Ameliorating the Impact of Complications and Errors on Surgeons: Resilience Training for Surgeons.
Phase: NA
Conditions: Effect of Training
Sponsor: Bournemouth University

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Research Protocol: January 2018-January 2020 
IRAS ID: 238751 
 
 
 
Ameliorating the Impact of Complications and Errors on 
Surgeons: Resilience Training for Surgeons. 
(Resilience Training for Surgeons) 
 
Research Protocol Version 1.1 
 11/06/18 
 
 
 
Research Team Members (Role) 
Dr. Helen Bolderston (Chief Investigator) 
Mr Kevin Turner, MA DM FRS(Urol) (Principle Investigator) 
Prof. Sine McDougall (co-investigator) 
Dr Kevin Thomas (co-investigator) 
Stephen Richer (Ph.D. Student) 
 
 
Funders: Bournemouth University and Royal Bournemouth and Christchurch Hospitals NHS 
Foundation Trust. 
Sponsor: Bournemouth University. 
 
 
 
 

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Research Protocol: January 2018-January 2020 
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Contents 
1: Background ......................................................................................................................................... 3 
2: Aims and Objectives ............................................................................................................................ 3 
3: Design .................................................................................................................................................. 4 
4: Participants ......................................................................................................................................... 4 
5: Sampling .............................................................................................................................................. 4 
Strategy ............................................................................................................................................... 4 
Sample Size ......................................................................................................................................... 4 
6: Recruitment ........................................................................................................................................ 4 
7: Randomisation .................................................................................................................................... 5 
8: Data Collection .................................................................................................................................... 5 
Data Collection Points ......................................................................................................................... 5 
Primary Outcome Measures ............................................................................................................... 6 
Secondary Outcome and Process Measures ....................................................................................... 6 
9: Data Analysis ....................................................................................................................................... 6 
10: Ethical Considerations ....................................................................................................................... 7 
11: Data Protection and Storage ............................................................................................................. 8 
Recordings ........................................................................................................................................... 8 
Data ..................................................................................................................................................... 8 
Confidentiality ..................................................................................................................................... 8 
12: Training Protocol with example timings. .......................................................................................... 9 
Training Session 1 ............................................................................................................................... 9 
Training Session 2 ............................................................................................................................. 15 
Training Session 3 ............................................................................................................................. 20 
13: Timelines ......................................................................................................................................... 24 
14: References ...................................................................................................................................... 25 
 
 
 
 

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1: Background 
 
 
There is a high likelihood that surgeons will experience adverse outcomes due to patient 
complications following surgery sometime during their careers (Patel et al., 2010). Such adverse 
events can have undesirable effects on the surgeon in terms of quality of life and mental well-being 
(e.g. anxiety, feelings of regret) and lowered professional confidence and impaired perceptions of 
professional competence. Furthermore, numerous studies have indicated that these kinds of 
negative impacts can also lead to burnout and depression, (Pinto 2011, Shanafelt 2012). As well as 
the detrimental effects on surgeons and those around them, this in turn may lead to more errors 
and poorer outcomes for patients.  
 
Research in a range of occupational settings has indicated that resilience plays an important role in 
ameliorating the impact of adverse events in high pressure environments. This project will use a 
randomised controlled trial research design to assess the efficacy of brief one-to-one Acceptance 
and Commitment Training (ACTr), designed to enhance surgeons' psychological resilience. According 
to acceptance and commitment therapy (Hayes, 2004), psychological flexibility is implicated in 
psychopathology. Psychopathology is primarily the consequence of psychological inflexibility i.e. 
inability to persist or change behaviour according to long-term values due to language and cognition 
skills (Hayes, 2006), which has particular significance when an individual is confronted with stress or 
adversity. 
 
 
 
2: Aims and Objectives 
 
The main aim of our research is to assess the efficacy of a brief Acceptance and Commitment 
Training course. We wish to ascertain whether such a course can increase surgeons' resilience by 
increasing psychological flexibility, valuing and self-compassion (all of which are expected to be 
positively impacted by this training). This research will fill a gap in the relevant research literature; 
namely that no research project as far as we are aware has evaluated ACTr as a means to enhance 
resilience in surgeons. In fact any research conducted on resilience training with a surgical 
population is rare. 
 

