“Professionalization is foremost a transformative process of socialization that prepares members to join an ongoing moral and political dialogue, with colleagues and with society at large, over affairs in a specific area.”26
Over the past decade, there has been a growing interest in medical professionalism which has focused largely on educating students and residents.24,46,49 This attention to the newest members of the profession has raised the issue of a generation gap in professional values between senior physicians and trainees.28,33,41 Medical administrators and recruiters are also calling for more efforts to bridge generational differences in the work place to maximize the productivity of this new cohort of physicians.1,32,48
For the past 11 years, I have experienced and observed both sides of the developing dialogue on professionalism. As a law student, graduate student in law and bioethics, and then medical student and resident I have observed and been taught professionalism. I have also taught professionalism in large and small groups, at conference workshops and pizza lunches, to students, residents and faculty. Along the way I have been guided by great mentors, two of whom are writing in this series. The see one, do one, teach one approach that permeates clinical training has come full circle, giving me an opportunity to stop and reflect on building professionalism, like my own professional identity, as a work in progress. This paper draws on experience and observation as teacher and learner, as well as a review of the literature drawing from medicine, the history of medicine, nursing, sociology and business.
Individuals develop their professional values and identity as they progress through the hierarchical career stages of medicine. At the same time, the collective values of the profession evolve with changes in the wider society. This leads to recurring small but significant generation gaps in professional values. For the past half century, this gap has centered on the concept of altruism and quality of life. In order for professionalism to develop at the individual level as well as for the community of physicians, the generational differences must be bridged and negotiations for change must build on common ground. The final section of this paper offers strategies to facilitate the evolution of professionalism at this crucial intensive training period.
Professionalism is not a static structure within which we deliver medical care. Rather, it can be viewed as a dynamic framework derived from the interaction of many forces such as the tradition of healing, social change, rising medical challenges, and scientific advances, as well as the interests of members and subgroups within and outside the profession.3 The medical profession today is more diverse than ever. In addition to growing ethnic, cultural, and gender diversity, the profession includes physicians who trained over more than a 50 year span.43 The different generations within medicine represent subgroups which each influence the collective values. The generations and their predominant traits have been described elsewhere.3,43 However, the newest physicians, on whom the current debate about a generation gap focuses, largely come from generation X, born between 1965 and 1981.
More Common Ground than Difference
There is general agreement that professionalism encompasses competence, integrity, honesty, altruism, promotion of the public good, a monopoly over the practice of medicine, self-regulation and autonomy. There is very little discussion of a generational difference for most of these values. In the absence of debate, we can assume significant similarities across the generations of physicians. For example, the principles of honesty and confidentiality are recited by all cohorts of physicians who take the Hippocratic oath or a modern adaptation. Subsequent generations of medical students learn the importance of honesty and integrity in their explicit medical school curriculum.43,45 Lapses in this commitment may span the generations equally.15 Residents and students today enter the medical profession with unrivaled access to and demand for knowledge.36 Medical students continue to display a strong commitment to community service and show no less concern for justice issues such as access to care.8 Generation X trainees are learning in and preparing for increasing cultural diversity.55
The debate over a generation gap in professional values focuses mainly on the concept of altruism, or the conflict between self-interest and patient's interests.19 This is sometimes expressed as a lack of commitment, particularly time commitment, to patient care.41 The words altruism and obligation inspire heated debate among new medical students seeking to define this concept for their careers. The younger generation may seek limits on the primacy of patient interests. In particular, they emphasize the need to balance professional demands with a personal life.20
Altruism goes to the heart of the generation gap in values as it embodies the physician's ongoing struggle between personal and professional life. It is essential to understand the factors which contribute to this small but significant generation gap over lifestyle.
Medical students become professionals as they learn their skills, responsibilities, and privileges. They are not professionals upon admission.10,20 Thus the generation gap over altruism and lifestyle reflects the hierarchical training structure of medicine and the significant socialization process that occurs as students progress to residency and then to attending physician.
