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Original Article |

Special Report:  Suicidal Ideation Among American Surgeons FREE

Tait D. Shanafelt, MD; Charles M. Balch, MD; Lotte Dyrbye, MD; Gerald Bechamps, MD; Tom Russell, MD; Daniel Satele, BA; Teresa Rummans, MD; Karen Swartz, MD; Paul J. Novotny, MS; Jeff Sloan, PhD; Michael R. Oreskovich, MD
[+] Author Affiliations

Author Affiliations: Mayo Clinic, Rochester, Minnesota (Drs Shanafelt, Dyrbye, Rummans, and Sloan and Messrs Satele and Novotny); American College of Surgeons, Chicago, Illinois (Drs Balch, Bechamps, Russell, and Oreskovich); Johns Hopkins University, Baltimore, Maryland (Drs Balch and Swartz); Winchester Surgical Clinic, Winchester, Virginia (Dr Bechamps); and University of Washington and Washington Physicians Health Program, Seattle (Dr Oreskovich).


Arch Surg. 2011;146(1):54-62. doi:10.1001/archsurg.2010.292.
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Published online

Background  Suicide is a disproportionate cause of death for US physicians. The prevalence of suicidal ideation (SI) among surgeons and their use of mental health resources are unknown.

Study Design  Members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life.

Results  Of 7905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported SI during the previous 12 months. Among individuals 45 years and older, SI was 1.5 to 3.0 times more common among surgeons than the general population (P < .02). Only 130 surgeons (26.0%) with recent SI had sought psychiatric or psychologic help, while 301 (60.1%) were reluctant to seek help due to concern that it could affect their medical license. Recent SI had a large, statistically significant adverse relationship with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment) and symptoms of depression. Burnout (odds ratio, 1.910; P < .001) and depression (odds ratio, 7.012; P < .001) were independently associated with SI after controlling for personal and professional characteristics. Other personal and professional characteristics also related to the prevalence of SI.

Conclusions  Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeon's degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.

Figures in this Article

Suicide is a disproportionate cause of mortality for physicians relative to both the general population and other professionals.14 Although suicide is strongly linked to depression,5,6 the lifetime risk of depression among physicians is similar to that of the general US population.1,7,8 This observation suggests that other factors may contribute to the increased risk of suicide among physicians. Access to lethal medications and knowledge of how to use them has been suggested as 1 factor; however, the influence of professional characteristics and forms of distress other than depression (eg, burnout) are largely unexplored.

The prevalence of suicidal ideation (SI) in the previous 12 months for the general US population is approximately 3.3%.5 The 2003 National Comorbidity Survey found that approximately one-third of individuals with SI make a plan, 72% of those with a plan make an attempt, and 26% proceed directly from SI to an unplanned attempt.6 In aggregate, these statistics suggest that as many as 50% of individuals with SI may eventually make a suicide attempt, with the majority of attempts occurring within 1 year of onset of SI.6 Recent data suggest that the increased risk for suicide among physicians may begin as early as medical school.9,10

In the study reported here, commissioned by the American College of Surgeons (ACS) Committee on Physician Competency and Health, we evaluated the frequency of SI and the use of mental health resources among surgeons who were members of the ACS and measured the relationship between SI and surgeon burnout, quality of life (QOL), and symptoms of depression as assessed by standardized metrics.

PARTICIPANTS

As previously reported,11 members of the investigative team conducted a survey evaluating burnout and QOL among American surgeons in June 2008. All surgeons who were members of the ACS, had an e-mail address on file with the college, and permitted their e-mail to be used for correspondence with the college were eligible for participation. Participation was elective and responses were anonymous. Participants were blinded to any specific hypothesis of the study. Institutional review board oversight was provided by the Mayo Clinic.

