Volume 8 no 1

Mind the gap: thoughts on intergenerational relations in medical leadership


Glen Bandiera, MD, MEd

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Mind the gap: thoughts on intergenerational relations in medical leadership

Glen Bandiera, MD, MEd

Originally published CJPL 5(2)



Numerous models categorize, characterize, and explain differences among generations in society. Currently, four distinct generations are engaged in the physician pipeline from early training to late career. The distinct differences in how they view the world, their self-perceptions, and how they conduct relationships create real and imagined tensions. However, the significance of these differences is debated, as variability among those within a generation is likely larger than that between generations. Nevertheless, medical leaders and educators will be wise to develop an appreciation for generational differences to ensure that everyone may live up to their full potential. Opportunities exist to gain greater appreciation for how generational differences manifest in day-to-day interactions, adopt new approaches to interacting with those of different generations, and identify points of leverage across generations to optimize relationships and outcomes. Seizing these opportunities will require tough introspection and effort by leaders to overcome stereotypes and adapt to the challenges presented by those of generations ahead and behind them. This article looks at generational differences from a medical leadership perspective, offering observations and suggestions to address tensions in four domains: feedback, communication, collaboration, and problem-solving and lifelong learning.


KEY WORDS: Boomers, Generation X, Generation Y, Millennials, physician leaders, intergenerational differences


CITATION: Bandiera G, Mind the gap: thoughts on intergenerational relations in medical leadership Can J Physician Leadsh 2021;8(1):5-10 https// doi.org/ 10.37964/cr24745


Roughly four distinct generations are currently engaged in medical careers: Traditionalists (born roughly 1925–1945), Baby Boomers (1946–1964), Generation X (1965–1980), and Generation Y or the “Millennials” (1980–1996).1-3 Howe and Strauss4 argued to both popular acclaim and criticism that these are recent iterations of a repeating cycle of generational “archetypes” throughout the modern history of the developed world. The cycle starts with a high point after a crisis, creating an idealistic “prophet” generation adhering to an optimistic view of what the collective can accomplish with new opportunity, conformity, and dedication. These are the Boomers. Generation X comprises reactive “nomads” who begin to develop a consciousness about the implications of blind conformity and the importance of questioning societal directions. They seek increasing personal autonomy and the erosion of institutional authority. The archetype of the “hero” typifies Millennials, who are more civic-minded and adhere to a need for security and belonging fed by their overprotected childhood and a sense of impending “social unraveling.” Still to rise within the profession (and also represented by the departing Traditionalists) is the fourth archetype, the “artist.” People in this generation also had overprotected childhoods during a crisis and seek security through due process, order, and fairness for all.


The experiences of each generation drive the archetypal characteristics. For example, the Boomers emerged after the crisis of two world wars. Their strong adherence to conformity and social change drove the expansion of corporate America, the sense of company loyalty, strong nuclear family values, and the expectation that hard work, calculated sacrifice, and dedication pay off in personal affluence and well-being. Top


Millennials entered the workforce during a time of unraveling with serial financial downturns, the rise of terrorism, and rapid advancement of technology. They are products of overprotective home environments, they seek a strong voice in matters related to them, believe strongly in their potential to influence people and outcomes, and see the power of the generation in the ability to collectively self-determine, rather than conform to existing norms. They have a strong affinity for sharing and collaboration. Manifestations of these perspectives, enabled by modern technology include the #metoo movement, the Arab Spring, crowdsourcing, and the long overdue increased focus on gender-based and other forms of equity within institutions.


One can see potential sources of friction between the generations. These may be amplified by the belief that each has in its own validity: while each generation self-identifies unique characteristics, with the Millennials seeing themselves as most distinct, each generation notably feels they are smarter than the others.5 Millennials, although junior, feel that others have much to learn from them.


Although this framework might seem like a convenient way to make sense of professional relationships and related observations, it is important to consider dissenting views. Davey6 outlines some risks of over-reliance on these models and encourages consideration of the individual first: “It’s time to stop thinking about problems as ‘generational issues.’ If you have a problem with an entire generation, that’s your problem and your prejudice. If you have a problem with one employee who happens to be of a different generation than you, then you have a problem with one employee, period.” These cautionary words notwithstanding, there is some utility in exploring further the role of generational differences in leadership.


