Who better to help us understand the upcoming generation of physicians than the individuals who are preparing them for careers in medicine? Hearing what these educators have to say about the Millennials and how they’re different from the generations of physicians before them will both concern you and give you relief.
According to Dr. Byron Joyner, Vice Dean for Graduate Medical Education at the University of Washington School of Medicine, it helps to understand how the era that shaped their upbringing, as well as the parenting style they received. Shuttling them around as precious cargo within a luxury SUV with a ‘Baby on Board’ sign, their helicoptering parents kept them safe in an era of AMBER Alerts and 9/11-style catastrophes. They received trophies simply for “showing up” for practice and they grew up calling adults informally by their first names. No wonder they feel entitled to high salaries, rapid promotions at work and don’t adhere to traditional customs of respect.
WHAT GROUND RULES?
“You need to set out very explicit Millennial Learners expectations for this generation—for dress, attendance, hours and scheduling. The rules as you know them can be translated very differently by the agile-minded Millennial—especially for behavioral matters,” says Joyner. Each generation is different, as it should be. For example, the Boomers showed up in ties, on time. Millennials are less formal, having grown up glorifying the tech startup culture. They may only know ‘business casual’ as their professional best.
“How do patients perceive you? We need to present ourselves in a manner that messages that we are medical professionals bringing our best selves to the patient interaction. Millennial learners are bright but they don’t wear their curriculum vita on their chest. We care for a wide variety of patients from many generations and they all deserve that respect,” says Joyner. This could come down to organizational culture, but if you have strong ideas about professional presentation, don’t leave it up to broad interpretation, says Joyner. If you mean a jacket and tie or dress blouse under a white coat, explicitly say so.
Do you need Millennials at work on a project in the office for four hours? Be clear that you want them physically present. Otherwise, the request could be translated as “Well, I can work at home for two hours then come in for the remaining two.” If the important part is that they be on-site to collaborate with others—spell out your intentions. Do not leave it up to interpretation. Remember to include the reasons why your prescribed methods matter.
BUT WHY?
This generation was raised to question; they don’t just want to take orders. This is a good thing but may seem quite different from the Boomers who followed directions and paid attention to authority figures. Millennials want to understand why they are being asked to do what they need to do. Does this make for laborious explanations of what Boomers consider the obvious? Perhaps to some, but it also leads to fresh, new ways of thinking that, frankly, we could all benefit from, no matter what field.
Millennials are becoming known as tinkerers and collaborators. They want to make things better—for all of us. If they question why you’ve done it ”that way” for so long, don’t take offense. They yearn to contribute and make a difference, so if they suggest improvements, it might be worth listening to them. Having grown up with automated tellers and computers, they are accustomed to immediacy. They might not belabor graciousness in suggesting a better ways to do things, either. However, as anyone who has been on the receiving end of unsolicited advice can tell you, Millennials will be wise to learn finesse in delivering their ideas. If needed, coach them to learn more about what they’re seeking to improve; they’re curious and the result is that you might learn something new.
GETTING FEEDBACK
The incoming generation wants ongoing feedback, in real time, not in retrospect. However, they like it to be mostly positive. Critical feedback is hard for this younger generations to handle; they were raised with burgeoning methods of “positive discipline.” Says Dr. David Ruiz, Residency Program Director at PeaceHealth Southwest Medical Center and Clinical Professor in the Department of Family Medicine at the University of Washington School of Medicine, “In my experience, they are slow to trust or respect older generations, experience alone won’t cut it. However, they love strong mentorship and parental coaching when it is positive rather than dictatorial.” In contrast, Joyner recalls his own residency days when the only feedback provided was when residents did something wrong. “No one ever said anything positive to us. There was a lot of ‘No, no, that’s not right. Never do that again!’”
Recent decades have brought feedback techniques where the critic surrounds the bad news with positive feedback – the so-called “feedback sandwich” – as if wedging it between good news makes it easier to digest. Joyner is not a fan of the feedback sandwich. Framing the conversation is a crucial part of providing feedback. “I tell students they won’t improve by always being right. They need to be able to take critical feedback.” Joyner’s preferred method incorporates the students’ thinking into the feedback loop by using the Ask-Tell-Ask-Act methodology. First he asks the learner what she thinks of how something went, tells them the critical feedback, asks if they understand the feedback, then discusses the act of what should take place next time. Joyner says this “Ask-Tell-Ask-Act” approach shows respect for the student’s thoughts and engages her, but, at the same time allows her to clearly spell out the desired change.
TECHNOLOGY CHANGED THE GAME
Technology has shaped this generation more than others. Instructors have had to get used to half-filled classrooms, as the universities have begun podcasting lectures. Students can come in person, or listen to a lecture when it is most convenient for them; the instructor will always be there for them—online. As for memorization, if you can search for it online, why memorize it? Millennials are masters at managing digital data and there is a slew of evidence based apps and point-of-care decision support tools that students can carry around in the palm of their hand. Joyner thinks that this is a different paradigm which has its benefits but disadvantages, too, primarily that of being able to place information in the appropriate context. This is critical in medicine.
Ruiz agrees. “What worries me about relying on search skills to reference knowledge is that you’re missing context.” Technology should save us time, but when does it become a dangerous short cut? Ruiz says the process of memorization imbeds knowledge and valuable context. He acknowledges this generation is adept at quickly integrating all modalities at once to arrive at the same outcomes, and emphasizes a blend of visual, tactile, and e-learning modalities.
