HSSJ (2020) 16 (Suppl 2):S305–S310
DOI 10.1007/s11420-019-09727-6
ORIGINAL ARTICLE
Symptoms of Burnout Among Surgeons Are Correlated
with a Higher Incidence of Perceived Medical Errors
Tom J. Crijns, MD & Joost T. P. Kortlever, MD & Thierry G. Guitton, MD, PhD & David Ring, MD, PhD &
Grace C. Barron, MD
Received: 19 May 2019/Accepted: 20 September 2019 /Published online: 6 January 2020
* Hospital for Special Surgery 2020
Abstract Background: Nearly 44% of practicing physi-
cians in the USA report symptoms of burnout. Psychological
distress and loss of joy in medicine are associated with
malpractice lawsuits and attrition from medical practice
and may correlate with the rate of perceived medical errors.
Questions/Purposes: We sought to answer two questions:
(1) What physician factors are associated with the number of
perceived medical errors among practicing surgeons in the
prior 3 months? (2) What characteristics are associated with
symptoms of burnout among practicing surgeons? Methods:
We created a cross-sectional survey and invited members of
the Science of Variation Group to respond between Decem-
ber 2018 and January 2019. Participating surgeons complet-
ed the Abbreviated Maslach Burnout Inventory, the two-
item Patient Health Questionnaire (PHQ-2), and information
about practice characteristics and demographics. We created
a negative binomial and a multivariable linear regression
model to seek factors independently associated with the
number of perceived medical errors and symptoms of burn-
out. Results: A greater level of emotional exhaustion was
associated with a greater number of perceived medical
Level of Evidence: Level IV: Cross-sectional Survey
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11420-019-09727-6) contains supplementary
material, which is available to authorized users.
T. J. Crijns, MD (*) : J. T. P. Kortlever, MD : D. Ring, MD, PhD :
G. C. Barron, MD
Department of Surgery and Perioperative Care, Dell Medical
School, University of Texas at Austin,
1701 Trinity St,
Austin, TX 78712, USA
e-mail: Tom.Crijns@austin.utexas.edu
T. G. Guitton, MD, PhD
Department of Plastic Surgery, University Medical Center
Groningen (UMCG),
Groningen, The Netherlands
–
errors, while practice location in Europe was associated with
fewer perceived errors. A higher PHQ-2 score was indepen-
dently associated with symptoms of burnout. Conclusion: It
is possible that symptoms of burnout cause surgeons to be
more likely to perceive an imperfection as an error or that
burnout distracts surgeons, contributing to a greater likeli-
hood of a verifiable error. Additional studies are merited to
investigate a potential causal relationship between symp-
toms of burnout and medical errors.
Keywords medical errors . burnout . depression . surgeons .
malpractice
Introduction
Burnout is a syndrome that can result from unresolved
“chronic workplace stress,” according to the World Health
Organization (WHO). In 2019, the WHO included burn-
out in the 11th Revision of the International Classifica-
tion of Diseases (ICD-11) as an “occupational
phenomenon” [23]. Burnout consists of three domains
[8]: emotional exhaustion (feeling overwhelmed or se-
verely fatigued on the job), depersonalization (feeling
cynical about work), and a sense of reduced personal
accomplishment (losing confidence in one’s professional
abilities). A higher score on the Maslach Burnout In-
ventory in any of these three areas indicates greater
symptoms of burnout [8, 11].
Nearly 44% of practicing physicians in the USA reported
at least one symptom of burnout in 2017 [18]. Evidence
suggests that physicians in emergency medicine, urology,
and physical medicine and rehabilitation are more likely
than those in other specialties to report symptoms of burnout
[11, 17]. Prior studies have shown that distress and burnout
in physicians are associated with alcohol misuse, suicidal
ideation, malpractice lawsuits, and attrition from medical
practice [2, 5, 16].
S306
When physicians experience greater sense of occupa-
tional fatigue or a professional ineffectiveness, their
work performance may deteriorate, increasing the risk
of medical error and patient harm [11, 15, 22]. A prior
survey among surgeons indicated that medical errors are
associated with symptoms of burnout [15], and a recent
systematic review and meta-analysis found physician
burnout to be linked to an increased risk of “patient
safety incidents” and reduced quality of care and patient
satisfaction [9].
Therefore, we investigated whether surgeons’ worry
about potential errors or adverse events is associated
with burnout. An international database of orthopedic,
plastic, and general surgeons allowed us to study the
prevalence of symptoms of burnout in these surgeons
and to test its relationship with the number of perceived
medical errors. We assessed the following questions: (1)
What physician factors are associated with the number
of perceived medical errors among practicing surgeons
