57. Alex Hajduczok, MD: The Future of Wearable Technology in Cardiology and Healthcare

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Our guest today is Dr. Alexander Hadchuck, and before I introduce him as the doctor he's known to be, I want to primarily introduce him as a healthcare hero, a friend, and someone who is just a truly remarkable human being. You see, Alex is Ukrainian, and he grew up here in the States, but he has very strong ties to his culture and to his people across the seas in Eastern Europe. Now recently he traveled to the Polish-Ukrainian border to provide medical aid to the refugees fleeing the country. He also set up a GoFundMe page that has raised more than $18,000 to provide medical aid. If you want to support this mission and you want to check out Alex's story, I will provide links in the show notes that you can check out. Now, Dr. Alex Hadchuck is the doctor. He is a first-year cardiology fellow at Thomas Jefferson University Hospital in Philadelphia. He completed his internal medicine training at Penn State Hershey, which is where I did, and went to medical school at University of Rochester School of Medicine and Dentistry in Rochester, New York. He is interested in a career as an academic cardiologist specializing in advanced heart failure and transplant. His main research interests include remote monitoring for heart failure, human dynamics, and cardiogenic shock. He started using WOOP in 2017 to optimize CrossFit training and has been a level one certified CrossFit trainer since 2016. Alex leads multiple clinical trials with wearables and uses device-measured objective data in his own life to improve performance. Now, our discussion with Alex spans everything cardiology from his long journey into the field and how he got really interested in using wearables technology and now using WOOP not only for patients in the hospital, but also us residents in terms of burnout and wellness. All right, without further ado, let's dive deep into this conversation with my friend and health care hero Dr. Alex Hadchuck. Hi, my man Alex, here with us on Medicine Redefine. What's going on, man? How you been? Good. Good. It's been a while. I guess like a year or so since I've been in Hershey, but I feel like toward the end of the pandemic, no one saw each other or not the end of the pandemic, but the end of my time in Hershey. Yeah, that's right. I mean, I was with you. So for context with listeners, right, Alex is currently a card's fellow at Jefferson, but you did your internal medicine residency at Penn State Hershey, which is where I am right now. And so when I was an intern last year, Alex was a senior. I think we had two teams that we were on together, which were pretty fun. So, how's Philly trading, you man? You're back in my hometown. You're originally from New York. So, how's Philly? Philly is great. I'm right in center city. Like you said, first year cardiology fellow here at Thomas Jefferson, and I did my residency at Penn State Hershey with you there. And I did med school and college and med school, both at the University of Rochester up in New York. And I'm from Buffalo initially. So you know, kind of moving my way down the east coast here, nice to be in a big city. I'm right in center city. Like I said, like a block away from the hospital. So that's very useful for my cardiology perspective, because we're quite busy. That's the best area Philly, man, Midtown. Have you been a fat salmon yet? Is the real question of this whole episode? I don't think so. But I'll add that one to the list. You can walnut the best sushi. It's a sushi restaurant. What is that? Freaking amazing. Oh, you know, it's like a full vibe with like purple lights, blue lights. And there it's pretty, pretty small, but it's amazing. Yeah, yeah. Actually, everything you place that I've been to around here has been like, you know, a little bit of a selection that's been heard. To the food staff here. It's pretty bad. Cool, man. Well, why don't you tell our listeners a little bit about who you are and kind of your journey in terms of how you kind of chose cardiology? That was a great question. Man, my journey is kind of not traditional, you know, like I kind of, I thought it was, but had some, had some pivots along the way. So like I said, I grew up in Buffalo. I went to college at the University of Rochester. I was always interested in medicine from, because of my interest in physiology, from like AP bio in high school. And I went to college major in biochemistry, double major in economics, actually. And then I dropped the econ major second, or like second semester senior year, I was like one class away from finishing it, but I didn't want to wait. You know, kind of, I wanted more free time, basically. And so major in biochem, and I did a bunch of research in college more from a structural biology standpoint, basic biochemistry. I spent a summer in Germany doing extra crystallography in NMR on a membrane protein, came back to Rochester and worked in a lab studying yeast, G protein, coupled with receptors. And all of it was kind of under the, like my interest in signal production, because that was heavily implicated in clinical medicine, specifically like beta adrenergic signaling, which is, you know, key in heart function and vascular tone. Obviously beta blockers work on the beta adrenergic receptor. And I was always interested in cardiovascular physiology the most from a, because it really like a structure begins function. You know, you have structural heart failure, and then that leads to clinical sequela. And so I kind of had that parallel, both from a GPCR standpoint, which is structural biology. And so I was actually in