Keeping Up With Changing Times in Education: Fostering Lifelong Learning of Millennial Learners

At least four generations of physicians are present in the medical education system, and differences among these generations may have a profound effect on trainees (1–4). Table 1 outlines the age ranges and general characteristics that define the four generations discussed in this column. We recognize that in the very exercise of constructing this table, we have introduced generalizations and stereotypes, yet we argue that these definitions can draw some helpful contrasts and better enable the reader to understand overall trends when considering educational delivery.

The Traditionalists, or Silent Generation, were born between 1922 and 1945. Although many from this generation are retired or hold an emeritus status, faculty may remain in teaching roles. The Baby Boomers, born between 1946 and 1964, include mostly faculty and program directors, who are often responsible for the overall curriculum in residency programs. Baby Boomers are typically full professors in academic rank. Generation X, born between 1965 and 1980, are largely clinician educators and faculty who were (and are being) taught by the Baby Boomers. Generation X faculty are assistant or associate professors. The Millennials, born between 1981 and 2000, represent the majority of the incoming group of medical students and residents (1, 4). The focus of this column is on the Millennial Generation.

The Millennials: General Characteristics

Population theorists have postulated a set common attitudes and behaviors that distinguish the Millennials (also known as the Net Generation, Generation Next, or Generation Y) from other generations (7–9). Although the existing literature regarding generational differences in medical education is not specific to psychiatry trainees, these characteristics are likely generalizable and applicable in the field of psychiatry. Having participated in group projects, Millennials typically are team oriented and enjoy collaborative learning. They have been involved in service pursuits and are committed to helping others and creating social change (7, 9, 10).

The Millennials have been raised in the most child-centric time in our history, and some have parents who “hover like helicopters near their children, ready to swoop in at a moment’s notice to help resolve problems big and small” (11). These parents often continue to be involved in decisions as their children enter college and medical school and venture into their career. This generation has been taught the importance in believing in themselves, that anything is possible, to never give up on dreams, and that self-belief is essential for success (12). They may display a great deal of self-assurance and can appear overconfident at times (7). This is the first generation to grow up surrounded by the digital media, and they are fluent with technology (13). For this group, staying connected to the Internet is essential and expected, and they have become accustomed to receiving and communicating information instantaneously.

Borges and colleagues (14) examined whether there were differences between Generation X and Millennial students on 16 selected personality factors. Millennial students scored significantly higher than Generation X students on factors including rule consciousness, emotional stability, and perfectionism, whereas Generation X students scored higher on self-reliance (14). In a subsequent study, research by Borges and colleagues supported the assertions of population theorists that Millennial students differ in their learning preferences (15).

Measuring motivation using the Thematic Apperception Test, a projective method of personality assessment for use in the understanding of an individual’s current needs, motives, emotions, and conflicts, the investigators found differences in needs for achievement, affiliation, and power between Millennial and Generation X medical students. Millennials scored higher on affiliation and achievement, and Generation X participants scored higher on the motive of power (16). In an additional study, Twenge (15) reviewed meta-analytic studies and findings from a number of studies and found that today’s students scored higher on assertiveness; self-liking; narcissistic traits; high expectations; and stress, anxiety, and poor mental health.

Learning Styles

Researchers have made many suggestions about how generational differences influence teaching the Millennials; however, few are hypothesis driven or evidence based (4). A small but growing body of research focuses on the instructional preferences of Millennial learners and the implications for medical education. Again, although the existing literature is not specific to psychiatry trainees, these techniques are likely to be effective for psychiatry trainees from the Millennial generation.

Elam and colleagues conducted focus groups with first- and third-year medical students on their perceptions of characteristic Millennial attitudes and behaviors (9), and the researchers’ pilot study supports the observations population theorists have proposed. The findings suggest that Millennial medical students prefer hands-on learning experiences in a noncompetitive environment, behaviorally based and individualized feedback, and use of technology to manage information. Additional findings were that students desire help with transitions to medical school, improved advising and mentoring, and assurance of education on the cutting edge (9). Other studies have suggested that students indicated a preference for lectures combined with group work and discussions; this was ranked as the most preferred instructional format, regardless of generation (4).

