Millennial Health Care: Change You Can Believe in

Abstract

A millennium is 1,000 years. In little over a decade after the beginning of the new millennium in 2000, remarkable changes have occurred in health-care education and health-care delivery. A new millennial generation of students, trainees, junior faculty, and young practicing physicians has come of age. The numbers of women in medicine have vastly increased. Technology has impacted education with an array of educational content-delivery techniques vastly different from the usual broadcast method of teaching. New curricula have expanded to encompass teamwork with interprofessional education of the entire team. Outcomes of educational efforts now include not only knowledge transfer but also performance improvement. Delivery of health care is also dramatically different. The sentinel driver of the quality and patient safety moment, To Err Is Human, was published only 12 years ago, yet fundamental changes in expectations and measurement for health-care quality and safety have occurred to alter the health-care landscape. Financing health care has become a prime issue in the current state of the US economy. New themes in health-care delivery include teamwork and highly functioning teams to improve patient safety, the dramatic increase in palliative care and end-of-life care, and the expanded role of nursing in health-care delivery. Each issue emanating since the beginning of the millennium does not have a right vs wrong implication. This discussion is an apolitical “environmental scan” with the purpose of illuminating these dramatic changes and then outlining the implications for health-care education and health-care delivery in the coming years. A millennium is 1,000 years. In little over a decade after the beginning of the new millennium in 2000, remarkable changes have occurred in health-care education and health-care delivery. A new millennial generation of students, trainees, junior faculty, and young practicing physicians has come of age. The numbers of women in medicine have vastly increased. Technology has impacted education with an array of educational content-delivery techniques vastly different from the usual broadcast method of teaching. New curricula have expanded to encompass teamwork with interprofessional education of the entire team. Outcomes of educational efforts now include not only knowledge transfer but also performance improvement. Delivery of health care is also dramatically different. The sentinel driver of the quality and patient safety moment, To Err Is Human, was published only 12 years ago, yet fundamental changes in expectations and measurement for health-care quality and safety have occurred to alter the health-care landscape. Financing health care has become a prime issue in the current state of the US economy. New themes in health-care delivery include teamwork and highly functioning teams to improve patient safety, the dramatic increase in palliative care and end-of-life care, and the expanded role of nursing in health-care delivery. Each issue emanating since the beginning of the millennium does not have a right vs wrong implication. This discussion is an apolitical “environmental scan” with the purpose of illuminating these dramatic changes and then outlining the implications for health-care education and health-care delivery in the coming years. American College of Chest Physicians Agency for Healthcare Research and Quality continuing medical education Centers for Medicare and Medicaid Services Institute of Medicine National Quality Forum Generational characteristics of educators and learners are important drivers of educating and learning. A generation is born over an approximate 20-year time period, shaped by shared experiences, and characterized by certain qualities. While it is not an exact science, generational analysis is often highly illuminating to define unique and distinctive characteristics of any given age group. Generally, four generations are described: a silent generation born from 1925 to 1945, the baby boomer generation, born from 1946 to 1964, generation X born from 1965 to 1980, and the most recent generation, known as the millennial generation, born from 1981 to 2000, whose current age in 2012 is 12 years to 31 years.1Howe N Strauss W Millennials Rising: The Next Great Generation. Vintage Books, New York, NY2000Google Scholar Millennials have been described as “digital natives,” while the older generations are “digital immigrants,” arriving on the digital shores later in life.2Prensky M Use their tools! Speak their language! March 2004.http://www.marcprensky.com/writing/Prensky-Use_Their_Tools_Speak_Their_Language.pdfGoogle Scholar It is important to