By Christina Hernandez Sherwood
A new generation’s changing expectations of how to balance work and life, combined with new technologies, may be shifting the culture of work in academic medicine—for everyone.
The performance required of an academic physician is a challenge worthy of a professional athlete or principal dancer at the ballet, if only the abstract difficulty of the act could be portrayed in a purely physical form. Sometimes described as a feat of juggling prowess and sometimes a matter of balance, the triple act of excelling simultaneously as a clinician, educator, and researcher, is itself a virtuoso achievement. And that’s not even considering the time and resources required for complex life demands outside of medicine. From childcare to eldercare, and from hobbies to managing personal health and wellness, it’s no easy feat to combine the needs of intensive academic medical work with all the other pieces that complete the rounded whole of a person’s life.
The intensity of that challenge, combined with historical and structural biases, is a major contributor to the underrepresentation of women and many minorities in academic medicine at the senior and leadership levels.
The Pew Research Center uses these birth years to delineate the birth years of recent generations, described as "a somewhat imprecise but useful cultural grouping of Americans by age."
||Born after 1980
||1927 and earlier
Definitions can vary. For example, in a 2015 report, the U.S. Census Bureau defined millennials as those born between 1982 and 2000. Census data indicate that this generation is more racially and ethnically diverse than those that came before.
But as a new generation enters the stage, the choreography of the performance appears to be changing. To better build fulfilling and successful careers and lives, younger professionals in academic medicine are making conscious choices in their approach to the culture of overwork based on their observation of the struggles of the generations preceding them. At the same time, new technologies, new initiatives to counteract biases and structural features of the work environment that perpetuate unequal disadvantages, and other shifts in the terrain and in the culture are defining what academic medical careers mean now and in the future. The stories and perspectives below offer a series of snapshots of that ongoing change.
Juggling the Pieces, Not Balancing the Scales
The combination of changing technology and changing expectations of younger generations in academic medicine is increasingly blurring the lines between work and personal lives—accelerating a shift toward “work/life integration” in place of the concept of “work/life balance.”
Usrina Teitelbaum, MD
Keeps Separation Between Work and Personal Responsibilities
Ursina Teitelbaum, MD, keeps separate key chains for home and work, a symbol of her effort to strike a balance by largely segregating her two worlds. She sets her alarm for 4:30 a.m. to get two hours of uninterrupted work time so she can be fully present for her school-aged children when they wake up. An associate professor in Hematology/Oncology, and clinical director of the Pancreatic Cancer Research Center at Penn’s Abramson Cancer Center, Teitelbaum prefers her “secret” pager to her mandatory cell phone because it gives her more control over when to respond. “There’s no safe space when you’re always accessible,” she said.
Benjamin Abella, MD, MPhil
Prefers Integrating the Two
Her husband, on the other hand, is more comfortable allowing work and family time to mix. As vice chair for research and an associate professor of Emergency Medicine, Benjamin Abella, MD, MPhil, has been known to host research meetings at his backyard barbecues. He doesn’t mind squeezing in a few work calls during vacation or after his family has gone to bed. The flip side, Abella said, is that although he sometimes conducts work calls during his kids’ soccer games, he’s also usually able to attend their midday school programs. “I don’t think I could look at my life and say I have work hours and play hours,” Abella said. “It’s all intermingled.”
While some physicians, like Teitelbaum, are fighting against the integration of work and personal life, many others report observing that the combination of changing technology and changing expectations of younger generations is increasingly blurring the lines between them. “At a place like Penn Medicine, you know you’re going to work hard and there are lots of issues of demand,” said Lisa Bellini, MD, GME’94, vice dean for academic affairs. “Balance is not really the right concept. It’s much more about integration.”
When Oana Tomescu, MD’04, PhD’04, GME’07, was going through medical school and residency at Penn, the coping strategy for work/life balance issues was that there was no strategy. “The mentality was, you don’t really talk about it, you just put your head down and keep working,” said Tomescu, who studies physician burnout and is an associate professor of Clinical Medicine and Pediatrics and associate program director of the internal medicine/pediatrics residency program. “The term ‘burnout’ I never heard once when I was in med school or a resident.”
But while budding physicians in the millennial generation, who make up the majority of medical students and residents today, have the strong sense of altruism common among more senior doctors, Tomescu said, they also have the expectation that their own health won’t be compromised in the care of others. And as digital natives, Bellini said, millennials intuit ways to optimize technology to achieve the work/life integration they crave. These two factors are leading millennials to accelerate a shift toward work/life integration that started years ago.
