How do physicians from two generations communicate with each other?

Abstract There is no leadership without communication. This is especially paramount in hospitals to guarantee optimal processes and teamwork. But do physicians belonging to younger generations, the so-called Generation Y, need another approach to leadership and communication? And does the concept of generations stand up to scientific standards? This study is based on a literature review on leadership communication in healthcare across generations and hierarchies and in-depth interviews with physicians from Swiss hospitals on communication. The thematic analysis of the interviews revealed four main fields of communication patterns: 1. Increasing demand for information and transparent communication; 2. Low power distance versus high power distance; 3. Feedback; and 4. leadership communication. Younger generations, so-called Digital Natives or the Generation Y, have an increased need for transparent communication and involvement in the process of decision-making. More than previous generations and based on flatter hierarchies, Generation Y dares more to question its boss and his or her decisions and expect at the same time more feedbacks. New forms of leadership are needed to optimize communication between the generations and prepare young physicians for the increasing demands of more complex healthcare systems.


Introduction
Few data exist on the topic of leadership communication in hospital settings between generations (. Therefore, the authors designed the study using a two-step methodology to explore the topic. First, they executed a literature review on leadership communication and multigenerational workplace setting, focusing on the healthcare setting. Second, the literature review was followed by indepth interviews with resident physicians and head physicians in various Swiss hospitals. The goal was to analyze requests and needs in communication and leadership communication and correlate it with age and hierarchy levels. The study analyzed communication and leadership communication between head physicians and resident physicians.

Methods
To achieve a comprehensive approach on this topic, the study used a two-step methodology. The study is based on a literature review on leadership communication and multigenerational workplace settings with a special focus on the healthcare sector. Additionally, semi-structured qualitative expert interviews were conducted and analyzed by thematic analysis.
The research questions were how physicians experience leadership communication at the workplace and whether there is a difference to be found between generations in their needs and requirements concerning communication with their superiors and/or with other employees in Swiss hospitals.
The search terms used to perform the literature review were based on expert knowledge and extensive discussions within the research group. To perform the search, major search engines were used as well as specific searches based on seminal literature. The following search terms were used on PubMed and Google Scholar: Communication and leadership communication, generation vs. generational cohort, generational difference such as motivation and work values.
Addressing the explorative nature of the research question the interview study was designed with an open frame for the purpose of learning from social phenomena instead of interpreting them in the light of pre-existing theoretical assumptions (Braun & Clarke, 2013). This inductive principle is particularly valuable for discovering communication needs and habits among physicians from different generations in Swiss hospitals. The thematic analysis approach generated the key themes.
First, interview partners were identified in a theoretical sampling approach. While potential participants were chosen based on convenience sampling, the selection process considered crucial sociodemographic factors such as age, career position and work experience to cover diverse opinions within the two generational groups of Baby Boomers and Generation Y (see literature review for generation and generational cohort definition). 26 physicians were asked for an interview of which 16 refused or did not answer to three email requests. Altogether, 10 semi-structured interviews with Swiss German speaking physicians from 9 different hospitals were conducted between May and August 2018 (see, Table 1). The interviews were based on a preliminary discussion outlining the content of the study. The following information regarding the aim of the interviews were provided: content such as leadership communication, motivation, and work values. All the interviews were conducted by the first author. The interviewing process as well as the guideline development was iterative and considered insights gained during the process. Interviews lasted between 50 minutes and 1 hour 30 minutes with an average of 1 hour 10 minutes. The interviews were immediately transcribed and coded by content structuring by the first author (Bock, 1992). In a first step, the transcripts were paraphrased and by this, the content was broken down into codes.

Sampling procedure
The interview participants, all from the German part of Switzerland, 1 were selected based on function, age group, place of work, department, and gender from the personal network of the authors. Further criteria were hospital size (university hospital vs. cantonal hospitals) and specialization (internal medicine vs. surgery vs. psychiatry). The selection was chosen to get a purposive sample to help answer the questions of the research. Care was taken to present all characteristics in a balanced manner, but this was not always possible with the small number of 10 interviews. No interview partners from the Italian or French part of Switzerland were included nor was there an interview conducted with a female head physician. These two limitations were due to the fact that physicians of these groups did not respond to the email requests or were unavailable at the time of the request. Most of the interviews were telephone interviews. They have been recorded with Audacity (Team Audacity Developer, 2018) and transcribed with f4transkript (Dresing & Pehl GmbH, 2016).
Of special importance was the recruitment of interview partners from the two major disciplines: medicine and surgery. While it did not cause any problems to convince head physicians of internal medicine for the interview, it was difficult to recruit physicians from surgery. The reasons for nonparticipation were the lack of time for an interview (mostly head physicians) and fear of career consequences (mostly resident physicians). A balanced relationship between physicians working in internal medicine and physicians working in surgery could therefore not be maintained.

