Generational Influences in Academic Emergency Medicine: Structure, Function, and Culture (Part II)

Authors

  • Nicholas M. Mohr MD,

    1. From the Division of Emergency Medicine and the Department of Anesthesiology, Washington University in St. Louis (NMM), St. Louis, MO; the Division of Emergency Medicine, Stanford University (RSC), Palo Alto, CA; the Department of Emergency Medicine, West Virginia University (HL), Morgantown, WV; the Department of Emergency Medicine, University of California at Los Angeles (PLD), Los Angeles, CA; and the Department of Emergency Medicine, University of California at San Francisco (SBP), San Francisco, CA.
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  • Rebecca Smith-Coggins MD,

    1. From the Division of Emergency Medicine and the Department of Anesthesiology, Washington University in St. Louis (NMM), St. Louis, MO; the Division of Emergency Medicine, Stanford University (RSC), Palo Alto, CA; the Department of Emergency Medicine, West Virginia University (HL), Morgantown, WV; the Department of Emergency Medicine, University of California at Los Angeles (PLD), Los Angeles, CA; and the Department of Emergency Medicine, University of California at San Francisco (SBP), San Francisco, CA.
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  • Hollynn Larrabee MD,

    1. From the Division of Emergency Medicine and the Department of Anesthesiology, Washington University in St. Louis (NMM), St. Louis, MO; the Division of Emergency Medicine, Stanford University (RSC), Palo Alto, CA; the Department of Emergency Medicine, West Virginia University (HL), Morgantown, WV; the Department of Emergency Medicine, University of California at Los Angeles (PLD), Los Angeles, CA; and the Department of Emergency Medicine, University of California at San Francisco (SBP), San Francisco, CA.
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  • Pamela L. Dyne MD,

    1. From the Division of Emergency Medicine and the Department of Anesthesiology, Washington University in St. Louis (NMM), St. Louis, MO; the Division of Emergency Medicine, Stanford University (RSC), Palo Alto, CA; the Department of Emergency Medicine, West Virginia University (HL), Morgantown, WV; the Department of Emergency Medicine, University of California at Los Angeles (PLD), Los Angeles, CA; and the Department of Emergency Medicine, University of California at San Francisco (SBP), San Francisco, CA.
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  • Susan B. Promes MD,

    1. From the Division of Emergency Medicine and the Department of Anesthesiology, Washington University in St. Louis (NMM), St. Louis, MO; the Division of Emergency Medicine, Stanford University (RSC), Palo Alto, CA; the Department of Emergency Medicine, West Virginia University (HL), Morgantown, WV; the Department of Emergency Medicine, University of California at Los Angeles (PLD), Los Angeles, CA; and the Department of Emergency Medicine, University of California at San Francisco (SBP), San Francisco, CA.
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  • on behalf of the Society for Academic Emergency Medicine Aging and Generational Issues in Academic Emergency Medicine Task Force


  • Approval: This SAEM Aging and Generational Issues in Academic Emergency Medicine Task Force Report was approved by the SAEM Board of Directors in May 2010.

  • Disclosures: The authors have no relevant financial information or potential conflicts of interest to disclose.

  • Supervising Editor: Mark Mycyk, MD.

Address for correspondence and reprints: Nicholas M. Mohr, MD; e-mail: mohrn@wustl.edu.

Abstract

ACADEMIC EMERGENCY MEDICINE 2011; 18:200–207 © 2011 by the Society for Academic Emergency Medicine

Abstract

Strategies for approaching generational issues that affect teaching and learning, mentoring, and technology in emergency medicine (EM) have been reported. Tactics to address generational influences involving the structure and function of the academic emergency department (ED), organizational culture, and EM schedule have not been published. Through a review of the literature and consensus by modified Delphi methodology of the Society for Academic Emergency Medicine Aging and Generational Issues Task Force, the authors have developed this two-part series to address generational issues present in academic EM. Understanding generational characteristics and mitigating strategies can address some common issues encountered in academic EM. By understanding the differences and strengths of each of the cohorts in academic EM departments and considering simple mitigating strategies, faculty leaders can maximize their cooperative effectiveness and face the challenges of a new millennium.

This article is part two of a two-part series1 on generational influences in academic emergency medicine (EM). Academic emergency physicians (EPs) are confronted by the overlapping of generational boundaries in their careers. Generational boundaries are defined by groups of individuals with shared experiences and common values. In this article, the authors focus on generational issues with respect to 1) the structure and function of academic emergency departments (EDs), 2) organizational culture, and 3) scheduling in EM.

