- Email: [email protected]
The millennials have arrived: What the surgeon educator needs to know to teach millennials
Surgery xxx (2019) 1e4
Contents lists available at ScienceDirect
Surgery journal homepage: www.elsevier.com/locate/surg
The millennials have arrived: What the surgeon educator needs to know to teach millennials Peter A. Ebeling, MD, Daniel L. Dent, MD, Jason W. Kempenich, MD* Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 13 May 2019 Available online xxx
Numerous authors have described the millennial generation, defined as a cohort of people born between the early 1980s and late 1990s, as unique from preceding generations, such as Generation X and the baby boomers. Many surgical educators generally belong to elder generations, and there is some concern that intergenerational differences may be source of friction between teacher and learner. There is renewed interest in both addressing pedagogic strategies to train millennial surgery residents and providing the nonmillennial surgeon educator with instruction techniques best suited for millennials. However, surgical educators sometimes encounter or propagate uncertainties, conflicts, or stereotypes regarding millennial characteristics and ideal teaching strategies. We review the relevant literature regarding intergenerational teaching strategies as they pertain to training millennial surgery residents. © 2019 Elsevier Inc. All rights reserved.
Introduction There is increasing interest among surgical educators to characterize the millennial generation. A motivating factor for doing so is a belief that millennials are distinct from prior generations of surgical residents and require a different pedagogic approach.1,2 Although generational cutoffs are variably defined, the millennial generation usually includes individuals born between the early 1980s and the late 1990s.3 Most sources typically describe this generation as being uniquely shaped by the technologic revolution of the mid-to-late 1990s and early 2000s, the September 11 terrorist attacks, and the Great Recession of 2008. Earlier generations, such as Generation X (1965e1980) and the baby-boomer generation (1946e1964) are similarly thought to be influenced by the seminal events of their own eras. Baby boomers came of age during a postwar period of prosperity and benefited from the country’s buoyant economy, but were also shaped by the racial and political unrest of the 1960s to 1970s. Generation Xers likewise are said to be influenced by the AIDS epidemic, the Challenger shuttle explosion, and the first Gulf War.4,5 Various writers have ascribed personality characteristics to each generational group.1,5,6 For example, baby boomers are often described as industrious, diligent, and conservative. In contrast, * Reprint requests: Jason W. Kempenich, MD, Department of Surgery, University of Texas Health Science Center at San Antonio, General and Minimally Invasive Surgery, 7703 Floyd Curl Dr, San Antonio, TX 78229. E-mail address: [email protected] (J.W. Kempenich).
https://doi.org/10.1016/j.surg.2019.05.028 0039-6060/© 2019 Elsevier Inc. All rights reserved.
there is no shortage of criticism leveled at millennials in popular media. Born to helicopter parents and raised among the iridescent glow of computer screens and iPhones, millennials are narcissistic, have short attention spans, and expect to be praised daily.4,7 At least, this is the common narrative sometimes recited by elder superiors. Surgical residencies must now confront training a generation of new surgeons sold as being wholly different than their predecessors. Virtually 100% of medical and surgical residents are millennials.8 The Association of American Medical Colleges projects that 1 in 3 physicians will be 65 years of age by 2027, and impending retirements will soon leave millennials as the largest cohort of physicians in the United States.9 In light of these changing demographics, it is reasonable to ask what unique challenges this generational cadre represents to surgical educators. It is worth noting that psychologists have examined the notion of generational bias, the belief that one’s own generation is superior to others.6,10 Three key points emerge from this research. First, there is some degree of bias among generations and between them. Second, generational stereotypes that spur bias are seldom completely accurate. Last, generational bias can hurt the nonmillennials just as easily as millennials. For example, baby boomers may be cast as reticent to adopt new technology and too stuck in their ways.10 Often, generational stereotypes propagate from whichever generation is currently the dominant force in the work place. These notions usually have little to do with true generational differences and are merely an expression of one generation’s insecurity with another.
