How dire is our healthcare crisis?

Reader responses: How dire is our healthcare crisis?

In a recent issue of the Credentialing Resource Center Connection email newsletter we asked MSPs to share with us their thoughts about our nation’s so-called broken healthcare system.
Here are a few of the anonymous responses from in-the-trenches MSPs. Feel free to leave your own opinion in the comment box at the end of the post.
“If all I did in my position at the hospital were my duties as Medical Staff Coordinator, I would probably wonder what kind of “crisis” is being discussed.
However, I also work in risk management and am the first person contacted by patients with concerns and complaints. I find from my many conversations with patients, that many have really poor and confusing insurance coverage, that many are putting off vital healthcare due to the expense, and that our ED is becoming a substitute for the PCP’s office. I speak daily with tearful and frightened individuals who feel they have nowhere to turn, and who are fearful of ever-mounting personal medical debt.
Our hospital is located in a rural environment. We have many Medicare patients, and a good percentage of the younger ones are uninsured or under-insured, as we do not have many large employers in our community that provide employee health insurance coverage. If we are at all typical, we do indeed have a “crisis”.”
“Our credentialing database feeds a file that goes to 30 different payers each month as our managed care organization is delegated for credentialing approximately 3,500 practitioners. We need to maintain not only approved practitioners, but each address at which they are approved by contract to provide service. In some cases, such as radiologists or pathologists, this is over 100 addresses per practitioner. The payers review each claim against this information for payment, and then the terms of the contract to see how much is covered, generate and send the statements to the biller and the patient, and handle the claims wrangling that ensues. And this is above and beyond all the paperwork required by physician offices and hospitals in getting the bills coded and sent to primary and secondary payers, and then billing the patient. What a monumental waste of effort that would not be required in a single payer health care system.
Second, two-thirds of people who claim bankruptcy in the US cite medical expenses as the main cause. Of those, three-quarters have health insurance. Our co-pays, deductibles, uncovered expenses and maximum limits causes thousands of families over the brink into financial ruin. Meanwhile, in other industrial countries with government supported healthcare systems, no one goes into bankruptcy for health care expenses because it is all covered.”
“I personally find that we are so regulated that is hard to find time to give good patient care. We spend large portion of our shifts doing paper work to conform to regulatory needs that it leaves not enough time to give to our patients the one-on-one time they require. I work in an acute care rehabilitation hospital. I know that regulations are necessary. But I think it would help to combine some agencies and unify how Medicare, medical and the CMS along with the joint commission do their surveys. There are so many different processes to comply with that we stress out the thin staff that are giving the care.”
“I have worked in many areas of administration for the healthcare industry. I know first hand that both the physician and patients are getting the short end of the revenue stick. Patient care has diminished, because physician patient loads are unmanageable. Physicians are constantly being prodded by insurance carriers to give the least expensive patient care to avoid jeopardizing their reimbursements. Which acquire the patients being treated for cause and effect symptoms only. Physicians have abandoned the prevention care plans to keep their patients healthy. Insurance companies for the most part outsource their customer service to [overseas], where patients and physicians are not able to communicate much less get any resolutions to their issues. When we think that in the United States, we can figure out how send people to the moon – but can’t solve healthcare something is dead wrong. In my opinion the healthcare industry is long overdue for an overhaul and there should be no sacred cows!”
“Government taking over healthcare is a grave concern of mine. I do not believe that “control” is the answer. Abuse and neglect are the issues that need to be addressed. We need to research the control that insurance companies and medical supply and medication companies have on healthcare. The role of our government and elected officials is to enforce the law, not make the law as they see appropriate. We the people need to stand up and take back control of our government and quit allowing elected officials to run us. I’m willing to be involved [in this issue] outside of my work environment as this will be something that affects my children and grandchildren in the future.”
“The broken system is multifaceted but socializing medicine, i.e. having a government run program, is not the answer. Look how well Medicare has done. Giving people a choice between government run or private insurance is not the answer either. Managed care plans manage not to give patient’s care, manage not to pay doctors, and manage not to save money.
Forcing Electronic Medical Records on physicians is not an answer either. It will create a logistical nightmare and the cost is prohibitive for most practices. Ah, but wait, the government will give you a credit, and that will not begin to cover the cost. Not only is there the cost of the software, but there will be additional hardware and storage costs. It also does not increase “accuracy” as garbage in, garbage out – only if the data inputted is accurate and on the right person. Reimbursements are spiraling downward and expenses are going up. On some drugs with Medicare and Medicaid, we pay more than the reimbursement. I don’t know what the answers are, but I do know that more government involvement equals a more fractured system.”
“Yes, I do believe that health care is as broken as they say it is and part of it is their issue, but only a small part of it. The cost of healthcare has outstripped many employers’ ability to provide satisfactory health care coverage and in many cases they can no longer afford health care coverage. Pharmaceutical companies are charging for medication at an exorbitant rate. The American public is being charged for [research and development] on drugs that have long since had the expense paid for, while other countries, to whom the drugs are being sold, receive a discounted price. I understand that revenue is needed to develop newer, better drugs, but how about leveling the playing field and charging all customers the same price. Hospitals, physicians, and radiology companies have also played a large part in inflating costs. If they had taken care of the garden and not fertilized the weeds, we would be in much better shape. Anytime a radiologist gets a salary of $250,000 a year and only works 6 months, there is something seriously wrong with the system. The fact that the average length of stay in hospitals in the eastern half of the United States is almost double in the western half is unacceptable. The west has done its best to keep with reducing length of stay while the east is supplemented for over utilization. What about the medical supply companies? A simple item is priced much higher as the same item in another line of service, just because it has the term hospital or health care attached to it. Many physicians are treating the patient with every possibility of care because they can, not because it is truly beneficial to the patient. Though no one wants socialized medicine, I am afraid it is the only way we are going to get cost under control and provide health care coverage to the citizens of our country. We have too long taken advantage of the system and it is our own fault.
Dental health care has also gone awry. Dentists often refuse to bill insurers. Dentists and physicians often opt out of Medicare or Medicaid, leaving many people unable to pay and attain the services they need.
Just to let you know how my opinions have developed. I have been in health care for 44 years of which the last 18 has been as a MSP. I have attempted to receive a degree in nursing and worked as a nurse aid for 23 years all the while observing and experiencing many of these issues. I have staffed a hospital, and worked as a ward clerk and a member of an ethics committee. If you keep your eyes open and your ear to the ground you can easily come to the same conclusion.”
“After working 30+ years in healthcare from physician office practices to Quality/Risk Management/UR, to home care, and now in the medical staff office, it is difficult for me to give a perspective only from the MSP viewpoint. I don’t necessarily think the US healthcare system is “broken”, but I do believe there is so much that can be done to improve it. I don’t believe that national or universal healthcare is necessarily bad; just look at the WHO outcome statistics from other countries who have universal healthcare and the U.S. does not fare well in comparison. I could go on and on, but at this point, will only focus on a couple of things I think are of major importance.
First, I think the pharmaceutical industry needs to be regulated. They are making millions of dollars each year on the backs of poor and middle class people who have no insurance and/or who cannot pay for astronomical high priced medications, most which are necessary to keep chronic diseases such as hypertension and diabetes, under control.
Patients stop or cut back on these medications that they cannot afford which many times result in hospitalization. Major cost savings and improved patient care could result with lower drug costs. The government controls milk prices but not medication prices…why doesn’t this make sense??
Second, regarding universal health care, my fear is that our government will formulate universal health care without involving appropriate healthcare people. I’m not talking about physicians who sit on healthcare boards and haven’t seen a real patient for years, but frontline healthcare workers who know and see what the real issues are. This should include more than just physicians, but also nurses, quality people, CEO’s, CFO’s, and even some MSP’s sitting around the table when this is discussed.
I certainly don’t have all the answers, but I know there are a lot of questions. Regarding my current role, I feel there are still too many “substandard” physicians practicing that can go from state to state and that the NPDB is not an effective mechanism for detecting who they are.”
“We have the most advanced healthcare system in the world providing services to individuals who pay for their care, via health insurance or private pay, and those who do not. Businesses and the employed workforce pay hefty taxes to fund Medicare, Medicaid and other programs to provided care for those who can not pay. And we should do those things – no one wants a child to suffer for lack of healthcare. But to believe that some of the people can provide for all of the people – via government run healthcare – is not realistic. It is comparable to the US Postal Service One Flat Rate Priority Delivery. It’s a great pitch, great idea in theory, but fails in delivery – you never know when your package will arrive at its destination.”
“Yes, our healthcare system is wildly out of control. As a 51-year-old, taxpaying American citizen and as a 30-year (and counting!) career healthcare professional, I have come to believe the following things.
1.) We made a mistake long ago to divorce the patient (also known as “the customer” and the “end-user”) from the decision making process about healthcare. The entire Medicare program as well as employer-paid health insurance alone account for most of this distortion. By taking personal responsibility, final decision making and fiscal responsibility away from patients, we opened the door to out-of-control costs and a healthcare philosophy based around illness rather than on wellness and quality of life. Solution: a.) Do away with Medicare and place responsibility for basic care of infirm elderly and disabled individuals in the hands of the States and the local community charities; b.) Do away with employer-paid health insurance. People can make their own decisions about these things. Let’s concentrate on public education about being responsible for taking care of our bodies and our families. Require folks to take charge of the process by either paying as they go or by purchasing their own insurance. This will ultimately result in a more balanced and sensible use of healthcare services by patients, and it will result in prices re-stabilizing naturally, all by themselves, without regulation. (Imagine that!) It will also result in all of us learning about the consequences of our own behavior.
2.) We have “villainized” physicians for a long time, and we ask of them what we would not dare to ask of any other professional in terms of responsibility. All the while, we as a society and as an industry have been dictating to them more and more about how to do their work, without taking much of the responsibility for the outcomes onto ourselves. Solution: a.) Reform the legal system, state by state. Currently, we allow patients to victimize physicians. Most of the law suits that I have ever read were about bad luck, unfortunate genetics, foolish behavior, hurt feelings or unrealistic expectations on the part of a patient. Many were also about poor quality communication between patients and physicians – a two-way street and a joint responsibility. I have rarely seen suits that were truly about malpractice by a physician. Yes, malfeasant physicians do exist, as do criminals from all walks of life. They are the exception and not the rule. We do not need to build our world around them. A few good laws and the National Practitioner Data Bank suffice. b.) Reform the hospital accreditation system. Period. More is not better. I think the public would be outraged if they understood the cost of the paper chase we indulge ourselves in. c.) Support the transition to coordinated electronic health records and do away once and for all with the expense and the dangers of disjointed, illegible records. This is the true way to coordinate care and engender patient safety.
3.) We have gotten silly, as a culture and a society, about what we think we need or deserve or have a right to. Solution: Get back to basics: the Bill of Rights, the Declaration of Independence, the Golden Rule, the Ten Commandments. Simple guidelines for just, self-reliant and compassionate people.
4.) We have gotten cowardly, undignified and unreasonable about acceptance of death, dying and aging. Solution: Take a longer view. We are all meant to come and go. In the end, each one of us is fleeting. There is no dignity in trying to defy death or nature.”

