Digital Transformation, Wearable Technology, and Physician Wellbeing

As physicians, we make countless decisions during busy clinical care for every patient, consultation, and surgical case planning. All such decisions are only possible based on countless patient-specific data, including history, exam, lab results, cultures, pathology reports, and imaging studies. The most pertinent are realtime vital signs and measurements during surgery and as monitored in critical care units. All this data can reassure us that our patients are safe and responding to care plans, or they can convey the opposite, demanding new and often immediate decisions and interventions.

Given our absolute dependency on technology as physicians, are we as a workforce “early adopters”? What is our own attitude toward the use of digital technology to monitor and enhance our performance as surgeons? How many of us know or use data on our own vital signs, quality of sleep, emotions, and metrics for our daily physical activities?

This has been the best and worst year of my career. Stopping clinical practice and leaving all that I’ve ever known has been the worst part, yet my complete dedication to my body and mind has now allowed me to regain a nearly normal range of motion in my right shoulder and has resolved my cervical radiculopathy. I’m grateful that I’m stronger than I’ve ever been.

I also spent another year reflecting on potential individual and system solutions that can adequately address the invisible injuries to physicians—primarily secondary traumatic stress, post-traumatic stress disorder, physical and emotional exhaustion, anxiety, depression, and moral distress. What I’ve learned about digital and now wearable technology leads me to believe that they can, and should, be used to improve physician wellbeing and performance.

Thinking about Wearables

This article has been slowly brewing in my mind for most of 2022, but the following events inspired me to finally write it down:

• My husband Dave got me an Apple Watch on my birthday (Apple had already shipped 32.1 million devices in the first quarter of 2022—I win for being an ultra-late adopter at age 52!)
• My Apple Watch has countless apps that can monitor my wellbeing, including apps that have the ability to detect my heart’s sinus rhythm or atrial fibrillation, warn me of excessive loud noise exposure, and measure my commitment to close my three daily activity rings (move, exercise, and stand). I now have virtual coaches and countless workout partners who are accessible to me anytime on the Apple Fitness+ studio for treadmill.
• In early 2022, I met Tran Tu Huynh, DO, founder of OpticSurg Inc, Wilmington, Del. A breast oncology surgeon with biomedical engineering, entrepreneurial, and biotechnology background, her company created Vision Beyond, smart glasses coupled with software to enable telecollaboration between healthcare workers and remote providers in a variety of healthcare settings including the hospital, intensive care unit, emergency room, home health, rural health, nursing homes, assisted living, and others.
• In October, I joined Hall of Fame sports psychologist Jim Loehr, EdD, along with incredible experts in performance, behavioral health, and technology, in Alpine, N.J., where tennis star Novak Djokovic trains before every U.S. Open. I was blown away to see how technology is used for training and performance for top athletes, the breadth and depth of data and feedback available to them and their coaches, and the use of biomarkers, biochemistry, and visual, auditory, and touch response times for training and performance. Data have profoundly impacted not only athletes but the entire industry, including sponsors and organizations. I learned about PlaySight SmartCourts, an action review system with cameras and sensors all over the court that provides realtime playback with debriefing data, auto status, game management, and immense feedback for the players to improve their performance instead of simply repeating their actions with less-than-predictable or measurable progress.
• I had several recent conversations with Sarah Bowe, MD, and Natalie Krane, MD, both of whom were super early adopters of wearable technology.
• As of this writing, I’m currently reading a book for one of my master of medical management courses called, “Digital to the Core: Remastering Leadership for Your Industry, Your Enterprise, and Yourself” by Graham Waller and Mark Raskino. The book highlights countless examples of how tiny sensors are now part of many products and generate so much data that provide the ability to see new patterns and variations. The ability to connect things to the Internet is used by all of us on daily basis as we control their operations remotely and manage our surroundings with so much precision. Dave controls nearly our entire house, including the thermostat, indoor lights, lawn irrigation, music, computers, and internet connections, even when we’re thousands of miles away.