Adds Joyner, “Boomers tend to be more process-oriented while the Millennials are more outcome-oriented. The Millennials want to get to the outcome faster, in a way that seems more efficient for them. But, I often wonder if they might be mixing up the steps - or missing some rigor needed to provide thorough care?”
CONNECTEDNESS OF CARE
Also different for this incoming generation is the increase of mid-levels doing more of the bedside care. Recalls Joyner, “Once upon a time, we had a deep connectedness to our patients. We were often the ones wheeling our patients into radiology, or sleeping in a patient’s room because we were worried about carefully monitoring a them. But, due to a number of factors, including duty hour restrictions, today the work has, by necessity, been disaggregated. We have nurses, other professionals, and even computers doing some of the work for us. How do we keep Millennial learners centered on the patient, maintaining connection?” Not knowing such personally connected care, Millennials will need to find their own methods to forge connections with their patients.
However, since parallel processing is like drinking water for them, app-savvy and e-mail-savvy Millennials may be more prepared than most to use technology to help them stay focused on patients. Digital immigrants, like Boomers who were not raised with technology, may be toggling their attention between patient and screen. Used successfully, a Millennial’s comfort with technology may well be an answer to getting through large volumes of work, while providing a sense of patient connection.
WHAT? BALANCE AND AN 80-HOUR WORK WEEK?
As committed as they may be to their career choice, many Millennials saw the futility of over-dedication when their workaholic Boomer parents eventually got laid off after years of long hours and service. Their friends, families, and free time are incredibly valuable to them. It’s been said that Gen Xers desired life balance, but the Millennials are demanding it.
Maybe they’re on to something. With levels of burnout climbing and physician resilience now informing the Quadruple Aim, it seems that some things may soon shift. There’s a history of military-like training in medicine, some have called it hazing. Is it really a good idea—a safe idea—for care providers to work twice the number of hours the rest of the population does? Performing back-to-back surgeries for up to 10 or 12 hours a day? Seeing 18 to 20 clinic patients a day, while also being responsible for another three to four hours of computer work to record and code what they have done? The productivity formulas are back-breakers; who has time to think about solutions for patients, let alone rejuvenate and stay fresh? According to Ruiz, “in organized medicine, we haven’t figured out how to make it all work and keep doctors fresh in the first few years of their career. If we don’t figure that out, we’ll have huge turnover.”
The debt load after school is tremendous, so most young physicians won’t view a career change as an option. While some providers may work 70 to 80 hours (or more) per week, this may not be what the next generation has in mind for their career. Says Ruiz, “You can almost see some of them calculating how fast they can pay back their loans, then cutting back to .8 FTE to have life balance.”
COLLABORATION
In some ways, the team approach to medicine may be an answer to long hours. The trick is keeping the continuity of care. The good news is that Millennials, as natural collaborators, may be just the ones to refine this model. They are good at teamwork, being inclusive, using technology to keep the team on the same page, and even in engaging the patient as a member of the care team.
However, Millennials must know their patients, Ruiz cautions. “An older patient is not as interested in being a decisionmaker in their own care. They are more accustomed to holding the physician up as the ultimate authority,” he says. They may lose confidence in a physician who does not take the reins. And patients can grow weary with a drawn-out process with a large team, which can start to feel like “medicine by committee.” Ruiz stresses to his students the importance of being an authority and taking the lead, when needed.
Further, he says, “It’s a good thing they are collaborative, adaptive, and like to create solutions, “because we’ll need the next generation to undo some of the mess created by the Gen Xers, Boomers, and the marketplace as a whole.” As Millennials look for happiness and meaning in their work, consider looking to them to lead. They are well-suited to walk us into the next era of medicine. They want to matter. Helping medicine be successful in this transition may be how they can matter most.
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Every June, our residency conducts two weeks of orientation for the incoming Intern class. I have the opportunity to engage with these fresh, young, idealistic minds before reality of sleep deprivation, massive download of medical knowledge, 80-hour work weeks, and “culture shock” provoke a disquieting sense of anxiety in most and fear in some. For all, it is a test of their character and endurance.
This year, I happened to take a recertification course in Advanced Cardiac Life Support a few days before they were scheduled for theirs. Passing by a small work table in the resident room, I found six of the eight huddled around a laptop doing the mandatory “pre-test” quiz to be completed before attending the class. It was a stunning moment. They had actually transformed mandated study and compliance into a collaborative social event. Each question was meticulously discussed, with consensus achieved before one of them submitted the answer on behalf of all.
This was in contrast to my Boomer method of study. Quiet room, no distractions, focused and determined sense of mission, and internally, mercilessly driven to achieve 100 percent for the satisfaction of submitting a piece of paper to the course director that would validate my intellectual prowess. It took me four tries to get the 100 percent. Instead of focusing on the joy of knowledge acquisition, I was left with a feeling of partial failure. No group-think, no socializing, no fun.
Well, perhaps it was not that bad, but it did point out a few of the intergenerational differences in medical professionals. Millennials have become our emerging workforce in medicine. They are wondrous. I am determined to embrace and learn from their unique approach to balancing all aspects of their lives, and I attempt daily not to be disturbed by some of their traits that, in my mind, may seem not serious or noble enough for the gravitas required in this endeavor of providing medical care for others. It is about finding common ground—a journey of many steps.
David R. Ruiz, MD, FAAFP
Residency Program Director, Family Medicine
PeaceHealth Southwest Medical Center and
Clinical Professor, Family Medicine Department
University of Washington School of Medicine
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