DATA COLLECTION

A detailed description of the survey has been published.11 The survey included 61 questions about a wide range of variables, including demographic information, practice characteristics, self-perceived medical errors, and career satisfaction. Standardized survey tools were used to identify burnout,1215 mental and physical QOL,16,17 and symptoms of depression.18,19 Burnout was measured using the Maslach Burnout Inventory, a 22-item questionnaire considered a standard tool for measuring burnout.1215 The Maslach Burnout Inventory has 3 subscales to evaluate the 3 domains of burnout: emotional exhaustion, depersonalization, and low personal accomplishment. We considered surgeons with a high score for medical professionals on either the depersonalization and/or emotional exhaustion subscales as having at least 1 manifestation of professional burnout.12,2023 Symptoms of depression were identified using the 2-item Primary Care Evaluation of Mental Disorders,18 a standardized and validated assessment for depression screening that performs as well as longer instruments.19 Mental and physical QOL were measured using the Medical Outcomes Study 12-Item Short-Form Health Survey,16,17 with norm-based scoring methods used to calculate mental and physical QOL summary scores.16 The mean (SD) mental and physical QOL summary scores for the US population are 50 (10) (range, 0-100).16

Recent SI was evaluated by asking surgeons, “Have you ever had thoughts of taking your own life, even if you would not really do it?” as well as “During the past 12 months have you had thoughts of taking your own life?” These questions originated from an inventory developed by Meehan et al,24 have been used in studies of physicians in training,9 and allow ready comparison with the prevalence of SI in the general US population.25 Surgeons were also asked whether they had sought psychiatric or psychologic help in the previous 12 months, whether they had used antidepressant medications in the previous 12 months, and, if so, who had prescribed medication for treatment of depression. All surgeons were also asked, “If you were to need medical help for treatment of depression, alcohol/substance use, or other mental health problem, would concerns about the repercussions on your medical license make you reluctant to seek formal medical care?” (Survey items are available from the corresponding author upon request.)

STATISTICAL ANALYSIS

Descriptive statistics were used to characterize sample demographics. Comparisons between surgeons with recent SI and surgeons without recent SI were tested using Wilcoxon rank sum, Mann-Whitney, and Fisher exact tests. Such comparisons with approximately 7300 and 500 surgeons reporting in the 2 groups have 80% power to detect an average difference of 11% times the SD, a small effect size.26,27 Accordingly, the P values in this report are not as important as the observed effect sizes. Consistent with recent advances in the science of QOL assessment,26 we a priori defined a 0.5 SD in QOL scores as a clinically meaningful effect size.26,27 Linear regression was used to evaluate the incremental effect of each measure of distress on recent SI. In addition, the odds ratio (OR) for recent SI associated with screening positive for depression or each 1-point change in burnout or QOL score was calculated. The multivariable associations among demographic characteristics, professional characteristics, and distress with recent SI were assessed using logistic regression. Both forward and backward elimination methods were used to select significant variables for the models in which the directionality of the modeling did not affect the results. The independent variables used in these models included age, sex, relationship status, spouse/partner current profession, having children, age of children, subspecialty, years in practice, hours worked per week, hours per week spent in the operating room, number of nights on call per week, practice setting (private practice, academic medical center, Veteran's Affairs hospital, active military practice, not in practice or retired, or other), current academic rank, primary method of compensation (eg, salaried, incentive-based pay, or mixed), percentage of time dedicated to non–patient-care activities (eg, administration, education, or research), self-perceived medical error in the previous 3 months, depression, and burnout. All analyses were done using SAS version 9 (SAS Institute Inc, Cary, North Carolina) or R (R Foundation for Statistical Computing, Vienna, Austria; http://www.r-project.org). A likelihood ratio test was used to test the overall fit of the model. The likelihood ratio test compares the likelihood function of the final model with the likelihood of the reduced model. A significant P value for this test indicates that the expanded model fits the data better than the reduced model. Since the hazard ratio measures magnitude of risk rather than a model's ability to accurately classify individuals, the C statistic was also used to further evaluate the discriminatory value of the model for predicting SI.28 The C statistic estimates the proportion of correct predictions of the model (C = 1 indicates perfect discrimination between those with and without SI; C = 0.5 is equivalent to chance).