acknowledge that no matter how fluent digital immigrants become, they will continue to be different from digital natives, always retaining to some degree a “digital immigrant accent.” Defining moments and feedback characteristics differ for each generation.3Elan C Borges N Millennials in medicine: a new generation comes to medical school. Slideshare website.http://www.slideshare.net/Medresearch/millennials-in-medicine-medical-students-in-the-21st-centuryGoogle Scholar For the silent generation, defining moments include the 1929 stock market crash, the Great Depression, and World War II. Feedback characteristics are characterized by “no news is good news.” For the baby boomer generation, defining moments include the assassination of John F. Kennedy, the Vietnam War, civil rights advances, women's rights, and Watergate. Feedback characteristics include “once a year, with lots of documentation.” For generation X, defining moments include the Challenger disaster, AIDS, Three Mile Island, and working parents. Feedback characteristics include “sorry to interrupt, but how am I doing?” Defining moments for millennials include September 11, Facebook, and Twitter. Feedback is “whenever I want it at the push of a button.” The millennial generation's label refers to those born after 1980: the first generation to come of age in the new millennium. A recent Pew Research Center study describes them as “confident, self-expressive, liberal, connected and open to change.”4Keeter S Taylor P The millennials. Pew Research Center Publications website.http://pewresearch.org/pubs/1437/millennials-profileGoogle Scholar The millennials are the first “always connected” generation. Eighty percent of them sleep with a cell phone by their bed, three-quarters have a social networking site, and nearly two-thirds admit to texting while driving. Multiple modes of self-expression are embraced; nearly 40% have tattoos, many with multiple body designs. Of the four generations, millennials are the only ones that do not cite “work ethic” as one of their principal claims to distinctiveness. In contrast, millennials have very strong work-life issues. Perhaps because only 60% were raised by both parents (a smaller share than older generations), over half of them say being a good parent is their top priority, with a successful marriage equal in importance. They respect their parents and relate well to them. They have been inculcated with diversity in all areas of their lives. They are comfortable and enjoy working with teams and teamwork.5McGee JB. Teaching millennials. University of Pittsburgh website.www.ame.pitt.edu/documents/McGee_Millennials.pdfGoogle Scholar Millennials are also very impatient; they want everything and they want it now, as illustrated by the following quote of Suhail Raoof, MD, a senior pulmonary fellow, made to the CEO of the American College of Chest Physicians (ACCP) (personal communication, August 2011): “I am graduating in less than one year from my fellowship training. I aspire to be President of the ACCP in 10 years. How can I get involved and how can the College help me to realize this dream?” This statement can easily be viewed through a generational prism. The statement is not right or wrong; it just reflects the attitudes of the current generation of our students, trainees, junior faculty, and young practicing physicians. Could that impatience have a positive influence, for example, on the push for shaping health-care regulations or finally incorporating electronic health records into practices? Our challenge as educators and associates of this generation of physicians is not only to understand, accept, and, in my view, even respect the millennials for their attitudes but also to co-opt those characteristics into their educational and professional development design.6Borges NJ Manuel RS Elam CL Jones BJ Comparing millennial and generation X medical students at one medical school.Acad Med. 2006; 81: 571-576Crossref PubMed Scopus (126) Google Scholar As Marc Prensky2Prensky M Use their tools! Speak their language! March 2004.http://www.marcprensky.com/writing/Prensky-Use_Their_Tools_Speak_Their_Language.pdfGoogle Scholar says, “If we are smart, the mobile phone and games that our students are so comfortable with will soon become their learning tools.” We must rethink how we teach the “net generation.” As Tapscott and Williams7Tapscott D Williams AD Macrowikinomics: Rebooting Business and the World. 