These documents are the product of the Society for Academic Emergency Medicine (SAEM) Aging and Generational Issues in Academic Emergency Medicine Task Force, a group composed of academic EPs with academic interest or expertise in intergenerational issues. Task force members represented each of the four generations discussed in this paper, and a working subgroup drafted this white paper. Details of the project methodology are more fully described in part 1.1

Structure and Function of Academic EDs

As knowledge of generational differences increases, questions arise of how these differences might affect the structure and function of academic departments of EM. Generational cohorts have different values with regard to work–life balance, academic and personal motivation, desire for control over their work experience, and effective productivity incentives.2 Historically, academia has been a route of self-sacrifice, where individuals have adhered to rigorous standards and promotion ladders, usually working more hours for less financial gain than their colleagues in community practice. While this fits well with the values of some generations (i.e., boomers), it does not take into account the work–life balance so crucial to younger generations.

Academic medicine has had a rigid professional structure with a well-defined ladder faculty must climb. In this model, junior faculty members accept work to gain respect in anticipation of academic promotion and recognition in their specialty. Some experts, however, predict that generation Xers (Gen Xers) and the millennials will not adhere to this system.3 Gen X is exemplified by a need for balance between work and play sometimes characterized as self-interest. For them, success in the professional arena is an expectation of fulfilling requirements rather than sacrificing personal life. Consequently, some worry that fewer Gen Xers will choose to climb the academic ladder or accept leadership positions. Millennials, on the other hand, may be less independent and require more structure, guidance, and regular feedback.4 They are interested in continuous development and expect rapid advancement as they master an area. Millennials also value social involvement and are drawn to roles that incorporate collaborative teams. Younger generations are willing to perform tedious tasks if they feel assignments meet their personal objectives, but they try to avoid stagnant environments. They have less loyalty to their organizations, and they thrive on change. To recruit effectively and retain these generations, department leaders will need to proactively plan the mentorship and development of these cohorts as conventional methods distributing rewards based on traditional or boomer-designed criteria may not be effective.

Historically, senior faculty members were respected as mentors and revered as leaders who had set their departments’ course. Time and hard work led to rewards of salary increase, tenure, and eventually retirement. Today, EPs are not retiring as early. An increased life expectancy, the financial recession, and a global labor shortage mean that boomers will be in the workplace for some time to come.5 Issues facing the academic community include how to sustain and refresh senior faculty, grow leaders from younger generations, and adapt to physiologic changes affecting scheduling for faculty as they age. The balance between desire for job complexity and time commitment, between traditional teaching and an evidence-based culture, and between workplace and personal success are critical to the discovery of best practices in EM.

Traditionally the ideal faculty member has been the “triple threat”: a physician talented in all three aspects of academia (patient care, teaching, and research). Other desirable traits include the ability to procure funding, a positive attitude, and a strong work ethic. Boomers were acculturated to believe that they must put forth efforts in all three areas in order to be successful. These ideals may differ for millennials, who may not feel the need to be exceptional in all three dimensions or feel it impossible to master all three domains. A solution to these challenges might be to change the rules for promotion.

Gen Xers and the millennials also have different expectations when it comes to quantity of hours worked. They value their product more than the time invested. Gen X especially is known for efficiency in the management of their work day, and this is a particular area of conflict with boomers, who have put a great deal of time into their work and do not understand or respect those with a shorter work day. In addition, the ability to do administrative work or research remotely is attractive to Gen Xers.6 Another relevant cultural development for younger generations has been the implementation of the Accreditation Council for Graduate Medical Education (ACGME) duty hours. Born out of concern for patient safety in 2000, this set of rules has changed how residents think about work—they expect their work hours to be limited. Recent graduates are accustomed to more free time than resident physicians have ever had, potentially igniting a change for faculty members as they graduate.

The challenge for EM leadership is to understand how the culture in academic EM is viewed by each generation. A paradigm shift may be necessary to successfully harness the energy and productivity of younger generations by considering flexible shifts, split shifts, part-time options, and personal development plans.

