The Generation in Between: A Perspective from the Keystone IV Conference

The Generation in Between

This generation identifies a tangible sense of being in between 2 distinct generations, particularly as defined by both technology (between dictation and handwriting and the electronic medical record [EMR]) and sociodemographics (between Baby Boomers and Millennials).

• “We were residents before duty hour regulations so have a different work ethic than Millennials.”

• “We grew up with the implementation of the computer and the EMR. We went from bringing a typewriter to college to starting our first practice with implementation of an EMR. Since then we have adapted and grown with the various versions of electronic communication—EMR, secure messaging, telephone visits. While not being an expert in technology, we do not fear it and are able to make wise choices about adopting the changes that are most useful. When the EHR goes down, we know how to write SOAP notes.”

• “We fall somewhere in between regarding social media. Many of us are dabblers using it strictly for social purposes, not for business applications, marketing, patient resources, etc.”

• “Many of us rode the health maintenance organization [HMO] wave of primary care promise, and while we learned to speak about the value of primary care, some of us are deflated by the failure of that promise and, as a result, can be skeptical about the latest primary care emphasis. We also entered our careers on the downside of the “golden age” of medicine in which Medicare fueled a surge of spending in primary care; as we finished our residencies, prospective payment and sustainable growth rate [SGR] were being implemented.”

• “We also adopt and adapt to the social movements of other generations. There was neither a rallying movement that we shared as a generation nor as medical professionals. The physicians of our era followed varied values and movements. Some of us followed the movements of social justice forged in the 60s and 70s, others embraced the value of social change through technological innovation, while others followed the business model of health. For those of us that chose primary care, our leaders were those that started Family Medicine and primary care internal medicine. We bonded with their ideals of social justice, the promises and opportunities of improving health through work in primary care and heard of the frustrations of trying to change a health care system misaligned with achieving better health.”

• “I continue to try and figure out if our generation is the forgotten generation. I wrote down a quote from my notes … “Maybe the Millennials are the answer.” Wow … skipped right over us. So where does that leave us? Midcareer … not old enough, not young enough, not nostalgic enough, not selfish enough, not narcissistic enough, not old school enough, not new school enough … what is my authentic, unique perspective? Am I holding on to the old way, am I helping shepherd in the new way? Either way, I sometimes feel like I continue to bob back and forth. So maybe that is our role? The transition generation?”

Family Medicine and Midlife Crisis

The sense of being caught between 2 movements continued into our professional identity as well. Many of us wrote about a conflict between 2 different visions of our chosen profession.

Some wrote about tension, stress, disillusionment, sometimes tempered by hope and enthusiasm for change but clearly idealism hardened by experience. While in part a sentiment of age and experience, several mentioned their “midlife” crisis; it was also clearly expressed as a reflection of the tension in family medicine between the ideal of relationship-based care and population and community health with the harsh realities of financial challenges, productivity, and unsympathetic health care delivery systems.

• “Tension between holding on to the values of building and sustaining healing relationships and the demands of productivity focus and an increasing complexity of care within more complex systems.”

• “Keystone was hard for me. It embraced many of the things that I love about medicine and reflected value for how I practice. It offered hope from young physicians and patients. But, I struggled to find nuggets of ideas, strategies, for moving forward.”

• “When I think of Keystone, I think of how inspired and instantly conflicted I felt at the same time. I am inspired by the experiences of FM [family medicine] that many [in the] Baby Boomer generations have had and continue to have. I feel like I belong in their generation. I identify with the work ethic and passion and the concept that work is not a job, but an exciting adventure and honored profession. I identify with concepts of value and recognition as being primary drivers of satisfaction in my career, but really in life. I love hearing the stories of the country family doctor that would eat, sleep, and breathe their job. But I am conflicted because I also feel the pull of consumerism and technology and alternative types of healing relationships that do not need to be face to face. I sometimes want people to stop telling their nostalgic stories of how great it was to be a family doctor. I want to hear how great it is now. I do understand and actually greatly desire a better work-life balance, yet I am critical of the Millennials who demand it. I work for a large health care system that is getting primary care completely wrong, yet it is the only model that is viable in our region.”

• “My experience is about helping patients understand they have choices: that treatments have benefits and risks, that weighing risks and benefits is important, but that few choices are final and we can make changes if first choices are not working well. I am increasingly challenged by volume-driven appointment times and discouraged by lack of value/attention given to continuity. I am alarmed by the aggressive overtreatment by some of our subspecialty colleagues, and save the names of those who respect patients, evidence, and who communicate well with me.”

What Was This Generation's Experience of Keystone?

