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West J Med. Mar 2002; 176(2): 139–141.
PMCID: PMC1071692

Shaping America's health care professions: how the health sector will respond to “generation X”

Edward O'Neil, Director1

At the beginning of the 20th century, Americans could be expected to live to their early 40s. By the close of the century, they had added more than 35 years, almost doubling their life span. We often use these data to mark the aging of the US population, but they also dramatically point to another important phenomenon: the rise of generational consciousness. This awareness is a by-product of more generations being around. Four discernable generations now live in the United States. Their names and age ranges often vary, but they are commonly referred to as the “silent” (aged >55 years), “boomers” (aged >41 to <55), “generation X” (aged >21 to <41) and “millennial” (aged <21).1

Generational consciousness has also been highlighted by an extraordinary increase in the rate of change in society, particularly in technology, economics, media, education, and transportation. Such dramatic change in our lifetime means that a single generation can have entirely different cultural milieu in which to be born, come of age, and leave the family. Howe and Strauss have raised generational awareness to the level of a social mechanism rivaling the religion or individualism of earlier periods in American history.2


Much attention has been rightly paid to the so-called generation X cohort—those born roughly between 1961 and 1981—a term first coined in Douglas Coupland's 1991 novel, Generation X.3 They represent about 46 million individuals, or about 20% of the US population. This group is much smaller than the 77 million strong “boomer” generation. Part of what marks the beginning of the generation X age is the decline in birth rates afforded by the birth control pill being introduced in 1961, which effectively ended the postwar boom in births. As the boomer generation ages and retires, the generation X is increasingly called on to fill positions in health care professions. Because they are fewer in number, they will be in greater demand throughout the economy. As health care institutions and professions consider staffing and restructuring challenges over the next decade, the interests, skills, abilities, and values of this group need to be recognized and considered.


Of course, no iron law of generations exists. A labor organizer recently observed that his children wanted the same thing as his members—good pay, a safe work environment, challenging assignments, and opportunity for advancement. This is surely true, but important differences exist in the ways in which each generation perceives and values work. Several authors have noted that certain experiences frame the experiences of generation X, and they merit brief review here.

The divorce rate in the United States grew tremendously in the 1960s and 1970s, and the number of children who experienced their parents' divorce grew 300% from 1940 to 1980.4 More single-parent families were matched by a more active participation of women in the economy and the need or desire for two incomes, even with two parents in the home. Both facts contributed to the shrinkage in size of this generation, but it also left them less tethered to the traditions of the family.

The generation also grew up on a series of political tragedies, failures, and scandals that were for the first time widely broadcast on television. This began with President Kennedy's assassination and was followed by the disruption of the Vietnam War and then by Watergate. These shortcomings were fairly bipartisan. Not surprisingly, 1981, the year that marks the end of the birth years for the generation, is the year Ronald Reagan was inaugurated, promising a “new morning in America” and tacitly claiming to end the nightmare of the previous two decades.5(p8)

These political events were played out against a more profound change in the social expectations embodied in the civil rights, women's, gay and lesbian, and environmental movements. Some critics have speculated that “Gen Xers” inherited the disruption without fully appreciating the causes or fighting the battles. In terms of sexual mores, the generation was unmoored from repression by the sexual revolution of the 1960s but driven into a new age of confusion by the rise of AIDS after 1981.6

Political and social changes created by the boomers, but lived through by the Gen Xers, may over the next decade lead to conflict between the idealism of one generation and the realism of another. The older generation may perceive the younger as cynical and self-absorbed and, in return, be seen by the younger generation as pompous and paternalistic, unwilling to relinquish power and authority of failed regimes to new ways of thinking and acting.

Accompanying these social and political changes has been an economic revolution that has been less obvious but staggering in its consequences. As this generation has come of age, the third great economic age of western civilization has occurred, as the industrial age has given way to the informational. This was born out of the rise of the service sector, combined with the electronic technology that changed the face of information and communications. The information revolution has changed the nature of jobs and the structure of the corporate organization, spawned globalization, made work possible virtually anywhere, altered the value of education and the pattern of skill acquisition, and redistributed a fair amount of wealth and power. This new economy, even with the correction of the past 2 years, has been and will continue to be the employment and work reality for generation X.7(pp25-31)


Arguably this different reality has shaped the ways in which Gen Xers are likely to appreciate, understand, and approach work in general and in the health care sector in particular. Some of these orientations of the generation run counter to the way health care is organized and delivered in the United States, and others are consistent with the way health care is or is currently moving. Understanding and incorporating these realities into how work is created and reshaped will be an important factor for success in the future.