Implications for leadership


As Boomers make up the institutional senior ranks and early Generation X members the established mid-career cohort, most medical leaders arise from these groups. In contrast, those being taught, mentored, and overseen are predominantly late Generation X members and Millennials from Generation Y. If stereotypes are to be believed, current leaders are tenacious individualists with a high degree of practicality and a strong work ethic, who believe that resources are to be individually managed and you get what you earn. They are providing leadership and mentorship to a generation of overprotected, empowered collaborators, who believe that no individual has a lock on anything and that power exists in sharing and collective ownership. The tensions are obvious.


There is also a well-articulated leadership gap in medicine.7 Current physician leaders often took on sequential leadership roles out of necessity, a sense of obligation, or personal interest in making a difference through administration. Many learned about leadership on the fly, some adding formal education later. The currency for effectiveness is often personal impact and just portfolio stewardship. The allure of administration became muted as Boomers tended to hold on to power and influence, while Generation X exploited skepticism about organizational hierarchy and their need for autonomy and flexibility to avoid taking on leadership roles. The current health care climate and seemingly unending operational challenges do little to encourage mid-career individuals to step up.


Millennials, on the other hand, are connected and well-mentored. They have an invigorated energy to see a better future, one that depends on them. They formally prepare themselves for leadership roles and pursue opportunities to gain experience.  They are motivated by social consciousness in leadership.8 The typical Millennial would think nothing of jumping over a member of the preceding generation to take on a plum role, something that would be almost anathema to a Boomer. Again, more tension.


Finally, one need only look to medical leadership advertisements to identify one key desirable: the ability to influence others. This may pertain to one’s impact on a group, such as setting a direction and achieving goals within an institutional framework, both of which require the ability to influence others and create alignment to a vision. Leaders are also expected to attend to individual needs through provision of personal mentorship, support, and advice, as well as creating an environment in which each and all can reach their full potential. An appreciation of generational differences and adoption of mitigating strategies will be key for success in both areas. Leaders are also often involved in mediating conflict between others experiencing these same tensions. Finally, generating consensus and commitment to certain directions within an age-diverse group can present challenges when differing perspectives cannot be reconciled. Top


So what to do? The following sections provide some ideas for turning generational tensions into opportunities for success.

Mind the “feedback gap”


As Busari2 outlines, “While members of the Greatest Generation [Boomers] revere the institution of education as the source of all knowledge, conform to rules and regulations and tend to experience having failed if and when feedback is offered, members of the Millennial generation, and to a lesser degree the Gen Xers, thrive on immediate and continuous feedback, feel insecure without it and expect to be acknowledged based on how big their social network followers are.” Millennials are so used to explicit feedback that they find it hard to make inferences about their performance in its absence. Nuanced and implicit feedback, through such means as body language, is often lost on Millennials, frustrating teachers who may assume the learner didn’t listen or didn’t care.


Leaders should remember that Millennials welcome feedback, rather than seeing it as an imposition. Feedback should be both more frequent and more explicit to effect change in a Millennial. In education, this is a key feature of the new competency-based models, which involve frequent observation and feedback. For their part, Millennials, accustomed to constant validation, must be prepared for what they ask for: as one advances in a career, feedback is less uniformly positive.


Coaching frameworks have been championed as ways to make feedback more palatable for both participants: “Exciting research in recent years has moved medical education closer to an enlightened perspective on assessment and feedback. Robust assessment of learner competence and coaching for learner development are increasingly recognized as necessary partners in effective clinical education.”9


Frequent, explicit feedback and coaching in leadership relationships will help Millennials feel more welcome and support their development. Getting to know and understand their perspectives through focused questioning will also help to bridge the gap and may result in a more senior leader learning how to best optimize a Millennial’s role in the organization.


Davey,6 writing from a perspective outside medicine, offers suggestions: “Where have you seen great ideas that we could apply here?” “What can you teach me that would help me keep up with the digital age?” “Given what you’ve just told me… what advice would you give me to make this work?” “What do you see as the strengths you bring to the team?” She concludes, “For most people, young or old, seeing their ideas in action will reduce their resistance and start to bridge the divide.”