1st ed. Penguin Group, New York, NY2010: 323-463Google Scholar points out, education today has not substantially changed since the industrial revolution, in contrast to the dramatic changes in marketing and banking that have occurred during that period. Nineteenth-century banking was characterized by a physical building where banking was conducted. Today, with a smart phone and the right app, we can conduct banking transactions through a virtual bank. Nineteenth-century marketing was a poster or billboard; 21st-century marketing includes the Internet and social media sites such as Facebook or Twitter. Regrettably, however, education remains, for the most part, unchanged since the 19th century and still characterized by a lecture-focused “broadcast” model of learning.8Tapscott D Conan N Rethinking how we teach the “net” generation. NPR website.http://www.npr.org/2011/07/14/137853462/rethinking-how-we-teach-the-net-generationGoogle Scholar Tapscott and Conan8Tapscott D Conan N Rethinking how we teach the “net” generation. NPR website.http://www.npr.org/2011/07/14/137853462/rethinking-how-we-teach-the-net-generationGoogle Scholar makes the point that the millennial generation has grown up with and is used to multiple technology venues. We cannot expect them to sit in a classroom and passively listen to someone talking. We must incorporate new educational methods into our instructional portfolio, taking advantage of the strong generational characteristics the millennials possess despite our own generational bias, which make us uncomfortable at best and disdaining at worst. Future education will likely employ a similar set of educational methods across the educational continuum—undergraduate, graduate, and postgraduate education. All curricula should be delivered using evidence-based educational content-delivery techniques (Fig 1). The ACCP published data regarding the evidence-based continuing medical education (CME) guidelines.9Moores LK Dellert E Baumann MH Rosen MJ American College of Chest Physicians Health and Science Policy Committee Executive summary: effectiveness of continuing medical education: American College of Chest Physicians evidence-based educational guidelines.Chest. 2009; 135: 1S-4SAbstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Through an independent evidence-based practice center, a literature search was conducted to determine effective CME tools, educational tools, and techniques. The report clearly recommended both single and multiple instructional media be used, with a variety of instructional methods and multiple exposures to the content. From these data, we developed a graphic to describe the “menu” of evidence-based content-delivery techniques that could be used as the basis for an educational plan. We recently used this menu to develop an educational plan for a hospital-wide quality-improvement initiative that resulted in decreasing the incidence of VTE.10Pingleton SK Carlton E Williamson T et al.Reduction of venous thromboembolism (VTE) in hospitalized patients: a multidisciplinary, interprofessional approach aligning education with quality improvement. Association of American Medical Colleges website.https://www.aamc.org/icollaborative/r4r/264250/resource174.htmlGoogle Scholar Clearly, these education planning tools and techniques need not be limited to continuing education, but rather could and should be applied across the continuum of education. These techniques will become even more important and probably essential for the millennial learner. We must think outside of the box regarding education and focus on the learners. The Khan Academy is an example of such forward thinking; it is a comprehensive educational website with free, customized educational content in the areas of math, science, economics, and history.11Thompson C How Khan Academy is changing the rules of education. Wired.http://www.wired.com/magazine/2011/07/ff_khan/all/1Date: August 2011Google Scholar Students can view videos on their own time and save their classroom time for customized educational assistance, the so-called “flipping” of the classroom. Another example is the online Stanford course on artificial intelligence in which nondegree or noncredit “students” get the same assignments and examinations as those seeking credit.12Keller B The university of wherever. New York Times.http://www.wired.com/magazine/2011/07/ff_khan/all/1Date: October 2, 2011Google Scholar Currently > 130,000 students from across the globe are enrolled. Although the previous examples are centered on K-12 and college education, the same applies to medical student education. Just this past summer, a “new” medical school campus was opened in Salina, Kansas, with eight medical students.13Sulzberger AG Small-town doctors made in a small Kansas town. New York Times.http://www.wired.com/magazine/2011/07/ff_khan/all/1Date: July 7, 2011Google Scholar The core content of the curriculum is broadcast electronically through podcasts and interactive television sessions