2
P.A. Ebeling et al. / Surgery xxx (2019) 1e4
Millennial characteristics The millennial generation represents several demographic shifts for society. It is now the most diverse generation in the country, with 44% of millennials identifying as a minority group.11 Millennials are unique in their social makeup and have developed, at least by some authors’ accounts, a unique set of attributes. In their 2000 book,5 Neil Howe and William Strauss contend millennials are, among other things, special, sheltered, team-oriented, and pressured. They contend each of these characteristics represents a significant break from Generation X adults, who grew up under distinct social and familial environments. The children Howe and Strauss studied almost 20 years ago have now grown up and influence the workplace in unique ways. Gallup polling data from 2016 indicate millennials incorporate vocation into their identity more than prior generations.12 As work becomes enmeshed with the self, the dynamic between employer and employee (or teacher and learner) changes. In surgery, this transforms the attending from the boss to the coach in and out of the operating room. The chairperson not only hands down orders, but also he or she helps the millennial intern improve. The millennial resident views the surgeon educator as a shepherd on a path of personal, not just professional development. As the president of the Gallup organization put it, millennials are now about progress and development, and less about picking up a paycheck.12 This trend is not unique to American millennials. A 2017 survey of German medical students’ attitudes toward surgery showed that although the cohort thought surgery was an interesting field, the majority would not want to pursue a career in surgery.13 More important than pay or prestige was the promise of self-fulfillment in other specialties. Accordingly, some older surgeons have regarded this younger generation as less committed to surgery. We contend millennials are not less committed to surgery than prior generations. The millennial resident may have to contend with agespecific social situations, such as young children at home and new marriages, that elder surgeons already experienced earlier in their lives. What are often attributed as generational differences may actually be life stage differences between residents in their late 20s and attendings in their early 50s.14 Educators must recognize differing social situations and work with residents to fulfill necessary work and home obligations. The Nonmillennial teaching millennials Whereas millennials favor fast-paced change, surgery and medicine are conservative professions where change is implemented after careful deliberation. Some authors advocate using technology as the medium millennials are most comfortable with to teach surgical skills.1,2 Surgery and surgical education have been forever transformed by technology and simulation strategies. The Accreditation Council for Graduate Medical Education has long mandated that surgery residencies provide laparoscopic and endoscopic simulators.15 There are numerous examples in the literature demonstrating training on a simulator before scrubbing a case improves performance and has a durable effect.16,17 The shift toward improving simulation training in surgery occurred as some of the oldest millennials began residency training. Indeed, educators in various surgical fields have seen this generational shift coming for some time. Surgical educators are uniquely positioned to teach residents and students one on one. The operating room is an exclusive part of the hospital, one where only a few distractions can interject. This presents the surgeon educator with ample time to mentor and teach. Dr Peter Rhee wrote an editorial aimed at hand and upper extremity surgeons where he outlined the optimal non-millennial
and millennial relationship.18 Ideally, the attending and resident meet well before the case to discuss the approach. The attending shares references, in electronic format, with the resident who can then appropriately prepare for the case. During the case, the attending may offer positive and negative feedback knowing that both operators have a mutual understanding of what is expected of each other. Another article from Phillips and Isenberg19 focused on teaching millennial colorectal fellows, advising attendings to give prompt and balanced (not too negative or positive) feedback to the learner. They note millennials may be so accustomed to receiving information quickly and directly that older generations perceive them as needing to be spoon fed. There are of course pedagogic strategies to avoid this. Educators may ask a resident to read about a topic and present it briefly the following day or allow a resident to struggle through parts of an operation with appropriate verbal cues. One of the recurring attributes of the millennial generation is its desire for feedback at frequent intervals. This changing dynamic has and will clash with surgery’s historically rigid hierarchy. This has already made older methods of sharing information via scheduled meetings and along a chain of command increasingly uncommon. Waljee et al20 provided a system for mentoring millennial faculty emphasizing