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For the first time in history, four generations are working together – Traditionalists, Baby Boomers, Generation Xers, and Millennials. Members of each generation carry with them a unique perspective of the world and interact differently with those around them. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine (SAEM) Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic emergency medicine (EM). Understanding generational characteristics and mitigating strategies can help address some common issues encountered in academic EM. Through recognition of the unique characteristics of each of the generations with respect to teaching and learning, mentoring, and technology, academicians have the opportunity to strategically optimize interactions with one another.
“The magnitude of difference between the newer and older generations in the profession depends on how pronounced are the societal changes from one generation to the next.”1
Academic departments of emergency medicine (EM) exemplify many of the generational differences that social scientists and other workers have noted for decades. Departments of EM enjoy an academic heritage of open communication and free exchange of ideas. In addition, they have a clinical mandate that places them in a social environment where multigenerational teams are common, and generational tensions are accentuated.2
Generational boundaries are defined by groups of individuals with shared experiences and common values. Historically, this definition has classified generations that have evolved at the rate of change of world values. Currently, members of four generations occupy the U.S. workforce—a first in U.S. history. In part because senior workers are remaining in the work force longer, variability between generational norms and morés seems to be accentuated.
Each generational cohort includes members who had similar childhood experiences and a comparable world view, work traits, teaching and learning styles, communication preferences, and expectations of how they interact with their world.3 Individuals born on the border between generational groups may manifest attributes of more than one classically defined generation. These people, called “cuspers,” historically play an important role in facilitating intergenerational understanding and harmony.4
This paper is intended to offer readers a better understanding of each of the four generations currently working in EM and describe relevant attributes, values, and preferences. Each of these generations brings strengths to the workforce and can help to bridge differences that divide academic departments. Ultimately, this discussion can lead to a more productive and effective workplace and training environment.
In May 2009, the Board of Directors of the Society for Academic Emergency Medicine (SAEM) assembled the Aging and Generational Issues in Academic Emergency Medicine Task Force. SAEM members who had demonstrated academic interest or expertise in the area of intergenerational issues were charged with meeting several objectives, one of which was to develop a white paper to explore the effects of generational differences on academic EM. Task force members represented each of the four generations discussed in this paper, and a working subgroup drafted the white paper.
The task force performed a comprehensive literature search from MEDLINE, Web of Science, bibliographies from included publications, and references that members had previously collected for individual academic publications and lectures. Relevant articles were reviewed by task force members, and an annotated bibliography was compiled to include those articles judged to be most pertinent to academic EM.
Recommendations made in this two-part document were agreed upon by the working subgroup using modified Delphi methodology, and the document in draft form was approved by the SAEM Board of Directors for face validity prior to submission for publication.
Generational groups tend to share major life experiences and societal events. This common history leads to mutual values, beliefs, attitudes, and behaviors. Table 1 lists attributes of each of the four generations in the workplace today: the Traditionalists (born 1925 – 1945), the Baby Boomers (born 1945 – 1964), the Generation Xers (born 1964 – 1980), and the Millennials (born 1980 – 1999). Figure 1 shows the relative contribution of each generation to the U.S. population.5
Throughout this document, individuals are categorized into groups that can be described by generational traits. These descriptions represent generalizations, and not all constituents of a group are homogenous in their views, perceptions, and attitudes. As such, any discussion about trends of opinion or about recommendations for improvement is limited by the imperfect nature of these generational constructs, so the labels defined here are used primarily for illustrative purposes.
The Traditionalists (also called the “Silent Generation” or the “Veterans”) are often described as dedicated, patriotic, conventional, respecting order, and altruistic. The major life experiences they shared were the Great Depression and societal rebuilding after World War II. They lived in a world characterized by faith, patriotism, and justice.6 Traditionalists abide by duty and honor and have a strong sense of community. They are committed to taking care of their world and the institutions they serve.7 As they grew up in an era of limited resources, Traditionalists tend to be mindful of resources and waste.8 This generation married young, and they grew up in an era before divorce was common.