Millennials may perceive traditional didactics and formal lectures as unengaging. Residency programs have noticed a trend of decreasing attendance in formal lecture series (8), and awareness of these attitudes has prompted some training programs to shorten didactic programs, reexamine the quality of the content, and address alternative ways of providing information through new technologies (1). In light of educators’ concerns over decreased lecture attendance, Cardall et al. (17) conducted a survey with first- and second-year medical students to assess students’ perceptions, evaluations, and motivations concerning live lectures compared with accelerated, video-recorded lectures viewed online. Findings suggest that live attendance remains the predominant method for viewing lectures but that students find accelerated, video-recorded lectures equally or more valuable. Students’ responses indicate that their decisions to attend lectures or view recorded lectures are motivated primarily by a desire to satisfy their individual professional goals (17). Millennial residents identify good medical educators as those who integrate multimedia and use innovative teaching techniques (18), and the ongoing challenge is for educators to incorporate technologies students find useful while creating an interactive learning culture (17, 18).

Successful strategies for teaching the Millennials include instruction in shorter, more interactive, and more easily digestible segments (19); educators can use these strategies in teaching psychiatry trainees. Multimodal techniques, including audience response systems that provide immediate feedback to the participants and Internet-based materials (e.g., webinars), can be helpful in combating distractibility and enhancing the educational experience (20). In addition, self-directed learning activities can be valuable in empowering residents to take responsibility for their own learning and foster lifelong learning practices that will extend beyond their formal training.

Role-playing and case-based learning are additional examples of active and clinically oriented activities that may keep trainees engaged and move them from memorizing facts to a learning that develops a deeper understanding (4). In particular, the use of complex case scenarios may bring a practical perspective to the material being taught (20) and facilitate and encourage the learners to critically think, with open discussions on issues and clinical topics (21). The flipped classroom model is an increasingly popular active-learning technique that involves the preparation of a short audio or video lecture that the students review before the didactic session. Trainee participation in the information-gathering portion in advance allows the educators to focus their sessions on working through advanced concepts and applications of the material (22, 23).

The generational biases of instructors have the potential to inhibit interactions and negatively affect learning (21), and educators need to be aware of their own generation’s characteristics and how they might influence teaching. Older generations may focus on “the way we were taught” rather than on the unique educational needs of the current generation (21). An example might be faculty members who assign students to read large segments of a psychopharmacology textbook, which is likely too passive a learning exercise for today’s learners (24).

Communication Styles

Research supports the contentions of the population theorists that Millennials have greater needs to belong to social groups and to share with others, stronger team instincts and tighter peer bonds, and greater needs to achieve and succeed (6, 13). Stereotypical views characterize Millennials as technologically sophisticated but deficient in communication skills (25). Interpersonal and communication skills are one of the Accreditation Council for Graduate Medical Education’s six general competencies across medical disciplines, and the development of team skills and the tools to manage interpersonal conflict are essential in the clinical setting. When educators are fine-tuning this generation’s interpersonal communication skills, they must engage the learner and ensure that he or she actively participates in the process. Simply presenting learners with the information is insufficient (25).

One technique that may be effective is faculty providing prompt feedback about interview style following observation of the learner in a clinical interaction. Millennials are described as social learners and, in general, are considered to be successful team players and open to new ideas. Therefore, teamwork and cooperative learning strategies can be important elements in a successful learning environment (21). For example, medical students working together on an inpatient unit may benefit from the opportunities to collaborate and discuss their experiences as a group.

Effective Use of Technology

In response to questions about what makes their generation most unique, the most common factor mentioned among a group of Millennials was technology use (26). The Millennials are accustomed to and expect instant information and communication using a range of digital media. Present technology allows learners to rapidly access educational material at any time, in any place, and in a wider breadth of modalities than ever before. In previous generations, textbooks and formal lectures were irreplaceable references, with research requiring an intricate knowledge of the journal shelves of the library. Today, the acquisition of this information is nearly instantaneous through Internet searching and vast online libraries, and the Millennials have largely abandoned library sites (27).

