Millennials, the same doctors in a changed environment

Do we have a millennial physician problem?” asked Sachin H. Jain, MD, ACP Member, in a June column for Forbes.The seemingly binary question may be loaded with a generational supposition: that all millennials, including doctors, fall into the same pigeonhole because they were born between the early 1980s and 2000. Some older physicians may peg millennials as entitled, self-centered, and lazy, believing that the main offenders lack the dogged passion for medicine of generations before them.

Dr. Jain, president of CareMore Health System in California. “Those are attitudes that, for the most part, have never made their way into the medical profession, and suddenly you're starting to see more of a conversation around that.”

His column, for example, relays the story of a resident who, with 12 hours' notice, insisted on a personal day for an event that could've been easily planned in advance. “Some people struggle with the fact that their friends who work in other settings can take a personal day on short notice and it's not a big deal,” Dr. Jain said. “But when you're in medical training or you're working in an area of critical need, that's just something that you're probably not going to be able to do because of the nature of your job.”

But generational overgeneralizations aren't exactly Dr. Jain's style. Born in 1980, on the cusp between millennials and Generation X, he is quick to point out that stereotypes about millennials are not representative of the entire group. “I think this generation is just as dedicated as past generations, but I think we do have an emergence of some outlier cases,” said Dr. Jain.

Even though his question is not simple to answer, experts agreed that the behavioral differences physicians are noticing may have more to do with environmental and individual factors than generational ones. New attitudes about cross-coverage and work-life balance, for example, may stem from an evolving clinical climate and more women practicing medicine, they said.

Generational differences

It's likely that cohort effects, or differences between generations that may be the byproduct of unshared historical circumstances, exist beyond any effects of life cycle and period, according to the Pew Research Center. One substantial difference, for instance, is that millennials are “digital natives” who haven't had to adapt to new technologies such as mobile phones, the Internet, and social media, according to a 2014 Pew report.

Although there's always been a tendency for the older generations to believe the youth are different, the rate of technological change is contributing to the current disconnect, said Gurpreet Dhaliwal, MD, a professor of medicine at the University of California, San Francisco, and a staff physician at the San Francisco VA Medical Center. “There are some things that are completely different now, like electronic health records [EHRs], social media, work hours,” he said. “So if anything, it may make people more apt to draw a distinction between groups.”

But too many times, criticisms of younger doctors relate to either life-cycle differences or behaviors that would be equally egregious for all practicing doctors, Dr. Dhaliwal said. “There are specific things that physicians always decry about the generation that went before them, like the loss of physical exam skills,” he said. “You can look back almost a century and find stories of professors saying, ‘Young doctors these days, they love all this new technology, like the X-ray or the complete blood count.’”

Many arguments against millennials, Dr. Dhaliwal said, contain elements of fundamental attribution error because they ascribe differences to people's innate traits rather than the environment in which they trained or currently practice. “We make the mistake of overlooking that there's much more variation within a group than there is between 2 different groups,” he said. “Whatever characteristic you're looking for, you will find it widely distributed among young and widely distributed among old.”

Dr. Dhaliwal, born in 1973, belongs to Generation X, although he doesn't pay much attention to the label. “I think many people, when they really drill down into the science of intergenerational differences, actually have a very difficult time finding meaningful differences because the variation within any age cohort is massive,” he said. With 75.4 million people, millennials are now the largest generational group, followed by the baby boomers, who stand at 74.9 million strong, according to Pew.

Baby boomer Robert Centor, MD, MACP, whose first month as a ward attending was January 1980, before today's millennials were born, said that the older generation always tends to think the youth are overprivileged and not as dedicated. “I just don't see … any difference in millennials. They work just as hard as anybody ever worked,” said Dr. Centor, a professor of medicine and regional dean of the University of Alabama School of Medicine Huntsville Regional Medical Campus and past chair of ACP's Board of Regents.

As for the differences surrounding technology, he said that medical students and residents tend to be earlier adopters than their attendings. “I think they're much better at adapting and adopting EHRs than older guys are, and that's just because we had so many years of not having them, and we learned how to do things in a certain way,” Dr. Centor said. He added that he's seen students teach attendings how to text and that a young physician taught him how to use Twitter.

Nonetheless, millennial Alexandra Lane, MD, ACP Member, feels there is a sure divide between old and young in medicine. “I think there's definitely a sense from the older generation that the millennials are entitled and that they don't have the respect for the hierarchy that the older generation has,” said Dr. Lane, an internist at Cooper University Health Care in Camden, N.J., and assistant program director of its internal medicine residency program.

The ‘cross-cover mindset’

By and large, criticisms tend to arise most when younger doctors fail to hold themselves accountable for their patients, said millennial Jonathan Gotfried, MD, ACP Member, a second-year gastroenterology fellow at Temple University Hospital in Philadelphia. For example, “I don't know, I'm just cross-covering” is a common responsibility-deflecting statement from new trainees, he said. “That statement, whether to an older attending or to a co-resident or co-fellow, is not an acceptable answer. You still have to take responsibility for your patient,” said Dr. Gotfried.

