Strauss and Howe predicted that Gen Xers will continue to be known for their independence and will continue to show a reluctance to trust bureaucracies, even in middle age. The forecast for this generation includes continuation of a “free agent” mentality, including the tendency to change jobs regularly, to negotiate their own deals, and to have pride in their ability to “have a life.” As a result, we see that recruitment, retention, and grooming of Gen Xers will become even more important in the next decade, so that they are prepared to assume leadership positions. Such an approach is particularly important because Generation X is the smallest of the current workplace generations. Efficiency, work–life balance, and salary issues—all of which have been weaknesses for academic medicine—will need extra emphasis if recruitment and retention of Gen Xers are to be improved.
At UCD-SOM, we are already finding that Gen Xers are hard to recruit and retain and that salary, workload, and work–life balance issues all contribute to this difficulty. Several departments have had positions that remained open for more than a year, particularly in the subspecialties in which new graduates, who are undecided between academic careers and nonacademic clinical practices, would expect to make a great deal more money in private practice than in academia. Departments at UCD-SOM frequently lose Gen X faculty in clinically intensive faculty tracks to large group practices and managed care organizations. The salary differential has always made the recruitment and retention of faculty a challenge for AHCs, and we believe that this issue will intensify in the next two decades, because Generation X places a higher value on family needs—financial and otherwise—and less value on loyalty to an employer or to a mission or cause than have previous generations. Many departments at UCD-SOM make an effort to offer flexible work schedules to accommodate family needs and to encourage work–life balance; however, the flexibility, balance, and less-intensive clinical demands traditionally associated with academic careers are also being eroded in many of the UCD-SOM departments because of rising clinical demands on faculty to support the educational and research missions. As discussed earlier, the limited availability of state-supported Ladder Rank faculty positions also adversely affects the recruitment and retention of Gen Xers seeking to develop research-intensive careers. The lack of a tenure-type security further fosters the Gen Xers' “free agent” attitude and provides an incentive for them to look elsewhere for better opportunities and advancement. Our finding that Gen Xers favor skills-based workshops offered through the UCD-SOM faculty development office, such as grant-writing and medical writing workshops, may therefore reflect more than just an early career stage, and may also reflect this generation's desire to create “portable careers” by learning skills that they can take with them to their next position.
Preferences for faculty development events by Gen Xers and Boomers at UCD-SOM can be a window into the different lifestyle interests of these generations. We have found that Gen Xers preferentially chose work–life balance workshops, whereas Boomers lean toward time-management workshops at an attendance ratio of 4:1 for work–life balance workshops and 1:1 for time-management workshops. These choices may not simply reflect differences in career stage but may also reflect different generational approaches to the dilemma of too many work-related demands that is characteristic of careers in academic medicine and that is a common lament of the UCD-SOM faculty at all career stages. The Boomers' interest in acquiring time-management skills may reflect their workaholic desire to find a way to “do it all.” Alternatively, Gen Xers seem to deal with excessive work demands by seeking balance and perhaps choosing not to do it all. The tendency to say no to some activities in order to achieve balance may also be the reason that Gen Xers have the largest representation of faculty in the Health Science Clinical Professor series, the only academic series that does not require leadership in research or creative work.
Awareness of these generational issues and behaviors allows us to better plan for the needs of middle-aged Gen Xers in order to entice them to become part of the bureaucracy and assume the reins of leadership. We have noted that activities and roles that typically groom faculty for future leadership, such as participation in faculty leadership development programs, committee work, and associate director or vice chair roles, are unappealing to many Gen Xers because these activities frequently require attendance beyond the regular workday. At the same time, Gen Xers are very interested in innovation and efficiencies as ways to achieve their independence and balance. We have found that they readily embrace new technologies; as a result, Gen Xers are making major contributions in advancing initiatives begun by Boomers, such as telemedicine, medical informatics, and electronic medical records. The opportunity for using innovations to achieve their desired lifestyle may motivate Gen Xers' future involvement as leaders.
The generation that will emerge as new AHC faculty during the next 20 years is the Millennial generation. Strauss and Howe predicted that the Millennials will be an archetypal Hero generation, who, as young adults, will show a patriotic spirit, interest in the global community, and traditional values that strongly emphasize family and loyalty. Indeed, the Millennial generation is more globally oriented that any previous generation, because of the Internet and the development of other new media. Because Millennials have grown up in a collaborative, team-based educational environment, Strauss and Howe emphasized the importance of team-based employment.11 AHCs may be well suited to provide such an environment, because the patient-safety movement has led to the development of team-based patient care, and the use of team-based learning is growing in medical schools, including UCD-SOM. Recruitment and retention will require that these team-based experiences be satisfying and that they provide work–life balance, because other practice environments that academia has to compete with, such as multispecialty groups, also offer team-based work experiences.