Generational studies show that the loyalties and influences common to an age cohort are strongest early in life. With time, other affiliations such as career or building a family assume greater importance and “generational demarcation lines seem to blur”.9 The traditional values of the profession become more incorporated into an individual's identity the longer he or she is a member of the profession.18 Conversely, ties to the traditional values will be weaker among the newest members.
From the very first days of a medical career in the anatomy lab, students focus on standardized tests. Achieving “self-competency” commands their attention rather than more global issues such as the profession's interface with society.38 As a medical student progresses from clerk to intern to senior medical resident, priorities shift from self-focused skill mastery to patient welfare, to team performance, and to education and patient care. Increasing levels of responsibility facilitate development of professional values which require a broad, less self-centered outlook.23,40 A senior practitioner may view professionalism in light of his most important concerns: the reputation of the profession, general career satisfaction, or the health problems of the community to which he or she belongs.17 Residents, however, may associate professionalism with a set of traits limited to their experience with patient care such as empathy, competence, and respect as opposed to values like altruism or justice.2 Thus in comparison to senior physicians, residents and students appear to have an incomplete professionalism. This may appear as a generational difference but it should be distinguished from un-professional behavior.
Professionalism evolves with social change. As the values of the wider society evolve, so to do the values of the medical profession. Many of the core principles of professionalism can be found in the Hippocratic oath. Nonetheless newer fundamental principles such as the commitment to serve the public good within our domain become incorporated into the definition of professionalism as both physicians and society come to embrace and then expect it.7 The current debate over the physician's social responsibility is an example of such a process of change.50,51 This debate does not just happen within medical literature, in single issues, but occurs over time and across generations.13 Each new generation of physicians thus contributes to negotiating the values, responsibilities and privileges of professionalism with an ever-changing society.
With each succeeding medical school class or national cohort of graduating classes, the diversity of values and personal goals grows, reflecting the broader background from which the graduates come. What makes a loosely age-matched group of individuals a “younger generation” within the profession is the shared fact that their values have been shaped more by the social events of the time than by their career.9 Their common experience is mostly outside of medicine. There is always a younger generation bringing the imprint of social change into the profession.
Whether or not a noticeable gap appears between the newer and older generation in the profession depends on how different the society, which has influenced the younger members, is from the ones which shaped the values of the senior members. Generational lifestyle expectations change as slowly or quickly as the surrounding social and cultural milieu change.16 In stable societies, change may take lifetimes to occur. In more dynamic societies, generational differences may be observed every decade.16
The generation gap in medicine received a great deal of attention in the 1960's as society underwent significant transformation. The gap arises now as generation X students become physicians.24 These new physicians were raised during a period of unprecedented rapid social change. They experienced a significant shift in traditional family structure, entered increasingly diverse social networks, and adapted to the rapid access to endless information available in their homes through desktop technology.54 This group saw their parents subjected to corporate downsizing and the dissolution of institutional loyalty. They were the first generation of latchkey kids, learning independence early.54
Generation X physicians, like their peers in other disciplines, want more time for their personal life.54 The proportion of female physicians in the newest generation is the highest the profession in western society has ever had. Some suggest that the profession's values were created by men and need to accommodate different priorities for women.50 However, Lambert and Holmboe analyzed results from the AAMC Medical School Graduation Questionnaire concluding that men and women showed similar declining interest in careers with “uncontrollable lifestyle,”27 thus suggesting a generational trend rather than a gender one. Accordingly, the concept of altruism which can conflict with desire for a controllable lifestyle, or more time for a personal life, is a concept being negotiated by the new generation. Smith, however, reminds us that professionalism should not be equated with the number of hours worked.41
Generation X physicians have a different premedical socialization than their senior colleagues, reflecting greater social change, and this will impact the influence they have on the collective values of the profession.
