Teaching Across the Generation Gap: A Consensus from the Council of Emergency Medicine Residency Directors 2009 Academic Assembly


  • Lisa Moreno-Walton MD, MS,

    1. From the Department of Medicine, Section of Emergency Medicine, Louisiana State University Health Sciences Center (LMW, PMCD), New Orleans, LA; Department of Emergency Medicine, Oregon Health & Science University (PB), Portland, OR; Department of Emergency Medicine, Beth Israel Medical Center (SA), New York, NY.
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  • Patrick Brunett MD,

    1. From the Department of Medicine, Section of Emergency Medicine, Louisiana State University Health Sciences Center (LMW, PMCD), New Orleans, LA; Department of Emergency Medicine, Oregon Health & Science University (PB), Portland, OR; Department of Emergency Medicine, Beth Israel Medical Center (SA), New York, NY.
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  • Saadia Akhtar MD,

    1. From the Department of Medicine, Section of Emergency Medicine, Louisiana State University Health Sciences Center (LMW, PMCD), New Orleans, LA; Department of Emergency Medicine, Oregon Health & Science University (PB), Portland, OR; Department of Emergency Medicine, Beth Israel Medical Center (SA), New York, NY.
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  • Peter M. C. DeBlieux MD

    1. From the Department of Medicine, Section of Emergency Medicine, Louisiana State University Health Sciences Center (LMW, PMCD), New Orleans, LA; Department of Emergency Medicine, Oregon Health & Science University (PB), Portland, OR; Department of Emergency Medicine, Beth Israel Medical Center (SA), New York, NY.
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  • Presented at the Council of Emergency Medicine Residency Directors Academic Assembly, Las Vegas, NV, March 5–7, 2009.

  • CoI: The author reports no conflicts of financial interest.

  • Dr. Moreno-Walton’s work on this project was partially supported through the Tulane University/Louisiana State University Health Sciences Center Clinical and Translational Research, Education, and Commercialization Project, and by the Louisiana Board of Regents.

Address for correspondence and reprints: Lisa Moreno-Walton, MD, MS, e-mail: doctormoreno@gmail.com.


Background:  Four distinct generations of physicians currently coexist within the emergency medicine (EM) workforce, each with its own unique life experience, perspective, attitude, and expectation of work and education. To the best of our knowledge, no investigations or consensus statements exist that specifically address the effect of intergenerational differences on undergraduate and graduate medical education in EM.

Objectives:  To review the existing literature on generational differences as they pertain to workforce expectations, educational philosophy, and learning styles and to create a consensus statement based on the shared insights of experienced educators in EM, with specific recommendations to improve the effectiveness of EM residency training programs.

Methods:  A group of approximately one hundred EM program directors (PDs), assistant PDs, and other academic faculty attending an annual conference of emergency physician (EP) educators gathered at a breakout session and working group to examine the literature on intergenerational differences, to share insights and discuss interventions tailored to address these stylistic differences, and to formulate consensus recommendations.

Results:  A set of specific recommendations, including effective educational techniques, was created based on literature from other professions and medical disciplines, as well as the contributions of a diverse group of EP educators.

Conclusions:  Recommendations included early establishment of clear expectations and consequences, emphasis on timely feedback and individualized guidance during training, explicit reinforcement of a patient-centered care model, use of peer modeling and support, and emphasis on more interactive and small-group learning techniques.


A natural consequence of the maturation of emergency medicine (EM) as a discipline has been the aging of the emergency physician (EP) workforce and a growing gap between its most senior educators and the newest generation of medical school graduates entering residency training programs. Awareness of this phenomenon has led to considerable discussion about the perceived dissonance in values and expectations between generations of educators and learners. At the March 2009 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly, the principal author led a workshop on the challenges faced by EM educators in training residents and medical students from the demographic groups commonly known as late Generation X (Gen X) and Generation Y (Gen Y). A diverse group of nearly 100 EM residency program directors (PDs), associate PDs, and EM faculty members attended the workshop, one of four similar breakout sessions exploring best practices in EM residency training. After a didactic presentation and review of the literature on the definition and characteristics of the four generations present in the EM workforce today, participants engaged in a discussion of issues encountered by cross-generational teachers and learners, shared their insights and experiences with various educational interventions, and formed a consensus of recommendations for successfully addressing this phenomenon. The working group reconvened with the general CORD membership at the conclusion of the Academic Assembly to report on and further discuss the findings.


