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1. Have you felt burned out from practicing medicine at any point during your career? (Required.)

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2. Do you feel burned out now? (Required.)

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3. Please rate how burned out you feel now, with 1 being no feelings of burnout and 10 being worst. (Required.)

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4. What has contributed the most to your feelings of burnout? (Required.)

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5. Do you believe burnout negatively impacts your productivity and financial earnings? (Required.)

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6. How do you cope with burnout? (Required.)

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7. Have you ever talked to fellow physicians/colleagues about feeling burned out? (Required.)

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8. Do you plan to seek or have you sought professional help/counseling dealing with burnout? (Required.)

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9. Have you avoided expressing feelings of burnout because you’re concerned about being judged negatively by peers? (Required.)

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10. Have your feelings of burnout ever made you want to quit practicing medicine? (Required.)

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11. Do you think your workplace culture contributes to your own or others’ burnout? (Required.)

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12. How has burnout affected your career as a physician, if at all?

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13. What do you believe is the solution to physician burnout?

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14. What is your medical specialty? (Required.)

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15. What is your age? (Required.)

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16. How many years have you been practicing? (Required.)

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17. What is your gender? (Required.)

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18. Do you have an ownership stake in your practice? (Required.)

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19. Which of these best describes your practice setting? (Required.)

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20. How many hours do you work per week? (Required.)

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