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Journal of Oncology Practice, Vol 5, No 1 (January), 2009: pp. 13-17 © 2009 American Society of Clinical Oncology. DOI: 10.1200/JOP.0912503
Generational Differences Among Oncologists: Shaping the Future of PracticeYoung physicians starting practice today often have expectations about work hours and quality of life that differ significantly from those of older physicians. These differences are creating challenges for oncology practices that must recruit new physicians who will be a good match for the existing group, at a time when the oncology workforce is experiencing a growing shortage.More than one half (54%) of today's practicing oncologists will be 65 years of age or older by the year 2020, according to the American Society of Clinical Oncology's (ASCO) recent workforce study.1 As these physicians are replaced by a new generation of physicians, what will oncology practice look like? The changes in the training, values, and life experiences of the new generation may be laying the groundwork for a revolution in the way medicine is practiced in the future.
Although analysts' descriptions of each generation vary slightly, these are the broad characteristics most generally described. Members of the Baby Boom generation, born between 1946 and 1964, are idealistic and competitive, tend to be workaholics, and respect authority. Generation Xers, ages 28 to 43, are technically savvy, mistrustful of institutions, questioning of authority, and self-reliant. The Millennials (also called Generation Y), age 27 and younger, are super-techie, seek flexibility and options in everything they engage in, and are accustomed to working in teams.
Those involved in the training of young physicians provide perspective on the new generation. Michael Kosty, MD, the director of the hematology/oncology fellowship program at Scripps Clinic in San Diego, California, reports two "broad brush" changes he has observed since he joined the faculty in 1989. "First, the caliber of oncology fellows has, on average, increased. They are smarter in their book knowledge. But that is counterbalanced by the second change—their lifestyle expectations and work ethic are not at the same level as those entering training in the 70s and 80s. They don't want to be a slave to their profession." Those different lifestyle expectations—not putting work above all else—can create discord between faculty and trainees. Senior faculty say the generational differences seldom result in open clashes, but behind the scenes, grumblings are heard. One attending physician found it very upsetting, for instance, when an oncology fellow told him that she had to leave to pick up her children from daycare. Although clinic hours were technically over, duties still remained. The 80-hour work week limits imposed on training programs in 2003 have added to the differences between older and younger generations. "In my generation, you did what you did until it was done," states oncologist Lee Berkowitz, MD, internal medicine residency director at University of North Carolina at Chapel Hill. "The attendings are used to the old training—you worked people up, stayed overnight, and reported the next morning. Now the resident reporting to you in the morning obviously isn't the one who worked up the patient. That's hard to get used to." Educators have also noticed the questioning of authority that is part of the Gen X profile. "Trainees feel a lot more empowered now," Kosty says. "It used to be if you were asked or told to do something, you just did it. Now there is more pushback." Training in patient management has also changed, leading to different practice styles. For example, physicians who have trained under the recent work-hour limitations are more accustomed to patient hand-offs and have learned skills in communication needed for transfer of care. They are often much more comfortable than are older physicians with using hospitalists and physician extenders. Another change in training is the use of teams. Medical students are taught an integrative approach to patient care, in which experts from different disciplines, including pharmacists, nutritionists, and social workers, pool their knowledge, skills, and clinical judgment to best serve each patient. "It's no longer just one doctor, one nurse, and one patient," says 24-year-old Louis Golden, a medical student at Tufts. This team approach toward patients resonates with Millennials, who grew up playing team sports and had team assignments all through high school and college. Golden comments that this approach also may be better suited to the increasingly unmanageable volume of medical knowledge.
The changes in the training, priorities, and expectations of the younger generations have presented challenges for practices recruiting oncologists. Roger Lyons, MD, a managing partner of a 28-physician oncology group in San Antonio, Texas, graduated from medical school in 1967. He paints this picture of his generation of physicians: "In my era people went into medicine for the love of it. Most people had a passion for taking care of patients—that's what they lived for. Whatever else was going on was always secondary." His description of many young physicians is in stark contrast: "What we see now are people whose first interest is how many days off they get in a week, how many weekends they have to cover, how much vacation they get, and whether they have to take call in the evening." Diane Safner, a physician recruiter with 22 years' experience at Cejka Search, confirms this profile and understands the frustration of hiring physicians. "Years ago, applicants were willing to forgo instant income for the long-term potential. Now they're demanding much higher salaries to start. I spend a lot of time saying to clients [the recruiting physicians], ‘I understand this is not fair. You worked, you sweated, you went without sleep and took a low income in order to build this, and now a candidate, fresh out of school, has expectations for compensation and quality of life that may even exceed what you have now. It doesn't seem fair, but this is the reality of today's workforce dynamic."
