My Generation

Think back to the day you finished your residency. Were you prepared for the realities of falling reimbursement, reams of paperwork, and rising malpractice costs? Were you prepared to work until you were in your 70s?

How you answer that question depends on what year you finished that residency. And it lies at the heart of an emerging generation gap among younger and older physicians.

Ask anyone about the major source of differences -- and potential hard feelings -- between older and younger doctors, and the same issues come up repeatedly: there are fewer doctors willing to work 24/7, take call, or face the heavy workloads of full-time internal medicine or pediatrics. More doctors are choosing to work part-time, or to enter specialties that give them more free time.

Corporate America's move toward work-life balance has caught up with the medical profession.

For the new generation, skimping on their personal lives is no longer a given when they see that most older doctors aren't reaping the rewards of giving up everything for their profession.

Us against them?

"I don't see what I'd call a divide in my practice. But there are some generational differences," says Jennifer Shu, MD, chair of the AMA Young Physicians Section, which was founded in 1986 to help doctors make the transition from residency to daily practice. Shu, who is entering her seventh year of practice as a pediatrician at the Sharp Rees-Stealy Medical Group in San Diego, says, "Younger doctors have made work-life balance more of a priority. They've seen other physicians -- often their own parents -- burn out before retirement, and they go into the profession with more awareness of the burdens on practicing physicians. A lot of us make it a priority not to be brought down by that so we can do good practice over a long career."

"I think there are a fair number of longer-tenured providers who perceive that younger providers are much more focused on life balance," says Jayne Oliva, a principal with Croes-Oliva Group, a consultancy in Burlington, Mass. "They're approaching retirement, they want to scale back, maybe drop call. But they can't, because younger physicians are much less willing to take on more work. ... When you get down to best practice issues -- call, rounds, new patients, delivering babies -- when doors are closed in the practice boardroom and the younger doctors aren't saying, 'I'll do it, I'll do it,' that's an area of tension. Younger doctors are much more protective of their time."

Context for discontent

Merritt, Hawkins & Associates, a physician search and consulting firm in Irving, Texas, recently published its 2004 Survey of Physicians 50 to 65 Years Old; the survey results verify that older physicians are indeed disillusioned. Its 436 respondents overwhelmingly cited a "general dissatisfaction with today's medical practice environment."

Embedded in that survey was a two-part question about young doctors: Do you think they are as dedicated and hard-working as physicians aged 50 to 65? Sixty-four percent of the survey's 436 respondents said no. When asked if young doctors were more dedicated and hard-working than their older counterparts, a full 100 percent of respondents said no.

"We wondered if some of them must have checked the wrong box," says Kurt Mosley, vice president of business development at Merritt, Hawkins. "The purpose of the question was not to create a rift between older and younger doctors. It was to highlight the fact that 38 percent of doctors in practice today are over 50. We wanted to say, 'We're going to need the bulk of older doctors to continue to practice for five to 10 years until the new doctors grow into their roles.' But those older doctors have issues with the young doctors they should be mentoring. Their view of younger doctors is just one part of the substantial frustration and dissatisfaction of older doctors."

While one survey doesn't represent the entire medical profession, it seems clear that if more doctors are finding themselves on different sides of the work-life issue, conflict is bound to follow. And that conflict will be expressed in terms of how hard-working and dedicated doctors are, regardless of whether that's accurate. So let's examine some of the issues that can come up and ways practices can work toward a common resolution.

Part-time, full-time

"Flex-time is a big issue," says Shu. "A lot of doctors coming out today want to be able to work part-time in a clinical practice and spend the rest of their time doing research, writing for Web sites, or working for pharmaceutical [companies]. Older doctors weren't usually in group practices so they didn't have the option to not be there when the phone rang."

