We appreciate Dr Kawada’s interest in our paper and are happy to respond to his comments.

First, our decision to define those at risk for professional burnout as having a high score in either emotional exhaustion or depersonalization on the Maslach Burnout Inventory is based on the work of Maslach et al, Balch et al, Shanafelt et al, who have published extensively on the subject. Personal accomplishment is a metric used in the Maslach Burnout Inventory (with a low score reflecting a low sense of personal accomplishment) but has not been used in the definition of professional burnout in most physician studies. For this reason, the personal accomplishment scores were not used in the logistic regression analysis that included a high score in emotional exhaustion and/or depersonalization. However, we did run a separate analysis of personal accomplishment with the same variables. There was no correlation of low personal accomplishment scores with demographics, professional characteristics, career satisfaction, depression, alcohol abuse, suicidal ideation, or other factors.

Second, the author raises concern about our rate of low personal accomplishment (11%) compared with that of the study by Guveli et al (44%). He notes that we studied those with high academic ranks and excellent health. Given this, he raises concern about the generalizability of our results.

It should be noted that this study was small (n = 157 subjects) and studies health care professionals in Istanbul, Turkey. Only 19 of the subjects were physicians; the others were nurses (n = 19) and support staff that included orderlies, office workers, cleaning staff, security staff, and others (n = 137). Studies of US physicians and physicians in training have all noted similar levels of low personal accomplishment 11.6-13%. Additionally, a large study (n = 7288) of members of the American Medical Association found similar numbers for high (66.6%), moderate (20.9%), and low 12.4%) levels of personal accomplishment as did our study; 56% of these physicians were in private practice.

Finally, a multivariate analysis was completed. Results indicate that physicians with low mental quality of life (odds ratio, 3.23; 95% confidence interval, 1.82–5.72; P < .001), depression screen positive (odds ratio, 2.81; 95% confidence interval, 1.56–5.07; P = .001), feeling stressed and overwhelmed (odds ratio, 2.81; 95% confidence interval, 1.58–4.98; P < .001), and reluctance to seek care (odds ratio, 2.72; 95% confidence interval, 1.56–4.74; P < .001) were associated with a higher odds of burnout, although physicians who would encourage a child to enter medicine were associated with lower odds of burnout (odds ratio, 0.42; 95% confidence interval, 0.24–0.73; P = .002). This can be found on page 5 of our paper.