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A Piece of My Mind | April 7, 2015
The Other Generation
Shlok Gupta, MD1; Susanna Mak, MD, PhD2; Allan S. Detsky, MD, PhD3
[+] Author Affiliations
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 2015;313(13):1319-1320. doi:10.1001/jama.2015.1082.

What are we going to do about the other generation?
How will we ever communicate without communication?
“The Other Generation” from FlowerDrumSong (music by Richard Rodgers; lyrics by Oscar Hammerstein II)

Improvements in human living conditions occur inevitably over time. The unprecedented rate of change that has occurred in the last 150 years resulted from accelerated technological progress and social changes that allow us to live with more freedoms and at a higher standard than ever before. Simultaneously, the passing of time evokes tension between older and younger generations, each bemoaning their problems with the other. As life gets technologically easier, common generational caricatures emerge: older people feel that next generation lacks work ethic, discipline, and courtesy; young people think the world began the day they were born.
In medicine, generational conflict occurs in a much shorter cycle of time. Senior residents look at the work habits of first-year trainees, who are only 3 or 4 years behind them, with disdain. And this phenomenon predates the recent decade of changes in work hours. The words “lazy,” “entitled,” and “uncommitted” have been used to describe those who followed in the training pathway for as long as any of us can remember.
In an “Open Letter to My Elders,”1 Eric Biondi, an academic pediatrician in his first year as a faculty member at the University of Rochester, wrote: “We have so much to learn from you, the generations of physicians who came before us. … You are the keepers of the ideals of our medical forefathers, so pass those ideals on to us.”
We take up Biondi’s challenge and expand it by creating an intergenerational dialogue. Each of us—a second-year internal medicine resident, a midcareer academic cardiologist, and a senior general internist—will offer 5 key messages we would like each other to hear.

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ADVICE FROM SOME SENIOR PHYSICIANS

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The Importance of Continuity

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Physicians who care for patients over long periods have the advantage of intimate knowledge of the reasons for and responses to the clinical decisions made in the course of their illnesses. In addition, long-term relationships allow for the building of trust and a sense of responsibility. Patients generally prefer to see the same physician instead of starting over with a new one. Try as much as you can to emulate the spirit of “one doctor, one patient” in the care you deliver by looking for opportunities to maintain continuity.

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Know When to Review Images and Pathology Yourself

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When key clinical decisions depend on the nuanced interpretation of imaging and pathology findings, review those yourself with a radiologist or pathologist. Face-to-face communication between the clinician and radiologist or pathologist will more often than not yield insights for both parties that will improve the decisions you will make.

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Learn How to Deal With Uncertainty

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There will be many times when you cannot make a diagnosis and the prognosis is not clear. A good clinician learns how to manage that uncertainty. An important skill is the knowledge of when uncertainty is acceptable, and when it is not, requiring further immediate investigation. Another skill is getting patients to understand when it is in their best interests to stop looking for the cause of their symptoms and let time determine the outcome. I use this sentence frequently: “We have done many tests to figure out what is wrong and so far none of them have given us the answer. That is a good thing because some of those answers would not be the ones you would want to hear. So now, we are just going to pause and see how things develop over time. This is good news.”
Patients Want Hope, and Sometimes Can’t Hear Bad News

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Several years ago I made a diagnosis in a man that I knew meant he was going to suffer a long and painful death. I delivered the news to him and his wife. After he died in the manner I had predicted, his wife told someone I knew that I was the only doctor who was honest with them from the start. I asked him whether she appreciated my honesty and he answered, “No, she did not.” Patients and their families are always looking for hope. There is a time when honest appraisal is warranted, but recognize that, in addition to denial as a defense mechanism that prevents accepting bad news, you may well be resented for delivering it and may want to find a way to offer some hope, even if it is only temporary.

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Have a Family

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During your entire career, there will be a lot of people who may remember you fondly, but at the end of the day, the people you are most likely to be able to count on are the members of your immediate family, so make sure you have one (no matter how you create it). For me, the most important and satisfying thing I did was to have and raise children, although I can’t promise that they will never be a source of angst. And remember, if you choose to do likewise, there is never a good time to start, so don’t put it off too long.

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This exercise has been useful because it induced each of us—separated in age by almost 20-year intervals—to reflect on the important issues we feel should be communicated to other generations without presuming whose messages were most valid or important. We each wrote our sections without the knowledge of what the others would say; so it is not surprising that some of the messages have common themes (uncertainty, mistakes, personal life), while others are completely different. We can only wonder about the messages we might have received from the generations that preceded us, or ones we might receive from those that will follow us. But for now, we believe this intergenerational dialogue, which each of you can replicate in your own settings, forms the basis of an educational curriculum to help both young and old accept the inevitability of change, while simultaneously meeting Biondi’s plea to pass the ideals of medicine’s forefathers into the future.

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ARTICLE INFORMATION

Section Editor: Roxanne K. Young, Associate Senior Editor.
Corresponding Author: Allan S. Detsky, MD, PhD (adetsky@mtsinai.on.ca).
Additional Contributions: We thank Victor Fuchs, PhD (Stanford University), and Stephen Gauthier, MD (University of Toronto), for commenting on an earlier draft. Neither was compensated for doing so.
REFERENCES

1
Biondi  E.  In defense of my lazy and entitled generation: an open letter to my elders. Hosp Pediatr. 2013;3(1):76-78.
PubMed   |  Link to Article
2
Leckie  A. Ancillary Justice. New York, NY: Orbit US; 2013.