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Bridging the Millennial Generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty
Author’s Accepted Manuscript Bridging the Millennial Generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty Valerie N. Williams, Jose Medina, Andria Medina, Shari Clifton www.elsevier.com
PII: DOI: Reference:
S0002-9629(16)30647-4 http://dx.doi.org/10.1016/j.amjms.2016.12.004 AMJMS349
To appear in: The American Journal of the Medical Sciences Received date: 17 October 2016 Revised date: 2 December 2016 Accepted date: 5 December 2016 Cite this article as: Valerie N. Williams, Jose Medina, Andria Medina and Shari Clifton, Bridging the Millennial Generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty, The American Journal of the Medical Sciences, http://dx.doi.org/10.1016/j.amjms.2016.12.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Full Title: Bridging the Millennial Generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty Authors Valerie N. Williams, PhD, MPA Jose Medina, MHS, PA-C Andria Medina, MD, PhD Shari Clifton, MLIS, AHIP Authors’ Institutional Affiliations Valerie N. Williams, Ph.D., Vice Provost for Academic Affairs and Faculty Development, and Director, OUHSC Faculty Leadership Program, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Jose Medina, MHS, PA-C, Clinical Associate Professor, Director for Clinical Outreach, Physician Associate Program, College of Medicine, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Andria Medina, M.D., Ph.D., Assistant Professor, and Associate Program Director, Internal Medicine Residency, Department of Medicine College of Medicine, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Shari Clifton, MLIS, AHIP, Professor / Associate Director and Head, Reference & Instructional Services, Robert M. Bird Health Sciences Library, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Corresponding Author Contact Information Valerie N. Williams, Ph.D., Vice Provost, The University of Oklahoma Health Sciences Center PO Box 26901 Bird Health Sciences Library, Suite 164 Oklahoma City, OK 73126 Phone: 405-271-2688. E-mail: [email protected] Short Title: Bridging the Millennial Generation Expectation Gap Conflict of Interest Statement: The authors have no conflicts of interest related to the content or preparation of this manuscript. 1
Source of Funding Statement This project was completed without extramural funding. Abbreviations
CEO. Chief Executive Officer CME. Continuing Medical Education GME. Graduate Medical Education KSA. Knowledge, Skill, Attitude UME. Undergraduate Medical Education
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Abstract
Assigning attributes to a birth cohort is one way we identify society-wide, shared life experiences within a group collectively called a “generation”. Such assigned attributes influence society’s adoption of generation-based expectations held by and about people from a particular birth cohort. Census data and generational attributes inform perspectives on millennial generation birth cohort experiences and engagement as students. The eldest living generation in U.S. society has given way to three subsequent generations, the youngest of which is called the millennial generation. What generational attributes influence the effectiveness of teaching and learning between millennial learners and faculty members from other generations? Understanding the role of life cycle effects, period effects, and cohort effects can offer medical and health professions educators’ insights into different strategies for learner engagement. Specific strategies and teaching tactics are discussed that faculty members can use to engage millennials across a continuum of learning to bridge the “expectation gap”.
Key Terms:
Intergenerational Relations; Interprofessional Relations; Education, Medical; Teaching
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Introduction
A generational expectation gap is created when one generation purportedly holds forth a best (or only) way of being or doing something as an expectation. The gap to be bridged is the distance required to align it with the matching “best way” expectation of a different generation. Our current knowledge about contributors to this expectation gap is anchored in two views: census data, and interpretation of those data based on sociodemographic attributes. Census data enumerate the population statistics by age groupings within the U.S. population. They provide a profile by measureable and self-reported features such as age, race, Hispanic or Latino origin, (binary) gender, and residents/region of the country. Sociodemographic data analyses depict historic and current groups by assigning a birth cohort bandwidth of approximately 15-22 years and timeline-based attributes. This sociodemographic grouping is referred to as the “generation profile”.
Characterizing the Cohort
A Census Snapshot of the Millennial Birth Cohort. Who are the millennials? The Census Bureau describes this group as "millennials, or America's youth born between 1982 and 2000, who now number 83.1 million and represent more than one-quarter of the nation's population. Their size exceeds that of the 75.4 million baby boomers, according to new U.S. Census Bureau estimates. Overall, millennials are more diverse than the generations that preceded them, with 44.2% being part of a minority race or ethnic group (that is, a group other than non-Hispanic, single 4
race white)."1 While the term “millennial” is the most widely used, synonyms included “nexters”, “generation Y”, “Nintendo generation”, “ generation next,” and the “Internet generation”.2 By comparison, sociologic analyses offer a look at the context and living conditions associated with a particular age group in American society during specific time periods. Sociologists3 and other thought leaders4, 5 have variously described the millennial generation cohort.
The oldest living cohort, the Veteran generation born between 1901 and 1924, are also known as the G.I. generation or the Greatest generation. Today, relating to the millennials are three other generations in the workforce and education system. The oldest of these are members of the silent/traditional generation born between 1925 and 1942 and whose age in 2016 was 71 or older. Next is the baby boom generation, with birth dates between 1946 and 1964; in 2016 baby boomers were 52-70 years old. Following the boomers is Generation X, (Gen X). Members of this birth cohort were between 36 and 51 years old in 2016, having been born between 1965 and 1980. Members of our most recent generation, the millennials, were born beginning in 1981. In 2016 their ages ranged from 18-35 years old. The end date for this generation has not yet been established, so the youngest of the millennial generation has yet to make their mark on the education system.
