Moreover, burnout appears to be a surrogate measure of distress among physicians. In a national survey of practicing surgeons, alcohol misuse and suicidal ideation were up to 3 times that of the general population. When burnout was present the likelihood increased 25% and 90%, respectively. Among physicians in general, burnout increases the likelihood of depressive symptoms 170%. In surgical trainees, there is alarming prevalence of distress symptoms, with a recent national survey (manuscript in preparation) showing 16% suicidal ideation, 32% moderate to severe depression, 58% high stress and 61% alcohol misuse or abuse among PGY-3s. It has been proposed that chronic and overwhelming stress in the absence of adequate coping skills promotes burnout and associated distress symptoms. It has also been posited that performance deficits, from surgical errors to poor professionalism, derive in large part from the deleterious effects of stress on cognition.