Organizational Culture Clash

Transparency

Traditionalists and boomers feel that to ensure quality and fairness, it is important that the promotion process and the peer review of research proposals and scholarly manuscripts be confidential. Similarly, in the minds of traditionalists and boomers, salaries and productivity should be a private matter to encourage community.7 Gen X faculty members, on the other hand, seek openness and transparency to attain fairness and equity. Working in an environment based on the belief that secrecy ensures quality does not make sense to them. They feel that secrecy masks favoritism, cronyism, racism, and sexism.7

Research

The basic manner in which research is conducted is another source of conflict. Baby boomers are so numerous that they expect competition. They approach research from a detached, isolated vantage point because to them, collaboration might dilute the self-promoting effect of their work. This contrasts with the collaborative, multidisciplinary, problem-centered approach that appeals to Gen Xers.7 The concept of translational research focuses on making basic science findings more quickly applicable to medical practice (“bench to bedside”). This efficient, multidisciplinary, and collaborative strategy ideally fits and exemplifies the proclivity of Gen Xers.

The traditional definition of scholarship embraced by traditionalists and boomers has also been questioned by younger generations. Academic research is what has been most important for advancement. The emerging viewpoint held by Gen Xers is that teaching and mentoring, and service to community and profession, are equal in importance to academic research.7 For younger colleagues, academic citizenship carries more value than self-promoting activities. The value of these more nurturing activities should not be discounted. Creating a clinician/educator or clinician/service track for faculty is one way of addressing the value of this emerging viewpoint. Universities should take care not to consider these academic lines as second class, which would only serve to increase the generational divide.

Promotions

Promotion and tenure is a time-honored way of moving up the academic ladder and generations may view promotional standards differently. Historically, tenure was a race to publish and solidify a niche within the specialty, potentially to the detriment of other areas of personal life. Although the senior generations believe they use quality standards to assess faculty and recommend promotion fairly, Gen Xers challenge this premise. From their perspective, quality is subjective and influenced by social bias. Gen Xers feel that those in power create standards that allow them to remain in power.7 With the current sociodemographics, boomers may retain positions of power longer, which may prevent Gen Xers from having the same opportunities for leadership.8

A growing number of academic institutions are willing to roll back or stop the “tenure clock” or have other tracks that give faculty a better opportunity to take a break and focus on nonprofessional aspects of their lives (e.g., childbirth, adoption, aging parents). To younger generations, quality of personal life and work life is more important than stature, tenure, or earnings potential.9 They are more likely to prioritize autonomy, flexibility, lifestyle, and family.10 Given these values, academic institutions should embrace alternative models of success.

Loyalty

Baby Boomers are often concerned and frustrated by their younger colleagues’ lack of loyalty to their employer and their seemingly poor work ethic, and this leads to intergenerational turmoil in the workplace. While Boomers have questioned authority as part of their collective generational history, they value organizational hierarchy and usually cite career as the major focus of their time and effort. In contrast, Gen X is skeptical about organizations and the motivations that drive them, and they consider that time with their families and friends is at least as important as time devoted to the development of a career.11 Career change, unthinkable for a traditionalist physician, is not considered an unusual option for Gen Xers or millennials.12 This mobility drives some department chairpersons to be hesitant to invest heavily in new faculty members who may move to a new institution after only a few years.

Given the extreme variability in both the sense and the focus of loyalty among the generations, it is no surprise that there is misunderstanding and sometimes even anger when commitment to the medical profession, dedication to the hospital and the department, and willingness to sacrifice are considered. Older attending physicians who practice academic EM comment consistently that the traditional commitment to medicine is diminishing, and with it the concepts of patient-centered care and self-sacrifice.13 In a survey conducted by the Association of Academic Chairmen of Plastic Surgery (AACPS), 70 of 98 faculty members responded that they have difficulty relating to residents’ work ethic.14 It is often cited that Gen X and millennial physicians regard medicine as simply a job and “their desire to pursue multiple interests and careers can also hinder their commitment to more involved fields.”15 Therefore, teaching professional values to these generations is regarded as a challenge by medical educators of older generations.16

Recent changes in duty-hour regulations further polarize the generations around issues of loyalty. Too much work is now something from which millennials are to be protected.10 In sharp contrast to this viewpoint, baby boomers invested heavily in their careers, often at the expense of personal life. Boomers tend not to respect those whom they regard as practicing medicine as a hobby, leaving work early and signing out procedures and significant aspects of physical exams.6 Traditionalists, who emphasize loyalty to patients and to their institution, often view the younger physician as lazy and lacking loyalty and dedication. Gen Xers and millennials, however, focus on the quality of their product. If what they have done has been done efficiently and well, they are ready to go home at the end of their work day. Senior physicians feel that duty-hour regulations should be left behind with the other immature habits of residency. Rather than establishing a team approach to patient care and the day-to-day function of the ED, the divergent attitudes among the four generations regarding loyalty create a sense of tension in the already stressful environment of the ED.17

