Are you ready for Generation X? (Changing World View).

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.

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 [e-mail].