MARK R. WICK, M.D.
If one asks physicians of various ages the same question—“what defines ‘academic medicine’?”—a spectrum of answers would be expected. Baby-boomers (born between 1946 & 1964) probably would frame their answers around the traditional “triple-threat” paradigm that was in place when most of them trained as house-officers. That is, concomitant excellence in clinical practice, teaching, and research—with a substantial number of peer-reviewed publications—was the model in existence during their residencies and fellowships (1). At the pinnacle of academic medicine in the 1960s and early 1970s, extramural grant funds were still plenteous, and medical school faculties could afford to support many “teaching” staff members at all academic ranks, even though some of them did not actually teach (2). Faculties at that time comprised a mixture of “pre-boomers” with conservative values that were developed during the Depression-era and World War II or the Korean War, together with young boomers who had been influenced by the enthusiasm and vigor of the John F. Kennedy presidency. President Kennedy’s famous inaugural address, in which he said “ask not what your country can do for you, but what you can do for your country (3),” was an important message for boomers. They also had benefited from the increased public educational emphasis on Science in the post-Sputnik 1950s (4), and those factors conflated to create an enthusiasm—if not almost a religious fervor—for scientific and medical achievement.
That scenario began to change 20 years ago, with the proposals on health care reform that were advanced by President William J. Clinton and his wife, Hillary (5). They essentially advocated a “leaner and meaner” healthcare system, including the academic portion of it, and serious concerns arose over the continuing governmental funding of medical research. Hence, for MDs born between 1965 & 1979, representing “Generation-X” (GX), their training environment took on more uncertainty and an ever-greater emphasis on fiscal tightening. When other social factors of that group are considered, such as the increased number of single divorced parents who raised them, the after-effects of the Vietnam War, and the scandal of Watergate, it can well be understood that GXers developed a more jaundiced view of the world and their place in it (6). Those who entered Medicine did so with different goals and expectations that those of boomers, and they were much less likely to march pro forma to the same professional tunes. Loyalty to superiors, employers, and institutions was a definite casualty of that change, and the meaning of academic tenure was seriously questioned as GXers repetitively moved to greener vocational pastures. Because academic medicine in general was struggling to remain financially-solvent, a definite exodus into the private sector by university-based physicians in GX was observed in the late 1990s, which continues to this day. For many of those people, the attitudes of boomers are regarded as outmoded and obstructionist, partly because the common reluctance of boomers to retire appears to stifle possibilities for advancement on the part of GXers. Moreover, the concept of “professional duty” often differs considerably between members of those two groups. Another consideration is that GXers went to college and medical school at a time when tuitions were rising explosively, producing large loan-balances that had to be paid after finally entering practice (7).
Enter the latest generation that is now seen among medical students, house officers, and young staff physicians—the “millennials,” or “Generation-Y” (GY) (8). They are a complex and interesting group, who, in some ways, seem to be an illustration of the Strauss-Howe generational theory (9). That model holds that generational attributes are cyclic through time, and that after the “skip” of a generation or two, people will again adopt many of the values of their predecessors. Accordingly, GYers appear to again value the concept of devotion to vocation, and they are better attuned than GXers to institutional loyalty and professional achievement for its own sake. Nonetheless, there are some important differences as well. Millenials tend to stress “life-balance,” and may well opt for more leisure time instead of more salary, as would GXers. Perhaps because of their marked technocentricity—with expertise in all things digital and electronic—GYers have little patience or use for memorization and traditional modes of problem-solving. They like to attack problems in groups rather than individually, using all the benefits and immediacy that the internet and personal data-assistants have to offer. Perhaps because of the concreteness to this approach, millennials also prefer that their professional goals, tasks, and responsibilities be defined expressly. It is not unusual to hear “what do I need to learn?” or “precisely what are my duties?”, or “what, exactly, are my work-hours?” in that context. For boomers and even for many GXers, this attitude can be mistaken as that of intellectual and occupational slackers. Instead, it is merely an expression of the dependence on social media-like interactions, and the hyper-focus in problem-solving, that are unique to GY (10).
