Generation Gaps in Medical Education: Implications For

Teaching and Learning

Caroline Haynes, M.D., Ph.D.Caroline Haynes, M.D., Ph.D.Associate Dean for Medical EducationAssociate Dean for Medical Education

Duke University School of MedicineDuke University School of Medicine

Why the interest in generational differences in medicine?

More generations in the workforceRapid pace of cultural change makes experiences of generations more divergentMedicine demands effective interactions between members of different generations and cultures as emphasis on teamwork increasesNeed for more doctors in the workforce, making retention and job satisfaction important

At the end this presentation, you should be able to:

1. Describe stereotypical characteristics of the four most recent generations in our workforce

2. Enumerate conflicts between your learners and teachers that are often attributed to generational differences

3. Discuss whether you think these conflicts are related to generational differences, or to other factors

4. Suggest strategies to resolve these conflicts

Definition: a generation is a group of people Definition: a generation is a group of people whose characteristics were shaped and whose characteristics were shaped and defined by the societal events that defined by the societal events that occurred during their formative yearsoccurred during their formative years

Not every member of a particular generation Not every member of a particular generation will share everything in common with other will share everything in common with other members of that generation.members of that generation.

Since generations span 15+ years, their Since generations span 15+ years, their members still have varied experiences and members still have varied experiences and those on the those on the ““cuspcusp”” of previous or next of previous or next generations may not fit stereotypes as generations may not fit stereotypes as well.well.

Further “caveats”

Talking about generational differences requires sweeping stereotyping and oversimplificationStudies of generational characteristics are based on survey research, interviews, and sociological observations of behaviors, usually in the general publicGenerational differences measured in surveys could be based on generational experiences, age/stage of life, or accumulated life experience (are 80 year-olds of one generation different from 80 year olds of another?

Recent U.S. GenerationsRecent U.S. Generations

““GreatestGreatest”” or or ““GIGI”” Born 1901 Born 1901 –– 19241924

““SilentSilent”” Born 1925 Born 1925 –– 19441944

““Baby BoomBaby Boom”” Born 1945 Born 1945 –– 19621962

““Generation XGeneration X”” Born 1963 Born 1963 –– 19811981

““MillennialMillennial””, , ““Gen YGen Y””, , ““EchoEcho--boomboom””, , ““NextersNexters””

Born 1982 Born 1982 -- 20022002

?????? Born 2003 Born 2003 ––

traditional, respect authority, law and orderparents were strict, frugal and worriedmarried early, divorce rate rose in their mid-lifegender gap – wide but challenged by women working during WWIIprized values- security, wealthexperiences- end of Depression, FDR, Social Security, WWII, 1950’s prosperitytechnology – cars, radio, first commercial aviation

The Silent GenerationThe Silent Generation(born 1925(born 1925--1944, ages 661944, ages 66--85)85)

The stereotypic story of members of the Silent Generation

Strict discipline and witnessing of parental sacrifices during the Depression led to conformity and early commitment to job and family, and risk-avoidant behaviorSo, with increasing security and prosperity of 50’s, had a more “hands-off” style of childrearing with their boomer and Gen X kidsLater, in mid-life, triggered the boom in divorce rates and accumulated the most relative wealth of any generation

Stereotypic Organizational Style of Stereotypic Organizational Style of Silent GenerationSilent Generation

Devotion to job/profession and loyalty to Devotion to job/profession and loyalty to organizationorganizationFormal, respectful interactionsFormal, respectful interactionsExpect respect based on status, role in Expect respect based on status, role in hierarchyhierarchyBelieve in Believe in ““paying your duespaying your dues””May treat men and women differentlyMay treat men and women differently

Nov. 5, 1951

The Baby Boom Generation(born 1945-1962, ages 48-65)

optimistic, generous, permissive, rebellious, ambitiousparents were: relaxedmarried later, divorce rate doubledgender gap: wide but pressure to changeprized values: youth, health, personal success, material wealth, “live to work”experience: civil rights, birth control, women’s lib, moon landing, Vietnam, Cold War/arms racetechnology: TV, LPs, 8mm films, mainframe computers, plane travel, nuclear missiles