Working Beyond Boundaries
“To me, work/life integration means having the flexibility to address some aspects of my work whenever and wherever it best fits into my life,” said fourth-year anesthesiology resident Kristen Burton, MD. “We don’t have these finite boundaries and I think that’s a benefit to us ultimately for our balance.”
Burton said she can, for instance, make evening plans with friends because she can finish preparing for cases at home later via a secure connection. “In my former role as a chief resident,” she said, “I would often answer emails, calls, and texts from my co-residents on the go.”
Third-year medical student Jessica Dong, who plans to specialize in internal medicine, said she expects to value work/life integration over work/life balance throughout her career—and that’s something she perceives as an outgrowth of her dedication to patients. “A lot of my life is going to be spent working,” she said. “I want work to be something that fulfills me and is not just something I do as a means to an end of living my life separately.”
Having remote access to electronic medical records already allows for work/life integration. “If I want to leave the hospital early and go to the gym to make a workout class at a certain time and finish writing up my note afterwards,” Dong said, “that’s something I can do.”
Kerri Vincenti, MD
Values Work/Life Integration in Radiology
Kerri Vincenti, MD, a third-year resident specializing in radiology, said millennials like her are part of a movement to encourage hospitals to embrace the ways technology can make work more flexible. Recent examples include Penn Medicine’s adoption of the mobile app Cureatr, which allows secure texting within the health system, and her department’s pilot program to provide radiologists with home work stations.
Major Life Choices
Some medical students consider specialty choice and alternate career pathways as ways to create the flexibility that will allow for work/life integration. This year’s specialty match data shows that while the top picks among Perelman School graduates are internal medicine (24.1 percent) and pediatrics (10.6 percent), anesthesiology (5.9 percent), ophthalmology (5.3 percent), and dermatology (4.7 percent) also rank high.
Vincenti, who originally planned to pursue pediatrics, ultimately chose radiology, in part, because of its flexible hours and the potential to work from home. “The choice of going into radiology was one of the ways that I integrated my life into my work,” said Vincenti, who has two young daughters. “Among the specialties that met my intellectual interests, radiology stood out as an option that offered the balance I was looking for.” She noted that some faculty in the department set aside days for academic pursuits. “There are a lot of different ways that you can still be a radiologist, but not necessarily have to be going to work 12 hours a day, five days a week,” Vincenti said. “That’s something that appeals to me.”
The build-your-own career mentality may also suffuse choices beyond medical specialties. At Penn, 68 percent of medical students spend a year or more before residency on a non-medical pursuit, often a dual degree, such as MBA, MPH, JD or PhD. Louisa Pyle, MD, PhD, a research fellow in cancer prevention at Penn and a clinical fellow in genetics and metabolism at Children’s Hospital of Philadelphia, said her dual degree allows her to spend about 80 percent of her time on research, and the rest on clinical work. “I enjoy being able to [take a personal call on a Friday afternoon] from wherever,” she said, “but also knowing that I have a meeting on Sunday afternoon with some collaborators to go over some data.”
There is a sticking point for work/life integrators: the feeling that you could—and should—always be working. It wasn’t long ago that the only way to check in with the office while on vacation was to pick up the phone. Since the advent of email, however, it’s possible to largely continue work during your so-called getaway. Bellini said she tells junior faculty that while they might have to do some night and weekend work, it’s imperative to carve out time when they’re not worrying about work—or feeling guilty about not worrying about work. “You need to be able to disconnect,” she said. “If you can set some boundaries, then I think the concept of integration can work quite well.”
For Pyle, setting boundaries means sometimes turning off smartphone notifications. “At night, I don’t necessarily know if I’m getting a text, even if it’s work related, unless I’m formally on duty,” she said. “But I check as soon as I get up.”
On the whole, work/life integration isn’t a choice you make once. “The integration issues are all these little micro-decisions that you have to make,” Pyle said. In one instance, she was minutes away from a hard-won meeting with a senior person on campus when she received a call from a relative who was helping care for a family member on hospice. “It was that micro-decision,” Pyle said. “Do I answer? Do I not answer? What do I do? So many things ran through my mind in that moment. How am I going to handle this? How are they going to interpret it?”
Pyle took the call, and was glad she did, because as the only medical specialist in her family, she was able to help her relative support their family member in a moment of pain. “I was late for my meeting and everything turned out okay,” she said, “but that’s just an example of how it’s all these little decisions and they can be so tiring.”
A Department Confronts its Generational Culture Clash
How Penn Anesthesiology discovered an intergenerational conflict and set out to change its own culture to support its physicians at all levels.