Of the 24 922 ACS members surveyed, 7905 returned surveys (31.7%). A detailed description of the survey and analysis of the rates of burnout, QOL, and symptoms of depression among surgeons responding to the 2008 ACS survey has been reported.11 The personal and professional characteristics of responders are shown in Table 1. The prevalence of SI and reported use of mental health resources by surgeons are shown in Table 2. Of the 7905 returned surveys, SI data were successfully collected from 7825. Suicidal ideation was reported by 501 surgeons (6.4%) during the previous 12 months. Although the prevalence of SI among surgeons aged 25 to 34 years (7.3% vs 6.7%; P = .85) and 35 to 44 years (6.3% vs 6.8%; P = .21) was similar to that of the general population,25 SI was 1.5 to 3.0 times more common among surgeons relative to the general population among surgeons aged 45 to 54 years (7.6% vs 5.0%; P = .008), 55 to 64 years (6.9% vs 2.3%; P < .001), and 65 years or older (2.7% vs 1.2%; P = .02). Only 561 surgeons (7.2%) reported that they had sought psychiatric/psychologic help in the previous 12 months. More than one-third (3046 [38.8%]) of surgeons indicated that they would be reluctant to seek help for treatment of depression, alcohol/substance use, or other mental health problems due to concern that it could affect their license to practice medicine. Among the 461 surgeons (5.8%) who had used antidepressant medication in the previous 12 months, 41 (8.9%) had self-prescribed and 34 (7.4%) had received the prescription from a colleague who was not formally caring for them as a patient.

Table Graphic Jump LocationTable 2 Suicidal Ideation and Use of Professional Mental Health Resources

The relationship between SI and personal and professional characteristics is shown in Table 3. The prevalence was highest among surgeons aged 45 to 54 and did not differ significantly by sex. Being married (OR, 0.561; P < .001) and having children (OR, 0.668; P = .001) were associated with a lower likelihood of SI, and risk was higher among those who had been divorced (OR,  1.634; P < .001). Although SI was more common among the 7133 surgeons (91.5%) working more than 40 hours per week (OR, 2.071; P = .001), no further stratification of risk was observed by the number of hours worked for this subgroup. Surgeons with SI reported a greater frequency of overnight call (mean, 3.0 d/wk vs 2.6 d/wk; P < .001). The perception of having made a major medical error in the previous 3 months was associated with a 3-fold increased risk of SI, with 16.2% of surgeons who reported a recent major error experiencing SI compared with 5.4% of surgeons not reporting an error (P < .001). No significant difference in SI was observed by subspecialty discipline, hours spent in the operating room per week, percentage of time dedicated to non–patient-care activities (eg, research and administration), method of compensation, or years in practice, with the exception of lower risk among those who had been in practice for more than 30 years.

Table Graphic Jump LocationTable 3 Characteristics Among Surgeons With and Without Suicidal Ideation in the Previous 12 Months

The relationship between SI and surgeon burnout, QOL, depression, and use of mental health resources is shown in Table 4. Suicidal ideation was strongly correlated with measures of distress and QOL. Symptoms of depression were acknowledged by 390 of 501 surgeons with SI (77.8%) compared with 1938 of those without SI (26.7%) (P < .001). Suicidal ideation demonstrated a large positive correlation with each domain of burnout. For each 1-point higher score on the emotional exhaustion (OR, 1.069; P < .001) or depersonalization (OR, 1.109; P < .001) subscale or each 1-point lower score on the personal accomplishment (OR, 1.057; P < .001) subscale, surgeons were 5.7% to 10.9% more likely to report SI. The aggregate effect of the relationship between burnout and SI is large since the scale for emotional exhaustion ranges from 0 to 54, depersonalization from 0 to 33, and personal accomplishment from 0 to 48. Based on the strong association between both burnout and depression with SI, interactions between these variables were explored. The prevalence of SI increased in relation to the severity of burnout independent of symptoms of depression (Figure). Although SI demonstrated a strong inverse association with mental QOL (OR for each 1-point higher score = 0.906; P < .001), the association with physical QOL was small (OR for each 1-point higher score = 0.986; P = .03).

Place holder to copy figure label and caption
Figure

Relationship between depression screen, degree of depersonalization (A) or emotional exhaustion (B), and prevalence of suicidal ideation within the previous year. Thresholds to categorize physicians as having low, average, or high depersonalization were based on the published classifications for medical professionals12: low, 0 to 5; average, 6 to 9; and high, ≥10. Thresholds to categorize physicians as having low, average, or high emotional exhaustion were based on the published classifications for medical professionals12: low, 0 to 18; average, 19 to 26; and high, ≥27. The figures show that the prevalence of suicidal ideation increases as either depersonalization or emotional exhaustion increases (both P < .001), regardless of whether individuals screened positive for depression.

