Millennials in medicine

The millennials have arrived, and they are shaking up the workplace-including the practice of medicine.

The generation that came of age with personal computers, and more recently with smartphones, tablets, and social media now is starting to care for patients, educate medical students, and-although less frequently than their predecessors-start their own practices. Along the way they are infusing medicine with their attitudes, aspirations, and experiences.

Just how large is the millennial cohort? According to U.S. Census Bureau data analyzed by the Pew Research Center, Americans born since the early 1980s-those in their mid- to late-30s and younger-number more than 75 million. That makes millennials the largest living generation, surpassing the 74.9-million baby boomers (those born between 1946 and 1964.)

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Pew also finds that millennials now constitute about one-third of the American workforce. At 53.5 million, their numbers exceed both the generation that immediately precedes them-so-called Generation X-and the baby boomers.

Looking specifically at medicine, about 155,000 physicians, or 15% of the total, are under age 35, according to American Medical Association data, while about 25% of the American Academy of Family Physician’s active membership is age 39 or younger. One-fourth of the American Osteopathic Association’s membership is 35 or younger.

Apart from sheer numbers-and bearing in mind that a population of this size can only be discussed in broad generalities, to which there will be many exceptions-what distinguishes millennials from preceding generations? One of the most significant, observers say, is a familiarity with computers and other forms of technology, derived from having grown up with them.

Next: “They’re accustomed to having information at their fingertips”

John Prescott, MD, who graduated from medical school in 1981 and is now chief academic officer for the Association of American Medical Colleges (AAMC), has seen how technology has changed the way students learn. “My generation learned through books and slides and lecture presentations, but the generation since then has grown up using the Internet,” he says. “They’ll download lectures and maybe review it while exercising on a treadmill and use other tools to highlight certain aspects of their courses.

“They’re accustomed to having information at their fingertips,” Prescott adds. “Whereas before if you didn’t know something you had to go look it up, for this generation looking it up means taking a device out of our pocket and getting the information they need right away.”

Andrew Lutzkanin, MDAndrew Lutzkanin, MD, 31, is among those who grew up with the information revolution. “I think our generation is a lot more comfortable with the idea of ‘let’s just look it up while we’re here’ during a patient encounter,” says Lutzkanin, who is doing an obstetrics fellowship in Huntsville, Alabama. “As a resident I was pulling out my phone all the time to look up the proper dosage of a drug. Our EHR had built-in links to several databases for quick queries. There’s just a lot more clinical information that’s available very quickly.

“When I was a resident we had a speaker come in to talk about millennials as learners,” he recalls. “One of the things he said was ‘no longer is the practice of medicine limited to the content of knowledge of the individual physician.’ That has really stuck with me.”

Matthew Pfleger, DOMatthew Pflieger, DO, 35, the medical director of a Denver, Colorado, community health clinic, says his generation’s familiarity with technology sometimes hinders their relations with patients. “I’ve noticed greater patient dissatisfaction with some providers, and I’m starting to see it’s due to the way they’re giving attention to the computer rather than the patient,” he says. “I was still part of the generation where it was still very important to learn how to walk into the examining room and connect with the patient quickly. I don’t know if they’re being taught as much now because I’m not seeing them as much in my providers. They walk in and they’re already looking at the computer screen rather than looking at and talking to the patient.”

Because they have come of age with computers and the Internet, millennials are also more likely to use social media than their older colleagues. “A lot of young physicians nowadays are on Twitter, using it either as an information source or tweeting themselves,” says Morganna Freeman, DO, FACP, age 37. “The enthusiasm for engagement on social media has allowed us to see that you can make a lot of connections with people you won’t ever actually meet, but you can still form collaborative relationships with them.”

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As with any other method of communication, social media can be hazardous if used unwisely. Freeman, who is in her last year of a hematology/oncology fellowship, saw that first-hand while a chief attending resident. Several residents she oversaw posted inappropriate information on social media.

“We recognized we needed to provide guidance for what they could say on Facebook and Twitter or if they decided to blog, because a lot of the stuff on social media can go viral so quickly, and your online reputation these days is just as meaningful as what you do in your day-to-day activities,” Freeman says.

Older physicians are more likely to realize that information that breaches patient confidentiality shouldn’t go on social media, says Dea Robinson, MA, FACMPE, director of the Medical Group Management Association Healthcare Consulting Group, but among younger physicians that’s not always the case. “With this generation it’s like everyone knows everything about everybody. So there needs to be a dialogue about how an organization is going to use social media. What is our message going to be when we talk to people about our organization?”

A second characteristic of millennials, experts say, is a greater emphasis on finding balance between work and life outside of work than found in previous generations. Jean Twenge, Ph.D., who has written extensively about millennials, notes that this difference shows up in the longitudinal research that was the basis for her book “Generation Me.” For example, in 1976 75% of high school seniors said they expected work to be a central part of their lives, compared with 66% who felt that way in 2012. She cites a 2012 study of college employment counselors in which “flexible schedules” and “balance of work and life” were among the top qualities students were seeking in a job.

