Can We All Get Along?

Ah, youth... It's wasted on the young. Or is it?

"A lot of us feel like it's a really exciting time to practice medicine," bubbles Sindhu Srinivas, speaking for her generation of physicians.

Although many of the leading indicators show that the healthcare system is in crisis, Srinivas believes she and a battalion of young physicians are ready and willing to shape the world in their image. The recent graduate of New Jersey Medical School and former president of the American Medical Student Association admits that, "You hear nowadays in medical school that medicine isn't what it used to be." But she's convinced her generation will make a difference for patients and healthcare in general. "I feel like the future is up to us."

And that's precisely what older physicians are afraid of.

Looking at Srinivas and her "30-something" peers, many of today's established docs see not crusaders, but spoiled brats who don't understand the kind of dedication required to make medicine work, or the way that "real medicine" - the kind untainted by business concerns - should be practiced.

Quietly, in medical groups across the country, youthful cockiness is bumping up against middle-aged despair. The result? Backbiting, stress, and malaise. Generational conflict is eating away at the social fabric of group after group - sometimes revealing itself in arguments over call schedules and comp-ensation, sometimes causing docs young and old to leave their practices in disgust. It's no surprise to learn that such problems often emerge from real differences in what each generation thinks a career in medicine is all about.

The angry generation

For the bulk of active physicians, those who are roughly 40 to 59 years old, medicine just ain't what it used to be. And they're mad as hell about it. Many entered medical school expecting a lucrative career helping others while basking in appreciation from their community and patients. Instead, patients question their diagnoses with data gathered from the Internet, the government threatens to audit their files, they work like dogs, and their income isn't going anywhere.

This change in status is not all in their heads, either. According to the Medical Group Management Association's (MGMA) Physician Compensation and Production Survey: 2000 Report, physician compensation in 1999 rose 3.39 percent for primary-care providers and 6 percent for specialists. Sounds OK - until you read on and find out that, over the same period, physician gross charges leapt 11.55 percent for primary care and 8.51 percent for specialists. In other words, physicians are working harder, but that effort is not being reflected in their pay.

And that's especially tough to take for someone who entered medicine expecting a much better deal. This group remembers what the good old days were, and they can contrast that" with today, observes David J. Bachrach, founder of The Physician Executive Coach in Boulder, Colo. The result, says Bachrach, who has 27 years of experience as a leader in academic medical centers, is a generation characterized by anger.

Hal Patterson, a Denver-based career consultant who works with many disgruntled docs, agrees. "They all come out of residency programs full of spit and shine," he says, "then they just get beat to death. [Physicians] feel just like they're working in an assembly line." Patterson says many of the physicians he works with are contemplating a career change. Some are even throwing in the towel altogether.

According to a recent survey by physician recruitment company Merritt & Hawkins, 37 percent of physicians age 50 or older plan to retire in the next one to three years. Another 16 percent plan to "reduce their workload." And 56 percent reported they wouldn't choose a career in medicine if they had it to do over. Surprised? It gets worse.

Already pushed to the limit, the hard-working middle-aged generation of doctors is also dealing with an older generation ready to cut back their own hours and rely more and more on others to support them in their golden years. Looking for relief, the middle-aged physician might turn to the young, up-and-coming physicians - many of whom insist on taking call only once a week, working a 10-hour day, and collecting a big salary.

The young and the rested

These new physicians, like the rest of their generation, are "more inclined to balance. They want a balance with their personal life. They're more inclined to have the mountain bike, the backpacks - and they want time out of the office," observes Mike Taylor, vice president for marketing at Cejka & Co., a St. Louis-based recruitment and consulting company. "They want good incomes but insist on quality of life," Bachrach agrees.

John Potter, chief executive at Dreyer Medical Group in Aurora, Ill., explains it this way: "Junior docs see [medicine] as a job with hours, and then they're off. It's more of an employee perspective."

