1. Introduction

Five generations are currently living together on the planet, and each generation is of the age to have formed their own opinions and expectations. The different generations include the Traditional Generation [>1945], the Baby Boomers [1945–1965~], then Generations X [1965–1980~], Generation Y- “Millennials” [1980–2000~], and Generation Z [2000–2010s~] [1]. Each generation has special characteristics brought out by the times in which they have lived, which in turn has affected the way they communicate in both reception and expression of information. The following chapter looks at key differences between the generations in the United States and discusses their application to medical education and patient engagement.

To better understand health professions students, educators need first to understand themselves. Everyone views the world through the lens of their own personal histories. Each generation will have a brief synopsis of characteristics followed by suggestions for health profession teachers and communication recommendations for learners. This chapter aims to improve communication between educators, learners, health professionals, and their patients. While this chapter focuses on generational differences in the United States, much of the content can be extrapolated to other parts of the world as well. People worldwide may experience history differently and, therefore, may have different characteristics. Using the information in this chapter, one can be mindful of the past and perceptions of the people around them and use that information to better relate and connect with others.

2. The traditional generation

The Traditional generation (aka Traditionals), those born before 1945, was shaped by the Great Depression and World War II, among other events. They have been described as “emotionally conservative,” and this is one reason they are also called the “Silent Generation” [2]. They tend to be disciplined, more formal, and have a keen sense of duty. Traditionals like to follow the chain of command and prefer to make decisions based on what worked in the past, but they still seek out technological advances. They value respect, stability, privacy, integrity, order, consistency, practical communication skills, and paying your dues. Traditionals are loyal workers who are highly dedicated, risk-averse, and committed to teamwork and collaboration [2]. They want satisfying work opportunities that are stable, and they appreciate the personal touch such as handwritten notes [1].

2.1 For educators

Teachers from the Traditional Generation should try to understand that the formality and stoicism of their generation seem old-fashioned to younger generations. These characteristics mean less to younger generations than meaningful or genuine interactions [2]. Also, while paying your dues is important to Traditionals, younger generations believe if you are talented and work hard, you should be given a chance to prove yourself [2]. However, Traditionals, Millennials, and Generation Z do have a trait in common. It is their sense of duty [2]. While Traditionals’ sense of duty is more targeted to their country or employer, Generation Z’s sense of duty is more targeted at a cause. Younger and older generations are both proud of their work, but older generations are proud of the work product, and younger generations are prouder of the experience. All the generations mention wanting to contribute to the greater good as well [2].

2.2 For learners

When communicating with the Traditional Generation, learners should understand that a few well-chosen words of appreciation mean more to this generation. Showing respect is important to them. They expect students to work hard, not complain, and not look for a lot of recognition. However, when Traditionals praise someone, it is short but genuine and meaningful [2].

Learners should be relatively formal and direct but respectful when communicating with clinical teachers. Do not expect a lot of positive feedback, but when you get a few words, know it is meaningful. Appeal to their sense of duty. Be direct but polite. As they appreciate actions more than words, consider making a small card with a thank you. You may also consider doing something that saves them time, like gathering a patient’s history or test results before they get in or while they are doing something else [3].

2.3 For healthcare providers

Patients from the traditional generation trust their physicians [4, 5]. They are more likely to do what their healthcare providers tell them to do without questioning it. They look to their physicians for education about their health nearly exclusively, and they expect to visit in person. Their physicians need to be explicit in recommendations as the traditional patient will tend to do precisely what you say [6]. While the recent pandemic has forced many to reach a certain comfort level with telehealth, they still prefer in-person visits when possible. They will sign up for a portal but will likely use it to review results only [7] (Table 1).

