Alder 2007.

Methods	Randomization procedure: Unclear. Groups were randomized and stratified for position and gender. Did not say it was concealed. Per e‐mail correspondence from primary author ‐ randomisation allocation was by statistician using computer generated random order list  Informed consent obtained: Yes Protection against contamination: Inadequate. All of the providers in both the control and intervention group worked in the same department in the same hospital during the duration of the study as did the study authors who were 2 of the trainers. Contamination is likely Outcomes assessors blinded: Adequate. Six independent raters, psychology students, were blinded for group and were trained to evaluate videotapes of physician‐patient interactions at T1 and T2. Patients were also blinded  Intention to treat analysis: Did not indicate that it was done Potential for unit of analysis error: Yes. It was adjusted for. Randomized by physician, but some outcomes were at level of patient. They used a general linear model for repeated measures with a two‐fold factor group (training and control group) and a two‐fold factor time (pre and post intervention) Comments on study quality: Power analysis was computed to assess the sample size needed for ? level 5% in pre‐intervention differences and 80% in post intervention differences. They needed between 5 and 17 for the different sub scores, planned for 32 and started with 35. 31 were followed up
Participants	Profession: Medicine Specialty: Obstetrics & Gynecology Years experience: mean 6.9 years in training group.  Mean 4.6 in the control group Clinical setting: University Hospital Obstetrics & Gynecology department Level of Care: Primary Country: Switzerland Health problem/Type of Patient: Both real & simulated patients were used.  Health problems were not defined
Interventions	Aim of study (hypothesis): To determine whether patient‐physician communication in obstetrics and gynaecology can be improved by a training program and to investigate if physicians with poorer performance before the training show greater improvement in communication skills scores over the course of the study. (605) Content of intervention: The training program consisted of three different parts: workshops, practice seminars and progress assessment meetings one‐day workshop: to give participants the theoretical background for consultations and the communication skills processes Three half day practice seminars: 4‐5 participants practiced acquired knowledge and skills (with video‐feedback). Role plays and modelling were used as added teaching strategies. five to six 1 hour supervision sessions: for each participant (single setting and small groups) over a 3‐month period. Trainees discussed problems related to communication they had encountered in their clinical work, were supervised by the group, and the trainer Conceptual Focus: Encouraging sharing control of the consultation.  Sharing decisions about the intervention. A focus in the consult on the patient as a whole person with individual preferences situated within social contexts.  Interactional skills.  Doctor patient relationships/Interviewing skills.  Bio‐psycho‐social model.    Number of providers receiving intervention: n = 19/39 start, n = 16/32end Number of patient receiving intervention:  T1 real patients = 22, sim = 122, T2 real = 11 sim = 113 Fidelity/integrity of intervention: The training sessions were given by the authors. Video taped sessions were supervised by on of the authors
Outcomes	Primary Outcomes: Physician Communication Skills (From analysis of video tapes) Consultation process: Observation from videotapes (patient‐centred communication, establish a therapeutic relationship, understanding the problem, give information and educate, shared decision making) as measured by the MAAS‐R. Satisfaction: Satisfaction with consultation and relationship, as measured by subscales of adapted version of Kravitz survey Health behaviours: Compliance as recorded in the Kravitz questionnaire for patients Health status: NA
Notes	Linear regression analysis for lower performance at T1 predicting higher improvements in communication skills scores were significant Meta‐analysis: 1) Consultation Process : Continuous (used shared decision making since 5 outcomes in table 2 for continuous; did not take from table three since ICC needed for table 3; table 2 is physician level data‐no ICC needed) Unadjusted sample sizes: intervention: 16 control:16
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Did not give details of sequence generation but author states in e‐mail correspondence that statistician used computer software to generate sequence
Allocation concealment (selection bias)	Low risk	Did not specify if it was concealed. Likely, as randomisation was done by statistician
Blinding (performance bias and detection bias) All outcomes	Low risk	Six independent raters, psychology students, were blinded for group and were trained to evaluate videotapes of physician‐patient interactions at T1 and T2. Patients were also blinded
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	3 intervention and 7 controls lost to follow‐up; not clear that intention to treat analysis was used
Selective reporting (reporting bias)	Low risk	Sample size calculation was computed to detect pre‐ and post‐ intervention differences in patient satisfaction and communication skills. They found no effects for communication skills or satisfaction scores. They did report some benefit of training in physicians with poor baseline performance, but we did not give credit for this in either the qualitative or quantitative review
Other bias	High risk	Contamination was likely, no attempts to control. This may have accounted for the negative findings, as it would lead to underestimation of intervention. Potential for unit of analysis error was addressed