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Everyone knows the type: they have been described as smart and talented yet needy and demanding. The newer generations of physicians and surgeons have so much to offer and, at the same time, also seem to want it all. For older physicians, particularly in high-demand specialties such as neurosurgery, integration of young men and women with these traits can be challenging as values clash from the classroom to the surgical suite. Creation of successful, multi-generational surgery practices and care teams requires an appreciation of the change in workforce demographics and an understanding of cultural differences among the various age groups. Failing to successfully prepare and integrate the newer generations of physicians is not an option as our earlier generations are moving into retirement, leaving the next generations to adapt to and manage a rapidly changing healthcare system. Attracting, training and retaining younger generations in the workforce will be critical in this evolutionary period for all professions. In her February 2012 article, “Don't dismiss your Gen X talent,” Sylvia Ann Hewlett, author and regular blogger for the Harvard Business Review, suggests that the Generation X workforce (those born between 1965 and 1978) cannot be neglected by the Baby Boomers. "Smart organizations will seek to understand what motivates them in order to sustain, retain, realize, and maximize their potential," she writes.1 Hewlett offers several suggested ways to keep talented Gen X employees engaged, from mentoring and sponsorships to intergenerational business partnerships—ideas that can be applied to medicine generally and neurosurgery more specifically. The differences among today's generations are more marked than in any other time recorded.2 As Danielle S. Walsh, MD, of East Carolina University explains it, people born in different eras with different external influences develop different viewpoints in priorities, preferences and values.2 In “Mind the Gap: Generational Differences in Medicine” Walsh says that the physician world has been slower than some fields to study the impact of these differences on the profession, but effects are felt in “hiring, work habits, financial decisions, and even patient interactions.” Generally, Walsh says, while baby boomers are most likely to embrace the corporate culture, seeking promotions, responsibility, and sense of identity that it brings, Generation Xers, more prone to seeking happiness and expressing individuality, see medicine as a job through which they make a living and achieve personal goals. And while they value learning new skills and are interested in new technology, they want manageable work schedules, and don't necessarily want to lead a team or be the boss. Millennials, also known as Generation Y, born between 1980 and 2000, grew up with an emphasis on teamwork and shared credit for victories. They thrive under a well-defined structure with detailed guidance and clear rules, as well as frequent, positive feedback.2 GENERATIONAL DIFFERENCES AND MEDICAL TRAINING Generational differences are felt at every level in the medical profession, beginning in residency training. Jarod Wall, MBBCh, FACS, assistant professor of surgery at Southern Illinois University School of Medicine, describes Millennials as “educated, skilled, comfortable with technology and very self-confident,”3 but emphasizes that “approaches to teaching utilized for past generations may not be successful for the Millennial Generation.”3 In “Millennium Generation Poses New Implications for Surgical Resident Education,” an article in the American College of Surgeons, Wall explains why Millennials may need different approaches in medical training than earlier generations. He reminds readers that as a group, Millennials have been protected and sheltered by their parents, having experienced prolonged exposure to structure and supervision. Therefore, he suggests, Millennial students are likely to need rigorous schedules, and surgical residents “may require guidance from mentors about how to balance and prioritize the multiple duties in residency.”3 Senior neurosurgeons may need to be tolerant and willing to provide clear feedback to Millennial-age residents, whose close relationships with their parents prevent them from recognizing hierarchical structures, and who may see their professors as equals, expecting them to be approachable and supportive.3 Because this generation is “wired” with expectations for the availability and usefulness of technology such as iPods and tablets, blogs and podcasts, “investment in and utilization of these modern forms of media is likely to be beneficial for Millennial residents.” Wall explains that Millennial residents will interpret good medical educators as those who incorporate multimedia and other non-traditional instructional methods in their curricula. This generation also expects more leisure time than earlier generations. For medicine, that means many students are interested in pursuing specialties with more sociable hours such as dermatology and anesthesiology vs general surgery and family practice.3 Seeking a balance of work and life, a residents' reluctance to take on 80-hour weeks may be perceived as a lack of professionalism. For this generation, explicit rules and expectations for behavior during lectures, appropriate dress, punctuality and patient care must be clearly defined.3 In an article in the Journal of Surgical Education, Jennifer A. Swanson of the Department of Surgery at University of Minnesota describes her research on the personality traits of Generation X surgical trainees. She and her colleagues administered personality tests to 41 surgery residents and found that the most frequent personality type of the resident surgery was introversion. That contrasts significantly with the results of previously published personality profiles of practice surgeons, which showed a preference for the extrovert personality type.4 Because personality differences can affect temperament, communication style with other team members, decision making and information processing, the authors state, these differences “may lead to misunderstanding and misinterpretation in the care of patients on the surgical ward.”4 Swanson et al conclude that as surgical training continues to evolve, it is imperative that the personality traits of modern trainees are considered, since “the impact of attracting a new breed of surgeon will reverberate throughout our education and clinical systems impacting all aspects of care.”4 GENERATIONAL DIFFERENCES AND PHYSICIAN RECRUITMENT Generational differences also may pose challenges for senior medical professionals when recruiting young physicians, since expectations of post-residency life can be dramatically different from the reality of neurosurgical practice. David Cornett, writing in Physician's News Digest, cites a JAMA study and other research that has demonstrated that job candidates seek generous vacation policies, respond positively to employers offering flexible work hours, call