American College of Physicians: Internal Medicine — Doctors for Adults ®

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Is the generation gap a growth opportunity?

From the April ACP Internist, copyright © 2008 by the American College of Physicians.

By Jessica Berthold

A few years ago, Lawrence Smith, FACP, was asked for advice by a concerned group of physicians while he was dean of medical education at Mt. Sinai School of Medicine. The doctors had been mentoring medical students in their community for years, but the task had become less rewarding recently. The reason was simple: They no longer liked the students.

“They didn’t relate to them or feel a sense of collegiality,” said Dr. Smith, who is now chief medical officer of the North Shore-LIJ Health System in Long Island. “I realized then that there was a serious issue of a generation gap in medicine.”

The issue, in a nutshell, is this: Many older doctors think young students and residents are lazy, self-interested and pampered because they don’t want work to interfere with other parts of their life. Young doctors and students, meanwhile, consider their mentors to be harsh, uncompromising and unaware of how the world has changed since they were medical students. The end result is a festering hostility in hospitals and medical practices, experts said.

“There is an unbelievable tension between older and younger (physicians),” said Douglas Paauw, FACP, a professor at the University of Washington Medical School. “It will be interesting to watch how it plays out when the current group comes through residency and gets hired into practices with older doctors.”

Defining the generations

To be sure, experts have found unique characteristics of each generation that could easily clash in the workplace. The traditional hard-working “veterans” generation, born between 1922 and 1945, are perhaps the easiest to get along with, but are leaving the workforce in rapid numbers. The main conflict now is between the baby boomers (born 1946-1964) on one side and Generation X (born 1965-1980) and Generation Y (born 1981-2000) on the other, said Dr. Smith, a frequent speaker on generational differences.

Boomers define professionalism as total dedication to one’s job, and often measure that dedication by number of hours worked. They are driven by money, title and recognition, and believe in “paying dues.” Physicians from Generation X meanwhile, watched their boomer parents work long hours, and they reactively value balance in their own lives. They are wary of authority, and respect demonstrated skill over experience, Dr. Smith said.

Generation Y is less cynical than X, but shares a desire for work-life balance. Its members also value honesty and integrity, and want their work to be meaningful, he added.

Kristofer Smith, MD, an internal medicine resident at Mt. Sinai School of Medicine, and his father, Lawrence Smith, FACP, chief medical officer of the North Shore-LIJ Health System in Long Island, have very different experiences from and expectations for their careers in medicine.


Kristofer Smith, MD, an internal medicine resident at Mt. Sinai School of Medicine, and his father, Lawrence Smith, FACP, chief medical officer of the North Shore-LIJ Health System in Long Island, have very different experiences from and expectations for their careers in medicine.



In a 2007 questionnaire of graduating medical students by the Association of American Medical Colleges, 52% of respondents agreed that a physician’s work “interfere(s) too much with other interests and pursuits,” while even more felt it interfered too much with family relations.

“What this means is that the boomer attitude of ‘I’m a doctor first and all else comes second’ has given way to one of ‘Being a doctor is interesting and good and I hope I’m good at it, but there are a lot of other things in my life that are equally important,’” said Dr. Paauw.

For Landon Dickson, a fourth-year medical student at the University of Utah, the differences between generations are immediately apparent when you walk onto a hospital ward.

“The older generations are wearing white coats and ties. They carry notebooks. They are on time. They expect students to spend long hours in the library so they can become experts in their area,” Mr. Dickson said. “The younger guys show up late, sometimes without white coat or tie; they carry BlackBerrys and cell phones. They are satisfied with not being experts in order to make room for other interests.”

Generations X and Y are also more interested in working together than their predecessors—a positive trait in this era of collaborative medicine, said Gregory W. Rutecki, MD, director of medical education at Mount Carmel Health System in Columbus, Ohio and a researcher on generational differences in medicine.