in the prior 3 months? (2) What characteristics are
associated with symptoms of burnout among practicing
surgeons?
Materials and Methods
We invited members of the Science of Variation Group
(SOVG) to participate in our cross-sectional survey be-
tween December 2018 and January 2019. This group
consists of several hundred orthopedic, plastic, and gen-
eral surgeons who are interested in studying variation in
care. The 30-question survey included a standardized
questionnaire to measure symptoms of burnout, a
screening tool for symptoms of depression, and ques-
tions on practice characteristics and basic demographics.
We measured symptoms of burnout on a continuous
scale using the abbreviated Maslach Burnout Inventory
(aMBI), a nine-item questionnaire measuring the three
domains of burnout [6, 10]. This scale contains state-
ments such as “I feel emotionally drained from my
work,” “I feel I treat some patients as if they were
impersonal objects,” and “I feel exhilarated after work-
ing closely with my patients” in order to assess the
degree of burnout according to each of the respective
domains. Surgeons were asked to indicate how often
each statement applied to them on a 7-point Likert
scale, ranging from “always” to “never.” We measured
symptoms of depression among surgeons using the two-
item Patient Health Questionnaire (PHQ-2), an accurate
and validated screening tool for symptoms of depression
that has substantive correlations with more extensive
instruments, such as the PHQ-9 [1, 4, 7]. This question-
naire asks the respondents to rate on a 4-point Likert
scale, ranging from “not at all” to “nearly every day,”
how often they have been bothered in the prior 2 weeks
by “Little interest or pleasure in doing things” and
“Feeling down, depressed or hopeless.”
In addition, we collected practice characteristics (sub-
specialty, continent of practice, hours worked per week,
HSSJ (2020) 16 (Suppl 2):S305–S310
and hours dedicated to scientific research) and basic
demographic information (gender, age, marital status,
and number of children). We inquired about the frequen-
cy of perceived medical errors in the prior 3 months
with the question, “How many days in the last 3 months
have you been uncomfortable in the aftermath of care or
worried about errors or adverse events in spite of con-
scientious effort?” A prior study utilized a similar for-
mat for this question, but asked surgeons about the
frequency of “major medical errors” [15]. We hypothe-
sized that surgeons might be more inclined to acknowl-
edge unease if it were phrased as discomfort or worry
about care or adverse events [19].
We developed the online survey using SurveyMonkey
(Palo Alto, CA, USA) and invited all members of the
SOVG to participate through an emailed link. SOVG
members are invited on a monthly basis to complete
surveys and are interested in studying variation in care
without financial compensation. Due to the considerable
number of inactive members, it would not have been
possible to calculate a meaningful response rate. This
survey study was conducted in accordance with the
1964 Helsinki declaration and its later amendments.
Of 203 surgeons who completed the survey, 186
(92%) were male and 104 (51%) practiced in North
America (Table 1). A majority specialized in hand sur-
gery (n = 84; 41%) and orthopedic trauma (n = 66;
33%). The surgeons had a median work week of 60 h,
with an interquartile range (IQR) of 50 to 70 h. Sur-
geons had an average aMBI emotional exhaustion score
of 7.3, with a standard deviation (SD) of 4.7 (range 0–
18), an average depersonalization score of 3.8 (SD 3.3,
range 0–14), and an average personal accomplishment
score of 15 (SD 2.6, range 7–18).
Statistical Analysis
To determine the correlations between the number of
perceived medical errors in the prior 3 months, the
aMBI, the PHQ-2, and surgeon characteristics, we per-
formed Pearson correlation analysis for all continuous
variables; we also performed Kruskal–Wallis and Mann–
Whitney U tests for categorical variables, when appro-
priate. All variables with p < 0.10 in bivariate analysis
were moved to negative binomial regression analysis,
seeking factors independently associated with the num-
ber of perceived medical errors. We assumed the data
would have a Poisson distribution but opted for a neg-
ative binomial model, as our data did not meet the
assumption that the mean equates to the variance. We
calculated the total aMBI score per surgeon by adding
up the individual scores for the domains emotional
exhaustion and depersonalization and subtracting the
personal accomplishment score (a higher personal ac-
complishment score indicates fewer symptoms of burn-
out). To address our secondary null hypothesis, we
performed bivariate analysis using Pearson correlation
for continuous variables, Student t tests for dichotomous
variables, and one-way analysis of variance (ANOVA)
HSSJ (2020) 16 (Suppl 2):S305–S310 S307