this process element. Overall, they recommend providing more frequent, shorter feedback meetings along with opportunities for the mentee to provide his or her own perspective to a team of mentors. Hopkins et al21 reviewed the generational learning literature to elucidate better teaching strategies for third- and fourth-year medical students. Overall, their recommendations include incorporating items such as twitter, peer-to-peer learning, and gamification. Most authors on this subject recognize the vast influence mobile technology has had on millennials. Yet, it remains unclear if this actually changes the dynamic between teacher and learner. Millennials simply happened to grow up during this technologic era and do not have some secret command of technology other generations could not just as easily learn. For example, some residency programs have had their trainees watch instructional videos before performing a minor procedure.2 The group that watched the videos did indeed perform the task more efficiently than the group that did not, but what this really shows is that instruction and preparation lead to better outcomes. Simply put, no one is born with an app already downloaded into his or her brain. Surgical educators can learn how to optimize their interactions with this generation by looking to other institutions’ experience. Lessons from the military The present surgical education literature emphasizes the use of video instruction, simulation, and quick, direct feedback to reach the millennial resident. What is largely lacking is a concrete pedagogy directing how the nonmillennial and millennial surgeons should interact. Perhaps the largest single institution in the United States that has already dealt with this demographic sea-change is the armed services. In 2015, nearly two-thirds of all active duty personnel in the United States Department of Defense were <30 years old.22 The military has always had to incorporate young people into its forces and, for the most part, has already developed sound principles for doing so. There are intuitive parallels between military service and surgery residencies; both require constant influx of young talent, there is a hierarchy to each, and both systems must adapt to changing circumstances. An article from the Kellogg School of Business publication at Northwestern University illustrates a framework for mentoring millennials in the military,23 but it could be easily adopted by surgeon educators. Three key elements are included:
P.A. Ebeling et al. / Surgery xxx (2019) 1e4
3
Table Examples of millennial behavior in surgery residency situations and suggested responses Millennial behavior
Suggested non-millennial response
Jr resident challenges staff on rounds or patient care Resident reports suboptimal work space conditions Jr resident challenges staff during complex surgery
Acknowledge resident’s knowledge base and encourage subsequent conversations Inspect resident working conditions
1. Recognize ambition and set expectations Young interns need to stretch their legs. Some may want to scrub every Whipple even though they have not yet mastered closing skin. Leaders should recognize this ambition, encourage it, and work with the learner to meet their respective milestones. This may require more personal, one-on-one direction than older surgeons are accustomed to or received during their training. However, the hallmark of a good leader is taking ownership of his or her trainees. 2. Communicate on their level The author notes that military commanders are expected to inspect their recruits’ readiness by walking the barracks and performing equipment and wellness checks. Commanders must, “Go into their space, meet them where they are.”23 This is a challenging concept for a busy surgical attending pulled between clinical, academic, and personal obligations. However, this level of interaction could be invaluable to help establish a durable rapport between the senior attending and the incoming resident. “Communicating on their level” may also extend to electronic platforms, that is, messaging on Twitter, Facebook, or Instagram. 3. Give them room to innovate There is often tension between the educator and learner when the trainee seems to challenge the senior’s plan or authority. This friction is constantly evident in surgery, where there is a hierarchy in training programs and generations of surgical dogma. The nonmillennial teacher should recognize that, far from being insubordinate, the young learner is stretching his or her knowledge base. Challenging work systems in the hospital should be a positive aspect, and this enthusiasm for change needs to be anticipated and encouraged. Table summarizes examples of millennial behaviors and recommended nonmillennial responses. There will always be some degree of intergenerational friction in complex learning systems. Senior commanders within the United States Air Force have already recognized both the perceived challenges and benefits to bring this younger generation into the fold.24 Their recommendations echo the aforementioned scheme, including tolerating millennials’ seemingly cavalier attitudes toward communicating with people high up in the chain of command. Moreover, there is a perception among some military commanders that younger recruits lack a commitment to the service. It is not difficult to imagine an elder surgeon similarly casting dispersions on the millennial generation’s commitment to surgery. The simple solution is to accept the millennial learner at face value and bring him or her into the fold. Molding a learner into a competent surgeon takes time, patience, and sacrifice. Perhaps most prescient, the authors note most inter-generational tension stems from older commanders and their perceived slights, not the millennial subordinates. The ending of the article summarizes what should be the motto of any surgical residency, “None of us is as smart as all of us, and as we try to tackle today's … problems, we want the millennials on our side.”24