the MD PhD program at the University of Rochester. I did the first two years in the lab. Sorry, first two years in med school, then I moved into the lab for a couple of years, and unfortunately my boss moved. And it was just going to be a lot more years in the lab to finish the PhD. And I decided that, you know, I still had a lot of medical training left to go. So I had two years of med school and residency and fellowship and beyond. So it's like, okay, you know, we will pivot a little bit here. And so I spent seven years in med school at the University of Rochester. Three were full time in the lab. We did some interesting work. But I went into third year being like, I don't remember anything. I don't remember what a call is to stack to me is I had to look these things up. Everyone's coming up with step one. Like just absolutely, just like they know everything. And I was like, I don't know some of these words. And I started on cardiac surgery, actually, which was good because no one really has a lot of experience in the OR. So it was kind of like a clean slate or, you know, equal playing field. And I was interested in cardiology. So that was probably the one thing that I did know. And then I moved on to like surgical oncology. And I was absolutely lost, you know, doing like wipples for 12 hours. But my first like surgery rotation, I was, every case was 12 hours, like eight to 12 hours long or whatever. And I didn't realize that like that I did like a week on like just generally doing that. Colies that like you can do like four or five cases in a morning. Oh, okay, that's kind of neat. Anyways, I went into like medicine, my medicine rotation. And I was like, oh my god, this is so hard. Like, how do people know all this stuff? Or you know, these people have all these complex things. And I still remember like, so this was in like 2015, 2016 and 2017. And so people trouble starting was was just kind of big on the scene. And parent IHF was published in 2014. And I remember being like, oh, there's like this new heart failure. But this is kind of interesting. And so I always just found the mechanism of activation interesting for a lot of these. Again, you know, beta blockers and ACE inhibitors and then Arnie's. And so I was like, hmm, let me let me file that in the back of my mind. I basically like barely passed like all of my rotations in in med school. Because I was like, I was working hard, but I just like didn't have like the like the attitude. Because I was out of the game for three full years. And then third or fourth year, I did like a sick you rotation. And I feel like I started to get my feet under me just because you're like so ingrained in everything. And the patients are really complex, but you're just like right in front of them. And there's like one or two of them. So it's like, okay, maybe I can do this and stuff like that. And so applied internal medicine and matched at Penn State Hershey. And at that point, like the goal was to do cardiology. And that was just solidified throughout medical school. Even when I went back into third year, I was like the card stuff was always like was gravitating to it. I actually like to do I did a cardiac anesthesia rotation. That was really neat. You see a little bit more of the human dynamics in real time during the CT surgery cases. You're thinking more about pressors, you're thinking more about invasive monitoring, cardiopulmonary bypass, TEEs in real time for either valve replacements or really anything. And so I was like, wow, this is neat, like human amics are really cool, but like I don't understand that. Like maybe I'll understand it, who knows. And so I went to Penn State and I started a camera or like a clinic or whatever. Early in the fall, I had my cardiology rotation and I was like, oh man, this is so cool. Like acute cardiology, bypass rapid pace. People are coming in with, with heart attacks and you're, you know, you're helping them and you're fixing them up and you're getting them out. Or, you know, arrhythmia management, which like EP is still kind of a black box for me. But then the heart failure service, Dan's heart failure, I said, wow, these patients are so sick. And they're, they're always coming in to the hospital and I was just fascinated by the progress. The pathology, really of chronic heart failure. And this was back to like my initial interest in GPCRs because essentially what happens is you have chronic desensitization of the receptors from the cell membrane. You have kind of beta arrest and pathways that are activated. They pull the receptor off the cell membrane and then it's, it is not sensitive to the next stimuli of, you know, adrenaline or circulating hormones like epinephrine or epinephrine. And so that's why beta blockers work. And principle is, is what they do is they block the beta receptor and as an antagonist so that you don't have activation. And because of that, they stay at the cell surface. And then when you actually need the stimuli, you know, when you need that enhanced contractility, that I'm a trophy, the receptor is still there. So that's why it's essentially like a heart failure treatment. And so I was like, wow, this is so cool. This is what I used to work on in the lab. Like I used to do biochemical reconstitution assays, radioactive binding, we purified membranes from insect cells and whatnot and did all these like need experiments. And now I'm seeing like how that works firsthand with, you know, treating these patients. I was like, this is basically like the bench to bedside model, maybe not from a research standpoint, but from a clinical standpoint, because I'd seen all of it. And I was always, I was still interested in