Entry Information

Filed Under: healthcare news

Tags: healthcare

About the Author: Emily Berry is an associate editor at HCPro in the credentialing market. In addition to managing information on CRC she writes the Briefings on Credentialing newsletter and the Credentialing Resource Center Connection weekly email newsletter. A native of Ohio, she graduated from Case Western Reserve University in Cleveland before moving east to attain her MS degree in journalism from Boston University. She’s always looking for new ideas for articles, so if you have any to share, please email her at eberry@hcpro.com.

1. 
   Emily | Jul 7, 2009 | Reply
   
   Don’t overlook the multiple free EHR’s that don’t require doctors to invest in expensive software. There are affordable solutions for electronic health records available if you know where to look. Wikipedia has a good comparison chart.
   
2. 
   louis | Jul 8, 2009 | Reply
   
   Hey, you have a great blog here! I’m definitely going to bookmark you! Increasing your web traffic and page views Add, add your website in http://www.directory.itsolusenz.com/ site, it’s pretty awesome too!
   
3. 
   Mary | Jul 8, 2009 | Reply
   
   I licensed medical professionals for many years, worked for the State government, and now credential medical professionals for a private hospital. I am appalled at the high cost of medical insurance, especially that which is paqrtially funded by employers. The cost is so high, many of my co-workers cannot afford it. When I worked for the State, an attempt was made to turn the statewide healthcare plan for welfare recipients into a type of HMO, where anyone can join and pay according to their income. This would have been an excellent plan and would have left NO ONE uncovered as welfare recipients would still be on it, but would pay nothing or very little. It would have encouraged preventive care. However, taxpayers voited AGAINST it, not understanding how it would have worked and now we are all paying the price as taxpayers have to cover the exorbitant costs of medical care for people who, if they had had insurance and preventive care, would not be hospitalized with majoe health problems and would most likely be enjoying good or fair health. Preventive care is much cheaper, yet taxpayers cannot comprehend that.
   
4. 
   Pearl Forsyth | Jul 10, 2009 | Reply
   
   I work for a large highly regarded healthcare system in Kansas City. I hear everyone complaining about the high cost of healthcare and how government control can “fix” it. Get real people!! I can name you any number of employees on our staff who have jobs BECAUSE of all the government regulations that we must meet. Recovery Audit Control, CMS, Joint Commission, to name a few. All expenses we have due to government regulations and we must pass these expenses along to our customers or close our doors. We do a huge amount of indigent care within our health system. So our customers including our health system employees are already paying for these uninsured folks to have healthcare, by our taxes, increased health insurance premiums, co-pays, and no raises. I too think the system needs fixing and feel a large part of the problem is government regulation and greedy insurance companies. However, I am not sure that a single payor system that cuts out competion in the marketplace is the answer and I AM SURE more government control is NOT the answer.
   A physician in our area has begun a clinic where he charges a set fee for everyone for various office calls, procedures, etc. He prints you an itemized receipt which you can turn in to your ins. co. if you so desire. However, he accepts no insurance of any kind. His overhead is minimal and his care is excellent because he does not have to focus on administrative, etc. duties. I applaud his courage and ingenuity. After all, these are the qualities of our forefathers that made this country great. Perhaps a little more inventiveness and less apathy and belly-aching on the part of John Q Public would get us back on track!!
   
5. 
   Jeff Jimerfield | Oct 5, 2009 | Reply
   
   In you blog, you stated, “Second, two-thirds of people who claim bankruptcy in the US cite medical expenses as the main cause. Of those, three-quarters have health insurance”. I would like to use this in my report but I need sources. Is there any way you could e-mail me your sources, only for that statement, I seem to have most of the information I need with resources. I live in a very conservative area and have to have references for anything I say that goes against typical John Burch mentallity
   
6. 
   Emily Berry | Oct 9, 2009 | Reply
   
   NOTE: Posted on behalf of L.H.
   In response to the question about the appalling correlation between health care costs and personal bankruptcy, I found information on this at the web site of the National Coalition on Health Care Costs. It cites a study reported on in the American Journal of Medicine regarding this.
   “A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance.9″
   9. Himmelstein, D, E., et al, “Medical Bankruptcy in the United States, 2007: Results of a National Study, American Journal of Medicine, May 2009.
   http://www.nchc.org/facts/cost.shtml
   I hope this information helps.
   

Recruitment, retention, and management of Generation X: A focus on nursing professionals

By Cordeniz, Judy A
Publication: Journal of Healthcare Management
Date: Monday, July 1 2002
HEADNOTE

EXECUTIVE SUMMARY

HEADNOTE

Two-thirds of the nurse workforce are now over the age of 40, and between 40 percent and 60 percent of these nurses

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are expected to retire within the next 15 years. Enrollment in programs at all nursing education levels is declining. Generation Xers, those born between 1963 and 1977, comprise between 10 percent and 15 percent of the current nursing workforce. Although relatively new to the workforce, Generation Xers have their own ideas of what constitutes an acceptable workplace, and usually the terms of their employment are not negotiable. Further complexity arises from the fact that management of this workforce falls primarily on Baby Boomers-those born between 1943 and 1960. Because of the events that molded their collective characteristics, Baby Boomers entered the workforce driven and dedicated. This group equates work with self-worth, contribution, and personal fulfillment. Many selected their profession not based on economic prospects but with the desire to make the world a better place. In addition, their competitive nature drives them to aspire for higher monetary compensation and titles.

The challenge for healthcare leadership is understanding and creating harmony between these two generations. This article presents a summary of recent literature and studies that explain the basic distinctions in cultural characteristics and work ethics between Generation Xers and Baby Boomers. The summary, I hope, provides a guideline for recruiting, retaining, and managing Generation X workers in the nursing field.

