Resident Perspective | Generation Why: Neurosurgery and the Millennial Moment

Entitled. Narcissistic. Disrespectful of the hierarchy. These are the reflex impressions many neurosurgeons invoke when describing members of Generation Y — more commonly known as millennials. Although this sharp perspective is clearly one-sided, it captures a kernel of important truth — a considerable philosophical divide appears to separate members of the millennial generation from its predecessors and its ramifications are more startling to senior neurosurgeons than analogous generational differences were in the past.

Neurosurgeons are not alone — most medical specialties and large companies across the world are devising ways to manage this generational disconnect, without sacrificing productivity. There is something to the close-knit, trust-dependent, hierarchical nature of neurosurgery that has left many members of our community concerned regarding the impact that the millennial worldview may have on the specialty and its training programs. This generational conflict in neurosurgery is nicely outlined in a recent editorial in Neurosurgery by Spiotta et al. (https://academic.oup.com/neurosurgery/article/83/2/E71/5003032). Most, if not all, current residents belong to the millennial generation, while the majority of attendings fall within the Baby Boomers or Generation X — our goal was to provide a mutually informative perspective on the generational differences to facilitate a more constructive approach to training millennial neurosurgeons.

Baby Boomers came of age during a moment of dramatic social and cultural change, encompassing the Civil Rights movement, Vietnam War, Cold War/Space Race and the dawn of television, among other milestones in American history. Key to an understanding of their underlying philosophy is the “American Dream,” or the notion that every hardworking American man is entitled to a competitive salary, home ownership and a robust family and social life. Remarkably, American geopolitical and economic ascendancy paralleled the maturation of these individuals, resulting in seemingly endless opportunity and a de facto realization of the “Dream” for the vast majority of mainstream American citizens, particularly highly ambitious individuals, such as those drawn to neurosurgery. These conditions also generated a competitive, optimistic and principled culture, built around strong work ethic and a sense of ownership that captures the quintessential neurosurgeon’s worldview. In many ways, boomers are not only people who “live to work,” but they bought into the associated system of values and saw ample rewards for their dedication. Correspondingly, the neurosurgical Boomer generation is generally trusting of hierarchy and institutional power structures, the tried-and-true pathway to the top delivers the most reliable results.

Generation X was predominantly raised by the early Baby Boomers and saw a world of fewer black-and-white issues, which were often marked by a less unambiguous role or outcome for American culture, ranging from Watergate to the Gulf War, the AIDS crisis, the “punk” and “grunge” youth cultures and the remarkable proliferation of video content via cable TV and the VCR. Although Baby Boomers enjoyed remarkable professional success as a generation, their domestic landscape was far more fraught and the record-high divorce rates observed among Boomers resulted in a startling number of Gen X children growing up in single parent households. Coupled with the rise of feminism and the empowerment of women in the workplace, this also meant that a large fraction of individuals from Gen X grew up in daycares or were “latch-key children.” This resulted in a more individualistic and independent mindset, albeit one marked by skepticism and, at times, resentment of the same institutions-of-power for which their parents “lived to work.” Consequently, the concept of “work-life balance” first gained significant traction in the Generation X worldview, particularly via a more independent and individualistic brand of professional self-realization. While their philosophy is distrusting of many sociopolitical hierarchies, individuals belonging to Gen X highly value advanced education, with almost 30 percent achieving a bachelor’s degrees or higher. Although many of the neurosurgeons born within Gen X largely took up the training standards set by their Boomer predecessors, the emergence of resident well-being and the notion that observing duty hours may be of some benefit to one’s education are their hallmark contributions, as well as the introduction of a skeptical voice within the academic discourse.

Perhaps the most common critique of Millennials is that they lead a “sheltered” early life, with excessively involved parents — early Gen X members, for the most part — whose infatuation with their children’s ostensible exceptionalism gave rise to the hallmark features of the caricatured millennial: grade inflation, participation trophies and polymath activity schedules. Through this lens, millennials are often critiqued for being “whiny,” “entitled,” or simply “unrealistic” in their expectations. However, these relatively superficial perspectives on the generation overlook two extraordinary changes that occurred in the background of the Millennials’s collective maturation.

First, if Gen X saw the erosion of institutional hierarchy, then the millennials witnessed the full-on detonation of what remained in traditional power structures — literally in the 9/11 attacks and the ensuing longstanding American military involvement in the middle east, as well as figuratively in the wildly unstable financial and employment markets, typified by the bursting of the “dot com” and “sub-prime mortgage” bubbles. Many recent college graduates in this era struggled to find jobs at corporations. Put another way, while Boomers saw daily reaffirmation that hard work would invariably lead to professional and financial success, the realization of their proverbial “Dream,” millennials watched the best and the brightest of their generation either fail to find gainful employment or succeed by joining industries and institutions that levied a tremendous social cost.

Second, as the Boomers grew up alongside the broadcast television industry, millennials developed in parallel to the Internet, the home computer and the ever-smarter cell phone. Correspondingly, not only are millennials accustomed to rapid change and evolution as part of the social fabric, but they are also very comfortable with instantaneous access to a broader knowledge base and, potentially, a higher level authority — a concept that is particularly salient in the age of evidence-based medicine. With this background, millennials may question or reject tradition or accepted aspects of neurosurgical care, particularly if there is a lack of evidence to support them, which often puts them at odds with Gen X and the Boomers responsible for their training.

Putting these trainee perspectives together with what we know about the constitution of the Boomer and Gen X mentors, we can perhaps offer a few pieces of advice to inform our mostly millennial readership of ways they may be able improve their communication and rapport with mentors.

Millennials: Avoid anything that may be perceived as “whining,” particularly about your conception of what is “fair.” When you identify inefficiency or injustice in the system, remember that the patient and the job always come first, even though you do deserve (and should be granted) an opportunity to voice your concerns once those priorities are addressed. Avoid complaining about problems; instead, identify problems and then make practical suggestions for meaningful solutions. Innovation and disruption are your lifeblood, but do not lose sight of the fact that “different” does not always mean “better,” and that medicine and neurosurgery are conservative spheres for a good reason — there are lives at stake and the collective wisdom of your predecessors deserves respect, consideration and primacy (in the absence of evidence). Embrace negative feedback — you know less than you think and you should always keep in mind that the greatest privilege of residency is learning from your mistakes. Your predecessors may not always be right, but they will always be more experienced, and you do yourself and your patients a disservice by under-valuing a senior perspective. Never forget that you are part of a team, with the shared goal of exceptional patient care; at times, that means having to do an unpleasant, non-educational, or simply inconvenient job for the sake of the greater good. Do it, do it right, do it well and don’t grouse about it—a negative attitude has no place in neurosurgery.

Ultimately, there is no right or wrong approach to communication across generations, and our observations are by no means comprehensive, nor universally applicable. However, we hope that in reading them, a neurosurgeon from any generation will glean some insight into the challenges of working alongside someone with a remarkably different generational perspective.

Neil Majmundar, MD
Neurosurgery Resident, Rutgers NJMS

Christopher S. Graffeo, MD
Neurosurgery Resident, Mayo Clinic. Rochester