research, but I was like, I can't split myself and do bench research. Also, I wrote GPCRs, but there really wasn't a ton going on at Hershey. And so I was like, okay, like what else is there? And I got hooked up pretty early on with John Bamer, who's one of the advanced heart failure specialists at Penn State. And he's done a lot with remote monitoring. And both, specifically non-invasive remote monitoring, algorithm development, predictive of heart failure, hospitalization, worsening heart failure, and improvement of outcomes. And so we got hooked up actually through Amy DeWaters, who is one of the program directors at the time. She was like, yeah, you know, this, this would be good for you, because a lot of it is very science heavy and mathematical. And I think that you'd be a good fit. And basically from there, we like took off doing a bunch of stuff, started initially doing heart sound research, which is actually still I'm going. Now part of a larger clinical trials for that, using a non-invasive vast that measures EKG, heart sound, breast, competing positions, not to a respiratory rate. We're specifically looking at S3 as a marker of heart failure, essentially what happens is you have early diastole, so right after S2, you have filling. That blood comes through the mitral valve and hits the ventricular wall, you'll have a low-pitched rumble, which is essentially, or murmur, that is S3. And so it's been shown years of data back to the 80s that S3 magnitude, oscultated by a clinician, correlates with, or outcomes in acute decomposal failure and chronic heart failure. But now we had the opportunity to measure this in a more objective way. And so basically using measuring it in an inaudible range, using a very sensitive microphone, and then converting that into amplitude measures, normalizing it against the other heart sound so that you're not just measuring like how good you are at measuring the heart sound in general. You're kind of getting into the fact that it's a pathophysiologic marker. And what we're doing there is basically correlating that to outcomes fuel that are more likely to get rehospitalized, but also looking at accelerometers and whatnot. But anyways, so... You're deep into the shape. Damn. This is how I got started in a remote battery, because I was fascinated with a lot of this stuff. And so, actually, Dr. Bamer and I were sort of sitting in his office one day, and he had this large clinical trial with this company called Nanoware. And he was like, we're talking about just people being not compliant because they have to wear a vest for like 12 hours overnight and measure these heart sounds. I was like, you know, I have something actually that may be improved with compliance. Maybe you don't get all of the data, but you have some of these interesting parameters. Like, not to arrest for rates, resting heart rate, heart rate variability, and then sleep parameters. And that being what you're hammering here. And so, that basically, like, we actually have like a feasibility trial going on with heart failure patients and who... And some interesting data basically showing changes prior to re-hospitalizations for a lot of these folks. I'm really excited to eventually explore that deeper. But this was all kind of set in motion early on, and this is where I know you're familiar with the stuff that we did in that with resident wellness. And I know we'll talk about that a little bit more, but you know, that was really my journey of going, you know, being interested in medicine. Then kind of like having this player for research, but just kind of finding my way. You know, it was always like interested in things, but really just trying to figure out how do you put that in the big picture. And what, you know, what you can kind of do with that. And, you know, my point is like, I think that a lot of this is really neat and can make a big impact. But it's not the easiest thing to do, so it just takes a lot of elbow grease. But I think that we're starting to figure out ways to help that treat patients. Actually FDA gave an extended approval for cardio mems, which is invasive PA pressure monitoring in heart failure patients. Expanding that to class to heart failure patients based off of the results from the guide a Jeff trial, which is published in the Lancet earlier this year. And they already had, they already had approval based off of champion trial, which was published in 2017. And that was just in a more narrow heart failure patient population, a classroom heart failure with a prior hospitalization. So anyways, yeah, that's that's kind of our journey, a lot of a lot of nerdy stuff, a lot of remote monitoring, but a lot, a lot of a lot of excitement on my end if you can't tell. Yeah, no, definitely dude, it pops out of the screen. And you know, what I really appreciate is having these conversations with the folks and when we ask a question about their journey, a lot of times we hear a personal story. Right, the reason why, like for me, right, for going to sports medicine, Darshan is somewhat similar in the sense why we're going to something musculoskeletal medicine related. As we have an athletic background, fitness background, you've experienced some injuries, some dysfunction, which you can with cardiovascular disease as well. But a lot of what you're talking about is just just geeking out on the science of it, right, the physiology, right, from the basic mechanistic standpoint all the way to the clinical aspect of it. I'm wondering though, from a personal standpoint, you know, with cardiovascular disease being, I mean, the number one killer in the developed world and just every single person essentially is touched by the