		General	Educators	Learners	Patients
Traditional >1945	Traits	Stoic, formal, risk-averse, dutiful, digital immigrants	Formal, rule follower, appreciates actions more than words		Implicit trust in their doctors
Traditional >1945	Needs	Stability, a persona touch, personal satisfaction	Formal curriculum, know less formality is not disrespected to other generations.	Appreciate the few words of praise offered, be respectful, be direct but polite.	Explicit instructions, in-person interaction,
Baby Boomers 1945–1965	Traits	Optimistic, conflict avoidant, team- oriented, cause-oriented. “Show-me generation” strong sense of fairness	Actions mean more than words; nonconfrontational, love innovation, workaholic	Loves a cause, questions everything,	More likely to challenge physician’s opinions
Baby Boomers 1945–1965	Needs	To know they make a difference	Make a difference, be mindful of words as they can come out harsh	To be diplomatic, work hard, share ideas, appeal to a sense of fairness	Increase access to physicians through the portal to ask questions, personalized care
Generation X 1965–1980	Traits	“Latch-key kids,” fiercely independent, pragmatic, creative, value actions, and accomplishment, cynical	Values hard work over intelligence, words can seem harsh	Results-driven, skeptical of authority, prefers a call	Skeptical of authority, fiercely independent, more likely to use the internet for information than the previous generations
Generation X 1965–1980	Needs	Structure and direction, work–life balance	Balance feedback to include positive reinforcement, be mindful of words	Be direct and practical, show independence	Provider to acknowledge internet info and prescribe good sites to find info
Generation Y 1980––000	Traits	Confident, optimistic idealists, respect, dedication, meaning, words mean more than actions, good at teamwork	Actions mean more, dedicated	High expectations of authority, short attention span. Prefers text or e-mail to call.	Not likely to take physicians’ advice. More likely to listen to advice online.
Generation Y 1980––000	Needs	Encouragement, coaching. To know they are making a positive difference in the world	Respect, positive contribution, be clear on what and how they are teaching, be encouraging	To be heard, balanced life, team activities, clear and organized material, rapid return of information, encouragement, validation be respectful	Acknowledgment, two-way digital communication, reputable sites to find information
Generation Z 2000–2010s	Traits	Still forming. Digital natives. Believe trust is earned, value meaning, social justice warriors. Values effectiveness over convenience		Prefer face-to-face communication. To be part of a greater good	The least likly to seek mental health treatment. Expects digital communication,
Generation Z 2000–2010s	Needs	Still forming		Frequent check ins/feedback. Use technology to communicate with students	Easy, instant/convenient, digital communication with the healthcare system

Table 1.

Traits and needs of various generations pertaining to educators, learners, and patients. [the empty cells do not have enough in that category to characterize.]

3. The baby boomers

The Baby Boomer Generation are those born between 1945 and 1965, although the exact years vary slightly depending on who you are reading [1]. They witnessed and partook in the political and social turmoil of their time: the Vietnam War, the Civil Rights Movement, the John F. Kennedy (JFK) and Dr. Martin Luther King, Jr. (MLK) assassinations, Watergate, and the sexual revolution as well as Woodstock, and the freewheeling 1960s [2]. Baby Boomers grew up in an era of prosperity and optimism, bolstered by a sense that they are a unique generation capable of changing the world. They respect authority but do not always trust it. Many are accepting of diversity, optimistic, more politically liberal, conflict-avoidant, and relationship-oriented. They also thrive on the possibility of change and love a noble cause. They have a fierce sense of right and wrong. Baby Boomers have been described as the “Show Me Generation,” which translates to words meaning little to them and actions meaning more [2].

3.1 For educators

The Baby Boomer Generation will tend to look on the bright side and hold back criticism due to their optimism and conflict avoidance [2]. However, because actions mean more to Baby Boomers than words, their verbal or written communication can seem insensitive and harsh to younger generations as the younger generation values words more. It is helpful to be mindful of their words and avoid “You” terms that can be interpreted as a personal attack. If they must give negative feedback, addressing the action and not the person is interpreted less harshly [3].

3.2 For learners

When communicating with the Baby Boomer generation, one should be diplomatic to avoid seeming confrontational. Confrontation can be interpreted as disrespect, which is something this generation will not tolerate well. Since they value actions, students should work hard and point out what their actions mean [3]. Speak up if you have ideas as Boomers enjoy innovation [2]. Keep a higher ground stance and appeal to their sense of right and wrong.