from the main campus in Kansas City. Clearly, use of the Internet for Web-based education using a variety of educational tools and techniques will be needed for our millennial students and trainees Another dramatic change in health care since the beginning of the millennium is the remarkable increase in women in medicine and science. According to the 2009 Association of American Medical College's Women in Academic Medicine report, there has been a 25% increase in female residents (36%–45%), a 21% increase in assistant professors (34%–41%), a 30% increase in associate professors (23%–30%), and a 64% increase in female professors (11%–18%) in the last 10 years since the beginning of the new millennium.14Leadley J Sloane RA Women in US academic medicine and science Statistics and benchmarking report, 2009–2010. Association of American Medical Colleges website.http:www.aamc.orgGoogle Scholar Currently one-half of all assistant professors are women! However, there are over twice as many male associate professors and five times more male professors than female professors. Regrettably, in one of five medical schools, women departures exceed new hires, and at every academic level there are more women in the clinical sciences than the basic sciences. Although these data only reflect academic medicine, clearly, similar trends also exist in private practice. In both academic medicine and private practice, senior faculty and practitioners have the responsibility to support, mentor, and develop our female physicians, with the ultimate goal of their creating successful and satisfying careers in medicine. Likely related in part to the increasing number of millennial physicians, young female physicians are electing more and more to work part-time. This trend is not limited to medicine when analyzed across professions.15Hymowitz KS Why the gender gap won't go away. Ever. Women prefer the mommy track. City Journal. Summer 2011.http://www.city-journal.org/2011/21_3_gender-gap.htmlGoogle Scholar However, according to the American Medical Group Association retention survey, there has been a 62% increase in part-time physicians. The two fastest growing segments of part-time physicians are female physicians entering practice and male physicians approaching retirement. The data show 40% of female physicians between the ages of 35 and 44 are part-time.16American Medical Group Association, 6th annual retention survey. American Medical Group Association website.http://www.amga.org/AboutAMGA/News/article_news.asp?k=509Google Scholar Some observers are very critical of this part-time work trend in young female physicians.17Sibert KS Don't quit this day job. New York Times.http://www.nytimes.com/2011/06/12/opinion/12sibert.html?_r=1&scp=1&sq=Dont%20quit%20the%20day%20job&st=SearchDate: June 11, 2011Google Scholar They note that medical education is supported by public dollars, there is a continuing and increasing shortage of physicians (especially primary care), and the cap on residency training slots limits the number of physicians trained, and their moral conviction is, “Medicine shouldn't be a part-time interest; rather it deserves to be a life's work.”17Sibert KS Don't quit this day job. New York Times.http://www.nytimes.com/2011/06/12/opinion/12sibert.html?_r=1&scp=1&sq=Dont%20quit%20the%20day%20job&st=SearchDate: June 11, 2011Google Scholar This is clearly a highly controversial issue where the opposite opinion emphasizes the important work-life balance, especially of new mothers and children.18The work-family balance for doctors. New York Times.http://www.nytimes.com/2011/06/15/opinion/l15doctors.html?scp=3&sq=Dont%20quit%20the%20day%20job&st=SearchDate: June 14, 2011Google Scholar, 19Seeking a balance: part-time doctor and mom. New York Times.http://www.nytimes.com/2011/06/17/opinion/l17doctors.html?scp=3&sq=women%20in%20medicine&st=SearchDate: June 16, 2011Google Scholar However, it is an important issue to acknowledge and discuss. Given the millennial influence, it would appear that this trend will continue. The consequences of this trend on the profession as a whole are uncertain. Questions remain. Will part-time work continue as children grow? Does it result in more satisfied and efficient female physicians? Does it affect the quality of care? There is concern that this could have negative repercussions on how women physicians are viewed. Will medical school admission committees come to reflect and act on this part-time trend? Should they? Recently, colleges of nursing, medicine, pharmacy, dentistry, public health, and osteopathic medicine came together to issue a joint report titled “Core Competences for Interprofessional Collaborative Practice.”20Interprofessional Education