Table 1 Baseline demographics Results

Variables Value
Among participating surgeons, 90.3% reported at least one
perceived medical error in the prior 3 months. The median
N 203
Male 186 (92%)
was three perceived errors, with an interquartile range of two
Age 49 ± 9.7 to 8.5 (Table 1). In bivariate analysis, the following variables
Marital status were associated with a greater number of perceived medical
Married 167 (82%) errors: a greater number of children (r = − 0.13; p = 0.08),
Domestic partnership 14 (6.9%) continent of practice (p = 0.004), more hours worked per
Divorced 10 (4.9%)
Single 12 (5.9%) week (r = 0.13; p = 0.079), higher aMBI emotional exhaus-
Number of children* 2 (2–3) tion score (r = 0.40; P < 0.001), higher aMBI depersonal-
Subspecialty ization score (r = 0.21; P = 0.003), higher PHQ-2 score (r =
Hand surgery 84 (41%) 0.26; p < 0.001), currently seeing a psychologist or psychi-
Orthopedic trauma 66 (33%)
Shoulder and elbow 17 (8.4%) atrist (5 [IQR 5–10] vs. 3 [IQR 2–7]; p = 0.028), and seeing
Total joint arthroplasty 7 (3.5%)
General surgery: trauma 7 (3.5%)
Foot and ankle 6 (3.0%)
Surgical sports medicine 5 (2.5%) Table 2 Bivariate analysis of factors associated with the number of
Pediatric 4 (2.0%) perceived medical errors
Plastic surgery 4 (2.0%)
Spine 3 (1.5%) Variables Perceived P value
Continent medical errors
North America 104 (51%)
Europe 73 (36%)
South America 17 (8.4%) Sex 0.37
Australia 4 (2.0%) Male 3 (2–7)
Asia 4 (2.0%) Female 5 (2–10)
Africa 1 (0.50%) Age (r) 0.0007 0.99
Treating burn patients 58 (29%) Marital status 0.11
Working hours per week Married 3 (2–10)
Clinic* 20 (12–30) Domestic partnership 3 (1–5)
Surgery* 20 (12–24) Divorced 5.5 (2.5–10.5)
Administrative tasks* 9 (5–14) Single 5 (3–45)
Research* 4 (1–6) Number of children (r) − 0.13 0.08
Total* 60 (50–70) Subspecialty 0.47
Scientific publications in the last 5 years* 9 (4–20) Hand surgery 5 (2–10)
Perceived medical errors* 3 (2–8.5) Orthopedic trauma 3 (1–10)
Maslach Burnout Inventory Shoulder and elbow 3 (2–5)
Emotional exhaustion (range) 7.3 ± 4.7 (0–18) Other 3 (2–6)
Depersonalization (range) 3.8 ± 3.3 (0–14) Continent 0.004
Personal accomplishment (range) 15 ± 2.6 (7–18) North America 5 (2–10)
Patient Health Questionnaire-2 (PHQ-2)* 0 (0–1) Europe 3 (1–5)
Seeing a psychologist or psychiatrist South America 3 (2.5–6)
Currently 9 (4.6%) Other 6 (5–10)
Past 41 (21%) Treating burn patients 0.25
Yes 3 (2–7)
Continuous variables as mean (± standard deviation); discrete variables No 5 (2–10)
as number (percentage) Working hours per week
*Values as median (interquartile range) Clinic (r) 0.065 0.37
Surgery (r) 0.12 0.10
Administrative tasks (r) 0.027 0.71
Research (r) 0.055 0.44
Total (r) 0.13 0.079
for categorical variables. Consequently, we created a Scientific publications in the last 5 years (r) − 0.064 0.37
Maslach Burnout Inventory
multivariable linear regression model seeking factors Emotional exhaustion 0.40 < 0.001
independently associated with symptoms of burnout. In Depersonalization 0.21 0.003
our final models, all two-tailed p values below 0.05 Personal accomplishment − 0.034 0.64
were considered statistically significant. A post hoc Patient Health Questionnaire-2 (PHQ-2) 0.26 < 0.001
Seeing a psychologist or psychiatrist
power analysis demonstrated that 203 surgeons provided Currently 0.028
over 99% power (α = 0.05) to determine factors asso- Yes 5 (5–10)
ciated with the number of perceived medical errors, with No 3 (2–7)
an average rate of 9.3 events (perceived errors) per 3 Past 0.072
months and an increased rate of 12% per unit of in- Yes 5 (2–10)
No 3 (2–7)
crease in the aMBI domain of emotional exhaustion,
assuming perceived medical errors had a Poisson Italicized entries indicate statistical significance. Variables with
distribution. P < 0.10 are moved to multivariable analysis
S308 HSSJ (2020) 16 (Suppl 2):S305–S310