morbidity aspect of it. Did you have like a close one loved one who was affected with something like heart failure? Like, you know, why is it I know you mentioned the physiology of heart failure is more fascinating than anything else. But did you have that aspect of it too that fed into the personal story of basically adding another three years on to your seven years that you've already did, like, you know, plus three as a residency, you know. So I was pretty fortunate to not have anybody in my family die of heart disease either early coronary disease or heart failure and things like that. Actually, it's more unfortunate, but when I was in my cardiac surgery rotation as a third year, my aunt, who were really close, she was my godmother. She got diagnosed with the, with a GBM. And actually, basically quickly decompensated had was had it removed, but there was like an entrop bleed and so she basically had a stroke and was trying to rehab from that, but never made it out of the hospital. And so that was very unfortunate, but you know, you kind of see, you know, from the from the patient and from the family member of the patient perspective, like how difficult it can be to lose a loved one. And, you know, I think that that is, you know, the same throughout whether the causes, heart failure, coronary disease or stroke or cancer and things like that. You know, so I think having that empathy being on the other side of the ball, it's obviously, you know, very unfortunate. And yeah, you know, so I definitely definitely have that side of things. And so I know that a lot of other people have, have, have moving stories and, and you know, what gets you into medicine and things like that. And I think that that's what makes this career path just really beautiful. And a sense is that so many people have phenomenal stories of what motivates them and they're, you know, so different, you know, if you talk to some, to some people, it's like, oh, my, my mom was a doctor and she did, you know, this and that. And I was inspired from an early agent. It's just like so cool to hear all that. And so, you know, I'm happy to be a part of that, that cohort of people that get to take care of other people for a living. Yeah. No, I certainly agree. What I'll tell you is just hearing the passion and your voice when you describe, you know, your research from the PhD side and all the way to the final side, it's almost refreshing for me, right? I think, you know, I have the sense that when, when somebody comes in with that personal story that you can empathize with the patient, right? So, for instance, you give the anecdote of GBM, let's say somebody, you're taking care of all of a sudden somebody who has brain tumor, right? Which Darshan, I often do in our specialty because we're seeing folks in the patient rehab side. And if you're somebody who has been through that trauma personally, it might make it extremely challenging to care for that patient or on the flip side, the level of empathy, the connection that you have at a deeper level might make the experience that much better. You can go either way. I'm wondering though, do you think that, again, you said you've been fortunate enough that you haven't had that level called adversity or, you know, our experience? Do you think that that helps or does it make it more challenging for you to care for your patients? I think a little of both, you know, I never wish that on anybody. But like you said, I mean, sometimes you see that love wonder family member in some of your patients. And, you know, I think that, you know, you're already given 100%, 110%, maybe you just kind of spend just a little bit more time with them at the end of the day, kind of just talking from a realistic sense, you know, you're not thinking about writing notes and putting in orders. And you're really just kind of taking the person in front of you at face value and saying that they're human being and we're here to help. And I feel like that, you know, it just makes them so much more appreciative, you know, just kind of sitting down with them, maybe instead of standing. And, you know, that that personal touch is put in your hand on their on their arm or on their leg and just knowing that you're there for them, because I think we've all been there with alongside people that are, you know, on their final days or hours. And that was even more so highlighted during COVID, especially with some of these folks passing and they couldn't even be around their loved ones. And so, you know, you become that person. And I think for a lot of us in residency, like those experience are never going to leave us because that was, you know, unprecedented. That's really never happened before ever, you know, calling people and saying, I'm sorry, you know, it's hospital policy, we can't let you in. Yeah. And or, you know, whether it's face timing with them, but still have the same and you're just kind of, you know, I remember being at the VA and being like, I don't want to go home and leave this person here. They're all alone and you can just see like the pain in their face and you're talking with the family members and you hear the pain, you know, from them and you're like, I don't have a solution. So yeah, that was a little bit of a segue regarding COVID, but you know, I think that all of these things impact us, you know, without a doubt. Yeah. And as you alluded to earlier, one of the things that you guys, this initiative that you guys had it over at Penn State Hershey last year is that the resident wellness thing, which is kind of what you're touching on, but I want to come back to that little bit later. Before we, the bulk of this conversation, the reason why