Associate Dean for Medical EducationAssociate Dean for Medical Education Duke University School of MedicineDuke University School of Medicine

Generation Gaps in Medical Education: Implications For

Teaching and Learning

Caroline Haynes, M.D., Ph.D.Caroline Haynes, M.D., Ph.D.

Why the interest in generational differences in medicine?

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

related to generational differences, or to other factors

4. Suggest strategies to resolve these conflicts

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

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

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

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

Further “caveats”

Talking about generational differences requiressweeping stereotyping and oversimplification Studies of generational characteristics arebased on survey research, interviews, andsociological observations of behaviors, usually inthe general public Generational differences measured in surveyscould be based on generational experiences,age/stage of life, or accumulated life experience(are 80 year-olds of one generation differentfrom 80 year olds of another?

Recent U.S. GenerationsRecent U.S. Generations

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

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

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

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

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

Born 1982Born 1982 -- 20022002

?????? Born 2003Born 2003 ––

experiences- end of Depression, FDR, SocialSecurity, WWII, 1950’s prosperity technology – cars, radio, first commercial aviation

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

traditional, respect authority, law and order parents were strict, frugal and worried married early, divorce rate rose in their mid-life gender gap – wide but challenged by womenworking during WWII prized values- security, wealth

The stereotypic story of members of the Silent Generation

Strict discipline and witnessing of parentalsacrifices during the Depression led toconformity and early commitment to job andfamily, and risk-avoidant behavior So, with increasing security and prosperity of50’s, had a more “hands-off” style of childrearing with their boomer and Gen X kids Later, in mid-life, triggered the boom in divorcerates and accumulated the most relative wealth of any generation

hierarchyhierarchy Believe inBelieve in ““paying your duespaying your dues”” May treat men and women differentlyMay treat men and women differently

Stereotypic Organizational Style ofStereotypic Organizational Style of Silent GenerationSilent Generation

Devotion to job/profession and loyalty toDevotion to job/profession and loyalty to organizationorganization Formal, respectful interactionsFormal, respectful interactions Expect respect based on status, role inExpect respect based on status, role in

Nov. 5, 1951

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

optimistic, generous, permissive, rebellious,ambitious parents were: relaxed married later, divorce rate doubled gender gap: wide but pressure to change prized values: youth, health, personal success,material wealth, “live to work” experience: civil rights, birth control, women’slib, moon landing, Vietnam, Cold War/arms race technology: TV, LPs, 8mm films, mainframecomputers, plane travel, nuclear missiles

Stereotypical Story of the Baby Boomers Growing up in an era of relaxed parenting andthe economic boom of the 50’s and early 60’s,they felt secure and that there were limitlesspossibility – man went to the moon! The Women’s Lib and Civil Rights movementsfostered a sense of rebellion as empowering–and this erupted in the late 60’s around anunpopular war and the assassinations of culturalheroes The widespread availability of effective birthcontrol ushered in the Sexual Revolution and allowed women to marry later, enter theworkforce, and be more independent - and divorce rates soared

mind tomind to”” Deeply invested in job/profession as major partDeeply invested in job/profession as major part of identityof identity May still be some gender biasMay still be some gender bias

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 work Expect respect based on expertise,Expect respect based on expertise, accomplishmentsaccomplishments Believe inBelieve in ““getting aheadgetting ahead””,, ““get the job doneget the job done””,, ““go for itgo for it””,, ““you can do anything you put youryou can do anything you put your

Jan. 6, 1967

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

fun-loving, self-reliant, troubled, cynical,“misunderstood”, independent parents were: underprotective, often not home gender gap: narrowing prized 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, Watergate technology: cable, PCs, internet, solar power, cassettes/CDs, VCRs, calculators

Stereotypical Story of Gen X

Relaxed style and high divorce rate of workingparents resulted in “latch-key” kids who learned independence early and rebelled against rules Less cohesive family relationships and eventslike Watergate and the Chernobyl disaster led tocynicism about government and organizations Less allegiance to family and organizationspromoted a sense of isolation, alienation, andbeing “misunderstood”, and marriage and birthrates declined

Organizational Characteristics of Gen XOrganizational Characteristics of Gen X

Cynical and less trusting of organizations, moreCynical and less trusting of organizations, more willing to change jobs/find new opportunitieswilling to change jobs/find new opportunities Casual interpersonal styleCasual interpersonal style Less likely to affiliate with elders or seekLess likely to affiliate with elders or seek mentoringmentoring –– ““II’’ll do it myselfll do it myself”” Expect respect based onExpect respect based on quality of workquality of work

Gender neutralGender neutral

Expect to get the job done and have time for theExpect to get the job done and have time for the rest of liferest of life –– not as likely to identify with jobnot as likely to identify with job

June 9, 1997

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

family-oriented, mobile, consumerist, brandconscious, hopeful, idealistic, want feedback parents were: protective, “helicopter” style gender gap: narrow marrying earlier again, kids when younger prized values: tolerance, cooperation,connection/communication, novelty,conformity/perfection experience: global news, AIDS, Kosovo, Sudan,Rwanda, Iraq, 9/11, climate change technology: VCRs to TiVo, IM/texting, cellphones, MP3s and iPods, hybrid cars

Stereotypical Story of the Millennials Being 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 kids Technology 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 desireHighly affiliated with peer groups and desire affiliation with mentors/teamsaffiliation with mentors/teams Casual interpersonal style; may treat faculty asCasual interpersonal style; may treat faculty as friendsfriends TechnologyTechnology--savvy and acceptingsavvy and accepting Expect respect based on affiliation/utilityExpect respect based on affiliation/utility Want to get the job done, have fun, and save theWant to get the job done, have fun, and save the world, all with friendsworld, all with friends Gender blindGender blind

Feb 11, 2008

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

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

??????????