Graphic Jump Location
Table Graphic Jump LocationTable 4 Distress Among Surgeons With and Without SI in the Previous 12 Months

Surgeons with SI were more likely to have sought psychiatric/psychologic help in the previous 12 months (26.0% vs 5.8%; P < .001) but were also more likely to report that they were reluctant to seek professional help due to concern that it could affect their license to practice medicine (60.1% vs 37.4%; P < .001). Similarly, although they were more likely to have used antidepressant medication in the previous 12 months (21.8% vs 4.8%; P < .001), they were also more likely to have self-prescribed (15.7% vs 6.9%; P = .006).

Finally, we performed multivariable logistic modeling to identify factors independently associated with SI. Burnout, depression, and report of a recent medical error were strongly and independently associated with SI after controlling for other personal and professional characteristics (Table 5). The likelihood ratio test was significant (P < .001), indicating that the model was a good fit to the data. The discriminatory value of the model was also significant, with a C statistic of 0.8. Although SI did not differ significantly based on whether a surgeon had children, those whose youngest child was aged 19 to 22 years were at higher risk than were those with children of other ages. Practicing at an academic medical center and having incentive-only–based compensation as opposed to salary-based compensation were associated with reduced risk of SI. Being married was also associated with a reduced risk. Notably, number of nights on call per week, number of hours per week in the operating room, subspecialty discipline, and number of hours worked were not associated with SI after controlling for other factors.

Table Graphic Jump LocationTable 5 Factors Independently Associated With Suicidal Ideation in the Previous 12 Months on Multivariable Analysis

In this large national study, 1 of 16 responding American surgeons had experienced SI in the previous year. The rate of SI among surgeons 45 years and older was approximately 1.5-fold to 3-fold greater than that of the general US population. The higher rate of SI among surgeons is even more striking considering that surgeons are highly educated, nearly universally employed, and overwhelmingly (88%) married—all factors known to reduce risk of suicide in the general population.5,6 It is also notable that although individuals aged 45 to 54 in the general population have a lower risk of SI than younger individuals do,5 the reverse appears to be true for surgeons. Although the relative risk of death by suicide for physicians compared with the general population in some previous studies was higher for women than for men,3,4 the absolute rates of SI among the surgeons in our study did not differ significantly by sex.

Suicidal ideation among surgeons in the study reported here was strongly related to symptoms of depression and degree of burnout. Although the relationship between SI and depression is well recognized,5,6 the association between SI and burnout has only begun to be defined. Several members of our investigative team first reported this relationship in a large, prospective, longitudinal study of US medical students.9 In that study, burnout at study entry predicted for subsequent SI during the following 12 months. Burnout had a substantial dose-response relationship with SI that persisted on multivariable analysis controlling for symptoms of depression.9 Notably, the relationship between SI and burnout was reversible, with recovery from burnout decreasing the likelihood of subsequent SI.9 A strong association between burnout and SI was also recently reported in a study of more than 2000 Dutch medical residents, although that study did not control for depression.29 The findings of the study reported here suggest that burnout and depression are independently associated with SI where the consequences of burnout may be particularly important among individuals with underlying depression (Figure). Since the burnout syndrome affects a wide range of professionals (eg, teachers, police officers, social workers, and nurses),12 the relationship between burnout and SI requires further evaluation in the general population. Suicidal ideation among physicians was also markedly increased among surgeons who perceived they had made a major medical error in the previous 3 months, highlighting the personal consequences of medical errors on physicians.30