you're here is because you are a champion for basically whoop, but a lot of this wearable technology, right? Particularly focusing on the cardiovascular system, that's your specialty. And I think whoop is largely marketed as a, you know, consumer, consumer variable for fitness, right? And for wellness, essentially, it's safe to assume that you're fitness junkie, you're an exercise enthusiast, just like we are, right? But you're affiliate, no pun intended, is cross it, right? And that's what you, you like to do. That's how you like to train. And you know, I'd love to hear a little bit about that side of the story is what attracted you towards that particular mode of exercise? So this is a great question. The first time I heard about CrossFit was actually through my buddy who was in the military, he went to West Point, and he was in Iraq, and he was like, oh, so we're doing some of these like high intensity workouts. And I think it's like something like this CrossFit thing, but I don't really know what that is. And I just remember being like, I was in college, and I was like, I don't know either. Like, I don't know, I just try to go to the gym and lift a little bit. I don't have time to matter, like that sounds weird. And then pick things up and come down a couple of years later, like hockey with this guy in men's league, but I was in med school. And he was like, yeah, so I started doing CrossFit. I think he'd really like it. And I'm like, no, I just want to go to the gym and stuff like that. Like, oh, that's like, what is this, like, the swinging pull ups and like all these like weird things. I don't want to be pervies, like, blah, blah. And then I was down in the cat skills for Fourth of July weekend. We actually used to go to all of these dance camps growing up. And I was also part of that for portion of my childhood doing Ukrainian dancing and L.A. And we're in tights and things like that. It's actually very helpful for playing hockey. That is a little bit of a side. And we're down in the cat skills that literally is like 30 dancing, like, what panels, blah, blah, blah, just big performances. Some of my professional groups from New York City would be performing. And my buddy was, he used to roll crew at Cornell. And we were having a couple cocktails and joking around. And he was doing CrossFit. And he was like, yeah, one of the things is like rowing, which obviously used to do. And I was like, oh, yeah, I started doing like a little bit of that at the gym. And like, I'm not good at it at all. Like, it's very difficult. And he's like, oh, yeah, like, what kind of numbers are you pulling? And I don't know. It's like some abysmal things. He's like, all right, try this. Let's see who can row a sub 130, 500 meter row first. And I was like, well, you'll smoke me because you wrote crew. He's like, well, I'm like a little bit out of the game. And I'm definitely not in like rowing shape like that. Okay, it sounds good. I'm always up for a challenge. And it's basically just looking all sprint to do it under under a minute and a half. And kind of like a benchmark. So I went back the next day after the weekend. And I tried it like in the morning before work. I got like 131. And then I was like, oh, my God, it's so close. Like you gotta go. So I went back right after work. And I hit it. I was like, 129, 5 or something like that. This was in July of 2014. And I was like, okay, I'm sold. I got my own friend telling me this. My other friend doing that. And actually in the background, I was spending so much time at the gym and just like texting and not getting a good sweat and stuff like that. I was like, I gotta do something more cardiovascular. And so I was always a fan of Rocky. And so I was like, let me get a jump rope because they do it in the training montage and whatnot. I think these crossfit people like do jump ropes. Like so I could like crossfit jump rope. Like one of those. And I started doing that before I would go like work out at the gym. And I was like, oh, this is pretty cool. I started to do like what are these double understood? It's like trying to figure that out. And so like that plus like this growing challenge is like, okay, like I'll give it a shot. So I went to this gym that was nearby called Flower City Crossfit. And I walked in. It was like they would do heavy lifting on Wednesdays. And I'm like walking into the back gym where they did like the boot camp thing. And I go, hold on, I want to like lift. Like what's going on? I don't want to go do the stuff in the back. I did the stuff in the back. And they were like, okay, yeah, you'll be fine for like the real thing. We just need to teach you some of the movements and onboard you. And then you can start next week. Came back like a week later to do the real thing and just got absolutely great. Just like on the ground, like in pain. It was like a seven minute workout. I go, I don't even know how this is possible. And it was like burpees and pull ups and like kettlebell swings. And I was like, yeah, I don't know how to do these picking pull ups. I can't do a burpee to save my life. And I still basically am in that position. But yeah, so I started it and like the rest was history. I started going three, four or five times a week, making time for extra mobility sessions and flexibility. I think that was actually one of the first eye openers because I remember having like shoulder pain just from bunching all the time or doing curls and whatnot. And I went and started doing CrossFit. And I was like, oh, you like hurt yourself. But because of the emphasis on like movement patterns and flexibility and mobility, particularly in particular. All that pain went away. Like