Understanding how health care is changing Eric N. Berkowitz, PhD Looking at the world through the lens of your patients, your community, and your co-workers

Would you wear Flip Flops to the White House?

Northwestern 2005 NCAA Championship Lacrosse team

To understand your patients and how patient behavior is changing To better work in clinical care teams more effectively To recognize that the community is more demanding of health care institutions today The answer you have may be in understanding which cohort you belong to!

Or have you found yourself asking these questions? Why do the new employees not seem to want to work very hard? How can my kids do their homework and instant message at the same time? Doesn’t anyone read the newspaper anymore? Do I have to go to another group meeting?

This is the perspective of cohorts!!!!

Cohorts……. A new way to look at your patients, physicians, employees, colleagues….

The concept of cohorts is actually not so new…first posed in 1928!!! Karl Mannheim a sociologist wrote an essay “The Problem of Generations” Essays on the Sociology of Knowledge (1928, 1952) London: Routledge & Kegan Paul

As we talk about cohorts, it affects….. *patient behavior *clinical teams *management & leadership challenges

The Management Implications of what we talk about tonight are significant! Improving health care today means working cooperatively in teams It is leading a symphony of varying cohorts

Disclaimer for protection of the presenter As we talk about cohorts and you find yours, it is not meant to imply that you hold these values, did these things, or come from these types of families, OK??? In another words, don’t be too serious!

What’s a cohort? A group bound together in history by the events that were happening as they were ‘coming of age’ : ~ Major historical events: wars, political dislocations, technological revolutions, sociological upheavals

“Cohort” vs. “Generation” A ‘Generation’ is usually: – Defined by when a group is born – About years in duration A ‘Cohort’ is: – Defined by when a group is coming of age – Can be as long, or as short, as the events that define it

Events Form Values The ‘cohort-forming’ events form similar value sets in those who come of age during those events The value sets tend to change little during a lifetime Thus the groups are bound by their similar (and unchanging) value sets*

Cohort Definition Depression World War II Post-War Boomers I & II Generation X N Gen Millenials Matures

Depression Cohort: only our patients Born between 1912 and 1921 (89 to 98 years old) Defined by the Great Depression financial security rules their thinking preserving their homes a central concern S & P 400 declined 69% between 1929 and Not until 1953 did S & P get back to where it had been in 1929

How do events affect cohorts? If you have grandparents or parents who are from the depression cohort and enter their kitchen what do you always find?

Depression cohort kitchens have? (a) a rug near the stove (b) linoleum on the floor (c) Moxie in the refrigerator (d) an area called a pantry (e) a chute for the ice

Depression cohort kitchens have? (a) a rug near the stove (b) linoleum on the floor (c) bottles of Moxie in the refrigerator (d) an area called a pantry (e) a chute for the ice

Depression Cohort Patients” Loved by Hospital CFO’s and Doctors: Why? They always paid their bills!

Who are the matures? Patients, some employees, and the community Born between 1922 and 1945 World War II The Post War

Matures

World War II Cohort Born , came of age 1940 to 1945 (age 83 to 88 today)--5% of population defined by World War II defined role in war was for many highest status achieved common experience was a sense of deferment and delayed gratification*

World War II: The Best Patient: Why? Defining experience of this cohort was the warTook an order, marched to it And, you will succeed, You’re the clinician give an order, they will comply!

Post War Cohort: patients, community, workforce Born between 1928 and 1945, came of age 1946 to % of the present population beneficiaries of a long period of economic growth tenor of their times conservative, seeking comfort and security time that promoted conformity*

Boom Times in America per capita income grew in the 1950s by 48 percent Home ownership increased by 50 percent Those fitting into “middle class” category reached 60 percent Tulgan,Managing Gen X,p.42

Post War were the first sandwich cohort! Can’t really accept the pride of the World War II group yet They ain’t Boomers ?

Post War Cohort values --The Post Wars are more cautious and quietly assertive quietly assertive --value conformity Levittown

Mature Values --Accomplished their goals through hard work --Matures believe in hard work and sacrifice --Matures are fiscally responsible --self-sacrifice is a virtue --strong trust in authority and institutions --delayed reward --adherence to rules

Post War Key value: great trust in Institutions A Health System Development Director’s Dream! This is the group whose value as well as their stage in life cycle leads them to support institutions, but hold on!