The familiarity of Millennials with new technologies provides both opportunities and challenges in delivering educational material. Millennials may prefer information to be presented digitally as opposed to through didactic lectures but simultaneously enjoy structured learning environments, regular feedback, and clear objectives (28). Although the Millennials are characterized as being technologically savvy, there is the danger of exploitation of this generational characteristic to promote certain teaching techniques. Educators have noted that some feel “pushed” into using technology because they believe that is what today’s students want (29). For example, many educators have turned to PowerPoint in an effort to modernize their approach yet have not addressed the underlying desire for increased interactivity (28, 29).

Social media use, for both personal and reference purposes, is widespread, especially by the Millennial Generation (30). These advances in technology have added a new dimension to defining and teaching in the medical setting. Social media has enormous potential for both physicians and their patients. For example, social media sites may be used to disseminate information and as a tool to develop professional relationships.

However, trainees must learn to be mindful of professionalism related to social media and other technology, and these benefits must occur within the proper framework of professional ethics (31). Trainees must be cautious while using social media to protect the privacy of patients and clinicians as well as the image of institutions, physicians, and the practice of medicine. Faculty need to become aware of the social media and teach trainees in this generation about professionalism is this age of technology (21, 32). An open exchange of ideas around these issues during residency can help educate trainees as well as model professional behavior (32).

Access to such vast amounts of digital data requires an equally well-developed ability to sift through and identify accurate information (30), but it also raises concerns regarding the potential for misuse. This raises two important points. First, educators must teach trainees how to search for medical information online and provide guidance on using the best tools and resources (33). For example, Wikipedia is highly used by clinicians as a source of reference material, despite known shortcomings in the depth of material as well as occasional errors. In addition, teachers must provide training on appropriate uses of social medial (30). Second, answers to specific knowledge-based questions may be easily located on the Internet. To encourage critical thinking and the application of such knowledge, problem-based questions are highly recommended (21).

Clear Expectations

The Millennials were raised in a time of scandal, as they witnessed leaders falling from grace, and a time of fear and anxiety about the global economy and environment (21). This generation may benefit from consistency, reassurance, and reminders that they are learning within a framework that is fair and reasonable. An example is providing clear learning goals, objectives, and expectations for didactics and clinical rotations.

Millennial trainees might have different expectations as to the acceptability of checking e-mail on a smartphone or using a tablet, laptop, or other media device during a teaching session; they might not appreciate that it might be rude or distracting to others (19, 34). Faculty should role model by limiting their own texting and e-mailing during teaching sessions. If teachers have a strong preference regarding such device use, they also might find it worthwhile to express what behavior they expect of students at the beginning of any teaching session.

Researchers also have suggested that Millennial trainees benefit from highly structured schedules and explicit instruction on how to balance and prioritize their different duties (18). Millennial leaners may have difficulty with ambiguous instructions or in new learning environments (15). In this regard, faculty and educators should be accommodating in providing clear and supportive feedback and instruction to Millennial residents.

Giving Feedback

Millennials seek frequent and ongoing positive reinforcement from their supervisors, which can help build their confidence and increase feelings of security (11). This generation has become accustomed to frequent feedback, and other generations may perceive Millennials’ craving for feedback and praise as excessive (25). Those in the Millennial Generation have often been rewarded for participation rather than performance; however, many types of unwarranted praise can lead to complacency, as well as foster narcissism (11). Although Millennials expect immediate and ongoing feedback, they might not be used to receiving negative feedback, and receiving critical feedback may be very challenging. Educators need to develop skills for giving effective feedback, including areas for improvement.

Self-assessment can be a valuable tool for this generation. Asking questions such as “What did you think you did well?” or “What do you think you could improve on?” helps to give the educator insight into the learner’s perceptions and whether he or she is aware of any deficits. It also helps to involve trainees in active learning, where they are given the opportunity to work collaboratively. This type of open discussion can help encourage the resident to discuss challenges or gaps in learning. In addition, trainees may be less likely to become defensive if they critique themselves first.