Over-Generalization of Birth Cohort Attributes. Pew Research Center data indicate that people born in the millennial cohort years do not particularly identify themselves as "millennials". Pew American Trends panel survey results show that each birth cohort embraces their "generation 5
label" differently. About 79% of 51-69-year-old (baby boomer) respondents embrace the "boomer" label, but others do not. Only 58% of 35-50-year-old (Gen X), and 40% of 18-34-yearold (millennial) respondents embrace their generation label. Finally, only 18% of the 70-87year-old (silent/traditional) respondents identified with their generation label. Pew notes, "generational names are largely the creation of social scientists and market researchers. The age boundaries of these widely used labels are somewhat variable and subjective."6
As shown in Table 1, among survey respondents, 33% of the millennial cohort identified as "Gen X” and 34% of the silent/traditional cohort identified as "Boomers", suggesting that in each generation some may see themselves uniquely affiliated with a generation other than the one assigned by their birth year, particularly if born in “cusp” years.
What generational effects impact learning in the millennial cohort? Three types of effects are described in generational research: life cycle effects, period effects, and cohort effects. Life cycle (or age) effects are observed differences between older and younger people, largely due to their respective positions in the life cycle. Period effects are when everyone, regardless of age, is simultaneously impacted and affected long-term by events related to social forces, or to circumstances such as war, economic conditions, or technology. Pew cites the shift in public views about the issue of terrorism and the related priority given to fighting terrorism globally following the 9/11 attacks as a period effect. Cohort effects are an observed byproduct of a unique historical circumstance that members of an age cohort experience, particularly during
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the time when they are forming opinions. The Great Depression and its aftermath are cited as having a cohort effect on members of one generation.7
Period Effects, Cohort Effects and the Millennials. Millennial learners are reported to be a very matter-of-fact group and have learned to question nearly everything. Born during an era of massive technology growth, this cohort effect has accustomed millennials to have instant access to information and extensive amounts of data integrated into everyday life. These two conditions prompted their development of highly efficient information sorting skills. Millennials are a generation of intelligent and developed mindsets, and as a cohort they often seem misunderstood. They are collaborative and team-oriented, but expect to be given meaningful assignments/work and are not motivated by monetary reward or accolades. They are polite and deferent to authority, but they also expect to be partners with their leaders. They do not necessarily accept the status quo and feel empowered to question the system, but at the same time are the generation of standardized educational content and standardized testing.
Millennials have been active participants in their household and in society to an extent unlike any generation before them. Their access to information along with encouragement from parents and teachers to question their world has made them comfortable engaging “higherups” with less regard to the traditional hierarchy: they are not afraid to e-mail the CEO of a company with their opinion. The millennial generation has been resistant or unresponsive to traditional leadership styles, making them question rules and procedures. Millennials need to feel a sense of buy-in and ownership in what they are being asked to join.8 7
Effectively engaging a response from millennials can be done by 1) helping them to understand what they are doing, why they are doing it, and how it can become part of the future greater good, 2) keeping teaching fast-paced by integrating relevant and up-to-date technology, and 3) using a more hands-on approach and outside-the-box thinking when presenting conventional ideas. Another important attribute is that millennials see leaders and authorities as part of a participative process: while they definitely respect authority, they are not by-default impressed by it – unlike previous generations.
From this vantage point, exploration, investigation, analysis and assessment of teaching and learning strategies are crucially important processes for faculty of medical schools and health professions education programs. Career choice9 and learning roles and role perceptions10 may be differentially affected by generational cohort experiences. Indeed, concerns about differences across the generational divide have led to calls for leaders to address this aspect of diversity in the physician workforce.11, 12 These factors draw focus on three specific questions: 1) What facts about the millennial generation birth cohort experiences can inform institutional preparation for teaching these learners? 2) How do millennial learners engage as students? and 3) What teaching tactics can faculty members use to engage effectively millennials in undergraduate, graduate, and continuing medical education, or the UME-GME-CME continuum of life-long-learning?
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Teaching Millennials
What facts about the millennial experiences can guide institutional preparation for teaching these learners? American higher education opened its doors to this new generation of learners in 1998. As they complete undergraduate education, the workforce, the graduate education community and medical and health professions colleges are welcoming this new group of learners.
Millennial learners will enter the next tier of academic pursuit at a time when the environment and expectations for teaching in classroom, laboratory13, clinical14, and community settings is increasingly complex, financially challenging15, and time-sensitive as pertains to training requirements16, duty hours17 and work-life balance.18 They are expected to bring a set of learning styles, life experiences, and personal values that resonate within their cohort19, but may be potentially less resonant for other generations.20
Addressing this variability may avoid both stereotyping the generation cohort and making broad assumptions about individual members or their learning style or experiences. Since the National Academy of Sciences’ publication of How People Learn21, evidence-based understanding of the way teaching and learning interface has advanced.21 However, with caution in mind not to stereotype individuals from any generation, these data can be useful for education planning in at least two ways. First, information about cohort experiences, knowledge, skills and aptitudes, can be used strategically for curriculum planning, and for 9
identifying academic infrastructure and personnel needed to support contemporary learning. Second, expert faculty members can be engaged and faculty development can be offered to ensure they have knowledge about, and access to, effective tools for individual millennial learner development. If they do identify with ascribed generational attributes, addressing those cohort characteristics will allow college leaders and educators to advance effective preparation for engagement.
Direct opportunities to leverage millennials’ desires include reinforcement and guided redirection of their ideals. Serving as mentors, educators can engage millennials early on by explaining and reinforcing exemplars of competence expectations in medicine. For example, millennials are reported to want: leaders to show honesty and integrity; opportunities for growth and development; friendships with peers; humor and fun; respectful treatment; and flexible activities.22 Many of these desired elements can be integrated into formal or informal mentoring and learning opportunities, such as discussing vision for the greater good resulting from individual knowledge, skill and teamwork, providing clear instruction followed by practice of simulated/actual team leadership, and intentional role modeling of leadership behaviors to make the skills observable to the learner. Following up with shared reflection to discuss what worked as expected and what did not work well in an interprofessional team or leadership situation can connect both learner and educator in building learning insights. Shared reflection also invites rapport-building between learner and faculty member.
