Surgery on the edge: shaping the future between motivation, burnout, and gender inequities-a narrative review

A growing crisis of surgical vocation has emerged worldwide, characterized by declining interest in general surgery, increasing attrition during training, and persistent workforce shortages. Burnout has been identified as a central driver of this phenomenon, interacting with generational changes, training intensity, and gender disparities. This narrative review synthesizes current evidence on burnout in surgery and its relationship with workforce dynamics, generational expectations, and structural determinants, including surgical training pathways and gender-related barriers. Burnout affects approximately 40-70% of surgeons and trainees, with higher prevalence among younger physicians and women. Emotional exhaustion and depersonalization are the most prominent dimensions, driven by excessive workload, administrative burden, poor work-life integration, high training intensity and workplace culture. These factors negatively influence patient safety, team performance, and career sustainability. Generational shifts have redefined professional expectations, with greater emphasis on work-life balance and long-term sustainability. Persistent gender disparities further impact access to mentorship, career progression, and leadership opportunities, contributing to workforce instability. Italian data reflect similar trends, with underrepresentation in senior roles and ongoing challenges in training pathways. In the 2025 Italian national residency selection cycle, 247 of 662 General Surgery contracts remained unassigned, corresponding to an unassigned rate of 37.3%, highlighting the relevance of workforce instability in a publicly funded healthcare system. The crisis of surgical vocation is a multifactorial and systemic issue. Addressing burnout requires coordinated multilevel strategies, integrating individual, institutional, and policy-level interventions. Improving the quality and sustainability of surgical training, while promoting inclusive and supportive professional environments, is essential to ensure the future of the surgical workforce.