To be useful and effective, feedback should be ongoing and timely, and it is essential for teachers to be fair and straightforward. Educators should be specific and focus on details and behaviors, rather than commenting on personality traits of the trainee. For example, a faculty member suggesting that the resident speak louder during rounds would be more useful than commenting that the resident is shy.

Considerations Specific to Learners of Psychiatry

Strategies discussed in this column are relevant for educators teaching medical students in both psychiatry clerkships and psychiatry residency programs. However, the existing literature about Millennials in medical education is not specific to psychiatry, which raises questions, including how generalizable and effective these techniques are for psychiatry trainees and whether certain characteristics of today’s psychiatry trainees make Millennial educational concepts more or less applicable.

In comparison with other medical specialties, psychiatrists have several unique characteristics. Psychiatrists are thought to be more open-minded, to think more abstractly, and to be interested primarily in ideas (34). Psychiatrists are also more likely to have an arts or nonscience background (35). Additionally, in comparison with other medical specialties, on average, psychiatrists are an older workforce. In a 2010 survey of 36 specialties within medicine, 57% of working psychiatrists were older than 55 years, the third oldest of any specialty (36), which makes the majority of psychiatrists either Traditionalists or Baby Boomers. Additionally, in 2011−2013, medical students going into psychiatry had the largest percentage of those 30 years or older (26.9%), in comparison with other controllable lifestyle specialties, primary care, and surgical specialties (37).

The experience of senior mentors is invaluable in psychiatry, where much relies on judgment and experience and where treatment choices may include multiple appropriate possibilities. Educators should be encouraged to start mentorship relationships early with trainees and create opportunities for building career development into education (38). Understanding generational differences may also help Millennial psychiatry trainees better understand the context of the lives of their patients, who will certainly span all four generations.

Psychiatry trainees may need additional training and mentoring regarding the use of technology to access information. Whereas other fields of medicine frequently use technology to access facts, guidelines, and protocols, psychiatry often relies on a combination of findings from the literature, expert opinion, understanding of cultural considerations, and clinical judgment to make diagnoses and treatment recommendations. Although the correct solution is important in psychiatric education, the process by which one obtains it is equally, if not more, important. Providing challenging case scenarios for which answers cannot be found with simple online searches can help stimulate curiosity in the trainees and provide learners valuable opportunities to synthesize, analyze, and interpret complex information (21).

Additional objective evidence is needed to confirm to what extent medical students and psychiatry residents embrace or differentiate themselves from Millennial stereotypes. We need to continue to develop assessment tools to measure the characteristics of the different generations and support or refute the differences among current generations of trainees in medicine.

Conclusions

The Millennials are energetic, curious, and motivated to learn. Both trainees and educators need to take advantage of the rich learning opportunities that arise in clinical medicine. Providing challenges or problems without straightforward answers, rather than asking them to simply recite facts, can encourage trainees to think creatively (21). Educators should also work to create a culture in which the faculty and learners are encouraged to question their actions and knowledge. Whereas previous generations might have had a sense of duty and often did what they were told without asking, the Millennials may need the purpose and meaning of activities explicitly spelled out.

We recommend that technology be incorporated into and used to augment our teaching. Teaching resources, including videos, handouts, and other materials, should be available digitally. In addition, Millennial students will likely benefit from teachers describing their expectations regarding the use of technology during didactics or bedside teaching and recognizing that a degree of flexibility and compromise may facilitate better rapport with their students. Millennials are collaborative learners and work best in groups, which is fortunate, given that multidisciplinary care is the future of modern medicine. In this regard, we recommend activities that engage small groups of residents, which may yield better trainee engagement and enhance learning.

As psychiatrists, we need to understand the Millennials’ perspectives and realize that they are reflections of contemporary culture; this generation are doing what they have been taught by parents, teachers, and media. We should strive to teach this generation by promoting active and hands-on learning and model the importance of lifelong learning. The Millennial generation is the future of our field. They have many strengths, such as a drive to succeed, an ability to multitask, and knowledge of how to adapt technology. Harnessing the strengths of this generation can lead to improvements and innovations in medical education and in patient care (15).