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Awareness15, 23 of a generation’s cohort effect experiences offers a window-in-time snapshot of potentially important influences that shaped an individual's perspectives, expectations24, 25, and behaviors. These attributes are ingrained into the way millennial learners will interact with their teachers and the college/curriculum during professional education.
Cohort effects, contributing to learned behavior, preferences, values, and expectations set the stage for the learner to embrace or eschew various educational approaches. For example, one consistent description of millennial cohort learners is that they are "digital natives" 26; because their cohort has grown up in such a technologically-advanced society where information is so readily available, their educational mindset is unique. Other cohort effects influencing learning include: 1) micro-technology, such as tablets and smart phones, replacing computers; 2) Internet use (and availability) replacing television; 3) preference toward results and actions rather than knowledge base acquisition; 4) view multitasking as a social norm, even in the classroom; 5) typing and texting rather than hand writing; 6) apply technology connected with multiple devices and intra-device applications; and 7) instant information gratification, breeding lower tolerance for delay and greater expectations for immediacy and availability.27
Determining a teaching and learning approach that will guide these learners through progression from their digitally masterful but health professions novice state to expected competence is an opportunity and a challenge for educators.
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How does the millennial generation cohort prefer to engage? How do they compare to the engagement preferences of other generations? Table 2 provides an overview of engagement approaches used and preferred by each generation cohort. The center column notes learner engagement approaches. Two generations are grouped to the right and left of the engagement focus column. Note the relative ease in bridging the gap between adjacent generations, as well as the wider conceptual expectation gap for how engagement works between generations born 1922-1960 and those born 1960-2003.
Each generation in academic medicine and healthcare has traversed the learning continuum beginning with personal expectations about that journey and meeting head-on the realities of what is required to complete the journey and enter the profession. Career life in healthcare and medicine, as in any profession, includes experience-building to become more expert, and personal maturation to achieve greater acumen about the intricacies of work in the chosen field. In healthcare and medicine, the novice-to-expert maturation pathway requires: 1) prepreparation; 2) acceptance by those established in the field; 3) instruction, coaching, and mentoring (next tier preparation); and 4) feedback and assessment designed to provide challenge and continuing growth from experts in the field. This last assessment phase now also includes a stated expectation and commitment to life-long learning. Simply stated, these components operationalize the UME-GME-CME continuum.
Expert members take responsibility for novice new entrants and are tasked to teach and guide them from the entry point (greatest naïveté) to competence demonstration readiness. Experts 12
must regularly adapt their methods and tactics to fit the current setting where their expertise is being applied. In higher and professional education, the no-tech or low-tech environment has given way to greater use of digital and "smart" tools, providing the perfect setting for millennial cohort learners. For example, as they grew up, millennials had access to online learning resources, such as the Khan Academy.28 In 2013, recognizing the potential value for medical school applicants, the Association of American Medical Colleges partnered with the Khan Academy and the Robert Wood Johnson Foundation to create a free Medical College Aptitude Test (MCAT) preparation resource. The purpose was to offer this resource to any aspiring future medical student, using technology available in their home or pocket, or through their local library.29, 30 Where once expensive test preparation was available only to those who could afford it, today’s students can access Khan Academy resources with any smart device. This was clearly a strategic bridging partnership to increase the number and diversity of qualified applicants who are well-prepared to take the MCAT for medical school admission, but also to allow educators to engage the millennial learners using their preferred technological language, environment and tools. The potential uses faculty members could make of Khan Academy tools or similar innovative resources to advance medical education seem unlimited.
What personal teaching tactics can faculty members use to engage effectively millennials across the UME-GME-CME continuum? Teaching techniques based on observed millennial cohort behavior should consistently include three items: 1) clear direction and structure; 2) role modeling, coaching and mentoring; and 3) engagement and feedback. Table 3 compares generation cohort indicators of regard for expertise and authority. These indicators suggest that 13
there is a clear transition between expertise and authority expectations of the generations born 1922 – 1960 and those born 1960 – 2003.
The following teaching tactics provide the means to bridge the gap and engage millennial cohort learners: 1. Provide clear direction and structure. Teachers should afford learners with persistent and consistent opportunities to develop and practice critical thinking, while performance expectations up-front. Attention should be given to clearly articulating the sequence of performance benchmarks and competencies.31 When connected and completed, these learning objectives take the learner from lower level to higher level Knowledge, Skills, Abilities/Aptitudes (KSAs) for critical analyses and in preparation for demonstrating Entrustable Professional Activities (EPAs).32 Providing clear direction and structure can reduce both learner and faculty frustration. For example, quality and safety issues in contemporary clinical practice settings require that clear direction be provided when working with interprofessional teams; benefits accrue for patient outcomes and team efficiency. 2. Role Model, Coach, and Mentor. Role modeling is an effective tool. Directly related to clear direction and structure, it can also set the stage for feedback and assessment. Learners who identify with millennial cohort attributes appreciate engagement and are seeking guides/teachers who model integrity and trustworthiness. Demonstrating personal commitment through (enthusiastic) engagement in the work is a component of professional socialization.33 Fortunately, role modeling, coaching and mentoring34, 35 are 14
already deeply embedded in, physician, health professions, and basic biomedical science education. 3. Engage and Provide Feedback. Educators should provide opportunities for engagement with real-time performance feedback.36 As the millennial learner acquires competencies for mastery experiences37, engagement in new and stimulating situations is important. Simulation provides one such opportunity, as do sessions with standardized patients. Feedback on the quality of the learner’s engagement, the process of engagement (as directed), and the outcomes is highly sought after by millennialidentifying learners.38 In addition, correcting errors or eliminating ill-advised approaches to professional behavior can be accomplished through valuing the millennials’ appreciation for collaborative effective teamwork.
