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Thanksgiving brought a revelation. I was sous-chef to my children and my mother, a sounding board for my son as he completed college applications and my parents as they navigated different doctors, and the planner working around the needs of my children, husband, parents, and in-laws. I now realize what it means to be part of the “sandwich generation.”

My generation is also squeezed between older and younger cohorts in the professional world — especially medicine and healthcare. I am solidly Gen X and lie squarely between the boomers and the millennials.

These days, no matter where you turn, the realities of the U.S. healthcare crisis are impossible to ignore. From access to medications, availability of health insurance, affordability of medical costs, even trust and reliability in the messaging or directives we hear, the situation is daunting at best and overwhelmingly dark at worst.

Perhaps the canary in the coal mine has been the growing healthcare workforce crisis.

Physician burnout and moral injury, worsened by COVID-19, drove millennial and even Gen X doctors and nurses to leave the field. Adding to the dearth of primary care physicians as the U.S. population ages with worsened chronic diseases, the imminent retirement of a large cohort of boomers results in projections of a shortage of a combined 400,000 physicians and nurses by 2037.

I can’t help but feel the weight and responsibility of my generation of doctors in the world of medicine, along parallel lines of my personal life.

When we were born and grew up shapes the decisions we make and the ways we manifest and execute them. In his book Birth and Fortune, Richard Easterlin, an economist and demographer who researched happiness, posits that the size of the cohort you are born into shapes your generational opportunity.

Large cohorts, such as the baby boomers, face competition, but they also get the benefits of institutions that bend to their size. Smaller cohorts in the shadow of the larger generation ahead of them often contend with fewer resources and less investment. That’s Gen X in a nutshell.

And it models my experiences in the world of Philadelphia medicine almost perfectly.

Even within these cohorts, Easterlin illustrates, there are differences and disparities. Resources and opportunities available to early boomers became scarce to the later boomers, as the systems were slow to meet their needs. Those returning from the Vietnam War later were more likely to feel this dearth of structures and resources — such was the “birth” of homelessness as we recognize it now.

I saw that firsthand in Philly as a member of the Homeless Death Review team — a small group of experts from across the city convened by the Medical Examiner’s Office. We reviewed every death of a person experiencing homelessness in Philadelphia.

From a systems-level view, it became clear that a lack of resources decades ago created a disparity that was perpetuated throughout the lives of specific demographics. They contributed to their premature deaths.

Boomers created the healthcare system we know today. Building on advances in science, research, and opportunity, they expanded and deepened training pipelines. They established medical specialties, subspecialties, and leadership roles.

They also continued long-standing practices anchored in hierarchy and compliance, where gravitas comes from the company you keep and not always the merit and competency you demonstrate.

A look across academic medical leaders in Philadelphia shows several with tenures that started in their 40s or early 50s and continued for well over 20 years, ongoing even now. Our city’s medical leadership — whether it be the Philadelphia County Medical Society, Pennsylvania Medical Society, or the American Medical Association — shows many of these same individuals making decisions across organizations.

The same voices, same perspectives, and same ideas have been echoing across institutions for years — even when not representative of the rest of us.

Take the American Medical Association. While being known for having the largest lobbying budget of all medical associations, it represents only 20% of the doctors across the country. The AMA designed and owns the Current Procedural Terminology — the five-digit codes that are commonly used in medical billing. That coding system creates an avenue for higher payments for procedures over primary care prevention with a percentage for them as middleman.

Years ago, I wrote about how my approach to being an emergency physician evolved as I saw a changing world of healthcare that was not meeting the needs of the patients who turned to me for help.

That same month, the Wall Street Journal reported on the shift among doctors from “GOP stalwarts” to Democratic voters. My Gen X brethren look different from the generation before us: more women, more people of color, a broader range of ethnicities and cultures. It makes sense that we vote differently, in line with our priorities, values, and missions. Just as it makes sense that we lead differently, as well.

As Gen X doctors, we trained under the “old rules” of loyalty, compliance, endurance, and strict hierarchy. We worked with paper charts, well before computers became the central source of our clinical work. We mastered clinical skills and memorized reams of information. We also understood how issues outside the exam room and beyond our control impacted our patients.

My cohort went on to learn to practice medicine as the corporatization of hospitals took hold and our profession took on the additional contours of a business. We met productivity quotas and metrics around how quickly we saw patients and moved on to the next. We eventually even learned to ask corporate conglomerates for permission to get the tests, procedures, and medications our training and expertise, together with our direct evaluation, told us our patients needed, through prior authorizations.

Boomers continued to adhere to their definition of an ideal physician over the last 25 years — fixating on their commanding expertise and a brand of patient care they developed. In the process, they ceded governance of medicine, including financial oversight and systems design, to non-medical stakeholders. They often treated these issues as beneath them.

For the bulk of our careers, we Gen Xers were complicit — through our silent obedience and compliance. Many of us had learned from personal experience that speaking up or being seen as contrarian to those in power was overtly punished or covertly met with retaliation.

Now however, Gen X physicians are positioned to do something the generation before could not: carry medicine’s core values forward while shedding the destructive traditions and practices that broke the system.

We are facing AI in medicine, further decentralization of medical care, technology and innovation, unprecedented availability of our own health data through wearables, simultaneously with more difficult access to the doctors we have always turned to, and fewer hospitals in our communities.

I see us at a critical generational inflection point. And it’s time to assert ourselves in a few tangible ways:

• Claim leadership by redefining it. We don’t have to wait to inherit positions when those who have inhabited them for decades finally vacate. Gen X knows well that true leadership doesn’t come through hierarchy or titles. In the words of my dear friend Jeremy Nowak: “Power belongs to the problem solvers.”
• Reclaim and own our voice. Our predecessors confused apolitical detachment with impartial professionalism. In the process, the discussions, decisions, and policymaking that shaped physicians’ reality excluded us. It’s time we lean in unapologetically and stop waiting for permission. 
• Reject passive compliance as a virtue. Our silence has helped no one. The courage we spent decades swallowing is exactly the courage we need now to right this ship. We must be intentional in how we define ourselves, our profession, and our value: clinical integrity, collaboration, dignity, empathy, humanity, all come to mind as our unmatched superpowers. 

It feels we are standing at the precipice of the unfamiliar and unknown. Where technology and AI will redefine what is possible, but the needs of our patients will demand practical and accessible solutions.

Sustainable change will come from us — crammed in the middle. At the risk of making a sweeping generalization, Gen X believes in fairness, head-down work, and accomplishment. We have learned and adapted throughout our lives. Unlike the boomers and millennials on either side of us, we are “raised analog, fluent digital, comfortable with a rotary phone and an AI dashboard.”

We are the stewards of the medical profession — not its museum guards. We can bridge the meaningful lessons of our past with the awareness of today and the promise of the future, while centering empathy, values, missions, and ethics.

The silver lining is this: Our hard-earned lessons have become the foundation for a new kind of courage. It’s one that refuses passivity, demands better, pushes into all the spaces that exclude us, and insists that we show up not just for ourselves, but for our colleagues, our patients, our community, and the generations coming behind us.

Priya E. Mammen is an emergency physician, healthcare executive, and public health specialist who helps the nation’s most impactful companies integrate clinical integrity at scale.