Interview guide
The interviews followed quality criteria and techniques for qualitative research standard (Braun & Clarke, 2013). A first version of the interview guide was developed based on several discussions with two head physicians from a Swiss university hospital according to the criteria for in-depth interviews (Hohl, 2000) and on the literature review. The preliminary discussions were not part of the 10 interviews used in the study.
The research design and the interview guide were presented to academic peers in communication within the Institute of Competitiveness and Communication of the University of Applied Sciences Northwestern Switzerland (FHNW) during a research roundtable. 2 The feedback served to improve the interview guide. The interview guide was extended after each interview as further topics were added. Nevertheless, care was taken to ensure that the subject areas remained manageable, so that the interview duration of 1.5 hours was not exceeded.

Content structuring and analysis
This first step corresponds to Bock's qualitative content analysis (Bock, 1992). Hereby, the interviewees' individual topics are at center: What is or seems particularly important to them? What aspects do they come back to in the conversation? Where do special emotions occur? After the transcription of the interview, the individual passages or contents were distinguished from superfluous phrases, filler words and the like. Similar statements were combined. Then, statements were written or rewritten in such a way that external readers can see connections (e.g., from previous statements). Information on the interviewee may have been added (e.g., previous employment relationships). Abbreviations that are particularly common in medical jargon were explained.
In the last step, the main statements were extracted and sorted according to categories or patterns (Braun & Clarke, 2013). At the beginning, the categories followed the topics of the interview structures. Gradually, further subject areas were added or rearranged. For example, the category "communication" was divided into the categories "Patient-doctor communication" and "Leadership communication". Also, the "socio-economic changes" were divided into subcategories for better classification. The analysis resulted in a paraphrased short version of the interviews.
According to current Swiss law on human research (Humanforschungsgesetz, HFG), the analysis of data that are not patient-related does not require approval by local ethics committees. Participation of physicians in the expert interviews was voluntary, the data was analyzed anonymously.

Generation and generational cohort
The sociological term of generation has been defined as early as 1927 by Karl Mannheim as individuals that have their birth years and a set of life experiences in common (as cited in: Lüscher et al., 2009). Sociological literature distinguishes between a generation and a generational cohort (often cited as generational group). The former defines a group of individuals according to the date of birth and summarizes 20-25 years. The generational cohort, on the other hand, groups people together based on formative experiences that convey values and attitudes (Parment, 2013b). Therefore, there is no strict number of years to define a generational cohort (Cogin, 2012). In the majority of the literature found and cited in this article, generation equals generational cohort, hence a group of human beings characterized by their year of birth and a common view of social and historical events (Gurtner et al., 2013).
There is a sociological understanding that generation is viewed as an identifiable and distinguishable group of people sharing similar life experiences. These formative experiences lead to a common attitude and thinking as is the expectation of many social anthropologists (Kupperschmidt, 2000;Wey Smola & Sutton, 2002). Generation in this context is viewed as developing an own personality (Jurkiewicz & Brown, 1998) or how Howe and Strauss (1992) called it, a "peer personality". Crumpacker and Crumpacker (2007) cite a proverb, that summarizes the concept of generation well: "Men resemble the times more than they resemble their fathers". The value system of individuals is believed to be shaped strongest during childhood and young adulthood and remain stable afterwards and throughout adulthood (Glass, 2007;Lubinski et al., 1996;Scott, 2000). There is an understanding that cultural, political and economic events and developments are effectively shaping a generation on a regional as well as global scale (Cogin, 2012).
The concept of generation is discussed controversial in scientific literature. A cohort selection based solely on the year of birth, and social and historical events seems too vague, according to some social scientists (Künemund & Szydlik, 2009). Education, gender, family class, and circles of friends contribute more to the social imprint than the year of birth. Certainly, common national and international experiences can create a certain overarching basic understanding, but a generation cohort cannot be a homogeneous mass from their point of view as for example, Levenson (2010) and other stated Kels et al., 2015). Other studies have found generational differences but relate them more to age than to the affiliation of a generation (Wong et al., 2008). Most of these studies lack the use of longitudinal data which could help eliminate the age and generation distinctions (Schaie, 1965). Some of the cross-sectional studies, for example, the Australian study between three generations by Wong et al. (2008) admitted that the stated differences could also be related to career stage rather than generation.
Despite the vagueness of the generational concept and the definition, the generational concept is seen mostly as given. Furthermore, it is useful in reducing complexity and creating patterns and frameworks when talking about various generations (Kels et al., 2015). Generation models with their associated stereotyping and simplifications are helpful to HR and supervisors in managing employees.
With the definition of generation in mind, the authors feel confident to adapt the category of generations to physicians working in Swiss hospitals and dividing them into two groups for this study: head physicians from Generation Baby Boomer and assistant physicians from the Generation Y. This seems tolerable for the following reason: For this study, physicians from hospitals in German-speaking Switzerland are considered. Most physicians working in these hospitals have a similar cultural background, language, and socialization.