A consistent theme in descriptions of the generation is their “anti-institutional orientation.” This may be too strong, but clearly many traditional promises and expectations have been broken between this generation and people in positions of authority. These changing rules range from their own families with higher divorce rates to the promise of a better life and more opportunity that has consistently changed over the years of their young adulthood. This was perhaps also reflected in the tumultuous political times of their youth. Their bias is perhaps to be more distrustful of institutions, particularly large institutions, than were their parents.

As a generation, this cohort also seems more open to diversity. Having grown up after much of the civil rights movement and in a period of increasing growth in the multicultural life of the United States, the generation's life experiences are imbued with a more ready acceptance of diversity as the essential fabric of life in this country as opposed to the transformation that moved through the life of the boomers.

These two qualities of openness to diversity and a non-conformist attitude also make this generation more flexible in expectations and work rules. In fact, the rigid hierarchy of many employment settings is simply not something that they value. Many Gen Xers find it difficult to comply with traditional expectations—simply because they are traditional.

Given their attitude about institutions, the next value of generation X may seem counterintuitive. Because they may put less value in some traditional out-of-work settings, particularly family, Gen Xers may invest the social life created by their co-workers with more importance than have earlier generations. This seeming paradox of valuing the social life of work, but not necessarily the institutions of work, may leave leaders and managers wondering how to motivate, involve, and invest generation X in the work settings of health care.

These skills are even more valued as they incorporate the technologic skill of information exchange and communication. Unlike older generations, this one has grown up with many of the new technologies and does not fear change associated with such technologic transformations. In fact, high value may well be placed on those employment sectors and institutions that are perceived to be on the edge for incorporating these technologies into their day-to-day work.

Beyond the social dimension of work, the generation may have lower expectations of what institutions and society in general are likely to return to them for their investments. They seem more interested in the skills and experiences that work can offer, particularly when they can be credentialed in a way to make them transportable. This value, development of skills and self, seems to move many in generation X the way a commitment of lifelong employment moved their parents. This will mean a great deal in attracting, training, and retaining workers. workers.

Table 1
Values and health care employment*

Although the generation may be less institutional in its orientation and perhaps more transitory in its expectations, it nonetheless seems to harbor a rich desire for service beyond self. But it is service that is decidedly outside of the traditional. This commitment may be more likely to be motivated by idealistic or ethical commitments, such as animal rights or the environment, and as likely to be addressed against large institutions that might exploit these idealistic values as to be worked through the institutions by joining their causes.

The Table presents a summary of some of the general value orientations that generation X seems to have and contrasts them to how health care is likely perceived by them as possible employers.

Figure 1
The social life of work is more important than in previous generations


Competing interests: None declared

This is the second in a series of articles from the Center for the Health Professions at UCSF addressing the major forces that will shape America's health care professions.

Summary points

  • Important generational differences exist in expectations and values for health care professionals
  • These differences occur with attitudes about institutions, diversity, service, education, and commitment
  • Institutional leaders should be mindful of these differences when designing new systems


1. Facts and Figures. Economics 210: Topics in Economics: The Deficit, Debt and Generation X. Available at www.coloradocollege.edu/Dept/EC/generationx96/genx/genx3.html . Accessed October 14, 2001.
2. Howe R, Strauss V. Generations. New York: Random House; 1998.
3. Coupland D. Generation X: Tales for an Accelerated Culture. New York: St Martin's Press; 1991.
4. Hinkley SE. Talking to Generation X. First Things February 1999: 10-11.
5. O'Neil WJ. Coming Apart. New York: Pantheon; 1972.
6. Jochim J. Myths of GenX shred. Nevada Outlook May 5, 1998.
7. McCann JM. Digital Dawn. Durham, NC: Duke University Press; 1997.

Articles from The Western Journal of Medicine are provided here courtesy of BMJ Group
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