In November 2022, Mark Linzer, MD, and his colleagues published an article in JAMA Health Forum about trends in clinician burnout with associated mitigating and aggravating factors during the COVID-19 pandemic (JAMA Health Forum. 2022;3:e224163). The study surveyed 20,627 clinicians across 120 large U.S. healthcare organizations between February 2019 and December 2021 (67% physicians, 51% females, 66% White). Burnout rates increased from 49% in 2019 to 60% by the end of 2021.

What I found most interesting was that through multivariable regressions the researchers discovered that high stress was reported as the greatest factor related to burnout, followed by poor values alignment and then poor work control. —Julie L. Wei, MD

But what I found most interesting was that through multivariable regressions the researchers discovered that high stress was reported as the greatest factor related to burnout, followed by poor values alignment and then poor work control. (We in medicine use the word “stress” to describe experiences, events, a work environment, and/or a workplace culture that creates negative physical, emotional, and psychological strain.) Excessive home electronic health record use—what we commonly call “pajama time”—which was often reported as the top key factor for physician burnout in the past decade, was found to be the least associated factor based on adjusted odds ratio.

I find the contrast interesting that in industries that focus on performance, such as the training of professional athletes and even U.S. Navy Seals, the term “stress” is used coupled with the term “recovery” and is accepted as a positive and critical factor for growth and improvement. Given that the perception, experience, and response to stress is highly variable for physicians as individuals, global and efficacious solutions to reduce physician stress often seem futile. Is wearable technology combined with various platforms our new great hope?

Advanced Wearable Technology

Wearable technology (wearables) is a category of electronic devices that can be worn as accessories, equipped in clothing (shirts, belts, glasses, etc.), implanted in the user’s body (medical devices for drug delivery), jewelry, shoes, or even tattooed on the skin. They are often hands-free and powered by microprocessors, and they send and receive data via the internet. Artificial intelligence hearing aids and virtual reality headsets for gaming are two other examples.

Wearables are embedded with built-in sensors that track bodily movements and provide biometric identification and/or location tracking. Many devices track steps, distance, intensity, calories, electrocardiography results, heart rate and heart rate variability, and sleep monitoring. Most smart watches monitor vital signs using a strap around our wrists and can measure pulse rate variability.

Both heart rate variability and pulse rate variability are noninvasive techniques for monitoring changes in the cardiac cycle and assessing autonomic activity. Heart rate variability reflects changes in the cardiac sympathetic and parasympathetic branches of the autonomic nervous system. Most wearable technology uses the wrist and may report heart rate variability, although it’s arguably pulse rate variability since heart rate variability is measured from an electrocardiographic signal. (Pulse rate variability has been used to refer to heart rate variability information obtained from pulse wave signals such as photoplethysmograms and has been accepted as a valid surrogate for heart rate variability, but the relationship is not entirely clear as they can differ significantly under certain circumstances.)

I think that when we can optimize our performance, as any athlete does, not only does it benefit us, but it benefits our patients. —Natalie Krane, MD

Heart rate variability has long been used as a marker to indicate wellness and state of health for sports performance, emotional states, and even social interactions. Low values of heart rate variability indices have been found to correlate with cardiac events like myocardial infection, atherosclerosis progression, and heart failure. Other studies found correlations between low heart rate variability values and coronary artery disease and even sudden death. Many other conditions of acute and chronic inflammation, such as diabetes mellitus, stress, metabolic syndrome, and even clinical depression have been associated with heart rate variability values.

Polar Electro (known as Polar) was founded in Finland in 1977 and developed the world’s first wireless heart rate monitor. Polar manufactures a range of heart rate monitoring devices, as well as accessories for athletic training and fitness, and measures heart rate variability. They make a variety of sensors in watches and chest straps, coupled with apps and services (not only for humans but also for horses!).

Whoop is a fitness tracking and fitness coaching wearable and app that uses one’s physiologic data to simultaneously improve training and fitness. The latest version promises new biometric tracking, including skin temperature, oxygen saturation, gentle waking that’s optimally timed based on sleep needs and cycles, and, interestingly, your percentage of “recovery.” Whoop uses a combination of one’s heart rate variability, resting heart rate, and sleep performance to tell you if your body is “ready” to perform and what it needs to rest on a scale of 0% to 100%. You can see what range your body’s recovery is in: green for ready to go, yellow as for maintaining health and the ability to handle another strenuous day, and red, which suggests that you need to make time for rest and active recovery.