Acknowledge resident’s knowledge base and set expectations about the resident’s role in complex operations
Far from representing the downfall of surgery, millennials will carry the mantle of safe surgery for decades to come. Although none of us can overlook the impact new technology has had on medical education, it is even more important to recognize the substantial, but not insurmountable character differences between older and younger generations. Video lessons and simulations are invaluable teaching tools for surgery programs, but nothing is a substitute for working directly with dedicated surgeon educators. The non-millennial teacher should strive to communicate on the young learners’ level through direct, frequent feedback. Millennial ambition should not be mistaken for disrespect, but a desire to improve the status quo. Lastly, leaders in surgery should encourage their millennial residents to challenge themselves and the health care systems they encounter. Funding/Support The authors have indicated that they have no conflicts of interest (or funding) regarding the content of this article. Conflict of interest/Disclosures The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. References 1. Schlitzkus LL, Schenarts KD, Schenarts PJ. Is your residency program ready for generation Y? J Surg Educ. 2010;67:108e111. 2. Rowse PG, Ruparel RK, Aljamal YN, Abdelsattar JM, Heller SF, Farley DR. Catering to millennial learners: Assessing and improving fine-needle aspiration performance. J Surg Educ. 2014;71:e53ee58. 3. Fry R. Millennials are the largest generation in the US labor force. Pew Research Center. Available from: http://www.pewresearch.org/fact-tank/2018/04/11/ millennials-largest-generation-us-labor-force/. Accessed February 5, 2019. 4. Stein J. Millennials: The me me me generation. Time. 2013 May 20. Available from: http://time.com/247/millennials-the-me-me-me-generation/. Accessed March 6, 2019. 5. Howe N, Strauss W. Millennials rising: The next great generation. New York: Vintage Books; 2000. 6. Wong M, Gardiner E, Lang W, Coulon L. Generational differences in personality and motivation. J Manag Psychol. 2008;23:878e890. 7. Dilullo C, Mcgee P, Kriebel RM. Demystifying the millennial student: A reassessment in measures of character and engagement in professional education. Anat Sci Educ. 2011;4:214e226. 8. Boysen PG, Daste L, Northern T. Multigenerational challenges and the future of graduate medical education. Ochsner J. 2016;16:101e107. 9. Mann S. Research shows shortage of more than 100,000 doctors by 2030. AAMC News. 2017 Mar 14. Available from: https://news.aamc.org/medicaleducation/article/new-aamc-research-reaffirms-looming-physician-shor/. Accessed February 13, 2009. 10. Cox CB, Young FK, Guardia AB, Bohmann AK. The Baby Boomer bias: The negative impact of generational labels on older workers. J Appl Soc Psychol. 2018;4:71e79. 11. Millennials outnumber baby boomers and are far more diverse, Census Bureau reports. United States Census Bureau. 2015 Jun 25. Available from: https:// www.census.gov/newsroom/press-releases/2015/cb15-113.html. Accessed February 15, 2019. 12. Chokshi N. How badly companies misunderstand millennials. The Washington Post. 2016 May 11. Available from: https://www.washingtonpost.com/news/ wonk/wp/2016/05/11/how-badly-companies-misunderstand-millennials/? noredirect¼on&utm_term¼.487d1a67dc96. Accessed January 29, 2019.
4
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13. Kleinert R, Fuchs C, Romotzky V, et al. Generation Y and surgical residency: Passing the baton or the end of the world as we know it? Results from a survey among medical students in Germany. PLoS One. 2017;12: e0188114. 14. Deal JJ, Altman DG, Rogelberg SG. Millennials at work: What we know and what we need to do (if anything). J Bus Psychol. 2010;25:191e199. 15. Reznick RK, MacRae H. Teaching surgical skillsdChanges in the wind. N Engl J Med. 2006;355:2664e2669. 16. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic training on bench models: Better and more cost effective than operating room experience? J Am Coll Surg. 2000;191:272e283. 17. Grober ED, Hamstra SJ, Wanzel KR, et al. Laboratory based training in urological microsurgery with bench model simulators: A randomized controlled trial evaluating the durability of technical skill. J Urol. 2004;172: 378e381. 18. Rhee PC. Socrates’ dilemma: Challenges in training the millennial generation of hand and upper-extremity surgeons. Tech Hand Up Extrem Surg. 2016;20: 89e90.
