Issue No. 646
Catching Up With Roy Ziegelstein
Date: July 5, 2013
As he plunges into his new job as vice dean for education at the Johns Hopkins University School of Medicine, cardiologist Roy Ziegelstein brings a history of educating medical students and residents about providing compassionate, patient-centered medical care while also helping to develop the careers of young scientists.
During his 27-year career at Johns Hopkins, the Sarah Miller Coulson and Frank L. Coulson, Jr., Professor of Medicine directed the internal medicine residency program at Johns Hopkins Bayview Medical Center for nearly a decade and serves as co-director there of the Aliki Initiative, a program that emphasizes the importance of knowing patients as individuals.
Ziegelstein, who succeeds David Nichols, is the medical school’s second vice dean for education. The position oversees undergraduate, graduate, residency, postdoctoral and continuing medical education programs as well as the Welch Medical Library. He recently discussed adjusting medical education to fit society’s needs; how, what and how long doctors should be taught.
Do you think medical education is tailored enough to the future needs of our society?
Medical education needs to address the aging of the population, the increasing diversity that could contribute to disparities in health and health care, and the epidemic of obesity.
To meet those needs, we need a workforce well-versed in primary care because primary care physicians are going to be principally responsible for taking care of an older population living with multiple medical conditions.
A future that has more people with chronic disease also brings a greater need for doctors to work in teams with other health care workers. Training programs for interprofessional education must therefore prepare our medical students, residents and fellows to work with nurses, social workers, physical therapists, occupational therapists, case managers and pharmacists.
As the population becomes more diverse, we need a more diverse health care workforce as well. Medical education must also adequately address patient safety and quality, and trainees must be well-prepared to help patients change negative health behaviors linked to many medical conditions.
Talented and inspired people here are working to develop what and how we teach, so that it is more responsive to the needs I’ve just outlined.
There is a national conversation about how to address the growing shortage of primary care physicians. Some say medical training should be shortened. How is Johns Hopkins looking at this issue?
Let me present the problem this way: Imagine that we have two trains speeding towards each other on a collision course.
One train is carrying the extraordinary amount of information that we need to teach our medical students. There has been an explosion of knowledge in medical science. Additionally, we think our doctors should understand the health care financial system, know about social determinants of health, understand our critical role in patient safety and quality, and know how to change health behaviors.
The other train is burdened with the long, arduous and very expensive training involved in medical school and residency. Medical students graduate with huge debt, which may be a particular problem if we want to diversify the pool of applicants. We must also realize that there are very talented young people who, in the past, would have chosen medicine, but now go into another field like engineering or business because they feel that becoming a doctor takes too long.
So there are these two trains headed toward each other: One is screaming for longer training so that we can pack in more and more information, while the other screams that training is already too long and costly.
One answer is to specialize training earlier. Some students may say, “I don’t want to do medical school in only three years.” That’s OK. But there may also be some who, right from the get-go, know they want to be surgeons, or ophthalmologists or primary care doctors.
If we’re going to shorten training, at least for some, we probably can’t train everybody in everything, as we do currently.
Johns Hopkins research suggests that restricting the number of continuous hours that residents work may increase patient “handoff” risks and compromise training. What is your opinion?
This is a very complicated topic, because there are two very important outcomes to consider. One is how work hours affect a resident’s training, and the other is how they affect patient care.
It turns out that these two outcomes are not easy to assess. Residents’ training is not only measured by what they learn and how often they attend teaching conferences, but also by how the training affects their professional attitudes. Patient care is not only measured by whether someone’s acute condition improves or whether that individual avoids harm or medical error, but also by whether the patient feels cared for.
I also think it’s important to think about residents’ quality of life. It’s hard to have a life outside of the hospital when you’re there 120 hours a week. It’s hard to raise a family, to exercise regularly, eat normally and maintain good emotional health. All those things, you might argue, are not just important to the trainee and the trainee’s family, but also to society.
We have an obligation to train doctors who are skilled and knowledgeable, and who are able to use modern technology wisely to deliver safe, high-quality and low-cost care. And we also have an obligation to ensure that we are training doctors who are caring, compassionate and sensitive.
I think Johns Hopkins should lead the way in figuring out how many hours is too many, and how many is not enough. My personal view is that it’s not just important how long residents work, but what they do. The “right number” of work hours can only be determined in the context of workload.
—Reported by Linell Smith