Expert teachers help novice learners develop discernment capacity and competence by refining novice critical thinking skills and testing emerging skills under increasingly complex conditions.39 For learners identifying with the millennial-age cohort, faculty members who help them bridge life-learned experience and professional discernment are crucial to closing the generation expectation gap.
Training a cadre of “master educators” who are skilled in mentorship, teaching and evaluation techniques leverages the normative/strategic approach. It recognizes a needed investment in faculty development, and emphasizes the roles of faculty members in guiding the progression of a learning cohort as well as guiding individual learners. DeWaay recommends creating a 15
"productive, pedagogically sound and deliberately competency-based system" that prepares the learner to engage expertly in understanding the pathophysiology of disease, and function as an effective member of an interprofessional team.40 Such competency-based training would be designed to include implementation, assessment and evaluation, and EPAs.32
Summary
Social scientists identify life cycle, period, and cohort effects that contribute to establishing generation labels and defining attributes. Health professions educators must keep in mind that societal level effects are not chosen intentionally by birth cohort members. Emergent social sector opportunities and costs, as well as decision opportunities, can affect the entirety of the living birth cohort generations—including learners in health care education and their faculty. Each must choose how to self-assess the impact of generational influences. Each must decide how to adapt to partner effectively in the teaching/learning experience of medical and health sciences.
As health professions educators in particular engage learners to bridge the learning gap between their own birth cohort, that of faculty colleagues in a different cohort, and the learners themselves, three factors are key. Educators must structure the environment and expectations against which the learner must demonstrate performance. The educator’s role should embrace instructor, mentor, coach and role model, based on strategically designed learning encounters. Finally, the educator must offer engagement opportunities and robust
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feedback as a means toward evaluating learner mastery. Learners must increasingly partner in these roles.
How will birth cohort effects remain relevant once observed performance attributes take center stage in the eyes of learners and educators alike? Faculty members serve in a linchpin role in guiding individual learners to serve in the physician or medical profession role through reinforcement of KSAs that align with criteria such as patient care quality, safety and ethical practice. When expert faculty members, as Master Teachers, help learners identify both criterion-based adaptive performance attributes, and those that are neutral or maladaptive as selected by the learner, better engagement is achieved. When learners partner with educators, the engagement process is enriched and individual performance criteria can be clarified through mentoring, shared reflection, and feedback. An individual learner must depend on unbiased assessment of criterion-based performance by the educator. Such a criterion-based approach used by physicians and interprofessional faculty can help build mutual understanding and bridge the generation expectation gap between today’s educators and millennial cohort learners.
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Acknowledgements
The authors thank our students, department and campus colleagues, and our mentors for sharing their experiences and insights.
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Table 1. Generation-reported attributes and how members self-identify % of generation saying [attribute] Share of generation that identifies as… describes their generation overall Generation
Attribute
%
Patriotic
12
Millennial
Responsible
24
18-34 year
Hardworking
36
olds
Self-reliant
27
Millennial
Gen X
Boomer
Silent
Greatest
40%
33%
8%
5%
8%
04%
02%
34%
18%
34%
Compassionate 29 Patriotic
73
Silent
Responsible
78
70-87 year
Hardworking
83
olds
Self-reliant
65
Compassionate 60
Adapted from: 6 Pew Research Center. Most Millennials Resist the ‘Millennial’ Label, http://www.peoplepress.org/2015/09/03/most-millennials-resist-the-millennial-label/; September 3, 2015. Accessed October 14, 2016.
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Table 2. Engagement approaches used and preferred by each generation cohort. Generations born betw 1922 - 1960
ENGAGEMENT
Generations born betw 1960-2003
Silent (Traditional)
Baby Boomers
FOCUS
Gen X
Millennial (Gen Y)
Top down
Guarded
Communication Style
Hub and spoke
Collaborative
Classroom
Facilitated
Learning Style
Independent
Collaborative and networked
The hard way
If “Too Much” will
Training opportunity
“Required to Keep Me”
Disengage Seeks approval from
expected
Team informed; my
authority
decision
Not comfortable
Not adept
Continuous and
Decision-making
Technology Use
Team included; our
Team decided; what all
decision
agreed to goes
Needed for max
Expected in all settings
engagement None is fine/Less is
Rare. Only when
more
necessary
Feedback
Weekly/Daily
Immediate and often
Rewards
Freedom
Meaningful work
Material gain; $, “Job well done”
perquisites, title
Adapted from: 8 Lancaster LC, Stillman D. When generations collide: who they are, why they clash, how to solve the generational puzzle at work. New York: HarperCollins; 2002.
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Table 3. Indicators of regard for expertise and authority Generations born betw 1922 - 1960 Silent (Traditional)
Baby Boomers
Respect
Love/Hate
EXPERTISE & AUTHORITY
Generations born betw 1960-2003 Gen X
Millennial (Gen Y)
Indifference
Politeness
Person in Authority Treated with Leader/Expert Shows Hierarchy
Consensus
Collaboration with Competence
Authority through
Command and Control
Take Charge or Get
Leader/Expert Style
out of the Way
is to Use
Others
Coaching
Negative if Delivered Discourteous or vulgar
Politically incorrect
Partnership
Too Uninhibited; Cliché
or Received as
Unethical
Adapted from: 8 Lancaster LC, Stillman D. When generations collide: who they are, why they clash, how to solve the generational puzzle at work. New York: HarperCollins; 2002. Zemke R, Raines C, Filipczak B. Generations at work: managing the clash of veterans, boomers, xers, and nexters in your workplace. AMACOM; 2000.
