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Catching Up with Roy Ziegelstein
Q. Do you think medical education is sensitive enough to the future needs of our society, such as the growing number of elderly Americans and those with chronic conditions like diabetes?
There are certain societal imperatives that education needs to address: the aging of the population; the increasing diversity that is bringing greater potential for disparities in health and health care; and the epidemic of obesity with its many related health conditions.
If you're going to design an education system to meet those needs, you want to make sure it can produce 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. You want to design training programs for inter-professional education that teach 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, you need a more diverse health care workforce as well. You also want to make sure that education adequately addresses patient safety and quality, and that trainees are 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.
Q. Statistics show that less than a quarter of today's biomedical Ph.D.'s are becoming academic researchers. Instead they are working for pharmaceutical and biotech companies and entering careers such as science writing. What do you see for our graduate biomedical education?
As we evaluate what and how we teach our medical students, we must give the same attention to teaching the life sciences. Not only is there more information to learn than when I was in training, but there are diverse career paths for which we must also prepare our trainees in biomedical science. Our mission is the same for developing physicians and scientists: to train leaders. One of the most exciting and innovative approaches to graduate biomedical education is our own Center for Innovation in Graduate Biomedical Education (CIGBE). Its goal is to provide an infrastructure to support novel approaches to biomedical education.
Q. What about individualized programs of study?
While we develop a broader view of what we teach, we must also consider tailoring education for each of our trainees. We talk a lot about the importance of getting to know every patient as a person in order to deliver the best care. I think the same model applies to our trainees. We need to develop individual learning and development plans for all of our students, whether they are clinical trainees or biomedical scientists.
Q. There is a national conversation about the growing shortage of primary care physicians and what can be done to remedy it. Some say medical training should be shortened to accommodate the need. 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. First, there has been an absolute 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 about 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. We can't just keep teaching everybody everything. 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.
As a cardiologist, I don't think I'll ever need to deliver a baby. So the question is: As a doctor, should I be expected to know how to deliver one? I learned how, but did I need to? I realize that it helped me understand what gynecology/obstetrics is, and I almost certainly would not have considered that career path if I hadn't been exposed to it. However, if we're going to shorten training, at least for some, in order to continue to attract the best and brightest, prevent students from amassing huge debt and diversify the pool of applicants, we probably can't train everybody in everything.
Q. The first class trained on the Genes to Society curriculum graduated this year. What methods do we have to evaluate the effectiveness of this instructional approach?
For a start, we can certainly ask the opinions of experienced educators and of our students, and we can look at scores on standardized tests. In addition, though, we are trying to staff and operationalize an office of assessment and evaluation. This office would do at least three things: better evaluate the tests our faculty members develop to assess students' knowledge and skills and link those test results to future outcomes; provide information for faculty involved in medical education research; and help develop individualized learning plans for students by obtaining and maintaining better data about them.
Q. Do we have ways of tracking how our graduates are faring?
Judging the efficacy of your program without looking at long-term outcomes is like building a Toyota factory, evaluating the assembly line at every point and test driving the cars, but never determining whether they last for 200,000 miles or 20,000 miles on the road. This is part of what the office of assessment will eventually do once it is fully staffed and operationalized.
Q. An important part of education and training in the new Johns Hopkins Medicine Strategic Plan relates to interprofessional education. Why that focus?
It is becoming increasingly clear that teams of highly-skilled health professionals, each with different training and expertise, are needed to provide the best care to patients and to meet their diverse health care needs.
Several things have happened to make this necessary. First, patients have become more complicated. Our health care model was designed primarily to deliver acute care during discrete episodes of illness, but today's patients often have multiple chronic illnesses that require coordinated care. Second, the health care delivery system itself has become more complex, and health care teams now have more critical members with discrete roles. And finally, the scope of practice of each member of the health care team has become more complicated. Doctors, nurses, pharmacists, social workers, physical and occupational therapists each must learn more in order to develop expertise in his or her domain.
It is not only important for each member of the team to develop this practice-specific expertise, but also to understand and appreciate the skills and knowledge each member of the team brings to the care of the patient and to learn to work in teams.
Interprofessional education and practice is a real paradigm shift, and requires deliberate planning and implementation. With respect to the training of physicians, that means that the training environment needs to change for undergraduate and graduate medical education, and that the environment in which people practice needs to change as well. We have unique talent and expertise here at Johns Hopkins.
Q. 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 it affects patient care. Society cares about both.
It turns out that these two outcomes are not easy to assess. Resident 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.
Q. You have spent the last 20 years – the bulk of your Johns Hopkins career –at Johns Hopkins Bayview. How has working there shaped your vision?
The Bayview culture has always seemed unique to me, with many role models with exemplary integrity, compassion and humanity. Great physicians like Phil Zieve [former director of the Department of Medicine at Bayview] and John Burton [former director of the Johns Hopkins Division of Geriatric Medicine and Gerontology] have had a great impact on the campus, and on me. David Hellmann [vice dean, Bayview] is an innovative leader who always asks "What problems do we face?" and in the same breath, "What can we do to fix them?"
The Aliki Initiative at Bayview is a great example of that. It teaches residents and students the importance of knowing patients as individuals to deliver optimal patient care. The desire to always try to make things better, and to lead the way in innovation for the public good, is part of Bayview, and part of Johns Hopkins in general.
Q. You came to Johns Hopkins in 1986 as an intern. After 27 years, you must have great insight into the "Hopkins Way." Is there any downside to working at the same place for so long?
So-called "Hopkins lifers" like me sometimes think "What could possibly be bad about spending your entire career at the best place in the world?" I think it has some risk if a person's vision is confined to a single institution and if he or she doesn't look outside to learn what other people might be doing better. And by "outside" I don't just mean other academic medical centers, I mean other professions, even those outside of health care.
When a problem confronts us at Hopkins, we often immediately begin to develop a solution as if no one else could be thinking about this as well. It turns out that in many cases, we can learn a lot from our colleagues elsewhere. Hopefully we will wind up doing it better... after all, that is the "Hopkins Way," but we can also learn from what others are doing.