Mature Leadership is Directive!! Take Charge !!! Delegate !

How do other cohorts view Matures Dictatorial Rigid Inhibited Too set in their ways They’ve got all the money Learn to use your computer Boomers Gen Xer Trust Good leaders Gen Y

Mature view of work: Inevitable duty rather than a sense of meaning and fulfillment and social interaction (Kupperschmidt, 2000) A good day’s pay and recognition from authority are just rewards for a day’s hard work ( Lancaster and Stillman, 2002) Believe in command and control leadership ( Zenke et al., 2000)

Pre-Boomers: The management challenge Need technology training Use traditional perks for motivation Personal touch—phone calls and notes Coaching should be tactful and private

A work environment for the Matures Matures like consistency and conformity Matures are conformers Matures are disciplined Matures believe in law and order Command and control leadership Obedience over individualism

Boomers Born 1946 to 1964 –two distinct groups 45 % of today’s workforce

Leading Edge boomers Born between 1946 and % of the population, came of age between first to experience television as a pervasive influence on culture came of age in the 60s--Vietnam, Kennedy assassination heavily values individualism, indulgence of self, and questioning everything

Boomers

The Boomer Motto “Never trust anyone over 30” -Abbie Hoffman

Oh God, We’re 50 hitting 60 (and older!!!!!)

The March to 60! Nearly 8,000,000 Boomers turned 60 in 2007 That is 330 per hour that year !

Boomers II Trailing edge boomers born between , came of age 1973 to 1983 external events are stopping Vietnam War, Watergate--faith in institutions gone and idealistic fervor disappeared narcissistic preoccupation with self (“I’m OK, You’re OK”) oil crisis, S & P declined 30% between 1973 and debt was way to maintain lifestyle

Boomer I’s and Boomer II’s Idealistic Workaholics Career first, family second Active participants or aware observers of the 60s More cynical Boomer I’s Boomer II’s

Then: Long hair Now: Longing for hair Then: A keg Now: A ekg Then: Acid rock Now: Acid reflux Then: Moving to California because it's cool. Now: Moving to California because it's hot. Then: Watching John Glenn's historic flight with your parents Now: Watching John Glenn's historic flight with your kids Then: Trying to look like Marlon Brando or Elizabeth Taylor Now: Trying not to look like Marlon Brando or Elizabeth Taylor Then: Seeds and stems Now: Roughage Then: Popping pills, smoking joints Now: Popping joints Then: The President's struggle with Fidel Now: The President's struggle with fidelity Then: Paar Now: AARP Then: Killer weed Now: Weed killer Then: Hoping for a BMW Now: Hoping for a BM Then: The Grateful Dead Now: Dr. Kevorkian What they knew, What they know!

The Boomers 86% high school graduates More than 26% have college degrees Boomers have a sense of privilege Highest level of education! Why?

Boomers are aging differently By 2010, estimated 96 million people over will be fashionable: ‘50 is where it’s at, baby!’ Inner-directed focus will lead to a new spiritualism, contemplativeness Boomer elders will be seen as wise, reflective, ‘keepers of values’ In October 2007 the first Boomer applied for Social Security at 62!

Boomers are aging differently 2000: ‘Youth’ still holds sway (50 is still ‘bad’) – Youth-emulating – Age-denying – Activity-driven in ‘retirement’

Boomer values individuality not conformity rule breakers what they get is more than what they earn, it is what they deserve fights are a clash of moral principles Good vs. evil want to be in charge work centered

Trailing Boomers Possibilities not so bright! --three mile island --energy crisis

Boomers and Work “workaholics” with a relentless pursuit of success and achievement ( Kupperschmidt 2000 & Zemke 2002) Highly competitive ( Foot 1998, Lancaster & Stillman 2002) Place great value on their careers as a central focus on their lives (Smola and Sutton, 2002) Career is a key to personal fulfillment (Kupperschmidt 2000 & Lancaster & Stillman 2002) Not technologically savy & do not like change ( Raths 1999) Even when working in a team, want their individual contributions recognized (Weston 2001)

The Boomer Challenge Let them know their experience counts Communicate the change agent potential Show them how they can be a star Need to be encouraged to take advantage of training opportunities Give them public recognition*

Boomers Motivate with personal appeal Provide public recognition Name recognition Reward hours and effort Coach tactfully Use questions, not statements Treat as equals

