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The term 'professional crisis' or 'vocational crisis' in surgery refers to a situation in which general surgery residents increasingly choose to specialize in a particular surgical or medical subspecialty, rather than pursuing a career as a general surgeon.The ancient Confucian teaching "Choose a job you love, and you will never have to work a day in your life" echoes with particular intensity in the world of surgery. For generations, surgeons have embraced this ideal, merging vocation, discipline, and technical mastery into a unified ethical identity.Historically, young physicians entering surgery perceived themselves as part of a lineage, inheriting the values of craftsmanship, courage, altruism, and humility from their mentors. The operating room was not merely a workplace but a symbolic environment where technical mastery intertwined with moral duty.Yet today, the landscape has dramatically changed. The traditional harmony between calling, competence, and identity is increasingly disrupted. What older generations of surgeons viewed as the natural progression from apprentice to master now appears uncertain, fragmented, and in many cases unsustainable. The modern trainee encounters not only the inherent demands of surgical practice but also a healthcare environment characterized by structural constraints, administrative overload, and shifting cultural expectations. The very notion of "vocation," once synonymous with sacrifice and devotion, is increasingly contested by younger physicians who prioritize balance, wellbeing, and long-term quality of life. This combination has contributed to what is now often described as a crisis of surgical vocation, a phenomenon with significant implications for recruitment, retention, and the future of the entire discipline 1.This article provides an opinion-based perspective supported by a focused narrative review of the literature. Relevant studies were identified through searches of PubMed/MEDLINE and Google Scholar, prioritizing systematic reviews, meta-analyses, and large surveys addressing surgeon burnout, surgical workforce trends, and factors influencing career choice in surgery over the past decade. Additional relevant sources were identified through cross-referencing of key publications.Over the last two decades, a marked decline in the attractiveness of general surgery among medical graduates has been observed, reflecting two closely related and partially overlapping phenomena: reduced specialty appeal and attrition during surgical training or professional practice. The former is largely driven by evolving generational expectations regarding lifestyle balance, career sustainability, and professional fulfillment, whereas the latter is more closely associated with occupational stress, unfavorable working conditions, and burnout-related factors.Burnout is well-characterized in the literature and is typically defined by the triad of emotional exhaustion, depersonalization, and diminished personal effectiveness.Emotional exhaustion reflects physical and emotional depletion; depersonalization involves negative, detached reactions to work; reduced efficacy denotes feelings of incompetence or low self-esteem. Individuals experiencing burnout are depleted, impairing work performance. With rising rates, exacerbated by the COVID-19 pandemic, burnout in medicine is now considered a public health crisis 1. A recent review by Park and McElveen linked burnout to the deterioration of physicians' physiological health behaviors, emphasizing the importance of optimizing surgeons' sleep, nutrition, and physical activity. These foundational elements correspond to the physiological and biological needs described in Maslow's hierarchy of needs. According to Maslow, meeting these basic needs is essential for individuals to thrive at higher levels of well-being across multiple domains, including safety, social connection, esteem, and self-actualization 2.Burnout has become a major concern in surgery, affecting both trainees and practicing surgeons.Despite being a well-recognized concern for many years, it remains unclear whether burnout is truly increasing or simply plateauing.In 2014, Elmore et al. conducted a national survey on burnout among U.S. general surgery residents, using the Maslach Burnout Inventory to assess emotional exhaustion, depersonalization, and personal accomplishment 3. They found that 69% of residents met burnout criteria in at least one domain, with higher rates observed among women, those planning to enter private practice, and those working longer hours.Burnout is not limited to trainees but also affects practicing surgeons. A 2008 American College of Surgeons survey reported high burnout rates, linked to younger age, having children, specialty (trauma surgeons most affected), on-call frequency, work-life integration conflicts and inadequate compensation 45. Additional stressors included keeping up with regulations, electronic health records, technological advances, patient expectations, and legal concerns.In a follow-up survey of 7,905 surgeons, 6% reported suicidal ideation in the previous year, though only 26% sought psychiatric help due to license concerns 5.More recently, a 2018 survey of six general surgery programs in North Carolina revealed that 75% of residents and faculty experienced burnout, with 39% meeting depression criteria and 12% reporting recent suicidal thoughts. Barriers to appropriate selfcare included lack of time, denial, and