Crossing the Generational Divide

Michael K. Keng, MD
Assistant professor of medicine at the Emily Couric Clinical Cancer Center in the University of Virginia Health System in Charlottesville, Virginia

“Millennials” or “Generation Y,” those of us born in the early 1980s who came of age around the turn of the century, don’t have a great reputation: We’re arrogant, lazy, and have little respect for those who came before us. Can we all really be that bad? Or is it another case of the older generation hastily writing off the next – just by virtue of their youth?

Some of us probably are as arrogant and spoiled as we’re purported to be, but I’d like to take the time to dispel a few misconceptions that senior physicians may have about the younger generation of doctors joining the ranks – coming from the perspective of just one millennial doctor who likely shares some of your same concerns.

It must be difficult to deal with arrogant young millennials, and I’m sure it is tough for the older generation to see doctors who are roughly the same age as their children. They must be wondering – justifiably – if their kids are ready to care for people’s lives. You can see that parent-teenager tension reflected in some of the interactions between older and younger doctors. The teenager knows everything about life – and gained in such a short time on the planet! – and the parent has two choices: Gently step back and let the teenager figure it out for himself or slap him silly with a reality check.

But, just as the younger generation has to be teachable and moldable, so must the older generation. Be open to new evidence-based protocols, be willing to try something different. Yes, the fact that someone your child’s age is instructing you may be hard to swallow, but discounting that information means you might miss a new-and-improved tool that might actually improve your practice.

Trust us; we learned from you.

Finding the Common Ground

Do you remember the moment in your first job out of fellowship when you looked around and realized there was no one looking over your shoulder? It was absolutely terrifying, for me at least. The safety net has been abruptly removed and, all of a sudden, we have to be able to justify every action we recommend to our patients, to the insurance company, and to the court of law if we ever find ourselves there. The “my-attending-made-me-do-it” defense just won’t fly in the court of law.

Our older physician colleagues are a shoulder to cry on and the experienced guides we run to when we don’t know what to do. Throughout training, we’ve learned to trust their opinions over our own, then – seemingly all of a sudden – there’s just us.

Frankly, my Gen Y colleagues are probably just as terrified of the older generation retiring or leaving medicine as they are of us taking over.

We are only as good as our mentors; when the umbilical cord of mentorship is yanked after three years of fellowship, we start to begin to build the experiences that will allow us to become that life-source to the next generation of doctors. However, we still need the nurture of our senior colleagues until that time.

Experience Versus Evidence

I suspect that older doctors think that the junior generation of physicians are more rigid in their management of medical practice. I can’t argue with that perception. The younger generation’s medical practice is primarily protocol-driven and evidence-based.

In the past decade, medical training has become so compartmentalized that the millennials are armed with very focused clinical knowledge. Physicians before us had a much broader medical training, and, therefore, their medical knowledge covers more depth and breadth than the newer trainees. Rather than relying on the report of a pathologist, for example, older physicians can make clinical decisions based on physical examination and peripheral smears.

During residency education, much of the focus is on research, quality, and standards of care handed down by the governing bodies. Yet, when you ask older physicians why they do things a certain way – even though it may deviate from the prescribed standard of care – their answer is, “It just works. Trust me.”

Younger physicians, obviously, lack that base of experience. We stick close to protocols and evidence in the literature in the place of that experience – making us more rigid in our approaches. Older generations, having had time to develop and practice “the art of medicine,” are more comfortable exercising the exceptions to every rule.

Us, though? We look like young, nervous Doogie Howsers who think they know it all because we have our precious protocols, but not the life experience to back it up. One day we’ll get there.

A Shifting Work Ethic

With the recent movement toward “shift work” and stricter work-hour restrictions, our work ethic has been called into question. Any change has its pros and cons. Obviously, the “pro” is humane work hours for residents and fellows: Quality-of-life in training is improved and the threat of fellowship enslavement isn’t as scary as it used to be. The “con,” though, is when those rules become an excuse for skirting around patient care.

Rest assured, that concern is not unique to the older generation.

Supposedly, the work restrictions were put in place to improve patient care and protect against medical errors. But the truth is, we all know that there are major quality “dis-provements” that can do more harm than good. The shift-work model comes with unwanted side effects: increasing the number of patient hand-offs, complicating physician–nurse communication (a century-old issue), and promoting the “softness” that results from work-hour restrictions becoming an excuse for good patient care. These are the conflicts that the new millennial doctor has inherited.