“Kids. I don’t know what’s wrong with these kids today” --from Bye Bye Birdie Or what I often hear Boomers say about Gen Xers and other younger cohorts

Gen X or

Generation X Born , came of age , 21.9% of the population children of divorce, latch key kids--searching for anchors little hope of lifestyle of parents politically conservative*

W. Strauss And N. Howe, (1991) Generations: The History of America’s future ) New York: Morrow; C.Raines,(1997) Beyond Generation X, Menlo Park, Ca. Crisp. In the 1960’s 75% of the families looked like these popular TV shows – “Leave It to Beaver” – “Ozzie and Harriet” 40% of Gen Xers were in single parent households as children By 1997 only 3 in 100 families looked like this!!!!!!!!!! American College of Physician Executives 58

Who are these Gen Xers the most demographically diverse 69% Caucasian 13% African American 13% Hispanic 3% Asian American 1% Native American*

The Boomer view of a Gen Xer But Boomers shouldn’t look askance!

Would you have invested in these boomers?

Do Boomers really see themselves?

The New Gen Xer David Filo Jeff Bezos Michael Dell

Reality Bites And they wonder why those of us in our twenties refuse to work an eighty hour week just so we can Afford to buy their BMWs. Why aren’t we interested In the counter-culture that they invented as if we did Not see them disembowel their revolution for a pair Of running shoes. But the question remains, what are We going to do now? How can we repair all the Damage we inherited? Fellow graduates the answer is simple. is simple. The answer is…………I don’t know.” --Elaine Pierce (Winona Ryder)

Generation X

What Gen Xers Know 1980 Carter signs Chrysler bailout bill 1981 Pope John Paul II shot 1982 John Lennon shot 1983 PCP drug rages 1984 Bernard Goetz shoots four in NY subway 1985 Crack street drug first appears 1986 AIDS quilt 1987 Gary Hart has some problems 1989 Exxon Valdez 1990 Bush breaks taxes promise 1991 Dr. Kervorkian gets attention 1992 Charles and Di separate 1993 First World Trade Center bombing 1994 Kurt Cobain commits suicide

But they also know……. Post-it notes (1980) Pac-man (1981) Smurfs (1982) Teenage Mutant ninja turtles (1983) The Cosby Show (1984) Cds become popular (1985) Oprah goes syndicated (1986) Geraldo appears (1987) Last Playboy Club closes in Lansing, Michigan (1988) Berlin Wall Falls (1989) Saturn launched (1990) Anita Hill accused Clarence Thomas (1991) Clinton elected (1992) Michael Jackson accused of fondling a boy (1993) Michael Jordan takes up baseball (1994)

Gen Xers have grown up with... Only knowing color TV PCs and microprocessors Jobs not careers Being pragmatic

Xers on the Job of their 52 million, nearly 18 million change their full time jobs annually! They are not slackers– according to the U.S. Census Bureau, they work an average of 3.56 hours per week more than the national average

The Xer Organizational Challenge Challenge

Keys to the Xers Xer’s were affected by their parent’s experiences of disappointments of downsizing and being laid off (Meda 1996; Tulgan 1995) Reward their innovation Want to continuously learn new things Work in teams where they are given responsibility Motivated in an environment that they describe as a “culture of fun” (Ramo 1977)

Gen Xers are... Self reliant Want balance Like informality Approach to authority is casual Technologically savvy

Flexibility in work environment!! Work/life balance Augusta Medical Center Medical College of Virginia 9 month work schedules to conicide with a child’s School schedule

Gen ‘xers: most want…… (d)

The “N - GEN” (Y) (‘Network’ or Internet) aged today “Crystallizing Event” is the Internet, 9-11 Archetypical opposite of Gen X; recurring characteristics similar to Depression/WW II Positive, idealistic, hard-working, stressing team-play (not free-agency) – More modest, mannerly, civic-spirited

A Positive Cohort Most studies show up to 80 percent believe they will be financially better off than their parents 46% in high school class of 2000 said the had an “excellent relationship with their parents up from 34% as freshman (Newsweek poll 2000) 1.2 million of the 3.3 million N Gen received college degrees in 2000

The N Gen Less likely to gender stereotype Less racial stereotype Barriers of time and space are different—less absolute meaning*

N Gen Women When Boomer were young women, 1 in 27 participated in sports In 1998 one in three young women participate in sports

Gen Y job expectations Gen Y’s have been using computers since preschool Work enthusiastically in teams Grown up over-supervised—now eager to manage their own time!