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3: Design 
 
The proposed study will initially take the shape of a small pilot study (n=10) and following this a 
randomised controlled trial. (n=100) 
 
The intervention will consist of Acceptance and Commitment Training (ACTr), on a 1:1 basis. Flaxman 
(2013) devised a workplace training program which will form the basis of this training protocol. ACT 
as a workplace training has been supported by numerous studies including Lappalainen et al (2007),   
Finnes and Ghaderi (2017). A recent manual, Flaxman, Bond and Livheim (2013), will be utilised for 
this study, with a bespoke tailoring to the surgeons’ population. See section 12 for full details. 
 
 
4: Participants 
 
Trainee surgeons and consultant surgeons from local hospitals, initially  Royal Bournemouth 
Hospital, Bournemouth, Dorset; and Poole Hospital, Poole, Dorset. Then the John Radcliffe Hospital , 
Oxford; Southampton General Hospital, Southampton and Portsmouth General Hospital. 
 
5: Sampling 
 
Strategy 
Block randomisation (blocks of 4) will be used to help ensure equal-sized groups. An external 
statistician will generate random blocks of 4. 
Sample Size 
For the RCT, we intend to recruit 100 to allow for some attrition and still have approximately 45 
participants per condition. This number is based on previous studies(e.g Flaxman and Bond, 2010) 
conducted using ACTr based training; this will give enough statistical power, particularly with regards 
to mediation analysis. 
 
 
6: Recruitment 
 

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Recruitment will initially be through Royal Bournemouth Hospital and will be initiated by Mr Kevin 
Turner, MA DM FRCS(Urol) (Principal Investigator). An invitation email will be sent to potential 
participants (again identified by Mr Turner) and further information regarding the study will be 
forwarded to the potential participant on their request only. 
 
 
 
7: Randomisation 
 
Participants will be allocated one of two groups, the experimental group (who will receive ACTr) or 
the wait-list control group. Participants allocated to the wait-list control will be offered the same 
ACTr sessions once the current study has ended. 
 
 
 
 
 
 
 
 
8: Data Collection 
 
Data Collection Points 
T1 – 2 Weeks before training session one. Via email/on-line questionnaires. 
S1- First training session 
Interval (4 weeks RCT, 2 weeks Pilot) 
T2 – Immediately before the beginning of training session two.  
S2 – Second Training session 
Interval (4 weeks RCT, 2 weeks Pilot) 

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T3 - Immediately before the beginning of training session three. 
S3 – Third Training session 
T4 –Within two week of completion of training session three. 
T5- Follow-up, 12 weeks after training session three. Via email. 
 
Primary Outcome Measures 
Resilience - Brief Resilience Scale (BRS) 
General Health - General Health Questionnaire (GHQ-12) 
 
Secondary Outcome and Process Measures 
CBI (Copenhagen Burnout Inventory)  
DASS21 (Depression Anxiety and Stress Scale)  
VLQ (Value Living Questionnaire)  
WAAQ (Work related Acceptance and Action Questionnaire)  
AAQII (Acceptance and Action Questionnaire)  
SCS (Self Compassion Scale) 
SPS (Sense of Preparedness Scale) 
 
9: Data Analysis 
 
 
Data will be analysed on an intention-to-treat basis. For the pilot study a series of analyses of 
variance with time (1-5) as a within-subjects factor will be employed to examine changes in outcome 
and process measures. For the RCT, a series of analyses of variance will be conducted with time(1-5) 
as a within-subjects factor and condition (treatment vs control) as a between-subjects factor. 
Mediation analysis based on regression will be used to test the role of study processes to ascertain 
whether outcome measure changes are mediated by process measures. 
Furthermore the Jacobson and Truax (1991) method of assessing change for each individual 
participant will be used in both the pilot and the RCT studies. This will be used to determine whether 
the magnitude of change for a given client is statistically reliable. 
 

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 Data collected will be presented and analysed descriptively. The consort flow diagram (2010, figure 
1.) will be followed to document relevant recruitment data. 
 