Recurring Generation Gap
Career stage differences in values and changing preprofessional socialization are not new influences on medicine; neither is the generation gap. Throughout the last fifty years, there has been a recurring generation gap in professional values nearly every two decades as a new cohort of students enters medicine. Demands for a personal-professional life balance favoring the former have always been at the heart of the generational conflict.13 It arises specifically between medical students and residents and senior physicians as the younger physicians' desire for more family or leisure time clashes with the long hours demanded for training and patient care.20
Half a century ago, residents' commitment to patients and the profession was questioned as resident demands for reasonable work hours and a salary created tension between generational cohorts. Prior to World War II, interns and residents lived in the hospital and few were married. Some hospitals prohibited marriage. By the 1950s most lived outside the hospital, receiving stipends instead of room and board, and an increasing number were married.29 The older generation perceived a widening gulf between it and the younger generation over the latter's desire for a personal life distinct from a professional life and their rejection of “outdated” behavior guidelines.29
A study of medical students from 1949 to 1976 concluded that the career choices and values of medical students demonstrated striking changes in the two and a half decades studied, in parallel with changing societal values and culture.13 Succeeding generational cohorts showed distinct career patterns swaying from subspecialization, to research intensity, to socially active interests. Over the 26 years studied, students' attitudes showed a marked trend in desired lifestyle so that by the mid 1970s, “nearly all students wish[ed] to work fewer hours and to have more time for their families and for outside activities.”1,3 Such statements sound very similar to ones describing the current “generation X” physicians, viewed by some as “self-absorbed and self-oriented …quality time issues are paramount and they tend to define themselves by their personal wants rather than through career or corporate achievement.”35
Significantly, with time, each new generation of medical students has migrated to the ranks of senior physicians. Some are then surprised at the lifestyle demands and expectations of the newest group of physicians. Yet, if the profession had not allowed evolution of the balance between personal and professional life it would be very difficult to recruit new physicians to serve today's patients. Medicine's professional values must be constantly renegotiated with a changing society and with a changing cohort of members. For such negotiations to take place responsibly, however, new generations of physicians must learn professionalism. The key time during their intense training is also when the generation gap appears greatest and risks polarizing generations preventing the sharing of values. Thus the next section focuses on strategies to bridge the generation gap in developing professionalism for individuals and the profession as a whole.
Long-term Developmental Approach
If we accept that medical students become professionals, then learning professional values and applying them to oneself is a “transformative process of socialization”26 that requires a long-term development plan. The profession shapes the younger generation's values in many ways, such as through admissions selection, teaching, role-modeling, rewarding, discouraging and reinforcing specific behaviors.5,6,31,44 Patience is essential to allow young physicians' values to develop with time and experience. The teaching and evaluation of professionalism must recognize these goals.50 Perhaps a distinction needs to be made between incomplete, or developing, professional values and unprofessional ones.21
Teach and Reward Career-stage Appropriate Values
The first step in sharing professionalism across the generations must be effective, career-stage appropriate teaching. While all aspects of professionalism are important, certain aspects are more prominent, or frequently challenged, in the daily activities of students and residents.37
The first two years of most medical training programs are dominated by testing of knowledge acquisition reinforcing the drive for competence. Clinical clerks often feel they have little ability to influence team dynamics or values.12 The commitment to social justice or self-regulation is often ignored in the clerkship curriculums,43 and may therefore seem irrelevant to clinical clerks, or someone else's responsibility. However, a third year clerk undertaking the first responsibility for patient care experiences the privilege of patient trust based on the sometimes conflicting principles of commitment to competence and altruism.11
Efforts to identify the values most frequently or visibly in use during different career stages will help guide teaching toward what is relevant to a specific group.38 Such efforts will also ensure that values not encountered in the daily activities are incorporated into the curriculum in other ways. This will help prepare a group for the values needed in the next stage of their career. Thus, an intern will benefit from the mentoring of a senior resident on the importance of teaching and team leadership as well as patient care. Lectures by physician leaders engaging with community or political leaders may highlight the essential role that young physicians must also eventually fill. Wear and Kuczewski suggest hospital administrators should expose trainees to the difficult decisions affecting allocation and structuring of services which form an important part of the art of medicine.50
Relevant references should be used when teaching or inquiring about values in a group with limited experience.