19. Phillips BR, Isenberg GA. Training the millennial generation: Understanding the new generation of learners entering colon and rectal residency. Semin Colon Rectal Surg. 2015;26:147e149. 20. Waljee J, Chopra V, Saint S. Mentoring millennials. JAMA. 2018;319: 1547e1548. 21. Hopkins L, Hampton BS, Abbott JF, et al. To the point: Medical education, technology, and the millennial learner. Am J Obstet Gynecol. 2018;218: 188e192. 22. Parker K, Cilluffo A, Stepler R. 6 facts about the US military and its changing demographics. Pew Research Center. Available from: http://www.pewresearch. org/fact-tank/2017/04/13/6-facts-about-the-u-s-military-and-its-changing-demographics/. Accessed February 18, 2019. 23. Calvert D. How the US army recruits and retains millennials; based on insights from Col. Robert Carr. Kellogg Insight. Available from: https://insight.kellogg. northwestern.edu/article/how-the-us-army-recruits-and-retains-millennials. Accessed February 18, 2019. 24. Hinote CS, Sundvall TJ. Leading millennials: An approach that works. Air Sp Power J. 2015;29:131e138.
Contents lists available at ScienceDirect
Surgery journal homepage: www.elsevier.com/locate/surg
The millennials have arrived: What the surgeon educator needs to know to teach millennials Peter A. Ebeling, MD, Daniel L. Dent, MD, Jason W. Kempenich, MD* Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 13 May 2019 Available online xxx
Numerous authors have described the millennial generation, defined as a cohort of people born between the early 1980s and late 1990s, as unique from preceding generations, such as Generation X and the baby boomers. Many surgical educators generally belong to elder generations, and there is some concern that intergenerational differences may be source of friction between teacher and learner. There is renewed interest in both addressing pedagogic strategies to train millennial surgery residents and providing the nonmillennial surgeon educator with instruction techniques best suited for millennials. However, surgical educators sometimes encounter or propagate uncertainties, conflicts, or stereotypes regarding millennial characteristics and ideal teaching strategies. We review the relevant literature regarding intergenerational teaching strategies as they pertain to training millennial surgery residents. © 2019 Elsevier Inc. All rights reserved.
Introduction There is increasing interest among surgical educators to characterize the millennial generation. A motivating factor for doing so is a belief that millennials are distinct from prior generations of surgical residents and require a different pedagogic approach.1,2 Although generational cutoffs are variably defined, the millennial generation usually includes individuals born between the early 1980s and the late 1990s.3 Most sources typically describe this generation as being uniquely shaped by the technologic revolution of the mid-to-late 1990s and early 2000s, the September 11 terrorist attacks, and the Great Recession of 2008. Earlier generations, such as Generation X (1965e1980) and the baby-boomer generation (1946e1964) are similarly thought to be influenced by the seminal events of their own eras. Baby boomers came of age during a postwar period of prosperity and benefited from the country’s buoyant economy, but were also shaped by the racial and political unrest of the 1960s to 1970s. Generation Xers likewise are said to be influenced by the AIDS epidemic, the Challenger shuttle explosion, and the first Gulf War.4,5 Various writers have ascribed personality characteristics to each generational group.1,5,6 For example, baby boomers are often described as industrious, diligent, and conservative. In contrast, * Reprint requests: Jason W. Kempenich, MD, Department of Surgery, University of Texas Health Science Center at San Antonio, General and Minimally Invasive Surgery, 7703 Floyd Curl Dr, San Antonio, TX 78229. E-mail address: [email protected] (J.W. Kempenich).
https://doi.org/10.1016/j.surg.2019.05.028 0039-6060/© 2019 Elsevier Inc. All rights reserved.
there is no shortage of criticism leveled at millennials in popular media. Born to helicopter parents and raised among the iridescent glow of computer screens and iPhones, millennials are narcissistic, have short attention spans, and expect to be praised daily.4,7 At least, this is the common narrative sometimes recited by elder superiors. Surgical residencies must now confront training a generation of new surgeons sold as being wholly different than their predecessors. Virtually 100% of medical and surgical residents are millennials.8 The Association of American Medical Colleges projects that 1 in 3 physicians will be 65 years of age by 2027, and impending retirements will soon leave millennials as the largest cohort of physicians in the United States.9 In light of these changing demographics, it is reasonable to ask what unique challenges this generational cadre represents to surgical educators. It is worth noting that psychologists have examined the notion of generational bias, the belief that one’s own generation is superior to others.6,10 Three key points emerge from this research. First, there is some degree of bias among generations and between them. Second, generational stereotypes that spur bias are seldom completely accurate. Last, generational bias can hurt the nonmillennials just as easily as millennials. For example, baby boomers may be cast as reticent to adopt new technology and too stuck in their ways.10 Often, generational stereotypes propagate from whichever generation is currently the dominant force in the work place. These notions usually have little to do with true generational differences and are merely an expression of one generation’s insecurity with another.