While most Traditionalists are now retired, they still comprise 10% of all active physicians.9 Many of these people are the founders of EM and have been the leaders of modern academic departments. Traditionalists value formality, hierarchy, and loyalty to their organizations, and they subscribe to conformity without challenging the systems in which they work. Members of this group work hard in their professions, expect rewards for their hard work, and value lifetime employment at a single institution.10 Delayed gratification is an accepted norm. Many have an expectation that society will take care of them (e.g., retirement benefits, pension plans) in return for their hard work. Traditionalists have made great sacrifices for their careers and value experience and seniority. The term “company man” was coined for members of this generation. They view medicine as a vocation rather than a day job.
Dedicated to their careers, Traditionalists often remain in medical practice to teach and share their knowledge and skills with younger generations. They fulfill the role of a “classic” Professor Emeritus, and they tend to focus more on the process of education rather than the outcomes.11
The Baby Boomers (also called “Boomers,” or the “Me Generation”) were the largest generation in history. They were born during the post-World War II years and are often described as optimistic, driven workaholics. The major life experiences Boomers share are the Vietnam War, the civil rights movement, and the women's rights movement. They were born during time of great economic and educational prosperity. Their world was one of television, rock-and-roll music, and a traditional nuclear family. Most families were characterized by a stay-at-home mother and a hardworking father. Due to their populousness, Boomers have always been demographically powerful and a dominant force in U.S. society.7 Boomers currently account for 55% of active physicians, and occupy the majority of positions of authority.9
Boomers are a driven cohort and equate work with self-worth, contribution, and personal fulfillment. Boomers are often early to arrive and late to leave their workplaces.12 Many chose their professions, in part, for their desire to improve their world. Baby Boomers tend to be very competitive, aspiring to higher monetary compensation and professional titles, and they are willing to sacrifice their personal lives for professional success. Individuals in this group work hard out of loyalty, expect long-term jobs, and view self-sacrifice as a virtue.6,13 Boomers were promised compensation for their loyalty, and they feel promotion should be earned over time. They value recognition and management positions.9 Respecting authority, members of this group value a strong chain of command and may be judgmental of differing views.
Generation X (Gen X) is often described as independent, self-directed, pragmatic, and flexible, which contrasts sharply with some of the societal-based attributes of prior generations.14 The major life experience this group shares was a childhood near the end of the Cold War in a nation with increasing national debt and limited economic prospects. Because the divorce rate had tripled,14 many were raised in single-parent households, and many two-parent households had both parents working outside the home. Many Gen Xers spent much of their childhood as “latch-key kids,” returning to an empty home after school where television served as a babysitter. As adults, Gen Xers seek a greater sense of family, tend to be focused equally on personal life and work, and are less likely to place their jobs before family or friends. Gen Xers “work to live” rather than “live to work.” Gen Xers account for 30% of active physicians, and often hold mid-level positions.9
This group tends to be loyal to themselves and their families rather than to institutions. They watched their parents fall victim to downsizing and economic turmoil. As such, they are more likely to leave jobs with limited upward mobility for others with better prospects for advancement.6 Gen Xers question authority and resent top-down management. They believe in being evaluated by their accomplishments rather than by the quantity of time they spend at work.13 Gen Xers are direct and outspoken, and they believe that mentoring is a right rather than a privilege.