Education and work/life balance were the values prioritized over nearly 80 others in a survey conducted last year among both residents and faculty in the department of Anesthesiology and Critical Care at Penn. But the ways Baby Boomer and Generation X faculty and millennial residents hoped to achieve these values often looked different. And thus a generational cultural divide came to light.
Lee Fleisher, MD
Leads Department in Cultural Transformation
A few examples of the generational disconnect: Residents deemed some teaching techniques too harsh, while attendings felt residents weren’t receptive enough to feedback. Residents were afraid talking to faculty about their emotions would make them appear weak, while senior doctors said they wanted to support those feelings. Residents struggled to complete their operating room tasks, while attendings tried to squeeze in teaching time.
In response, the department created a program to address the cultural changes happening in medicine—and within the department itself. Through this Culture of Change initiative, the subject of a forthcoming paper in the journal Academic Medicine, a group of residents and faculty began regularly discussing what they wanted the anesthesiology department to be while an anthropologist observed. They told their stories—with names changed—via a newsletter. The effort led to formal and informal changes, all geared toward improving professional interactions within the department. Changes include initiatives that range from scheduling to mentorship.
“We’re developing a new culture,” said department chair Lee Fleisher, MD, “by having sufficient people who wanted to change and were willing to risk open discussions with their colleagues and the residents, many of whom are millennials.” That process, he acknowledged, could have been “chaotic, but instead became incredibly productive.”
As part of a cultural assessment exercise, department members in different professional roles affixed stickers alongside values that they most wanted Penn Anesthesiology to espouse in the future.
Thanks to the Culture of Change, the residency program worked to ensure the next day’s schedule was sent to residents at least an hour earlier. Now residents can complete their next day’s pre-operative tasks, such as researching their patients, earlier in the day. The change shaved up to an hour off their workday. “That’s had a huge positive impact on work/life balance,” said fourth-year and former chief resident Kristen Burton, MD.
Millennials came of age experiencing frequent, intense assessment in education, said Justin Clapp, PhD, an anthropologist and research associate for the department. “They’ve been subjected to so much assessment that they constantly seem to be worried about how they’re performing,” he said. As a result, the department is changing how residents are assessed and given feedback among other changes in teaching.
Millennial residents, for instance, have less tolerance for “pimping,” the practice of publicly quizzing medical trainees, Clapp said. Instead, they prefer more formal and individualized—and less public—assessments. But most faculty are accustomed to asking direct questions rather than waiting for volunteers to raise their hands, Fleisher said. “More residents and medical students are less comfortable showing a lack of knowledge in a group setting and they’re willing to express that,” he added. “We need to figure out how to [teach and assess learning in ways] where it’s a win-win.”
Emily Gordon, MD, MSEd
Gen X/Millennial Cusp
Supports Mentoring for Anesthesiology Students
Responding to anesthesiology residents’ dissatisfaction with the department’s lack of a formalized mentorship process, the residency program established one, in which residents choose a faculty mentor within their first three months. “We know residency is tough,” said Emily Gordon, MD, MSEd, an assistant professor and associate program director for the anesthesiology residency. “Having that touchstone person for you that can serve on many levels is vitally important to your success.”
The one catch: mentor and mentee can never review one another. “It’s a low-stakes meeting,” Burton said. “Because the two of you don’t evaluate each other, it’s a nice safe space.”
The mentorship program will be evaluated annually, with the department expanding what works and fixing what doesn’t. “That’s the nice thing about our department,” Gordon said. “It’s this constant evolution. If we see a niche that needs to be filled, we’ll work on filling it.”
Transforming Culture Across the Medical School Landscape
Funded by a $1.3 million, first-of-its-kind grant from the National Institutes of Health, a randomized controlled trial recently completed at the Perelman School of Medicine sought to improve the workplace to help both men and women succeed. Getting there is complicated, but the study provided a roadmap.
Women and men begin medical careers on seemingly equal footing—the typical gender ratio of medical school classes in recent years is close to 50/50—but as they advance through the ranks in academic medicine, women lag behind. Less than a quarter of full professors in academic medicine are women, according to 2014 benchmarking data from the Association of American Medical Colleges. An even smaller fraction of women serve as department chairs and division chiefs.
Stephanie Abbuhl, MD
Led Study Focused on Women's Advancement
“Making sure that we have the 50 percent of our talent who are women maximizing their ability to fully contribute to academic medicine here at Penn, and at all academic medical centers, is the goal,” said Stephanie Abbuhl, MD, GME’83, a professor of Emergency Medicine and executive director of FOCUS on Health & Leadership for Women, the program at the Perelman School of Medicine focused on fostering women’s advancement in academic medicine and promoting research on women’s health. “And if you do that, you improve the situation for everyone—women and men.”