3.3 For healthcare providers

Baby boomers tend to see their physicians more often due to increasing health needs coupled with the desire to have some control over their health [6].

In part, because they are the “Show-me Generation,” Boomers will tend to ask new and follow-up questions in the office and via a portal. They also expect high-quality, individualized healthcare [6]. Patients in their 1960s are just as likely as younger patients to register for their patient portal and will use it to ask questions and review results [6, 8]. Patients in this age range will use telehealth services but prefer to use them more for acute issues, and they like it due to convenience and affordability [7].

4. Generation X

Generation X (Xers, as they are known in short) are those born between approximately 1965 and 1980. Gen Xers grew up in a period of financial, familial, and societal insecurity associated with a significant recession. They witnessed their parents being laid off along with the decline of the American global power. Also, Xers grew up with a stagnant job market, corporate downsizing with limited wage mobility, and are the first individuals predicted to earn less than their parents did [2]. They have grown up in homes where both parents worked. This created a “latch-key kid” generation, where they were obligated to fend for themselves. They were influenced by music television (MTV), the HIV/AIDS epidemic, the fall of the Berlin Wall, and their mantra in high school was “question authority” because they felt authority had let them down [9].

Due to their economic hardships, Xers started to walk away from the workaholic lifestyle of the previous generation. They value a balance between work and life and are fiercely independent, entrepreneurial, pragmatic, and creative. They value actions more than words and accomplishment more than money [2].

4.1 For educators

Much like the Boomers, Xer’s words may sometimes sound harsh to younger generations. They tend to be straight to the point and less formal [9]. They will notice when a student is trying their best or putting in more hours and be more likely to acknowledge hard work over intelligence. Being mindful of these personal tendencies will hopefully help mitigate them. Learning to give impersonal, balanced feedback can make interactions more meaningful. Making sure to include positive reinforcement and not just point out what a student does wrong is also helpful [3].

4.2 For learners

When communicating with the Gen X generation, be direct and practical. Do not be afraid to share ideas. As mentioned previously, Xers appreciate innovation. Learners should show independence and initiative, like looking things up before they are told or finding a patient’s test results that they know the preceptor is waiting for. Asking thoughtful questions also shows that learners are listening and trying to learn, not just going through the motions or biding time until they can leave. Teachers can tell who is really trying and who is not [3].

4.3 For healthcare providers

Since the average age of practicing physicians is 53.8 [10], Gen X healthcare providers are more likely to be the same age or younger than most of the patients they see. This may create some sense of distrust that must be overcome by exhibiting confidence and excellence and educating patients thoroughly on your proposed diagnosis and recommendations.

Surprisingly, Xers are most likely to conduct independent research on conditions and medications – even more than Generation Y or Z. They are less likely to heed all of the physician’s advice than the older generations (38%) but also less likely than Generation Z (43%) [5]. This is likely due to the aforementioned insecurity and independence they grew up with. Since so many patients investigate medical issues on the internet, the decision-making process may improve if efforts are made to share the burden of responsibility for knowledge. Further benefits may arise from physicians who assist patients in the information-gathering process [10]. To combat online misinformation, healthcare providers must positively influence patient selection of online materials [10]. This means that physicians should have some idea of certain websites they could recommend to their patients that are accurate and up to date.

5. Generation Y, aka millennials

Millennials are those born between 1980 and 2000, depending on who you listen to. Millennials are now the largest generation since the Baby Boomers’ population is shrinking. They are also estimated to make up 75% of the workforce by 2025 [1]. This generation has been shaped by parental excesses, computers, dramatic technological advances, and relative peace. They were raised with close parental involvement (the so-called “helicopter parents”). As children, they were showered with constant praise and therefore may be overly confident [11]. As a result, Millennials are “optimistic idealists.” They value respect, being heard, and dedication, and they want leaders who display these qualities. Millennials hold steadfast to ideas or causes but not as much to people or employers. They value meaning and validation and wish to contribute positively to the world [2].