 
 
Figure 1 (Consort 2010 Flow Diagram) 
10: Ethical Considerations 
 

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Ethical approval will be sought from the university ethics team and the Integrated Research 
Application System (IRAS). The researcher will undertake ‘Good Clinical Practice’ training. Informed 
consent will be gained at the time of recruitment and verbally prior to the start of each session 
Participants will be made aware of their right to withdraw at any time. In the highly unlikely event 
that participants experience an unexpected uncomfortable response during the session, emotional 
'grounding techniques' will be utilised by the trainer. Furthermore, Clinical Psychologist Helen 
Bolderston (Chief Investigator) contact details will be made available to participants, as will details of 
the BMA's Doctors for Doctors website and helpline (who can offer ongoing counselling). 
 
11: Data Protection and Storage 
 
 
Recordings 
Training sessions will be recorded as a further safeguard and assessment tool. The only purpose of 
recording the sessions is to ensure the ACTr process is being delivered accurately and correctly. 
Randomly selected section of sessions will be assessed by an independent ACTr assessor (Dr 
Bolderston will source the assessor and this will be kept on file) to rate fidelity to the established 
ACTr protocol. If, a randomly selected recording identifies the participant or anyone else, it will NOT 
be forwarded to the independent assessor, and another recording will be randomly selected. 
Data 
All information will be kept on a secure university hard drive. All data will be password protected. All 
data will be identified only by participant number. An Excel file linking participant to participant 
number will be kept on a separate drive, on a separate computer, password protected. Paperwork 
will be kept in a locked filing cabinet in a locked office at Bournemouth University,. Computers are 
both password secure and encrypted. NO personal information will be kept on laptop computers.  
Confidentiality 
The NHS code of confidentiality will be adhered to. Both Dr Helen Bolderston and Mr Kevin Turner 
are both NHS employees and as such have been trained within the last 12 months in Information 
Governance and Confidentiality. Bournemouth University staff will adhere to the requirements of 
the Data Protection Act. Furthermore, Access to personal data will be limited to the research team. 
All data will be anonymised at the earliest possible stage. Personal information will not be kept once 
participants have completed their 3-month follow-up session. Participants may withdraw at any time 
and all personal data will be destroyed if this is the case. 

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12: Training Protocol with example timings. 
 
Training Session 1 
 
 
Develop a rapport with individuals and create a climate of safety and warmth. 
 
Describe the basic format, content and aim of the training. 
 
Install hope that training has the potential to be unusual, interesting and effective 
 
Range of empirically supported ACT exercises as per Flaxman, Bond and Livheim (2014) such as those outlined below 
 
Day 1 Phase 
Intervention  
Detail 
9.00  
 
 
 
Welcome and 
Introduction 
 
Mindfulness or values 
warm-up exercise 
 
 
 
Re-consent 
Recording sessions - rationale 
 
Designed to build rapport, engage and be ‘ACT’ consistent. To gather 
hopes and expectations for the training.  
 
Introductions 

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– name, work details, 2 activities they do on automatic pilot and 2 
activities they perform with more psychological awareness 
 
We teach ACT skills experientially as well as didactically so there’ll be 
a mix of information sharing, skills practices, discussion, goal setting 
etc. 
 
Confidentiality: It’s not therapy but it is personal. 
 
What do you hope to get out of it personally? 
 
Important to attend every session 
It’s a psychological and behavioural skills training program – training - 
not therapy 
Research evidence 
Training is not limited to work-related resilience and wellbeing – the 
skills can be applied to all areas of life 
Practicing skills between sessions is an essential part of the training  

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9.20  
 
Overview of the 
training 
 
Presentation of two 
skills organising 
diagram. 
 
 
 
 
To offer empirical evidence for both ACT in occupational settings and 
for particular processes or components - e.g. mindfulness 
 
Two broad related skills: mindfulness and values-based action 
The diagram is basically an overview of the entire training 
 
More about mindfulness and values-based action 
Mindfulness evidence base – can be used to enhance resilience in 
people who are already fairly resilient, and can also be used to 
reduce stress, burnout, depression and so on, when people are going 
through challenging times 
Values-based action – goal setting with a difference 
 
Together they can also help when we’re experiencing loss of purpose 
in life, self-doubt, increase effectiveness and performance 

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9.35 
Introduction to 
mindfulness 
 
Raisin exercise 
Brief mindfulness of 
body and breath. 
 