Work values
Work values are defined as ideas, actions and ideals that are considered desirable or expectable (Brown, 1976). The literature review on generations raises the question if different generation develop different work values. Most articles cited above assume that the answer to this question is yes, values vary between generations (Cennamo & Gardner, 2008;Krings et al., 2008;Wey Smola & Sutton, 2002;Wong et al., 2008), and that different work values lead to conflicts at the workplace (Cennamo & Gardner, 2008;Cogin, 2012;Krings et al., 2008;Twenge & Campbell, 2008;Twenge et al., 2010). Divergent desires and requirements are based on the disparities in their work values. This could consequently lead to conflicts and problems at a multigenerational workplace like hospitals as Zvikaite-Rotting 2007 suspects (as cited: Gursoy et al., 2008). Valuable studies like the ones done by Cherrington et al. (Cherrington et al., 1979;Cherrington & England, 1980) or Murphy et al. (Murphy et al., 2004) demonstrate the differences in cross-generational work values and state the importance of adapting management and HR practices.

Communication and leadership communication
Leadership is in the words of Hackman and Johnson (2013, p. 11) "human symbolic communication that modifies the attitudes and behaviors of others in order to meet shared group goals and needs". To achieve these goals leaders need competent communication skills (De Vries et al., 2010). Communication is paramount for successful leadership which has been widely confirmed by many studies in the last decades (Bass & Riggio, 2006;Madlock, 2008;Towler, 2003). Communication skills of leaders have proven to be the most important item for employer's satisfaction, even more important that specific personality traits (Emerson & Loehr, 2008;Di Meglio, 2007;Mikkelson et al., 2015). Concepts like the transformational leadership model are based on these assumptions (Bass & Riggio, 2006). Communication competences are described as involving two elements. First appropriateness and second effectiveness (Spitzberg & Cupach, 1984). These two elements of competent communication were shown to be correlated to occupational success (Spitzberg & Cupach, 1989). Spitzberg has further narrowed down the concept of communication competence and defined it as "the degree to which meaningful behavior is perceived as appropriate and effective in a given context" (Spitzberg, 2013, p. 30).
Many studies have demonstrated that leadership communication is key to the daily routine in health care settings and has a positive impact on team motivation, patient treatment process and patient safety (Kosnik, 2002;Schull, Ferris et al., 2001;Sugrue et al., 1995;De Vries et al., 2006). It is also proven by various studies that insufficient communication is one of the main reasons for underperforming medical teams, for example, emergency teams (Donchin et al., 1995;Weberg, 2012). On the other side many studies have found a correlation between insufficient leadership communication (amongst other factors) and increasing anxiety and depression amongst employees (Levey, 2001;Shanafelt et al., 2002).
Insufficient communication could be categorized in various types, e.g., poor timing (occasionrelated), missing or inaccurate information (content-related), unclear or unachieved purpose of communication (purpose-related), excluding key individuals (audience-related). Failure in communication will lead to "inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural errors" (Lingard et al., 2004, p. 332). Cole and Crichton (2006) showed that poor communication skills, e.g., yelling at team members, result in loss of confidence.