stigma, leading many surgeons to advise against surgical careers for their children 5,6.Meta-analytic evidence reinforces the high prevalence of burnout.Gili-Miner et al. analyzed 21 cross-sectional studies involving 3,325 general surgeons and reported that 43% experienced emotional exhaustion (EE) and 41% depersonalization (DP). Although the analysis explored potential moderators, significant heterogeneity remained unexplained, suggesting that burnout arises from a complex interplay of personal, professional, and systemic factors. No publication bias was detected, supporting the robustness of the findings 7.Trauma surgeons appear to be particularly vulnerable. A systematic review and meta-analysis of 19 studies involving 4,634 trauma surgeons reported a pooled burnout prevalence of 60%, markedly higher than most other surgical specialties. Emotional exhaustion and depersonalization were especially prominent, yet personal accomplishment remained relatively preserved, suggesting inherent resilience factors in this specialty. Younger age, long working hours, and administrative burden emerged as major contributors to burnout, whereas mentorship and protected non-clinical time appeared protective. 8 A systematic review of 103 studies including 63,587 surgeons and trainees in the US and Canada found that 41% of surgeons overall met criteria for burnout, with trainees more affected than attending surgeons (46% vs. 36%). According to Etheridge JC et al, over the 25-year period analyzed (1996-2021), burnout prevalence remained largely stable, showing a slight, nonsignificant decrease (-4.8% per decade). Emotional exhaustion and depersonalization scores declined modestly over time, while personal accomplishment scores remained unchanged.Despite adjustments for specialty, training status, practice setting, and study quality, high heterogeneity persisted across the studies. These findings suggest that although burnout may not be increasing, it remains at unacceptably high levels, emphasizing the ongoing need for targeted interventions across all surgical training levels and specialties. 9 Conversely, a less optimistic review from Golisch KB et al highlights that burnout in surgery remains a significant and growing concern, disproportionately affecting younger and female surgeons.Contributing factors include poor work-life balance, long working hours, and workplace mistreatment. Despite structured interventions to reduce dissatisfaction and emotional exhaustion, rates continue to rise. According to the authors several surveys indicate that 35-50% of attending surgeons and up to 70% of surgical trainees experience burnout, with stress and distress levels 2-5 times higher than in the general population. Trauma surgeons are particularly affected, with only 43% satisfied with work-life balance and 61% reporting burnout symptoms. Collectively, these data highlight that surgical burnout is a widespread, systemic issue requiring targeted interventions 10.The well-being of surgeons may also influence trainees. A recent French survey examined the quality of life (QoL) of senior surgeons and medical students in visceral surgery. Among 106 respondents, students reported slightly lower traumatic stress scores than senior surgeons, yet their overall mental health and burnout levels were positively affected by their supervisors' well-being. Notably, the highest mental health scores among senior surgeons were associated with improved mental health and reduced burnout in students, highlighting the importance of role modeling and supervisory support 11.Over the past 20 years, fewer U.S. medical students have chosen surgery, with international graduates filling many residency spots. The causes are multifactorial.Generational differences play a role: while Baby Boomers (1946)(1947)(1948)(1949)(1950)(1951)(1952)(1953)(1954)(1955)(1956)(1957)(1958)(1959) As reported in several reviews, gender-related factors significantly influence the evolution of surgical careers. Although women now represent a growing proportion of medical students and surgical trainees in many countries, female surgeons continue to encounter structural barriers, including disparities in mentorship, leadership representation, and operative autonomy. In addition, challenges related to work-family integration remain particularly relevant, especially regarding the freedom to pursue motherhood, dedicate time to childcare, and maintain family and affective relationships. These factors may further contribute to discouraging some young physicians from pursuing long-term careers in surgery 14.Burnout among surgeons is a critical public health issue, affecting trainees and attending physicians alike. Emotional exhaustion, depersonalization, and reduced personal accomplishment result from demanding mental, emotional, and physical workloads, exacerbated by long hours, administrative burdens, workplace mistreatment, and poor work-life integration. These pressures negatively impact individual well-being, patient safety, team dynamics, and workforce sustainability 15.Addressing burnout cannot fall solely on individuals. Responsibility lies with healthcare systems, institutions, and professional organizations, as highlighted by Shanafelt et al 1516.More recently, the National Academy of Medicine's National Plan for Health Workforce Well-Being outlined a national framework for integrated action, engaging hospitals, academic centers, professional societies, insurers, and government entities to create a collaborative ecosystem