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PII: DOI: Reference:
S0002-9629(16)30647-4 http://dx.doi.org/10.1016/j.amjms.2016.12.004 AMJMS349
To appear in: The American Journal of the Medical Sciences Received date: 17 October 2016 Revised date: 2 December 2016 Accepted date: 5 December 2016 Cite this article as: Valerie N. Williams, Jose Medina, Andria Medina and Shari Clifton, Bridging the Millennial Generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty, The American Journal of the Medical Sciences, http://dx.doi.org/10.1016/j.amjms.2016.12.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Full Title: Bridging the Millennial Generation Expectation Gap: Perspectives and Strategies for Physician and Interprofessional Faculty Authors Valerie N. Williams, PhD, MPA Jose Medina, MHS, PA-C Andria Medina, MD, PhD Shari Clifton, MLIS, AHIP Authors’ Institutional Affiliations Valerie N. Williams, Ph.D., Vice Provost for Academic Affairs and Faculty Development, and Director, OUHSC Faculty Leadership Program, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Jose Medina, MHS, PA-C, Clinical Associate Professor, Director for Clinical Outreach, Physician Associate Program, College of Medicine, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Andria Medina, M.D., Ph.D., Assistant Professor, and Associate Program Director, Internal Medicine Residency, Department of Medicine College of Medicine, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Shari Clifton, MLIS, AHIP, Professor / Associate Director and Head, Reference & Instructional Services, Robert M. Bird Health Sciences Library, The University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK, 73126, USA. E-mail: [email protected] Corresponding Author Contact Information Valerie N. Williams, Ph.D., Vice Provost, The University of Oklahoma Health Sciences Center PO Box 26901 Bird Health Sciences Library, Suite 164 Oklahoma City, OK 73126 Phone: 405-271-2688. E-mail: [email protected] Short Title: Bridging the Millennial Generation Expectation Gap Conflict of Interest Statement: The authors have no conflicts of interest related to the content or preparation of this manuscript. 1
Source of Funding Statement This project was completed without extramural funding. Abbreviations
CEO. Chief Executive Officer CME. Continuing Medical Education GME. Graduate Medical Education KSA. Knowledge, Skill, Attitude UME. Undergraduate Medical Education
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Abstract
Assigning attributes to a birth cohort is one way we identify society-wide, shared life experiences within a group collectively called a “generation”. Such assigned attributes influence society’s adoption of generation-based expectations held by and about people from a particular birth cohort. Census data and generational attributes inform perspectives on millennial generation birth cohort experiences and engagement as students. The eldest living generation in U.S. society has given way to three subsequent generations, the youngest of which is called the millennial generation. What generational attributes influence the effectiveness of teaching and learning between millennial learners and faculty members from other generations? Understanding the role of life cycle effects, period effects, and cohort effects can offer medical and health professions educators’ insights into different strategies for learner engagement. Specific strategies and teaching tactics are discussed that faculty members can use to engage millennials across a continuum of learning to bridge the “expectation gap”.
Key Terms:
Intergenerational Relations; Interprofessional Relations; Education, Medical; Teaching
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Introduction
A generational expectation gap is created when one generation purportedly holds forth a best (or only) way of being or doing something as an expectation. The gap to be bridged is the distance required to align it with the matching “best way” expectation of a different generation. Our current knowledge about contributors to this expectation gap is anchored in two views: census data, and interpretation of those data based on sociodemographic attributes. Census data enumerate the population statistics by age groupings within the U.S. population. They provide a profile by measureable and self-reported features such as age, race, Hispanic or Latino origin, (binary) gender, and residents/region of the country. Sociodemographic data analyses depict historic and current groups by assigning a birth cohort bandwidth of approximately 15-22 years and timeline-based attributes. This sociodemographic grouping is referred to as the “generation profile”.
Characterizing the Cohort
A Census Snapshot of the Millennial Birth Cohort. Who are the millennials? The Census Bureau describes this group as "millennials, or America's youth born between 1982 and 2000, who now number 83.1 million and represent more than one-quarter of the nation's population. Their size exceeds that of the 75.4 million baby boomers, according to new U.S. Census Bureau estimates. Overall, millennials are more diverse than the generations that preceded them, with 44.2% being part of a minority race or ethnic group (that is, a group other than non-Hispanic, single 4
race white)."1 While the term “millennial” is the most widely used, synonyms included “nexters”, “generation Y”, “Nintendo generation”, “ generation next,” and the “Internet generation”.2 By comparison, sociologic analyses offer a look at the context and living conditions associated with a particular age group in American society during specific time periods. Sociologists3 and other thought leaders4, 5 have variously described the millennial generation cohort.
The oldest living cohort, the Veteran generation born between 1901 and 1924, are also known as the G.I. generation or the Greatest generation. Today, relating to the millennials are three other generations in the workforce and education system. The oldest of these are members of the silent/traditional generation born between 1925 and 1942 and whose age in 2016 was 71 or older. Next is the baby boom generation, with birth dates between 1946 and 1964; in 2016 baby boomers were 52-70 years old. Following the boomers is Generation X, (Gen X). Members of this birth cohort were between 36 and 51 years old in 2016, having been born between 1965 and 1980. Members of our most recent generation, the millennials, were born beginning in 1981. In 2016 their ages ranged from 18-35 years old. The end date for this generation has not yet been established, so the youngest of the millennial generation has yet to make their mark on the education system.