John (Jack) Keech, DO, a 57-year-old oncologist in solo practice in Chico, California, points to another important difference between his generation and the newcomers: the willingness to learn the financial and business side of practice and take the risks required in private practice. "We realized early on if we were going to succeed we had to take ownership," he says, speaking of his own generation. "But the young graduates today certainly don't want to become business people." Another senior oncologist described losing a "very nice, bright recruit" who didn't realize what was involved in private practice. "After a year with the practice he said ‘I'm not going out and shaking hands. I'm not going to build my practice. You provide me patients, and I will be here.’" The lack of adequate training in practice management—especially exposure to what community practice entails—adds to the challenges in successfully integrating new graduates into practice. Mihailo Lalich, MD, age 33, who completed his oncology fellowship in 2007, comments, "Part of the problem is that most faculty don't know what private practice is like—they've never done it." Prateek Mendiratta, MD, a senior oncology fellow at Duke University, notes that his training has not prepared him for the community practice he plans to pursue. "No one [starting out] has training about setting up a practice, how to get referrals, how to do a contact—none of that is taught. It's a huge problem." But although adequate management training is missing in residencies and fellowships, physicians running practices today didn't have such education, either—they learned on the job. Senior oncologists Lyons and Keech point out that it's the interest and initiative in running a practice that is missing in young recruits. The experience of David Groteluschen, MD, a 33-year-old oncologist, supports the notion that motivation, not training, is the key. After an initial year as an employee, Groteluschen is now one of eight partners in a group in Green Bay, Wisconsin. "I was not prepared for the business end of things, and not prepared for coding in any way whatsoever," he notes. "I've reflected on what's driving me to want to be a practice owner, and it's not the money, it's autonomy—the ability to make decisions about what hospital we contract with, whether we take a day off for a Christmas party, who our outreach partners are." The interest in the business side of practice has always varied, of course. In the past, a minority of physicians chose salaried positions that did not require their business involvement, or they went into academics. Today, however, employed arrangements are a first choice for a significant percentage of young physicians, according to recruiter Safner. She contrasts this to 15 years ago, when "being an employed physician for a lifetime was anathema—you didn't want to even suggest it." But practicing oncologists point out that both shareholders and employees need better preparation for the management side of practice. Senior oncologist Keech suggests that ASCO can play a useful and important role in integrating management education into fellowship training.
ASCO's recent workforce survey asked fellows completing training to rate the importance of various factors in choosing their practice options. Having the opportunity to balance work and professional life was among the top five factors, rated "extremely important" by 60%. This compares to only 20% who rated income as extremely important.1 These survey findings mirror the real-life choices of the young oncologist Lalich, who is now one of seven oncologists employed by St. Mary's Duluth Clinic in Duluth, Minnesota. The father of two, Lalich says he takes advantage of all the time off offered him—currently 6 weeks a year—and looks forward to years ahead when he will have 8 weeks' vacation. He is reimbursed totally on the basis of relative value units, and although he recognizes that he would make more money if he saw more patients and took less time off, he has established a schedule that accommodates 14 to 15 patients a day. He comments, "I really love being home with my family." Jorge Nieva, MD, age 38 and the father of two, has found a different work-life balance satisfying. "I don't always come home for dinner, and my family knows that on weekends they can expect not to see me if I'm on call. It's a trade-off they are willing to make in order for us to have economic security." Everyone must find his or her own balance and determine how to make it work. As stated by Domingo Perez, MD, age 42, who has two children and has been in practice in St. Paul/Minneapolis for 3 years, "Balancing professional and family life is the most difficult part of what we do. It's a work in progress." The balance often changes over the years. Many Baby Boomers, especially those with children, report that they and others they know have some regrets about their earlier priorities. For example, Berkowitz of University of North Carolina says, "When I started out, the job always came first. I missed some things with my daughter. Now I've made a transition to a place with more balance. I take time to exercise. I feel better."
Part-time positions and flexible work schedules are ways that an increasing number of young physicians, especially women, are achieving the work-home balance they want. In 2005, 48% of oncology fellows completing training were female, compared with 24% of women in practice. Thus, as the new oncologists replace the older generation, approximately half of the workforce will be women. The gender shift in the physician workforce may be driving changes as much or more than generational shifts, according to Edward Salsberg, MPA, director of the Center for Workforce Studies at the Association of American Medical Colleges. As an example, he notes that in the overall medical workforce, 25% of female physicians in their 30s and 40s work part time, whereas only 2% of male physicians do so. Mary Chamberlin, MD, sought a part-time job when she finished her oncology training in 2006. She and her family were already established in rural Vermont, and she didn't want the hour-long commute to Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, where she trained, so she focused on nearby options. She convinced a community hospital to expand its oncology clinic from a half day to 2 days a week. "I created this position for myself—they weren't really looking for anyone," she says. Since she's been there, the hospital has expanded its community outreach, and together they have initiated a breast cancer care program. Patients in her area don't want to make the trek to Dartmouth-Hitchcock Medical Center either, so Chamberlin's part-time practice has been a win for all. Karen Tedesco, MD, with a 2 year old and a newborn, also looked for a part-time position when she started practice 4 years ago in Amsterdam, New York. She reports that her colleagues are extremely supportive, but says she knows other physicians who have not been able to put together the work-home mix they would like. Now a shareholder in her 40-oncologist practice, Tedesco's job is considered 70% of a full-time position. She works three 12-hour days in the clinic and shares full-time call. On her days off she reviews her patients' lab reports and signs dictation from home, and she is available by page 24 hours per day, 7 days per week. She estimates that she works approximately 50 hours a week, including patient care and administrative responsibilities, teaching, and research. Salsberg, the workforce researcher at Association of American Medical Colleges, comments that it is not unusual in surveys to find that physicians indicate they work part-time and also report working more than 40 hours a week. Women physicians are the ones most likely to seek part-time schedules, but older physicians, too, often want to work part time, Salsberg says. "Physicians approaching the end of their career and preparing for retirement don't want to just leave—they want to scale back." He adds that some organizations are successfully pairing older and younger physicians in mentoring relationships and even job sharing. Dean Walker, who has worked in physician recruitment for more than 10 years with US Oncology, comments, "Practices are going to need to be flexible about part-time positions if they are going to recruit and retain quality physicians."