Due to having increased interaction with technology and less with people, words mean more to this group, and they are more idealistic than their predecessors [2]. Millennials desire a more balanced life than the Xers. They have been characterized as “demanding” because they have a high expectation of those in authority [2].

5.1 For educators

Millennials have grown up in an increasingly multicultural society and appreciate diversity. They grew up with technology, change, and political turmoil, so they are adept at going with the flow [1]. This makes them good at teamwork so that they may be more comfortable or adept at interprofessional education activities [11]. Because of significant digital communication, Millennials have grown up with, they have a short attention span [11], are used to things being clear and categorized, and prefer it that way. For example, an educator may be teaching a millennial something all day, but if the educator does not say, “I am going to be teaching you now,” it could be possible that the point is missed entirely by the millennial since they may not realize what is happening. Using specific words to relay what is happening or what needs to be observed by the student allows for better understanding since it is made clear to the learner from the beginning [3].

Millennials tend to expect a quick return of information. For example, if a millennial sends a presentation to an educator via e-mail, they will expect an acknowledgment of receipt. They prefer digital communication rather than phone calls by far. Millennials can get anxious with calls as they interrupt their day. Communication via phone may be more reactive and does not allow for well-thought-out ideas. They are likely to return e-mails on the weekend or at night. They perceive e-mails as less urgent than texts [12]. Millennials also tend to be less formal in their communication and seek connectivity with their coworkers and boss outside work. This may be more difficult for older educators or teaching physicians since they were trained to keep professional boundaries, and social interaction may be seen as taboo. It is acceptable to continue to lay firm boundaries but be sure to make the reasoning clear with positive communication [3]. Millennials are accustomed to “coaching” or “parenting” styles of feedback along with a lot of encouragement [11]. As mentioned previously, they appreciate validation and knowing they are contributing to the betterment of the world. Therefore, their contributions should be openly acknowledged if they cannot see them for themselves. Also, feedback, especially negative, should be framed as helping to improve them for their future patients and the greater good [13].

5.2 For learners

It is essential for learners in this generation to consider the adage “know thyself.” It is also important to understand where your educators are coming from. While Generation Y is likely to be more technologically advanced than their teachers due to exposure, they should understand that the generations before them did a lot more with a lot less of the technological advances that they had the opportunity to know. Millennials should try to respect the contribution of the older generations, just like they want them to respect theirs. If their teacher or clinical educator does not e-mail or text them back right away or accept an invitation to something after work, it does not mean they are ignoring them. Older generations are more comfortable with a more distinct set of boundaries. However, if they do reach out to a millennial student by e-mail, text, or phone, they must think it is important, so the student should respond as soon as reasonable [3].

5.3 For healthcare providers

Perhaps because they are more technological-oriented and less people-oriented [2], they are the generation who is most likely NOT to heed their physician’s advice [5]. However, they outspend baby boomers 2:1 on self-care [14]. Millennials are twice as likely as older generations to act on health advice they find online, believing that what they find online is as good as advice from a physician [15]. They expect to be able to communicate via technology for appointments, results, and consultations. Hence, they are unlikely to frequent an office that does not offer these [15]. Therefore, a provider should try to use these to communicate as well. Due to their exposure to technology, they tend to have short attention spans, so communication with them needs to be succinct and preferably dynamic [16]. It may also help to provide them with reputable websites so they can confirm or elaborate on the conversation with their provider.

6. Generation Z

Generation Z or Gen Z are people born around 1995 to 2010 [1]. They are just now entering the job market, so their characteristics are not fully known yet. They are called “digital natives” because they have known technology since birth [17]. Thus, they are deeply attached to technology and expect employers and schools to embrace it. Due to witnessing turbulent times and political turmoil, Gen Z has less trust for authority and believes respect is earned – more like Traditionals [17]. They value meaning and are motivated to contribute positively to the world. Gen Z members are technological idealists and social justice warriors [17].

Their generation is the most racially and ethnically diverse in history [18, 19] They embrace diversity and expect their leaders to do the same. They perceive that the world is smaller because of technology and use technology for communication more than any other generation. However, 72% of Gen Z workers prefer face-to-face communication at work, while 11% prefer texts, and 9% prefer e-mail [20]. Another study found that Gen Z respondents were more likely than technology-obsessed Millennials to value face-to-face communication, emphasizing effectiveness over convenience [21].

