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Time For 'Dr. Next'?

Elyas Bakhtiari, for HealthLeaders Magazine, July 9, 2009
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Generation X and its life-balancing, tech-oriented, team-playing doctors is taking over. But what kind of healthcare will they give us?

It has long been considered a rite of passage for medical students, before officially becoming practitioners, to first publicly swear an oath to "consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my good with him."

That line from the Hippocratic oath is often interpreted as a call to cherish medical education. In fact, modern versions have changed it to just that. But Hippocrates' original wording suggests a disconnect between student and teacher that goes beyond education. Is it possible that the oath was, in part, his way of making sure a younger generation of physicians would continue practicing medicine the way he had? That they would carry on his values and practice style, or if nothing else, at least show elder physicians proper respect?

As long as there have been physicians, there have been disagreements about how to practice. And in that sense, a generation gap between Baby Boomer and Generation X physicians is neither unique nor unexpected.

But if you ask practicing physicians today, both young and old will acknowledge that this generation gap is particularly wide and potentially problematic. More than two-thirds of physician leaders say a group's generational makeup affects practice operations, and nearly one in four say the problem is significant enough to affect recruitment, productivity, or practice culture, according to this year's HealthLeaders Media Industry Survey.

The complaints have been building for years—Generation Xers aren't as dedicated to medicine, they put in fewer hours, and they aren't as loyal to organizations, the Boomers say. They are right, to a certain degree, and there is mounting evidence.

But there is a flip side: Generation X physicians are tech savvy and collaborative and have the skills necessary to drive the many improvements needed in the healthcare system.

The question is: Where does that leave hospitals and practices caught in this generation gap? Generation X is no longer a newcomer to the healthcare industry—the oldest are in now their 40s and in the middle of their careers—and the schism between physicians has grown larger and more damaging. Whether they like it or not, the time is rapidly approaching for Boomers to hand off healthcare leadership to their successors.

The passing of the baton has in fact already begun. But the younger doctors don't yet have a firm grip, and the older physicians still seem to be clinging on. The result is an awkward, stumbling progression that keeps both from moving forward at full speed and causes tension in practices and hospitals.

For all the complaints, younger physicians have their share of improvements to make to the healthcare system once they come into their own. The challenge is making it through the transition.

All work and no play . . .
The case against Generation X physicians can be summed up in how 57-year-old Daniel Batton, MD, jokes about his son. "I worked much harder than him and made much less money when I was his age," he says, only half in jest.

Batton is chief of neonatology at Southern Illinois University School of Medicine and codirector of the perinatal center at St. John's Children's Hospital. His son, Beau Batton, MD, 33 and a year out of a neonatology fellowship, works in his father's department, and is an assistant professor of pediatrics at SIU School of Medicine.

When the senior Batton entered practice in 1984, he started with a group of four physicians and covered about twice as much call as the current eight-doctor group in which he and his son currently practice—and he made about one-third of what new physicians make today in inflation-adjusted dollars.

"It would not be correct or fair to say the current generation doesn't want to work as hard," he says, but he acknowledges that practice styles and physicians' priorities are very different.

For one, medical training has changed. In 2003, the Accreditation Council for Graduate Medical Education instituted work-hour restrictions preventing residents from working more than 80 hours per week. The idea was to avoid the exhausting and potentially error-inducing 100-plus-hour weeks physicians were accustomed to, but the consequence has been a change in how physicians perceive medicine, says Beau Batton, who has memories of his father's long hours as comparison.

"It's created an environment where residents think of their jobs as shift work," he says. "I'm supposed to come in, do my work, and then I leave because it's time for me to leave because I'm not allowed to be here beyond a certain time or a certain number of hours. As opposed to in years past when residents would come in and leave when the work was done."

Yet even for those trained before the work-hour restrictions, shift work, or at least a more controllable schedule, has been rising up the career priority list.

It's not that younger physicians don't care as much about patients, says Baby Boomer Mark Jarrett, CMO of Staten Island University Hospital, a 714-bed teaching hospital in New York. Most older administrators and physicians say younger doctors are extremely compassionate practitioners and work very hard while they are on duty. They just want a little more balance between work and personal lives. "Currently, the newer generation certainly believes in lifestyle as much as they do salary, and they therefore do not want to have it where medicine becomes their whole life," says Jarrett.

And in a way, who can blame them? Physicians for years have suffered from higher rates of depression, substance abuse, and even suicide than the general population. Perhaps younger physicians have realized that they have to take better care of themselves in order to take care of patients. Or perhaps they're just practicing under different circumstances, where more dual-income families, a more heterogeneous workforce, and a tougher private practice environment make the old model obsolete.

"But it becomes a problem because patients don't get sick between 9 and 5," says Jarrett. "Patients get sick in the middle of the night. They get sick on weekends. Who's going to cover all the ill patients on a 24/7 basis?"

The other physician shortage
The implications of this attitude change for hospitals are obvious: If physicians aren't putting in as many hours and aren't as productive as before, then it will take more physicians to do the same amount of work.

When Saint Vincent Health Center, a 427-licensed-bed nonprofit hospital in Erie, PA, recently conducted a community needs assessment, it not only found projected shortages in hard-to-recruit medical and surgical subspecialties like gastroenterology, cardiology, and urology, but it also foresaw additional need based on lower aggregate productivity from fewer physicians.

The drop in physician productivity couldn't come at a worse time. Most specialties are already predicting shortages—combining for a shortfall as high as 200,000 physicians by 2020, estimates say—and some regions are already in the midst of them. On top of that, the general population of Baby Boomers is reaching the age when health problems are increasing, sending demand for services skyrocketing.

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