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Health care delivery in the United States is being led by practitioners who have ascended to leadership roles primarily through years of loyalty to their organizations. But as burnout worsens and affects the youngest clinicians to the detriment of the system, is this the appropriate cadre to shepherd us towards necessary system transformation?

We share two stories that led us to think about this issue, and offer some suggestions for integrating the junior leaders of tomorrow.

Travis’s story: millennial physicians

Halfway through a recent lunch-hour meeting, I found myself baffled by the scene. My two colleagues and I, a family physician, all in our mid-30s, sat on one side of a giant conference table. On the other side were two senior physicians and the CEO of our medical group.


“What is it,” one was asking, perhaps rhetorically, “about these millennial physicians and burnout?” The CEO announced that he would like to hear from us only to pivot in the same breath to his own rant about younger physicians. He mentioned the existence of a growing body of evidence regarding burnout among millennials, but didn’t substantiate it with specifics. Before my colleagues or I — presumably expected to speak on behalf of all millennial physicians — could respond, the hour was up and our first patients of the afternoon were waiting for us to get back to work.

This meeting-turned-impromptu-lecture on millennials in medicine revealed management’s poor understanding of this generation’s professional needs. But it did serve to raise an important question: If our local medical group leadership did not understand the future of the health care workforce, what did that suggest about its ability to guide us into the future of health care delivery?


Ashley’s story: nurse teamwork

Despite a decade of nursing experience in cardiothoracic surgery, I felt like a novice in my first role as a nurse practitioner. I shouldn’t have. I quickly noticed that the process to bring me on board lacked structure, did not include up-to-date practices, and failed to convey consistent expectations from the senior practitioner and lead physicians.

Educational resources were all on paper, stored in folders stashed in cabinets. The amount of both patient- and nurse-facing education materials that needed to be updated — some handouts on the administration of heart failure medication had not been revised since 1990 — seemed alarming, yet the other practitioners did not share my sense of urgency.

After settling into my new role, I began to make gentle suggestions to update the practice and improve the efficiency of its processes, but these were consistently met with resistance from the senior practitioner. With critical details about updating our practices dismissed as unimportant, it became apparent that the leadership was resistant to change.

During my schooling to become a nurse practitioner, I learned the importance of teamwork, multidisciplinary collaboration, and patient-centered care. But from the perspective of my bedside work, these appeared to be theoretical concepts rather than part of daily practice.

In the day of networked computers, documenting evidence-based practice and sharing lessons learned from prior changes in clinical workflows should have been easy. But our team’s leadership did not appear to demand (or even aspire to) this. Were they comfortable with the underutilization of available technological resources, or simply unaware that these tools even existed?

The worst metric for leadership: seniority

Today’s health system leaders are confronted with the constant pressure to innovate. But who are these leaders and why were they appointed? What is it about the rationale for prior appointment and previous success that suggests these leaders are the right voices to be heard for steering health institutions into an uncertain future of increasing complexity and volatility?

Nursing management, medical group leadership, and those in hospital C-suites seem, in many cases, to have risen to their positions based on perhaps the worst metric: they have been in their organizations, or in their jobs, the longest.

Longevity is often seen as a reflection of loyalty. Years of service represent an accumulation of treasured institutional knowledge, its value infrequently compared to other merits such as prior demonstrated leadership success or potential for creative problem-solving. Instead of an asset for innovation, extended tenure could be a sign of growing comfort with a given status quo or operating context.

If older colleagues are slower to adopt or optimize the use of the latest technology, what can we infer about their eagerness to update local processes to reflect best practices or, further, to make boat-rocking decisions as an organization charts its course? The lure of generous pensions or retirement packages exacerbates the presence of long-lasting leaders.

While leadership ranks remain packed with “experienced” leaders for years, or even decades, what is being done to ensure that organizational change is sustainable? Grooming young talent requires concerted attention, whether that entails the creation of junior leadership roles, the establishment of formal mentorship structures, or simple inclusion in strategic committees. Yet even those efforts leave many young clinicians wanting more.

Institutions have it in their collective best interest to invest in bolstering young clinical leaders sooner rather than later. Input from the newest generation of health workers will be essential for navigating toward a future of safe, high-quality care that leverages technology and other new sources of efficiency along the way.

