Generations as Cultures: Can We Talk?
Nelson AL

At a recent symposium for Kaiser Permanente primary care physicians, two dynamic speakers, Katherine H. Balazy, MD and Sherwin Gallardo, MD, discussed the differences in values, attitudes, styles of learning, and preferred communications among the four different generations of physicians currently in practice.

At a recent symposium for Kaiser Permanente primary care physicians, two dynamic speakers, Katherine H. Balazy, MD and Sherwin Gallardo, MD, discussed the differences in values, attitudes, styles of learning, and preferred communications among the four different generations of physicians currently in practice: the Silent Generation (from the Great Depression and World War II); the Baby Boomers; the Generation Xers; and Generation Yers.

Balazy and Gallardo demonstrated that the confl icts among these different generations had the potential to cause problems as large as those seen in clashes between different cultures. Both speakers discussed how vitally important it is to recognize and respect the different perspectives of clinicians from different generations when they need to function together as a team.

One of the greatest potentials for value confl icts was seen between the Baby Boomers, described as "work-alcoholics," who see their careers as a calling, and the members of Generation Y, who are noted for their technologic profi-ciency and the high priority they place on their private time.

Communication between these two groups can be challenging. When asked a management question, the Baby Boomer generally seeks to justify his answer by describing the evidence to support it, but the Generation Y doctor usually wants the bottom line answer— he doesn't want to hear a lot of extraneous information.

The frustration the Generation Y physicians have in talking to Boomers is very similar to the challenges people raised in a literate society have when communicating with people raised in an oral tradition.

Oral traditionalists know that in order to communicate effectively and to be remembered, extensive repetition is essential. Someone raised in the oral tradition will usually tell a story, retell it with a slightly different spin to provide insight into the story, and then repeat the story a third time as it was originally told.

This storytelling pattern can irritate someone raised in a written world. After hearing the story the fi rst time, the reader usually understands the story and its implications and may become impatient (I heard you already!) when it is repeated two more times. Unless the reader understands why the oral traditionalist needs three repetitions, he may think his time is being wasted or that his intelligence is being questioned.

It is important to recognize not only that generational differences may cause challenges in communication between professionals, but also that they can also cause friction in the consultation room. The Generation Y physician is apt to start searching for possible diagnoses and management recommendations even before the Baby Boomer patient has finished describing her symptoms. The Generation Y doctor sees his actions as a model of efficiency and cannot understand why the Baby Boomer patient is angry and may not follow his recommendations when she feels that her doctor didn't hear a word she said.

As a card-carrying, dyed-in the- wool Boomer who has always wanted to know not only what the answer is but also what evidence there is to support the answer, I myself have been disappointed when residents and medical students are content to accept an answer that comes from some website or from a standardized protocol. We Boomers all fought so hard to gain recognition for the value of critical thinking and to replace the tyranny of expert opinion by evidenced-based practice. To see this next generation willing to uncritically adopt some authorities' "practice guidelines" seems to us to represent a capitulation and an unacceptable step backwards.

We Boomers ask: how will Generation Y physicians ever be able to critically evaluate new information? How can the Generation Y doctors know whether or not they should change their practice when a study, such as the Women's Health Initiative, produces radically new information about a given treatment?

The answer is that Generation Y physicians cannot and probably should not be expected to do so. Today, doctors are constantly bombarded by an overwhelming amount of available data that they cannot possibly sift through themselves. Even if they could develop independent ideas, thirdparty payers may not agree with their conclusions. It is increasingly evident that tomorrow's physicians will have to rely on others to inform their practices.

One of the consequences of this survival strategy is that practice protocols can be standardized not only to potentially increase quality of patient care, but also to reduce the costs of health care. Both of these outcomes are going to be top priorities for the Generation Y physicians throughout their careers.

The future focus will likely be on which medical groups—not individuals—can provide quality care efficiently. The winning groups will need Generation Y's technical skills and ideas. Asking Generation Y physicians to continually analyze data themselves may be counterproductive in the new practice-by-guidelines world. Individual interpretation could slow the transition to reliance in standardized protocols. In fact, for successful universal adoption of this new style of medical practice, it may be necessary to wait until the Boomers retire— the classic Joshua effect.

We Boomers can take some comfort in the thought that critical thinking will not be completely lost. There will be new metrics included in the analysis, such as cost effectiveness and numbers needed to treat. However, we will need at least a few Generation Y physicians to study the data in detail, to be the "MDs" behind the "MD Consults." They will be the elite developing the practice protocols— the new Wizards of Oz. We really do wish them well, and to reach them, we Boomers will probably still campaign for critical thinking. Please forgive us.

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Anita L. Nelson, MD
Editorial Board Member
Professor, Department of
Obstetrics and Gynecology
Harbor-UCLA Medical Center
Torrance, CA


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