A generation is defined as “a group of individuals born and living contemporaneously.”1 As such, they have lived through the same political and social events, were affected by the parenting styles that were accepted during their childhoods, and share many of the same traits. Table 1 summarizes the characteristics of generational cohorts.2

Table 1. 
Characteristics of Generational Cohorts
GenerationTraditionalistsBaby BoomersGeneration XGeneration Y
Date of Birth<19461946–19641965–19811982–2000
ExperiencesGreat Depression, WWII, GI Bill, Cold WarVietnam, protest, “sex, drugs, rock & roll,” economic prosperity, dual-income familiesSesame Street & MTV, personal computers, divorce, AIDS, crack, “loss of world safety”Gangs, drugs, pervasive violence, rapid expansion of media and technology
Work attitudesLoyalty, self-sacrifice, fiscally responsible; satisfaction in a job well done; firm belief in traditional hierarchy; value job security, want to remain productive after retirementWant to make a difference, organizational integrity; value titles and good pay, skilled at mentoring; career is most importantWant to build a career but skeptical about organizations; like team environment; prefer time with family, work should be funWork that has meaning; life–work balance; current job viewed as transition to other opportunities; career change is the norm
TraitsPatriotic, loyal, conservative; keepers of institutional memoryOptimistic, idealistic, do not ask for help, highly competitiveEclectic, self-reliant, adaptable, skeptical, resourcefulGlobally concerned, technologically literate, computer savvy
Feedback StyleDo not seek feedback; self-monitored and self motivated; job well done is its own reward.Feedback should be planned and scripted; desire documentation.Frequent, immediate, constant, face to face, and specificImmediate, but can be in electronic mode; want involvement in career development plan

Emergency medicine educators are primarily from the late Baby Boomer generation, with some early Gen X and late Traditionalists present in this cohort. They acknowledge the generally accepted characteristics that distinguish Gen X from their predecessors in the work force: a generation that is technologically adept and skeptical about organized medicine and believes in working to live rather than living to work.3

Generation Y, also known as Echo Boomers or Millennials, consist of the 75 million-plus offspring of Baby Boomer parents and are the majority of current residency applicants.4 Comparisons between Gen X and Gen Y yield important differences in attitudes toward authority, lifestyle preferences, and social values.5 Members of Gen Y demonstrate high expectations for their own performance but also place high demands on their work environment, requiring a more individualized approach to their professional growth and mentorship. Although members of Gen Y are described as optimistic, they insist on prompt solutions to problems,6 making them more challenging to motivate and manage in the work place.7


In March 2009, CORD offered four workshops on best practices in EM residency training as part of the annual academic assembly. More than 100 PDs and academic EM faculty attended the workshop on “Intergenerational Learning.” The principal author began the workshop with a didactic presentation defining generations, characterizing the four generations in the EM workforce, and providing examples from the literature illustrating how generational characteristics determine approach to work-related tasks. The group was then asked to identify problems that they had encountered in educating and training the new generation of EM residents. The workshop leader noted common features of these problems and divided them into the four key points for discussion with the consensus of the work group. During the second part of the workshop, the educators shared methods that they had used, successfully and unsuccessfully, to address the key points. These were discussed and consolidated into nine recommendations for best practices in EM residency education. On the final day of the academic assembly, a formal presentation of the key points of discussion and recommendations for best practices was made to the CORD membership.

Key Points of Discussion

Emergency medicine educators identified major factors that they observe affecting the learning styles and work habits of today’s residents: growing up in child-centered families where behaviors had no direct consequences, maturing during a period of rapid technological and scientific advancement, never knowing a medical training model in which physician wellness was not a major emphasis, and observing the eroding image of physicians in society.

Child-centered families

The children of Gen Y have the lowest parent-to-child ratio of all generations in U.S. history,8 but their parents have been described as indulgent. The physical and medical needs of this generation have been more adequately met than those of any other preceding generation.8 The parenting style reflects a philosophy of developing self-esteem by providing unconditional love and a sense of entitlement through constant, consistent praise and avoiding criticism in response to inappropriate behavior.7 Parents were protective and encouraged a close emotional attachment between parent and child. As a result, this generation has been characterized as “the most doted upon, privileged, and needy generation thus far”9 Although they are generally idealistic, they tend to think that their environment and experiences should be good, leading older generations to perceive them as lacking personal responsibility and professionalism in the work place. Many EM educators characterize them as requiring a lot of positive feedback and not perceiving the need to adapt to styles of other generations.