Priorities

Delayed gratification is the norm for traditionalists and boomers. They view medicine as a vocation rather than a day job. They feel that serious scholars need to make substantial personal sacrifices. Time devoted to family means less time for career7—they have created distance between their professional lives and their home lives. Younger physicians tend to value autonomy and work–life balance, feeling that quality of life is central to personal satisfaction. Because they feel that home life and work life need to blend constructively, Gen Xers and millennials may be less willing to stay late or take on additional administrative or teaching responsibilities. Intergenerational difficulty arises as the Gen X and millennial colleagues tend to be viewed by traditionalists and boomers as less committed physicians with misplaced priorities and a poor work ethic.15

Work Space

Elements of the physical workspace can cause conflict. Older workers are dissatisfied with restless and noisy workrooms.18,19 EPs from the millennial and Gen X generations often prefer to work with music and lights up, which can be bothersome to older generations. There is evidence that music enhances quality of work, but diminishes time on task.20 The use of earphones while charting is a simple and plausible solution to this intergenerational issue.

Nonclinical Work

Traditionalists and baby boomers generally view work as a place they go. Younger workers, on the other hand, view work as something they do—anytime and anywhere. Millennials, for example, use their mobile devices to communicate and work from home or elsewhere: not necessarily from their physical offices. Millennials believe in efficiency, in working hard, and in spending time wisely in an effort to strike a balance between work and home life. They view meetings as generally unnecessary and an inefficient use of their time. Millennials view good supervisors as ones who minimize time spent on inefficient tasks.21 Their difference in perspective is a source of generational conflict, because senior colleagues misinterpret their values as a lack of conscientiousness or laziness, perhaps questioning their younger colleagues’ commitment to their work.

Those who are accustomed to coming to the office to work may feel that they shoulder more administrative responsibilities, because they are more “geographically available” when unscheduled tasks need to be completed. Faculty who work from outside the office may miss out on the synergy afforded by physical proximity. Academic colleagues in the workplace bond with one another, exchange ideas, reach agreements, collaborate, and advance projects based on spontaneous face-to-face interactions, and some of their collegiality cannot be completely replaced by digital connectivity. Some generational conflict is born out of junior faculty feeling that they are not asked to participate in collaboration and decision-making, while senior faculty feel they are expected to carry more of the unscheduled administrative burden.

Clinical Work

In EM, clinical work is shift work, and the impact of shift work on one’s health is significant. Chronic disruptions in the sleep/wake cycle inherent in a career in EM may be associated with an increase in a variety of disease states including heart disease, ulcers, cancer, and diabetes.22,23 Although these health risks are not generational, advancing age increases the probability of disease.18

Attitude toward shift work differs significantly between generations. Generally, young people enjoy the benefits of rotating shift work (i.e., limited hours, free time during the day) without suffering from circadian disharmony as much as their older colleagues. This is because the physiologic ability to tolerate night shifts worsens with age. Boomers and traditionalists find that their sleep is more disturbed and shortened both at night and during day sleep between successive night shifts.24–27 This physiologic difference can lead to friction between generations. An expectation among traditionalists and boomers that their youthful counterparts should do a greater number of night shifts is viewed as a lack of fairness by younger physicians. Offering more remuneration for working at night is a solution that can lessen the tension between generations. Another biologic difference is that the circadian schedules of older adults tend physiologically to shift toward “morningness,”28 which suggests that senior physicians may have fewer problems with early morning shifts than their younger colleagues. Departments may choose to accommodate their senior members by allowing them to do fewer night shifts, but how these decisions are made may be a source of intergenerational conflict as well. Traditionalist and boomer faculty members will likely view the expectation of fewer night shifts as a “right” that comes with seniority, while Gen X and millennials tend to be more egalitarian and thus may resent such expectations.

Challenges and Opportunities

Focusing on academic medicine solely, there are challenges and opportunities for each generation. A common need for all generations, however, is to find a new avenue to enhance personal fulfillment from one’s career. The opportunity to retrain, augment, or redirect oneself is an ongoing career challenge.