As professionalism develops with time and experience, we must teach, expect, and reward career-stage appropriate values. This must be reflected in evaluations that recognize the developing nature of professional values and the limited opportunities to display certain values in different settings and roles.
Effective teaching of professionalism to bridge the gap in values and develop collective principles does not require inventing new methods. One of the most powerful tools for teaching professionalism is role-modeling.23,54 Academic medical centers have undergone significant changes in the last several decades decreasing interaction time between house staff and senior physicians.29 Constantly changing rotations and training over multiple sites makes the development of mentor-type relationships between trainee and role models more difficult. Existing opportunities must be exploited for role-modeling and new ones must be created.
Senior physicians who continually demonstrate professionalism must nonetheless be comfortable discussing these principles and initiating reflection on the myriad of daily displays of and challenges to professional values. This may require faculty development on teaching professionalism, for which several successful programs exist.42
Kenny and colleagues suggest a need to further explore the policies, environment, rewards and corrective approaches that facilitate effective role modeling.23 The impact of negative role models is well-established.12 Thus, efforts to seek input from the role models and the learners in each environment as to what facilitates good role-modeling should guide curriculum development.52
Real-time teaching opportunities must be placed in the larger context of professionalism as a set of principles, obligations and privileges that are constantly negotiated with society. In order to derive the most value from these bedside interactions, students and faculty must share a cognitive base of professionalism.6 There is now substantial literature on the topic which can be shared with learners to introduce them to the essential concepts.30,46
Seigler suggests that the first approach to teaching something new to medical students should be to ask and answer why it should be taught.39 The ultimate goal of developing professionalism is to improve care for individual patients and the wider community we serve.
Encourage Discussion and Guide Evolution
Recognizing that professionalism evolves, senior physicians can help guide and facilitate evolution by promoting the necessary reflection and empowering learners to apply the abstract concepts of professionalism in their own experiences. Ginsburg and colleagues found that student perceptions of unprofessional behavior did not easily fit into the distinct concepts and language used by instructors.14 A dialogue is essential to help teachers and learners develop a common understanding.
Students and residents should be asked how their experiences, role-models and work environment promote or hinder the development of the desired professional principles. The current reality of healthcare training imposes time and physical constraints on patients and trainees leading to more transient relationships.4 Suggestions should be sought from trainees on how to promote key values of presence, responsibility to patients and collegiality in this modern health care environment. Such feedback can be used in structuring the learning experience and work environment,50 and empower trainees to assume responsibility for the progression of their professional development and collective values.
Clear and accessible paths to discuss ways to enhance professional development or deal with lapses in professionalism in colleagues, faculty, other team members, or the environment must be made available to students and residents to reinforce the understanding that professionalism is expected of all physicians, not just trainees. Wear and Kuczewski suggest “[t]hose whose professionalism we are developing must come to believe that they can do something about the environment when it falls short of the standards of professionalism.”50
Adapt to the Different Learning Style of Generation X
While students and residents are developing their professionalism, and the collective values of the profession evolve with a changing society, teachers must adapt to the changing learning styles of the new generation of physicians. Medicine can learn much from business literature on managing multigenerational workplaces and can borrow specific strategies for teaching and working with Generation X physicians.