Because the literature is not consistent, the first thing that needs to be clarified is the date range that defines Generation X. Date ranges found in the literature include:

1969-1978

1961-1981 (Tulgan 1997; Kupperschmidt 1998)

1965-1975 (Santos and Cox 2000; Hays 1999)

1965-1976 (Adams 1999; Woodward 2000)

1963-1977 (Rosner 1999)

1965-1980 (Jochim 1997; Karp, Sirias, and Arnold 1999; Poindexter 1999)

1987-1984 (Manolis, Levin, ana Dahlstrom 1997)

1965-1981 (Smith 2000)

1963-1982 (Kennedy 2000)

1965-1977 (Ravenswerks.com 1999)

1963-1977 (Tulgan 2000; Weston 2001)

Based on the literature, 1963 appears to be the most popular starting date, and 1977 is the most frequently used ending date. This date range coincides with the writings of Bruce Tulgan, who appears to be the initial investigator and predominate authority on Generation Xers in the workforce. For our purposes, 1963-1977 will be used as the range of birth years that identify Generation X. The literature is consistent in its description of Generation X by contrasting it with the Baby Boom generation, which approximately begins in 1943 and ends in 1960.

Following is a summary of the events and conditions that contribute to the mindset of the Baby Boom and the Generation X groups.

THE BABY BOOM GENERATION

The Baby Boom generation began just after World War II ended. Baby Boomers were raised in prosperous, optimistic times and, for the most part, were doted on as children. They tend to think of themselves as the "stars of the show." Baby Boomers typically were raised in a nuclear family in which the "father-knows-best" model was followed. If the family life differed from this ideal, it was not made public. When many Baby Boomers were children, they witnessed man travel to the moon, John F Kennedy as president, and television sets invade living rooms. Life was comfortable and had a great purpose.

Baby Boomers entered adolescence with fits of idealism, rebelling and questioning the status quo. Older Baby Boomers were teenagers during the hippie culture of the 1960s. Groups set out to change the world through love, music, and nonviolent demonstrations. Civil rights protests and antiwar marches were commonplace. Current beliefs about the status of women are related to the many changes brought on by this generation. Younger Baby Boomers had a different teenage experience. The prosperity of the 1950s and 1960s tumbled with the oil embargo and the dramatic discoveries of the Watergate scandal. As a result, both older and younger Baby Boomers learned not to respect authority. Instead, they learned to challenge authority and question the integrity of leaders. They still tend to believe that no one in charge is to be trusted. Their heroes, unlike those of previous generations, were not war heroes, political leaders, or large businessmen. Their leaders were more likely those who opposed the status quo and rebelled against authority (Wiley 2000).

The tremendous size of the Baby Boom generation spawned alterations in the American culture and economy. When they were children, they made up 40 percent of the population. As a result, school systems were routinely overloaded. Competition was fierce in academics and sports because of the sheer volume of candidates. The special demands of raising millions of children and teenagers transformed the market for consumer goods, and the cost of raising Baby Boomers soared (Hays 1999).

As they entered the workforce, they were driven and dedicated. Having grown up with a sense that they were special and capable of changing the world, they equate work with selfworth, contribution, and personal fulfillment. Many selected their profession not based on economic prospects but with the desire to make the world a better place. In addition, their competitive nature drove them to aspire for higher monetary compensation and titles.

The introduction of the birth control pill, legalization of abortion, and liberalization of divorce laws ushered in smaller families; nontraditional family constellations of single parents and stepparents; dual-career families; and the phenomenon coined "latchkey kids" (Kupperschmidt 1998). The fear of a population explosion seemed to further erode the status of children among Baby Boomer parents, fostering a societywide hostility toward children. This cultural mindset resulted in many couples electing not to have children and parents spending less time with their children and adopting more permissive parenting styles.

Because of the different patterns they have followed for having children, Baby Boomers vary from having young children to having successfully sent their children to college. Many are parenting teenagers while dealing with aging parents. More than any other generation, they are dealing with a time squeeze. Demands of work, expectations of parenting, goals for healthy living, and a strong sense of idealism have kept most Baby Boomers running from morning until night. They have maintained a grueling work pace, but many have set goals to simplify their life. They have adapted to technology, motivated by the desire to be more productive and to have more free time.

GENERATION X

Generation X had a dramatically different childhood than the previous two generations. Most grew up in a home where both parents worked; this distance from their parents was further exacerbated by high divorce rates. As a result, 40 percent of Generation Xers were in single-parent households in their youth (Wiley 2000). As the first latchkey generation, they came home from school to empty houses, cooked themselves a snack in the microwave, and entertained themselves with video games. As teenagers, they formed strong bonds with friends, turning to schoolmates when family was not available. Because of the diversity of their conjured "immediate" family, Generation Xers are more tolerant of alternative lifestyles. They are accustomed to great diversity in family situations, relationships, sexual orientation, ethnicity, gender roles, religion, and political affiliation. In addition, their school activities focused less on individual performance and more on team-based learning.

This generation grew up in the information age and is innately comfor-table with technology. Automatic teller machines, personal computers, push-button phones, and digital clocks are standard equipment for them. Their continuous use of technology has promoted Generation Xers to expect instant response and satisfaction (Hays 1999). They were educated during a period of experimentation, as "new math," open classrooms, and curriculum specialists entered the picture. There was a rash of public concern about the decreased academic quality of Generation X's educational experiences. These experiences, based on the theory of learning known as "educational humanism," emphasized the effective development of the student rather than the ability to read and write (Kupperschmidt 1998). They were the first generation to be demographically fewer than their predecessors (Corbo 1997). These factors contributed to this generation's decreased need to compete for survival's sake.

Politically, Generation Xers were born during a period of steady decline in American global power, kicked off by the Vietnam War and punctuated by the Iranian hostage crisis (Tulgan 1997). The economic prosperity of the United States was usurped by the dominance of Japan in the world market. Even the technological prowess of this country was called into question when the Challenger space shuttle exploded, an event seen by Generation Xers on TV screens in their classrooms. Exposure to violence and adult themes on television often forced Generation X teenagers to deal with adult subjects before they were ready. Holtz (1995) refers to the 1970s as "the period of the youthification of poverty," brought on by family dissolution, disappearance of fathers, and government policy.

Generation X children achieved the distinction of being the most impoverished generation in America. The old and the young competed for limited social-welfare dollars as federal funding of programs for the elderly increased. Funding of programs for families and children decreased, and the tax law reform added to the economic burden of families (Gross and Scott 1990). Generation X witnessed a record number of bankruptcies, Wall Street scandals, and massive corporate layoffs with the loss of high-wage jobs and benefits. They watched their parents struggle with rightsizing, downsizing, and layoffs after years of dedication to the corporate mission.

THE LITERATURE FINDINGS

A good deal of the literature includes graphics of the generational differences between Baby Boomers and Generation Xers in terms of workplace characteristics, lifestyle characteristics, social values, motivators, de-motivators, communication styles, traits, workplace ideals, and stress strain and coping scales. This article focuses on communicating with Generation Xers in recruitment (attracting them), retention (keeping them), and management (the purest art form of communication). See Table 1 for a breakdown of the difference in communication styles.

Because of the unique behavioral traits of the different generations, recognizing what motivates each group is imperative. If the same nursing management methods are used for all individuals-regardless of generation-- unhappy nursing units will result. A number of the literature dealt with various means of collecting data on Generation X-what motivates them, what stresses them, and how do they view their own values. Focus groups tended to be the general method of data collection; however, some studies utilized questionnaire-type survey tools.

IMAGE TABLE 26

Table 1

One set of statistics that depicts the age generation distribution in nursing in general is the breakdown of the membership of the Association of Operating Room Nurses (AORN). These numbers were ascertained from a study conducted in an effort to isolate the work ethics and skills brought to the workforce by the Generation X nurse (see Table 2). This same study revealed the information in Table 3 when comparing the two generations of nurses (Hays 1999).