Gen Y and communication
Today, three generations of physicians are working in hospitals. The exact dates of the generations may vary within a span of a few years. But mostly, Baby Boomers are reported to be born before 1965, Generation X between 1965and 1980and Generation Y as born between 1981(Aaron & Levenberg, 2014Parment, 2013a). Generation Z has been excluded from this study as they are still in their medical education. These four generations are the largest diversity ever working together in history (Glass, 2007).
The description of the generations is very consistent (Eisner, 2005). The Baby Boomers are the post Second World War-born and have been the largest cohort for a long-time span. Their defining events are the economic boom, the women's liberation, the space race and the youth liberation (Glass, 2007). Those born after 1965 are called the Generation X with defining events like AIDS, economic uncertainty, the fall of the Soviet Union, the decreasing value of family with an increasing divorce rate. This is a tech savvy, independent generation, less committed to their employers and seeking more work-life balance as the generation before them (Beutell & Wittig-Berman, 2008;Twenge et al., 2010).
Generation Y, also referred to as Millennials, GenY, Next Generation, Digital Generation, Echo Boomers or Generation Me, is the youngest generation working in hospitals. This generation grew up in a world characterized by transparency, fast pace, many choices, constant communication and great individualism (Wey Smola & Sutton, 2002). In their youth, the development of the Internet and digital media changed the world. This and the social, economic, ecologic and political changes resulting from emancipation, globalization, climate change and patchwork families are social phenomena that have a particularly strong impact on the Generation Y, influencing and shaping its world views (Twenge et al., 2010;Zemke et al., 1999). In particular, emancipation should be mentioned. The improved compatibility of family and career, as well as the increased involvement of men in household and family care, has certainly led to a change in values and to an increased demand for part-time jobs and the desire for more time for the family. The general lengthening of the school years leads to a postponement of family planning. In medicine, emancipation has led to women now outnumbering men in the under-40 age group in both outpatient and inpatient settings (Hostettler & Kraft, 2018). Another aspect is the prosperity of Switzerland. In the latest WEF-report on competitiveness, Switzerland ranks among the frist three in the world for the eleventh time (Schwab & Zahidi, 2020). It is clear from the report that Switzerland has one of the most efficient labor markets, coupled with an excellent education and healthcare system. The prosperity also means that workforce can afford part-time work in the first place.
The literature is homogenous in describing the Generation Y as searching for meaning in its job, its high value of family and friends, and being prone to change jobs in search of flexibility, satisfaction, a non-hierarchical workplace and a better team collaboration (Piper, 2012;Twenge et al., 2010). Prensky was the first to call this generation digital natives (Prensky, 2001). He even suggested that this digital brought-up may lead to a change in brain structure and a different way of processing information. Something that many authors rebutted (Helsper & Eynon, 2010).
With their technical knowledge and upbringing they are obviously more connected, multitasking is considered normal and they are better educated than generations before them (Crumpacker & Crumpacker, 2007).
At University and medical school they are quick to learn and prefer web-based learning settings (Evans et al., 2016). On the job, they estimate flat hierarchies, constant feedback and like to be involved in the decision-making process (Francis-Smith, 2004 as cited in : Eisner, 2005). Besides this, they are high performer but expect appreciation and rewards (Perrig-Chiello & Dubach, 2012;Twenge et al., 2010). Some studies describe this generation as demanding and "high maintenance" (Eisner, 2005;Martin, 2005). These mainly negative connotated attributes are joined by other attributes like politically disinterested, too comfortable, consume oriented, ego-centered, overconfident and feeling entitled (Steckdaub-Muller, 2015;Twenge et al., 2010).
According to surveys in the last 10 years, younger employers seem to have different needs and applications of communication than older employers (Parment, 2013a;Schulenburg, 2016). One main research areas that surveys revolved around in the past decade is the technological aspect of communication of Generation Y. The fact that Generation Y is the first digital generation leads to, according to many researchers, better digital skills (Glass, 2007;Huntley, 2006;Zemke et al., 1999). They are usually early-adapters, interactive and benefit from modern technology (Glass, 2007;Martin, 2005). They tend to be more connected to digitally available information as well as to friends and family (Eisner, 2005).
The second main research area is around the content and quality of information. Transparency and information are important aspects to describe Generation Y. This leads to a desire for more and more direct communication. They expect to be comprehensively informed about their career options and career planning. This information should arrive, in the eyes of this generation, timely, accurate and extensively (Parment, 2013a;Piper, 2012).
The third main research area is feedback. Compared to Baby Boomer and Generation X, the youngest generation in the workplace expects more feedback. While Baby Boomer may be satisfied with "No news, good news" and little feedback is needed to accomplish a job, Generation Y is getting unsettled by getting no feedback which is interpreted as "No news, bad news". It expects feedback to be immediate and the annual personal development meeting may not be sufficient and satisfactory (Crumpacker & Crumpacker, 2007;Francis-Smith, 2004). This different approach to feedback could result in misunderstandings. A collaborator of the Baby Boomer generation may feel insulted by detailed instruction or feedback while a Generation Y-collaborator needs it to do a good job (Glass, 2007).

