Several Ways Generation Z May Shape the Medical School Landscape.

Just as medical colleges have adapted to the Millennial generation of students, a new generation is poised to enter as matriculants. Learner attributes of this generation, Generation Z, are in stark contrast to previous ones, but more than that, they provide new challenges that undergraduate universities are already facing. This article aims to highlight some of these challenges, including those relating to student counseling services, volunteering activities, learning environments, and learner perspectives. These challenges are framed and discussed within the context of medical education.

Introduction

Each generation of learners has unique attributes that set them apart from previous cohorts. Understanding this generational diversity is paramount for medical educators as they seek to tailor instructional approaches to student learning behaviors.[1] In this manner, curricular transformations and shifts in teaching modalities across institutions of medical education are adapted to generational attributes.[2-5] For example, medical educators have adjusted to the learner attributes of Generation Y (“Millennials”) by reducing the number of large-group didactic sessions and incorporating web-based instruction from videos, podcasts, and software applications.[6-8]

Now, students from Generation Z (“iGen”) are becoming the predominant population in medical schools. Striking differences have already been noted between Generation Z (individuals born after 1995) and Generation Y, such as preferences for face-to-face interactions over digital interactions and a desire to design their own course of study, which has already led to changes in the way undergraduate majors are constructed.[9-11] However, generational changes go beyond shared student learner characteristics. Recent studies have highlighted other attributes of Generation Z that are poised to affect medical education.[9,12,13] The aim of this commentary is to highlight some of these attributes so that medical educators can be better informed and prepared to teach the incoming generation.

Student counseling services

Over the past decade, there has been an increased focus on the mental health of medical students. This shift was prompted by reports that nearly half of medical students suffered from burnout, an alarming 11.2% of students admitted to suicide ideation, and 82% showed signs of psychological distress.[14,15] In response, medical schools have instituted measures to improve the mental health of their students, including the expansion of student counseling services and modifying their curricula and grading systems in an attempt to reduce anxiety and depression.[16,17]

Shockingly, mental health tendencies of Generation Z show they are even more prone to psychological distress than earlier generations, and this tendency is getting more pronounced over time. A recent study using data from the National Survey on Drug Use and Health found a 63% increase in major depression episodes in young adults, 71% increase in psychological distress, and 49% increase in suicidal thoughts between 2005 and 2017.[18] The data suggest the problem is worsening at an accelerating rate, with depression, anxiety, suicide, and self-harm rising dramatically in children of Generation Z.[12,19] In fact, the defining characteristic of Generation Z is the decline in psychological wellbeing, not economic factors and war as with previous generations.[13,20]

In the time since young adults of Generation Z have entered college, campus counseling centers have been strained. College counseling center directors now report student clients with severe psychological problems are the majority of cases.[21] Colleges have had to enlarge their counseling capacity to handle the upsurge in demand for psychological care by increasing the number of councilors and consulting hours and by expanding their referral networks.[21] As Generation Z students enter postgraduate programs, rates of psychological distress are set to rise in medical school. Providing adequate treatment for distressed students is imperative, not just for student health, but for the care of their future patients. Even subclinical levels of psychological distress reduce empathy and acts of altruism, impair the ability to develop plans to help others, and garner a more egocentric perspective when reasoning about the mental state of others.[22-24] Medical colleges may have to expand student counseling services or adopt other strategies for combating the growing numbers of distressed students.

Volunteer work

Volunteering is a ubiquitous component of medical education that gives students clinical exposure and opportunities to treat rural and traditionally underserved populations. Three-quarters of medical schools have student-run clinics that use medical student volunteers.[25] Volunteering experiences are deemed nearly as important as Medical College Admission Test (MCAT) scores and grade point average (GPA) by applicants to US medical colleges.[26,27] The majority of residency program directors also view volunteering experiences as an important factor in their acceptance decisions.[28] Yet, Generation Z students are likely to have less volunteering experience and demonstrate reduced motivation to volunteer in clinical settings than previous generations.[29]Although two-thirds of Generation Z high school students participated in community service, less than one-third reported they will volunteer on entrance to college.[30] This is supported by recent surveys of first-year college students that show only 12% participated in volunteer activities.[31]

The decline in volunteering among Generation Z students coincides with an increased emphasis on providing solutions to societal problems, particularly using entrepreneurial and technological approaches.[32] In their qualitative study of generation Z community engagement, Seemiller and Grace[9] find when students volunteer, they would rather do it in a manner that addresses underlying causes of a problem. One example they give is, rather than working at a food bank to help starving individuals, students would rather work on a way to help eradicate hunger in their community.[9] Such a plan may involve the development of a new technology that is crowdfunded, reflecting their technological and entrepreneurial proclivities.

At the medical school level, the emergence of different attitudes about volunteering may be anticipated in the coming years. Declines in volunteering have the potential to reshape medical education. Medical student volunteering hours are positively correlated with student engagement in clinical training.[33] Volunteering also increases the number of professional interactions to which medical students are exposed and improves perceptions of the overall quality of their medical education.[33] Volunteering in clinics can also influence which specialty students ultimately decide to enter.[34] Thus, the newest generation of students may have different perceptions of their medical education and use different criteria to select their area of practice in comparison with past generations.