It's not flex-time itself that causes problems, but a lack of organized, formal response to the demand for it, says Oliva. "If you work on a team, you cover for each other and it's informal and personal, so decisions about going to part-time are treated as personal agreements made between collegial partners. But these agreements come under stress when legitimate operational ramifications like coordinating care and taking call come up. When it seems like it's always the younger doctors who expect to go part-time, this can cause age-based resentment."

To avoid problems, Oliva suggests that groups devise a compensation formula "that [encourages] the behavior the group wants. If some people don't want to take call, those who do should be [more] highly compensated. Be very clear about expectations and contributions on both sides."

A case in point is West Ashley Family Medicine in Charleston, S.C., founded in 2000 by John Gastright, an internal medicine specialist. The practice has three doctors in their 30s and two in their 60s, including Gastright. "We have two younger doctors working three days a week," says Gastright. "They were part-time from day one. One of the reasons it works out well is that we all take call equally, and that prevents any problems between doctors concerning workload."

Gastright admits that he and his younger colleagues have different priorities when it comes to work. "We keep tension from building up about this by addressing it. Sometimes we'll say to the younger doctors, 'This is something you have to do.' And then they'll do it, if you put it like that. But it disrupts their activities outside the office.

 "That's what's really different about younger doctors: their life outside the practice is extremely important to them. We older doctors love our families and our outside lives, too, but we always put the practice first, life second. Our primary identity in life is doctor. I respect young doctors and their commitments, but I wouldn't change places with them. I get a lot of pleasure out of being a traditional doctor."

The role of technology

Improvements in technology and the overall quality of healthcare help drive the move to part-time work and more time for family and other interests. "Conditions that were life-threatening and required time-consuming care 30 years ago can be cured with a prescription or minor surgery today," says Mosley. "And younger doctors can do more in less time with technology. It allows them to maintain continuity of care without the huge time commitment."

But even practices suffering from a generation gap can level the technology playing field. "Physician leadership is crucial when it comes to technology adoption," says Pamela Moore, senior editor, practice management, for Physicians Practice. "Nontechnical physicians will get on board if they see other physicians achieving real time and cost savings. The hurdle usually isn't lack of ability or technophobia, it's that it can be hard to see the advantages of change."

Gastright is one who does. "When I started this practice, I wanted it to be technically advanced," he says. "In fact, we're paperless. I think the age-difference problem has been overplayed; while it can be challenging, it's equally challenging for young and old. In our practice, all the doctors use their PCs to check patient charts from home, for example, and that kind of technology use helps us all get out of the office on time."

What's gender got to do with it?

When the subject of working part-time comes up, the fact that more and more women are becoming doctors inevitably follows. It seems logical to assume women will be more likely to go to part-time because of child-rearing responsibilities. But part-time is not a clear-cut gender issue.

"It's true that we can assume this was originally a female-driven trend," says Oliva. "But women don't dominate all specialties. [Over] 48 percent of pediatricians are women; that's the specialty with the highest percentage of female practitioners, and only 28 percent of those women work part-time. So if part-timers are an issue in medicine generally, then we have to look beyond gender."

 "In part, it's women in the workforce who want to have a little time off with their children, but I think it's more a question of working couples where both people are doctors," adds Shu. "In the past, most doctors were male and their wives stayed home with the children. Now you have a lot of male doctors who are married to female doctors and they both choose to be more flexible so they can share in household and family responsibilities. I know of a lot of dual physician couples, including my husband and myself."

Come together

There are clearly differences between younger and older doctors. But that difference doesn't have to drive a wedge between them. It can unite doctors by giving them all a chance to change the way they work and achieve a measure of work-life balance.

"We're saying it's OK for anyone, of any age, to practice medicine successfully while also having a successful personal life," says Shu. "No one's saying, 'Oh, those old doctors were so crazy.' It was a different world, there weren't many options. Now there are, and they're open to everybody." 

Lori Rogers-Stokes can be reached at editor@physicianspractice.com

This article originally appeared in the June 2004 issue of Physicians Practice.