Several are the main findings of the present investigation. Firstly, burnout represents a common feature of young Italian Internal Medicine physicians, being detectable in more than one-third of the study population. Secondly, burnout was mainly associated with external factors, such as workload and working setting; in addition, the lack of guidance and training for soft skills represents an important factor associated with burnout.

Burnout has become a growing problem among healthcare professionals in the last decades. Rothenberger and colleagues, in their study enrolling physicians from 24 different specialties, showed an upward trend in the incidence of burnout from 2011 to 2014 in all specialties, especially in emergency medicine, urology, orthopedics, internal medicine, and anaesthesiology [10].

The increased prevalence could be explained by the older age, major complexity, and increased fragility of patients treated in Internal Medicine settings than in previous decades. The management of these patients is more challenging and demanding, thus increasing the stress and the feeling of exhaustion among doctors [11]. Moreover, discharging these patients has become very complex due to an inadequate domestic/social environment to support them thereafter [12, 13]. The fragility of internal medicine patients puts them at high risk of complications related to hospitalization, such as infections and bedsores, which in turn represent the main cause of arguing between family and doctors, increasing their level of stress and frustration, ending in burnout [14]. Finally, the increased amount of paperwork required from hospitals and administrative duties puts internists in a condition to use their work time in filling these documents instead of dedicating it to their patients [15].

In this study, the prevalence of burnout among young Italian internists was 37.2%. A recent study evaluating the prevalence of burnout among Internal Medicine specialists in Japan reported the prevalence of burnout pre-COVID and post-COVID as 34.6% and 34.5%, respectively, corroborating our findings. [16]. Another study, published in 2021, enrolling Spanish internists during the COVID-19 outbreak, reported a prevalence of 40.1% similar to our findings. [17] In their study, burnout was independently related to the assistance of patients with SARS-CoV-2, overworking without any compensation, and the fear of being contagious to their relatives [17].

In line with a recent report [18], being an internal medicine resident, especially in the first 2 years of residency, is associated with an increased risk of burnout. Notably, an insufficient learning environment can accelerate the levels of stress among resident doctors, who may feel inadequate and unable to cope with the increased responsibility [19]. In this study, the risk of burnout was also associated with the satisfaction for the level of knowledge and the related level of stress.

Burnout was higher among those working in university hospitals compared to their counterparts working in non-teaching hospitals. Working in university hospitals may seem to be less stressful because of continuous guidance, but the demands, expectations, workload, and complexity of cases seen may add up to the burnout state. This finding is also consistent with a previous study showing a high prevalence of burnout in academic hospitalists due to interference by medical students and having to balance the ability to perform teaching, research, and clinic with high demands from superiors and patients [20]. Physicians managing both inpatients and outpatients were found to have an increased risk of developing burnout. This can be a consequence of the excessive workload, long working hours, and the impairment of work–life balance as reported in previous studies [21, 22].

The present study showed that poor work–life balance and longer working hours were associated with burnout. Despite work-hour restrictions in Italy, many residents and tutors do not follow these restrictions, leaving limited time for wellness and spending time with family members/friends. Additionally, outside of the hospital, residents are often engaged in research work, answering emails, and studying, among others, thereby increasing their fatigue levels and impeding self-care [22].

The present investigation showed that training or guidance for soft skills was associated with a low risk of burnout. Previous research suggests a link between inadequate communication skills training and burnout [23]. One of the most frequently cited stressors is breaking bad news, particularly when physicians do not feel adequately trained in communication [24]. Moreover, conflicts within the healthcare team, especially if unresolved, might raise stress levels among physicians, leading to burnout [24].

Despite the high prevalence of burnout reported by the respondents in the present study, only 2.8% of them reported the presence of a support system to deal with burnout in their hospitals. Burnout, if unrecognized and untreated, leads to loss of productivity at work, dissatisfaction, and regrets about career choices [25]. Moreover, according to a study enrolling internists and cardiologists, although the sample size was small, burnout was strongly associated with medical errors [26].

Due to the high prevalence of burnout among young Italian Internists and its implications, measures to prevent or face burnout should be encouraged. Successful intervention for burnout should consider its multiple causes to help with a more holistic approach by applying stress-reducing techniques, having discussions on specific professional high-stress situations, and improving interpersonal skills training [27]. Moreover, organizational approaches involving programs focused on the work environment are necessary with the goal of reducing work overload.

Results of the present study also suggest the need for improving soft skills among young Italian internists. Effective communication skills and empathy with patients and their relatives help to reduce misunderstandings and improve doctor–patient relationships, resulting in reduced frustration [28]. Various approaches to enhance communication skills have been explored to address this issue [23]. Conflict resolution and teamwork provide avenues to handle disagreements constructively and create a less stressful and more enabling work environment [29]. Finally, leadership and time management help the team to prioritize tasks and set realistic goals, creating a better work-life balance. Investing in soft skills training during residency in Internal Medicine can equip future internists to handle stress, communicate better, and maintain a healthy work–life balance, preventing or delaying the onset of burnout.

Support system services, including employee assistance programs to face burnout, should be present in every hospital to manage physicians who experienced burnout from the budding stage with the aim of a quick recovery to avoid negative consequences. Additionally, this will help prevent the relapse of doctors who have already experienced burnout.

The present study has limitations: firstly, the small sample size and the study's design. Secondly, a sampling bias could be present in the study, as with all online surveys, that are completed only by persons who have access to the internet and social networks where it was shared and by those who are interested in the subject. Furthermore, it was not possible to extrapolate the distribution of the respondents in the country nor whether some of them work in the same hospital. Finally, the present survey mostly involves Internal Medicine Residents, with a low response rate from Specialists; further efforts are needed to include data from this category.