Collaborative Expert Panel Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Interprofessional Education Collaborative, Washington, DC2011Google Scholar This remarkable interprofessional collaborative effort underscores the reports' recommendations of competency domains: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork. Clearly, this is a dramatic change in emphasis for health-care education, which has come about only in the last few years. Real barriers to interprofessional education exist, and fundamental rethinking of education structure and methodologies must occur before real change is made. The question is how these competencies will be operationalized in health-care education and in health-care delivery. One of the most concrete examples of change since the new millennium is the quality and safety of health-care delivery. It has only been a little over 10 years since the Institute of Medicine (IOM) published the sentinel To Err Is Human, which reported as many as 98,000 patients die annually as the result of medical errors,21Kohn KT Corrigan JM Donaldson MS To Err Is Human: Building a Safer Health Care System. National Academy Press, Washington, DC1999Google Scholar and another book, Crossing the Quality Chasm,” described a “chasm” between ideal and real patient quality performance.22.Committee on Quality of Care in America, Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st Century. National Academic Press, Washington, DC2001Google Scholar These landmark books galvanized the attention on quality and safety within the health-care system. All stakeholders, including the public, health-care professionals, payers, health-care administrators, government officials at all levels, and patients, began a discussion on quality and safety. What have those reports changed since the new millennium?23Leape LL Berwick DM Five years after To Err Is Human: What have we learned?.JAMA. 2005; 293: 2384-2390Crossref PubMed Scopus (990) Google Scholar First and foremost, the IOM reports profoundly changed the conversation of the causation of error from one of “bad people,” where individuals made bad decisions, to system thinking, emphasizing “bad systems” in which a system problem caused the error. Second, a broad list of stakeholders has been formed and engaged in a process of improvement. Congress designated the Agency for Healthcare Research and Quality (AHRQ) as the lead governmental agency for patient safety and authorized it to conduct patient safety research, enlarging its scope dramatically. Out of the AHRQ's work came a fundamental rethinking of the definition of patient safety compared with a decade ago. For example, with the development of the AHRQ Patient Safety Indicators, patient care is now deemed unsafe if potentially preventable complications, such as a decubitus ulcer or postoperative blood clot, develop during hospitalization.24AHRQ quality indicator user guide: patient safety indicators (PSI) composite measures, version 4.3. Agency for Healthcare Research and Quality website.http://www.qualityindicators.ahrq.gov/Downloads/Software/SAS/V43/Composite_User_Technical_Specification_PSI_4.3.pdfGoogle Scholar Other organizations, especially the National Quality Forum (NQF), the Joint Commission, the Veterans Health Administration, and the Centers for Medicare and Medicaid Services (CMS) have made patient safety and quality a priority. The NQF is a nonprofit public-private organization authorized by Congress in 1999 to be the national consensus-standard-setting body. Its > 450 members include purchasers, physicians, nurses, hospitals, health systems, certification bodies, other organizations, and specialty societies. The NQF has currently endorsed > 1,500 quality and safety measures to date.25.NQF-endorsed standards. National Quality Forum website.http://www.qualityforum.org/Measures_List.aspx#p=75&s=n&so=aGoogle Scholar The Affordable Care Act created new responsibilities for the NQF, including the development of a National Quality Strategy. To fulfill this role, the NQF convened the National Priorities Partnership, a collaboration of 48 major national organizations.26National Priorities Partnership. National Quality Forum website.http://www.qualityforum.org/Setting_Priorities/NPP/National_Priorities_Partnership.aspxGoogle Scholar In a report to the secretary of Health and Human Services this fall, national aims of better care, affordable care, and healthy people and communities were identified.27Input into the NQS. National Quality Forum website.http://www.qualityforum.org/Setting_Priorities/NPP/Input_into_the_NQS.aspxGoogle Scholar Within these priority areas, specific measures and concepts will now be developed. The NQF work is a splendid example