Generation Xers who responded to a Time-CNN poll described themselves as worried about and expecting tough economic times and expressed difficulty in climbing the corporate ladder. They voiced decreased expectations for, and their intent not to invest in, long-term corporate relationships and expressed a higher threshold for unhappiness than previous workers. Respondents admitted to their tendency to change jobs or start their own business if they are dissatisfied with the work and work environment. They claimed to be motivated by work that aligns with their values and demands and includes performance appraisals; reviews quantifying their achievements; outcome-- focused, short-term projects; and pay for performance (Barna 1992). The investigative work of Kupperschmidt (1998) lists the following as the most common characteristics of Generation Xers:

IMAGE TABLE 32

Table 2

Table 3

Self-absorbed

Independent, industrious, and resourceful

Value fun and balance in life

Slow to commit long term to relationships:

Extended adolescence-they remain in parents' homes and resist assuming adult roles

Boomerang-they leave and return to parents' home for economic reasons

They marry late to avoid commitment or divorce

Pluralistic and comfortable with diverse cultures and lifestyles

Materialistic-practical, seasoned consumers

Creative, decisive problem solvers

Flexible, adaptable, and comfortable with change

Voracious learners

Innovative risk takers and entrepreneurs

Value quantity and quality time with significant adults

Lack basic skills in reading, mathematics, and communication

Have a cynical, pessimistic, practical, reality-driven worldview

Have unrealistic expectations for quick solutions to adult problems

In a study where approximately 250 telephone interviews were conducted (Tulgan 1997), Generation X respondents described themselves as hard workers who view jobs and work as a means to an end and claimed to have little confidence in and loyalty to leaders and institutions. They said that college attendance is an essential job preparation and a competitive necessity. In descending order, they ranked the following elements of life as important: family, health, time, friends, religion, living comfortably, career, and money.

Bradford and Raines (1992) found in their interview with Generation X cohorts that the respondents demand and expect more, including having input into high-level decisions, from their organizations and managers than any previous generation. The researchers praised Generation X's comfort level with and knowledge of pluralism and multiethnic work places. Bradford and Raines described them as rebellious and irreverent workers who change jobs frequently-an average of once every 3 1/2 years; however, they argued that with appropriate leadership, Generation Xers are energetic, innovative employees. According to their findings, managers should spend time with them, asking what they do and do not want in their jobs. Managers should not expect Generation Xers to change their values but should learn to see their values positively.

Tulgan (2000) states that organization leaders have two choices: (1) focus more directly on the particular management needs of Generation X or (2) pay the price of losing the talents and innovations of a whole generation. He believes surveys reflect negative portrayals of Generation X because they were conducted by Baby Boomers with jaded expectations. Using a purposive sampling technique, Tulgan interviewed 85 cohorts that are diverse in gender, ethnic heritage, geographic location, and job experience. He posed the following two questions to each subject: (1) How are you being managed? and (2) How is that management style affecting your work? Respondents repeatedly articulated that they do not want to be managed by nor are they motivated by the use of fear, longterm rewards, managers who waste their time, and micromanagement techniques. According to Tulgan's research, Generation Xers want leaders who: (1) invest in their employees, (2) are willing and able to provide effective feedback, (3) understand work issues and respond to their needs and concerns, and (4) possess and exercise power to access the necessary information and resources.

Tulgan summarizes negative perceptions of Generation X as faulty interpretations and his findings as fact. He argues that Generation Xers are not disloyal, uncommitted, and cynical (faulty interpretation); instead, they are eager to contribute but cautious because their collective life experiences have taught them to expect little from life, adults, and institutional relationships (fact). Tulgan contends Generation Xers do not have a short attention span (faulty interpretation); rather, they want many answers to many questions from many sources. They are voracious learners, and their learning and communication skills are shaped by the information revolution (fact). Generation Xers are not intense and arrogant (faulty interpretation) but are powerfully independent, resourceful, and comfortable with new technology (fact). The charge that Generation Xers are greedy for rewards and eschew dues paying (faulty interpretation) is countered with the fact that they did not experience the fabled old-employment contract and promised job security. Instead, they are cautious investors who insist on a new employment bargain-a bargain that demands for managers who foster entrepreneurial abilities and provide opportunities for self-building and for assuming personal responsibility for work outcomes. The new employment bargain is an if-then premise-that is, if leaders will, then Generation X employees will (fact) (Hays 1999). Kupperschmidt (1998) further poses the following questions: Are Generation X employees-empowered, self-directed, flexible, creative, innovative, risk takers, problem solvers-what nursing has been talking about and longing for? Do nurse administrators understand the dynamics of and challenges posed by Generation X employees? Will nursing leaders adopt leadership strategies aligned with Generation X's work values and demands?

Santos and Cox (2000) explored the factors influencing occupational adjustment related to workplace stress among 413 nurses. Baby Boomers and Generation Xers reported quite different issues and perceptions of occupational stress. The researchers utilized a questionnaire and follow-up focus groups to collect their findings. A comprehensive instrument measuring three components of occupational adjustment (stress, strain, and coping) was given to registered nurses at staff meetings. Sixty-eight (68) percent of the RN population completed the instrument (n=413). Ten focus groups were held to clarify these findings associated with problematic scales (n=44). Of the 413 nurses, 1 percent were of the Mature generation, 43 percent were Baby Boomers, and 41 percent were Generation Xers. Respondents had the following educational attainment: 20 percent had associate degrees, 13 percent held nursing diplomas, 56 percent had a B.S.N., and 4 percent earned a M.S.N. Results revealed significant differences in perceptions of occupations stress between the Baby Boomers and Generation Xers.

Baby Boomers had significantly higher mean scores on stress scales of role overload-when resources exceed demand and role boundary, conflicting demands and loyalties. Two other significant differences were seen on role insufficiency: (1) training and skills exceed job demands, for which Baby Boomers had the highest mean scores, and (2) physical environment, where the workplace itself provides extreme conditions, for which Generation Xers had the highest mean scores. The focus groups further enhanced the following three generational themes: (1) orientation toward work, (2) length of service, and (3) workplace behavior. Baby Boomers, the largest group in this setting and the largest group working in all industries today, were angry at what they interpreted as lack of commitment and slacker attitudes of the Generation Xers. In addition, they considered the Generation Xers arrogant and self-absorbed. Baby Boomers were also tired of the revolving-door orientation of the Generation Xers. The negative perceptions were understood, but the intensity of these perceptions was compelling.

In contrast, Generation Xers did not convey negative perceptions of Baby Boomers with whom they worked. They also voiced great commitment to the profession and organization, but some clearly indicated they anticipated movement out of the institution one day and a few indicated they would move from the profession entirely during the course of their work life

to provide themselves with a more diversified skill set. They indicated that the arrogant attitude was not arrogance at all but their need to be self-reliant, as they have had to be throughout their lifetime (Smith 2000).

The work of Manolis, Levin, and Dahlstrom (1997) was intended to develop a scale measuring attitudes associated with the generation born between 1965 and 1980. The purpose was to gain insight into attitudes associated with Generation X. The investigation identified several reoccurring sentiments that provided a preliminary assessment of the extent to which individuals from Generation X concur. In addition, the study contrasted the attitudes expressed by members of Generation X with those expressed by Baby Boomers. The scale development method of the study was abstracted from sentiments derived from the 1991 novel Generation X by Douglas Coupland. The objective was to characterize these sentiments and to contrast the sentiments with those expressed by older people. The initial scale, consisting of 125 items, was categorized into seven dimensions: (1) parental units, (2) shopping, (3) McJobs, (4) yuppies, (5) time passages, (6) platonic shadows, and (7) worldview. A sevenpoint Likert-type scale (anchored by ,strongly agree' and 'strongly disagree') was developed based on the categorical sentiments and tested for construct by senior doctoral candidates in consumer behavior. The test pared down the items to 102 and the dimensions to six, eliminating worldview. Subjects consisted of 445 shoppers from a mall in southeastern U.S. The resulting sample consisted of 187 persons born between 1946 and 1962 and 258 persons born between 1964 and 1980. Although the study validated the Generation X scale (GXS) as a common measure of affect across numerous generations of persons, the test confirmed that differences do exist between members of Generation X and other generations based on the developed psychometric scale.

In a study conducted by Poindexter (1999), a large number of people were unfamiliar with the term Generation X, although newspapers and other mass media had increasingly been using the term. In her quest to evaluate the depth of the stereotypical term "Generation X" a random sample of 489 adults 18 years or older in the Austin, Texas, area were surveyed by telephone. Phone numbers were randomly selected from the area phone book and then 1 was added to the last digit of each number selected and that number was called. This method, called plus-- one sampling, gives those in different prefix areas a chance of being selected. This sampling method assumes that unlisted number are evenly mixed among listed numbers. Although that may not always be the case, it is a worthy tradeoff if one does not have the resources to fund a true randomdigit dialing sample (Lavrakas 1993). The survey, which took an average of 20 minutes to complete, focused on knowledge, opinions, and behaviors about the mass media's portrayal of Generation X. Three questions were used to measure familiarity with and meaning of the label Generation X:

(1) How familiar are you with the term Generation X? (Answer: Very, Somewhat, Not Familiar); (2) When you hear or see the term Generation X, what word or words come to mind? (Answer: Open ended); and (3) In general, would you evaluate the term Generation X as: (Answer: Positive, Neutral, Negative. Refusal to answer and "don't know" were also categorized).

