Over my 20 years with a multispecialty clinic in southeastern Wisconsin, I've seen and dealt with many operational issues and personnel problems. But none has been so divisive as a recent controversy over our primary care call schedule. The tug-of-war that ensued between two competing generations nearly led to a break-up. But compromise and common sense finally produced a solution that was both flexible and fair to everyone.

The problem had been brewing for several years, as the clinic, particularly its primary care department, had steadily grown. When I arrived in the mid-1980s, there were only four primary care physicians; now there are 17. The call schedule conflict started out as just another growing pain, but it soon developed into something more like renal colic.

Along with an increase in size, our department has undergone a significant change in demographics over the years. The first partners were all male; the new mix was 10 male and seven female. There were intergenerational differences as well, on topics ranging from work ethic to lifestyle priorities, with a clear clash of cultures between our Baby Boomers and Gen Xers.

Those young doctors needed some reassurance that everyone was willing to pull their fair share of the call load. But the older doctors wanted the rights of seniority for their years of service. Clearly, we were going to need a new policy to preserve harmony in the department. The lines of battle were drawn, and three groups emerged: the "old-timers" approaching or past the age of 55; the "greenhorns" in their 30s; and my group, the "muddled middle," then in their 40s.

Battle lines are drawn by generation The old-timers felt that the "55 and out" system had worked just fine for years, and they saw no reason to change it. As they pointed out, the issue had already been debated (many years before), voted on, and resolved. Going off call was a reward for decades of toil. In fact they argued that the "55-and-out" policy would actually attract new blood to the department if recruits knew there'd be a reward at the end of the rainbow.

Most of the older group had started with the clinic when they were in their late 20s, and some of them now felt that the department's younger doctors were too "soft." They didn't appreciate what call had been like in the "old days," when it meant delivering babies and covering the ED every third night.

The greenhorns agreed that call had changed over the years—but for the worse. Patients had become more demanding, they claimed, often calling at ridiculous hours for relatively trivial matters. As for the old-timers' tales about how tough call was in the old days, they had the same effect on the young docs as the stories parents bore kids with about how they walked three miles to school through three feet of snow.

The young doctors pointed out that each on-call physician was now covering for 16 other doctors, not half a dozen, as in the old days. And in an age when everyone is paid on the same RVU scale, they argued, allowing some of the older doctors to "coast" just wasn't fair to the others. In fact, it would encourage older doctors to prolong their practices, leaving little room for new hires, and allowing the department to stagnate.