““The young people of today think of nothingThe young people of today think of nothingbut themselves. They have nobut themselves. They have no reverencereverence for parents or old age. They are impatientfor parents or old age. They are impatientof all restraint.of all restraint. They talk as if they aloneThey talk as if they aloneknew everything and what passes forknew everything and what passes forwisdom with us is foolishness with them.wisdom with us is foolishness with them. As for girls, they are forward, immodestAs for girls, they are forward, immodestand unwomanly in speech, behaviour andand unwomanly in speech, behaviour anddress.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 mostThe thing that impresses me most about America is the way parents obeyabout 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 potentialSo, how are these potential differences manifest in thedifferences manifest in the academic environment?academic environment?

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

Survey sent to listservs for these groupsSurvey sent to listservs for these groups 466 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 ofSilent and Boomer groups comprised of physicians and nonphysicians and non--physicians (responsesphysicians (responses did not vary significantly)did not vary significantly) Gen X and Millennial groups comprisedGen X and Millennial groups comprised primarily of medical studentsprimarily of medical students

Differences in LearningDifferences in Learning PreferencesPreferences

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

Tensions related to learningTensions 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 mandatorym not coming in today, there are no mandatory eventsevents WhatWhat’’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 uset they use demonstrations and more technology to teachdemonstrations and more technology to teach us?us? Why should I lecture if no one is interested andWhy 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, take notes

read, take notes

discuss with others

manual activity

Silent Boom Gen X Millennial

What should determine whether orWhat 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

presenter preference

class content requires

presence of patient

should always be allowed

Silent Boom Gen X Millennial

Potential StrategiesPotential Strategies Videostream lectures and use face time forVideostream lectures and use face time for interactive techniques:interactive techniques: PBL, TBL, reviewPBL, TBL, review sessions, labs, simulationsessions, labs, simulation DonDon’’t rely on guilt to encourage attendance;t rely on guilt to encourage attendance; have meaningful consequences if mandatoryhave meaningful consequences if mandatory Time events for peak learning hoursTime events for peak learning hours Provide alternative learning strategies forProvide alternative learning strategies for different learning stylesdifferent learning styles Set clear rules based on learner needsSet clear rules based on learner needs for 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’’tt answered two emails I sent this AM! They donanswered two emails I sent this AM! They don’’tt really care about studentsreally care about students I canI can’’t get hold of the student, s/he has nott get hold of the student, s/he has not answered my (university) email! How is s/heanswered my (university) email! How is s/he going to learn to take on the responsibility ofgoing 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 patientt I post a picture of me and my patient on Facebook or write about my patients in myon 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 ofMy current frequency of use of this modality of

communication iscommunication is ““frequentfrequent”” ““

0 10 20 30 40 50 60 70 80 90

100

land line cell phone voice mail email

silent boomer Gen X millennial

Potential SolutionsPotential Solutions

Extremely explicit and clear policies about use ofExtremely 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 andwith repeated education devoted to this and clear consequences for violationsclear consequences for violations Use studentsUse students’’ technological savvy to designtechnological savvy to design systems and contentsystems and content –– let them teach facultylet them teach faculty and provide individual faculty training onand provide individual faculty training on updates in school technology systemsupdates in school technology systems

Differences in Attitudes about Time andDifferences 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 roundsThese 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 teachThese residents are always too busy to teach but want us to hang around and wait forbut want us to hang around and wait for something to dosomething 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 timell have time for my family and my other activitiesfor my family and my other activities DonDon’’t these students realize that Medicine is at 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:””

0 10 20 30 40 50 60 70 80 90

100

a calling that directs

life decisions

a way to contribute

a type of employ-

ment

start of my career, other

endeavors late

Silent Boomer Gen X Millennial

Incentives for teaching by faculty/residents toIncentives for teaching by faculty/residents to that balance of teaching of/service by studentsthat balance of teaching of/service by students feels more appropriatefeels more appropriate 360 evaluations360 evaluations

Potential SolutionsPotential Solutions

Team TrainingTeam Training Clear expectations of all team members forClear expectations of all team members for attendance, punctuality, how work is sharedattendance, punctuality, how work is shared Policies/Systems for communicating need forPolicies/Systems for communicating need for excused absences, with clear consequences forexcused absences, with clear consequences for unexcusedunexcused