Almost one in three adults said they were unfamiliar with the term, and 40 percent of those who were familiar with the term said it was negative. That negative evaluation increased to 45 percent for those under 30 (Poindexter 1999). The study revealed that if the newspaper industry and mass media are concerned about alienating current and potential readers (or for our purposes, employees), they (we) should use the Generation X label with caution when describing the 45 million young adults in this cohort.

As a marketing strategy, youth-oriented material on movies, music, and technology packaged with dazzling color, flashy graphics, and with the terms "Generation X," "GenXers" and "Xers" can be very self-defeating.

NURSE RECRUITMENT AND RETENTION TO DOS

Recruiting Generation Xers

Billingsley (2000) cites three general themes that explain the work ethic and mindset of the Generation X workforce:

1 .Their loyalty belongs to themselves. They have no aspirations for gold watches or a silver tray after 40 years. They will stay in a position as long as it is good for them. They see themselves as independent contractors or free agents. Guilt tripping will never work with them.

2. They demand training. They want to learn everything. In fact, they want to know everything already, but because that is not possible, they will settle for intensive learning and heavy precepting so that all their questions can be answered right away. Once the successful ones have essentially exhausted the learning opportunities, usually within a couple of years, they start to sniff the air for better opportunities.

3. They think they should have a "life." The classic shift-weekend-holiday rotation will not cut it with this group. They are looking for a workplace that offers flexible scheduling, liberal vacations, daycare centers, workout

rooms, on-site drycleaning, florists, and the list goes on. They will pick the job that allows them to get the most fun out of life.

This laundry list is enough to send a Baby Boomer nurse, hands on hips, huffing out to the smoke shack. After all, they entered this profession knowing and expecting lifelong low salaries and hard work. Besides they believe that once a nurse, always a nurse. However, today new B.S.N. graduates can look to a bright future with any number of biotech or pharmaceutical organizations if care delivery does not appeal to them. Then there are those "travel agency" nursing opportunities whose recruitment ads read like a travel brochure and a Generation X manifesto:

Name your location

Name your specialty

Name your shift

Get paid incredible, above-market wages, premiums, and a sign-on bonus

All expenses paid

How are healthcare organizations responding to the phenomenal cultural influence? Who will be the 'hard sell'the executives and board or the older staff nurses? The executives will have to accept the necessity of such radical, and potentially expensive, changes in the work environment. The Baby Boomer nurses who have stuck it out for all these years and finally have the seniority to pick their shifts will need much mentoring to help them understand the need for a different, "kinder and gentler" workplace. The new mantra will need to be "Stop eating your young. They are your ticket to retirement!"

Across all generations, the literature points to communication as the key factor in retention-an old theme that lives on. In a 2001 article in Nursing Spectrum, author Carrie Farella lists seven nurse "cravings" that need to be satisfied to keep motivation high and to send morale soaring:

1. Talk with me. Nurses want their managers to communicate to them good or bad information. Having as many facts as possible about their work environment is essential. Whether the news is about reengineering of a unit or a high-level hospital merger, nurses appreciate managers who provide them with solid information about changes that may affect their jobs.

2. Work with me. Often balancing several tasks in the air at once (staffing, budgeting, and ordering supplies to name a few), managers who occasionally push their duties aside to lend a hand say patients and staff are better for it.

3. Stand up for me. When the chips are down, knowing the manager will defend staff nurses is important.

4. Know who I am. Knowing expectations outside of work can help a manager better understand staff at work.

5. Be with me. Whether sharing a cup of coffee after charting is completed or after the shift is over or having a catered lunch on the floor, gettogethers create solid bonds among nurses.

6. Help me grow. Just getting by is not enough any longer. Staff, par-ticularly the younger ones, craves professional development and a work environment that stimulates educational experiences.

7. Do make me laugh. Humor, laughter, and fun are very important in the workplace.

Corbo (1997) provides another list of Dos in her article "The Xer Files" Increase interpersonal skills. Many Baby Boomers were socialized during a time when keeping work life and personal life separate was a valued trait. In contrast, Generation Xers like to talk about personal issues but do so in a rather abrupt manner, lacking the social niceties Baby Boomers were trained to observe.

Provide individual attention. Generation Xers like individual attention. Providing a specified drop-in time will meet the Generation Xer's need for this type of attention while providing structure that soothes the Baby Boomer.

Use an abbreviated style. Generation Xers prefer brevity. They prefer to read about new procedures or policies, watch a video, or access information online. Drop the meeting requirements.

Appreciate diversity. Generation X is more culturally diverse and should be viewed as an asset in managing culturally diverse patient populations and workplace issues.

Use humor. Humor defines us as humans, brings out a personal and childlike part of us, and is an effective way to reduce stress.

Be empathetic. For many Generation Xers, navigating a career path has not been easy and that will not be changing soon. As a result, they stress personal happiness and the importance of holding a challenging and fulfilling job. An essential ingredient is to have coworkers and managers who are compassionate and understanding.

Do unto others. Generation Xers are eager to learn, especially about company politics and social graces to get ahead. No matter what your background or experience, you can always learn from others.

Retaining Baby Boomers

The final Dos surround the concept of retaining senior nurses on staff. Many Baby Boomers, whose existence surrounds work, are not expected to retire fully at retirement age. The healthcare industry should not encourage a mass exodus if it intends to have a safe ratio of nurse to patient. Johnson (2001) suggests several ways to keep senior nurses productive and effective:

Promote the benefits of working parttime instead of retiring.

Use senior nurses as trainers and planners, freeing up younger nurses for direct patient care.

Use senior nurses to staff community benefit and healthy communities programs.

Have senior nurses take courses in geriatric nursing and give "caregiver" programs.

. Have senior nurses teach or tutor high school students in science.

The challenges of recruiting a younger generation of nursing staff and meeting retention demands of crossgenerational needs will be a challenge like no other seen in healthcare. I hope that this summary sheds light on the signs that clearly mark the path of future successful staffing patterns and management styles.

REFERENCE

References

REFERENCE

Adams, J. T. 1999. "But What About GenXers Who Manage Boomers?" HR Magazine (December): 8.

Barna, G. 1992. The Invisible Generation. Glendale: Barna Research Group Ltd. Billingsley, M. 2000. "Satisfying Gen X: Can

We Do It?" Nursing Connection 13 (1): 72-74.

REFERENCE

Bradford, L., and C. Raines. 1992. Twentysomething. New York: Master-Media Ltd.

Corbo, S. A. 1997. "The X-er Files." Hospitals and Health Networks 71 (7): 58.

Farella, C. 2001. "Are Nurses Getting What They Need?" Nursing Spectrum (May 4). Gross, J., and S. Scott. 1990. "Proceeding with

Caution." Time (64): 56-62.

Hays, S. 1999. "Generation X and The Art of The Reward." Workforce (November): 4448.

REFERENCE

Holtz, G. 1995. Welcome to the Jungle. New York: St. Martin's Griffin.

Jochim, J. 1997. "Reality Shreds Myths About Gen X." Nevada Outpost (data collected

REFERENCE

from The Arizona Republic, March 19, 1997, and The Wall Street Journal, June 28, 1996).

REFERENCE

Johnson, D. E. L. 2001. "Retention May Be Key to Nurse Shortage." Health Care Strategic Management (March): 2-3.

Karp, H., D. Sirias, and K. Arnold. 1999. "Teams: Why Generation X Marks the Spot." The Journal for Quality and Participation (July/August): 30-33.

Kennedy, M. M. 2000. 'Engaging the Values of Each Generation." Association of California Nurse Leaders, ACNL Pre-Conference Program (Fall).

Kupperschmidt, B. R. 1998. "Understanding Generation X Employees." Journal of Nursing Administration 28 (12): 36-43.

Lavrakas, P. J. 1993. Telephone Survey Methods: Sampling, Selection, and Supervision. Newbury Park, CA: Sage.

Manolis, C., A. Levin, and R. Dahlstrom. 1997. "A Generation X Scale: Creation and Validation." Educational and Psychological Measurement (August): 666-84.