And who can blame them? These days, young physicians probably are employees. An increasing number of physicians are working their first jobs employed in a group practice or hospital; they aren't starting up a fledgling one- or two-doc practice, as their predecessors did. They've seen - and maybe experienced first-hand - the problems inherent in working 100-hour weeks and ignoring their families. "The ratio of failed marriages and troubled children suggests there might have been a problem with that [unbalanced] paradigm all along," comments Eric Lister, MD, a managing partner at the organizational consulting firm Ki Associates, who specializes in governance, leadership, and change management. "From a psychological perspective, the search for balance is a step forward."

A relaxed attitude also corresponds to revised expectations for the career: Why give everything to a job that gives so little in return? In response to a survey conducted by the Association of American Medical Colleges, 37.6 percent of graduating medical students "strongly agreed" that medicine will not be as financially rewarding as in the past; another 49 percent "agreed" with that statement. Eighty-three percent "agreed" or "strongly agreed" that the administrative requirements of healthcare are too burdensome. Fifty-six percent "agreed" that a physician's work interferes too much with family relations.

'Passive and sanguine'

Like their older colleagues, new physicians don't think much of some of the demands of their chosen field. The younger crew, however, is "more passive and sanguine about it. It's more like a shrug" than a shaking fist, Lister observes. However, their desire for a decent salary doesn't carry that same polite indifference.

The 2000 class of medical school graduates hit the streets with an average debt of $93,000, according to the American Medical Association. Meanwhile, their nonmedical peers are off at high-tech jobs, carrying little or no debt, and pulling in $100,000 a year or more for designing Web graphics.

Seasoned healthcare professionals annoyed by the salary demands of these prospective, young employees might be surprised at how little experience counts for in the 21st century. The median salary for a family practice physician with one to two years of experience is $124,041, but a physician with eight to 17 years of experience makes only about $26,000 more. Similarly, a young, invasive cardiologist pulls in around $212,044; his older colleagues make around $336,488 - this according to the MGMA's Physician Compensation and Production Survey: 2000 Report (1999 data). In short, it can be argued that the older physicians are justified in feeling like they are getting a raw deal. And new physicians may be equally justified in insisting on time off and a decent salary.

But justice and reason rarely get in the way of emotion. Both sides end up angry about call schedules, compensation, or unspoken - expectations.

Talk things over

it doesn't have to be that way. The solution to generational differences is to explore, spell out, and insist on what the group expects from each and every member. Then they must learn from their mistakes. Of course, that's not as easy as it sounds.

Lister describes the problems encountered by a well-established group that hired a number of young physicians. The leaders of the group gave the new crew the same orders they had given others for years - something like, "Take your time and build your practice," he says. However, the young physicians heard "take your time," while the older ones expected everyone to "roll up their sleeves and get to work." No one addressed the miscommunication until it was too late. So, after about a year, the younger physicians realized everyone was mad at them but didn't know why; the older physicians felt like they were being taken advantage of. "Just because a physician has come of age in clinical competence doesn't mean they understand group politics," Lister points out.

Reluctant to insult new colleagues by explaining the rules at length, hiring physicians prefer to let newcomers figure things out for themselves. It's a mistake, Lister insists: "Groups need a concise awareness of their own goals and culture." Groups also should put in place what Lister calls an "induction" process to teach new physicians about that culture - spell out how the practice works and what it means to be a good citizen. Consider setting up both a formal mentor and informal "schmoozing" partner for recent additions. Otherwise, Lister warns, a year or two later the group will be shaking its collective head wondering why the new guy doesn't fit in. "Well, you never said what you expect, so how could he fit in?" Lister asks.

He adds that it's especially important to define expectations concerning call schedules and productivity - top conflict detonators. "Candidates don't ask enough questions up front," says Nelson Tilden, a medical consultant and trainer, and founder of Medical Search Institute.

For example, candidates might be told that they will share call duty with the other physicians in the group. What no one mentions, though, is that three of the senior physicians in the group don't take call at all. Suddenly, the burden is higher than expected.