There also is a growing trend for medical school graduates to pursue nonclinical careers, such as careers in state or federal agencies, health care administration, and nonuniversity research settings, according to an analysis of the Association of American Medical Colleges National Graduation Questionnaire from 1997 through 2007.13 This trend is anticipated to continue, because of the growing opportunities in biotechnology, entrepreneurial endeavors, and pharmaceutical and health care consulting industries. These career choices represent a new source of competition to AHCs for recruitment and retention of young faculty members. These alternative career choices may reflect the interests of both Gen Xers and Millennials in work–life balance and in obtaining higher salaries to enable them to more quickly reduce their student loan debt.
Debt has always been an issue for medical students, but Strauss and Howe predicted that debt and financial challenges will be a greater challenge for the Millennial generation than it has been for their predecessors. The Millennials' financial challenges include a larger student loan debt and higher home prices than previous generations faced. Economic status may therefore become a larger issue influencing career paths.11 At UCD-SOM and elsewhere, we are already seeing that debt, chiefly due to student loans, is a growing factor in a medical student's choice of medical specialty or practice environment, including the choice between pursuing a career in academic medicine and practicing medicine in an underserved area. This represents a change from 10 years ago, when debt was not observed to be a significant factor.13–15 The average indebtedness of the students at UCD-SOM has more than doubled in the past 10 years. Because that level of debt is not expected to decrease, AHCs will have to address this issue in order to recruit and retain faculty members from the Millennial generation.
Addressing the Future at UCD-SOM
Strauss and Howe's model asserts that the issues of the future are present today and that this knowledge allows us to be proactive in planning. We anticipate that we will be better able to address each generation's issues as the generations move through the different stages of life and that we will be able to maximize the use of faculty talents to meet institutional goals. Many of these issues facing AHCs are not new, but examination through the lens of generational differences suggests opportunities for new approaches or strategies. We are therefore taking the following steps at UCD-SOM to plan for the future on the basis of these generational observations and forecasts for the future.
Succession planning is an important focus for the future because state-funded tenure-track and leadership positions are turning over more slowly as the senior generations delay retirement. We are therefore planning ahead strategically to ensure that optimal opportunities to advance are available for the younger generations and that an appropriate legacy can be created for the senior generations. An illustrative example is the succession planning taking place in one of the UCD-SOM clinical departments that has a prominent tenured senior faculty member. This faculty member is a leader in one of the school's major multidisciplinary research programs, which he helped to create. He has passed retirement age, but he has active grants to support his continuing work and therefore has expressed interest in delaying retirement for several years. His department and the leadership in the dean's office are working with him on a succession plan. This process is facilitated by the University of California's retirement plan, which has several features that encourage retirement and that have been recognized as excellent by the American Association of University Professors.16 It is the practice of UCD-SOM that, when a tenured faculty member retires, the tenure-track position does not stay within the department but reverts to the dean for assignment to the program or department of the dean's choice. However, in the succession plan for the case in question, the dean has promised that the tenure-track position will stay within the department— specifically, within the program that this senior faculty member helped to create. The position will be used to expand this program along a new path, identified by the senior faculty member and his department, that also fits the school's overall goals. The department has promised to provide financial support for this expansion and to work with the school's development office to obtain additional funding. University policy requires that all tenure-track positions be filled through a competitive search, but several midcareer and junior faculty members who have been mentored by this senior faculty member should be competitive candidates when a search occurs. Because the senior faculty member has been involved in a succession plan that reflects his interests and addresses his legacy—the latter concern being important to members of the senior generation—he has now expressed interest in retiring earlier than originally anticipated and in continuing his grant-funded work as an emeritus faculty member on recall status. This plan is thus a win–win–win for the senior faculty member, for a midcareer or junior faculty member who will now have a meaningful and substantial career opportunity, and for the programs of the department and school.