Rest of the session – an introduction to the two main skills 
 
Present-moment awareness training 
 
Widely recognized effective introduction to mindfulness (Kabat-Zinn 
1990). Aid recognition of the experiential distinction between 
automatic-pilot and present moment awareness. 
9.50 
Break 
 
 
10.00 
Introduction to 
Values-Based 
Action 
 
Values card sort. 
(I) Provide practical definition of values from ACT perspective. Show 
potential benefits of guiding daily behaviour through personally 
chosen values. (ii) Encourage participant to choose one value for one 
life domain and translate into a series of specific actions (for next 
session). (iii) Help participant anticipate the thoughts and feelings that 
may function as internal barriers to valued behavioural activation. 
 

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10.20 
Introduction to 
Values-Based 
Action 
(continued) 
 
Compass metaphor. 
 
Activate nature of valuing (Hayes et al. 1999). Using the metaphor to 
illustrate the distinctions between values, value-based goals and 
value based actions and to illustrate that values are not ‘in the future’ 
but available as a potential guide to action in each and every 
moment.  
 
 
 
 
10.30 
Presentation of 
rationale for the 
program 
 
Two sheets of paper 
technique. 
 
One sheet has word ‘VALUE’ written on it, the other ‘”UNHELPFUL” 
THOUGHT/FEELING/MOOD’ Geared towards helping client make 
personal values a more prominent guide to daily actions and life 
goals. 
 
 
 

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10.40 
Discussion of 
home practice 
assignments 
 
Home practice 
handouts; 
Environmental 
reminders: 
Coaching around 
effective goals setting 
– worksheet 
3 valued based 
actions 
10-minute mindfulness 
of breath 
 
Define one value and translate into specific actions for the next 
session. To notice what it is like deliberately taking actions that are 
guided by personal values. To become aware of any internal barriers 
that actually (or almost) interfere with value-directed action. 
 
Reminder that participant can make contact between sessions if 
there are any concerns or queries  
 
 
 

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Training Session 2  
(4 weeks after session 1; 2 weeks for pilot) 
 
 
 
Reduce excessive entanglement with unhelpful thought content. 
 
Undermine experiential avoidance. 
 
Cultivate acceptance skills. 
 
Range of empirically supported ACT exercises as per Flaxman, Bond and Livheim (2014) such as those outlined below 
 
 
 
Day 2 
Phase 
Intervention  
Detail 
8.45 
Data Collection  
Collect Data 
 
9.00  
 
Opening 
mindfulness 
Mindfulness of breath; 
noticing thoughts and 
Involves participant sitting in upright position, eyes closed of 
unfocused and cast down towards floor, hands resting 

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practice and brief 
review 
 
 
 
feelings and allowing 
them to come and go. 
 
 
 
comfortably on lap or arms of chair. Participant will be invited to 
become aware of physical sensations before setting attention on 
sensation of movement in the abdomen whilst breathing. 
9.10 
Home practice 
review 
 
 
 
Discussion 
 
Clarify understanding of the key feature of mindfulness and value-
based action processes. Emphasise the importance of 
generalising mindfulness and value-based action from the session 
to daily life. Provide reinforcement to participants who have 
engaged in mindful and value-based action exercises outside the 
training. Getting clues about barriers – what got in the way if 
homework was difficult to complete, 
9.20 
Presentation of 
training rationale 
 
Passengers on the bus 
metaphor. 
ACT metaphor found in numerous ACT texts (Hayes et al. 1999). 
Used to portray the functional link between mindfulness and 
value-based action. Illustrates person driving bus to some extent 
distinct from own thought and feelings. Some passengers 
(thoughts/feelings) can be unhelpful and exert subtle/not so 

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subtle) influence over driver’s actions. Removing passengers may 
not be helpful.  
A lot of unpacking – it’s a key learning from the training – your 
thoughts/memories/emotions/bodily sensations/urges can all be 
saying do one thing and you can choose to do another, because 
it’s in the service of your value 
9.40 
Untangling from 
thought barriers to 
valued action 
 
Hand in the face 
metaphor 
Old film metaphor 
Self-reflection on 
unhelpful thought 
content 
Thoughts on screen 
exercise. 
2 of 4 options? 
Cognitive Defusion. Defusion exercises train people to take 
unhelpful thoughts a bit less seriously; notice the ongoing process 
of thinking; and learn experientially that thoughts do not have to 
control action (Harris, 2009). ACT’s defusion strategies focus 
primarily on helping participants relate differently to thoughts that 
interfere with valued action. 
9.55 
Break 
 
 
10.05 
Mindfulness of 
mood/emotion 
Brief mindfulness of 
stressful event or 
Enhancing the participant experiential acceptance skills. Defusion 
and acceptance are related processes within the ACT model. 