Embrace different communication styles


Bernard Shaw reputedly said, “The single biggest problem in communication is the illusion that it has taken place.” This rings truer now than ever. Many emphasize the importance of not jumping to conclusions about motives or character based on one’s manner of communication.


One obvious example is technology use. Millennials grew up connected and are accustomed to instantaneous, abbreviated conversation segments. Older folks, less so. Citing Erikson,10 “The crux of most technology-based team misunderstandings is not the technology per se — it is how team members interpret each other’s intentions based on communication approaches.”


Ellaway11 offers a label in her paper, “The informal and hidden curricula of mobile device use in medical education,” emphasizing problems with misguided assumptions about mobile technology. One should avoid assuming Millennials are detached or pre-occupied when they focus on their device; they may be involved in problem-solving or bringing others into the conversation.


A barrage of emails with explicit demands and expectations of a rapid response can seem intrusive. This, however, is how Millennials communicate with each other. More senior leaders should set an early pattern of when and with what urgency they will respond to emails, advise when a response will be delayed, follow-up with a verbal conversation at a next meeting, or send an auto-reply something akin to, “I check emails infrequently, if this is urgent please call or visit my office.” Top


E-communication may also seem impersonal or distant to an older generation, sometimes to the point of offense or worry about the lack of interpersonal contact. Those afflicted should reassure themselves that this is a style issue rather than a personal slight.


Explicitly stating one’s communication preference may help, as Millennials may not realize they have “permission” to approach superiors directly rather than digitally. Conversely, Millennials would do well to understand that tardy delays are not dismissive, as others are not tied to devices as they are. They should try to avoid feeling frustrated or rejected by a delayed response. Everyone in the modern workplace should develop multi-modal communication strategies suited to purpose.


Accept greater collaboration but proceed with caution


Millennials were told their opinions matter, they should express them freely and they would be listened to. This generation is, thus, very collaborative and open with their opinions. They see knowledge as available for everyone, not something to be hoarded. Their view is that real power lies in the collective and the ability to consult, engage, and involve others quickly and liberally.


In medical circles, these propensities play out in several ways. Millennials prefer to collaborate widely rather than take a sole role in academic endeavours, a practice that may make their CVs hard to interpret for more senior academics.7 In a clinical teaching session such as questioning on ward rounds, seeking out information “on the fly” is smart to a Millennial but may be seen by their teachers as “cheating” or being underprepared.


Similarly, sharing information may have different meanings; Hopkins et al.12 provide an excellent example of the tensions that may arise when Millennials liberally share information that their supervisor took to be protected. A key principle seems to be: encourage collaboration to maximize input and impact, but be sure everybody is comfortable with it.


Boomers and Generation X members would do well to become comfortable with embracing the democratization of information and increased open collaboration. Encouraging Millennials to share their strategies or to explain where and how they got information can have a positive effect on a relationship. Millennials should use caution when sharing information provided by their teachers and leaders and ask for permission or guidelines.

Think about problem-solving and lifelong learning differently


When problem-solving, the Boomer perspective would bring a small group of key individuals together in a formal, scheduled meeting to talk things through, whereas the Millennial perspective would involve more people accessed asynchronously and quickly via electronic means. Erikson10 frames this dichotomy as such: “[Millennials may view] work as ‘what you do’ vs. ‘where you go’” and asks some challenging questions: “Is someone who arrives at 9:30 necessarily working less hard than other team members who are there at 8:30? Is it okay for some members to work from alternate locations? Is adherence to time and place norms important for the team to accomplish its task? Is it viewed by some as an important sign of team commitment?”


Boomers should recognize that Millennials’ reluctance to commit to structured meetings is not reflective of detachment or lack of commitment, rather it represents a different manner of engagement in which as many opinions as possible are valued and meetings are unnecessarily rigid in terms of both scheduling and structure. Leaders should consider creating some space for Millennials to collaborate in this way, perhaps between formal meetings scheduled less frequently. Millennials, in turn, should recognize that some initiatives must be contained to fewer individuals and check on the appropriateness of more general consultation before engaging in it. They may also consider embracing the structure of meetings as a way to engage in the details of a topic and more fully appreciate the perspectives of others.