Since computers were developed and introduced while they were in school, Gen Xers are adept users of a wide range of technology. Gen Xers are voracious learners who are resourceful, assimilating changing information quickly and able to engage in parallel thinking. They are problem solvers, and they tend to learn better by participating in cooperative learning experiences.15
Millennials (also known as Generation Y, Generation Next, Echo Boomers, and the Net Generation) are often described as optimistic, collaborative, team-oriented, and techno-savvy. The major life experiences members of this group share are economic globalization, September 11th, school violence, multiculturalism, and widespread cell phone, e-mail, and internet use. “Technology is so deeply embedded into everything [Millennials] do that they are truly the first native online population.”16 Millennials are globally oriented, culturally diverse, and constantly connected worldwide. They have an expectation of instant results and access to information, which sometimes brands them as impatient. This generation is highly accomplished with rich and diverse curricula vitae, and many feel some commitment to global health and advocacy for the underserved in their work lives. They often have multiple interests in addition to medicine.8 Members of this group account for 5% of active physicians, and are the majority of medical students and residents today.9
As children, many Millennials were doted on by protective parents concerned about their safety, education, and success. They have been described as the most rewarded, recognized, and praised generation. As such, Millennials expect frequent feedback and tend to need praise. Members of this group cherish close family relationships and value being connected with others. They grew up with “play dates” and “structured play,” so they tend to be comfortable following rules and collaborating.11 Conversely, they may be less spontaneous and introspective than prior generations.
Some refer to the Millennials as Echo-Boomers, and this is not a misnomer. Millennials are eager to contribute to positive social change with an ability to organize and mobilize. They expect scheduling flexibility for work-life balance, but they also want to connect deeply with colleagues. As their parents often solicited their opinions on family decisions, Millennials feel they should have input in decisions being made in their workplace.11 They tend to be socially bold, and they express their opinions.8
Millennials have been exposed to technology their entire lives, and have high expectations of the usefulness and availability of technology. They prefer internet resources to textbooks for learning. Millennials are optimistic about their careers, and are more trusting of authority than Gen Xers.17,18
For centuries, traditional medical education has been based on the Socratic Method. In contrast to lecture-based instruction, the teacher in the Socratic Method questions one or two learners in the presence of a student group in order to prompt and guide students' thinking. It is a method well suited to the education of Traditionalists, who have a high regard for instruction, respect for hierarchy, and a willingness to yield to authority almost without question.7 During their medical training, technology progressed at a rate slow enough to insure that the educator was abreast of all the current literature and knew all the answers to the questions he was asked—a condition virtually unfathomable in today's environment of numerous print and online journals, UpToDate, and eMedicine.
Traditionalists teach out of a sense of duty to their profession and its history. They are comfortable teaching and learning in a large group lecture format, but they recognize that didactic instruction alone is incomplete learning. They are unlikely to have much respect for knowledge that learners glean from web sites when this knowledge is not borne out by experience. Their bedside teaching is often characterized by anecdotes, and they see themselves as keepers of institutional memory.4
As the Baby Boomers entered U.S. medical schools, their appreciation of peer recognition and acknowledgment of hierarchy9 continued to lend support to traditional medical education. Professional values were beginning to change to reflect those of the wider society, but they were still reliant on educators to teach them actively. To the Baby Boomers, the Socratic Method appeared to be a method to demonstrate the ignorance of the student and the superiority of the teacher. This method became known as “pimping,” and was characterized by students and residents as a method of teaching by intimidation. For a generation for whom equality was the by-word, such a situation was unacceptable, and mentorship became the norm.19-22
From the time that Gen Xers entered training in the 1980s, they were perceived by their Boomer supervisors as being unprofessional and reticent to embrace “physician-hood.” Gen Xers were viewed as self-absorbed, cynical, and lacking a strong work ethic14 when compared to workaholic Boomers. The unique independence that Gen Xers experienced in their childhood facilitated their ability to quickly assess and manage complex and difficult situations,19 an essential skill to the successful practice of EM. Growing up on “Sesame Street,” they excel at cooperative and interactive learning,15 and they believe that education should be fun. In the mentoring relationship, they appreciate immediate responses with frequent, face-to-face, and specific interactions.4 They perceive themselves as entitled to mentorship and education in the workplace, and they critically evaluate their mentors and supervisors at the same time that they are being evaluated.