6.1 For educators

A study by The Center for Generational Kinetics found that 60% of Gen Z members prefer multiple check-ins with the boss during the week, and 40% of those workers would prefer that those check-ins happen at least daily [20]. According to the study, if these check-ins and interactions do not occur regularly, a Gen Z worker/student is likely to think they have done something wrong [22]. Therefore, didactic and clinical educators should understand that this generation will request frequent and instant feedback. However, it does not have to be lengthy. A few words of affirmation or correction will do much of the time. It may be beneficial to carve out a set time at the beginning or end of the day to give a little more formal feedback on whatever they are working on. Appeal to their beneficence and point out how they are contributing to the good of their patient or the community [3].

6.2 For learners

Try not to stereotype your teachers as “less connected” or in tune with tech, even though they may be. Generation Z’s characteristics are much more like the Xer’s than one may think in that you both like direct face-to-face communication and value innovative ideas. Healthcare Educators, particularly those in clinical practice, tend to be very busy. If they cannot give their students the feedback or attention that the students feel is needed immediately, they should be patient. Perhaps ask for a few minutes to discuss something at the end of the day or after the student has had a chance to look up the topic. The learner should offer to look up new research or guidelines and share them with their clinical educator so you can be a value-added resource as well. Learners should try to ask well-thought-out questions. They should also look things up while waiting but not in the room with the patient or while someone is talking to them. That can be perceived as disrespectful. The educator may think they are looking at social media instead of medical research [3]. Chances are that educators are going to be older than learners. Therefore, the learners should read the previous sections on the older generations to learn the best way to communicate with their educators.

6.3 For healthcare providers

Generation Z is the least comfortable visiting a physician [5]. Gen Z members are also 1.6 to 1.8 times more likely to report not seeking treatment for a behavioral health condition than millennials [16]. Because they are digital natives, they are more likely to go to social media for advice from other young people or follow mental health social media personalities to manage their behavioral health challenges. They are also more likely to use emergency rooms and crisis services. Gen Z is increasingly dissatisfied with the traditional healthcare model, and 45% do not have a primary care provider (PCP). They are turning to holistic and preventative care, seeking a convenient experience where they can have full autonomy over their health [23]. To improve communication with Generation Z, healthcare providers must embrace technology. They should offer patient portals and telehealth visits. They should also maintain a social media presence and try to post articles that may benefit various generations. Given the looming mental health crisis among Gen Z, [24], it is imperative that healthcare professionals find ways to improve Gen Z’s comfort with and likelihood of accessing general and mental health services.

7. Conclusions

While this information in this chapter is focused on the differences between the generations, it is worthwhile to point out some similarities as well. Notably, several generations have similar descriptors. However, the magnitude of how much that descriptor applies is what changes over time. For example, Traditionals, Boomers, and Xers all value action more than words, but that characteristic became less prominent over time. While Millennials and Gen Z both value words more than actions, it seems more apparent in Z so far. It is also notable that beneficence is a common thread throughout the generations. It seems wanting to know that we are contributing to the greater good is a universal attribute.

Since empathy comes from being able to put oneself into another person’s shoes, understanding each other’s backgrounds that contribute to our personality traits will also contribute to our empathy. This, in turn, hopefully, will improve our communication and, therefore, our teaching results. Knowledge of generational differences can also be used by students and preceptors in their communication with patients.

This chapter has outlined many characteristics of various generations and communication strategies to use with them. Of course, these are broad generalizations, and other factors like personality type, cultural background, and personal history may keep some people from being stereotypically like the rest of their generation. That is why getting to know your learners by asking them about themselves and their goals is important for the teacher and the learner. Keeping these typical characteristics in mind when interacting with members of these generations can improve communication both ways. In medical education, improved communication can facilitate better learning and more productive and pleasant experiences for the teacher, the learner, and the patient.

Anju Gupta

Chapters authored

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