Boomers and Generation X members are more likely to accept “packaged” education products with a firm plan and structure, and the focus is likely to be on learning facts and skills. Classrooms, lectures, traditional conferences, and reading papers and chapters resonate with them. Millennials typically do not respond well to some traditional instructional methods, such as public inquisition (being put on the spot in ward rounds), single-moded information sources (listen to the expert), and large group lectures with one-way communication. This has implications for faculty and organizational development.


Those looking to reach early-career learners should consider newer educational models, such as e-modules, flipped classrooms, and gamification.3 Flipped classrooms involve providing learners with materials in advance and using an in-person environment to discuss issues, answer questions, and interact with the materials through such things as case studies, simulation, and Q&A sessions. This may prove uncomfortable with previous generations who may be reluctant to “leak” the content and risk reducing the value-added of the session. Millennials can help by providing input into the design of interactive sessions, preparing as required in advance, and demonstrating appreciation for the perspectives of more experienced individuals. Top


Millennials are highly skilled at accessing information. So much so, that they fuss far less about remembering vast amounts of information than their predecessors did.10,12 Erikson10 refers to this generation as “largely ‘on demand’ learners” who “figure things out as they go.” They will take advantage of their networks and electronic information sources to figure out a course of action and expect others to do the same.


Again, tolerance is foundational to creating a way forward. Older generations have had to face the reality that they cannot know or remember everything and should accept that Millennials are demonstrating how to manage information in a different way. The value-added by older generations may be to demonstrate how to be better curators or brokers of information, how to be appropriately critical of information, and how to use information to eventually make wise decisions.


Given Millennials’ expectations of rapid responses and direct interaction with their leaders, it might be advisable for leaders to create a forum for such interchange. Certainly having individual simultaneous email conversations with each member of a large group is not a palatable endeavour, nor are group email discussions that serve only to clog inboxes. Setting up a discussion forum or blog or setting aside time for open web-based sessions to discuss topics may be helpful strategies that allow leaders to manage their time while also providing frequent access to those they are leading.




Intergenerational differences are well described and, to a degree, real. Recognizing that interpersonal differences are still paramount and can be larger than group differences, leaders should consider how to use the described generational differences to advantage as they develop as leaders. The key principles for success seem to converge on the following: strive to understand, be slow to assume, validate perceptions, and look for common ground. These, along with some of the more specific strategies outlined in this paper, may be helpful to all within the profession as they struggle with how to best seek synergy among generations. Top



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3.Evans KH, Ozdalga E, Ahuja N. The medical education of Generation Y. Acad Psychiatry 2016;40:382-5.

4.Howe N, Strauss W. Generations: the history of America’s future, 1584 to 2069. New York: William Morrow & Company; 1991:538.

5.Taylor P. The next America: Boomers, Millennials, and the looming generational showdown. New York: PublicAffairs; 2014.

6.Davey L. The key to preventing generational tension is remembering that everyone wants to feel valued. Harv Bus Rev 2018;16 July. Available: https://tinyurl.com/w5v6mbur

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9.Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ 2018;2 Aug. doi: 10.1111/medu.13645

10.Erikson T. The four biggest reasons for intergenerational conflict in teams. Harv Bus Rev 2009;26 Feb. Available: https://tinyurl.com/yb66fxc9

11.Ellaway R. The informal and hidden curricula of mobile device use in medical education. Med Teach 2014;36(1):89-91. doi: 10.3109/0142159X.2014.862426

12.Hopkins L, Hampton BS, Abbott JF, Buery-Joyner SD, Craig LB, Dalrymple JL, et al. To the point: medical education, technology and the millennial learner. Am J Obstet Gynecol 2018;218(2):188-92.



Glen Bandiera, MD, MEd, FRCPC, is associate dean for postgraduate medical education at the University of Toronto. He was born on the watershed between Boomers and Generation X and adopts the perspective of either, depending on the day. Top


Correspondence to:



This article has been peer reviewed.