Summary findings literature review
In Table 2 the main findings of the literature review are summarized.
Communication needs of Generation Y is founded in different attributes as described and summarized in the following Table 3.
Societal changes and the healthy economic situation have led to more women in medicine, more part-time and more work-life-balance to name a few. Demographic changes resulted in more and older patients with multiple illnesses. Medicine has changed significantly over the last 40 years. The technological progress in medicine has brought up more medical specialization and subspecialization and transparent communication between medical teams has a significant role. Digitalization led to safe handovers of patients at the end of the shift, which means that the doctor does not need to be on call 24/7. On the other hand, many working hours of a doctor are filled with administrative tasks today: internal medicine residents spend more time at work than scheduled and activities indirectly related to patients predominate (Wenger et al., 2017). This leads to the sense of more "useless" time.
In all this, communication plays a vital role. The need of resident physicians for a positive leadership communication is vital. But the areas of conflicts have a direct impact on the job satisfaction as the interviews have brought to light and a survey by Bolliger et al. on resident physicians in Switzerland has revealed (Bolliger et al., 2016).

Results
The study found generational views on communication. The results are elicited in detail below and discussed in the next chapter "Discussion" where results are put in relation to current literature.
The study revealed four main fields of communication areas that differ between resident/ attending physicians and head physicians in Swiss hospitals: (1) Increasing demand for information and transparent communication

Increasing demand for information and transparent communication
"Some issues within the hospital are just not discussed with resident physicians. They are kept from us, e.g., problems with the management, why we have to work so much overtime and other problems". (Resident physician) The in-depth interviews showed, according to resident physicians, a lack of forwarding important information by the head physicians. The latter rarely share stressful or difficult situation with their staff. Be it because they think it is not important or necessary or because they want to protect their medical staff from the annoying management leadership, as one head physician clarifies. The interviews with resident and head physicians revealed, that head physicians tend to share information mostly with senior members of staff. This leads to a mental distance with their resident physicians. There is a ditch between resident and head physicians, which is bothersome to the resident physicians. Missing important information disturbs them and the exclusion from the decision-making process is frustrating.
"To be a good boss means to me, someone who communicates promptly. Someone who is more colleague than boss, who communicates as equals", this resident physician states. Resident physicians want to be involved in the decision-making and have a desire to get information directly from the boss. Therefore, they criticize the missing communication flow.

Low power distance versus high power distance
"Today our team culture is more cooperative despite any professional hierarchies. We communicate more with resident physicians than in my times". (Head physician) Resident physicians in the study interviews are mostly critical towards hierarchies in hospitals. Examples of hierarchical behavior in the interviews are when head physicians don't mingle with residents, don't know their names, or don't talk to them if not to give orders. Other examples are when backtalking is not tolerated, closed door policy, exchanges in rough tones and few or no feedbacks. In the in-depth interviews mixed seating arrangements, sharing of information and an open-door policy is important to Generation Y. Also having a coffee break together is significant to them. Apparently, more informal interaction is not equivalent to a lack of respect, as one head physician states: "There is a certain informality, that is true. But I do not feel any disrespect from the resident physicians".
Resident physicians prefer flatter hierarchies and more informalities than head physicians in the interviews. They don't put up with anything and dare to critically challenge traditional settings and orders. "This generation doesn't put up with anything anymore. I think, it's our education. We scrutinize everything and we look after ourselves more than previous generation who were educated to obey" (resident physician). In their own words, the continuous questioning is less a form of disrespect rather than a form of permanent search for the best option and result. On the other hand, they recognize professional know-how and leadership qualities and respect their bosses for that.