Traditionalists

Traditionalists are battling fatigue and matters of diminishing personal health.18 They are discredited by younger health care workers because of their lack of familiarity with technological advancements. They are less able to judge accurately younger employees along usual definitions of professionalism. Traditionalist males are often perceived by female physicians to participate in gender discrimination.29,30 They are extremely loyal to their institutions and this aspect can be advantageous in today’s academic arena. They have deep personal commitments to others throughout the nation, and the networking that they do for their mentees carries weight. Traditionalists are very trustworthy individuals and others can rely on their word. Given the right roles, these individuals can continue to be essential contributors to academic EM.

Baby Boomers

Baby boomers face fatigue and personal health issues also, although less intensely than the traditionalists. They often have trouble understanding the motivations of their younger colleagues,31 and they may interpret an interest in work–life balance as laziness or an inexcusable lack of commitment to their careers. They feel that their experience should be valued while younger members of their field place value more on merit. They struggle with rapidly advancing technology and have feelings of inferiority when faced with electronically savvy younger colleagues. They have difficulty accepting change and are not as prepared to move to new jobs or careers as their younger collegues.31 Their optimistic, diplomatic approach brings a wealth of benefit to EM. Their industrious, diligent nature can be harnessed to power forward progress. The sheer numbers of boomers populating the workforce is advantageous. Creating roles for them as they continue to age will alleviate the potential strain created by “birth dirth.”

Generation X

Gen Xers bring their shortcomings and strengths to departments of EM throughout the nation. Their distrustful approach ruffles the feathers of their elders. They do not like being told what to do and prefer to work alone. They are unimpressed by authority and are quick to place limits on their roles in medicine. Their self-reliant nature can in fact be advantageous in the workplace. “Xers’ weaknesses as employees are their strongest assets.”31 Corbo31 recommends that since Gen Xers lack loyalty, it is best to give them short-term assignments. They rarely stay in one position long, so rewarding them with benefits such as time off and child care is better than compensating them with pension plans.31 Although they are considered by many to have short attention spans, they can process a great deal of information quickly and can multitask superbly. They are voracious learners,32 master new software quickly, and can bring process efficiency and creativity to their roles in medicine. These traits are all strengths in EM. They expect to be trained, no matter what the organizational cost. Gen Xers are looking for supervisors who are consistent in their handling of difficult conversations, who are direct and honest, and who admit and apologize when they are wrong.33 Their positive influence on academic medicine can be considerable. Gen Xers would like to see the medical faculty be more flexible, creative, and inclusive. They feel faculty should lighten up, admit their wrongs, and model integrity,33 which is a laudable message. They also feel strongly that work–life balance should be recognized, and not penalized, by department leadership.30,34,35 Their penchant for lifestyle can help set an example by which the boomers can pace themselves and remain in the workforce longer.

Millennials

In their short time in the house of medicine, millennials have been criticized for informal dress, manners, and speech. These observations have been widely interpreted as a breach in professionalism which places a strain on their relationships with traditionalists and boomers in the workplace. Some have reported that the difficulty in teaching professionalism is due to generational differences;16 however, there does not appear to be a generational basis for defining professional or unprofessional behaviors among educators and trainees.36 Work and family time priorities are areas where this generation clashes with older generations. The duty hour regulations enacted by the ACGME have reinforced differences between older physicians and millennials.37 Generally, millennials are less enthusiastic about lectures, but they are hearty participants in group-oriented education. They expect flexibility and prefer to work remotely if their tasks do not require physical presence.6 Because they often choose to view medical school lectures remotely, class attendance is lower and instructors are disappointed. Additionally, millennials require more direction and praise as they have been raised with positive feedback molding their behavior. A greater number of millennials move back home with parents after college than prior generations.38 Recruiting millennials means accommodating their busy lives and multiple interests.15 They are hopeful, optimistic, ambitious, collaborative, polite, and civic minded,14,15 which are all traits that serve them well in the multigenerational workplace.

Recognizing shared goals and values, such as excellence in patient care and education, can allow senior physicians and junior physicians to work well together. An example is “reciprocal mentoring,” in which millennials teach boomers about technology, while boomers teach professionalism, interpersonal skills, and medical knowledge.