literally, I was like, it was like literally like in mighty ducks when he was like, no, the pain is wrong with this one. So yeah, I like started the people at the gym became like a second family. And we would always be there. And you know, working out together, we would always go to like six a.m. And then I would try to go back after work if I could. And yeah, it's just like so much fun. And I started coaching in 2016. So like I would coach like three, three class a week and then continue to work out, which is, which is great. I coached through residency in Hershey and, and still have my own one, but haven't haven't coached here because I've been a little bit more busy. So I think CrossFit's awesome for that reason, right? I mean, I think the family aspect to it, right? You got that camaraderie, the accountability. And then I think a lot of people struggle on kind of mixing weightlifting and cardio kind of together, right? And getting that good sweat, like you said. I know you're kind of crazy and did did murfs, a lot of them. But before I ask you about those murfs, I wanted to ask you about whoop because the first time I ever heard a whoop was actually last year. So when did you first start wearing it and, you know, why why whoop? So this is actually funny as well, because one of my buddies like comes in and he's like, yeah, I like heard about this thing, like this wrist, like this Fitbit type thing or whatever. I go, oh, that sounds like interesting. Like what does it do? Oh, it tells you your recovery score and like your strain and stuff like that. Oh, that sounds pretty cool. And around actually they did a black Friday deal, which was at the time it was a flat fee is 500 bucks, but on black Friday, they did buy one, get one. So me and a buddy like split it. So it was like 250 like for one time fee and I got it and I was like, oh, this is like really cool. And I was immediately I was like, oh my gosh, I did not sleep like that. That was like the first thing that I figured out. And then I was like, oh, man, some of these metrics are cool. Like both from a recovery score, which is kind of proprietary blending in a lot of the things that, you know, a lot of the physiology from a cardiovascular standpoint. The main one being heart rate variability, but also rest of heart rate. And then your sleep, including REM sleep and deep sleep. And so I was like, wow, this is, this is neat. And this was my, this is my, this is 2017, January or December 2017. I started wearing it. And you know, continue to med school. And then when I went to residency, I was like, I didn't know it was possible to sleep less than I was, but I guess that's going on. And I got to the point where I was like halfway through is like February. Do you have any children to start? Do you have no children? That could change as well. I'm already like bottomed out. Yeah. Oh, trust me. Sorry. What do my friends tell you that she's like, you'll be great when you have kids because you're already so used to not sleeping like at all. I go, okay, we'll see. Maybe it'll be less than this. And then I'll be in trouble. But, but yeah, so we, I was doing across the competition in Miami called Wadapalooza. And I was home training for it, like the week before. And I was trying to get like really granular with the data and really trying to optimize all my recovery and training. I was like, let me pull some of my data through residency, just to, you know, just to kind of look at stuff, explore some end points. And it's like, does, you know, do I sleep more on certain rotations or sleep less or, you know, house my heart rate variability. And how does that change from rotation rotation and whatnot and just kind of figure out what's going on. And I had a graph that I think is actually published on some of the whoopsites. And it basically like looked at 18 months of data. I ran some regressions to figure out like where there was correlations and whatnot. And my sleep was gun brutal. Like there was a month that I slept an average of four hours and 40 minutes for 30 days. So that was kind of bad. And I was like, wow, this is this really correlates with, you know, the rotation. You're in the mic you, you're like not sleeping at all. You're doing nights, you know, sometimes you're worse than, or you're like on consults and clinic and, you know, outpatient. Like you guys and you're like sleeping like, I mean, for me, it was like still six hours. But that was, that was like a lot for me at the time. And I was like, wow, my wellness is so good. My heart rate variability is great. Like my training is going well. And then I would like hit the ICU and it would be like, so my, my thought was like, you know, I'm kind of training constantly throughout. But it seems like these changes in the metrics, particularly heart rate variability were very contingent on like the type of rotations. And even when I controlled for the amount of duty hours, there was still differences. And so I kind of attributed that to the stress on the certain rotations. You know, you can work a hundred hours in the clinic versus like a hundred hours in the ICU. Maybe a hundred is not a good number to pick. Like a full work week in the clinic versus a full work week in the ICU, even for the same amount of hours, like you generally a little bit more stressed in the ICU. And so my thought was like, can we capture this objectively? And because I had like my week data is kind of like a starting point. Did some power calculations figured out like what it would take to measure a significant change from baseline and heart rate variability. That and set up a clinical trial to do this in in residence. And we had almost 40 people where for 12 