A ‘generation war’ it isn’t, but the baby boomers and ‘matures’ definitely see a number of issues differently

EDMONTON | Every generation laments that the one behind it is delivering the world straight to hell in a handbasket. On the surface, the president of the Royal College of Physicians and Surgeons of Canada, Dr. Louis Francescutti, at age 57, seems to think that. “If we’re graduating the most entitled generation known to man, they may say, ‘Screw the public-health system.’ They may be unemployed and entitled. They won’t sit on the sidelines. They will start fighting for a full private parallel health-care system.”The Medical Post decided to take a look at intergenerational conflict and harmony. We talked to doctors across Canada—from various generations—for a deeper look at issues relating to age.We wanted a few questions answered: Are there significant differences between the generations of doctors? What impact do those differences have on doctors’ relationships? How do they affect patient care? What does the future look like? And why would Dr. Francescutti go out on a limb to say what he said?We’ll start with Dr. Francescutti. As he travels around the country, he keeps hearing that the crop of future specialists are worried they won’t get jobs. Their worries may be well-founded. For instance, he said, there are graduates in orthopedics right now who can’t find work.Today’s medical students—the children of baby boomers—have particular features: They feel the system owes them something, and they are deeply in debt, he said. “This generation of students has a real sense of entitlement. They really think there should be a job and that job should be nine-to-five and pay a lot of money. This sense of entitlement is very unique. I’m not saying it is good or bad. It is reality,” said Dr. Francescutti.What’s emerging is a new generation of doctors who will fight for what they believe is theirs, he said. “Say five years down the road we graduate 2,000 and 1,000 can’t find work. What do they do? They want a Canadian salary. They want to work in an urban area Monday to Friday. They say, ‘I’ve got skills and I’m going to set up a free-standing hospital.’ You’ll see a coalescence of disenfranchised grads.”For being outspoken, some call Dr. Francescutti courageous and others label him harsh. “I get so much trouble with this. I’m charged with being sexist and old-fashioned. But too many people are sleeping while this is going on. It has an enormous impact on the patient relationship, the patient-health-care relationship, the physician-physician relationship, the physician-health-care relationship.“People say, ‘How can you say things like that as president of the Royal College of Physicians and Surgeons of Canada?’ I have to. Because of the mess we’re heading for.”Dr. Francescutti suggests the federal government set up training programs that encourage new physicians to see the bigger picture: To control costs, to be accountable and to give back to the system.“Being a doctor is the greatest honour society could bestow on anyone. It’s not for you, you, you.”The important thing, he said, is to openly discuss this trend. “It’s happening. The landscape is changing. We had better be prepared, or we are going to be surprised.”Are the generations different?It is fairly well-established, according to Dr. Linda Duxbury (PhD), a professor at the Sprott School of Business at Carleton University in Ottawa, that there are four distinct generations operating in the workforce, and that each has a (perhaps stereotypical) attitude toward work. The Millennials, up to age 32, are willing to work hard and are easily bored. The gen Xers (32 to 45) are thought of as disenfranchised and pessimistic; the baby boomers (46 to 65) are known as competitive workaholics; the Matures (66 and older) find work to be an inevitable duty.In 2005, Dr. Duxbury published results of a study of more than 1,000 Canadians who were asked what values were important to them at work. Results showed, not surprisingly, that all groups want to be well-paid and secure. Beyond that, there were some interesting differences. The Millennials place great value on personal prestige, and they want work to be social. The gen Xers, who are often cynical, need work that is intellectually stimulating. The Matures and baby boomers like to do work that is altruistic—contributing to the well-being of society. That is the “giving back” to which Dr. Francescutti refers.What about doctors? Studies show young doctors work less than older doctors. In 2003, Dr. Diane Watson (PhD), an associate faculty member of the University of British Columbia Centre for Health Services and Policy Research in Vancouver, did analyses of population-based services and surveys across six provinces. She found that younger and middle-age GPs/FPs, who represent 80% of the workforce, had smaller workloads than their same-age peers had 10 years earlier. Traditionally, people are most productive in mid-career, she reported in Health Affairs. Not so doctors.Studies in Winnipeg found the same phenomenon on a local scale. The Manitoba Centre for Health Policy reports that FP workloads (measured by patient visit) have shifted remarkably toward older doctors in a very short period of time. FPs between the ages of 60 and 69 provided 33% more visits from 1991 to 2000 while FPs between 30 and 49 provided 20% fewer than 10 years before.The National Physician Survey done in 2010 reveals that younger doctors are less satisfied than older doctors. When asked whether they were satisfied with personal and professional commitments, younger doctors and their middle-age colleagues were far less so than older doctors. About 59% of doctors younger than 35 were satisfied; this dropped to just over half of doctors who are between the ages of 35 and 54, and rises dramatically to 74% in those older than 65.The survey found younger doctors are doing far more call than older doctors. While more than 77% of doctors younger than 44 are doing call, this drops to 67% after age 55 and down to 43% at age 65. Gen Xers may not be getting that intellectual stimulation their age group valued in the Sprott survey; time away from family is a very significant barrier to participation in CME for almost half of doctors in the 35 to 44 group, according to the NPS.New style of workingDr. Sarah Giles, age 33, is a family physician who does locums all over Canada, including the North, and recently Western Australia. She has no doubt there are large inter-generational differences among doctors. “Many older (mostly male) docs gave up their lives for medicine,” she explained. “They worked day in and day out, rarely developed hobbies, and largely left family