Strategies to Bridge Generational Issues in EM

A number of strategies can be considered by leaders in academic EM as they try to mitigate generational tension in their organizations:

1. Recruitment and Retention—EM must develop strategies for strengthening recruitment and retention of outstanding academicians from all generations. These strategies may include improving academic and career mentoring across generations with open acknowledgment of generational differences, incorporating information-sharing with engagement in problem solving, and offering frequent and focused feedback.39

A. Retention of Senior Faculty. Retention of senior faculty requires academic medicine to create positions that capitalize on the strengths of traditionalists and boomers. Placing senior faculty in career development positions to influence Gen X and millennial colleagues is one option. However, the job satisfaction and continued academic success of senior faculty requires that they put effort into understanding the basic distinctions in the cultural characteristics, learning styles, and work–life balance needs of younger colleagues. The experiential wisdom of traditionalists and boomers, a priceless resource for hospital and medical school committees, is further enhanced when partnering them with others who embrace evidence-based medicine or Web-based electronic programs. Developing guidelines for monitoring and coaching delinquent physicians, leadership training workshops, communication and professionalism curricula, and institutional policies on retention of physicians and nurses are just a few suggestions. To enable senior faculty to devote time to important issues facing the house of medicine, a reduction in clinical time may be appropriate. These solutions will require institutions to provide more alternative models of success and increase flexible work options.10

B. Retention of Midcareer Faculty. If one defines a midcareer faculty member as one who has been out of training for between 5 and 15 years, then the majority of midlevel faculty are members of Gen X. The major challenges for them are issues of work–life balance and frustration with the traditional hierarchy of academic departments. Historically, faculty members at this stage of their careers have been the most academically productive and have been viewed by academic leadership as being at the “peak” of their careers. Retention of this group will be predicated on recognition by senior faculty that there may be substantial differences between how current midlevel faculty members feel about their careers and how senior faculty members felt at that stage. Some specific strategies for retention might include flexibility in shift and meeting scheduling, flexibility and choice in shared departmental responsibilities, promotion roll-backs,40 and part-time work options.35 As Gen Xers tends to view their careers as mobile and seek career advancement over departmental loyalty, overt succession planning of the departmental leadership, and distribution of authority and responsibility may improve retention. This group is ideal to lead teams and generate consensus among faculty at all levels. Leveraging this strength will likely accomplish successfully departmental goals as well as enhance job satisfaction for midlevel faculty members.

C. Retention of Junior Faculty. Medical schools can improve the climate for retaining and promoting junior faculty by more inclusive networking, distance mentoring, attention to meeting times and child care, and improved professional interactions between faculty.41 Inviting faculty to provide leadership on specific projects that enhance their development and provide service to the department may augment the relevance of their service obligations. Recruiting and retaining medical students and residents from the millennial applicant pool means accommodating their busy lives and multiple interests.15 This may include time for advocacy service or global health, akin to minisabbaticals throughout their careers. Other suggestions for faculty retention are promotion rollback,40 part-time work,35 and generation-specific reward packages.6 Examples of these solutions might include intramural seed research support, student debt amelioration,2 policy changes related to work–life balance, succession planning, using multiple faculty tracks with different roles, generation-specific faculty development programs with menu options, and peer-reviewed awards.8,17 Faculty members may express specific interest and skill in advancing only one of a department’s many academic missions. Allowing colleagues the flexibility to work in parallel in one of several “faculty tracks” may be more effective at accomplishing institutional goals and may improve faculty satisfaction and retention.

2. Flexible Work Schedules—Older EPs may benefit from decreased night shifts or split shifts with other providers. This may help allow physicians to remain in the workforce longer and have greater job satisfaction. Younger physicians also benefit from flexible time management, allowing for a solution to work–life conflicts.39 One strategy might be to create and legitimatize part-time opportunities. Structural and cultural barriers cause these policies to be underutilized where they exist.41 Both men and women may desire part-time options, but do not wish to negate their role within their academic department. Lack of respect from academic colleagues and time-to-tenure policies have been cited as a disadvantage to part-time work.42 Despite these barriers, a recent study indicates that academic chairs in other specialties are open to this idea, citing more perceived advantages than disadvantages.43 The most frequently cited disadvantages included lack of shared goals of part-time faculty with the department. For part-time academicians to connect with their department, strong and effective two-way communication and well-developed divisions of nonclinical responsibilities need to be developed. Part-time and flexible work schedules have been identified as attractive ways to achieve balance between career and family.44 As more academicians seek work–life balance, academic medicine will be challenged to develop innovative models for part-time physicians to avoid losing this segment of the workforce.