months really saw really saw some interesting stuff kind of working on still analyzing the final data. But I think that's that's when when when Darsch comes in. We included the inclusion criteria was internal medicine residents only because we're really interested in the schedules. And I was like, sorry man, like I can't have you in this set. But like let's see if we can focus on board to collect some data. And then we got them on board. And I think that that was I still remember. Oh man, we're we're like the same. Oh wow. Look at that. So the likelihood that we're in the same one's pretty low. But yeah, I still remember we're in that I am zero patients. And I was like, yeah, let's like we got this going and you're interested like let's do it. And rest is I guess history, right? Absolutely. Let me let me ask real quick. You know, when when you thought about using boob and tracking your own progress, what did you think about HRB? Like how good of a marker did you think it was to really and truly look at your own fitness and health? Another another phenomenal question. And I think that in order to answer that properly, I'll take a step back and kind of explain what HRB is and how I think about it. So what HRB is is heart rate variability. Which if you think about it, it's your heart rate. Okay. So you're our intervals. If you're looking at it on an EKG or like a halter monitor or something and then it's variability. So, you know, people's heart rate changes over time. And when that change occurs, you can essentially measure the difference in that our interval. And you can look at it in many different ways. If you look at standard deviation, you can look at like root mean square differences. You can actually go way like there's a ton of literature. There's a ton of different ways. Look at low frequency high frequency. Look at the ratio. Essentially what it is in a nutshell though is it's the like the beat to beat variation in your RR intervals. And so that heart rate variability is essentially how your heart rate is changing to an external stimuli or internal. You're kind of your parasympathetic and sympathetic nervous system. Which is obviously under regulation of hormonal changes, stress, motions. But also like external stimuli, like if the tiger walked into the room right now, like probably my heart rate would jump up and I would run and we'd end this Zoom call. And you have activation of the sympathetic nervous system. So your heart is going to, your body is going to tell you to increase your heart rate, you know, a flight or flight response. And the rate that that heart rate changes how responsive it is to that external stimuli is essentially what heart rate variability is captured. So if you are well rested and well recovered and things like that in your heart rate is saying that it's like, you know, your resting heart rate is 50 or 60 beats per minute. And like boom, it'll jump up very quickly. Versus if you know you just came off of a 24 hour shift, which I did yesterday, and you're just kind of tired or whatever, you know, you're really stressed out. But your heart rate response is going to lag and so your variability is going to be lower because it's basically going to be similar, you know, variation in terms of like how many milliseconds are between your heart beats. And so that what that heart variability is is like a balance of your autonomic tone, your parasympathetic versus your sympathetic nervous system. And what that read out essentially means is like how recovered you are or how ready you are to take on additional strain. And I think that strain can be both a physical stress, you know, training in the gym or, you know, obviously going on a run or whatever, or mental and emotional stress. So you go in and we all have stressful lives and, you know, regardless of your medicine or not, you know, things are super stressful, like look at COVID, everybody's been under under the gun there. And so, you know, you're kind of looking at your heart rate variability is like something that you want to optimize over time, both on it from in the cute setting like day to day, but also long term trends. And so you can look at the cute setting heart rate variability is like, okay, it's what I did the day before the couple days before sensitive to like thing, you know, eat a late meal, you're going to have much more parasympathetic stimulation overnight. Versus like, you know, you're just really doing well with like eating clean, doing a lot of training, your heart rate variability will generally be high. But there's a lot of things that can change it, you know, you over train a bunch, like it'll eventually be lower, but the overall trajectory over time is going to be higher. So what I'm getting at is you can actually use that as a marker of overall improvements in fitness, and if you look at it, I actually recently wrote about this and used some my own data as an example. You could look at HIV trends on a month basis of averages and see if you're basically like improving your fitness, you're staying the same or if you're kind of like slacking a little bit. And, you know, you're like, oh, maybe I should allocate more time to diet and exercise, you know, if you're interested, or you can just be like, I'm good. I'm glad I have the data and I know what I'm doing, but you know, right now I'm really busy or I'm tied up with work and I can't make, I can't allocate any more time. So it really allows you to guide your lifestyle decisions, guide your, you know, kind of productivity from a from a work standpoint. And it kind of gives you that read out of like, this is what I've done and this is what I can do with it. And so I think that