2
P.A. Ebeling et al. / Surgery xxx (2019) 1e4
Millennial characteristics The millennial generation represents several demographic shifts for society. It is now the most diverse generation in the country, with 44% of millennials identifying as a minority group.11 Millennials are unique in their social makeup and have developed, at least by some authors’ accounts, a unique set of attributes. In their 2000 book,5 Neil Howe and William Strauss contend millennials are, among other things, special, sheltered, team-oriented, and pressured. They contend each of these characteristics represents a significant break from Generation X adults, who grew up under distinct social and familial environments. The children Howe and Strauss studied almost 20 years ago have now grown up and influence the workplace in unique ways. Gallup polling data from 2016 indicate millennials incorporate vocation into their identity more than prior generations.12 As work becomes enmeshed with the self, the dynamic between employer and employee (or teacher and learner) changes. In surgery, this transforms the attending from the boss to the coach in and out of the operating room. The chairperson not only hands down orders, but also he or she helps the millennial intern improve. The millennial resident views the surgeon educator as a shepherd on a path of personal, not just professional development. As the president of the Gallup organization put it, millennials are now about progress and development, and less about picking up a paycheck.12 This trend is not unique to American millennials. A 2017 survey of German medical students’ attitudes toward surgery showed that although the cohort thought surgery was an interesting field, the majority would not want to pursue a career in surgery.13 More important than pay or prestige was the promise of self-fulfillment in other specialties. Accordingly, some older surgeons have regarded this younger generation as less committed to surgery. We contend millennials are not less committed to surgery than prior generations. The millennial resident may have to contend with agespecific social situations, such as young children at home and new marriages, that elder surgeons already experienced earlier in their lives. What are often attributed as generational differences may actually be life stage differences between residents in their late 20s and attendings in their early 50s.14 Educators must recognize differing social situations and work with residents to fulfill necessary work and home obligations. The Nonmillennial teaching millennials Whereas millennials favor fast-paced change, surgery and medicine are conservative professions where change is implemented after careful deliberation. Some authors advocate using technology as the medium millennials are most comfortable with to teach surgical skills.1,2 Surgery and surgical education have been forever transformed by technology and simulation strategies. The Accreditation Council for Graduate Medical Education has long mandated that surgery residencies provide laparoscopic and endoscopic simulators.15 There are numerous examples in the literature demonstrating training on a simulator before scrubbing a case improves performance and has a durable effect.16,17 The shift toward improving simulation training in surgery occurred as some of the oldest millennials began residency training. Indeed, educators in various surgical fields have seen this generational shift coming for some time. Surgical educators are uniquely positioned to teach residents and students one on one. The operating room is an exclusive part of the hospital, one where only a few distractions can interject. This presents the surgeon educator with ample time to mentor and teach. Dr Peter Rhee wrote an editorial aimed at hand and upper extremity surgeons where he outlined the optimal non-millennial
and millennial relationship.18 Ideally, the attending and resident meet well before the case to discuss the approach. The attending shares references, in electronic format, with the resident who can then appropriately prepare for the case. During the case, the attending may offer positive and negative feedback knowing that both operators have a mutual understanding of what is expected of each other. Another article from Phillips and Isenberg19 focused on teaching millennial colorectal fellows, advising attendings to give prompt and balanced (not too negative or positive) feedback to the learner. They note millennials may be so accustomed to receiving information quickly and directly that older generations perceive them as needing to be spoon fed. There are of course pedagogic strategies to avoid this. Educators may ask a resident to read about a topic and present it briefly the following day or allow a resident to struggle through parts of an operation with appropriate verbal cues. One of the recurring attributes of the millennial generation is its desire for feedback at frequent intervals. This changing dynamic has and will clash with surgery’s historically rigid hierarchy. This has already made older methods of sharing information via scheduled meetings and along a chain of command increasingly uncommon. Waljee et al20 provided a system for mentoring millennial faculty emphasizing this