Feedback
"After a couple of years of being a resident physician we had a joke: 'The boss raises his eyebrows, I guess I did something right '. But we would have never dared to ask: Hey boss, tell me, how did I do today?". (Head physician) None of the head physicians in the interviews did get feedback during their residency. Not all of them missed it, but all of them value feedback today. Reasons for feedback in their eyes are patient safety and improvement, but also employer engagement: "Feedback is extremely important, and you can never give enough of it. If one of my employees is not happy, I know it's because I did not give enough feedback. Senior doctors immediately go away and look for a simpler work in a practice, if you don't give them enough feedback", said one head physician.
The in-depth interviews showed that the reason for feedback seeking of resident physicians is about self-improvement and patient safety. One resident physician called it: "I can only improve if I know that I make mistakes. That has nothing to do with caring excessively about the Generation Y". Resident physicians state in the interviews that they want to learn and improve because they understand that they can only get better with feedbacks directly from their superiors. They do appreciate formal feedback meetings that are mandatory in their formation by the SIWF (Swiss institute for postgraduate and continuing medical education). Needless to say, the earlier in their formation the more feedback these resident physicians need and seek.
The in-depth interviews reveal a misunderstanding about feedback between resident and head physicians. Resident physicians seem to appreciate the "informal" feedback more while head physicians seem to give more "formal" feedback. What is the difference? Formal feedback takes place during a structured meeting or feedback session or even during the annual performance review. It is also part of the postgraduate education program of resident physicians in Switzerland. Informal feedback is the feedback that takes place directly during or after an activity, e.g., a patient's interview, a surgical intervention, or an examination. Resident physicians seem to prefer the informal feedback as they can link it directly to their area of improvement. "After the night shift, you sit with your attending physician and discuss what you did well, what you can do better, what the goals are for the next shift. I like that. After this, I know what I am doing well and where I have to improve".
All interview partners admit that feedback is important. Most head physicians struggle with the implementation. Some head physicians eliminate informal feedback as they are time consuming. Others try to squeeze them in between two meetings, after an intervention or walking from one patient room to the other: "It's extremely difficult to insert feedback into the daily work. I try but I fail often". (Head physician)

Leadership communication
"My former chief physician communicated exclusively by his secretary. Even in the case of a patient decompensating, we had to call his secretary first". (Resident physician) Leadership communication constituted a major part of the interviews and included all facets of communication between employees and superiors. Resident physicians demand an open-door policy from their head physicians. They wish for more communication either formal (e.g., instructions, information regarding their work or work settings, feedback) or informal (e.g., conversation about their life outside the hospital). Superiors, as well, see an increased requirement for communication and information by the residents: "Yes, the need for discussion is increasing significantly. Significantly. And so do the sensitivities". (Head physician).
The superiors see not only an increase in volume as well as an improvement in communication between hierarchical levels: "We communicate better than in the past. We possess better technical conditions to exchange with our resident physicians than 20, 30 years ago and we have more formalized exchange nowadays", stated one head physician.
The in-depth interviews have shown that resident physicians are not prepared for leadership communication. As treating doctors, they must coordinate an interdisciplinary team consisting of nurses, physical therapists, and nutritionists, which is called lateral leadership. As one head physician states this is a source of stress as the resident physicians are not prepared for leading interdisciplinary teams.

Discussion
There are many studies about the Generation Baby Boomer, the Generation Y, and the difference between them. In Table 4 (below), the authors summarized some of the main attributes of the two age groups according to various studies. This article puts light on the communication between these two groups in Swiss hospitals. Based and structured on the four findings the results are being discussed and set in relation to current literature.

Increasing demand for information and transparent communication
Transparent communication is a matter of course for the younger generation. Therefore, Marc Prensky named Generation Y "digital natives" (Prensky, 2001). This in contrary to the generation of Baby Boomers, who he calls 'digital immigrants. Generation Y is the first generation who grew up with communication technologies such as internet and computers. They learned to live always "online" and "connected". They consider technical devices nearly as part of their bodies. With their supercomputers as smartphones and tablets they can retrieve any information in a matter of seconds (Eisner, 2005). A world without social media is not imaginable to them.
Considering this, transparency and information are the basis to understanding this generation. They are used to get any information needed in seconds and they demand direct and transparent communication. If they detect potential for improvement or are unhappy about a situation, they speak their mind. At work, they expect information about their career planning and possibilities of further education promptly and extensively (Parment, 2013a, p. 75).
Transparent communication means not only sharing information but also involving staff members into the process of decision-making. It is a change from authoritarian leadership towards participative or transformational leadership (Bass & Avolio, 1994;Schulenburg, 2016). In the participative leadership model team members are actively and democratically involved in decisionmaking process from developing strategies to execution (Likert, 1967). At the core of the transformational leadership model lies vision, mission, motivation and identity (Bass, 1985). Both concepts need strong and efficient leadership communications skills. Transparent leadership communication is enabling resident physicians to find their own solutions to problems. It is facilitating that this generation is self-assured, clever and trained enough to find their own solutions if empowered with necessary information (Salacuse, 2013).
Members of the Generation Y are considered team-players who like to share their knowledge and prefer to work in groups more than on their own. Furthermore, they see that untruthfulness will always come to light in this connected and transparent world (Thürkauf, 2018). "I do not understand why head physicians don't share their problems and frustration with us residents. We could stand together and rebel against the management board", says one resident physician. The idea of tackling and solving problems together is typical of Generation Y (Schulenburg, 2016). In addition, there is a decline in hierarchical power differentials, which in the case of this generation means that they welcome openness and a common approach in the team.