A three-year, randomized controlled trial, conducted by FOCUS and led by Abbuhl and Jeane Ann Grisso, MD, MSc, as principal investigators with their multidisciplinary team, set a lofty goal: Find concrete ways to improve the culture of the academic medicine workplace to help women succeed. Thirteen departments and divisions in the Perelman School of Medicine were randomized to receive a multifaceted intervention targeting junior women faculty, local departmental culture, and senior leaders, while 14 others acted as controls.
The trial, Transforming Academic Culture (TAC), was funded by a $1.3 million, first-of-its-kind grant from the National Institutes of Health. “[The NIH] usually focuses on more traditional medical research—discovering the origins and new treatments of diseases. This grant was about biomedical careers,” Abbuhl said. “But guess what: You’re not going to get the best biomedical research unless you have all of our talented faculty—women and men—with successful and satisfying careers that are sustainable. That’s the real key.”
As the trial’s main focus, women assistant professors participated in specific interventions. More than 130 junior women faculty took part in two programs during the trial: a manuscript-writing course focused on getting work published—a chief measure used for promotion—and a total leadership course geared toward work/life integration.
Hillary Bogner, MD, MSCE
Participant in NIH-TAC Trial
As an assistant professor at the time of the trial, Hillary Bogner, MD’96, MSCE’01, now an associate professor in Family Medicine & Community Health and director of research programs for FOCUS, participated in the trial. Women assistant professors across different departments met about 10 times during the months-long manuscript course. “We were encouraged to write and to set deadlines for ourselves,” Bogner said. They were also given practical tips on topics such as choosing a paper title and selecting a journal for submission. “That was extremely helpful and definitely increased my productivity,” Bogner said. “We brought back what we learned to the department.”
Over the course of the trial, whose results were recently published in the Journal of Women’s Health, both the intervention and control groups achieved significant improvements in academic productivity and work self-efficacy. The PhD faculty in the intervention group published significantly more than those in the control group, but there was no between-group productivity difference among MD faculty or overall. Yet the average work time per week for faculty in the intervention group declined by two and a half hours compared to the control group. “They were able to be just as productive as the control group, while shaving off some valuable time,” Abbuhl said. “This was truly improving efficiency.”
Emily Conant, MD
Headed Trial's Task Force Initiative
Leadership through Work/Life Integration
The total leadership program, run by Stewart Friedman, PhD, director of the Wharton School’s Work/Life Integration Project, zeroed in on finding connections between work, home, community, and self. Participants conducted mini-experiments meant to integrate—and improve—the four domains of their life. Bogner, who runs for exercise, signed up for races with her co-workers. “It was a nice way of taking care of myself, and also creating a stronger bond between myself and the people I work with,” she said. “When you think about work/life integration, it really is integration. You have to find ways where you can really satisfy both.”
Experimenting in Department-Level Change
At the local level, each of the 13 intervention departments and divisions created a task force, comprised of associate and full professor men and women, to head up its own change initiative to improve women’s career success. “While we can try to make major changes at the institution, the best environment for change is looking locally first,” said Emily Conant, MD’80, GME’89, head of the trial’s task force initiative and a professor and vice chair of faculty development in the department of Radiology. “The world moves so fast that this was really a unique opportunity to reflect on what we can do better in our departments.”
There were five main themes among the task force experiments, Conant said. One was mentorship, with several departments establishing mentoring committees for junior faculty members or promoting peer mentoring. Another was faculty cohesiveness—encouraging respect, support, and camaraderie by organizing social hours and other events. And administrative support was a hot topic, with departments adopting scribe programs to free physicians from EMR duties to better engage with patients.
Initiatives to encourage faculty development, advancement, and leadership opportunities were popular, Conant said. The creation by intervention groups of a new position devoted to this work—vice chair of faculty development—has since been adopted by departments across the medical school. Other intervention groups organized grant review panels and other writing supports for junior faculty.
Flexibility and work/life integration were addressed in specific ways unique to each intervention group. The pediatric division overhauled its on-call scheduling system to relieve some of the burden from junior faculty. The radiology department funded home reading work stations for doctors who preferred to take call away from the hospital. “Everyone was very pleased with it,” Conant said, “and happy they had more flexibility in when and from where they could read cases.”