schedules and job sharing, and often expect compensation levels close to those of experienced physicians and shorter time-to-partnership periods than were typical in the past.5 In his article “Expectations of Gen-X recruitment candidates,” Cornett suggests that while an employer's reluctance to consider a young physician's demands is understandable, it is ill-advised. Cornett, regional vice president of Cejka Search, a physician search organization, explains that physicians on search committees should understand the realities of the labor force, including the fact that today's young physicians expect to be able to pursue personal interests and fulfill their roles as spouses, which may translate to less long-term loyalty. “In addition to their own personal interests, young married physicians often face spousal expectations of levels of family involvement that, at least for men, did not exist a generation ago.” And he reminds them that career decisions may hinge on the ability to repay a high educational debt and on the physical location of the potential job. In an era of physician shortages, Cornett suggests, physician employers should consider these and other Gen X characteristics when developing recruitment strategies.5 Because Gen X workers place a high value on relationships and mentoring, Cornett suggest organizations offer strong orientation and mentoring programs, which he says also can benefit any physician practice “in terms of productivity and longer-term loyalty from young physicians than might be otherwise.” In addition to mentoring, Cornett said potential recruits will want to help building marketable, portable skill sets to enhance their future career success, financial assistance with high-level clinical training and professional management of the physicians' practices.5 GENERATIONAL DIFFERENCES IN MEDICAL PRACTICE The traits of Generations X and Y residents and recruits may become even more apparent once they are established as lifestyle departures from the older generations play out in their day-to-day practices. A younger physician, for example, might eschew non-technological means of finding a patient's chart or seeking drug information—even to translate medical instructions for non-English-speaking patients. These younger doctors might also demand part-time work to accommodate family and non-clinical career demands. An Associated Press story published in newspapers around the country earlier this fall said that the new breed of Millennial and Gen X doctors resent the term “slackers,” however, arguing that they are just as committed to medicine as the archetypical Marcus Welby from the 1970's television show. In fact, the article suggests that “the practice of medicine is in the midst of an evolution, and Millennial and Gen X doctors seem to be perfectly suited for it and in some ways may be driving it.” Millennial and Gen X physicians also may be more suited to be employed physicians than are the independent, career-focused senior generation of private practice doctors they are replacing. Their training endorsed working in teams which translates well to the multidisciplinary team approaches in development for the care of patients with complex diseases. And their excellent computer skills will make them ideally suited to embrace and optimize the use of the electronic health record. The article quotes Dr Darrell Kirch, president of the Association of American Medical Colleges, who thinks new doctors have a broader view of medicine and life than their professors, and calls it a positive trend: “I see no evidence that indicates that their ethnical commitment is any weaker, that they care any less for patients,” he said.6 It is important for physician practices to consider that the need for work-life balance among younger physicians can benefit the entire organization. Adaption to the need for cross-coverage and teamwork in surgical patient care can improve quality and efficiency of care. This model is also consistent with the changes in today's healthcare environment, which increasingly demand adherence to best practices over a single physician's treatment approach for a given patient. The corporate world, which has been quicker to consider the importance of these demographic shifts, offers some exceptional advice about incorporating Generation X and Y workers, which can be applied to medicine. Sylvia Ann Hewlett, in her Harvard Business Review blog, suggests that to prevent Generation Xers from feeling stalled and burning out, they need variety and training in different areas. And because Gen Xers require more autonomy and opportunities to lead earlier in their careers, companies are allowing younger workers to test their wings with appropriate project leadership to keep them engaged and feeling fulfilled in the workforce. In medicine, too, younger physicians will become more engaged, productive and loyal when they are given the chance to make a broader impact on the field, while fulfilling their own personal goals. Medical organizations could create a more distributed leadership model, allowing each young physician the opportunity to chair a committee, develop or lead a program. A young physician who feels she is contributing, growing and learning to lead will be less likely to lose interest or grow frustrated with an impenetrable hierarchy. A more collaborative management approach could benefit the organization, as well. Mentoring and sponsorship programs that pair Boomer managers with Gen Xers will help retain workers by promoting personal career growth and enrichment. Opportunities to spotlight their abilities also will help retain these workers, Hewlett explains. Deanne DeMarco, writing a white paper for Business and Legal Resources on strategies to create a Gen-X-friendly workplace, adds that because Gen-Xers are relationship builders, companies need to develop communication models that include strategies for building together—that means using a collaborative approach to decision making and problem solving. “Allow them to brainstorm with you to generate ideas. Or when you need to decide on a course of action, get their feedback on which option to pursue. Really listen to what they offer and act on their input. Be open to what they say; often their suggestions will amaze you.”7 These are great lessons for neurosurgery, a profession that can thrive within a structure that values the contributions of all members of the team, whether they are Baby Boomers, Gen Xers, or Millennials. This transition for older generations of neurosurgeons may be challenging, but neurosurgery practices and healthcare organizations willing to embrace mentorship and shared leadership and management models will ultimately benefit from the integration of the younger specialists. Neurosurgery practices that accept the different working styles, medical practice approaches and work-life balance demands of their younger colleagues will be more agile in the changing healthcare environment to recruit and retain the best and the brightest of the next generation.
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