a psychologist or psychiatrist in the past (5 [IQR 2–10]
vs. 3 [IQR 2–7]; p = 0.072; Table 2). After controlling
for confounding variables in multivariable analysis, a
higher aMBI emotional exhaustion score (regression co-
efficient [RC] 0.12; 95% confidence interval [CI] 0.073–
0.17; p < 0.001) was associated with a greater number
of perceived medical errors, while practice location in Europe
was associated with fewer perceived errors (RC − 0.80; 95%
CI − 1.2 to − 0.44; p < 0.001) (Table 3).
In bivariate analysis, a higher aMBI score was associated
with younger age (r = − 0.15; p = 0.030), fewer
children (r = − 0.19; p = 0.008), and a higher PHQ-2
score (r = 0.55; p < 0.001) (Table 4). In multivariable
analysis, the PHQ-2 score was independently associat-
ed with a higher aMBI score (RC 3.9; 95% CI 3.1–4.8;
p < 0.001) (Table 5).
Discussion
A significant proportion of US practicing physicians
report levels of emotional exhaustion and depersonali-
zation sufficient to qualify for a classification of “burn-
out” [3, 13, 17, 21]. Distress and burnout are associated
with malpractice lawsuits and attrition from medical
practice [2, 5, 16]. Greater occupational disengagement
may lead to a decrease in work performance, increasing
the prevalence of medical errors [11, 15, 22]. This
study sought to investigate whether there was an asso-
ciation between the number of perceived medical errors
and symptoms of burnout among surgeons. We found
that perceived errors were associated with greater levels
of burnout and a practice location outside of Europe.
Surgeons with more symptoms of depression reported
more emotional exhaustion and depersonalization and
less personal accomplishment.
This study should be read with the following limitations
in mind. First, surgeons completed the survey between De-
cember 25 and January 9, and mood is known fluctuate
somewhat by season; therefore, surgeons may report more
or fewer symptoms of burnout at a different time of year.
Second, we relied on self-report; although all data acquired
in this study were kept confidential and deleted upon publi-
cation, some surgeons may have felt uncomfortable
reporting medical errors, even in an anonymous survey.
Third, since the number of surgeons in some subspecialty
fields was too low to analyze separately, these data had to be
pooled, increasing the heterogeneity of the “other” group.
Fourth, members of the SOVG may be more academically
inclined than most surgeons, and this may affect the gener-
alizability of these findings. Additionally, our respondents
were largely male and the average age was 49 years, and our
findings may not apply to younger or female surgeons. Fifth,
cross-sectional surveys are not equipped to determine cau-
sality. Therefore, further study is needed to determine
whether there is a causal link between physician burnout
and perception of medical error. Finally, our wording of the
question on the number of medical errors left room for
differences in interpretation. For instance, surgeons might
also be worried about medical errors or complications that
are outside of their control or responsibility.
The observation that a greater number of perceived med-
ical errors are associated with higher levels of emotional
exhaustion is consistent with a prior study among a large
sample of American surgeons by Shanafelt et al. [15]. In
contrast with our current study, they found that all three
domains of the Maslach Burnout Inventory were associated
with reported medical errors. This discrepancy may be ex-
plained by differences in statistical methods (their study
used multivariable logistic regression comparing physicians
who reported an error to those who did not or by the wording
of our question on medical errors). In the study by Shanafelt
et al., 8.9% of surgeons reported a recent medical error [15],