Millennials compose current medical students, residents, and fellows. They are often less independent than their predecessors, so some of the unstructured learning that worked well for Gen Xers does not serve Millennials well. Many educators characterize them as “requiring … positive feedback and not perceiving the need to adapt to styles of other generations.”23 While they like structured learning and clear expectations, they do not thrive in didactic lectures, preferring instead that information be presented individually or via available technology.24 In response, some medical schools make available all of their first- and second-year curricula for on-line streaming, making it possible for a medical student to spend much of the first two years of the didactic portion of his medical education at home, without contact with teachers and fellow students.25 One might argue that the skill set required for this degree of independent learning is not so different from the skill set required of Traditionalists who sat in crowded lecture halls, listening to professors who never recognized them outside of class, and learning from textbooks in the library. EM educators have agreed, and through EM:Rap, EMedHome, iTunes, and other online learning tools, Millennials can learn EM using very individualized styles. In the mentoring relationship, they are more outspoken than Gen Xers,8 but they are also more respectful of authority and generally optimistic regarding their careers.17 They want frequent, personal, focused, positive feedback from their mentors.
Emergency medicine as a specialty has changed dramatically in the past 30 years. With the advent of bedside ultrasound, regional anesthesia, the electronic medical record (EMR), picture archiving and communication systems (PACS), and UpToDate, trainees today sometimes view their senior faculty as hopelessly out of touch, and wonder how they could possibly be competent to instruct them on the current practice of medicine.26 On the other hand, physicians who practiced EM in the 1970s and 1980s developed their skill sets on the job, performing direct patient care, while younger physicians have engaged in simulation and technology-based study. The lack of appreciation for the skill sets possessed by colleagues of different generations can serve as a barrier to inter-generational learning.1
Since older physicians are staying in the workforce longer, they must learn new technology and adapt to other changes.”27 Simulation is one example, providing an opportunity to “rethink the way medical education is delivered across a continuum of professional lifetimes. If [simulation] is well executed, it may truly make medical education better, safer, and cheaper, and provide real benefits to patient care.”28 These are areas in which junior EPs can help instruct senior faculty. Traditionalists and Boomers, with their respect for the medical hierarchy, can be uncomfortable with the concept of learning from their residents and junior faculty, and there is often the conviction that learning styles are too different.29
Mentorship, which has been the cornerstone of academic medicine, is one forum where generational differences readily surface. Gen Xers have a tendency to look at mentoring as a right rather than a privilege. They are often more outspoken than their mentors and more focused on their own goals. They can be viewed by older generations as being self-centered, which may lead to a challenging mentoring relationship. Millennials are interested in a supportive learning environment with someone who connects with them and is able to provide immediate response and feedback. Traditionalists tend to be more formal, and they see feedback as being necessary only to criticize or improve their mentees. Boomers are equally comfortable with only infrequent feedback.4 These differing attitudes toward mentorship and feedback can lead to conflict in the workplace. Since Gen Xers and Millennials value their relationships with others, effective feedback and a participation in mentoring with information sharing and involvement in creative solutions may be used to allow for more productive mentoring.13
Gen Xers are known to be distrustful of authority, which can manifest as a lack of respect for leadership. Their general lack of formal respect can cause friction. Given that there have been dramatic changes in the practice of EM, they are hesitant to fully embrace their mentors' wisdom. They feel the need to watch out for themselves, and they tend to use recent graduates who have just left the “ivory tower” as trail markers for their own careers. Gen Xers may feel more accepting of mentors if they have an opportunity to interview mentors and choose one who meets their personal career needs and with whom they can “connect.”
Mentorship is often more successful if organized with shared goals or experiences, such as research interests, work/life balance, gender, and family commitment. Having female role models is crucial to the recruitment of women into medicine.30,31 Finding similarities that cross generations allows for synergy in mentorship. Additionally, mentorship and collaboration could benefit from more influence from those physicians who fall between two generations. These cuspers are able to understand and identify with individuals older and younger than they, and are valuable workers to bridge the divide between two generations.8 With the youth of EM, mentors may be cuspers or even in the same generation as their mentees, and sharing, goal setting, and professional growth is more of a partnership. Other ways to improve mentoring include developing a respectful, collegial, and close relationship over time, and ensuring that the needs of the mentee are met.32
One of the most profound defining characteristics of generational conflict is the use of technology. Although it is recognized simply as a tool to enhance practice, the implementation of technology in the ED has been one of the most rapidly evolving workplace transformations in the history of EM. Gen Xers and Millennials had access to computer resources during their childhoods, laying a critical foundation for use of these systems later in life.33 Although Traditionalists and Baby Boomers have adopted systems they find useful, their lack of early experience may limit their enthusiasm about using further computer-based “tools” in the workplace. Implementation of technology in EM takes many different forms.