The technological generation

In a Technographics Benchmark survey published in 2008, data were gathered from approximately 61,000 consumers in the United States and Canada. A variety of Gen X and Gen Y characteristics were analyzed. Ninety percent of Gen Y owned a computer, and 82% owned a mobile phone, leading the study to conclude that “Technology is so deeply embedded into everything Gen Yers do that they are truly the first native online population.”10

Because science and technology have dominated the world of late Gen X and Millennial learners, they depend on clear cause-and-effect relationships and believe in consequences only when they are consistent. They are highly independent analytical learners, who need to know why educators ask them to learn a certain thing in a certain way and at a certain time.11 Although EM educators are impressed with these residents’ adeptness at multi-tasking, they also describe them as distractible and in need of constant stimulation. They are most receptive to education presented in a fast-paced and entertaining format.

Wellness has been a goal for residency during their entire exposure to medicine

Generation Y medical students are more likely to choose specialties that have favorable lifestyles.12 The acronym E-ROAD identifies these specialties: EM, radiology, ophthalmology, anesthesiology, and dermatology.12 In recent years, medical students have developed a greater interest in EM. Their perception of the lifestyle advantages of EM contribute to this interest. Many students are not willing to excel professionally at the expense of personal health and quality family time. They believe that “a fuller life outside of medicine makes us better doctors.”13

The perspective of Gen X and Gen Y residents regarding work-life balance is different from that of senior attending physicians. A series of focus groups was conducted at Duke University Medical Center to evaluate the work environment and assess faculty development.14 Participants discussed the meaning of “quality of personal and professional life.”14 The Gen Y concept of wellness focused on being fulfilled by work and leisure activities and on the general belief that work is not one’s real life but that a balanced life is preferable to success at work. Educators have the impression that residents and students appear to believe that life activities define wellness and that therefore too much work must create illness.

Society’s image of the doctor

The traditional image of the doctor has significantly changed in the past 20 years. Physicians today are regarded and even referred to as service providers. The secondary gains of society’s respect and prestige within the community are rapidly disappearing. Accordingly, veterans, Baby Boomers, and their more junior colleagues disagree over professional expectations and priorities.15 Educators consistently comment that the traditional commitment to medicine is diminishing and with it the concepts of patient-centered care and self-sacrifice. Residents are not patient-relationship focused but commodity-focused learners. The duty hour changes created by the Accreditation Council of Graduate Medical Education reflect, or further promote, this.

In a survey conducted by the Association of Academic Chairs of Plastic Surgery, 70 of 98 faculty members responded that they have difficulty relating to the residents’ work ethic.5 Fifty-six of 98 respondents identified a dilemma comprehending “where the residents are coming from.”5 Generation X and Gen Y physicians often regard medicine as simply a job, and “their desire to pursue multiple interests and careers can also hinder their commitment to more involved fields.”16 Although self-focused and ethnocentric, they do not derive their identity from their profession.


Educators recognize the futility of denying or attempting to alter the changes in society that have resulted in a changed image of the physician and a new generation’s approach to the practice of medicine, but it remains our goal to ensure that medical students and residents develop into the best physicians. By doing so, we fulfill our commitments to our patients and our learners.

The recommendations of our group demonstrated a creative approach to teaching that evidenced an understanding of the dynamics of this new generation of learners. Presented here are our general recommendations, as well as specific tools (Table 2) that may be used to enhance the training of late Gen X and Gen Y residents in EM.