Poindexter, P. M. 1999. "Generation X: Is Its Meaning Understood?" Newspaper Research Journal 20 (4): 28.

Ravenswerks.com. 1999. "Leading Generation X - Getting 'In Touch' With the Energy" [Online article, Issue #81.

Rosner, B. 1999. "How Do You Deal with Generation X Workers?" Workforce (July): 24-25.

REFERENCE

Santos, S. R., and K. Cox. 2000. "Workplace Adjustment and Intergenerational Differences Between Matures, Boomers and Xers." Nursing Economics (January/ February): 7-13.

Smith, B. 2000. "Managing Generation X." USA Today (November): 32-33.

Tulgan, B. 1997. The Manager's Pocket Guide to Generation X. Amherst, MA: HRD Press. . 2000. Managing Generation X: How to Bring Out the Best in Young Talent. New York: W.W. Norton & Co.

Weston, M. 2001. "Coaching Generations in the Workplace." Nursing Administration Quarterly (Winter): 11-22.

Wiley, D. L. 2000. "Developing Information Leaders: Harnessing the Talents of Generation X." Econtent (December): 85-87.

Woodward, N. H. 2000. "The Coming of the X Managers." The Secured Lender (July/August): 40-46.

AUTHOR_AFFILIATION

Judy A. Cordeniz, Seton Hall University, South Orange, New Jersey

AUTHOR_AFFILIATION

For more information on this article, please contact Ms. Cordeniz at: judycordeniz@chiwest.com

Are you ready for Generation X? - Changing World View - the five generations

KEY CONCEPTS
* Generational Analysis
* Generation X
* Differences between Generations
* Demographic Changes
* Changing World View
* Differences in Values

IN SEPTEMBER 1999 MY partner attended a regional, multi-county planning and dinner meeting on pediatric asthma. People arrived from all sorts of concerned professions: teachers, public health officials, lung association representatives, academicians, and private physicians. He sat at a table across from an interesting woman, who was about 20 years his junior. She was decked out in complete "gothic" style: a long, black, form-fitting dress covered her from her neck to her ankles; her hair was close cut, spiked, and dyed bright red; her face was made up ghostly pale white with very dark lipstick. They introduced themselves to each other. "I'm doing a fellowship in pediatric pulmonary medicine at the university," she said. Once again, our world has changed.

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Today nearly all the medical students and house officers entering our profession are members of the so-called Generation X. A physician executive reading this article is more than likely one or two generations older than the Gen-Xers, who will be coming into medical practice over the next two decades. The differences between generations will have significant consequences for the shape and direction of American medicine in the coming years. What are those differences? Should they concern you today?

Just as there was a major disparity between the Baby Boomers and the two generations who came before them, the members of Generation X (and Generation Y, who are younger still) have values and aspirations that differ from the Boomers in significant ways. Physicians in leadership roles must start paying attention to these differences as if the success or failure of their careers and organizations depend on it, for in fact this is exactly the case.

Generational analysis

Much as one might approach John Naisbitt's Megatrends (1) or Faith Popcorn's cocooning predictions, (2) generational analysis is interesting "pop-sociology" that can lead to helpful insights or be taken too seriously and stretched too far. Authors William Strauss and Neil Howe have presented a framework for looking at the generations. (3) They attempt to use generational analysis to predict the future of the United States for the next 70 years. Perhaps this is extending a useful idea too far--insight that can make sense out of the past does not necessarily predict the future. But the core analysis of generational trends can lead to some instriguing and useful conclusions about our present conditions.

Strauss and Howe named five generations, each with a different way of viewing the world based on collective experiences while growing up: (1) G.I., (2) Silent, (3) Baby Boom, (4) Thirteenth, and (5) Millennial. They argue that the types of generational differences are cyclical and recurring in American history. (3) We will simply consider the differences between the generations and what they mean to medical management.

The various generations do not have exact boundaries; for example, different authors will list somewhat differing birth years for the Baby Boomers. Obviously, not all members of a generation have exactly the same attitude on any given issue. Generalizations about group attitudes and outlook will have many exceptions. Even today, a member of Generation Y might more closely fit the description of the Silent Generation. Nevertheless, if we step back to see the forest rather than the trees, certain overall trends and directions appear.

1. 0.1. Generation: born between 1901-1925

The generation that survived the Great Depression and fought World War II was indelibly marked by its heroic journey. Tom Brokaw chronicles the history of this group in his current bestseller, The Greatest Generation. (4) Those members of the G.I. Generation who are still alive are 74 or older. This cohort of Americans believes in civic virtue and upward mobility--the American Dream. Throughout their lives they tended to be joiners of churches, professional organizations, and clubs. While most would express support for rugged individualism, the G.I. Generation lived for the camaraderie of group experience.

The shapes of our major institutions--civic, religious, fraternal, and professional--bear the mark of the G.I. Generation. These folks can rightly state that they left the world a better place for their efforts. John Wayne was the movie hero of this generation, who won every battle he fought. The 1942 classic film, Casablanca, defined romance at that time: hard edged, war torn, and bittersweet at the end. The heritage of the G.I. Generation was handed on to the Silent Generation.

2. Silent Generation: born between 1926-1945

Calling a group the Silent Generation sounds pejorative, but it need not be so. Most were too young to fight in World War II, but they were greatly influenced by the surge of patriotism and self-sacrifice of that struggle. The Silent Generation admired the G.I. Generation and had no wish to differentiate themselves. They may not have challenged the status quo, but they have been good caretakers of the institutions and the world they inherited.

People born between 1926 and 1945 have lived in the better world left to them by the G.I. Generation, and they worked to extend that environment rather than change it. The dominant motif for the Silent Generation is allegiance to proper principles such as law and order, patriotism, and faith. They expect to save and pay for what they get. "Don't rock the boat" could be their motto.

They lived in a Norman Rockwell world, or at least they remember it that way. In the 1940s, '50s and early '60s not as much attention was paid to the many areas where reality did not measure up to the innocence of a Saturday Evening Post cover. The movie Pillow Talk (1959) with Rock Hudson and Doris Day presented a lighthearted and mostly innocent view of romance and sexuality typical of the Silent Generation code. Certainly Hudson's off-screen sexual orientation would have been unthinkable for his millions of fans. Television shows like Ozzie and Harriet and Father Knows Best captured much of the tenor of this generation. More recently, the movie Pleasantville used the same set of assumptions as a foil for 1990s humor and as a statement that everything was not as wonderful as it appeared in the "black and white days."

3. Baby Boomers: born between 1945-1964

The term "generation gap" was coined to describe the gulf between the Baby Boomers and the two generations that came before them. This difference in outlook was profound and ongoing. The Boomers' journey has been one of self-discovery based on humanistic, altruistic, and narcissistic assumptions. The impacts of psychology in child raising were first applied in a generalized manner to this cohort of children raised in the 1950s and 60s. Perhaps this accounts for some of the differences between the generations; although blaming all of the generation gap on Dr. Spock seems facile. The big rift came from 1964 onward, starting with the Free Speech movement at Berkeley and moving onto the protests of the Viet Nam War and the Woodstock mindset. Anyone who lived through those times realizes that many of the assumptions of American pride, purpose, and trust were injured or lost during those angry years.

At 76 million strong, the Boomers have always been demographically powerful, so they are used to being the most important generation due to sheer numbers. In the 1950s and early 60s America built more schools to teach the Boomers. In the 1970s and 80s the U.S. had an enormous housing boom to build homes for Boomers. At every stage of life, the Baby Boomers have been the dominant force in our society. As they age, this will prove even more true. (5)
Instant gratification has always been key: buy now, pay later. This generation does not fear taking on debt the way the G.I. and Silent Generations did. The Boomers can be very moralistic, but they do not tend to accept authority statements or institutional principles regarding morals and ethics; they would much rather work things out for themselves--even if they get it wrong.
They are not joiners, and they are not as likely to sacrifice personal pleasures for the good of a group. Family stability has suffered as many Boomer parents have divorced and recoupled in an effort to find personal fulfillment. On a spiritual level, Boomers often mix and match religious traditions to suit themselves, rather than submit to the dogma and teachings of any single religion. "In an age when we trust ourselves to assemble our own investment portfolios and cancer therapies, why not our religious beliefs?" (6)

The quintessential Boomer movies would be The Graduate (1967) and Easy Rider (1969), along with Woody Allen's take on romance in Annie Hall (1977). In the early 70s the TV show All in the Family shocked its audience with its humorous and no-holds-barred look at the tension between the Silent and the Boomer generations. The invasion of the Beatles in 1964 set off a wave of generational angst over the haircuts of John, Paul, George, and Ringo--laughable today.