of not only how quality has been prioritized in the last ten years, but also the remarkable organizational infrastructure developed to measure, report, and hopefully improve quality. It remains to be seen whether the results justify the expense, but there is no question the train has left the station. Two other national organizations have contributed to the major changes in health-care quality and safety. The Joint Commission developed the National Patient Safety Goals in 2002 and systematically reviews them each year for potential new goals.28National patient safety goals. Joint Commission website.http://www.jointcommission.org/standards_information/npsgs.aspxGoogle Scholar Hospital accreditation now depends in part on compliance with the patient safety goals. The CMS's primary emphasis is to improve quality through aligning financial incentives. The CMS have defined pay for performance clinical quality measures each year.29Centers for Medicare and Medicaid Services Roadmap for quality measurement in the traditional Medicare fee-for-service program. Centers for Medicare and Medicaid website.https://www.cms.gov/QualityInitiativesGenInfo/downloads/QualityMeasurementRoadmap_OEA1-16_508.pdfGoogle Scholar New value-based purchasing initiatives based on process and patient experiences are set to take effect in fiscal year 2013 with payments for discharges occurring on or after October 1, 2012.30Open-door forum: hospital value-based purchasing, fiscal year 2013 overview for beneficiaries, providers, and stakeholders. Centers for Medicare and Medicaid website.https://www.cms.gov/Hospital-Value-Based-PurchasingGoogle Scholar With passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, the CMS assumed responsibility for implementation of the electronic health record and defined meaningful use criteria with financial incentives and penalties.31CMS EHR meaningful use overview. Centers for Medicare and Medicaid website.http://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.aspGoogle Scholar Great emphasis is now focused on financial discussions at a time of slow economic growth and massive debt. Further payment reform seems inevitable and already hardwired into legislation. The Accountable Care Act will slow Medicare beneficiary spending growth to approximately the growth rate of the gross domestic product, largely by reducing payments to providers and health-care plans.32Emanuel EJ Liebman JB Cut Medicare, help patients. New York Times.http://www.nytimes.com/2011/08/23/opinion/cut-medicare-help-patients.html?scp=1&sq=cut%20medicare%20help%20patients&st=cseDate: August 22, 2011Google Scholar Funding for health care, largely Medicare and Medicaid, will be cut.33Baicker K Chernew ME The economics of financing Medicare.N Engl J Med. 2011; 365: e7Crossref PubMed Scopus (14) Google Scholar How that will happen is uncertain. Will there be structural changes in compensation, such as development of an accountable care organization, bundled payments, and the medical home, an innovative health-care setting to improve primary care, for reducing payment, or will there be across-the-board cuts scheduled to begin in 2013? Other ideas to reduce costs include a “premium support” plan where Medicare would subsidize premiums charged by private insurers that care for beneficiaries under contract with the government.34Fixing Medicare. New York Times.http://www.nytimes.com/2011/11/21/opinion/fixing-medicare.html?_r=1&pagewanted=1&partner=rssnyt&emc=rsDate: November 20, 2011Google Scholar Clearly, changes will occur as health care is barely affordable now and could be “forbiddingly” unaffordable and unsustainable in the future.35Callahan D Nuland SB The quagmire: how American medicine is destroying itself. New Republic.http://www.tnr.com/article/economy/magazine/88631/american-medicine-health-care-costs?passthru=ZDY1YmFhOTg2YzhmMWE2Njg2MTMzNmM1OWUyYmUyMDQDate: May 19, 2011Google Scholar At the same time, seemingly in advance of the accountable care organizations and medical homes, physicians and physician practices are being employed by hospitals and health systems. Almost two-thirds of hospitals are making efforts to employ physicians, and 80% of hospitals are attempting to employ primary care doctors.36Iglehart JK Doctor-workers of the world, unite!.Health Aff (Millwood). 