for clinician well-being 17.Sustainable improvements require coordinated action across all levels. Individual-level interventions, resilience training, mindfulness, emotional intelligence development, and selfcompassion programs, have been shown to reduce psychological distress and improve professional motivation, personal accomplishment, and overall well-being 181920. However, systemic support is equally crucial. Hospitals and training programs that implement wellness initiatives, mentorship programs, protected time policies, and administrative support can reduce burnout and attrition 18,21. Leadership endorsement ensures engagement and reinforces the value placed on surgeon well-being.Emerging evidence emphasizes the impact of surgeons' personal relationships on burnout. Workhome conflicts, spousal stress, and higher divorce rates are associated with burnout, highlighting the need for interventions that support relationships. These include surgeon-controlled strategies (e.g., dedicated family time) and organization-controlled measures (e.g., flexible childcare, parental leave, part-time work, mid-career retraining, couple workshops) 222324. Delegating administrative tasks further preserves professional efficacy. National-level leadership that models well-being, promotes mentorship, enforces anti-bullying policies and advocates systemic change is essential for effective, sustainable implementation ensuring that interventions are implemented rigorously and consistently 25. These figures raise serious concerns in a system already strained by high retirement rates and longstanding shortages of surgical personnel across Italian hospitals. Without sufficient recruitment and retention, the national healthcare system (SSN) risks being unable to replace its surgical workforce or meet future clinical demands.Beyond structural challenges, the social prestige of surgical career in Italy has declined.Once regarded as figures of technical mastery and moral authority, surgeons are now often seen as overworked, legally vulnerable and inadequately compensated, potentially discouraging younger generations from pursuing the specialty.Residents in General Surgery training programs in Italy lament insufficient operative exposure, with limited opportunities to act as primary surgeon and substantial variability in surgical volume across training centers. Working conditions are often perceived as unsustainable, characterized by long hours, insufficient rest after night shifts, and a high risk of fatigue and burnout. Moreover, a substantial portion of their workload consists of non-educational task, such as administrative duties and frequent on-call shifts, which frequently overshadow structured learning. Residents also highlight limited medico-legal protection, noting unclear responsibilities during training and insufficient safeguards in the event of litigation. They further report that the economic compensation is inadequate compared to the workload and level of responsibility. Finally, career prospects are perceived as uncertain, with significant difficulties in securing stable positions and a frequent need for geographic mobility.In the most recent selection cycle, however, a partial reversal of trend has emerged: preliminary enrolments in General Surgery have increased to about 63% (247/662 position unfilled, 2025 ANAAO ASSOMED -ALS).Several factors may explain this improvement. Contributing factors likely include technological advances, particularly minimally invasive surgery and robotics, which make practice more modern, stimulating, and ergonomically favorable, as well as recent reforms in medical liability legislation, which have reduced perceived legal risk.Nonetheless, as highlighted by Docimo L., current President of the Italian Society of Surgery (SIC), this encouraging signal should not lead to complacency. The demand for surgeons will continue to rise in the coming years, driven by workforce turnover and increasing complexity of care.Strengthening structural training pathways, improving the quality and consistency of residency programs, and ensuring sustainable working conditions remain essential to securing Italy's future surgical workforce.The crisis of surgical vocation and burnout in surgery represent a pervasive and urgent challenge that threatens both surgeon well-being and the long term sustainability of the surgical workforce.Addressing this issue requires a structured, multilevel strategy integrating individual resiliencebuilding, supportive institutional environments, and coordinated leadership at the national and professional-society level. Enhancing the attractiveness of surgical careers will depend on the ability of universities, training programs, and healthcare systems to develop educational and working environments that combine technical excellence with sustainable working conditions.In countries with publicly funded healthcare systems, physician remuneration should be reconsidered and potentially increased to better reflect workload, professional responsibility, and the long duration and intensity of surgical training.Targeted interventions are particularly critical in light of the declining interest in general surgery and the growing shortage of trained surgeons worldwide. Ultimately, safeguarding the future of surgery will require reimagining surgical training and professional pathways to ensure that surgeons can achieve both clinical excellence and long-term professional well-being.
Cavallaro et al. (Mon,) studied this question.