The shift-work model forces us to practice medicine by the clock, rather than by our patients’ needs: Should I stay past the 16-hour mark to perform an urgent bone marrow biopsy? Or, do I go over my work-hour limit and lie about it to maintain the accreditation of the fellowship program? The obvious answer is to save the patient’s life.

Gone are the days of seeing a patient diagnosed with acute leukemia through tumor lysis and DIC. Instead, we sign out a patient in the middle of his initial work-up and only learn the results when we start our shift the next day after the treatment has already been initiated. The process doesn’t unfold in front of our eyes – and that puts us at a disadvantage.

The amount of pushback and the number of residents who play the “work-hour excuse” card to leave while the floor is in disarray is pretty horrific, I have to admit.

I know I’m not painting the rosiest picture of our work-hour restrictions and how the millennials potentially exploit them, but I do believe it’s the minority of young doctors who fall into that category. Many young physicians let their desire to do what’s best for their patients guide them, working around the restrictions when necessary – a trait we likely picked up from observing our mentors.

The Tech Crunch

Another common critique of millennials: We’re addicted to technology. It’s true, to some extent. If you were to tell trainees and residents to put away their smartphones, you might as well tell them to come to work naked. And, let’s face it, you can tell who the attending of the residency clinic is by sound alone: The slow-and-steady tapping of senior physicians typing up their notes, broken up by long pauses as they search for the backspace button, versus the piano concerto that the millennials are tapping out on the keyboard, seemingly without even moving their fingers.

These days, it’s not about how much we know, but if we know where to look it up. There’s drug indexes, PubMed searches, and, of course, Drs. Google and Wikipedia when we get desperate – or when we want to know what our patients are reading.

Of course, that’s oversimplifying the use of technology. We are still the brains behind the typing and tapping fingers, but that technology has exponentially increased the amount of information at our fingertips, and the speed at which we can access. We can have an answer at the ready quicker than we can say, “I don’t know.”

When we’re interacting with patients, that means we can look up drug interactions on our tablets or smartphones in seconds – a considerably shorter time than the old-school method of finding a pharmacopeia or pharmacist would take.

In theory, having all this technology should translate to improved efficiency; in reality, though, all that time saved is probably lost in the rest of the inefficient paperwork we wade through each day.

The danger, and what older generations might perceive as the problem, is when we become too reliant on technology. What happens when all that easily-accessible information is taken away from us? As a resident, I went on a medical mission trip to China and had no Internet access – plus, the iPhone hadn’t been invented yet. (Does that make me an “older” doctor?) There, the only technology tool available were my eyes and a good physical examination. It was amazing to be able to treat patients with knowledge obtained from the clinical skills class from my first years of medical school.

I am hardly opposed to technology, and I believe that it has revolutionized medicine, but technology also has the potential to take our focus away from the patient. The challenge – and where our medical training comes in – is in sifting through the giant trove of data to find the relevant answers to patients’ questions. When we manage to look up from our devices, of course.

It’s a Broken System, But It’s Our System

The recent trend toward an emphasis on quality, cost-effectiveness, and performance measures in medicine has, I’m sure, frustrated older physicians – as it has for everyone. The basic model of physician and patient care is changing. With so many insurance providers to deal with, an avalanche of paperwork to complete, and the pressures of bureaucracy to negotiate, it is difficult not to get cynical toward clinical medicine.

Many of the misconceptions, I think, stem from one truth: For younger doctors, the medical system that we were brought into is the only one we have ever known. We don’t know what it was like for the older generation to receive a goat and milk in exchange for their services. Okay, that was a joke.

What I really mean is, clinical medicine is not a simple unit; it’s a tree with multiple algorithms and domino effects that cause pressure on the ability to heal. I have seen many older physicians become so disgruntled with medicine today that they leave the field or opt for early retirement. As young millennial doctors just entering the health-care system, though, we have had no choice but to deal with these issues. The system has been as complicated and broken for as long as we have been physicians.

Of course, we are all dealing with a climate of political change. With the advent of Obamacare, there is so much red tape, so little reimbursement, and we are working so much harder to survive. This is the millennial generation’s challenge to take on, and future generations will probably inherit many of these same problems. I’m not surprised that the older generation is happy to retire.

We may talk a big talk, but the bottom line is, we still need you. We need your experience and your nurturing, so please don’t retire just yet.