Another trend in medical practice is toward midsized, single-specialty practices, according to the Center for Studying Health System Change.2 An analysis of practice data between 1996 and 1997 and 2004 to 2005 found that the proportion of physicians in large multispecialty practices was declining, and practices with one to five physicians also went down. But whereas the very big and very small groups were declining, the number of midsized groups of six to 50 physicians was increasing. Salsberg notes that larger groups have an advantage in scheduling. "I think the hospital-based cancer care centers have a leg up on recruitment. Larger organizations can accommodate requests from someone who wants to work Tuesday, Wednesday, and Friday, for example." Economies of scale and profit margin are also points in favor of larger practices. In oncology, the Medicare Modernization Act really "changed everything," according to solo practitioner Keech. Now, he says, "The cost of doing business makes practice for an individual or small group of two to three physicians absolutely unattainable. The margin is so small, it makes [the solo or small group] impossible as a business model." In addition, new physicians like the idea of joining a large group where they can get a lot of mentoring, according to recruiter Walker. This perspective is exemplified by the young oncologist Perez, who joined a 40-oncologist group. "I wanted to work with a large group, to be able to discuss cases with others," he says. Although large groups have advantages of profitability, ready consultation, and the ability to offer flexible schedules, Salsberg cautions that they face more intergenerational conflict. In large practices, physician leaders and managers often have to juggle conflicting lifestyle desires of the different generations. Corporate workplace consultants advise leaders to spend some time and energy determining the expectations of employees and identifying and implementing new approaches and policies to respond to changing expectations.3
Although the differing workstyles and expectations of older and younger physicians can create strain, each generation has strengths to offer the other. The younger physicians consulted for this article expressed profound respect and admiration for the experience of older oncologists and pointed to numerous qualities they hoped to learn from them:
Younger physicians have strengths to offer, too. They report helping some older colleagues gain technological know-how in accessing online information and education resources and quickly synthesizing the available information. They are comfortable using technology in clinical practice, in communicating, and in record keeping. As 31-year-old Mendiratta says, "My generation—anything that is rolled out, we pick it up." Young oncologists are often more up to date in molecular genetics and other scientific advances. In addition, they are often looked to for their experience with new drugs. It's clear that individuals from all generations can learn from each other in positive ways that can pave the way for what oncology practice will look like 20 years from now.
How do future physicians see the practice of medicine? Flexibility, community service, and a passion for medicine are all part of the mix. Tufts medical student Golden is drawn to the flexibility medicine offers and says that many of his fellow medical students chose medicine because of its rich options—combining patient care with interests in public health, international medicine, social change, or research, for example. With an engineering undergraduate major, Golden likes the fact that the human body is the "ultimate machine," about which so much is unknown and being discovered constantly. Dartmouth medical student Sarah Dotters-Katz, age 25, believes that community service is an important part of practicing medicine. "Giving back is so important," she says. She adds that "medicine is unique because it is a profession that is self-gratifying while at the same time allowing you to give to others." Laurel J. Lyckholm, MD, the fellowship director at the Medical College of Virginia in Richmond, Virginia, thinks that oncology remains a "sort of a calling" for those going into the specialty. "People know they want to be oncologists," she states. Asked if she sees medicine as a calling, 25-year old Rana Yehia, MD, says, "I wholeheartedly see it as a calling. I don't know how anyone could go through training as rigorous as this without truly desiring to be a physician. You spend the entire time accumulating debt; you put your 20s on hold. If you are looking to make money, there are easier ways to do it." Yehia, now a first-year internal medicine resident at Johns Hopkins, is the immediate past chair of the Medical Student Section of the American Medical Association. The younger generation's commitment to medicine may look less than 100% to their older colleagues. Individuals in the new generation have diverse interests—both Yehia and Mendiratta are marathon runners, for example—and as noted earlier, they don't want to be a "slave to their profession." But ultimately those going into medicine, especially those who have chosen oncology, share with the older generation the same drive to help patients. As noted here, the generational differences are challenging for practice leaders to integrate into practice. But practices stand to gain from innovations pushed by those in the younger generation, such as more widespread use of electronic medical records and increased use of teams to gain efficiencies and deal with complex aspects of patient care. And the younger physicians need mentoring and will benefit from the guidance and experience of the older generation of oncologists.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1935-469X. Print ISSN: 1554-7477
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Profiles of Three Generations
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