Stereotypical Story of the Baby BoomersGrowing up in an era of relaxed parenting and the economic boom of the 50’s and early 60’s, they felt secure and that there were limitless possibility – man went to the moon!The Women’s Lib and Civil Rights movements fostered a sense of rebellion as empowering–and this erupted in the late 60’s around an unpopular war and the assassinations of cultural heroesThe widespread availability of effective birth control ushered in the Sexual Revolution and allowed women to marry later, enter the workforce, and be more independent - and divorce rates soared

Organizational Style of Baby BoomersOrganizational Style of Baby Boomers

Prize ambition, invention, hard work, Prize ambition, invention, hard work, accumulated body of workaccumulated body of workExpect respect based on expertise, Expect respect based on expertise, accomplishmentsaccomplishmentsBelieve in Believe in ““getting aheadgetting ahead””, , ““get the job doneget the job done””, , ““go for itgo for it””, , ““you can do anything you put your you can do anything you put your mind tomind to””Deeply invested in job/profession as major part Deeply invested in job/profession as major part of identityof identityMay still be some gender biasMay still be some gender bias

Jan. 6, 1967

Characteristics of Generation X(born 1963-1981, ages 29-47)

fun-loving, self-reliant, troubled, cynical, “misunderstood”, independentparents were: underprotective, often not homegender gap: narrowingprized values: diversity, balance, free time, environment, “work to live”experience: working/single parents of “latch-key”kids, space shuttle and Challenger disaster, Chernobyl and Three Mile Island, Watergatetechnology: cable, PCs, internet, solar power, cassettes/CDs, VCRs, calculators

Stereotypical Story of Gen X

Relaxed style and high divorce rate of working parents resulted in “latch-key” kids who learned independence early and rebelled against rulesLess cohesive family relationships and events like Watergate and the Chernobyl disaster led to cynicism about government and organizationsLess allegiance to family and organizations promoted a sense of isolation, alienation, and being “misunderstood”, and marriage and birth rates declined

Organizational Characteristics of Gen XOrganizational Characteristics of Gen X

Cynical and less trusting of organizations, more Cynical and less trusting of organizations, more willing to change jobs/find new opportunitieswilling to change jobs/find new opportunitiesCasual interpersonal styleCasual interpersonal styleLess likely to affiliate with elders or seek Less likely to affiliate with elders or seek mentoring mentoring –– ““II’’ll do it myselfll do it myself””Expect respect based on quality of workExpect respect based on quality of workExpect to get the job done and have time for the Expect to get the job done and have time for the rest of life rest of life –– not as likely to identify with jobnot as likely to identify with jobGender neutralGender neutral

June 9, 1997

Characteristics of Millennials(born 1982-2002, ages 8-28)

family-oriented, mobile, consumerist, brand conscious, hopeful, idealistic, want feedbackparents were: protective, “helicopter” stylegender gap: narrowmarrying earlier again, kids when youngerprized values: tolerance, cooperation, connection/communication, novelty, conformity/perfectionexperience: global news, AIDS, Kosovo, Sudan, Rwanda, Iraq, 9/11, climate changetechnology: VCRs to TiVo, IM/texting, cell phones, MP3s and iPods, hybrid cars

Stereotypical Story of the MillennialsBeing planned and wanted by industrious Boomer parents who protected their self-esteem at all costs, Millennials grew up feeling special and powerful (“entitled?”)Boomer “helicopter” parents have hovered and protected, and showered them with material goods, delaying the onset of independent adulthood (“Emerging Adulthood” stage), and have maintained close, more friend-like relationships with kidsTechnology has allowed them to feel constantly in contact with friends/family, and travel and the diversity of our society has led them to feel like “global citizens”Closer ties with others, increased awareness of global and environmental concerns and a sense of being special and powerful have led to unprecedented activism and volunteerism and a renewed sense of civic responsibility

