This study collects descriptions and opinions of a sample of Italian hospital medical doctors on their own HC, including specific behaviours, thoughts, and feelings they might experience while getting ready for and performing difficult communication tasks. Moreover, it informs some of the factors and how they might relate to burnout metrics.
Results are consistent with those of previous surveys, mainly focused on the disclosure of the diagnosis, such as that from the American Society of Clinical Oncology. [10, 13–15] The majority of our respondents believed that BBN mainly equals discussing a poor prognosis, that discussing prognosis is the most difficult communication task, and that BBN is very emotionally engaging or stressful. Most clinicians admitted not using a consistent evidence-based framework for BBN encounter, not asking the patients the amount of information they want to receive, and checking for understanding only if they think this may be impaired. Fear is generally reported as the most frequently emotion raised in patients while discussing such topics. Respondents rated themselves good or at least fair in BBN and mostly reported acquiring CS empirically by observing colleagues. Of note, they reported very low rates of CS training both at medical school and beyond.
Also the frequency of burnout in our population is similar to that reported in US practising physicians, where nearly 60% of them experience the syndrome at some point in their career. [2, 16, 17] In Europe, similar rates were documented among French and Swiss physicians, 49% and 70%, respectively. [18, 19] Present data also confirm that younger medical doctors or residents have been reported to be exposed to an even higher risk. 
The other important finding of our study is that, for the first time, it documents significant associations between some self-efficacy patterns regarding communication to patients and the risk of burnout. This study shows that physicians for whom BBN means discussing a poor prognosis and self-assessing BBN as a stressful task are exposed to a higher risk of burnout, from almost 2.5 to more than 3.5 fold, respectively.
Previous researches have so far reported that conversations with patients about prognosis have always been challenging for clinicians, either because many of them are concerned that honest information about prognosis can damage patients’ hope or because they feel uncertain in estimating patients’ survival.  In the last few years, while new therapeutic technologies have progressively enabled patients to live longer with their disease than ever before, this has become even more complex.  Moreover, by demonstrating the increase of several physiological indices (e.g. heart rate, blood pressure, skin conductance, cortisol levels, etc…) during BBN encounters, other studies have empirically confirmed that physicians perceive BBN as a stressful task. [6–8]
Our report supported by quantitative data suggests that these areas of self-efficacy, related to the distress, deriving from the uncertainty and the emotional burden, are linked to burnout.
Interestingly, clinicians who disclose prognosis only talking about the success rate of therapies find themselves at a higher risk of burnout - although this was detected only in the single-item analysis. This finding suggests that the sole conscious positive estimate of treatment efficacy may have unintended consequences not only for patients, who may be led to seek life-sustaining therapies even in phases where active treatments will not be helpful, but also for physicians, who expose themselves to burnout, by risking losing patients’ trust when things get worse. 
Our data show that an evidence-based theoretical framework for the encounter may be protective of burnout in a statistically significant manner. This is even more important if we consider that the majority of our interviewed physicians admit not to plan a BBN encounter because of lack of time or because they consider this approach to be worthless. Previous qualitative studies found evidence that simple behavioral training has potential to positively affect physician-patient relationship and are felt beneficial by physician in terms of reducing BBN-related stress.  Our findings supported by quantitative data the effectiveness of this approach, and, together with the data that physicians who delay serious news discussions may experience high levels of burnout, further validate the importance of planning difficult communication tasks as a burnout prevention strategy. Furthermore, we found that physicians who are aware of communication skills by means of textbooks and scientific literature are exposed to low levels of burnout, in a statistically significant manner. Indeed, although understanding what patients want to know and delivering worrisome information may be stressful for clinicians, it has been reported that standard communication protocol may increase the confidence, the ability of physicians to disclose unfavourable medical information, eventually reducing the BBN related-stress, and may also increase patients' rating of medical professionalism.  These findings, associated with the results of the single-item analysis, reporting low levels of burnout for physicians addressing patients' emotions with empathy and fostering shared decision making, further support the relevance of acquiring, practising and improving basic CS as burnout prevention strategy. 
Our study has some limitations. First, it was conducted on a sample of physicians who work in Modena, therefore the results we describe could not represent the entire national or international population. However, it should be recognised that a measurable rate of the interviewed physicians attended medical schools in different Italian regions, increasing at least in part the generalizability of the results. Second, the design of our study does not allow to establish an undoubted cause-effect association between the communication patterns and burnout metrics. Repeated monitoring of the same population over time would have consolidated the results. However, it has been recognised that the use of multiple assessments impairs similarly the reliability of the studies by increasing the likelihood of finding results. The data was a non-validated survey looking at a variety of domains of HC and by definition was a measure the clinician own perspectives without any objective data. Objective measures of CST efficacy including the use of audio-recording of the medical encounters would provide more objective data about their communication habits. However, our data are consistent with the results of other surveys about communication and burnout rates in different countries and in different historical periods.