process element. Overall, they recommend providing more frequent, shorter feedback meetings along with opportunities for the mentee to provide his or her own perspective to a team of mentors. Hopkins et al21 reviewed the generational learning literature to elucidate better teaching strategies for third- and fourth-year medical students. Overall, their recommendations include incorporating items such as twitter, peer-to-peer learning, and gamification. Most authors on this subject recognize the vast influence mobile technology has had on millennials. Yet, it remains unclear if this actually changes the dynamic between teacher and learner. Millennials simply happened to grow up during this technologic era and do not have some secret command of technology other generations could not just as easily learn. For example, some residency programs have had their trainees watch instructional videos before performing a minor procedure.2 The group that watched the videos did indeed perform the task more efficiently than the group that did not, but what this really shows is that instruction and preparation lead to better outcomes. Simply put, no one is born with an app already downloaded into his or her brain. Surgical educators can learn how to optimize their interactions with this generation by looking to other institutions’ experience. Lessons from the military The present surgical education literature emphasizes the use of video instruction, simulation, and quick, direct feedback to reach the millennial resident. What is largely lacking is a concrete pedagogy directing how the nonmillennial and millennial surgeons should interact. Perhaps the largest single institution in the United States that has already dealt with this demographic sea-change is the armed services. In 2015, nearly two-thirds of all active duty personnel in the United States Department of Defense were <30 years old.22 The military has always had to incorporate young people into its forces and, for the most part, has already developed sound principles for doing so. There are intuitive parallels between military service and surgery residencies; both require constant influx of young talent, there is a hierarchy to each, and both systems must adapt to changing circumstances. An article from the Kellogg School of Business publication at Northwestern University illustrates a framework for mentoring millennials in the military,23 but it could be easily adopted by surgeon educators. Three key elements are included:
P.A. Ebeling et al. / Surgery xxx (2019) 1e4
3
Table Examples of millennial behavior in surgery residency situations and suggested responses Millennial behavior
Suggested non-millennial response
Jr resident challenges staff on rounds or patient care Resident reports suboptimal work space conditions Jr resident challenges staff during complex surgery
Acknowledge resident’s knowledge base and encourage subsequent conversations Inspect resident working conditions
1. Recognize ambition and set expectations Young interns need to stretch their legs. Some may want to scrub every Whipple even though they have not yet mastered closing skin. Leaders should recognize this ambition, encourage it, and work with the learner to meet their respective milestones. This may require more personal, one-on-one direction than older surgeons are accustomed to or received during their training. However, the hallmark of a good leader is taking ownership of his or her trainees. 2. Communicate on their level The author notes that military commanders are expected to inspect their recruits’ readiness by walking the barracks and performing equipment and wellness checks. Commanders must, “Go into their space, meet them where they are.”23 This is a challenging concept for a busy surgical attending pulled between clinical, academic, and personal obligations. However, this level of interaction could be invaluable to help establish a durable rapport between the senior attending and the incoming resident. “Communicating on their level” may also extend to electronic platforms, that is, messaging on Twitter, Facebook, or Instagram. 3. Give them room to innovate There is often tension between the educator and learner when the trainee seems to challenge the senior’s plan or authority. This friction is constantly evident in surgery, where there is a hierarchy in training programs and generations of surgical dogma. The nonmillennial teacher should recognize that, far from being insubordinate, the young learner is stretching his or her knowledge base. Challenging work systems in the hospital should be a positive aspect, and this enthusiasm for change needs to be anticipated and encouraged. Table summarizes examples of millennial behaviors and recommended nonmillennial responses. There will always be some degree of intergenerational friction in complex learning systems. Senior commanders within the United States Air Force have already recognized both the perceived challenges and benefits to bring this younger generation into the fold.24 Their recommendations echo the aforementioned scheme, including tolerating millennials’ seemingly cavalier attitudes toward communicating with people high up in the chain of command. Moreover, there is a perception among some military commanders that younger recruits lack a commitment to the service. It is not difficult to imagine an elder surgeon similarly casting dispersions on the millennial generation’s commitment to surgery. The simple solution is to accept the millennial learner at face value and bring him or her into the fold. Molding a learner into a competent surgeon takes time, patience, and sacrifice. Perhaps most prescient, the authors note most inter-generational tension stems from older commanders and their perceived slights, not the millennial subordinates. The ending of the article summarizes what should be the motto of any surgical residency, “None of us is as smart as all of us, and as we try to tackle today's … problems, we want the millennials on our side.”24