Intramural research support
To ensure that junior faculty members at UCD-SOM are well positioned to step into opportunities such as that described above, the school provides many forms of support via internal grants and faculty development programs. Examples of grant support include the UCD Health System Research Award Program, which is designed to encourage new research initiatives by the assistant and associate professor ranks, to foster new lines of research among established faculty, and to help develop preliminary data that will strengthen proposals submitted to federal funding agencies.17 The UC Davis Cancer Center also offers intramural grants through its P30 Cancer Center Support Grant to support collaborative studies in any of its scientific program areas. Individual departments also offer internal grants to help launch their faculty members.18 The Department of Pathology and Laboratory Medicine has realized a fivefold return on its investment since beginning its departmental research awards. Members of that department who received internal funding for pilot studies went on to successfully obtain outside funding, which enabled several junior faculty members to move from adjunct positions into a faculty track that holds positions on the academic senate. UCD-SOM and its health system have also been successful in obtaining institutional training and faculty development grants, such as the National Institutes of Health Building Interdisciplinary Careers in Women's Health grant, the Howard Hughes Medical Institute Med into Grad Initiative Program, and grants from the California Institute for Regenerative Medicine.19,20 This success leverages the accomplishments of Boomers to provide opportunities for the next generation of faculty. This strategy is important, because an increasing number of junior faculty members first receive support through this sort of program, and that allows them to become competitive for their own awards in the future.
Faculty development programs
In recent years, UCD-SOM has expanded its faculty development programs with an eye to grooming our faculty for the future. The Junior Faculty Professional Career Development Program is a highly interactive curriculum designed to engage assistant professors in learning core competencies that are necessary for effective career development and professional advancement in academic medicine. The program consists of eight half-day sessions with titles such as “Working and Leading with Emotional Intelligence,” “A Mentee's Guide to Being Mentored,” and “Mental Models: An Exploration of Human Paradigms,” as well as skills-based workshops on PowerPoint, time management, grant writing, and other topics.21 Many of these same topics are also covered in one-time offerings for faculty members who do not want to commit to a long program. Programs for the school's specific missions, including the Mentored Clinical Research Training Program22 and the Teaching Scholars Program, are also available. UCD-SOM also has developed a successful department-based mentoring program in which each department has designated a senior faculty member as the director of faculty development. This person receives a small financial stipend from the school in acknowledgment of his or her role in leading the mentoring among the department faculty.23 Other school programs, such as a midcareer program and a program for department chairs and emerging senior leaders, are geared toward older generations. To keep the faculty development programs fresh and responsive to current needs, a Faculty Development Council meets monthly to provide advice to the associate dean of faculty development and faculty life and the director of faculty development. The Faculty Development Council is composed of members of all faculty generations.
Team-based work environment
Cultivating a team-based culture is also important for planning the future. The team-based work environment is becoming more commonplace and is favored by younger generations, who experienced team-focused learning during training. In addition, the value of team-based work is reflected in the goals of many modern initiatives in clinical care, education, and science. The National Institutes of Health Roadmap emphasizes multidisciplinary work, which, by definition, requires team-based collaboration. Educational trends are moving toward team-based learning, and the growing complexity of patient care requires multidisciplinary clinical teams. Enhancing the team-based culture at UCD-SOM therefore meets multiple goals and is expected to make the work environment a more attractive tool for the recruitment and retention of the younger generation of faculty. The research awards described above all prioritize collaborative team-based research and are designed to help faculty obtain National Institutes of Health or similar funding. Collaborative research also is particularly important to the pilot grants funded though UCD-SOM's Clinical Translational Science Center, because translating basic research from bench to bedside to community requires multidisciplinary teams. The awards funded to date have created innovative research teams involving clinicians, basic scientists, social scientists, public health scientists, and medical informaticians.24 UCD-SOM is also emphasizing team-based learning in its curricular initiatives. To facilitate this effort, workshops are offered on team-based learning, as previously mentioned, and online instructional videos and virtual workshops on this technique are available on the Faculty Development Web site.25 The necessities of patient care and national initiatives to improve health care quality and patient safety have created team-based environments in many clinical areas. For example, UCD-SOM has more than 40 monthly interdisciplinary tumor board conferences that serve as a vehicle for both clinical care and education.