2011; 30: 556-558Crossref PubMed Scopus (6) Google Scholar Since the new millennium, the percentage of physician practices owned by hospitals has more than doubled, increasing from 20% to over 50%.37Kocher R Sahni NR Hospitals' race to employ physicians—the logic behind a money-losing proposal.N Engl J Med. 2011; 364: 1790-1793Crossref PubMed Scopus (163) Google Scholar This trend is similar for both primary care doctors and specialists. What are the consequences of a majority of physicians being employed by the hospital? Who will be the voice of the patient in this situation? This is a fundamental change in health-care delivery that American physicians and American health care have never seen before. Along with hospital and health system quality and safety expectations, there are now also new expectations of physician competency. Following earlier IOM recommendations, virtually all specialty certificates are now time limited, and recertification requires physician practice data submission for the Maintenance of Certification.38MOC competencies and criteria. American Board of Medical Specialties website.http://www.abms.org/maintenance_of_certification/MOC_competencies.aspxGoogle Scholar Credentialing and recredentialing of medical staff now require the reporting of physician competency data as prescribed by new Joint Commission standards, the Focused Physician Practice Evaluation and Ongoing Physician Practice Evaluation.39Standards FAQ details. Joint Commission website.http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=213&ProgramId=1Google Scholar New Accreditation Council for Continuing Medical Education requirements for CME credit now go beyond knowledge transfer to require demonstration of competence and performance improvement.40Accreditation requirements. Accreditation Council for Continuing Medical Education website.http://www.accme.org/index.cfm/fa/AccreditationRequirements.home/AccreditationRequirements.cfmGoogle Scholar Thus, since the new millennium, the clinical world presents a completely different quality and safety external environment. This environment requires the demonstration of clinical and physician performance and improvement and a focus on health-care finances. So how are we doing? Are we, as the title of a journal article asked, “Still crossing the quality chasm—or suspended over it”?41Dentzer S Still crossing the quality chasm—or suspended over it?.Health Aff (Millwood). 2011; 30: 544-545Crossref Scopus (25) Google Scholar Results are mixed. According to a recent study, the United States lags behind other Western countries in mortality amenable to health care.42Schoenbaum SC Schoen C Nicholson JL Cantor JC Mortality amenable to health care in the United States: the roles of demographics and health systems performance.J Public Health Policy. 2011; 32: 407-429Crossref PubMed Scopus (38) Google Scholar Adverse patient events may be ten times greater than either voluntary reporting or the AHRQ patient safety indicators show when carefully analyzed using a specific tool in three large hospitals.43Classen DC Resar R Griffin F Frederico F Frankel T “Global trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured.Health Aff (Millwood). 2011; 30: 581-589Crossref PubMed Scopus (672) Google Scholar However, there are also success stories. Bloodstream infections declined 63% from 2001 to 2011 as the result of a dramatic multistep process with multiple stakeholders: states and federal agencies, hospital associations, regulatory and nonprofit associations, local hospitals, and physicians.44Pronovost PJ Marsteller JA Goeschel CA Preventing bloodstream infections: a measureable national success story in quality improvement.Health Aff (Millwood). 2011; 30: 628-634Crossref PubMed Scopus (73) Google Scholar Highly functioning teams and teamwork impacting quality and safety are other important changes since the new millennium. According to an IOM report, Engineering a Learning Health Care System, common themes in today's health-care delivery include that system processes should be patient focused, the expectation of errors in performance of individuals but perfection in performance of systems, and that teamwork trumps command and control.45.Committee on the Learning Healthcare System, Institute of Medicine Engineering a Learning Health Care System. National Academic Press, Washington, DC2007Google Scholar It is interesting to remember that the To Err Is Human title no longer reflects the reality of errors. Over 90% of errors are systems errors, not human error (Brent Jones, MD, personal communication, May 2011). Intermountain Health focused on the processes of health-care delivery, not the physicians who executed those processes, and dramatically reduced health-care costs and errors.46James BC Savitz LA How Intermountain trimmed health care costs through robust quality improvement efforts.Health Aff (Millwood). 2011; 30: 1185-1191Crossref PubMed Scopus (200) Google Scholar During a period of time where patient acuity increased, Ascension Health demonstrated significant mortality reduction by emphasizing a teamwork safety culture so inevitable mistakes would not harm the patient.47Pryor D Hendrich A Henkel RJ Beckmann JK Tersigni AR. The quality “journey” at Ascension Health: how we've prevented at least 1,500 avoidable deaths per year—and aim to do better.Health Aff (Millwood). 