From the Editor: Gods and Monsters

Aug 31, 2017


For the first time in history, four generations of physicians work side by side in the U.S. health care system. An expanding population, longer life expectancies and later retirement ages all contribute to this phenomenon. Each of these generations has made significant contributions to modern surgery and how we practice it. For better and for worse.

Traditionalists, or the Greatest Generation, were true surgical pioneers. DeBakey, Cooley, Fogarty, their names now adorn everything from instruments to medical centers. They truly founded the modern system of surgery. Born between 1900 and 1945, Traditionalists were forged in the crucibles of the Great War and the Great Depression. Their core values were hard work, discipline, and sacrifice. A large number were combat veterans who valued conformity and adherence to the rules. Traditionalists set up our current hierarchical departments of surgery. Mirroring their values, they employed a military chain of command approach. Many traditionalists rose to positions of absolute power, and some were corrupted by this power. Gods became monsters. Abuse, both verbal and physical, came to be commonplace and accepted in the surgical work environment.

Born between 1946 and 1964, Baby Boomers were raised in the aftermath of a war none of them saw. More optimistic and idealistic than the Traditionalists, the Boomers valued success. Their goals became more individualistic. Chasing money, titles and recognition, Boomers wanted to build a stellar career. Fifty-hour work weeks became 70, 80, or 90. Ambition led to wealth, dramatic successes, and remarkable careers. Their choices also led to divorce, drug abuse, and suicide. While burnout has become a modern concern, its roots are clearly tied to this era. Now serving as our deans and department chairs, the Boomers also made several notable contributions. Specific to our field, Boomers oversaw the development of vascular surgery as an independent specialty and the expansion of fellowship training programs. Coming of age in the 1960s, Boomers also led the integration of our field with the acceptance of both minorities and women.

When I first heard the term “Generation X” I thought “Dumb name, won’t last.” Not my best prediction. Born between 1965 and 1980, Generation X grew up during the home computer revolution. Quick to adopt new technologies, Gen Xers were far more adaptive to change than previous generations. Labeled as having short attention spans, most Gen Xers were task/goal oriented. While these attributes helped drive the endovascular revolution, they may also be the reason we have approximately 983 FDA approved devices to treat SFA disease. Generation X entered surgical training eager to please the more senior Traditionalists and Boomers. This wouldn’t last. Children of divorce and latch key kids, Generation Xers are eclectic, resourceful, and self-reliant. Most of all they value freedom. Watching their predecessors work themselves and others to near death, Generation X revolted. Uncapped duty hours, limitless call, and pyramidal residencies were all institutions in the 1980s, and they all fell. Generation X were portrayed as nihilistic slackers but their true motivation was often distrust of institutions. Watching the Boomers descend into burnout, Xers tried to achieve a more reasonable work-life balance. Though they successfully fought for lessening the abuses of surgical training, few Gen Xers actually reaped the benefits. I vividly recall watching slack-jawed as an intern scrubbed out of a case to go home because he was post call. A Martian landing in the OR and offering to assist with the anastomosis would have brought no less amazement.

 With their careers spanning the endovascular revolution, Generation X has seen perhaps the greatest era of transformation in our profession. Our competition is no longer general or cardiac surgery, but rather interventional radiology and interventional cardiology. Gen X is also the first generation to earn less than their predecessors. Throw in their obscene tuition payments and one can see how Gen Xers fell well short of the financial heights of the Traditionalists and Boomers. Generation X are the masters of the work hard/ play hard ethos. You will see them at VEITH entertaining their European colleagues at 3 a.m. then running the 6 a.m. breakfast sessions. While the Boomers often seemed old by 40, Xers appear desperate to salvage their lost youth.

Born between 1981 and 2006, Millennials are already the most populous generation. Their chief attributes are confidence, sociability, and a realistic outlook. Knowing they can’t please everyone, they rarely try. They want work to be meaningful in and of itself. They also value team work over individual approaches. Millennials are civics minded and have a strong sense of volunteerism. Their parents often tried to shelter them from the evils of the world, and they were the first generation of children with schedules. Because of their upbringing, Millennials are far more likely to seek guidance than the independent-minded Gen Xers. Raised to believe their voice mattered, they are now often reviled for it. It is with some degree of awe that I watch our Millennial students brazenly march into the Dean’s and Chancellor’s office to discuss their “careers.” As a medical student I first saw my Dean at graduation, and I certainly didn’t even know what a Chancellor was. Generation X is often baffled by the self-interest Millennials exude. But we shouldn’t be, we have seen it before. Raised by Baby Boomers (The Me Generation), Millennials inherited their self-driven outlook. This is also the reason Boomers and Millennials struggle to work together. They are too alike. Boomers see Millennials as “snowflakes” who are scared of work and selfie obsessed. Millennials bristle at the authoritarian nature of Boomers.

For vascular surgery to advance as a field, we need to recruit, train, and mentor this new generation. If only there was some guide: “The Proper Care and Feeding of Millennials”? As senior attendings, program directors, and section chiefs, Generation X must now serve as a bridge between two larger forces, the Boomers and their offspring, the Millennials. Of course whatever generation you are from is the best but we must confront our biases. It is easy to seek out the same personalities to be your trainees and partners. Don’t. This pool will shrink every year. Millennials are more self-aware of their capabilities and therefore of their limitations. We may become flustered by their need for hand-holding, but what if it is appropriate? Was all of the autonomy you were granted during training truly good for the patients? Graduated responsibility and roles that push their limits help Millennials grow. I know they don’t value punctuality or dress codes but they are better team players and openly motivated by learning. I formed our integrated vascular residency with two positions per year specifically to foster the team building Millennials crave. Yes this is the generation that got 8th-place trophies so you must constantly award progress. Fortunately, now that surgery is unencumbered by such things as “massive salaries” and “status,” Millennials enter our workforce with purer intentions.

Finally, what will surgical training and culture look like under the leadership of Millennials? Millennials respect competency not titles, so our hierarchal system may transform to networks. The omnipotent Chair may be replaced with individual specialists in charge of education, business, research, and other roles. Millennials value flexibility so wholesale changes to our traditional work schedules may occur. Shift work, duty hours, and night float may follow from residency into practice. Education may be moved to a more modular framework. Competency-based residencies may develop with flexible time frames and advancement commensurate with achievement.

We may want to make Millennials match our values, traits, and behaviors but each generation has departed radically from the ethos of their predecessors. Let’s see what the kids can do. ■

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