When generations collide

In today’s hospitals and clinics, four generations of physicians are working side by side—Boomers, Gen X, Millennials and Gen Z residents. Each can have distinct values, communication styles and definitions of professionalism. It can be a prescription for misunderstandings and disrespect—or an opportunity for better communications and understanding.Unarticulated expectations between individuals, especially if they are of different generations, often underlie disrespectful behaviour, says Kelly McShane (PhD), a clinical psychologist and professor at Toronto Metropolitan University who co-wrote, “Incivility and disrespect as a workplace hazard: a new framework from occupational health and safety,” recently published in the Canadian Journal of Physician Leadership.She gives the example of someone who expects a patient handover to take place in person on site. “When that expectation is violated and you have left the premises and you call me and give me the handover information, I am angry. Why? Because I’ve never told you that my expectation around handovers is that it’s done in person at the site. That leads to a three-year argument, tension for which those two physicians will never, ever work the same shift again.”Although there’s plenty of debate about how significant generational differences really are—people within the same generation can differ more than people across generations—it’s still valuable for medical leaders and educators to understand these differences, says Dr. Glen Bandiera, executive director, specialty education at the Royal College of Physicians and Surgeons of Canada and author of “Mind the gap: thoughts on intergenerational relations in medical leadership” (Canadian Journal of Physician Leadership), which addresses domains such as feedback, communication, collaboration and lifelong learning.He says that understanding intergenerational approaches to work are key to fostering respect and collaboration in medicine.Acknowledging that the insights he offers are based on his reading and experience, not empirically derived truths, he zeroes in on some of the differences that can lead to disrespect. “Those who are nearing retirement age now are either Boomers or Gen X. Both tend to be respectful of hierarchy and willing to sacrifice for long-term rewards or community betterment,” said Dr. Bandiera, also a professor of medicine at the University of Toronto’s Temerty faculty of medicine.Yet even between those groups, perspectives differ. “Boomers generally take the view, ‘Look what we built through blood, sweat and tears—now it’s time for us to steward the system until we can’t anymore.’ Gen X, on the other hand, would more likely say, ‘Look what I endured; I’m tired, but I got through and now I should reap my rewards.’”By contrast, Millennials and Gen Z approach their work differently. “They’re more oriented toward their peer group and more immediate rewards,” he said.One common tension point, he said, is in feedback and mentorship. “Boomers and Gen X adhered more to a ‘Watch what I do and do what I say’ type of mentorship,” he explained. “They learned in an apprenticeship model, where implied feedback made sense—smart people would just figure it out.”Younger physicians, by contrast, were surrounded by feedback their entire lives “to the point where they have a hard time functioning without explicit feedback,” he said. “They value frequent, constructive guidance—but critical judgment about performance or value judgments about their perspectives do not often land well with them.”This disconnect often leaves both sides feeling disrespected. “(In my research), I frequently heard teachers say they gave feedback ‘constantly,’ while learners said they got little feedback,” Dr. Bandiera said. “It was a ‘lost in translation’ phenomenon.”His advice to mentors is to label feedback explicitly and frame it as supportive rather than evaluative. “Using phrases like, ‘To improve your impact even more…’ or, ‘As your coach, here’s what I see that may help…’ can make feedback feel constructive rather than judgmental,” he said.Assumptions and stereotypesMcShane is working on a project about the impact of avoiding feedback in medicine. “Particularly in the context of feedback and evaluation, there is an increase in the incivility from both learners and preceptors,” she said. “This has a direct impact on clinical care. Bottom line, instruction on how to provide feedback and how to action feedback are key skills needed—so that we do not present feedback in an uncivil manner nor respond to feedback in an uncivil manner.”You can’t talk about intergenerational differences without talking about assumptions. Generational differences in medicine are often misunderstood because much of what we think we “know” about generations is rooted in stereotypes, notes McShane.