Over-Generalization of Birth Cohort Attributes. Pew Research Center data indicate that people born in the millennial cohort years do not particularly identify themselves as "millennials". Pew American Trends panel survey results show that each birth cohort embraces their "generation 5
label" differently. About 79% of 51-69-year-old (baby boomer) respondents embrace the "boomer" label, but others do not. Only 58% of 35-50-year-old (Gen X), and 40% of 18-34-yearold (millennial) respondents embrace their generation label. Finally, only 18% of the 70-87year-old (silent/traditional) respondents identified with their generation label. Pew notes, "generational names are largely the creation of social scientists and market researchers. The age boundaries of these widely used labels are somewhat variable and subjective."6
As shown in Table 1, among survey respondents, 33% of the millennial cohort identified as "Gen X” and 34% of the silent/traditional cohort identified as "Boomers", suggesting that in each generation some may see themselves uniquely affiliated with a generation other than the one assigned by their birth year, particularly if born in “cusp” years.
What generational effects impact learning in the millennial cohort? Three types of effects are described in generational research: life cycle effects, period effects, and cohort effects. Life cycle (or age) effects are observed differences between older and younger people, largely due to their respective positions in the life cycle. Period effects are when everyone, regardless of age, is simultaneously impacted and affected long-term by events related to social forces, or to circumstances such as war, economic conditions, or technology. Pew cites the shift in public views about the issue of terrorism and the related priority given to fighting terrorism globally following the 9/11 attacks as a period effect. Cohort effects are an observed byproduct of a unique historical circumstance that members of an age cohort experience, particularly during
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the time when they are forming opinions. The Great Depression and its aftermath are cited as having a cohort effect on members of one generation.7
Period Effects, Cohort Effects and the Millennials. Millennial learners are reported to be a very matter-of-fact group and have learned to question nearly everything. Born during an era of massive technology growth, this cohort effect has accustomed millennials to have instant access to information and extensive amounts of data integrated into everyday life. These two conditions prompted their development of highly efficient information sorting skills. Millennials are a generation of intelligent and developed mindsets, and as a cohort they often seem misunderstood. They are collaborative and team-oriented, but expect to be given meaningful assignments/work and are not motivated by monetary reward or accolades. They are polite and deferent to authority, but they also expect to be partners with their leaders. They do not necessarily accept the status quo and feel empowered to question the system, but at the same time are the generation of standardized educational content and standardized testing.
Millennials have been active participants in their household and in society to an extent unlike any generation before them. Their access to information along with encouragement from parents and teachers to question their world has made them comfortable engaging “higherups” with less regard to the traditional hierarchy: they are not afraid to e-mail the CEO of a company with their opinion. The millennial generation has been resistant or unresponsive to traditional leadership styles, making them question rules and procedures. Millennials need to feel a sense of buy-in and ownership in what they are being asked to join.8 7
Effectively engaging a response from millennials can be done by 1) helping them to understand what they are doing, why they are doing it, and how it can become part of the future greater good, 2) keeping teaching fast-paced by integrating relevant and up-to-date technology, and 3) using a more hands-on approach and outside-the-box thinking when presenting conventional ideas. Another important attribute is that millennials see leaders and authorities as part of a participative process: while they definitely respect authority, they are not by-default impressed by it – unlike previous generations.
From this vantage point, exploration, investigation, analysis and assessment of teaching and learning strategies are crucially important processes for faculty of medical schools and health professions education programs. Career choice9 and learning roles and role perceptions10 may be differentially affected by generational cohort experiences. Indeed, concerns about differences across the generational divide have led to calls for leaders to address this aspect of diversity in the physician workforce.11, 12 These factors draw focus on three specific questions: 1) What facts about the millennial generation birth cohort experiences can inform institutional preparation for teaching these learners? 2) How do millennial learners engage as students? and 3) What teaching tactics can faculty members use to engage effectively millennials in undergraduate, graduate, and continuing medical education, or the UME-GME-CME continuum of life-long-learning?
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Teaching Millennials
What facts about the millennial experiences can guide institutional preparation for teaching these learners? American higher education opened its doors to this new generation of learners in 1998. As they complete undergraduate education, the workforce, the graduate education community and medical and health professions colleges are welcoming this new group of learners.
Millennial learners will enter the next tier of academic pursuit at a time when the environment and expectations for teaching in classroom, laboratory13, clinical14, and community settings is increasingly complex, financially challenging15, and time-sensitive as pertains to training requirements16, duty hours17 and work-life balance.18 They are expected to bring a set of learning styles, life experiences, and personal values that resonate within their cohort19, but may be potentially less resonant for other generations.20
Addressing this variability may avoid both stereotyping the generation cohort and making broad assumptions about individual members or their learning style or experiences. Since the National Academy of Sciences’ publication of How People Learn21, evidence-based understanding of the way teaching and learning interface has advanced.21 However, with caution in mind not to stereotype individuals from any generation, these data can be useful for education planning in at least two ways. First, information about cohort experiences, knowledge, skills and aptitudes, can be used strategically for curriculum planning, and for 9
identifying academic infrastructure and personnel needed to support contemporary learning. Second, expert faculty members can be engaged and faculty development can be offered to ensure they have knowledge about, and access to, effective tools for individual millennial learner development. If they do identify with ascribed generational attributes, addressing those cohort characteristics will allow college leaders and educators to advance effective preparation for engagement.
Direct opportunities to leverage millennials’ desires include reinforcement and guided redirection of their ideals. Serving as mentors, educators can engage millennials early on by explaining and reinforcing exemplars of competence expectations in medicine. For example, millennials are reported to want: leaders to show honesty and integrity; opportunities for growth and development; friendships with peers; humor and fun; respectful treatment; and flexible activities.22 Many of these desired elements can be integrated into formal or informal mentoring and learning opportunities, such as discussing vision for the greater good resulting from individual knowledge, skill and teamwork, providing clear instruction followed by practice of simulated/actual team leadership, and intentional role modeling of leadership behaviors to make the skills observable to the learner. Following up with shared reflection to discuss what worked as expected and what did not work well in an interprofessional team or leadership situation can connect both learner and educator in building learning insights. Shared reflection also invites rapport-building between learner and faculty member.