This investigation is one of few studies to evaluate physicians' use of mental health resources where much of the available data is nearly 30 years old.7 Only 26% of surgeons with SI in the previous year had sought care from a mental health provider during this interval—a value that appears substantially lower than the rate of approximately 44% for individuals with SI in the general population.5 The magnitude of this difference is again underscored by the fact that surgeons are overwhelmingly insured, have ready access to medical care, and are aware of the implications of untreated mental health problems—factors that should lead to higher use of mental health care services. Most (60%) surgeons with recent SI reported that they were reluctant to seek professional help due to concern that it could affect their medical license. Although this concern is well documented,31 to our knowledge, its prevalence has not been studied. Physicians' concern regarding the implications of mental illness on their medical license is likely reinforced by the fact that 80% of state medical boards inquire about mental illness on initial licensure applications and 47% on renewal applications.32 The study reported here indicates that distrust regarding how such information is used by licensing boards may be a disincentive for physicians to seek mental health care despite the fact that many licensing boards now focus not on whether a mental health condition is present but whether it is an impairment.32,33 Requests for information about treatment for psychiatric problems by hospitals, clinics, and malpractice insurers may also perpetuate physicians' concerns, independent of the efforts made by licensing boards to address this issue. Other factors, including a professional culture that discourages admission of personal vulnerabilities and places a low priority on physicians' mental health, may also be barriers to seeking professional help.1

Surgeons' reluctance to seek mental health treatment may have implications for patients as well as the affected surgeons. Studies suggest that physicians' personal health habits affect the health and prevention counseling they provide,3436 and, in a consensus statement, Center et al1 suggested that physicians' greater attention to their own depression and SI may improve the mental health care that they provide patients. In this regard, studies suggest that physicians fail to detect or treat 40% to 60% of cases of depression in their patients37,38 and that approximately 40% of individuals who die by suicide had contacted their primary care physician within a month of suicide.39,40 Surgeons' inattention to their own distress may also adversely affect modeling of self-care and mentoring for physicians in training. This is notable since studies suggest that the prevalence of SI among medical students and residents may be even higher than among surgeons and that these physicians in training are unlikely to seek help on their own initiative.9,29 Providing comprehensive recommendations for individual surgeons, health care institutions, academic medical centers, and state licensing boards to address physician suicide are beyond the scope of this article; detailed guidelines prepared by expert panels have recently been published.1,41

Our study is subject to a number of limitations. First, although similar to national survey studies of the members of physician societies,42,43 our response rate of 31.7% is lower than that of physician surveys in general44,45 and could therefore introduce substantial response bias. It is unknown whether distressed physicians are less likely to complete surveys due to apathy or more likely to complete surveys related to job stress due to greater interest in the topic. It is tempting to speculate that distressed physicians were less likely to participate and that the results represent a conservative estimate of the prevalence of SI among American surgeons. Second, while it is by far the largest surgical society in the US, it is also unknown as to what degree the ACS members are representative of American surgeons in general. Third, the study was cross-sectional, and we were unable to determine whether the associations between SI and measures of distress (eg, burnout) are causally related or the potential direction of the effects. Fourth, unmeasured confounding variables could explain some of the associations observed. The survey used a screening instrument for depression rather than a diagnostic instrument and did not evaluate for fatigue, substance abuse, or the presence of other mood disorders (eg, bipolar disorder) related to SI.5 Previous studies suggest that physicians are far less likely to be current users of illicit substances than the general population but are more likely to use alcohol and minor tranquilizers.46 Among physicians, however, surgeons appear to have the lowest rates of substance abuse and dependence.47 Other confounders, such as personality traits (eg, narcissism, arrogance, cynicism, or self-criticism), could influence both an individual's vulnerability to distress and likelihood of SI.

In conclusion, although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric/psychologic help. Recent SI among surgeons is strongly related to perceived medical errors, symptoms of depression, and degree of burnout. Additional studies are needed to evaluate the unique factors that contribute to the higher rate of SI among surgeons in conjunction with efforts to reduce surgeons' distress and eliminate barriers that lead to underuse of mental health resources.

Correspondence: Tait D. Shanafelt, MD, Mayo Clinic, 200 First St, Rochester, MN 55905 (shanafelt.tait@mayo.edu).

Accepted for Publication: October 27, 2009.

Author Contributions:Study concept and design: Shanafelt, Balch, Dyrbye, Russell, Rummans, Sloan, and Oreskovich. Acquisition of data: Shanafelt and Bechamps. Analysis and interpretation of data: Shanafelt, Balch, Dyrbye, Satele, Swartz, Novotny, Sloan, and Oreskovich. Drafting of the manuscript: Shanafelt, Balch, Satele, Sloan, and Oreskovich. Critical revision of the manuscript for important intellectual content: Shanafelt, Balch, Dyrbye, Bechamps, Rummans, Swartz, Novotny, Sloan, and Oreskovich. Statistical analysis: Satele, Novotny, and Sloan. Administrative, technical, and material support: Shanafelt, Dyrbye, and Russell. Study supervision: Shanafelt, Balch, and Oreskovich.