Table 3 Negative binomial regression analysis of factors associated with the number of perceived medical errors

Variables Regression coefficient Standard P value Pseudo R2 Akaike

(95% confidence interval) error information
criterion

Continent 0.072 1184

North America Reference value
Europe − 0.80 (− 1.2 to − 0.44) 0.18 < 0.001
South America − 0.30 (− 0.88 to 0.29) 0.30 0.32
Other 0.092 (− 0.65 to 0.83) 0.38 0.81
Number of children − 0.12 (− 0.24 to 0.0044) 0.062 0.059
Working hours per week (total) 0.0076 (− 0.0033 to 0.018) 0.0055 0.17
Maslach Burnout Inventory
Emotional exhaustion 0.12 (0.073 to 0.17) 0.024 < 0.001
Depersonalization − 0.022 (− 0.082 to 0.037) 0.030 0.46
Patient Health Questionnaire-2 0.13 (− 0.062 to 0.32) 0.097 0.19
(PHQ-2)
Seeing a psychologist or psychiatrist
Currently 0.43 (− 0.35 to 1.2) 0.40 0.28
Past − 0.32 (− 0.73 to 0.090) 0.21 0.13

Italicized entries indicate statistical significance, P < 0.05

HSSJ (2020) 16 (Suppl 2):S305–S310 S309

Table 4 Bivariate analysis of factors associated with the total Maslach practicing physicians found bivariate associations between
Burnout Inventory score the number of perceived medical errors, emotional exhaus-
Variables Maslach P value
tion, and depersonalization [20]. Symptoms of burnout may
Burnout Intentory cause surgeons to be more likely to perceive an imperfection
or a variation as an error. Symptoms of burnout may also
Sex 0.63 distract surgeons, contributing to a greater likelihood of an
Male 14 ± 8.1 objectively verifiable error.
Female 13 ± 6.7 The observation that European surgeons reported
Age (r) − 0.15 0.030 fewer perceived medical errors might be influenced by
Marital status 0.94
Married 13 ± 7.9 the fact that malpractice premiums are notoriously
Domestic partnership 15 ± 8.4 higher in the USA than in most European countries
Divorced 15 ± 7.4 [12]. It is thus possible that US surgeons are more
Single 19 ± 7.1 concerned that relatively minor imperfections and varia-
Number of children (r) − 0.19 0.008
Subspecialty 0.55 tions might leave them open to a lawsuit. Consistent
Hand surgery 15 ± 8.4 with prior studies [20, 24], we observed a relationship
Orthopedic trauma 14 ± 7.9 between symptoms of depression and symptoms of
Shoulder and elbow 14 ± 6.3 burnout among physicians, suggesting an overlap be-
Other 15 ± 7.6
Continent 0.20
tween these phenomena. Symptoms of burnout are the
North America 14 ± 8.6 most important predictor of career dissatisfaction [13].
Europe 14 ± 7.6 Although bivariate analysis demonstrated inverse corre-
South America 15 ± 7.1 lations between the number of children, surgeon age,
Other 14 ± 4.9 and symptoms of burnout, these correlations were not
Treating burn patients 0.45
Yes 13 ± 8.5 significant when accounting for symptoms of depression.
No 14 ± 7.7 Additionally, we found no relationship between the total
Working hours per week hours worked per week and burnout. In prior research,
Clinic (r) 0.022 0.76 the number of hours worked per week accounted for a
Surgery (r) 0.098 0.17
Administrative tasks (r) 0.097 0.18 small proportion of symptoms of burnout [13]. On the
Research (r) 0.036 0.61 other hand, time spent on the most meaningful activity
Total (r) 0.049 0.49 is inversely related with the risk of burnout [14]. This
Scientific publications in the 0.016 0.82 suggests that helping surgeons establish and maintain
last 5 years (r)
Patient Health Questionnaire-2 0.55 < 0.001
meaning in their work may be more effective in reliev-
(PHQ-2) ing symptoms of burnout than decreasing their work-
Seeing a psychologist or psychiatrist load. Raising awareness about the early signs of
Currently 0.83 possible burnout can potentially help reverse the increas-
Yes 15 ± 9.5 ing rate of burnout among surgeons [11].
No 14 ± 7.9
Past 0.52 This large international survey among orthopedic,
Yes 15 ± 8.0 plastic, and general surgeons found that the number of
No 14 ± 8.0 perceived medical errors in the prior 3 months was
associated with the degree of emotional exhaustion,
Italicized entries indicate statistical significance. Variables with P < 0.10 one of the major domains of burnout. Variation observed
are moved to multivariable analysis
in the number of reported errors between practice loca-
tions suggests that differences in the medicolegal envi-
while in our study, only 9.7% reported having made no ronment might influence how surgeons perceive
medical errors in the prior 3 months. This may indicate that imperfections and variations in care. Since the time
our definition of perceived medical error (which included spent on activities that evoke a sense of meaningful
having a “feeling of discomfort after delivering care”) was accomplishment is associated with less burnout, surgeons
more inclusive. Another study of medical residents and might try to focus their daily work on meaningful activities.