Organizational Style of MillennialsOrganizational Style of Millennials

Highly affiliated with peer groups and desire Highly affiliated with peer groups and desire affiliation with mentors/teamsaffiliation with mentors/teamsCasual interpersonal style; may treat faculty as Casual interpersonal style; may treat faculty as friendsfriendsTechnologyTechnology--savvy and acceptingsavvy and acceptingExpect respect based on affiliation/utilityExpect respect based on affiliation/utilityWant to get the job done, have fun, and save the Want to get the job done, have fun, and save the world, all with friendsworld, all with friendsGender blindGender blind

Feb 11, 2008

““Children today are tyrants. They contradict Children today are tyrants. They contradict their parents, gobble their food, and their parents, gobble their food, and tyrannize their teachers.tyrannize their teachers.””

Socrates, 469 BC Socrates, 469 BC –– 399 BC399 BC

??????????

““The young people of today think of nothing The young people of today think of nothing but themselves. They have no reverence but themselves. They have no reverence for parents or old age. They are impatient for parents or old age. They are impatient of all restraint. They talk as if they alone of all restraint. They talk as if they alone knew everything and what passes for knew everything and what passes for wisdom with us is foolishness with them. wisdom with us is foolishness with them. As for girls, they are forward, immodest As for girls, they are forward, immodest and unwomanly in speech, behaviour and and unwomanly in speech, behaviour and dress.dress.””

Sermon by Peter the Hermit in A.D. 1274Sermon by Peter the Hermit in A.D. 1274(generational differences are not a new phenomenon)

The thing that impresses me most The thing that impresses me most about America is the way parents obey about America is the way parents obey their children. their children.

Edward, Duke of Windsor, Edward, Duke of Windsor, LookLook, , 5 March 19575 March 1957

(the specific generational differences we are talking about may be unique to American culture)

So, how are these potential So, how are these potential differences manifest in the differences manifest in the academic environment?academic environment?

GSA/GEA/OSR Generational GSA/GEA/OSR Generational Attitudes Survey ResultsAttitudes Survey Results

Survey sent to listservs for these groupsSurvey sent to listservs for these groups466 responses from four generations,466 responses from four generations,

by gender, F>M for all (16 Silent, 138by gender, F>M for all (16 Silent, 138Boomers, 96 Gen X, 212 Millennials)Boomers, 96 Gen X, 212 Millennials)

Silent and Boomer groups comprised of Silent and Boomer groups comprised of physicians and nonphysicians and non--physicians (responses physicians (responses did not vary significantly)did not vary significantly)Gen X and Millennial groups comprised Gen X and Millennial groups comprised primarily of medical students primarily of medical students

Differences in Learning Differences in Learning PreferencesPreferences

Younger learners prefer multiple learning styles Younger learners prefer multiple learning styles to just lecture and noteto just lecture and note--takingtakingYounger learners prefer to work late and night Younger learners prefer to work late and night and when they choose toand when they choose toYounger learners appreciate use of Younger learners appreciate use of sophisticated and mobile technologies, and use sophisticated and mobile technologies, and use them EVERYWHEREthem EVERYWHEREYounger learners like to Younger learners like to ““multitaskmultitask”” and work and work ““strategicallystrategically”” on whaton what’’s most importants most important

Tensions related to learning Tensions related to learning preferencespreferences

What do you mean, close my laptop?What do you mean, close my laptop?II’’m not coming in today, there are no mandatory m not coming in today, there are no mandatory eventseventsWhatWhat’’s going to be on the test?s going to be on the test?These lectures are so boring, canThese lectures are so boring, can’’t they use t they use demonstrations and more technology to teach demonstrations and more technology to teach us?us?Why should I lecture if no one is interested and Why should I lecture if no one is interested and comes? They are so disrespectful!comes? They are so disrespectful!