Financial Disclosure: None reported.

Funding/Support: Funding for this study was provided by the American College of Surgeons.

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Pirkis  JBurgess  P Suicide and recency of health care contacts: a systematic review. Br J Psychiatry 1998;173462- 474
PubMed Link to Article
Mann  JJApter  ABertolote  J  et al.  Suicide prevention strategies: a systematic review. JAMA 2005;294 (16) 2064- 2074
PubMed Link to Article
Allegra  CJHall  RYothers  G Prevalence of burnout in the U.S. oncology community: results of a 2003 survey. J Oncol Pract 2005;1 (4) 140- 147
PubMed Link to Article
Kuerer  HMEberlein  TJPollock  RE  et al.  Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 2007;14 (11) 3043- 3053
PubMed Link to Article
Kellerman  SEHerold  J Physician response to surveys: a review of the literature. Am J Prev Med 2001;20 (1) 61- 67
PubMed Link to Article
Asch  DAJedrziewski  MKChristakis  NA Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50 (10) 1129- 1136
PubMed Link to Article
Hughes  PHBrandenburg  NBaldwin  DC  Jr  et al.  Prevalence of substance use among US physicians. JAMA 1992;267 (17) 2333- 2339
PubMed Link to Article
Hughes  PHStorr  CLBrandenburg  NABaldwin  DC  JrAnthony  JCSheehan  DV Physician substance use by medical specialty. J Addict Dis 1999;18 (2) 23- 37
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure

Relationship between depression screen, degree of depersonalization (A) or emotional exhaustion (B), and prevalence of suicidal ideation within the previous year. Thresholds to categorize physicians as having low, average, or high depersonalization were based on the published classifications for medical professionals12: low, 0 to 5; average, 6 to 9; and high, ≥10. Thresholds to categorize physicians as having low, average, or high emotional exhaustion were based on the published classifications for medical professionals12: low, 0 to 18; average, 19 to 26; and high, ≥27. The figures show that the prevalence of suicidal ideation increases as either depersonalization or emotional exhaustion increases (both P < .001), regardless of whether individuals screened positive for depression.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2 Suicidal Ideation and Use of Professional Mental Health Resources
Table Graphic Jump LocationTable 3 Characteristics Among Surgeons With and Without Suicidal Ideation in the Previous 12 Months
Table Graphic Jump LocationTable 4 Distress Among Surgeons With and Without SI in the Previous 12 Months
Table Graphic Jump LocationTable 5 Factors Independently Associated With Suicidal Ideation in the Previous 12 Months on Multivariable Analysis

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Pirkis  JBurgess  P Suicide and recency of health care contacts: a systematic review. Br J Psychiatry 1998;173462- 474
PubMed Link to Article
Mann  JJApter  ABertolote  J  et al.  Suicide prevention strategies: a systematic review. JAMA 2005;294 (16) 2064- 2074
PubMed Link to Article
Allegra  CJHall  RYothers  G Prevalence of burnout in the U.S. oncology community: results of a 2003 survey. J Oncol Pract 2005;1 (4) 140- 147
PubMed Link to Article
Kuerer  HMEberlein  TJPollock  RE  et al.  Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 2007;14 (11) 3043- 3053
PubMed Link to Article
Kellerman  SEHerold  J Physician response to surveys: a review of the literature. Am J Prev Med 2001;20 (1) 61- 67
PubMed Link to Article
Asch  DAJedrziewski  MKChristakis  NA Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50 (10) 1129- 1136
PubMed Link to Article
Hughes  PHBrandenburg  NBaldwin  DC  Jr  et al.  Prevalence of substance use among US physicians. JAMA 1992;267 (17) 2333- 2339
PubMed Link to Article
Hughes  PHStorr  CLBrandenburg  NABaldwin  DC  JrAnthony  JCSheehan  DV Physician substance use by medical specialty. J Addict Dis 1999;18 (2) 23- 37
PubMed Link to Article

Correspondence

CME


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