In terms of when these shifts in responsibility began, many point to 2003, when the Accreditation Council for Graduate Medical Education (ACGME) introduced the 80-hour work week. The ACGME modified duty hours even further in 2011, when Dr. Gotfried started as an intern. For him, this sense of on-duty versus off-duty seems to be more of a symptom of the duty-hour restrictions than a millennial attitude. “I think before, when you were taking care of your patients nonstop, there wasn't so much cross-coverage and you just kind of knew all your patients,” Dr. Gotfried said. “Now, with the work restrictions, there's an element of ‘I'm just cross-covering.’”

An us-versus-them distinction is much easier to see because of the work-hour rules, which were a “fundamental shift in identity formation for physicians,” said Dr. Dhaliwal. “Spending endless hours at the hospital to hone your craft and prove your dedication was a rite of passage to reach clinical excellence. But I would assert that's never really been proven, and it's not been my observation either. I find millennials as hardworking and as dedicated as any group before.”

The current clinical climate, with its EHRs and regulations imposed by the government and insurance companies, has undoubtedly impacted medical training, said Dr. Centor, who went to medical school in the 1970s. “When I was a medical student, patients would get admitted for a week, 10 days,” he said. “And if you didn't work them up today, you worked them up tomorrow, and you watched them for a little while. Now, there's much more of a rush. In many ways, I think they work harder now than we did then, but they work less hours of harder.”

Dr. Jain agreed, saying that millennial physicians in training are forced to see a higher volume of patients in a shorter period of time than previous generations. “I think that in general, there's just been a failure of the profession to deal with all the unintended consequences of the 80-hour work week. … It's taken years, and I think a lot of programs are still struggling with the issues around handoffs and patient ownership as you change shifts,” he said.

Dr. Jain and colleague Kiran Kakarala, MD, called this breakdown of responsibility the “cross-cover mindset” in a 2012 article in the Journal of Patient Safety. Although Dr. Jain learned true patient ownership by watching other residents rise to the occasion, he said there is room for more explicit discussions about the attitudes and professional values that come with being a physician. “The pedagogical model in residency, which is entirely a learn-by-doing model, needs to be turned on its head to include reflective practice and thinking more about what we're actually doing,” he said.

Work-life balance

Another issue is that millennials are voicing new and different attitudes about work, such as the approach to work as being just one of many aspects of a physician's life, said Dr. Lane. “The focus on work-life balance has changed because there are more women in the workforce and because women continue to be the primary caretakers, even when they are working. There has to be a balance,” she said. “But men are becoming more involved in caretaking, so they also want a balance.”

Dr. Dhaliwal added that every medical conference has a session on work-life balance, and these sessions are attended by physicians of all ages. “Sometimes we have false memories of ourselves, which is when we were in training, we had no interest in that, that we were completely dedicated to the profession,” he said. “But I seriously doubt any doctor from previous generations wasn't interested in what their friends were doing after work or trying to get to a concert when they were young.” As Dr. Dhaliwal put it in a December 2015 opinion article in JAMA, “Being self-focused is a temporary and adaptive condition of early adulthood, not a permanent generational characteristic.”

In general, medicine is still working on finding the “sweet spot” when it comes to work-life balance, Dr. Gotfried said. “I think our generation is exposed to this idea of ‘There are limits that you're supposed to draw in your practice because [too much work] might be detrimental,’ whereas at least that attitude didn't exist for people 30 years ago,” he said.

Dr. Dhaliwal added, “There's no shortage of people in the older generations who also want more lifestyle balance that they wouldn't have asked for 20 years ago, and that's strictly because society has changed, not because a generation has.”

When Dr. Centor was training in the ‘70s, he said most physicians were very concerned about their lives outside of practice. “It's just people say it now; you weren't allowed to say it back then. You weren't allowed to talk about work-life balance,” he said, adding that both men and women were “a bit macho” about how hard they worked. “I think as we've had more women [become physicians], some of whom had kids, work-life balance became much more of an issue.”

Dr. Jain said that the medical profession has always, by choice, been one of imbalance because patient care comes first. “The reality is that this is a lifelong struggle [that] anyone who works in a healing profession is going to have to face,” he said. “If you're truly going to be there for your patients, it means that there will be times that you're not there for other things. It means that you will occasionally have to work through lunch or work after hours.”

For all the grumbling, many older physicians actually stand in admiration of the younger doctors, Dr. Dhaliwal said. “Some are very honest, and they'll say, ‘Listen, being a resident is actually way harder now than it was back when I was a resident and you were expected to treat your patients and write in a paper chart and that was it,’” he said. “And now, the mountain of paperwork, computer work, and regulatory work is unprecedented.”

One way to stop experienced physicians' broad generalizations about younger doctors is to make it personal, Dr. Dhaliwal suggested. “I ask them, ‘Do you have a son or a daughter who's in health care? Do you remember a recent student or resident who you really were proud of?’ They think of that example of one instead of broad generalizations, and they often dial back their assertions about the entire generation,” he said.