Table 5 Multivariable linear regression analysis of factors associated with the total Maslach Burnout Inventory score

Variables Regression coefficient Standard error P value Adjusted R2 Akaike information

(95% confidence interval) criterion

Age − 0.069 (− 0.17 to 0.033) 0.052 0.18 0.31 1287

Number of children − 0.51 (− 1.3 to 0.24) 0.38 0.18
Patient Health 3.9 (3.1 to 4.8) 0.45 < 0.001
Questionnaire-2 (PHQ-2)

Italicized entries indicate statistical significance, P < 0.05

S310
Compliance with Ethical Standards
Conflict of Interest: Tom J. Crijns, MD, Joost T. P. Kortlever, MD,
Thierry G. Guitton, MD, PhD, and Grace C. Barron MD, declare that
they have no conflicts of interest. David Ring, MD, PhD, reports
royalties from Wright Medical, grants and royalties from Skeletal
Dynamics, editorial board membership at Clinical Orthopaedics and
Related Research, honoraria as a lecturer from various hospitals and
universities, and fees as a legal consultant, outside the submitted work.
Human/Animal Rights: All procedures followed were in accordance
with the ethical standards of the responsible committee on human
experimentation (institutional and national) and with the Helsinki
Declaration of 1975, as revised in 2013.
Informed Consent: Informed consent was waived from all subjects
included in this study.
Required Author Forms Disclosure forms provided by the authors
are available with the online version of this article.
References
1. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-
2 and PHQ-9 to screen for major depression in the primary care
population. Ann Fam Med. 2010;8(4):348–353. https://doi.org/
10.1370/afm.1139.
2. Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal conse-
quences of malpractice lawsuits on American surgeons. J Am
Coll Surg. 2011;213(5):657–667. https://doi.org/10.1016/
j.jamcollsurg.2011.08.005.
3. Barron C, Ring D, McGlone M. Is there a better term for ‘burn-
out’? [blog post]. Dell Medical School Blog. 2017. Available
from https://dellmed.utexas.edu/blog/is-there-a-better-term-for-
burnout
4. Carey M, Boyes A, Noble N, Waller A, Inder K. Validation of the
PHQ-2 against the PHQ-9 for detecting depression in a large
sample of Australian general practice patients. Aust J Prim
Health. 2016;22(3):262–266. https://doi.org/10.1071/PY14149.
5. Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Utility of a brief
screening tool to identify physicians in distress. J Gen Intern
Med. 2013;28(3):421–427. https://doi.org/10.1007/s11606-012-
2252-9.
6. Kemper KJ, Wilson PM, Schwartz A, et al. Burnout in pediatric
residents: comparing brief screening questions to the Maslach
Burnout Inventory. Acad Pediatr. 2019;19(3):251–255. https://
doi.org/10.1016/j.acap.2018.11.003.
7. Kroenke K, Spitzer RL, Williams JBW. The Patient Health Ques-
tionnaire-2: validity of a two-item depression screener. Med
Care. 2003;41(11):1284–1292. https://doi.org/10.1097/
01.MLR.0000093487.78664.3C.
8. Maslach C, Jackson SE. The measurement of experienced burn-
out. J Organ Behav. 1981;2(2):99–113. https://doi.org/10.1002/
job.4030020205.
9. Panagioti M, Geraghty K, Johnson J, et al. Association between
physician burnout and patient safety, professionalism, and patient
satisfaction: a systematic review and meta-analysis. JAMA Intern
HSSJ (2020) 16 (Suppl 2):S305–S310