Tilden reports hearing a lot of younger physicians complain that they never would have joined a group if they had really understood what was expected of them. Thus, it's better to make it clear from the beginning, he suggests, rather than invest time and energy in someone who is not really a good fit for the job.

Productivity expectations - especially when tied to financial incentives - also tend to be left unexplained. "There's a lot of crossing your fingers and hoping for the best," Tilden observes. Lister agrees. Rather than just setting out benchmarks, "better organizations try to work with physicians to show how it's possible," he says.

More and more groups also are recruiting to their "culture," Taylor reveals. "Up front, physicians who are recruiting are doing more groundwork on things that would have been assumed years ago," he says. "People are shaping their groups around their culture." If, for example, the group has enough self-awareness to know it is composed of a bunch of workaholics, it's not a bad idea to tell that to candidates. Let them know exactly what to expect, as soon as possible.

It's too late, baby

Of course, if your group is already bickering or even splintering, it's too late to take the proactive approach. Luckily, disputes can be managed post-facto, too. Stanley Wachs, a consultant who specializes in helping physicians deal with conflict, promises that generational differences - or differences of any kind - can be resolved if the parties involved learn (and practice) a specific set of skills.

First, recognize that conflict is an emotional issue, Wachs says. In the middle of an argument, people tend to believe they are simply supporting the cause of truth and justice. In fact, they get emotionally, even physically, involved. Rather than behaving rationally, quite often they end up yelling and sweating. "You have to notice yourself in an emotional emergency, or you'll just get caught up in it and respond. You have to recognize that you have a choice and can practice other ways to proceed," advises Wachs, adding that the most important goal is to keep the practice together and functioning well.

Second, stop what you are doing and listen carefully to what your opponent is saying. If you are angry with an older colleague who won't take call, you need to stop talking, listen, and understand why he is taking this stance. The key here is to "really listen empathetically," as Wachs puts it. "The work is in not arguing. You need to be truly curious about someone else's viewpoint." It's not enough to listen for five minutes while still mentally reviewing why your opponent is wrong. "We can deeply hear and empathize even if we disagree," Wachs says.

And listening isn't just about being nice. It will facilitate a resolution, according to Wachs. For instance, if you are in an argument and feel your opinion hasn't been heard or that your opponent doesn't respect you, you will not stop arguing. You will keep fighting to be heard. On the other hand, if you have been heard and respected, it's less likely you will go on being mad and resentful. In fact, you feel compelled to cooperate, Wachs suggests. "You can't dig your heels in as much" once you've been listened to, he says. "People tend to drop their guard."

Next, Wachs advises stepping back and objectively summarizing the differences at stake. Say something like: "So, you really feel like you were deceived about how much call we expected you to take, and you need to spend more time with your family," Wachs suggests. That clearly sets out the problem and shows that you've understood. Once the problem is out in the open, ask what can be done to solve it.

This isn't about finding the perfect answer, Wachs stresses, but about getting a step closer to one another so that you can go on running the practice without constant nagging. You are "creating a solution" together, not forcing a pre-set answer on your opponent, Wachs says. In this way, you resolve the conflict through a frank - not a weak - discussion and without giving in to pure emotion, he adds.

As groups work at resolving generational differences, they can easily lose sight of what all physicians have in common. And that's where Srinivas' hopeful comments about the future of medicine - and her youthful optimism - resonate. Srinivas imagines an American medical system shaped by physicians for the good of their patients. The same ideal lies behind the anxiety of her older colleagues. They are unhappy precisely because they, too, want to better the state of medicine and have been frustrated in their efforts so far. Younger and older physicians alike "share a resistance to the bureaucratization of medicine. Physician autonomy remains a core value," Lister explains.

With that proud premise behind them, physicians of different generations and backgrounds may be closer together than they think.

Pamela L. Moore, senior editor of practice management for Physicians Practice, can be reached at pmoore@physicianspractice.com.

This article originally appeared in the May/June 2001 issue of Physicians Practice.