Keystone served to highlight our generation's internal conflict. The intergenerational representation at Keystone brought out the vivid sense of being “in between.” But Keystone was also an affirmation of the power of relationship and brought many of us to a balanced appreciation of core values, experience, and our place in time.

• “Personally I define my life experience as a personal physician as being adaptable to changing systems. We were trained in the era of Clinton health reform, anticipated changes in payment models, consolidation of health delivery systems, promised primacy of primary care, the end of the solo practitioner, and frequent changes in leadership and clinic ownership. We saw primary care clinics change ownership 2 to 3 times in less than 5 years, while the people (docs and the patients) remained relatively unchanged. We learned that the constancy was the relationship between patient and doctor and what changed were the logos on the white coats, cards and clinic signs.”

• “I think I live in a very idealistic place doing what I do. However, I would say that interacting with other FPs [family physicians] of our generation, I feel like we are settling into our stride, with enough years behind us to be confident and realistic, but still with the fire in our bellies to make things right in our health care system.”

• “Like young adults, we recognize the humanity of those in the generation ahead of us and are humbled to recognize that we are also human as we assume mantels of leadership in primary care. We face the promise and practicalities of primary care and hope that we can use this latest wave of favor for primary care to move the model a little further. We have mixed emotions about the generation to follow, hoping that they can help us preserve the values of primary care as we move to population health, virtual relationships, and social-media enriched care.”

• “Return to the core values of being a personal physician and the value to me, the patient, the community, and the health care system. I left Keystone reinvigorated and more resolute that the relationship between the patient and care provider is still the most important aspect of both why I am a physician and how I can improve the health of my community and health system.”

It is very likely that the angst voiced by this generation mirrors that of Generation II from the previous Keystone meeting.² The similar themes of lack of balance, frustration, and feeling of being caught in between resonate and suggest that this is a common condition in this stage of professional life. While too easily labeled as a “midlife crisis,” we observe the development from this mixture of emotions to a gradual affirmation of foundational values.

Time and Place

The Keystone conversation was initially focused on exploring the dimensions of time and place and how they apply so uniquely to family medicine. No other medical profession or discipline prides itself on longitudinality over life spans; understands and nourishes the length of time in relationship with patients; or uses time as a treatment, as a diagnostic tool, as a friend, and not necessarily as a nemesis.

Place is a parallel and just as critical dimension of family medicine. Much of our scholarship, folklore, and legend are embedded in place: the countryside, the small-town family doctor, the home visits, the inner city, the school and community. Indeed, population health is more dependent on geography than any other factor.³ We have special programs in rural health, urban underserved, refugee and immigrant communities, schools, and hospitals.⁴

It is surprising how little we have studied time and place in relation to family medicine. The literature certainly appreciates continuity of care, definitions of the primary care relationship, and the singular importance of having a primary care physician. ⁵ But other aspects remain untouched. What is common and different about family medicine in different neighborhoods and communities? How does a family physician's practice change over the course of decades? What is the meaning of a relationship over long periods of time?

On this last point Keystone delivered. Woven throughout the discussions of relationship were the implicit values of time and geographic community. Conversely, Keystone participants wrestled with asynchronous relationships in an age of social media–based, team-based, and technology-assisted relationships.

• “Keystone has helped me shape my view of how time, place, and relationships need to change in some ways and how they need to stay the same in other ways.”

• “The power of person (relationships) and place impacted me deeply. Personally, certain key lessons stood out for advancing and distinguishing our specialty:

  1. Build relationship-centered teams

  2. Relationships give sustenance, a community of healing; relationships generate community solutions

  3. Resilience and vulnerability

  4. Boldness in your doctor; create a balance of boldness and tenderness: ‘Be my doctor, my teacher, my coach…’

  5. Context of place is changing; the doctor's office meets where the patient is: ‘embrace places where needs are the greatest’

  6. Find ways to always create joy in work”

Reason for Hope

From intergenerational angst and self-reflection, Keystone also engendered hope and reaffirmation. Often when family physicians gather there are common laments. More rarely—and Keystone was one of those times—there is a recognition of the gifts we receive and give, the blessing of being with people over time and place, the unique meaning in our work.

• “My favorite part of Keystone was simply witnessing fellow family physicians from all generations and all locations united in sharing the joys and challenges of family medicine. For a brief moment, I felt part of something bigger, more meaningful, something that would withstand the tests of time.”

• “Perhaps if we fight for relationships, even over health, we can rally the people to join us in a renewed countercultural revolution.”

• “It just felt good to be around a lot of thoughtful people of multiple generations who were leaders and passionate about carrying on the tradition of doing the right thing for our patients. The commitment to being there for our patients was probably the strongest theme for me.”