Arena Strive by Arena Labs is a performance coaching platform built specifically for frontline clinicians. This platform emphasizes helping clinicians achieve “high performance” as measured by self-awareness of one’s physical, mental, and emotional states, stress adaptation based on tracking the body’s physiological responses to stress over time, and, as for all professional athletes, rest and regeneration based on how well the body recovers from stress. This last idea of “rest and regeneration” certainly isn’t a concept that has been historically applied to physicians, surgeons, or any clinicians in healthcare, but hopefully it will be.

Wearables and Physician Wellbeing

I recently asked Dr. Krane, who’s an assistant professor in the division of facial plastic and reconstructive surgery at Oregon Health and Science University, to share her experience using wearable technology.

JW: How did you first get interested in wearable technology specifically for physician wellbeing purposes?

NK: I was initially very interested in sleep optimization and mentioned this to my former fellowship director, Clinton Humphrey, MD, who clued me in on Whoop. I began wearing Whoop in 2020 primarily to delve deeper into my sleep quality and efficiency, eventually utilizing the wearable to track the impact of changes to my day-to-day practices, such as alcohol consumption, the timing of meals, and sleep schedule consistency. Eventually, I coupled the data from Whoop with the data from a continuous glucose monitor to understand the impact of glucose stability on my sleep. I quickly realized that the two are interrelated in multiple ways and made actionable changes using these devices to optimize my metabolic health, sleep quality, and recovery. (I am an investor in Levels, which is a company that uses continuous glucose monitoring to optimize metabolic health. I have no financial involvement with Whoop.)

JW: What technology do you personally wear now on daily basis? What have you tried in the past?

NK: I wear a Whoop band to track my sleep and recovery. Every three to four months I might place a continuous glucose monitor to get back on track in terms of accountability and health optimization. I no longer feel the need to utilize the glucose monitor on a consistent basis as the learnings from wearing one consistently for at least six months have helped me make long-term impactful changes to my diet and eating patterns. I do think that “digital detoxes” are important, so when it feels right, I ditch all wearable technology and take a break. I think this is important for overall mental wellbeing.

JW: What has been the greatest impact to you since using wearable technology? What surprised you?

NK: I think the interconnectedness between diet and sleep quality was surprising to me. This includes the timing of meals, the composition of meals, and the impact of glucose stability on my sleep quality. I think I also recognized very quickly how detrimental the intake of alcohol was to my sleep no matter the amount, and, because of this, I no longer drink alcohol during the week.

JW: What do you believe is the potential for application beyond individuals— for example, for entire residency and fellows/trainees, or even division or department faculty?

NK: I work with a company called Arena Strive (I have no financial interest) that’s looking to utilize wearable devices, such as Whoop, in a group setting to optimize team dynamics and personal recovery. I think the personal recovery piece is going to be a large asset to institutions, including residency programs and departments, by utilizing known methods for stress mitigation and recovery optimization. Although I don’t think wearable devices and individual-focused programs are a solution to the systemic problem we find ourselves in regarding the burnout epidemic, I do feel as though arming physicians with the tools necessary to create healthy habits is imperative.

JW: What should our readers know that’s on the horizon and exciting?

NK: I think the use of wearable technology is going to be commonplace in no time and regular use by both physicians and patients for health optimization is on the horizon. I have a huge interest in this translation of biometric data to actionable changes with real-time feedback. I think that when we can optimize our performance, as any athlete does, not only does it benefit us, but it benefits our patients. And when considering our patients, I would love to be able to place a continuous glucose monitor and/or Whoop on my patients prior to elective surgery to optimize health habits, glucose stability, and sleep. Who knows the benefit to surgical outcomes we may see?

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Dr. Wei is chair of otolaryngology education for the University of Central Florida College of Medicine. She is also an associate editor on the ENTtoday editorial advisory board.