Many observers believe that the millennials’ search for work-life balance is at least partially responsible for the declining number of physicians entering full-time clinical practice. For example, in 2009 about 29% of graduating medical students intended to pursue either full- or part-time non-academic clinical practice, compared with 25% in 2013, according to AAMC data.

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Conversely, the percentage of graduates intending to practice full or part-time as a salaried hospital employee increased from 7.4% in 2009 to 9.5% in 2013. And the percentage saying they wanted to pursue full- or part-time clinical teaching and research on a university faculty increased from 36.4% to 41%.

Next: Millennials "less interested in autonomy and more focused on work-life balance"

Emily Briggs, MD, MPHEmily Briggs, MD, MPH, 36, started her own full-scope family practice in New Braunfels, Texas, six years ago. But having her own practice makes her part of an ever-smaller cohort, she admits. “The physicians coming up behind me are less interested in autonomy and more focused on work-life balance,” she says. “They want a life outside medicine, to be able to spend time with their kids, or just pursue their hobbies.”

Lutzkanin ascribes the interest in work-life balance among millennials to a growing awareness of, and desire to avoid, burnout. “They find that sometimes in their rotations when they’re with older docs and see how frustrated they are, how overworked they are and they don’t want to get into a situation where that might be their fate,” he says.

Most physicians his age, he adds, “want to know what hours they’ll be at work and when they don’t have to be at work so they can spend time with family or explore other interests,” Lutzkanin says.

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The new emphasis on work-life balance has produced some grumbling among older doctors, says Lutzkanin, who recently completed a term as the resident member of the American Academy of Family Physicians board of directors. “There are some who feel we’re all a bunch of lazy kids who aren’t as dedicated to the profession as they were because we don’t want to work the same hours,” he says. “I push back and say ‘no, we see how overworked and frustrated many of you are and we don’t want to do that.’ We want a rewarding career but one that doesn’t prevent us from doing other things we enjoy.”

A third overarching characteristic of millennials is a willingness to question authority and established procedures. Accustomed to constant access to information, and not overly concerned with career advancement at the expense of other aspects of life, millennials often are less reluctant to ask awkward questions than were their predecessors.

Next: “This generation wants to know the meaning behind what they are doing"

“This generation wants to know the meaning behind what they are doing-not the philosophical, abstract meaning important to the Boomers, but what it means overall,” Twenge writes in “Generation Me.” If the task is important, then they will feel important doing it. For GenMe [her term for millennials] there is no better motivator.”

Freeman recalls that when making inpatient rounds as a resident if the attending said a certain drug was best for treating a condition, “you just accepted it as fact and maybe you looked it up later. These days, students can just whip out their smartphone and say ‘this one is actually better.’ It’s great that you can look things up at the point of care, and that has also made this generation more likely to question.”

“I believe they [young doctors] come into a practice or a hospital asking why things are being done in a certain way and saying we’re not just going to accept what was there before,” says the AAMC’s Prescott. “And that’s not to question just for the sake of questioning, but to ask how can we make it better?”

Kyle Matthews, CMPEKyle Matthews, CMPE, 35, has seen-and experienced-the millennial willingness to question authority first-hand in his role as chief executive officer of Cardiovascular Associates of Mesa P.C. The 16 providers in the Mesa, Arizona cardiology practice range in age from 22 to 76. “Millennials don’t necessarily care that you’ve been working someplace for 20 years,” he says. They’re all about that your position and your honor are earned.”

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Matthews says that after becoming practice CEO he rewrote its partnership agreement so as to require a supermajority to remove a partner, “so I don’t have the younger docs coming to me saying this guy is slow, he’s made mistakes, we can do things better, let’s just toss him out.”

Matthews adds that being part of the millennial cohort himself does not exempt him from the scrutiny of his younger employees. “The way they look at it is they understand technology, they think they understand business, and they are going to have a hard time justifying paying practice administrators. So from the first day we walk in the door we have to prove our worth and show how we can help them achieve their goals.”

Next: Millennials as healthcare consumers

Millennials as healthcare consumers

Millennials aren’t affecting medicine just as providers of healthcare. Their impact as healthcare consumers is just as profound, if not more so.

Start with the sheer numbers: The millennial generation-those born since about 1980-now numbers more than 75 million and makes up more than one-third of the workforce. Their estimated annual spending totals about $200 billion, although no current information exists as to how much of that goes to healthcare. (According to the Centers for Medicare & Medicaid Services, Americans up to age 45 spent $762.8 million on healthcare in 2010. That figure does not reflect the impact of the Affordable Care Act, however, and includes some spending by people older than the millennial cohort.)