Table 2. 
The interviewUse the interview not only to screen candidates you would or would not want to take as residents, but also to help candidates screen EM and your program.
Orientation manualIf your program does not have an orientation manual, develop one with the input of the residents. This helps them to develop ownership of the residency and to establish expectations of those who will become part of their program.
The open-faced sandwichExplain to the resident what tasks need to be mastered and suggest ways he or she might try to master these. Ask trainees to come back and give you feedback on how the methods work. This style works well with the learner’s desire for independence and autonomy.
The shock value exit letterMany educators prepare the letter that the resident would get if he or she graduated today and ask the resident what he or she would like to do to ensure that this letter is not the one presented upon completion of the program. Some educators ask residents to write their own exit letter and then discuss the problem areas that are identified. Still others recommend showing a good exit letter of a recent graduate and asking residents to identify changes that need to be made for them to receive a similar exit letter.
Verbal end-of-shift evaluationsAt the end of each shift, inform residents of at least one specific task that they did exceptionally well and suggest one specific item that could be improved upon. Ask trainees to tell you a teaching point that they learned during the shift. Some educators suggest that, on rounds, each resident share one specific thing that was learned during that shift.
Pre-shift planningAt the start of each shift, ask each of the residents to tell you what types of cases and procedures they require to improve their clinical skills. Attempt to provide these experiences during the shift. Alternatively, if the ED is crowded, and this objective becomes too challenging, help the trainee establish a personal learning goal for each patient presentation.
360° evaluationsThe Residency Review Committee recommends these evaluations, which are highly effective ways of letting learners know how they are perceived by their peers. Many educators also suggest asking students to evaluate the residents they work with and ask for peer evaluation of resident didactic sessions.
  • 1Establish the rules early. During the interview process, the ethics and standards inherent to the practice of EM should be clearly presented to candidates in a way that will allow them to make an informed decision about entering the specialty. They should understand that EM educators expect residents to participate in their own learning actively and to be active in the teaching mission of the department.
  • 2During the orientation process, carefully and methodically review the program’s orientation manual. It should explicitly state the consequences for clearly identified unacceptable behaviors and should be revised and updated annually with the assistance of the chief and senior residents. Review the manual with all residents at the start of every academic year and have them sign a statement of understanding and compliance.
  • 3Increase the use of feedback. This generation values personal contact with faculty and frequent assessments of the quality of their performance. Effective feedback separates the personality from the action and suggests an alternate behavior that is more acceptable. Generation Y seeks to understand the reasoning that supports the need for modifications in behavior, and the effective educator will elucidate this.
  • 4Tell them what they need to learn and why they need to learn it. Resident physicians should have the goals and outcomes of residency training described clearly in terms that are unequivocal. The rationale behind these outcomes should be clearly stated, with the opportunity for residents to clarify points they wish to challenge and the consequences of failure to reach these established endpoints emphasized.
  • 5Establish a sense of personal responsibility. When intervention or remediation are necessary, allow the resident to participate in the design of an individualized learning plan that must be mastered to achieve the learning objectives, clinical goals, and professional behaviors that need to be addressed. Residents must be aware of expectations and the personal consequences of failing to meet those expectations. As one of our experienced educators stated, “Be obnoxiously and rigidly consistent!” (attributed to Douglas Mc Gee, DO, Philadelphia, PA).
  • 6Help instill the basic values of good medical practice. Loyalty to the patient is a doctor’s first responsibility and is expected of our residents. Staying late to complete an examination or perform a procedure on a patient with whom the resident has developed a relationship does not detract from the quality of the resident’s personal life. Residents should understand that they represent EM to patients, visitors, nurses, ancillary staff, consultants, and the community at large. Generation X and Gen Y enjoy a sense of unity, and they excel at team work. When they uphold the standards of the program and of our profession, EM is a team they can be proud to be a part of.
  • 7Faculty must be uniformly consistent on issues of professionalism. Faculty must model the behaviors desired of residents and must be willing to enforce all the rules with all the residents and with the same consequences, jointly and consistently. Program directors may need to remind younger faculty that being the resident’s educator must take precedence over being the resident’s friend.
  • 8Use peer pressure. Residents entering medical training from the Millennial generation place a great deal of importance on lateral peer relationships, including peer-to-peer evaluations. This quality should be incorporated into the evaluation process in addition to traditional faculty evaluation.
  • 9Increase the use of mentoring. Millennials respond well to high-quality feedback that is prompt and personal. They enjoy individualized communication with faculty, whether face to face or electronic, and see it as an essential part of their training. Assign residents upper-level peers and faculty as mentors, using near-peer relationships and faculty guidance at frequent intervals.

Conference and Didactic Learning Recommendations

Traditional methods of teaching and learning, such as didactic lectures with PowerPoint slides, have become nearly obsolete. As educators of Gen Y, we must consider using advanced technological resources in the educational process. Several recommendations were discussed during the CORD break-out session and are itemized in Table 3.

Table 3. 
Recommendations for Improving Didactic Learning
Establish clear goals and objectives for each learning experience.
Develop the utility of visual metaphors for concept-building exercises.
Use case-based conferences to bring a practical perspective to the material being taught.
Promote the use of multi-modal techniques to combat distractibility.
Encourage the use of audience response systems to provide immediate feedback to participants.
Organize discussion groups in a small-group format with defined and achievable tasks.
Increase the use of simulation-based learning.
Use Internet-based resources, such as pod-casts and live webinars, to enhance the educational experience.
Develop case-based blogs for asynchronous learning.
Explore the use of instant messaging or live chat discussions as a teaching tool.
Implement a task force to develop small-group teaching modules regarding generational learning.


Emergency medicine can and should adapt and respond to changes in the workforce and the residents in training. CORD membership constitutes the most experienced and dedicated educators in the field of EM. The recommendations for enhancing the education and training of residents made at the 2009 Academic Assembly create an effective tool for advancing EM in the new millennium. Understanding intergenerational diversity and structuring educational experiences to meet the needs and predilections of this new generation of physicians will allow us to work together toward the common goals of EM. Understanding and championing our learners in an environment of constant change will create enhanced learner opportunities and stronger emergency physicians.