I learn most efficiently when I:I learn most efficiently when I:

0

5

10

15

20

25

30

35

40

45

listen, takenotes

read, takenotes

discuss withothers

manualactivity

SilentBoomGen XMillennial

What should determine whether or What should determine whether or not laptops can be used in class?not laptops can be used in class?

0

10

20

30

40

50

60

presenterpreference

classcontentrequires

presence ofpatient

shouldalways beallowed

SilentBoomGen XMillennial

Potential StrategiesPotential StrategiesVideostream lectures and use face time for Videostream lectures and use face time for interactive techniques: PBL, TBL, review interactive techniques: PBL, TBL, review sessions, labs, simulationsessions, labs, simulationDonDon’’t rely on guilt to encourage attendance; t rely on guilt to encourage attendance; have meaningful consequences if mandatoryhave meaningful consequences if mandatoryTime events for peak learning hoursTime events for peak learning hoursProvide alternative learning strategies for Provide alternative learning strategies for different learning stylesdifferent learning stylesSet clear rules based on learner needsSet clear rules based on learner needsfor classroom behavior/use of devicesfor classroom behavior/use of devices

Differences in Use of TechnologyDifferences in Use of Technology

I canI can’’t get hold of the professor, s/he hasnt get hold of the professor, s/he hasn’’t t answered two emails I sent this AM! They donanswered two emails I sent this AM! They don’’t t really care about studentsreally care about studentsI canI can’’t get hold of the student, s/he has not t get hold of the student, s/he has not answered my (university) email! How is s/he answered my (university) email! How is s/he going to learn to take on the responsibility of going to learn to take on the responsibility of being a doctor?being a doctor?Why canWhy can’’t I post a picture of me and my patient t I post a picture of me and my patient on Facebook or write about my patients in my on Facebook or write about my patients in my blog? The patient doesnblog? The patient doesn’’t mind!t mind!

Duke Survey of Generational Attitudes/ExperiencesDuke Survey of Generational Attitudes/Experiences““My current frequency of use of this modality of My current frequency of use of this modality of

communication is communication is ““frequentfrequent”” ““

0102030405060708090

100

land line cell phone voice mail email

silentboomerGen Xmillennial

Potential SolutionsPotential Solutions

Extremely explicit and clear policies about use of Extremely explicit and clear policies about use of technology in educational and clinical settings, technology in educational and clinical settings, with repeated education devoted to this and with repeated education devoted to this and clear consequences for violationsclear consequences for violationsUse studentsUse students’’ technological savvy to design technological savvy to design systems and content systems and content –– let them teach faculty let them teach faculty and provide individual faculty training on and provide individual faculty training on updates in school technology systemsupdates in school technology systems

Differences in Attitudes about Time and Differences in Attitudes about Time and Work/Life BalanceWork/Life Balance

Whose time is it, anyway?Whose time is it, anyway?These students disappear as soon as rounds These students disappear as soon as rounds are over! I can never find them.are over! I can never find them.These residents are always too busy to teach These residents are always too busy to teach but want us to hang around and wait for but want us to hang around and wait for something to do something to do ––itit’’s a waste of our time!s a waste of our time!I need to chose a specialty so that II need to chose a specialty so that I’’ll have time ll have time for my family and my other activitiesfor my family and my other activitiesDonDon’’t these students realize that Medicine is a t these students realize that Medicine is a calling, not a job?calling, not a job?

