MBI ‐ not reported empathy ‐ Jefferson Scale of Physician Empathy ‐ not reported mental health physical well‐being ‐ Medical Outcomes Study Short‐Form Health Survey 8 items ‐ not reported depression screen ‐ 2‐question approach Outcomes reported: job satisfaction ‐ PJSS perceived stress ‐ PSS engagement, empowerment and meaning at work ‐ EWS quality of life ‐ single‐item linear analog question overall burnout ‐ MBI burnout, emotional exhaustion ‐ MBI burnout, depersonalization ‐ MBI depression screen ‐ 2question approach Time points measured and reported: 1) pre‐intervention; 2) during intervention at 3 months (during 9‐month intervention); 3) during intervention at 6 months (during 9‐month intervention); 4) post‐intervention (at 9 months, i.e. end of 9‐month intervention); 5) 3‐month follow‐up (3 months post‐intervention); 6) 12‐month follow‐up (12 months post‐intervention) Adverse events: not specified
Notes	Contact with authors: We contacted the authors to ask for the means and SDs for the outcomes at all time points and the procedures in dealing with missing data (West 2017 [pers comm]). Study start/end date: study conducted between September 2010 and June 2012 Funding source: supported by the Mayo Clinic Program on Professionalism and Ethics and the Department of Medicine at Mayo Clinic Rochester; funding source had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication Declaration of interest: no conflicts of interest reported Ethical approval needed/obtained for study: approved by the Mayo Clinic IRB Comments by authors: trial registration: clinicaltrials.gov Identifier: NCT0115997 Miscellaneous outcomes by the review authors: not relevant Correspondence: Colin P. West, MD, PhD, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 First St, Rochester, MN 55905; west.colin@mayo.edu
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "Participants were randomized in a concealed fashion into 2 groups via a computer‐generated algorithm. Randomization was stratified by sex and specialty (general internal medicine or other internal medicine specialty) using permuted blocks." Quote: "Baseline characteristics of the 2 trial groups were generally similar, with no statistically significant differences observed, although the intervention arm had slightly higher rates of high emotional exhaustion and overall burnout." Quote: "Because of baseline differences across groups for several variables, all analyses were adjusted for levels of distress at study onset." Judgement comment: The investigators describe a random component in the sequence‐generation process (computer‐generated algorithm) and there is verified baseline comparability of groups for sociodemographic characteristics and outcomes of interest on the basis of analysis
Allocation concealment (selection bias)	Unclear risk	Quote: "Participants were randomized in a concealed fashion into 2 groups via a computer‐generated algorithm." Judgement comment: insufficient information to permit judgement of ‘Low risk’ or ‘High risk’; exact method of concealment not specified; unclear if random‐sequence generation was concealed from personnel and/or participants
Blinding of participants and personnel (performance bias) Subjective outcomes	High risk	Judgement comment: blinding of participants and personnel probably not done (face‐to‐face intervention) and the outcome is likely to be influenced by lack of blinding
Blinding of outcome assessment (detection bias) Subjective outcomes	High risk	Judgement comment: Insufficient information about blinding of outcome assessment (online questionnaires); however, due to potential performance bias (no blinding of participants), the review authors judge that the participants' responses to questionnaires may be affected by the lack of blinding (i.e. knowledge and beliefs about intervention they received)
Incomplete outcome data (attrition bias) All outcomes	High risk	Quote: "Of the 37 participants in each arm of the study, 34 (91.9%) provided survey responses." Quote: "The changes in each well‐being metric from study baseline to study end, as well as at 3 and 12 months following the study, were analyzed according to the intent‐to‐treat principle using generalized estimating equations to account for the repeated‐measures design." Judgement comment: reasons for missing data unlikely to be related to true outcome with relative balance in missing data between groups (IG: 2 withdrawals, CG: 0; no reasons reported); no imputation of missing data (information received from authors); per‐protocol analysis (with participants who took part in allocated intervention, i.e. without 2 participants in IG who withdrew consent) and available‐case analysis (with participants for whom outcomes were obtained)
Selective reporting (reporting bias)	High risk	Judgement comment: trial registration available (clinicaltrials.gov/ct2/show/NCT01159977); several reported outcomes were not prespecified; PRESPECIFIED in trial registration: job satisfaction, burnout; AND: not all of the prespecified outcomes (prespecified in the publication) were reported; PRESPECIFIED in publication: job satisfaction, perceived stress, quality of life, empowerment and engagement at work, burnout, mental and physical well‐being, fatigue, empathy; REPORTED: all outcomes except for mental and physical well‐being, fatigue and empathy