Low power distance versus high power distance
Generation Y desires a boss who communicates with them on an equal footing and stands out not by his title but by his professional competence. Low power distance, it is called by Hurrelmann and Albrecht (2014). This generation wants to learn through coaching and not through blindly followed instructions. It appreciates flat hierarchies, as the in-depth interviews have impressively shown. They want to find open doors and ears for their concerns. Teamwork and a sense of comradery is  -Tremblay et al., 2010;Martin, 2005). Baby Boomers on the other hands have grown up in a society where hierarchy was more pronounced, and the style of leadership was strictly top-down. Regular feedback in the hospital setting was not usual nor appropriate. It is a high power distance environment (Hurrelmann & Albrecht, 2014).
More than previous generations and based on flatter hierarchies, Generation Y dares more to question its boss and his or her decisions-the "why" in Generation Y (Crumpacker & Crumpacker, 2007). In doing so, they bring a greater self-confidence than the generations before them. This might have to do with a rather anti-authoritarian education with much attention and appreciation from their parents (Glass, 2007). Their comprehension of respect is connected to knowledge, responsibility and leadership qualities of their bosses (Martin, 2005). Respect, however, cannot be earned solely by age. In the eyes of Generation Y, power and statusdo not create respectcompetence and experience, however, do (Hesse et al., 2019;Mangelsdorf, 2015). Young employees want a boss they can respect for his or her knowledge but would like to be treated on eye-level and feel part of a team (Hurrelmann & Albrecht, 2014). The differences in leadership style and the attitude toward respect are presented in Table 4 below.

Feedback
For Generation Y feedback, especially instant feedback, is a very important issue: they crave for constant communication and connection and 42% want feedback every week, which is more than twice the percentage of every other generation (Van den Berg et al., 2017). Some consider members of Generation Y to be "praise junkies" that are accustomed to frequent positive feedback (Aaron & Levenberg, 2014). 79% of Generation Y want that their boss serves more as a coach or mentor, just like their Baby Boomer parents have treated them their entire life (Noise and The Intelligence Group, 2014). The term "helicopter parents" describes the situation where parents constantly hover over their kids, comment, and guide their kid through school and other activities. This over-involvement combined with a stream of "likes" on social media platforms could explain the demand on feedback (Glass, 2007).
Methods of feedback that worked well with previous generations may not work well with Generation Y (see , Table 5). Therefore, Baby Boomers and Generation X-ers may be uncertain as to how to provide constructive feedback to this generation and to acknowledge the difference in learning preferences (Aaron & Levenberg, 2014). Ferri-Reed calls for managerial coaching that balances praise with constructive criticism: Superiors should praise members of Generation Y when they truly deserve it but be careful to soften the negative feedback because acceptance and others' perception of them are highly important to Generation Y (Aaron & Levenberg, 2014; Ferri-Reed, 2010). However, feedback is not a one-way street: when preparing members of Generation Y for future leadership positions, reverse mentorship involves pairing senior executives with junior staff members in order to bridge generational knowledge and cultural gaps and to empower leaders (Qast, 2019). Learning someone's passion, motivation and goals while simultaneously providing him or her with advice and guidance is an invaluable process that takes time and commitment (Hernandez et al., 2018). When performed in a two-way manner, not only the mentee will get more out of the investment in this relationship but also the mentor (American College of Healthcare Executives 2020; Hernandez et al., 2018). Table 5 demonstrates differing perceptions and attitudes of the two generations towards feedback. Baby Boomer physicians were educated with lesser feedback than younger generations. Therefore, they are used to receive scarce feedback and more formal feedback such as medical teaching. Head physician value feedback nowadays but struggle to incorporate it in their daily routine due to time constraints. Younger generation and especially the Generation Y are educated with more and more frequent feedback. Feedback is seen as reinforcement and a tool for selfimprovement and patient safety but also as an instant gratification for their work.