“The good news is that [Generation Y] appears to like teamwork a lot. My generation was brought up with doctors in one silo and nurses in another. The younger generation is willing to collaborate with a larger professional audience,” Dr. Rutecki said.

Indeed, nearly all of the medical students and residents interviewed for this article said the most important thing to them in a job or residency was feeling comfortable with their colleagues.

“Most important to me is working with a group of people who are very invested in what they are doing, and who are using medicine as a tool for improving the public’s health,” said Kristofer Smith, MD, an internal medicine resident at Mt. Sinai (and Dr. Lawrence Smith’s son). “I want to work with people who see their job as primarily helping people, not just a way to earn a salary or be well-respected.”

Importance of gender roles

One of the most important, and defining, characteristics of young doctors and students is that they don’t adhere to gender roles, as boomers often did. More than half of incoming medical students today are women, when they used to be mostly men with homemaker wives. Students and residents of both sexes now often have a working spouse, and that person is more likely than ever to be a physician, Dr. Lawrence Smith said.

“My son has pointed out to me that I had a wife who managed my business, raised my kids, organized my house, planned my vacations, paid my bills and balanced my checkbook,” said Dr. Smith. “He and his wife are both physicians who have an hour in the evening between the two of them.”

Louis Weinstein, MD, chair of obstetrics and gynecology at Thomas Jefferson University in Philadelphia, also recently noted the impact of professional couples juggling child care duties. He was helping a hospital set up a program where OB/GYNs work in 12-hour shifts on labor and delivery units, and assumed the unit wouldn’t find enough people to take the night and weekend shifts. He was wrong.

“It turned out we had the most trouble filling weekdays. And that is because the [Generation] X and Y physicians wanted to work shifts opposite to their significant others—who usually worked days—so that one of them would always be home for the kids,” Dr. Weinstein said.

Older doctors often believe women are the main force behind the younger generations’ preference for a balanced lifestyle, due to child-rearing needs, said E. Ray Dorsey, MD, a neurology instructor at the University of Rochester Medical Center and a researcher on gender and work preferences. Yet male medical students are generally more likely to desire control over their work hours than women, according to Dr. Dorsey’s September 2005 study in Academic Medicine, which found 36% of women chose specialties with controllable hours compared with 45% of men.

“I don’t think I’d work at a place where I didn’t see young faculty like myself being successful in managing the roles of father, husband and physician,” said Dr. Kristofer Smith, who has two young children.

Resentment over work hours

A 2007 survey of physicians age 50 to 65 years old by Merritt Hawkins & Associates found that 68% thought physicians coming out of training today were less dedicated and hard working than they and their peers were at the same stage in their careers.

In all likelihood, the generation clash between doctors has been brewing for some time, but Drs. Paauw and Lawrence Smith said they can clearly identify the event that brought the contrast into plain view: the restriction of resident work hours in 2003 to 79.5 hours a week. These rules have made some boomers, who endured 120-hour work weeks, a bit contemptuous, students reported.

“A lot of senior doctors make constant comments about how residency should be easy for us because we’ll only have to work 80 hours a week,” said Maya Babu, ACP Student Member, a third-year medical student at Harvard Medical School.

Yet residents in the “good old days” had a lot more down time during their 120 hours than do today’s residents, noted Dr. Lawrence Smith.

“The new rules have compressed work that was done in the 120-hour week into 79.5 hours, and taken out all the time to reflect and think, to eat a midnight supper and socialize with colleagues,” Dr. Smith said. “These residents today work really hard with no social support; it is brutalizing work.”

As well, the 120-hour workweek was never ideal for patient care, Dr. Rutecki noted, with research showing sleep deprivation can affect the brain in ways similar to drinking alcohol.

“Older doctors forget that the mistakes of our generation in the middle of the night were a factor of being sleep-deprived and not thinking clearly,” Dr. Rutecki said. “It’s not safe for patients to be treated by zombie-like doctors who haven’t slept for days.”