Adequately addressing faculty needs for work–life balance needs as the future unfolds will be another major challenge. Interest in work–life balance began with the Boomers, as women entered the medical professions in growing numbers. This issue will become even more critical to the maturing Gen Xers and Millennials, in part because of their generational profiles, but also because the composition of medical school classes has become predominantly female, and students' partners tend to have careers outside the home. UC Davis as a whole began to address this issue several years ago through its work–life balance initiatives, which included extension of the time clock to promotion for assistant professor and an expansion of faculty leave provisions for childbearing and childrearing. UCD-SOM further expanded these leave provisions and made them applicable to all academic series and departments. These efforts have been described fully in our previously published article on generational issues.1 However, to address everyday working life, the processes for encouraging work–life balance must extend beyond leave policies for special situations. Many work–life balance issues must be addressed on the department level, because unique solutions may be required to fit a particular work environment or duties. Departments at UCD-SOM are offering more flexible work hours for faculty members, even allowing faculty members to leave work in the middle of the workday to address family needs and then to return to work later in the day. Technologies such as telemedicine, electronic medical records, and remote access to health system computer networks also have allowed faculty members to conduct their work more easily from home or elsewhere. UCD-SOM has a new Work–Life Balance Council composed of faculty members from all generations, which focuses on staying abreast of work–life balance needs, working on solutions, and sharing successful strategies among departments. This council is currently developing a work–life balance “tool kit” for faculty and departments. In addition, faculty development workshops on work–life balance are offered, and a growing number of faculty development programs are being offered as online videos or tutorials, so that faculty members can access them when it is most convenient. The online tutorials receive more than 92 hits per month. More online additions are planned. It is interesting to note that only 26% of the hits occur outside of normal business hours or on the weekend, which may indicate that users prefer to protect their family or personal time and not add on to their workdays. Most of the departments at UCD-SOM have no standing committee meetings after 5:00 pm.
Student indebtedness will be a major challenge to the development of future faculty members during the next 20 years. This issue will not be easy to address: The average debt for a student at UCD-SOM has grown during the past 10 years from $49,661 to $108,271. To defray some of this expense, UCD-SOM has made efforts to increase internal student scholarships. These efforts include the Leadership Council Scholarship, which is a one-year stipend awarded to a medical student on the basis of his or her leadership qualities, volunteer or community outreach, future medical profession plans, good academic standing, and financial need. The Deans' Scholarship is an annual award supported by contributions from deans and other leaders of the UCD Health System and is given to a medical student who has demonstrated exemplary courage and dedication to overcome difficult circumstances in his or her journey toward becoming a physician. These awards join the long-standing Alumni Scholarship Award. The UCD-SOM development office is continually pursuing new funding opportunities to enhance and expand these awards. UCD-SOM also offers advice to students on planning and managing their debt and provides a helpful Web site.26 Given the enormity of the issue, these efforts are relatively small, but they demonstrate the commitment of UCD-SOM to future generations.
We recognize that forecasting and planning from this generational perspective has limitations. The generational archetypes presented essentially are generalizations, and, as with any generalization, there are exceptions. For example, there will always be individuals who seem to be born “out of their time,” and for whom the defining features will not fully apply. Nonetheless, a focus on general features is the norm in studying any large population or community, such as a generation. In addition, Strauss and Howe's model is specifically based on the repeating cycles of U.S. or Western European history and thus may not be fully applicable to the large number of faculty members born or raised in other parts of the world, particularly given the greater emphasis in Western cultures on individual achievement than on family responsibility. The United States, however, has always been a nation of immigrants, and Strauss and Howe have used the history of the nation to validate their model.10 This approach would perhaps imply that the model may be pertinent to faculty raised or educated in other cultures, and we wish to investigate further this aspect of the issue. We also recognize that the issues facing each generation are very complex and that the relatively simple descriptions and solutions we share may only superficially address the many generational needs at UCD-SOM and in academic medicine in general. No forecasting model is perfect, and new, unanticipated challenges are likely to emerge. It will be many years before we can see whether our forecasts are fully accurate and whether the programs we have implemented to meet them are effective. Nonetheless, we agree with Strauss and Howe's concept that many of the important issues and challenges of the future are present and identifiable today. We therefore believe that an awareness of the unique issues and needs of each generation as it matures in the AHC workplace provides an important and previously underappreciated perspective. We recommend that departments and schools consider generational planning using Strauss and Howe's model for strategic planning to ensure an effective faculty workforce that can meet the research, educational, and clinical care missions of the future.
The authors thank Vice Chancellor and Dean Claire Pomeroy, MD, MBA, for her review of and comments on this manuscript.
This work was presented in part at the Fourth Annual AAMC Physician Workforce Research Conference (Crystal City, VA, April 30–May 2, 2008) poster presentation on May 20, 2008, and on May 2, 2008, and June 3, 2008, respectively, at American Association of Colleges of Pharmacy Institute workshops in Lansdowne, Virginia (May 19–22, 2008) and Scottsdale, Arizona (June 2–5, 2008).
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