AAMC Generational Attitudes SurveyAAMC Generational Attitudes Survey““I see being a physician as:I see being a physician as:””

0102030405060708090

100

a callingthat directs

lifedecisions

a way tocontribute

a type ofemploy-

ment

start of mycareer,other

endeavorslate

SilentBoomerGen XMillennial

Potential SolutionsPotential Solutions

Team TrainingTeam TrainingClear expectations of all team members for Clear expectations of all team members for attendance, punctuality, how work is sharedattendance, punctuality, how work is sharedPolicies/Systems for communicating need for Policies/Systems for communicating need for excused absences, with clear consequences for excused absences, with clear consequences for unexcusedunexcusedIncentives for teaching by faculty/residents to Incentives for teaching by faculty/residents to that balance of teaching of/service by students that balance of teaching of/service by students feels more appropriatefeels more appropriate360 evaluations360 evaluations

Differences in Basis for Respecting Differences in Basis for Respecting OthersOthers

These kids use too much profanity and are too These kids use too much profanity and are too casual with patients casual with patients –– we need to teach more we need to teach more professionalism!professionalism!That student challenged my authority by That student challenged my authority by questioning my clinical decision on rounds! How questioning my clinical decision on rounds! How disrespectful!disrespectful!That attending criticized me in public! How That attending criticized me in public! How humiliating and abusive!humiliating and abusive!These student/professors donThese student/professors don’’t follow the rules!t follow the rules!

AAMC Generational Attitudes/Experience AAMC Generational Attitudes/Experience Survey Survey ““I tend to respect a person MOST highly I tend to respect a person MOST highly

based on:based on:””

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100

greatvalues- is a

"good"person

personalvalue to meas teacher,

etc.

professionalaccomplish-

ments

high rankor title

SilentBoomGen XMillennial

My typical approach to rules is:My typical approach to rules is:

0102030405060708090

complyunlessmorally

unaccep- table

complywithoutmuch

question

not comply if no

conse- quence

SilentBoomerGen XMillennial

My typical approach to rules is:My typical approach to rules is:

0102030405060708090

complyunless

morallywrong

complyif I

agree withrule

complyif

respect maker

complyto stayout oftrouble

SilentBoomerGen XMillennial

Potential SolutionsPotential Solutions

Set clear rules, explain the rationale, and have Set clear rules, explain the rationale, and have them announced by someone respectedthem announced by someone respectedInvolve all parties in setting the rulesInvolve all parties in setting the rulesOpportunities for teachers and learners to Opportunities for teachers and learners to participate in community service events that participate in community service events that allow them to share their valuesallow them to share their valuesMentoring programs that allow teachers and Mentoring programs that allow teachers and learners to recognize shared valueslearners to recognize shared values

Career Priorities and Career Priorities and Life MotivationsLife Motivations

These students want to run all over the world These students want to run all over the world and do good and do good –– dondon’’t they realize Medicine is not t they realize Medicine is not all about adventures? Who is going to stay home all about adventures? Who is going to stay home and take care of the patients?and take care of the patients?These professors are so sure that we can only These professors are so sure that we can only get a good education here get a good education here –– why canwhy can’’t we see t we see how medicine is practices other places. Theyhow medicine is practices other places. They’’re re so provincial!so provincial!

I see being a physician as:I see being a physician as:

0

10

20

30

40

50

60

70

a callingthat directs

lifedecisions

a way tocontribute

to the world

a type ofemploy-

ment

start of mycareer,other

endeavorslate

Silent - MDsBoom - MDsGen XMillennial

Physicians should be able to work Physicians should be able to work partpart--time:time:

010

203040

506070

8090

throughoutcareer

temporarilyduring some

periods

rarely, it's a full-time job

SilentBoom - MDsGen XMillennial

So, do we have a generation gap in So, do we have a generation gap in medical education?medical education?