Med. 2018;178(10):1317–1331. https://doi.org/10.1001/
jamainternmed.2018.3713.
10. Riley MR, Mohr DC, Waddimba AC. The reliability and validity
of three-item screening measures for burnout: Evidence from
group-employed health care practitioners in upstate New York.
Stress Health. 2018;34(1):187–193. https://doi.org/10.1002/
smi.2762.
11. Rothenberger DA. Physician burnout and well-being. Dis Colon
Rectum. 2017;60(6):567–576. https://doi.org/10.1097/
DCR.0000000000000844.
12. Schroeder SA. A comparison of Western European and US
university hospitals. A case report from Leuven, West Ber-
lin, Leiden, London, and San Francisco. JAMA.
1984;252(2):240–246.
13. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and
career satisfaction among American surgeons. Ann Surg.
2009;250(3):463–471. https://doi.org/10.1097/
SLA.0b013e3181ac4dfd.
14. Shanafelt TD, West CP, Sloan J, et al. Career fit and burnout
among academic faculty. Arch Intern Med. 2009;169(10):990–
995. https://doi.org/10.1001/archinternmed.2009.70.
15. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical
errors among American surgeons. Ann Surg. 2010;251(6):995–
1000. https://doi.org/10.1097/SLA.0b013e3181bfdab3.
16. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal
ideation among American surgeons. Arch Surg. 2011;146(1):54–
62. https://doi.org/10.1001/archsurg.2010.292.
17. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout
and satisfaction with work-life balance in physicians and the
general US working population between 2011 and 2014. Mayo
Clin Proc. 2015;90(12):1600–1613. https://doi.org/10.1016/
j.mayocp.2015.08.023.
18. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and
satisfaction with work-life integration in physicians and the gen-
eral US working population between 2011 and 2017. Mayo Clin
Proc. 2019. https://doi.org/10.1016/j.mayocp.2018.10.023.
19. Teunis T, Janssen S, Guitton TG, Ring D, Parisien R. Do ortho-
paedic surgeons acknowledge uncertainty? Clin Orthop Relat
Res. 2016;474(6):1360–1369. https://doi.org/10.1007/s11999-
015-4623-0.
20. Trockel M, Bohman B, Lesure E, et al. A brief instrument to
assess both burnout and professional fulfillment in physicians:
reliability and validity, including correlation with self-reported
medical errors, in a sample of resident and practicing physicians.
Acad Psychiatry. 2018;42(1):11–24. https://doi.org/10.1007/
s40596-017-0849-3.
21. Tucker T, Bouvette M, Daly S, Grassau P. Finding the sweet spot:
developing, implementing and evaluating a burnout and compas-
sion fatigue intervention for third year medical trainees. Eval
Program Plann. 2017;65:106–112. https://doi.org/10.1016/
j.evalprogplan.2017.07.006.
22. Williams ES, Manwell LB, Konrad TR, Linzer M. The relation-
ship of organizational culture, stress, satisfaction, and burnout
with physician-reported error and suboptimal patient care. Health
Care Manage Rev. 2007;32(3):203–212. https://doi.org/10.1097/
01.HMR.0000281626.28363.59.
23. World Health Organization. Burn-out an “occupational phenom-
enon”: International Classification of Diseases. 2019. Available
at https://www.who.int/mental_health/evidence/burn-out/en/
24. Wurm W, Vogel K, Holl A, et al. Depression-burnout overlap in
physicians. PLoS One. 2016;11(3):e0149913. https://doi.org/
10.1371/journal.pone.0149913.