The work ethic, career motivation and learning style of Generation X workers have been well documented by sociologists and business researchers.25,34,47 The small amount of data on physicians from Generation X are consistent with the traits of the wider cohort. Career motivation, satisfaction, and aspirations are different from more senior colleagues, reflecting the different social environment in which the Generation Xers were raised and their very different medical practice environment.25 Generation Xers are described as independent, respecting talent more than traditional authority and rank.47 This generation shows less faith in institutional security and lifelong jobs. They embrace self-advancement through learning and skill development more than through “paying dues”.34 This reliance on self is viewed by some as lack of commitment or unwillingness to serve time patiently until seniority allows advancement.34
Generation X physicians have entered the profession in a very different knowledge environment than their predecessors. There is a growing emphasis on evidenced-based medicine rather than “eminence-based” practice. Trainees' more brazen questioning of teachers is interpreted by some as arrogance.47 This group learns differently because of the influence of a society which is generally more questioning of authority, as well as the impact of technology and easy access to information.47
Portable Skills and Individualism
Generation X workers, raised in an era of weakened institutional loyalty, focus on developing a portable skill set that they may take with them wherever the best opportunity arises.34 While all physicians share the common goal of providing the best medical care, young physicians, lacking institutional leadership opportunities or ambitions, may seem more self-centered in their work and values as they focus on building their own skill set to serve patients.
Professionalism is best taught as part of the portable skill set required in every practice milieu, not specific to an institution's code. While Generation X embraces a more individualist culture, senior physicians can demonstrate the interdependence and collegiality22 of all physicians and how the reputation of the profession affects the work of each individual physician. For example, the care provided by each physician requires patient trust, autonomy, and an ever-expanding knowledge base, all of which are dependent on the collective commitment to our professional obligations.
Responsibility and Challenge
Generation X values responsibility and challenge,25 both of which are inherent in professionalism. Young physicians must know what tools the profession has to advocate for its responsibilities. Who represents physicians and negotiates on their behalf? What do professional societies do? What impact may a single physician have? The history of medicine suggests many individuals and institutions have effected change on a local or global level. Old and new physicians, generation after generation, must engage society to establish professional expectations and obligations.
Fast Pace of Learning and Shorter Attention Spans
The newest physicians were raised with the internet and pocket PCs. They expect quick access to unparalleled amounts of knowledge in information sharing sessions.47 This learning style can be well suited for bedside, real-time teaching. While the role of professionalism in orga-nizing physicians' services may seem vague to an intern, it can be made more concrete at the bedside. Senior physicians can offer this knowledge-hungry group the broader perspective of experience applied to the immediate situation.
Mentors not Micro-managers
Discussions of professionalism with Generation X physicians must be a two-way exchange. Checklists of values or multiple choice questions do not motivate a group less impressed with authority and more interested in learning through experience. They are used to multitasking and working independently and consequently wish mentors to guide them and facilitate their skill development. They do not want micromanagers.34
Generation X physicians are more autonomous learners who apply concepts to their own activities. Draw on this independence by encouraging new physicians to critically assess the impact of professionalism on their own work. The goal of teaching professionalism is to promote evaluation and assimilation of professional values, not for the student to simply attain a passing grade.36
Just as there is much commonality between generations, there is significant diversity within a single generation of physicians. Professional values will be shaped by the newest physicians over time. The direction of the evolution of professional values must mirror, in part, changes in the wider society, but it may also be guided by senior physicians. Just as teachers help new physicians develop skills for patient care, they must build the skills to meet professional obligations and negotiate the evolving role of physicians.
The recurring generation gap over lifestyle issues reflects career stage progression and socialization as well as the evolution of the wider society, rather than a fundamental difference in understanding what it means to be a physician. Recognizing and embracing the generation gap in values enables us to see this as part of necessary change for individuals who will develop with their career, and for a profession which must evolve with society.
Efforts to build professionalism must be based on a sharing of values over the long term. The career stage of learners must guide teaching efforts. Teachers must offer a clear cognitive base and discuss how learners interpret this in their actions and those of others. While role-modeling is essential, so is empowering new physicians to participate in building the environment, expectations and rewards which foster professionalism. Adapting teaching styles to changing generational learning styles will further bridge the gap in values. Professionalism evolves over a career, not just four years of medical education.
The author wishes to thank Richard and Sylvia Cruess for their mentorship and comments on earlier drafts. The author also wishes to thank Yvonne Steinert for her comments on earlier drafts.
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