How does all of this relate to academic medicine, and, more specifically, to academic pathology? Along with all other medical specialties in university-based medical centers, academic pathologists are seeing that their roles in Medicine are less and less different than those of private-sector practitioners (11). And yet, junior faculty members are still expected to be “triple threats.” It is tremendously more difficult to perform translational research now, as compared with 30 years ago, because of the draconian elements of the HIPAA regulations and tight constraints on non-grant-funded work. Service loads have also increased in academics, to the point where they exceed those of individual community pathologists at some centers (12). That factor compromises educational activities, because people simply do not have the time to teach. Salaries in academic pathology have indeed improved over time, but they are still less than those of private practice, when adjusted for “time in rank.” For GYers, who regard their personal time as precious and have large loans to pay off, this constellation of descriptors has become virtually untenable. Many junior faculty members in academic departments are willing to spend 3 to 5 years at universities, but then they commonly trade-up to better situations in the community after academic work experience.
At a national level, this situation has a definite impact on continuing medical education in pathology. The damping-down of formal publications in our specialty has made it increasingly difficult to identify those with rising talent in academics, who can be called upon to speak at professional meetings, serve on society committees, and review papers that are submitted to professional journals. Hence, the same aging persons—many of whom are now over 55 years old—are still asked again and again to do those tasks (13).
This essay should not imply that the only excellent practitioners reside in academic centers, because the community has very many of them in its ranks as well. However, the same problems attach to them, with regard to the roles I have just mentioned. How can they be found and vetted? There is no easy answer to that question, aside from word-of-mouth recommendations.
Pathology as a whole needs to develop a systematic program of professional succession planning, and we need to do it now. This task should be embraced by our specialty societies and actualized, not merely discussed. Our responsibility as individuals is to make certain that happens.
1. Benz EJ Jr: Doing our part to ensure the future of academic medicine. Trans Am Clin Climat Assoc 2013; 124: 1-13.
2. Wright NA: The waxing and waning of academic pathology: a personal view. In: Understanding Disease: a Centenary Celebration of the Pathological Society (Hall PA, Wright NA, Eds), Wiley, London, UK, 2006; pp. 109-120.
3. http://www.jfklibrary.org/Asset-Viewer/BqXIEM9F4024ntFl7SVAjA.aspx (Accessed 5-25-14)
4. Powell A: How Sputnik changed U.S. education. Harvard Gazette, Oct. 11, 2007.
5. Anonymous: http://en.wikipedia.org/wiki/Presidency_of_Bill_Clinton (Accessed 5-27-14)
6. Anonymous: http://en.wikipedia.org/wiki/Generation_x (Accessed 5-28-14)
7. http://online.wsj.com/news/articles/SB10001424052748703389004575033063806327030 (Accessed 5-25-14)
8. http://en.wikipedia.org/wiki/Millennials (Accessed 5-25-14)
9. Howe N, Strauss W: Generations: the History of America’s Future, 1584-2069, Quill Publishing, Kent, UK, 1991.
10. Hoover E: The millennial muddle. Chron Higher Educ, Oct. 11, 2009.
11. Trotter MJ, Larsen ET, Tait N, Wright JR Jr: Time study of clinical and non-clinical workload in pathology & laboratory medicine. Am J Clin Pathol 2009; 131: 757-767.
12. Hynes WM, MacMillan DH: Establishing a compensation model in an academic pathology department. Am J Clin Pathol 2005; 125 (Suppl): S8-S15.
13. Raphael S, Lingard L: Choosing pathology: a qualitative analysis of the changing factors affecting medical career choice J Intl Assoc Med Sci Educ (E-publication, Accessed 5-27-14) (http://www.iamse.org/artman/publish/printer_288.shtml)