matters to their wives. Many of them, I fear, could not pick their kids or grandkids out of a crowd! I think today’s generation of docs wants to be more balanced. We are less willing to give our lives completely over to medicine. We want call groups to sign out to and holidays without a pager.”She bristles at the idea that young doctors don’t work as hard as their older counterparts. “I do not believe we are slackers,” she said. “I think we want to work just as hard but in a smarter manner. I can work in a team and know that my patients will be well taken care of.”She said she doesn’t think the old way of working was better. “I don’t believe that ridiculous hours on call make a good doctor—I think they make a doctor who is tired, cranky and prone to mistakes.”Dr. Gabe Woollam, age 32, agrees that having a balanced lifestyle is a goal of younger physicians these days. He does admit that, as chief of medical staff at the Labrador Health Centre in Happy Valley-Goose Bay, N.L., he is a bit of a workaholic. Though he may not have time for much of a life outside medicine, he fits the mould in terms of being a Millennial who is easily bored.He not only has a leadership role in remote family medicine, including obstetrics, emergency, the OR, medical evacuations and inpatient care—he’s also involved in the Society of Rural Physicians of Canada and several other physician groups.Like Dr. Giles, he observes that young family physicians are a peripatetic group. “A lot of young people are moving around, doing shorter contracts, as opposed to setting up a practice and that’s where they work permanently. It’s potentially changing what a family practice looks like,” he said.Replacing older doctors toughTalking to Dr. Woollam reveals an important distinction between GPs and specialists. While, as Dr. Francescutti pointed out, young specialists could find themselves desperately looking for work, graduating generalists are in very high demand.“Younger GPs/FPs have a lot more options on where to go. We can go anywhere, anytime. Competition is high among employers, allowing for more competitive offers on the table. The world is our oyster,” said Dr. Woollam.Dr. Peter Vaughan sees that phenomenon from the other side. As vice-president of medicine at South Shore Health, based in Bridgewater, N.S., he is in charge of about 100 doctors in two counties outside of Halifax.“When one retires, it takes a minimum of two to replace that doctor,” he said. “An older doctor could be working 80 to 100 hours a week, and a new one 37.5. We’ve got three like that right now, so we need nine to replace them. Multiply that across the country and we need a lot more primary-care physicians than we are putting out at the current rate,” he said.Young GPs know they are in demand, he said. “They want a signing bonus of over $100,000 because they are $100,000 in debt. They ask for that with a straight face. They’ll get it somewhere else. It’s part of the expectation.”Dr. Vaughan, who is 58, thinks younger doctors nowadays are more interested in instant gratification than his generation was. “Lifestyle issues are paramount to them. Their focus is about paying off huge debt. This is a generalization, but a lot of students start borrowing to buy a car. We wouldn’t have done that in medical school. We might have waited until we were through residency, so it was delayed gratification.”Doctors are better paid these days, he said, and therefore young doctors don’t need to work overtime. “In the previous era, doctors worked extra. They did their regular hours plus emergency over and above it. They had two jobs to pay off the mortgage. It is increasingly common that younger doctors are more interested in working part-time or as much as they need to. In rural emergencies we have staffing issues. They’ll do emerg or family medicine but not both.“Before,” said Dr. Vaughan, “doctors were a passionate part of the sustainability of that emergency. They would have never left it uncovered. Modern thinking is, ‘It’s not my problem.’ That’s a cultural shift.”Dr. Melissa Yuan-Innes, age 37, is unapologetic about working her shift and going home. She has young children and finds that working in emergency medicine in both Cornwall and Alexandria, Ont. suits her. Her friends, similarly, have not set up practices. “The world has really changed. It used to be pick one place and be the town doctor. People don’t want to be on call 24/7 for 40 years. So they are sharing.”She said she believes intergenerational conflicts exist between doctors, but would like to find ways doctors can work together on improving patient care and negotiating better working conditions.She has worked in several provinces and various different hospitals. The culture of each hospital is all-important in whether generations of doctors work in conflict or harmony. “I think it is inevitable whenever there are different age groups that some who have been there longer think they know more, and they do. But there is value in more flexible thinking and new perspectives and new ways of doing things. This may not be heard.“At some hospitals,” she said, “older doctors are willing to step aside to make room for younger doctors, but at others the attitude is, ‘Screw you, I need the money.’ You can see it; younger doctors are sometimes thrown to the wolves.”All of the physicians we interviewed wanted to find common ground between the age groups and work collaboratively to improve the health-care system. Dr. Marco Terwiel, 74, a semi-retired family physician in Maple Ridge, B.C., and an assistant professor at the University of British Columbia, said it’s a matter of respect.“In this community,” he said, “there is harmony more than conflict by far. I see very young doctors because I teach second- and fourth-year medical students. I get to know them. Most of them are really bright and motivated.”Dr. Terwiel, formerly chief of staff of the local hospital, worked 80 to 90 hours a week when he was younger; his wife stayed home to look after their children. He was trying to pay off the mortgage. “One of my regrets is that I didn’t get to spend sufficient time with my children when they were little.”He said he respects younger doctors’ decision to work less and have a balanced lifestyle. He does admit that for the patients it means fragmented care rather than the old cradle-to-grave care. “The best thing is to embrace it and help steer it in a decent direction. You have to be respectful of other people’s lifestyles. We’ve come a long way in doing that in Canada.”

A ‘generation war’ it isn’t, but the baby boomers and ‘matures’ definitely see a number of issues differently

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