2011; 30: 604-611Crossref PubMed Scopus (24) Google Scholar Gawande48Gawande A Cowboys and pit crews. New Yorker.http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.htmlDate: May 26, 2011Google Scholar has placed systems and teamwork expectations on us and our millennial faculty and colleagues with the analogy that making systems work in health care is like shifting from corralling cows to producing pit crews. The development of highly functioning teams is not only an educational responsibility but also an operational responsibility to improve quality and patient safety. The growth of palliative care and the discussion of end-of-life issues are other remarkable changes in health-care delivery since the new millennium. The number of palliative care teams within hospital settings has increased 138% since the beginning of the millennium.49Palliative care in hospitals continues rapid growth for 10th straight year, according to latest analysis. Center to Advance Palliative Care website.http://www.capc.org/news-and-events/releases/07-14-11Google Scholar Nevertheless, there is still great opportunity to improve, especially in the area of end-of-life discussions. Not only is this important to our patients by focusing on improving the quality of days for a patient who is terminal instead of aggressively staving off death,50Gawande A Letting go: what should medicine do when it can't save your life. New Yorker.http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawandeDate: August 2, 2010Google Scholar but there are also enormous financial implications of end-of-life care. Commentators have made the association between our nation's debt crisis and our inability to face death while willing to spend whatever it takes to push death just over the horizon.51Brooks D Death and budgets. New York Times.http://www.nytimes.com/2011/07/15/opinion/15brooks.html?_r=1&partner=rssnyt&emc=rssDate: July 14, 2011Google Scholar Changes in nursing have occurred since the new millennium. A controversial report from the IOM, The Future of Nursing, recommends that nurses should practice to the full extent of their education and training, receive higher levels of education, and be full partners with physicians in redesigning health care in the United States.52Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine The Future of Nursing: Leading Change, Advocating Health. National Academies Press, Washington, DC2010Google Scholar Data indicate an array in the scope of practice regulations for nurse practitioners across the United States, from no requirements to consultation and collaboration agreements.53Aiken LH Nurses for the future.N Engl J Med. 2011; 364: 196-198Crossref PubMed Scopus (45) Google Scholar Currently, there is controversy and confusion regarding the doctor of nursing practice degree. Does it mean that nurses can identify themselves to patients as doctors?54Harris G When the nurse wants to be called “doctor.” New York Times.http://www.nytimes.com/2011/10/02/health/policy/02docs.html?scp=1&sq=calling%20the%20nurse%20doctor&st=cseDate: October 1, 2011Google Scholar Given the shortage of physicians, particularly in inner city and the rural areas, it seems likely that nurses will play a larger and larger role in health-care delivery as the millennium progresses. Physicians should acknowledge the important role of nurses in the health-care team. Health-care changes since the beginning of the new millennium have been and will continue to be dramatic. Drivers of these changes include millennial students and physicians, new technology, teamwork and interprofessional education, increasing numbers of women in medicine, quality and safety expectations, physician shortages, and decreased overall dollars. It is important to acknowledge these changes, adapt to them, and incorporate them in the development of our responses. Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: I would like to gratefully acknowledge Cynda Johnson, MD, president and founding dean of the Virginia Tech Carilion School of Medicine and Research Institute, for sharing her interest in millennial faculty with me; Dale Grube, MA, associate dean of continuing education and director of continuing medical education, University of Kansas School of Medicine, for conceptualizing evidence-based content-delivery techniques in a user-friendly format; and David Gutterman, MD, immediate past president of the American College of Chest Physicians, for setting me on this very interesting journey.