3. Sleep and Performance—To preserve employment for the aging workforce, solutions specific to the aging process need to be adopted. In the review by Silverstein,18 there are four strategies for intervention, presented in Table 1. Awarding more reimbursement to the night shift in return for the physiological burden and increased risk of disease is one possible solution. Encouraging “senior night shifts” that are shorter, fewer, or split among two individuals has also been successful. Improving the strategies used to mitigate the burden of shift work will benefit physicians at all stages of training and work.

Table 1. 
Strategies for Workplace Intervention18
 General WorkplaceEM
Adjustments in physical work environmentPhysical workload, rest/work schedule, and regulation of one’s own work and breaksLocation of clinical work (urgent care/observation units vs. ED), choices in shifts with adjustment in remuneration (e.g., no nights but less pay)
Adjustments in psychosocial work environmentFlexible work schedules, teamwork, management skills based on generation for supervisorsFlexible work schedules (shorter shifts, fewer nights), flexible office work schedule, formal team-building, maintaining electronic distance for leadership (e-mail, etc.), education on intergenerational differences, and improvement of the work culture
Health and lifestyle promotionPhysical exercise, risk factor reduction, occupational health servicesEM faculty health initiatives: stress reduction, weight reduction, and exercise
Worker skills and competency buildingNonthreatening ongoing continuing educationOffer attending-only educational workshops for ultrasound and technology-based tools (electronic medical records, video clips in presentations, and asynchronous communication forums); faculty development, leadership skills programs, leadership coaches

4. Sabbaticals—Faculty approaching midcareer and later may have the chance to enhance their careers by using sabbatical time. According to a 1998 survey, only 9% of EM faculty has taken a sabbatical leave.45 Obstacles to sabbaticals include lack of funding, lack of release time, and workforce shortage. Creative strategies to overcome these challenges should be encouraged for individuals as well as the specialty as a whole. Educational courses, workshops, seminars, and self-study are methods to fruitful faculty development.46

5. Research on Generational Issues—To meet the needs of colleagues from each generation, EM must begin outlining a specialty-specific research agenda to elucidate the needs of young trainees, aging physicians, changes in the work environment, and emerging areas of importance in academic EM (i.e., nonstandard employment, simulation, continuous life-long learning, modern professionalism). SAEM’s Aging and Generational Issues in Academic EM Task Force is a significant step in this important direction.

Limitations

The recommendations listed in this two-part series on generational issues in academic EM are not comprehensive. Other strategies likely exist to address the generational divide in academic EDs. We recognize that the concepts presented here in trying to represent a heterogeneous population are generalizations, but we feel that recognizing generational trends can illuminate aspects of faculty interaction that are motivated in this generational context. The literature on this topic is sparse with regard to EM specifically, and the paucity of relevant publications limits the conclusions that can be drawn.

As discussed in part 1, the members of the task force responsible for the findings and recommendations included in this document are a group of academic EPs with interest or expertise in this topic.1 While this white paper was approved by the SAEM Board of Directors, and members of the task force represented each of the four generations described in this document, the views expressed remain the interpretations of the authors alone.

Conclusions

Generational diversity has been a source of growing conflict in the modern workplace, including academic health centers. The four generations currently at work view the world differently because they were raised with varied sets of norms and values. By understanding the differences and strengths of the each of the cohorts in academic departments of EM and considering simple mitigating strategies, faculty leaders can maximize their cooperative effectiveness and face the challenges of a new millennium.

Acknowledgments

The authors wish to thank the White Paper Subgroup for their work in preparing this manuscript for submission (listed alphabetically): S. Promes, co-chair; N. Mohr, co-chair; P. Brunett, A. Chipman, K. Clem, P. Dyne, R. Gerhardt, H. Larrabee, A. Mills, L. Moreno-Walton, R. Ruddy, R. Smith-Coggins. The authors wish to thank members of the SAEM Aging and Generational Issues in Academic Emergency Medicine Task Force for their support in preparation of this manuscript: M. Biros, chair; P. Brunett, A. Chipman, K. Clem, J. Clinton, P. Dyne, R. Gerhardt, R. Hockberger, H. Larrabee, J. Marx, A. Mills, N. Mohr, L. Moreno-Walton, S. Promes, M. Ranney, R. Rothman, R. Ruddy, R. Smith-Coggins, K. Takakuwa, H. Thomas.

Ancillary