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thought – locating in 
the body 
Physicalizing exercise  
 
And it is useful to organise them under the same theme of 
noticing and untangling from internal barriers to valued action. 
This in turn feeds into the broader purpose of gradually increasing 
the prominence of people’s personally chosen values as a guide 
to goals and daily action (Flaxman et al., 2013) 
10.25 
Defining values and 
value-based goal 
and action 
planning 
 
Construction of four-
week values-based 
goal plan and action 
plan. 
 
Define values in at least two areas of life (preferably different 
areas as defined on Day 1. Set suitable specific short-term, 
medium term and long term goals that would help to bring one or 
two values to life. Participants will be encouraged to set 4 short-
term value based goals they are motivated to achieve in next 4 
weeks.  
 
Discussion of home 
practice 
assignments 
 
Home practice 
handout; 
environmental 
reminders; public 
commitment to one 
value  -based goal 
 
Participants are invited to engage mindfully in three value-based 
actions over the next weeks. These values should be selected by 
the participant from those identified in the previous /Defining 
values’ exercise. 
Think about continuing mindfulness practice homework – doing 
every day activities mindfully – brushing teeth, walking from car to 
hospital etc. 

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Reminder that participant can make contact between sessions if 
there are any concerns or queries  
 
 
 

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Training Session 3 
 (4 weeks after session 2 for RCT, 2 weeks for pilot) 
 
 
Booster Session. 
 
Further rehearsal of exercises; basic mindfulness training, physicalizing exercise, diffusion, mindfulness of thought, value-based goal and 
action planning. 
 
Range of empirically supported ACT exercises as per Flaxman, Bond and Livheim (2014) such as those outlined below. 
 
 
 
Day 3 
Phase 
Intervention  
Process/Reason/function 
8.45 
Data Collection 
Collection of Data 
 
9.00 
 
 
Welcome Back 
Two-skills diagram. 
 
Welcome back to part three and to reaffirm the empirical 
evidence for both ACT in occupational settings and for particular 
processes or components  - e.g. mindfulness 
Also, any evidence to do with medical professional in particular 
9.10 
Opening 
Mindfulness of body 
Preparation involves participant sitting in upright position, eyes 

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mindfulness 
practice 
 
and breath. 
 
closed or unfocused and cast down towards floor, hands resting 
comfortably on lap or arms of chair. Participant will be invited to 
become aware of physical sensations before setting attention on 
sensation of movement in the abdomen whilst breathing. 
Function of starting with a mindfulness practice: 
Bring attention into the room and the present moment 
More likely to be fully engaged in later exercises if do mindfulness 
practice now 
Brief inquiry after the practice 
9.20 
 
Home practice 
review 
 
Discussion 
Clarify understanding of the key feature of mindfulness and value-
based action processes. Emphasise the importance of 
generalising mindfulness and value-based action from the session 
to daily life. Provide reinforcement to participants who have 
engaged in mindful and value-based action exercises outside the 
training. 
9.35 
Assessing value 
consistency 
Self-reflection on 
value-consistent and 
inconsistent actions 
An important part of values work involves asking participants to 
reflect on the value consistency or inconsistency of their recent 
patterns of behaviour. Participants asked to rate both the 

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over past 2 weeks. 
importance they attach to a particular value in their life at this 
moment in time  and effective, successful or consistent they had 
been at pursuing this value over the last few weeks (Wilson et al., 
2010). Any high discrepancy between value importance and 
value consistency may indicate a particular value of life is that is 
being neglected. VLQ? Bull’s-eye? 
9.50 
Mindfulness of 
thought and feeling 
Thoughts on clouds 
exercise, contacting 
the resilient 
‘observer’ 
perspective. 
 