The EMR is likely one of the most transforming workplace technology initiatives of the 20th and 21st centuries. The “holy grail” of the electronic health information movement is the implementation of computerized systems that allow for creation of medical records, comprehensive review of medical records, computerized physician order entry, accessing electronic data from other institutions, decision support, and direct patient communication.34 Such an ideal has been unachievable by physicians who have thus far resisted complete adoption. Some have suggested that this resistance is a generational attribute.35-37 Employees in non-medical fields widely cite implementation of a new computer system as a barrier to productivity that affects senior employees more than those of Gen X and the Millennial generations.36-38 Others suggest that shortcomings in the technology are the primary deterrent to widespread adoption.39,40
Adoption of new tools in the workplace is tied most closely to their ultimate impact on physicians' personal productivity and success. The EMR has not yet proven to revolutionize physician capabilities.41 For younger physicians who have more experience with computer information systems and are more comfortable with changing technology, suboptimal systems are less of a barrier to functioning than for older physicians. With greater exposure to technological change, workers show an increased openness to change, and an increase in job satisfaction,42 making it possible for all generational cohorts to be “very comfortable” with technology when given the right training.27 As the systems used in the health care workplace improve, their value to physicians is enhanced. With this improvement, resistance to adoption is likely to wane from members of all generational groups.35
Bedside provider-performed ultrasound is one of the sweeping diagnostic changes in EM in the last decade. It appears to be a model for an effective, novel diagnostic tool with varying degrees of acceptance and diffusion within the EM community.
The introduction of ultrasound opened a window into the way that practicing physicians educate themselves on new technology. Ultrasound applications have a recognized learning curve, and the quality and utility of its use depend most on a combination of experience, education, and expert exposure.43 Traditionalists and Baby Boomers were largely unexposed to ultrasound education during residency training.44 Younger EM faculty members, in general, have had more formal training. Current trainees are looking for expertise in their clinical training, and they recognize ultrasound as one facet of the knowledge base they are looking to develop. Training faculty members alongside residents and medical students breaks down some of the traditional teacher-learner barriers, and this redistribution of knowledge can be very uncomfortable for faculty members.
Generational differences are perhaps the most pronounced in communication advances. Office-based collaboration was once restricted to face-to-face meetings and travel to conferences. The telephone offered a degree of separation, but interactions were very individualized and very personal. The computer revolution has evolved into a communications revolution, with an estimated 900 million workers worldwide relying on laptops, cell phones, or handhelds to perform their job duties.45 Communication is becoming less individualized, messages are broadcast more than before, and information is transmitted much more quickly.
The communication landscape has changed even more profoundly in the last decade. The ability to work from home computer connections means the expectation of availability has been expanded – one can be selectively available, able to access the digital world without necessarily being accessible to co-workers. However, Twitter, Facebook, and other social networking sites have become a staple for Millennials as they integrate their work with their home lives.
Selective availability has also contributed to the development of asynchronous communication forums. List servers, web forums, wikis, discussion pages, and digital online collaboration systems have been used to collaborate and to innovate. Online social networking tools are becoming more popular among physicians, and the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), and other EM organizations are adopting Twitter as a method of communicating with members.46 All of these modalities allow one to optimize creativity on his or her own schedule – not being tied to an agenda. Asynchronous communication forums are becoming among the preferred mechanisms national organizations use for collaborating. These solutions lead to the potential for the creation of gaps between the early adopters and those potentially intimidated by the technology.47
The premise of selective availability is sometimes not completely understood by Traditionalists and Baby Boomers. Grown out of an intense loyalty to their organizations, Traditionalists and Boomer faculty members tend to be perennially available. Their younger colleagues are more “wired,” but less available. Gen Xers and Millennials use technology as a means of keeping in touch with professional colleagues and personal friends, but they closely guard their personal time. They measure their value to the department by productivity and impact, not by time or accessibility.