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Awareness15, 23 of a generation’s cohort effect experiences offers a window-in-time snapshot of potentially important influences that shaped an individual's perspectives, expectations24, 25, and behaviors. These attributes are ingrained into the way millennial learners will interact with their teachers and the college/curriculum during professional education.
Cohort effects, contributing to learned behavior, preferences, values, and expectations set the stage for the learner to embrace or eschew various educational approaches. For example, one consistent description of millennial cohort learners is that they are "digital natives" 26; because their cohort has grown up in such a technologically-advanced society where information is so readily available, their educational mindset is unique. Other cohort effects influencing learning include: 1) micro-technology, such as tablets and smart phones, replacing computers; 2) Internet use (and availability) replacing television; 3) preference toward results and actions rather than knowledge base acquisition; 4) view multitasking as a social norm, even in the classroom; 5) typing and texting rather than hand writing; 6) apply technology connected with multiple devices and intra-device applications; and 7) instant information gratification, breeding lower tolerance for delay and greater expectations for immediacy and availability.27
Determining a teaching and learning approach that will guide these learners through progression from their digitally masterful but health professions novice state to expected competence is an opportunity and a challenge for educators.
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How does the millennial generation cohort prefer to engage? How do they compare to the engagement preferences of other generations? Table 2 provides an overview of engagement approaches used and preferred by each generation cohort. The center column notes learner engagement approaches. Two generations are grouped to the right and left of the engagement focus column. Note the relative ease in bridging the gap between adjacent generations, as well as the wider conceptual expectation gap for how engagement works between generations born 1922-1960 and those born 1960-2003.
Each generation in academic medicine and healthcare has traversed the learning continuum beginning with personal expectations about that journey and meeting head-on the realities of what is required to complete the journey and enter the profession. Career life in healthcare and medicine, as in any profession, includes experience-building to become more expert, and personal maturation to achieve greater acumen about the intricacies of work in the chosen field. In healthcare and medicine, the novice-to-expert maturation pathway requires: 1) prepreparation; 2) acceptance by those established in the field; 3) instruction, coaching, and mentoring (next tier preparation); and 4) feedback and assessment designed to provide challenge and continuing growth from experts in the field. This last assessment phase now also includes a stated expectation and commitment to life-long learning. Simply stated, these components operationalize the UME-GME-CME continuum.
Expert members take responsibility for novice new entrants and are tasked to teach and guide them from the entry point (greatest naïveté) to competence demonstration readiness. Experts 12
must regularly adapt their methods and tactics to fit the current setting where their expertise is being applied. In higher and professional education, the no-tech or low-tech environment has given way to greater use of digital and "smart" tools, providing the perfect setting for millennial cohort learners. For example, as they grew up, millennials had access to online learning resources, such as the Khan Academy.28 In 2013, recognizing the potential value for medical school applicants, the Association of American Medical Colleges partnered with the Khan Academy and the Robert Wood Johnson Foundation to create a free Medical College Aptitude Test (MCAT) preparation resource. The purpose was to offer this resource to any aspiring future medical student, using technology available in their home or pocket, or through their local library.29, 30 Where once expensive test preparation was available only to those who could afford it, today’s students can access Khan Academy resources with any smart device. This was clearly a strategic bridging partnership to increase the number and diversity of qualified applicants who are well-prepared to take the MCAT for medical school admission, but also to allow educators to engage the millennial learners using their preferred technological language, environment and tools. The potential uses faculty members could make of Khan Academy tools or similar innovative resources to advance medical education seem unlimited.
What personal teaching tactics can faculty members use to engage effectively millennials across the UME-GME-CME continuum? Teaching techniques based on observed millennial cohort behavior should consistently include three items: 1) clear direction and structure; 2) role modeling, coaching and mentoring; and 3) engagement and feedback. Table 3 compares generation cohort indicators of regard for expertise and authority. These indicators suggest that 13
there is a clear transition between expertise and authority expectations of the generations born 1922 – 1960 and those born 1960 – 2003.
The following teaching tactics provide the means to bridge the gap and engage millennial cohort learners: 1. Provide clear direction and structure. Teachers should afford learners with persistent and consistent opportunities to develop and practice critical thinking, while performance expectations up-front. Attention should be given to clearly articulating the sequence of performance benchmarks and competencies.31 When connected and completed, these learning objectives take the learner from lower level to higher level Knowledge, Skills, Abilities/Aptitudes (KSAs) for critical analyses and in preparation for demonstrating Entrustable Professional Activities (EPAs).32 Providing clear direction and structure can reduce both learner and faculty frustration. For example, quality and safety issues in contemporary clinical practice settings require that clear direction be provided when working with interprofessional teams; benefits accrue for patient outcomes and team efficiency. 2. Role Model, Coach, and Mentor. Role modeling is an effective tool. Directly related to clear direction and structure, it can also set the stage for feedback and assessment. Learners who identify with millennial cohort attributes appreciate engagement and are seeking guides/teachers who model integrity and trustworthiness. Demonstrating personal commitment through (enthusiastic) engagement in the work is a component of professional socialization.33 Fortunately, role modeling, coaching and mentoring34, 35 are 14
already deeply embedded in, physician, health professions, and basic biomedical science education. 3. Engage and Provide Feedback. Educators should provide opportunities for engagement with real-time performance feedback.36 As the millennial learner acquires competencies for mastery experiences37, engagement in new and stimulating situations is important. Simulation provides one such opportunity, as do sessions with standardized patients. Feedback on the quality of the learner’s engagement, the process of engagement (as directed), and the outcomes is highly sought after by millennialidentifying learners.38 In addition, correcting errors or eliminating ill-advised approaches to professional behavior can be accomplished through valuing the millennials’ appreciation for collaborative effective teamwork.