Beyond their spending, however, it is their attitudes towards providers, their preferences, and their use of social media and technology that most distinguish millennials from their elders. These differences are apparent in the findings of a variety of recent surveys and studies. For example:

59% of millennials say they prefer getting healthcare from a retail or acute care clinic rather than a physician’s office, compared with 31% of baby boomers, according to a 2015 survey commissioned by PNC Healthcare.

49% of millennials who received care from a doctor or hospital in 2015 say they looked at a scorecard or report card to compare performance compared with 30% of baby boomers (up from 31% and 22%, respectively, since 2013), according to the Deloitte Center for Health Solutions “2015 Survey of US Health Care Consumers.”

60% of millennials who are dissatisfied with a healthcare-related experience tell their friends about it rather than their provider, compared with 51% of older patients, according to research from Nuance Communications, Inc.

Next: Role of online reviews

About half of patients in the millennial and Gen X generations say they used online reviews the last time they sought a healthcare provider, compared with 40% of baby boomers, according to PNC Healthcare.

While patients across the age spectrum are relying more on technology to monitor and manage their treatments, the trend is especially strong among millennials. The Deloitte Center survey finds that 45% of millennials use some form of technology to track fitness and health improvement goals, compared with 28% of boomers (up from 25% and 17%, respectively, in 2013.)

54% of millennials say they have delayed or avoided treatment due to cost considerations, compared with 37% of boomers, according to PNC Healthcare.

The latter statistic highlights another key aspect of millennials: Many of them either use high-deductible insurance plans or lack insurance entirely, says Kyle Matthews, CMPE, the chief executive officer of a cardiovascular practice in Tempe, Arizona. “It means if they’re coming to the doctor they’ll be paying cash. So they’re going to be very picky, and they’re going to question every test you order and every follow-up. You have to make sure they’re getting value for their money,” Matthews says.

The way millennials define “value” extends beyond the examination room, he adds-“whether it’s being asked to reschedule an appointment, whether it’s the medical assistant doing all the work and the doctor just comes in for the last 30 seconds, whether the front desk person looked at them funny.”

As a millennial himself (he’s 35), Matthews experiences his generation’s viewpoint both from the professional and personal angle. Among his friends, he says, he hears the frequent refrain that “doctors are just in it for the money.”

“I hear it all the time, ‘doctors just order tons of tests to pad their own pockets when I don’t really need them,’” he says. “They research their conditions online, and rightly or wrongly they make judgments based on what the find online.”

Next: Making practices millennial-friendly

To appeal to members of his generation, Matthews says, practices must be technologically current. That means having Wi-Fi in the waiting area, an up-to-date website that is tailored to mobile devices (“hardly anyone under 35 uses a computer to look at the web anymore,” he says) and a robust patient portal.

But high-quality technology alone is not enough to engage millennials, he adds. They still value the personal touch-including meaningful face time with the doctor. “The doctor needs to be personable, and they can’t just zoom in and out,” he says. “They have to feel like they’re getting their money’s worth and getting time to really discuss their condition and get their questions answered. Otherwise it’s not going to be a long-term relationship.”

Making practices millennial-friendly

Given that members of the millennial generation will inevitably assume a larger role in medical practices, how can practice owners and managers best harness their talents, while ensuring intergenerational harmony? Experts offer two suggestions. The first is to set clear expectations. “When I onboard my new providers I do a lot of expectation setting so they won’t be coming back later and saying, ‘you pulled the wool over my eyes about this job,’’’ says Matthew Pflieger, DO, 35, the medical director of a Denver, Colorado, community health clinic. “My hope is if I tell them what it’s going to be then they’re not surprised and they can better deal with the stress that comes along with it.”

Many millennials were raised in an environment of constant praise and positive reinforcement, and expect it to continue in the workplace whether or not it’s deserved, says Dea Robinson, MA, FACMPE, director of the Medical Group Management Association (MGMA) Healthcare Consulting Group Robinson. That means managers have to be clear about when praise will be forthcoming. “I’m not going to say I’ll praise you all the time for everything you’re doing,” she says, “but I can say, ‘we recognize really good work in our organization and we call it out as much as we can.’ There’s a big difference.”

The second key to integrating millennials is creating an atmosphere of inclusiveness, through transparency and ongoing dialogue. Asked what managers can do to make a practice attractive to a young person Matthews says, “overcommunicate. For example, if you fail meaningful use [attestation] tell them what the penalties are going to be in dollars. Give the reason why you’re doing something.“

Next: "They [millennials] would much rather help solve the problem than be told the solution”

“It’s amazing what you can do when you get everyone in the room together and say, ‘here’s the problem, what do we do about it?” Robinson says. “They [millennials] would much rather help solve the problem than be told the solution.”

Prescott advises practice owners and managers who may be put off by some characteristics of millennials to focus on the benefits this cohort can bring. “In general these are very bright, dedicated physicians who are going to challenge you,” he says. “Listen to them because they will help open your eyes to new ways of doing business and new technology that would benefit your patients and your practice.”