Resident work hours aside, the perception that young students and doctors don’t want to work long hours isn’t born out by research. A Sept. 3, 2003 Journal of the American Medical Association article found that having clearly defined hours when one works, and not having to carry a beeper, was by far the most important factor for senior medical students in picking a specialty—more important than income or number of hours worked. In fact, students were actually slightly more likely to prefer specialties—like anesthesiology—with a higher average of work hours per week. Meanwhile, income explained just 9% of the variability in specialty preference.

“This is really different from the baby boomers, where income dominated all other factors in career choice,” Dr. Smith said.

Future of medicine

As the veterans and baby boomers retire or move to part-time practice, the younger generations increasingly will flood the workplace. That is particularly the case for the large Generation Y, which has 76 million people, while Generation X numbers just 46 million.

The challenge for all physicians, then, will not only be to foster understanding between older and younger generations, but to make changes to the practice of medicine that incorporate the best aspects of both, Dr. Smith said.

“We should insist on working hard when you work, but also allow work to predictably end when you must do other things,” Dr. Smith said. “And when there is a conflict between generations, the focus should be on what’s right for the patient.”

Physicians should move toward defining professionalism not by hours worked, but by whether a physician is caring, honest, altruistic and courageous, has integrity and embraces being a doctor, and is a team player, Dr. Smith added.

To foster these attributes, “educators need to talk more about the wonder, privilege and honor of being someone’s doctor, creating a positive, professional ‘hidden curriculum,’” Dr. Smith wrote in an April 2005 article in the American Journal of Medicine.

Practically speaking, residency program directors might try experimenting with different ways of making schedules more controllable, both as a nod to the values of the younger generation and with an understanding that “sleep is important,” suggested Ms. Babu.

“Can we rethink the way call works, maybe by having a system where people work floating night shifts so there is no overnight call?” Ms. Babu said. “Or, when we ask people to work long shifts, give them a full day afterwards to go home and sleep?”

As well, workplace environments need to acknowledge the growing desire for balance by offering more flexible and/or reliable work and call hours, several experts said. The University of California-San Francisco, for example, is discussing the idea of having surgical hospitalists to address this desire, Dr. Rutecki noted. The OB/GYN trend toward having “laborists” who work defined shifts on labor/delivery floors accomplishes the same purpose, as does, of course, hospitalism and the group practice model.

Offering child care in larger practice or academic settings would be another way to address concerns of the younger generation, noted Dr. Dorsey.

Younger doctors also need to take the initiative and present alternatives when something in their workplace isn’t working, Dr. Smith said.

“I have seen a lot of people in the younger generation who find it hard to fit into the older practice model, but I don’t see them walking in with a blueprint of a new practice model,” he said.

Older doctors, in turn, need to be open to those new ideas, said Dr. Rutecki.

“I think it’s easy for older people to say that the days of the giants in medicine are gone, and to just view every change in culture as negative,” Dr. Rutecki said. “But I actually have hope that people from the younger culture will fix problems we encountered—and created—in my own generation.”

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A guide to the new intergenerational workplace
.

Practice management consultants Carolyn Pickles and John F. Jessop offered the following advice for managing generational diversity in medical practices at the Medical Group Management Association annual conference last October.

Veterans

  • Respect their authority, experience and loyalty;
  • Use a directive management style; and
  • Spell things out concisely, and check progress often.

Baby boomers

  • Recognize they are ambitious, materialistic and value personal growth;
  • Give them a job they view as important and challenging; and
  • Monitor them and provide constructive feedback.

Generation X

  • Realize they are self-reliant, informal and value work-life balance;
  • Clearly state the goals and objectives of their jobs;
  • Provide the tools and authority for success (don’t micromanage); and
  • When providing feedback, explain why a behavior needs to be changed.

Generation Y

  • Recognize they are confident, resourceful and obedient;
  • Listen to their opinions and ideas;
  • Explain business decisions that affect them; and
  • Use teamwork when possible.

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