Core values of the N Gen Optimism Civic Duty Confidence Morality Diversity

N’ Gen (Gen Y) on the Job Expect diversity Network with others Resilient Multi-task Technological savy optimistic Technologically dependent Need supervision and structure Inexperienced in dealing with people issues AssetsLiabilities

The Millenials Born 1983 – 1993 Consistently list their parents as their “most admired choices” Trust their Grandparents the most followed by their parents 92% place “high value” on volunteer work

Show: All sizes - Large - Medium - Small Large Medium Small

Millenial Momentous Events Aids sweeps the world in the 1990s Nelson Mandela released from 27 years of prison Oklahoma City bombing April Dolly the sheep cloned July Viagra launched March America and Britain invade Iraq 2003 Madrid Bombings March

Messages for Millenials Be Smart—you are special --Baby Gap, Sports Illustrated for Kids, Nickelodeon (They have been appealed to, catered to) Leave no one behind –be inclusive Connect 24/7 –always on, always interdependent Achieve now—tutors in preschool, keep climbing Serve your community

8 Key Trends that affected Millenials Focus on children and family—90 percent of fathers attended birth of their children Federal Forum on Family Statistics reported national attention to children at an all-time high Scheduled, structured lives Multiculturalism—UCLA’s Higher Education Research shows that interracial interaction among college freshman has reached a record high Terrorism Herorism

Patriotism—UCLA Freshman Survey reported renewed political interest Parent advocacy—Generation 2001 Survey by Harris for Northwestern Mutual. Mom and Dad often cited as “Most Admired” Globalism

Understanding Millenials Computers aren’t technology--never known life without computers! Internet is better than TV—recent years the number of hours spent watching TV has declined Reality is no longer real—digital images have/can be altered Doing is more important than knowing—half life of information is short  actions more important than accumulation of facts Multi-tasking a way of life Staying connected a way of life Zero tolerance for delays  24x7 variety of modes

Millenials Spend their time Differently 16.7 hours per week on-line 13.6 hours per week watching tv 12 hours per week listening to the radio 7.7 on the phone

Millenials & Work Define success largely in materialistic terms (Lancaster & Stillman 2002) Achievement-oriented, willingness to work long hours at the expense of their private lives (Zemke et al. 2000) View change as positive & desirable, causing them to become easily bored (Lancaster & Stillman 2002, Smola & Sutton 2002) Place great emphais on prestige (Lyon et al. 2005)

Millenials Want committed coworkers Need continual stimulation and challenge— comfortable juggling many tasks Truth detectors always on—do not give second chances Expect to be asked for input regarding decisions (grew up being asked for advice about computers!)

Millenials on the job Assets Liabilities Multitasking distaste for menial work Goal orientation lack of skills for dealing with difficult people Technical savy impatience Positive attitude lack of experience Collaboration confidence

Getting the N’Gens & Millenials Encourage self-designated work teams Flexible work hours Virtual work teams Reverse mentoring programs

Reverse mentoring Sentara Health System puts computers outside the cafeteria It allows employees to friends and surf the net and help colleagues help less techno literate colleagues! B. Brown (2001)

Cohorts mean different patients…..different expectations…different behaviors

Cohort Patient Expectations Pre- boomer Boomer IBoomer IIGen x’erNGens/ Millenials Service/ promptnes s Will wait for good bedside manner Get me out fast Now MD personality Marcus Welby Academic/ERNot important StaffFriendlyProfession al EfficientQuick Office environme nt CheerfulProfession al Where’s a video No opinion Quality care Means OptimismClear explanatio ns Latest technology WEB based links Reaction to prognosis AcceptingSecond opinion Third opinion Check cites

Across the Cohorts MaturesBoomersXersN’gen Millenials OutlookPracticalOptimisticSkepticalHopeful Positive Work ethicdedicatedDrivenBalancedDetermined goal oriented View of authority RespectfulLove/hateUnimpressed Polite Positive Leadership byHierarchyAuthorityCompetencePulling Structure together RelationshipsPersonal Sacrifice Personal Gratification Reluctant to commit Inclusive friendly teams

Don’t try to cram it all in !!!