Table 3.

Conflict themes definition and illustrations

Category definition	Exemplary quotes
Work Ethic	Millennial:	Baby Boomer:
• Valuing self over patient	I resent the attitude that residents today are lazy. Older physicians have burned out and don’t do the right thing and take care of patients …Older people cherry picking charts, working slowly	There is a striking difference in apparent work ethic, with many younger workers (nurses more than docs, but both) seeming to be much less interested in actually accomplishing anything and more interested in punching the time clock as compared to older folks. Does my bias show? It’s “not my job” vs “I’ll make sure it gets taken care of…” Younger emergency physicians have bought into the philosophy that lifestyle (i.e., privilege) trumps taking care of patients (i.e., responsibility) Most younger physicians, nurses, ancillary staff do not realize the importance of their job. They take no initiative. They do only what the computer or EHR requires and that’s it
Treatment Approach	Gen X:	Millennial:
• Authoritarian v. patient-centered  • Sticking to tradition with lack of evidence	People in the generation right behind mine tend to question everything because they want to understand the right plan for the patient, but people in my generation and especially the generation above me tend to want their orders for a patient followed without question. I have seen this on numerous occasions where an older person asks a younger person to do something for a patient and gets upset when they get a million questions Work ups. New MDs rely heavily on radiological studies. Not physical exams Young practitioners practicing very defensively, high utility of labs, imaging; MDs and nurses driven by protocols and benchmarks (some that they don’t understand)	Older attendings not being receptive to current literature and doing things based on anecdotal evidence. When opinions vary in subjective scenarios and the older generation demands that one way be done because “that’s how it is always done” even with recent evidence to suggest otherwise I have difficulty getting more “old school” consultants on board with a collaborative approach to patient care—they tend to be more hands off
Technology Application	Baby Boomer:	Millennial:
• Underuse or overdependence on technology for patient care and communication  • Perception that technology use is replacing patient-centered care  • Less patient interaction and dependence on social media to communicate	I am less computer savvy than my younger partners, and thus have more difficulty learning ultrasound, using simulators, learning from “podcasts,” etc I ask another provider “do you remember the dose of ….?” and they pick up a smart phone and google it Everything is done electronically so the newer generation lacks social skill which is so vital to good patient care	Traditionalists can’t give up printing lab values out when they are on the EMR. A senior staff member occasionally submits hand-written requests for our online scheduling program Older ED physicians needing help navigating the EMR/system: putting in the correct orders, diagnoses, etc
Entitlement	GenX:	Traditionalist:
• Expecting individual accommodations  • Perception that the younger generations want rewards before they have “put in their time”	Entitlement among residents and/or junior faculty members Residents/junior faculty members craving direct feedback for improvement while older faculty feel uncomfortable providing such feedback	Younger physicians seem to want instant rewards rather than working their way up through a system Trainees wanting the program to adapt to them, rather than their adapting to a new role A medical student wanted time off that would not work with the schedule. She did not seem to understand that she was not special and schedule could not be bent to fit her specific requests I see that some newer people do not hesitate to switch jobs or leave a situation that doesn’t meet every single one of their expectations Lack of understanding that sometimes you have to just “suck it up”
Professionalism	Millennial:	Baby Boomer:
• Patient perception  • Problems with credibility  • Perceptions of respect	There are lots of little things that come up during the day—one of the most common is an older patient or a patient’s older family member making some remark about the resident or even the attending being “too young to be a doctor” or “too pretty.” The lack of professionalism in terms of timeliness, respect for authority Mostly related to accepted dress in ED	Medical students are not as respectful as we used to have to be—referring to attendings by first name. Older male colleagues will call female residents “blondie.” Younger physicians being poor at communicating with older patients as well as the reverse The older team member did not feel that the younger team member was professional in interacting with patients. The younger team member did not share the same social values held by the older team member. The younger was much more casual when interacting with older patients. The older team member felt this was too casual, calling patients by first names, not addressing them with Ma’am or Sir
Work-Life Balance	Millennial:	Traditionalist:
• Conflict related to staffing the ED  • Burnout because of desire to balance work/family life	Told by my female program director that taking more than 6 weeks maternity leave was selfish and unprofessional. She followed by saying that the Hippocratic oath never mentioned family, and that I need to get used to that fact that I’m a doctor now, so my career comes before everything, including my family There are really unspoken conflicts around scheduling, mainly night shifts Younger physicians, often parents, place high value on balance and family time. This is often misinterpreted as laziness or lack of investment in their profession, with negative consequences	Younger emergency physicians have chosen this specialty not for the work but for the time off to indulge their pleasure. They have forgotten that recreation, by definition, is to re-create one to return to their essential task-work Intermediate plans include getting off of night shifts by their 40’s, retire by their 50’s Some of the newer people seem to want much more vacation and more time off than what seems normal. This isn’t a part-time job or a per diem position Lots of conflict on the schedule, working hours, late stay, etc.-often different ideals between older docs (55 +) and younger Docs (mid 30 s) To some of the new grads lifestyle is much more important than professional achievement or income.—in my opinion
Communication Style	Baby Boomer:	Millennial:
• Critical feedback perception  • Use of language perceived to be offensive	Whereas traditionally important issues have been discussed in person during a meeting or at least one on one in a phone call more and more young doctors feel comfortable discussing important things via text or via e-mail Direct communication is perceived as anger. Young RN gets told to do a job. She/He perceives the tone of voice to be very aggressive and files a bullying charge Young residents do not take negative feedback well. They look only for positive reinforcement Residents communicate to attendings with text messaging in an informal tone; attendings interpret both the mode of communication and the language used as unprofessional. For example “hey” as a salutation, using all lower caps, using text messaging to let the attending know that they are running late to a shift, using text messaging to inform attendings that they are running late rather than ask for forgiveness for running late Younger generations are more cavalier about electronic communication—text messages in the middle of the night or to communicate operational or leadership issues, multiple phone calls without leaving a VM, preference for IM/text (immediacy) over email. Poor interpersonal communication skills Differences in communication style, particularly with written communication. The specific example is a resident communicating with attendings from other services via email and using improper punctuation, capitalization, grammar, and even emojis. She doesn't understand that work communication and texting with friends require different styles of communication	Younger people prefer to communicate about work via email or text while other generations prefer the phone Different modalities of communication and information gathering—social media vs. email I think this is more related to gender than age, and older men having difficulty with younger female physicians, and speak in a derogatory tone or not agree with management, when it is clearly appropriate, and also not do not take feedback well from a younger physician, especially younger female to older male