Finally, trial investigators met regularly with chairs and chiefs of intervention departments and divisions to garner feedback and ensure continued participation. For their part, the chairs and chiefs were responsible for supporting the women assistant professors and task forces. These chairs and chiefs were brought together once a year with task force members and leaders in the medical school to share ideas and updates. “There was a wonderful cross-fertilization of creative ideas to support faculty” at these meetings, Abbuhl said.
“The exciting thing about the whole NIH-TAC trial is there was a commitment by the leaders at the institution,” Conant said. “Because of that commitment, at all levels, there was an accountability but also permission to make things happen and try to experiment.”
In July 2015, Donita Brady, PhD, a highly sought after cancer biology researcher, was recruited and hired at the University of Pennsylvania, choosing Penn over more than 14 other opportunities.
“After my first visit to Penn, I knew I found the collegial, collaborative, innovative, and ambitious scientific environment I was looking for at one of the world’s top medical schools to initiate my independent research program,” said Brady, a presidential assistant professor.
Eve Higginbotham, SM, MD
Vice Dean, Inclusion and Diversity
Penn presidential professorships, made possible through support from Penn President Amy Gutmann’s office and a $2 million grant from the Pew Charitable Trusts in 2011, not only make it possible to recruit talented faculty like Brady (as well as Wendell Pritchett, JD, PhD, the law professor recently promoted to be Penn’s next provost). They are part and parcel of a larger effort to strengthen inclusion and diversity at Penn broadly and at the Perelman School of Medicine specifically. These values are mutually beneficial and enable everyone to fulfill their professional aspirations and innovate in a way that other environments would not make possible, according to Eve J. Higginbotham, SM, MD, vice dean of Inclusion and Diversity at the Perelman School of Medicine.
When the Office of Inclusion and Diversity (OID) was formally established in 2013 and Higginbotham hired to lead it, the Perelman School of Medicine’s standing faculty—that is, tenure track faculty and clinician-educator faculty—was 29 percent female, and five percent consisted of those from minority groups underrepresented in medicine. In 2016, the percentage of women had increased to 32 percent and those underrepresented in medicine stood at seven percent.
These modest gains have occurred against a backdrop of challenges in climate and cultural support of diversity that are widespread at all academic medical centers. As measured by a Diversity Engagement Survey developed by the Association of American Medical Colleges (AAMC) and the University of Massachusetts Medical School and DataStar, Penn Medicine compares relatively favorably to other institutions, but Higginbotham and other leaders are quick to point out that much more needs to be done both on campus and nationwide. Based on more than 3,000 respondents to the survey conducted in 2012, Penn saw mixed results, in the top third of AAMC institutions in access to opportunity, in the bottom third in cultural competence, and among the middle third in areas such as equitable reward and recognition with a common purpose, respect, trust, and a sense of belonging.
In June 2016, the OID announced a call for personal stories about inclusion across Penn Medicine. In a randomly selected a subset of 33 narratives, the team identified stark differences along lines of the respondents’ gender, LGBT identification, and racial identification, in responses to the open-ended question, “Is Penn a very culturally competent place?” The OID plans to repeat the survey in 2018 and compare it to the baseline after taking steps to build a more inclusive culture strategically aimed at the identified issues. The office’s three-pronged mission includes recruiting talented and diverse faculty, retaining a diverse community of faculty, staff, and students, and reaffirming the value and benefits of inclusion and diversity throughout Penn Medicine.
Higginbotham and her team utilize Penn resources, external funding, and additional strategies to recruit outside the institution, while also fostering collaboration among diverse groups throughout Penn such as the Alliance of Minority Physicians, Penn Medicine Program for LGBT Health, FOCUS on Health and Leadership for Women, Penn PROMOTES Research on Sex and Gender in Health, and the Center of Excellence for Diversity in Health Education and Research—extending the impact of the efforts of these different groups by fostering synergy.
Collectively, all these programs, along with unconscious bias workshops, Health Equity Week, an annual Dr. Martin Luther King Jr. Symposium and other events all work to this common goal. Next steps for the OID include fundraising for endowments to sustain anchor programs like these, as well as developing opportunities for junior faculty who have an interest in health equity.
In addition to supporting retention of a diverse faculty, these efforts support the success of a diverse student body. In the 2016 Perelman School of Medicine entering class, twenty six percent of students identified as part of a group underrepresented in medicine and the class was 50 percent female.
“We have complex problems that require complex solutions, and you need a diverse workforce to solve those problems,” Higginbotham said. “We need a robust, inclusive educational environment to prepare the next generation of health professionals to meet the challenges ahead.”
- Greg Richter
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