Reaffirm and enhance the participant experiential acceptance 
skills. Defusion and acceptance are related processes within the 
ACT model. And it is useful to organise them under the same 
theme of noticing and untangling from internal barriers to valued 
action. This in turn feeds into the broader purpose of gradually 
increasing the prominence of people’s personally chosen values 
as a guide to goals and daily action (Flaxman et al., 2013) 
Observer self: and who is it who’s doing the noticing? 
Dream metaphor 
Hierarchical relationship between observer self and content of 
experience rather than just a separate relationship  
Reflection on these practices – their uses and implications 

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10.10 
Break 
 
 
10.20 
Values-based goal 
and action 
planning 
 
Short-term, medium 
term and long term 
values-based goal-
setting exercise; 
values-based action 
map 
Define values in at least two areas of life (preferably different 
areas as defined on Day 1. Set suitable specific short-term, 
medium term and long term goals that would help to bring one or 
two values to life. Again, participants will be encouraged to set 4 
short-term value based goals they are motivated to achieve in 
next 4 weeks. 
10.30 
Recommendation 
for continued 
practice 
 
Home practice 
handout; top tips for 
building a valued 
life. 
Handout for home practice. Tips for future practice after this final 
session. 
10.40 
Final personal 
reflections on the 
training 
 
Discussion 
Discuss with participant the three training days, assessment of 
course delivery, potential for improvements.  
 
Reminder that participant can make contact post training if there 
are any concerns or queries 
 
 

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13: Timelines 
 
 
 
2017-2018 
Sept 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
June 
July 
Aug 
 
 
 
 
 
 
 
 
 
 
 
 
 
Training and Data Collection 
 
 
 
 
 
 
 
 
 
 
 
 
 
2018-2019 
Sept 
Oct 
Nov 
Dec 
Jan 
Feb 
Mar 
Apr 
May 
June 
July 
Aug 
 
 
 
 
 
 
 
 
 
 
 
 
 
Training and Data Collection 
 
 
 
 
 
 
 
 
 
 
 
 
Write Up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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14: References 
 
 
Clarke, S., Kingston, J., Wilson, K.G., Bolderston, H., Remington, B. (2012). Acceptance and 
commitment therapy for a heterogeneous group of treatment-resistant clients: A treatment 
development study. Cognitive Behavioural Practicvfed3, Vol 19, Issue 4, 560-572 
 
Finnes, A.,Ghaderi, A., Dahl, J., Nager., Enebrink, P. (2017) Randomized Controlled Trial of 
Acceptance and Commitment Therapy and a Workplace Intervention for Sickness Absence Due to 
Mental Disorders. J Occup Health Psychology. 
 
 
Flaxman P. , Bond, F.,  Livheim, F. (2013): The Mindful and Effective Employee: An Acceptance and 
Commitment Therapy Training Manual for Improving Well-Being and Performance. New Harbinger  
Publications; 2013 
 
 
Flaxman P., Bond, F. (2010) A randomised worksite comparison of acceptance and commitment 
therapy and stress inoculation training. Behavioural Research and Therapy. 2010 Aug;48(8):816-20. 
 
 
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment 
Therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44(1), 1-25.  
 
 
Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., Masuda, A., Pistorello, J., 
Rye, A. K., Berry, K., & Niccolls, R. (2004). The impact of acceptance and commitment training and 
multicultural training on the stigmatizing attitudes and professional burnout of substance abuse 
counsellors. Behaviour Therapy, 35, 821-835 
 
 
 

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Jacobson, N., Truax, P. (1991) Clinical significance: a statistical approach to defining meaningful 
change in psychotherapy research. J Consult Clinical Psychol. 1991 Feb;59(1):12-9. 
 
 
 
Lappalainen, R., Lehtonen, T., Skarp, E., & Taubert, E. (2005). Training students a few hours in CBT 
and in ACT: A randomized controlled trail. Paper presented at the meeting of the European 
Association of Behavioural and Cognitive Therapies, Tessaloniki, Greece, September. 
 
 
Pinto, A., Faiz, O., Davis, R., Almoudaris, A., & Vincetnt, C. ‘Surgical complications and their impact on 
patients' psychosocial well-being: a systematic review and meta-analysis’. BMJ Open 2016 Feb 16; 
Vol. 6 (2), pp. e007224. Date of Electronic Publication: 2016 Feb 
 
Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, 
Freischlag J. Burnout and medical errors among American surgeons. Ann Surg. 2010 Jun; 251(6):995-
1000.