Clear differences in learning preferences, Clear differences in learning preferences, technology usage, Medicine as a callingtechnology usage, Medicine as a callingMinor differences in approach to rulesMinor differences in approach to rulesSimilarities in basis for respect, attitude Similarities in basis for respect, attitude about partabout part--time worktime work

Cultural Competency as a Cultural Competency as a model for better understanding model for better understanding

and communicationand communication

Cultural Messages to MillennialsCultural Messages to MillennialsBelieve in yourself (focus on selfBelieve in yourself (focus on self--esteem esteem in parenting and education)in parenting and education)You are specialYou are specialYou can be anything you want to beYou can be anything you want to beI like you just the way you areI like you just the way you areI love you, you love meI love you, you love meBe yourself, do your own thingBe yourself, do your own thingBe nice!Be nice!Be happy, have fun! Be happy, have fun! Things are importantThings are important

““HelicoptorHelicoptor”” Parents of Parents of ““TrophyTrophy””Children have often:Children have often:

signed their child up for the signed their child up for the ““bestbest””preschool/play group, even before birthpreschool/play group, even before birthgiven choices rather than saying given choices rather than saying ““nono””showered children with material goods and showered children with material goods and huge collections of toys huge collections of toys defended kids, not teacher, if trouble at defended kids, not teacher, if trouble at schoolschoolinvested greatly in childreninvested greatly in children’’s multiple s multiple activities and achievements activities and achievements allowed missing school for special eventsallowed missing school for special eventsheld family meetings to make decisionsheld family meetings to make decisions

The educational background of The educational background of Millennials has often included:Millennials has often included:

““grade inflationgrade inflation””, lots of positive feedback, lots of positive feedbackEmphasis on individual interpretation, Emphasis on individual interpretation, independent study, independent study, ““freefree”” writingwritingallowed absences for trips, competitionsallowed absences for trips, competitionsrelaxed dress codes, or none at allrelaxed dress codes, or none at allaccess to snacks throughout the day and access to snacks throughout the day and multiple meal optionsmultiple meal optionsno scheduled classes for early AM or no scheduled classes for early AM or Fridays (college) Fridays (college)

The college and medical school The college and medical school admissions process rewards:admissions process rewards:extraordinary accomplishment in extraordinary accomplishment in endeavors other than academic (sports, endeavors other than academic (sports, arts, community service)arts, community service)students who have been intensely students who have been intensely coached to take SAT/AP/MCAT examscoached to take SAT/AP/MCAT examsstudents who are used to taking on students who are used to taking on leadership roles and having a say in thingsleadership roles and having a say in thingsstudents for whom exceptions have been students for whom exceptions have been made and have a sense of being specialmade and have a sense of being special

So, what do Millennial students So, what do Millennial students expect of their educators?expect of their educators?

Clear rules, consequences and grading Clear rules, consequences and grading policies, no unfair advantage for otherspolicies, no unfair advantage for othersLearning events that are engaging and Learning events that are engaging and worth their time, with competent use of worth their time, with competent use of technologytechnologyFrequent positive feedback and good Frequent positive feedback and good grades, even for average work (wegrades, even for average work (we’’re all re all OK they way we are), negative feedback OK they way we are), negative feedback that is gentlethat is gentleThat we are invested in their success and That we are invested in their success and will coach them to be successful in getting will coach them to be successful in getting the the ““rightright”” residencyresidency

So, what do Millennial students So, what do Millennial students expect in medical education?expect in medical education?

time to pursue talents and intereststime to pursue talents and interestsexceptions to attendance rules for exceptions to attendance rules for meetings, courses elsewhere, medical meetings, courses elsewhere, medical tripstripsto take on leadership roles, participate in to take on leadership roles, participate in decisiondecision--making, give us constructive making, give us constructive feedback right awayfeedback right awayTo dress, communicate with friends, and To dress, communicate with friends, and eat how and when they want toeat how and when they want to

Bridging Bridging ““culturalcultural”” gapsgaps

Getting educated about and understanding Getting educated about and understanding each othereach other’’s cultural backgrounds cultural backgroundRecognizing shared values and goalsRecognizing shared values and goalsAnticipating differences in approach to Anticipating differences in approach to goals based in cultural differencesgoals based in cultural differencesDeveloping effective communication styles Developing effective communication styles that bridge differencesthat bridge differencesNegotiating process, roles, rules, timeline Negotiating process, roles, rules, timeline to get to mutually desired outcomesto get to mutually desired outcomes