Acknowledge resident’s knowledge base and set expectations about the resident’s role in complex operations
Far from representing the downfall of surgery, millennials will carry the mantle of safe surgery for decades to come. Although none of us can overlook the impact new technology has had on medical education, it is even more important to recognize the substantial, but not insurmountable character differences between older and younger generations. Video lessons and simulations are invaluable teaching tools for surgery programs, but nothing is a substitute for working directly with dedicated surgeon educators. The non-millennial teacher should strive to communicate on the young learners’ level through direct, frequent feedback. Millennial ambition should not be mistaken for disrespect, but a desire to improve the status quo. Lastly, leaders in surgery should encourage their millennial residents to challenge themselves and the health care systems they encounter. Funding/Support The authors have indicated that they have no conflicts of interest (or funding) regarding the content of this article. Conflict of interest/Disclosures The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. References 1. Schlitzkus LL, Schenarts KD, Schenarts PJ. Is your residency program ready for generation Y? J Surg Educ. 2010;67:108e111. 2. Rowse PG, Ruparel RK, Aljamal YN, Abdelsattar JM, Heller SF, Farley DR. Catering to millennial learners: Assessing and improving fine-needle aspiration performance. J Surg Educ. 2014;71:e53ee58. 3. Fry R. Millennials are the largest generation in the US labor force. Pew Research Center. Available from: http://www.pewresearch.org/fact-tank/2018/04/11/ millennials-largest-generation-us-labor-force/. Accessed February 5, 2019. 4. Stein J. Millennials: The me me me generation. Time. 2013 May 20. Available from: http://time.com/247/millennials-the-me-me-me-generation/. Accessed March 6, 2019. 5. Howe N, Strauss W. Millennials rising: The next great generation. New York: Vintage Books; 2000. 6. Wong M, Gardiner E, Lang W, Coulon L. Generational differences in personality and motivation. J Manag Psychol. 2008;23:878e890. 7. Dilullo C, Mcgee P, Kriebel RM. Demystifying the millennial student: A reassessment in measures of character and engagement in professional education. Anat Sci Educ. 2011;4:214e226. 8. Boysen PG, Daste L, Northern T. Multigenerational challenges and the future of graduate medical education. Ochsner J. 2016;16:101e107. 9. Mann S. Research shows shortage of more than 100,000 doctors by 2030. AAMC News. 2017 Mar 14. Available from: https://news.aamc.org/medicaleducation/article/new-aamc-research-reaffirms-looming-physician-shor/. Accessed February 13, 2009. 10. Cox CB, Young FK, Guardia AB, Bohmann AK. The Baby Boomer bias: The negative impact of generational labels on older workers. J Appl Soc Psychol. 2018;4:71e79. 11. Millennials outnumber baby boomers and are far more diverse, Census Bureau reports. United States Census Bureau. 2015 Jun 25. Available from: https:// www.census.gov/newsroom/press-releases/2015/cb15-113.html. Accessed February 15, 2019. 12. Chokshi N. How badly companies misunderstand millennials. The Washington Post. 2016 May 11. Available from: https://www.washingtonpost.com/news/ wonk/wp/2016/05/11/how-badly-companies-misunderstand-millennials/? noredirect¼on&utm_term¼.487d1a67dc96. Accessed January 29, 2019.
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19. Phillips BR, Isenberg GA. Training the millennial generation: Understanding the new generation of learners entering colon and rectal residency. Semin Colon Rectal Surg. 2015;26:147e149. 20. Waljee J, Chopra V, Saint S. Mentoring millennials. JAMA. 2018;319: 1547e1548. 21. Hopkins L, Hampton BS, Abbott JF, et al. To the point: Medical education, technology, and the millennial learner. Am J Obstet Gynecol. 2018;218: 188e192. 22. Parker K, Cilluffo A, Stepler R. 6 facts about the US military and its changing demographics. Pew Research Center. Available from: http://www.pewresearch. org/fact-tank/2017/04/13/6-facts-about-the-u-s-military-and-its-changing-demographics/. Accessed February 18, 2019. 23. Calvert D. How the US army recruits and retains millennials; based on insights from Col. Robert Carr. Kellogg Insight. Available from: https://insight.kellogg. northwestern.edu/article/how-the-us-army-recruits-and-retains-millennials. Accessed February 18, 2019. 24. Hinote CS, Sundvall TJ. Leading millennials: An approach that works. Air Sp Power J. 2015;29:131e138.