Declines in volunteering may be offset by an increased demand for entrepreneurial opportunities, which some medical colleges are already providing.[35] Such opportunities may benefit medical education. For example, educational activities that require problem-solving within entrepreneurial settings have been found to foster critical thinking skills.[36] Creating medical educational pathways that allow entrepreneurship may also serve as a pathway to generate technological innovations.[37] In addition, volunteering experiences may be structured to utilize the skills and preferences of the new generation. Although most medical school volunteering occurs at student clinics where the aim is to gain clinical experience, many medical colleges also offer service opportunities within community organizations that enhance civic involvement and social responsibility, promote global health outcomes, or seek to prevent disease.[38,39] Instead of gaining clinical experience, these experiences would foster the development of other professional competencies. Developing programs where students participate in community-oriented service activities may not only suit their generational attributes but also help to form their profession identity, improve their understanding of social accountability, and grow their commitment to work in rural and underserved areas.[40,41] Although it remains to be seen how these generational differences related to volunteering will play out, medical school faculty and administrators should be aware of the shifting attitudes regarding volunteering and entrepreneurship.

Learning environments

Medical education exposes students to the basic and clinical science underlying injury and disease. As part of this instruction, many medical schools have required elective courses that delve into topics such as rape, abortion, addiction, abuse, and assault. This content is often disturbing and can make students uncomfortable, particularly if they have personal experiences related to the content, such as a loved one who died from the disease or if they themselves experienced rape or assault. Current attitudes of medical faculty are that this is a necessary part of medical education that needs to be taught because physicians must be able to communicate on sensitive subjects with their patients.[42]

However, student attitude toward disturbing educational content is changing now that Generation Z cohorts are in higher education. For example, at some institutions, undergraduate students have demanded trigger or content warnings be placed in syllabi or given in class before distressing material is discussed or shown.[43,44] In a survey of psychology faculty, the majority of professors now offer content warnings to students when teaching abnormal psychology.[45] Students are also asking to be exempt from learning material that distresses them and are calling for the creation of safe spaces where they can go to feel safe around others who agree to abstain from causing them discomfort.[46] In line with this, faculty have proposed the use of content warnings to serve, not only as classroom warnings, but as campus-wide interventions.[47] The concern of students and educators who are proponents of content warnings is that educational content that forces students to re-experience past physical or emotional trauma may adversely affect their mental state.[48]

A 2018 study of content warnings in medical school revealed few students (11%) were aware of what a content or trigger warning is, and fewer than one-third supported their use in medical education.[49] However, the number of undergraduate students reporting concerns to administrators about failure of faculty to implement content warnings is on the rise and may appear in medical education in greater numbers.[50] Some medical professionals have already begun to advocate for the creation of safe spaces where discomforting subjects can be discussed.[51] Although the psychological merits of content warning and safe spaces are still being worked out, medical schools may need to develop strategies that help students cope with disturbing content. Incoming medical students from Generation Z may already expect content warnings to be provided and may be surprised if none are given. Alternatively, faculty development and student services may be bolstered in a manner that helps identify and support affected students so they may better cope with their strong emotional responses to course materials. This approach may help faculty better model the ethic of care and be more responsive to student needs.[52] Instructors may also wish to handle surprising and unpleasant content by offering alternative assignments. However, this approach is controversial in that it may limit student exposure to important information.[53]

For physical spaces, iGen learner preferences are in near perfect opposition to those of Millennials. Although the previous generation prefers to work in large, open, unstructured environments where many people work together in a variety of areas, the new generation prefers quiet spaces with an intuitive layout where the intent of the activity to be performed is readily apparent.[54] Redesigning or partitioning existing learning spaces to accommodate task-specific educational activities may be desired by incoming medical students. In addition, iGen learners prefer spaces for collaboration and mentoring be made available. In both educational and work environments, this generation has the expectation of being mentored instead of learning independently through new experiences.[55] Educational spaces that accommodate small groups for mentoring and collaboration have been suggested to benefit both the learning and professional development of iGen members.[56] Also, despite a growing presence of technology in the classroom, members of Generation Z may wish for even greater technological integration into learning spaces. For example, a survey of college students in 2016 found 71% desired even more technology as part of their education than they were currently receiving.[57] They are also increasingly using social media to contact their instructors and show a growing preference for electronic classroom material and electronic examinations to written ones.[58] Creating campus spaces designed to address technological concerns of the new generation may facilitate learning more so than in previous generations.

Learner perspectives

In addition to changing perspectives on the incorporation of technology into learning, other generational differences in learner perspectives between Millennials and iGen have been described, which I will briefly summarize. Of note, the new generation sees themselves as compassionate problem solvers who prefer prescribed learning activities rather than as passive yet creative learners that thrive with more autonomy.[9] Whereas Millennials are able to work independently, the new generation requires more guidance, especially when working with peers, of which they tend to be more critical.[9] Although iGen students are “digital natives” who grew up around technology, they prefer blended activities that mix online with in-person collaborations.[54] Yet, because they are accustomed to obtaining information through online searches, they are able to find and synthesize information rapidly.[32] Consequently, they are also more likely to use outside resources and other learning materials that are not recommended by the instructor to help them learn.[59] When they use instructor-provided material, the majority prefer lecture-style videos or audio presentations, simulations, and case studies to group exercises and assigned readings.[60] Medical educators should take these learner perspectives into account when designing course material and during curricular transformations.

Conclusions

Generational diversity is an important factor that drives curricular transformation in medical education. The youngest generation now entering medical colleges have a unique set of attributes that sets them apart from previous generations. Faculty and administrators of medical institutions should seek to be better informed and prepared for how they may need to modify their instruction, curriculum, and learning environments to better accommodate students of Generation Z. Student counseling services, volunteering expectations, educational environments, and learner perspectives comprise major targets for change relating to the most recent generational shift, which is poised to transform the medical education landscape. Medical institutions should be ready to develop strategies in response to the traits of the incoming generation.