“We have a lot of conversations around assumptions and stereotypes. But there are also assumptions that I make about what assumptions I think others make of me. Double assumptions, or meta-assumptions.”For example, someone might be thinking others see them as old (or young) and are therefore disregarding them, and those double assumptions are carried into interactions or applied to situations that might be completely benign. “It’s unarticulated and super damaging,” said McShane.Systemic solutionsIn “Incivility and disrespect as a workplace hazard,” McShane and co-author Dr. P. Andrea Lum, a radiologist and past vice dean, clinical faculty affairs at the Schulich School of Medicine & Dentistry, Western University, have proposed treating disrespect like any other workplace hazard, similar to how occupational health and safety (OHS) handles physical risks. This would mean spotting harmful behaviours early, understanding what conditions cause them and using a structured set of interventions to fix them. Issues would be detected, understood and addressed at their source.“This shift wouldn’t require major regulatory changes and could build on ideas already used in healthcare, like ‘just culture’ and continuous quality improvement,” said Dr. Lum. “Framing it this way brings it under the umbrella of occupational health and safety and encourages organizations to look at conditions, culture and prevention, not just individual blame.”The authors argue that current ways of dealing with disrespect in medical workplaces have three big flaws. First, they overlook how far the ripple effects go. One rotten apple—or one disruptive, disrespectful physician—can indeed spoil the whole bunch, creating a toxic environment.Second, the tools used to address these issues are heavy-handed, slow and better for tearing things down than fixing them, like suspending or revoking licences. Instead, Dr. Lum calls for a systemic, psychologically safe approach grounded in OHS—like handling problems locally, bringing in neutral third parties or adopting a “just culture” approach (meaning a workplace that balances accountability with fairness and learning by encouraging clinicians to report errors and near-misses without fear of automatic blame).Third, in current approaches, the root causes are not addressed. Toxic behaviour erodes trust, makes teamwork harder and can threaten patient safety. “People become afraid to speak up because they expect backlash, which means there’s a real lack of psychological safety,” said Dr. Lum.The whole topic of respect, or civility, is really about communication, says Dr. Lum, sometimes generational, sometimes not.“One of the challenges that comes up is that we don’t have a common point of understanding. Things don’t get addressed because you say something that I interpret negatively and moving forward that changes the way we interact. So it really escalates to directly impacting patient care like, ‘I don’t think you should be the one to call the code,’ or ‘I’m the only one qualified to do this, and so I’m going to ignore you.’”Dr. Lum also points to contrast in communication tool preferences among generations.“Some would rather just put something online and have you do a thumbs up. That is not communication. And it does not help us to really understand how urgent a situation is. We have to make a protocol; we have to have a conversation.”Also, she says, whether to make it an in-person meeting, a video meeting, an email, are all sticking points that without set processes in place can create roadblocks and damage lines of communication.Aside from systemic changes, most important, she says, is trying to put yourself in the other’s shoes and show up with empathy. Nobody knows what an individual is going through (or has been through). That includes not making assumptions and asking about others’ experiences.“When you have someone new come in now, there are expectations—‘I am entitled to days for mental health when I don’t feel like getting out of bed.’ On both sides, you have to have that conversation about those expectations and how society has evolved. For example, ‘For you, what was that conversation like about mental health at the beginning of your career?’ or ‘What are your expectations?'”Damaging misconceptionsThe most damaging misconception, Dr. Bandiera says, is mistaking generationally different expressions of professionalism for disrespect. “The main problem I saw was the quick interpretation of professionalism that looks different from one’s own as laziness or lack of respect,” he said.Ultimately, Dr. Bandiera believed that the evolution of medicine depended on a spirit of shared learning across generations. “There’s a lot to be gained by seeing the teacher-learner interaction as a two-way sharing of perspective,” he said. As he wrote in “Mind the gap,” “The key principles for success seem to converge on the following: strive to understand, be slow to assume, validate perceptions and look for common ground.”

When generations collide

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