Expert teachers help novice learners develop discernment capacity and competence by refining novice critical thinking skills and testing emerging skills under increasingly complex conditions.39 For learners identifying with the millennial-age cohort, faculty members who help them bridge life-learned experience and professional discernment are crucial to closing the generation expectation gap.
Training a cadre of “master educators” who are skilled in mentorship, teaching and evaluation techniques leverages the normative/strategic approach. It recognizes a needed investment in faculty development, and emphasizes the roles of faculty members in guiding the progression of a learning cohort as well as guiding individual learners. DeWaay recommends creating a 15
"productive, pedagogically sound and deliberately competency-based system" that prepares the learner to engage expertly in understanding the pathophysiology of disease, and function as an effective member of an interprofessional team.40 Such competency-based training would be designed to include implementation, assessment and evaluation, and EPAs.32
Summary
Social scientists identify life cycle, period, and cohort effects that contribute to establishing generation labels and defining attributes. Health professions educators must keep in mind that societal level effects are not chosen intentionally by birth cohort members. Emergent social sector opportunities and costs, as well as decision opportunities, can affect the entirety of the living birth cohort generations—including learners in health care education and their faculty. Each must choose how to self-assess the impact of generational influences. Each must decide how to adapt to partner effectively in the teaching/learning experience of medical and health sciences.
As health professions educators in particular engage learners to bridge the learning gap between their own birth cohort, that of faculty colleagues in a different cohort, and the learners themselves, three factors are key. Educators must structure the environment and expectations against which the learner must demonstrate performance. The educator’s role should embrace instructor, mentor, coach and role model, based on strategically designed learning encounters. Finally, the educator must offer engagement opportunities and robust
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feedback as a means toward evaluating learner mastery. Learners must increasingly partner in these roles.
How will birth cohort effects remain relevant once observed performance attributes take center stage in the eyes of learners and educators alike? Faculty members serve in a linchpin role in guiding individual learners to serve in the physician or medical profession role through reinforcement of KSAs that align with criteria such as patient care quality, safety and ethical practice. When expert faculty members, as Master Teachers, help learners identify both criterion-based adaptive performance attributes, and those that are neutral or maladaptive as selected by the learner, better engagement is achieved. When learners partner with educators, the engagement process is enriched and individual performance criteria can be clarified through mentoring, shared reflection, and feedback. An individual learner must depend on unbiased assessment of criterion-based performance by the educator. Such a criterion-based approach used by physicians and interprofessional faculty can help build mutual understanding and bridge the generation expectation gap between today’s educators and millennial cohort learners.
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Acknowledgements
The authors thank our students, department and campus colleagues, and our mentors for sharing their experiences and insights.
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Table 1. Generation-reported attributes and how members self-identify % of generation saying [attribute] Share of generation that identifies as… describes their generation overall Generation
Attribute
%
Patriotic
12
Millennial
Responsible
24
18-34 year
Hardworking
36
olds
Self-reliant
27
Millennial
Gen X
Boomer
Silent
Greatest
40%
33%
8%
5%
8%
04%
02%
34%
18%
34%
Compassionate 29 Patriotic
73
Silent
Responsible
78
70-87 year
Hardworking
83
olds
Self-reliant
65
Compassionate 60
Adapted from: 6 Pew Research Center. Most Millennials Resist the ‘Millennial’ Label, http://www.peoplepress.org/2015/09/03/most-millennials-resist-the-millennial-label/; September 3, 2015. Accessed October 14, 2016.
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Table 2. Engagement approaches used and preferred by each generation cohort. Generations born betw 1922 - 1960
ENGAGEMENT
Generations born betw 1960-2003
Silent (Traditional)
Baby Boomers
FOCUS
Gen X
Millennial (Gen Y)
Top down
Guarded
Communication Style
Hub and spoke
Collaborative
Classroom
Facilitated
Learning Style
Independent
Collaborative and networked
The hard way
If “Too Much” will
Training opportunity
“Required to Keep Me”
Disengage Seeks approval from
expected
Team informed; my
authority
decision
Not comfortable
Not adept
Continuous and
Decision-making
Technology Use
Team included; our
Team decided; what all
decision
agreed to goes
Needed for max
Expected in all settings
engagement None is fine/Less is
Rare. Only when
more
necessary
Feedback
Weekly/Daily
Immediate and often
Rewards
Freedom
Meaningful work
Material gain; $, “Job well done”
perquisites, title
Adapted from: 8 Lancaster LC, Stillman D. When generations collide: who they are, why they clash, how to solve the generational puzzle at work. New York: HarperCollins; 2002.
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Table 3. Indicators of regard for expertise and authority Generations born betw 1922 - 1960 Silent (Traditional)
Baby Boomers
Respect
Love/Hate
EXPERTISE & AUTHORITY
Generations born betw 1960-2003 Gen X
Millennial (Gen Y)
Indifference
Politeness
Person in Authority Treated with Leader/Expert Shows Hierarchy
Consensus
Collaboration with Competence
Authority through
Command and Control
Take Charge or Get
Leader/Expert Style
out of the Way
is to Use
Others
Coaching
Negative if Delivered Discourteous or vulgar
Politically incorrect
Partnership
Too Uninhibited; Cliché
or Received as
Unethical
Adapted from: 8 Lancaster LC, Stillman D. When generations collide: who they are, why they clash, how to solve the generational puzzle at work. New York: HarperCollins; 2002. Zemke R, Raines C, Filipczak B. Generations at work: managing the clash of veterans, boomers, xers, and nexters in your workplace. AMACOM; 2000.
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