4. Generation X:
born between 1965-1981

This generation is called Thirteenth by Strauss and Howe because it is supposed to be the thirteenth one since the generation that founded the United States (born between 1701-1723). More commonly they are known as Generation X. The earliest use of this term appears to be the name of an early 1970s English band, which was rock star Billy Idol's first group. Generation X is also the title of a book by Douglas Coupland, which was the first to connect the term with this Thirteenth Generation. (7)

This is the "Baby Buster" generation, comprising about 41 million people-25 million less than the Boomers. They are wedged between two much larger birth cohorts and thus feel demographically overlooked. Gen-Xers feel that they will get less in a material sense than the preceding generations got. This changes their approach to materialism itself. Their journey is as residents of a new world-a world that changes shape rapidly and continuously. Insecurity is a major theme in Gen-X consciousness.

Many Gen-Xers sense an almost psychedelic reality that cannot be trusted. The 1999 hit movie. The Matrix, played to this notion that reality differs greatly from its perception (along with a great deal of video game style violence and a patina of religious symbolism) and resonated especially well with male members of Generations X and Y. (8) A look at the romantic side of Generation X life is presented in the 1997 movie Chasing Amy. This film's depiction of the comix underground with its sexual frankness and ambiguity can make anyone over 40 feel very old indeed, but the viewer gets a glimpse of Gen-X attitude with all of its complexity. For this generation, ambiguity is central to life itself, while reality and security are self-created.

The emphasis of Generation X is more on close friends and virtual families than on material success or traditional associations. The television show Friends captures this essence--young people creating their own extended family or "pod" in which they look out for each other. Personal experience counts for everything with the Xers. Institutions are highly suspect, but for different reasons than with the Boomers, For Boomers institutions promote repressive dogma; for Gen-Xers they lack authenticity or even reality.

Campus minister Jimmy Long argues that Gen-X is the first generation to be fully postmodern in its rejection of Enlightenment ideals. (5) He compares the four basic traits of Enlightenment thinking with their replacement Postmodernist parallels which typify Generation X:

Enlightenment         Postmodernism
Truth                 Preference
Autonomous self       Community
Scientific discovery  Virtual reality

Human progress        Human misery

The transition from Enlightenment to Postmodernism started long before Generation X was born. Nietzsche predicted much of the postmodern condition more than 100 years ago. With their strong sense of autonomy, the Baby Boomers kept alive some last flickering flame of Enlightenment thinking. If Long is to be believed, that flame finally died out with the advent of Generation X.

5. Generation Y:
born between 1982-2003

Generation Y (following X) is called the Millennial Generation by Strauss and Howe. This generation is just starting to graduate from high school. Demographically, they are not quite as big as the Baby Boomers, but at 60 million they are big enough. Gen-Y will have an enormous impact on business and infrastructure just as the Boomers did. Already they are changing the face of advertising and marketing. (10) This is a generation to watch because they will be socially significant through sheer numbers alone. If you are a Boomer, get ready to be displaced as the center of attention of business and marketing. Companies such as Levi Strauss and Nike are feeling the pinch already as their products are being ignored by Gen-Y in favor of new and trendier brands.

Generation Y has grown up with computers, email, and instant communication in the same way that the Boomers grew up with the telephone and Gen-X grew up with television. They have no memory of a time when the technology did not exist. "(T)he Internet.... has sped up the fashion life cycle by letting kids everywhere find out about the most obscure trends as they emerge. It is the Gen-Y medium of choice, just as network TV was for boomers. 'Television drives homogeneity,' says Mary Slayton, Global Director for Consumer Insights for Nike. 'The Internet drives diversity.'" (10)

Implications tar medical institutions

The generations of Boomer, X, and Y are creating profound impacts on medicine already with more to come. Some will be obvious and others less so. We should remember that any individual member of one generation may not fit these stereotypes at all. But when we consider these generations as large groups, we can see effects that they create today or will cause tomorrow.

The Boomers

The most obvious impact of the Boomers on medicine is the force of their demographic weight. And now the Boomers are growing old. For the next 15 years or so a Boomer will turn 50 every eight seconds. Many thoughtful individuals are already alarmed at the serious implications of the graying of this generation. Medical ethicist Daniel Callahan argues that nothing less than a total reworking of our country's legal, moral, and ethical attitudes toward medical care of the aging will get us through the coming health care crisis as we face a demand for medical care that cannot be met at any cost. (11)

Boomers have a charitable streak, but self-sacrifice for the good of the group has never been a main theme in their thinking. More to the point is the Boomer attitude, We want it all--and we want it now!" Even if this means driving health care costs through the roof. (12) As the Boomers grow old, our society will not be able to afford coronary artery bypass surgery for every anginal heart or a transplant for every cirrhotic liver. The debate is heating up about the costs of using tamoxifen to prevent breast cancer in the millions of women who are at high risk. Expect to see many more such debates in the coming years.

The Boomers have, by and large, kept themselves in better physical shape and have lived a bit healthier lifestyle than earlier generations, but the hand of time is inexorable. Being fit can put off inevitable decline for a while, but that is all. No matter how much the Boomers would like to believe otherwise, just like everyone else they will all grow old, sicken, and die. Indeed, the healthier and more fit may very well live longer and die much more expensively. Much of the coining debate will focus on how costly this process is going to be and how much our society can afford to spend on the health care of seniors.

A less well-noted impact of the Baby Boomers has been their reluctance to belong to membership organizations. This has affected main-line Protestant churches, fraternal organizations, and organized medicine. In every case, the desire for personal independence has depleted membership as Boomers decide that they can do just as well on their own. Churches are waking up to the fact that the Boomers are not going to become members in numbers large enough to sustain their traditions. Some denominations are focusing most of their attention on Gen-Xers as the next generation to become church members in significant numbers. In essence, the Boomers are being bypassed.

This same sort of membership problem seems to apply to organized medicine. In many parts of the U.S., Boomer physicians are not joining or staying with their local, state, or national medical societies. The American Medical Association is particularly hard hit. (13) If generational analysis is correct, the leaders of organized medicine should take a lesson from the churches and start making whatever changes are necessary to capture the interest and allegiance of the Gen-Xers, instead of trying to bring the Boomers back into the fold. An institution can lose one generation to membership and survive, but survival is questionable if two generations in a row are lost as members. Many churches understand this--will organized medicine wake up in time?

Generation X

One important fact about Gen-X is there are far fewer of them. They are young. healthy adults at the moment, so their impact on medical marketing will impact OB/Gyn and pediatrics most strongly in the near term. These specialties (and family practice to a lesser degree) will be competing for a slice of a smaller pie for the next ten to 20 years. On the longer term, starting 30 years from now, the demand for medical services will drop from the high levels needed for the Boomers, who will be dying off. As Gen-X passes middle age, the number of elderly in our country will level off or even shrink.

Previous marketing practices that worked for the Boomers do not resonate with Gen-Xers. Much of medicine is still pretty uncomfortable with marketing, but medical marketing has become a widespread practice and will increase in importance. Targeting Generation X means learning a whole new way to attract patients. An ad in the paper or even the Yellow Pages may not be as effective as a spot on cable TV. Any message will need to appeal to their sensibilities, which are different--the Volkswagen TV ad with two guys picking up and dumping a stinky chair is pure Gen-X marketing. Making the transition to this type of thinking for marketing purposes may be very hard for a lot of medical leaders and their consultants, particularly if they are Boomers.

Approaching Gen-Xers as patients will be different as well. Futurist Jim Dator notes:
"More and more people are rejecting authority figures. They're choosing either to fall back on some form of fundamentalism or to believe only in themselves. So the standard gatekeepers of information and expertise- journalists, professors, doctors- are losing their authority. The Internet is the latest development in a do-it-your-self culture that abhors the expert." (14)
This patient attitude is showing up in the Boomers already, but it will be a much stronger trend in Generations X and Y.

Health care professionals are already being forced to learn new ways to talk to patients who come to the office with a handful of articles downloaded from the Internet. It is relatively easy for a patient to learn more about his or her single disease or condition than a generalist or even a specialist can keep in mind. The implications of this change are far-reaching, but should especially focus on how we train tomorrow's physicians in medical school and residency. Unfortunately, our medical faculty members have no experience or role models in this new way of doctoring. Developing new curricula for this purpose will be difficult.