Leadership communication
Resident physicians expressed an increasing need for communication and exchange between the hierarchies in the interviews. This requires better communication skills from their head physicians and colleagues in leading positions. Flatter Hierarchies in the society have surely added to this evolution in the sense that a participative leadership model requires better leadership communication skills.
Positive communication like thorough debriefing and feedbacks result in better team performance (Kozlowski et al., 1996;Zaccaro et al., 2001). This appears to be very important in the communication between the generations, on one hand Generation Y expects to communicate as equals but on the other hand requires guidance. However, Baby Boomers perceive this balance act as difficult because guidance in their experience equals authoritarian communication. The young generation's reaction is then perceived as them being too sensitive. Debriefing critical clinical situation could provide a useful tool to overcome these difficulties. The act of debriefing fulfills two functions (Schull, Szalai et al., 2001). One is to compliment and appreciate good teamwork. The other is to address non-desirable actions and performances even though it resulted in a positive outcome. Therefore, Lingard et al. (2004, p. 332) followed that accurate communication should be "proactively, with complete and accurate data, to all relevant team members in order to achieve explicit and shared goals". Modeling leadership communications can not only improve the clinical outcomes and serve as a learning tool but also transmit an understanding for leadership to future physician leaders. This appears also to be crucial because we are seeing a rise in interprofessional teamwork in the health sector (Antoni, 2010).
Lateral communication and leadership are gaining an increasing importance and physicians are, based on their education, destined to inhabit the role of a leader in interprofessional teams. However, despite this increasing importance, to date it is not part of the academic education of medical students in Switzerland. This challenge will continue as the health care system diversifies and according to new skill and grade mixes, roles that were traditionally assigned to specific professions, i.e. nurses serving dinner to patients, are being transferred to other professionals, i.e. gastronomy (Streiff, 2017). Hence, young physicians are being confronted to communicate with a diversity of medical and non-medical professions and will be expected to assume a leadership role in these teams.

Limitations
Even though the current study has brought to light interesting outcomes it also has some weaknesses and limitations. First of all, the limited number of interviews. The current article is based on 10 in-depth interviews and need to be further validated. To weaken this effect, an open approach to the in-depth interviews was chosen. No limitations regarding time or subjects were placed during the interviews. A quantitative survey amongst physicians in Swiss hospitals is currently underway to challenge the results and validate them on a broader basis.
Special care was taken to choose interviewees in a balanced manner, which, however, was not possible with the small number of 10 interviews and the limited time. For example, while amongst resident physicians, male and female interviewees were equally distributed, no female head physician was interviewed. This was not an explicit decision but resulted from the interview partners who made themselves available. For head physicians, only the male would be reflected in this study. Also, the lower number of head physicians compared to residents might have introduced an emphasis on the view of younger participants. Furthermore, neither physicians from other language regions in Switzerland (French or Italian part) nor German physicians (physicians from Germany constitute a huge part of physicians in Swiss hospitals) were considered.

Conclusion: importance and impact of the study and future research
To our knowledge, this is the first study in Switzerland assessing team and leadership communication between physicians of two generations. It has produced new findings in multigenerational communication in Swiss hospitals. The study put forward socio-economical and medical changes and their contribution to communication in Swiss hospitals. The study shed light on important issues such as differences in expectations for leadership communication and intergenerational feedback. It showed the paramount importance of communication skills for supervisors. This includes knowledge about different expectations as well as mastering new communication tools. Findings can be used to derive practical insights for leaders in hospitals. Results will help align communication needs between different age groups and furthermore, help hospitals to focus on some hot topics such as feedback and leadership communication.
Due to the limited number of interviewees many influential factors such as gender or hierarchy level were missed. The study lends some support that these factors could be significant. Furthermore, the question of generation-versus function-related communication conflicts was left open. This inspired a consecutive quantitative survey currently in the works, which will take into account the multivariate setting of communication and gain further insight in the dimension of communication between physicians in hospitals. The findings could contribute to a communication and leadership model in hospitals to improve teamwork across different generations and functions.