The ease of accessing updated, relevant information at the click of a mouse has changed how Gen Xers and Millennials value knowledge, and correspondingly, the role that information resources play in academic EM. Almost 80% of Americans have access to the internet in their everyday lives.48 Physicians are much less likely than the rest of the population, however, to perform work-related tasks online. About one in three physicians use e-mail to communicate with colleagues, and less than 50% use online journals or clinical decision-support systems to support their daily practice. Not surprisingly, younger physicians and those in academic medicine use technology much more.49
With computer technology playing such an important role in answering clinical questions, the value of information as a commodity has diminished. Expensive textbooks are not the only key to medical understanding. Quality resources are available at the point of care, usually for free. Instead of keeping a file with landmark clinical trials or review articles, Gen X and Millennial faculty members often rely on popular mainstream search engines and electronic library collections to retrieve articles to answer focused clinical questions, and they use electronic storage for the files that match their clinical interests. Such availability has had the unintended consequence of devaluing non-digital resources. Information that is not rapidly and freely available is often not accessed at all.50
Electronic knowledge resources further dichotomize academic faculty. More senior faculty retain ownership of their knowledge, using their resources for the benefit of their students and residents. They often study carefully and rely on the organization of their personal knowledge repository to apply new knowledge. Younger faculty members value medical resources as a commodity that should be made freely available for the benefit of all, and one which does not necessarily need to be memorized in detail. They exchange citations and articles, and they maintain a “public library,” using personally validated online information resources as justification for their practice. Furthermore, this public accessibility has opened medical knowledge to patients through WebMD, eMedicine, and other online medical references, and many patients are also accessing these resources.51 Although entirely unintended, the availability of information to anyone, anywhere, has completely changed the value of that data to the end-user.
Generational issues have a significant effect on daily life, and academic life is not immune from these generational influences. As teachers and clinicians, it is important to understand the unique characteristics of each of the four generations that are currently present in the EM workforce: the Traditionalists, Baby Boomers, Generation X, and the Millennials. By appreciating generational characteristics, academicians have the opportunity to optimize their interactions with those of other generational cohorts. This article is part one of this series, and suggests strategies to empower individuals to address generational issues one might confront in academic EM related to 1) teaching and learning, 2) mentoring, and 3) technology. Part two of this series will focus on generational issues that arise around the structure and function of academic EDs and the organizational culture in academia.
The authors wish to thank the members of the White Paper Subgroup for their work in preparing this manuscript for submission (listed alphabetically): S. Promes, co-chair; N. Mohr, co-chair; P. Brunett, A. Chipman, K. Clem, P. Dyne, R. Gerhardt, H. Larrabee, A. Mills, L. Moreno-Walton, R. Ruddy, and R. Smith-Coggins.
The authors also wish to thank members of the SAEM Aging and Generational Issues in Academic Emergency Medicine Task Force for their support in preparation of this manuscript: M. Biros, chair; P. Brunett, A. Chipman, K. Clem, J. Clinton, P. Dyne, R. Gerhardt, R. Hockberger, H. Larrabee, J. Marx, A. Mills, N. Mohr, L. Moreno-Walton, S. Promes, M. Ranney, R. Rothman, R. Ruddy, R. Smith-Coggins, K. Takakuwa, and H. Thomas.
Disclosures: Dr. Moreno-Walton's work is supported by grants from Louisiana Clinical Translational Research, Education, and Commercialization Project, the Louisiana State Board of Regents, and the National Institutes of Health Research Supplement to Promote Diversity on Health-Related Research.
Approval: This SAEM Aging and Generational Issues in Academic Emergency Medicine Task Force Report was approved by the SAEM Board of Directors in May 2010.
Prior Presentations: None