As Gen-Xers become health care professionals, we will find that they bring a different set of priorities. Care of the sick will still be central, but the trappings of success or even its definition may change drastically. In our practice, we have noticed a change in the medical students who rotate through our office as part of their pediatrics clerkship. A much higher proportion are older (mid to late 30s) and are starting their second career. Many are women who started out In computer science or electrical engineering. They have worked for the major companies writing source code and the like, and they made a very good living doing this.

But these successful young people found themselves wanting to do something more meaningful. When they go into practice they will bring a very different attitude to the workplace. Money will not be the most important thing, and they certainly won't be afraid of information technology the way so many Boomer physicians are.

All of this will impact recruitment and retention efforts by medical groups. "Work your butt off and make a lot of money" may not attract applicants as it once did. Family time and balance between work and play may mean more to Gen-X physicians than large incomes. This becomes doubly important as fully half of the Gen-X new physicians will be women--second career or first. Strong retirement programs may mean more than high income to people who are less sure that tomorrow will be good to them. Wise medical executives will start to gather understanding of the differences in leadership that this generation will require.

Generation Y

They really are not out of high school yet, but the Gen-Yers are Impacting American life, much as the Boomers did. Why not? They are 60 million strong and that is nearly 20 million more than Gen-X. Marketing to this generation will require very different assumptions. Internet communications and email make word-of-mouth advertising instantaneous and immensely powerful. Successfully commanding these new forms of communication is not as easy as many business people think. (15)

Medical organizations haven't adjusted to the demands that Gen-Y is going to make, but we can be sure that they will impact medicine in their own turn. More concerning is the question of how many Gen-Yers will even want to utilize medical services. Today children are disproportionately over-represented in the ranks of the medically uninsured and underserved in our country. A large segment of this generation is learning how to get along without routine medical care. We might assume that as they grow up. the GenYers will want what they could not have as children and become good health care consumers, but for many of them medicine may seem unfriendly, uncaring, or unnecessary. These lessons from childhood may be hard to change.

We are about ten years away from seeing the first Gen-Yers graduate from medical school and closer to 15 years away from having a large number of them entering practice after residency. What will the impact of this generation be? This is not yet clear. The immediate future of medicine is in the hands of Generation X, but we must not forget that Y will follow before not too long. Getting locked into serving the needs of any one generation to the exclusion of others is a mistake.

Conclusion

This article presents a way of thinking that may be new to many readers. Generational thinking can be a fun mental exercise or it can be an important tool. Each generation has its own experience and sets of assumptions, and these vary markedly from one generation to the next. The speed of communications today allows individuals to know what others are thinking much more rapidly than even a few years ago. Thus the pace of change from one generation to the next is accelerating. A pessimist might sigh that along with all the other issues medical executives have to worry about, here is one more. The optimist will see generational analysis as one more useful tool to help make the business of medicine work even better.

References

(1.) Naisbitt, J. Megatrends. New York, New York: Warner Books, 1982.
(2.) Popcorn, F. The Popcorn Report: Faith Popcorn on the Future of Your Company, Your World, Your Life. New York, New York: Harperbusiness, 1992.
(3.) Strauss, W. & Howe, N. Generations: The History of Americas Future. 1584 to 2089. William Morrow & Co., 1992
(4.) Brokow, T. The Greatest Generation. New York, New York: Random House, 1998.
(5.) Dychtwald, K & Flower, I. Age Wave. Tarcher, 1989.
(6.) Creedon, J. "God with a million races." Utne Reader. # 88, July/August 1998, pp. 42-48.
(7.) Coupland. D. Generation X: Tales for an Accelerated Culture. St. Martins Press. 1992.
(8.) Essex. A. "Matrix Mania." Entertainment Weekly. May 14, 1999. pp. 40-41.
(9.) Long, J. Generating Hope. A Strategy for Reaching the Postmodern Generation. InterVarsity Press, 1997.
(10.) Neuborne. E. & Kerwin, K. "Generation Y." Business Week, February 15, 1999, pp. 81-88.
(11.) Callahan, D. False Hopes: Why America's Quest for Perfect Health is a Recipe for Failure, Simon & Schuster, 1998.
(12.) Robertson, K. "Health rates skyrocket to meet boomers demands." The Sacramento Business Journal. May 21, 1999. pp. 1.

(13.) Tye, L. "AMA in danger of vanishing from the scene." The Boston Globe. May 10, 1999. pp. C7.
(14.) Olafson, K, "The end of authority." Fast Company # 19, November 1998. pp. 74.
(15.) Cramer, J. "Pseudo-net firms just don't get it." San Francisco Examiner, May 16, 1999, pp. B2.

RELATED ARTICLE: THE FIVE GENERATIONS

The various generations do not have exact boundaries; for example, different authors will list somewhat differing birth years for the Baby Boomers. Obviously, not all members of a generation have exactly the same attitude on any given issue. Generalizations about group attitudes and outlook will have many exceptions. Nevertheless, if we step back to sec the forest rather than the trees, certain overall trends and directions appear

G.I. GENERATION: born between 1901 and 1925

The generation that survived the Great Depression and fought World War II was indelibly marked by its heroic journey. Members of the G.I. Generation who are still alive are 74 or older. This group believes in civic virtue and upward mobility--the American Dream. Throughout their lives they tended to be joiners of churches, professional organizations, and clubs. While most would express support for rugged Individualism, the G.I. Generation lived for the camaraderie of group experience. The shapes of our major Institutions--civic, religious, fraternal, and professional--bear the mark of the G.I. Generation.

SILENT GENERATION: born between 1926 and 1945

Calling a group the Silent Generation sounds pejorative, but it need not be so. Most were too young to fight in World War II, but they were greatly influenced by the surge of patriotism and self-sacrifice of that struggle. The Silent Generation admired the G.I. Generation and had no wish to differentiate themselves. They may not have challenged the status quo, but they have been good caretakers of the institutions and the world they inherited. People born between 1926 and 1945 have lived in the better world left to them, and they worked to extend that environment rather than change it. The dominant motif for the Silent Generation is allegiance to proper principles such as law and order, patriotism, and faith.

BABY BOOMERS: born between 1945 and 1964

At 76 million strong, the Boomers have always been demographically powerful, so they are used to being the most important generation due to sheer numbers. At every stage of life, the Baby Boomers have been the dominant force in our society. As they age, this will prove even more true. (5) Instant gratification has always been Key: buy now, pay later. This generation does not fear taking on debt the way the G.I. and Silent Generations did. The Boomers can be very moralistic, but they do not accept authority statements or institutional principles regarding morals and ethics. They are not joiners, and they are not as likely to sacrifice personal pleasures for the good of a group. On a spiritual level, Boomers often mix and match religious traditions to suit themselves, rather than submit to the dogma and teachings of any single religion.

GENERATION X: born between 1965 and 1981

Generation X is also called the Thirteenth Generation. This is the "Baby Buster" generation. comprising about 41 million people--25 million less than the Boomers. They are wedged between two much larger birth cohorts and thus feel demographically overlooked. Gen-Xers feel that they will get less in a material sense than the preceding generations got. This changes their approach to materialism itself. Their journey is as residents of a new world that changes shape rapidly and continuously. Insecurity is a major theme in Gen-X consciousness. Their emphasis Is more on close friends and virtual families than on material success or traditional associations. Personal experience counts for everything with the Xers. Institutions are highly suspect--they lack authenticity or even reality.

GENERATION Y: born between 1982 and 2003

Generation Y is also called the Millennial Generation. This generation is just starting to graduate from high school. Demographically, they are not quite as big as the Baby Boomers, but at 60 million they are big enough. Gen-Y will have an enormous impact on business and infrastructure just as the Boomers did. Generation Y has grown up with computers, email, and instant communication in the same way that the Boomers grew up with the telephone and Gen-X grew up with television. They have no memory of a time when the technology did not exist.

Earl (Trey) R. Washburn, MD, FAAP, is an Administrative Physician at El Dorado Pediatric Medical Group, Inc., in Placerville, California. He can be reached by calling 530/626-1144 or via email at edpmg@inforum.net.

COPYRIGHT 2000 American College of Physician Executives

COPYRIGHT 2004 Gale Group

Earl R. Washburn "Are you ready for Generation X? - Changing World View - the five generations". Physician Executive. FindArticles.com. 17 Oct, 2009.
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