The health system of the future

In the U.S., the fee-for-service system is gradually giving way to one that rewards value. Technological capabilities are expanding at an incredible pace and infiltrating health care, giving rise to better data and more sophisticated analytics to direct us along this path.

Are our clinical leadership teams made up of the right people to push us towards this future? We don’t think so, at least not in their current forms. A few numbers might be enlightening: There are still far fewer women than men in leadership roles, and their pay in those roles remains less than for men. Only 12% of health care CEOs are under 50 years of age, while 17% are over age 65. Just 39% of all health care CEOs have a formal succession plan.

Whether or not you buy into the argument that current leadership is not comprised of the right mix of experience or expertise, we might all agree that stronger formalized talent development would benefit everyone.

“What is it about these millennials?”

It is difficult for some to move beyond the lazy stereotype in which all millennials demand a trophy just for showing up. Abandoning it, though, would make clear that these workers have a different view of the health care system than their more senior clinical colleagues or leadership. This is informed by their recent education and training, augmented by evolving technology, shaded by the burden of educational debt, and shaped by front-line work in a system that is not serving patients well by many measures.

A high level of comfort with digital resources lets many millennials more easily see them as innovative tools to improve the patient experience — or even their own experiences as practitioners.

It is important to recognize generational differences between clinical leaders and more junior clinicians because differences in and diversity of perspectives provide value and opportunities for mutual benefit and learning.

Despite our disdain for the common framing of “burnout,” the phenomenon is a problem for clinicians, their employers, and patients. The drained nurse can make an error. The indifferent physician can fail to adequately address a patient’s mental illness. Both can leave patients dissatisfied.

Burnout comes from being pulled in many directions, performing suboptimally in each while having little autonomy to control elements of one’s work. Solutions such as on-site yoga, meditation classes for physicians-in-training, or physician coaching are simply Band-Aids that focus on the health worker, an approach that effectively suggests the individual has somehow failed to adapt to the rigors of the work. The true culprit, however, is the system.

If millennials leave medical practice for non-clinical roles as the health system morphs to meet the needs of the next decade, the looming shortage of health workers will be profoundly worse than anticipated.

Health system leadership, payers, and policymakers would be well served by giving younger nurses and physicians stakes in their local system’s performance and empowering them to direct their own professional service of patients and personal development. These clinicians would feel a sense of improved control over and fit within their immediate ecosystems, while medical groups and hospitals would benefit from different perspectives, reduced turnover, and eventually thoroughly groomed in-house leaders of tomorrow.

Travis Bias, D.O., is a family medicine physician and a clinical transformation physician consultant for 3M. Ashley Ramirez, R.N., is a clinical specialist at Elemeno Health and an advanced practice nurse at Sutter Health. Both consider themselves to be millennials.

  • Excellent article but I find it disappointing that, as usual, allied health professions were left out of the authors’ argument. Judging by the power structure of healthcare and by articles such as this, readers would be forgiven for thinking that healthcare was made up solely of physicians and nurses and all other staff are dolts and simpletons with little to offer, nevermind deserving of increased autonomy and a say in patient care. Much is bandied about nowadays about the stregth that increased diversity brings to teams and organizations but only so long as the “diverse” members display the correct credentials after their names. I have personally seen the local Durable Medical Equipment (DME) industry overtaken by MBAs with little-to-no understanding of the healthcare industry or the patients it serves. Of course, the staff nurses would never allow (and aren’t required to) a non-nurse manager overseeing them yet the retiring respiratory therapist manager (overseeing a department working with invasive ventilation patients) was replaced with a young MBA graduate who literally spends 90% of her day, everyday, in meetings. And don’t get me started on the fact that only nurses can be considered for management positions in most hospital departments. I find it incredibly frustrating that workers with so much to offer (intelligence, skill, experience, emotional intelligence), but without the “proper credentials”, are treated as nothing more than lackeys while doctors and nurses (with their formidable union) are catered to at the expense of the rest of the healthcare team. I hope at some point the people in power will look past their own self-interest and hollow words to truly include the rest of the healthcare team in leading the the future of healthcare and innovating for the patient’s sake.

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