Differences in Basis for RespectingDifferences in Basis for Respecting OthersOthers

These kids use too much profanity and are tooThese kids use too much profanity and are too casual with patientscasual with patients –– we need to teach morewe need to teach more professionalism!professionalism! That student challenged my authority byThat student challenged my authority by questioning my clinical decision on rounds! Howquestioning my clinical decision on rounds! How disrespectful!disrespectful! That attending criticized me in public! HowThat 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/ExperienceAAMC Generational Attitudes/Experience SurveySurvey ““I tend to respect a person MOST highlyI tend to respect a person MOST highly

based on:based on:””

0 10 20 30 40 50 60 70 80 90

100

great values-is a

"good" person

personal value to me as teacher,

etc.

professional accomplish-

ments

h igh rank or title

Silent Boom Gen X Millennial

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

0 10 20 30 40 50 60 70 80 90

comply unless

morally unaccep-

table

comply without

much question

not comply if no

conse-quence

Silent Boomer Gen X Millennial

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

0 10 20 30 40 50 60 70 80 90

comply unless

morally wrong

comply if I

agree with rule

comply if

respect maker

comply to s tay out of trouble

Silent Boomer Gen X Millennial

Mentoring programs that allow teachers andMentoring programs that allow teachers and learners to recognize shared valueslearners to recognize shared values

Potential SolutionsPotential Solutions

Set clear rules, explain the rationale, and haveSet clear rules, explain the rationale, and have them announced by someone respectedthem announced by someone respected Involve all parties in setting the rulesInvolve all parties in setting the rules Opportunities for teachers and learners toOpportunities for teachers and learners to participate in community service events thatparticipate in community service events that allow them to share their valuesallow them to share their values

Career Priorities andCareer Priorities and Life MotivationsLife Motivations

These students want to run all over the worldThese students want to run all over the world and do goodand do good –– dondon’’t they realize Medicine is nott they realize Medicine is not all about adventures? Who is going to stay homeall 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 onlyThese professors are so sure that we can only get a good education hereget a good education here –– why canwhy can’’t we seet we see how medicine is practices other places. Theyhow medicine is practices other places. They’’rere so provincial!so provincial!

I see being a physician as:I see being a physician as: 70

60

50

40

30

20

10

0 a calling a way to a type of start of my

that directscontribute employ- career, life to the world ment other

decisions

Silent -MD s Boom - MDs Gen X Millennial

endeavors late

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

0 10

20 30 40

50 60 70

80 90

throughout career

temporarily during some

periods

rarely, it's a full-time job

Silent Boom - MDs Gen X Millennial

So, do we have a generation gap inSo, 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 calling Minor differences in approach to rulesMinor differences in approach to rules Similarities in basis for respect, attitudeSimilarities in basis for respect, attitude about partabout part--time worktime work

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

and communicationand communication

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

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

signed their child up for thesigned their child up for the ““bestbest””preschool/play group, even before birthpreschool/play group, even before birth given choices rather than sayinggiven choices rather than saying ““nono”” showered children with material goods andshowered children with material goods andhuge collections of toyshuge collections of toys defended kids, not teacher,defended kids, not teacher, if trouble atif trouble at schoolschool invested greatly in childreninvested greatly in children’’s multiples multipleactivities and achievementsactivities and achievements allowed missing school for special eventsallowed missing school for special events held family meetings to make decisionsheld family meetings to make decisions

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

““grade inflationgrade inflation””, lots of positive feedback, lots of positive feedback Emphasis on individual interpretation,Emphasis on individual interpretation, independent study,independent study, ““freefree”” writingwriting allowed absences for trips, competitionsallowed absences for trips, competitions relaxed dress codes, or none at allrelaxed dress codes, or none at all access to snacks throughout the day andaccess to snacks throughout the day and multiple meal optionsmultiple meal options no scheduled classes for early AM orno scheduled classes for early AM or Fridays (college)Fridays (college)

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

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

Clear rules, consequences and gradingClear rules, consequences and gradingpolicies, no unfair advantage for otherspolicies, no unfair advantage for others Learning events that are engaging andLearning events that are engaging andworth their time, with competent use ofworth their time, with competent use oftechnologytechnology Frequent positive feedback and goodFrequent positive feedback and goodgrades, even for average work (wegrades, even for average work (we’’re allre all OK they way we are), negative feedbackOK they way we are), negative feedbackthat is gentlethat is gentle That we are invested in their success andThat we are invested in their success and will coach them to be successful in gettingwill coach them to be successful in gettingthethe ““rightright”” residencyresidency

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

time to pursue talents and intereststime to pursue talents and interests exceptions to attendance rules forexceptions to attendance rules for meetings, courses elsewhere, medicalmeetings, courses elsewhere, medical tripstrips to take on leadership roles, participate into take on leadership roles, participate in decisiondecision--making, give us constructivemaking, give us constructive feedback right awayfeedback right away To dress, communicate with friends, andTo dress, communicate with friends, and eat how and when they want toeat how and when they want to

BridgingBridging ““culturalcultural”” gapsgaps

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