it's an extremely powerful metric and it's why it's the largest contributor to the recovery score that we've used is. So Alex, you talked about this, the difference between the art to our interval, there might be some people who listening who are not familiar with what that terminology means. Do you mind to say that? So basically, I think a lot of folks have seen, you know, a tracing that can EKG tracing and you kind of have like the. So what that is is a QRS complex that's a ventricular contraction. It's usually proceeded by a P wave, which is the atrial contraction, but the art art interval is essentially like the peak to peak of those beats. So it's a marker of your heart rate. It's just a positive deflection towards towards the EKG lead. So that's that's what the R interval is. And then as that changes over time, almost like an accordion, that'll be like how you measure your heart rate variability. Yeah, and you know, this I found this discussion to be sometimes a bit challenging and maybe this because I don't understand this as well as someone like you might. And but the way that that I kind of tried to explain to people, what you just did was spectacular, but at the same time, you know, what you're talking about is that variability in order for it to be high. So we said that the art art interval is measured in milliseconds, that correct. Right. So so somebody who has high variability, it might be so, okay, so everybody, like you said, is familiar with how many how many times your heart beats per minute. Right. So it could be 60 seconds. If you're highly trained, it could be in the 30s or whatever it might be. And so people are familiar with that concept. But for HRV, it might be like 0.9. And the next one might be 1.2 and then 1.3 and then 0.8 again. And so that's a high variability right now. It's a bit kind of intuitive because you would you would think that hey, I wanted to be consistent throughout, right. But the way that I try to explain it, well, if your heart's capable of doing that and going up and down, then kind of going back to that tiger or saber tooth example that it's much more adaptable. Is that a fair assessment? That's exactly right. It's the ability to respond to that change. Because if if if not, then you're then you're you're basically your heart rate variability is going to be very low, you know, it's just going to be stagnant no matter what happens, you know, it's going to be the same or low variation or the same interval. Gotcha. Now, so we've talked about it quite a bit, right. That's the one that both you guys are using. So something that I often see then and maybe you guys can tell me is people talk about their strain score a lot. Now where does that fit in if somebody could explain what that is to me. Well, strain is a it's a proprietary metric that that would use as other people or other companies in more familiar with you're trying to guide or you're trying to describe how active you are essentially. And while I'll get to strain in a second, but you know, fit bit, for example, uses step counters or there's a lot of step counters out there for in terms of activity monitors. And so, you know, I think that over the years, a lot of people will talk about all get reaching 10,000 steps or whatever. I guess the question is like, is that really like a useful metric is just like going for a walk for 10,000 steps like useful. I mean, some of us walking around the hospital, I probably hit 10,000 steps. I don't feel like I'm necessarily like improving my exercise tolerance because of that. I'm just at work. Sure, it's better than being sedentary, but like, are you really going to improve your performance? Probably not. So what strain does is it is it. It analyzes your personal data and it looks at your heart rate changes over time and it says, okay, how high is your heart rate been compared to your personal baseline of your resting heart rate. And then that's basically like how much strain is is been put on under heart. And so the way that the the metric essentially works is that if you plot heart rate against time and then you take the integral of that. So the area under the curve that and that that is the measure that goes into strain. And then what wolf does is they they plotted on a on a one to 21 scale. But it's actually on a logarithmic scale. So it's easier to go from zero to four than it is to four to eight than it is to eight to 12, et cetera, et cetera. You know, like I've done extensive workouts and, you know, you can really basically can't even hit 21 like 20.7 is the highest that I've gotten. And I've hit that twice when I've ran a marathon. So, you know, earlier you mentioned how different variables, particularly the autonomic services autonomic nervous system, excuse me, can, you know, manipulations or, you know, aberrations in that can really affect your recovery score, right. And your HRV particularly. I think largely what we're talking about is we know that stress like physiological stress, pathological stress is going to affect the nervous system. So that's why, like, if you are, you know, if you are in a in a fight with your spouse or if you worked an ICU shift or you just finished a code, you know, you lost a patient, you lost the loved one, your body's going to have a similar responses. When it comes to training though, right. So for adaptation, we also have a mechanical strength, we have metabolic stress as well. Does, do those, the latter ones that I mentioned in terms of things that are required for adaptation positively for training right for performance specifically is what you touched on. Do those tend to affect HRV as well or is it particularly looking at the autonomic nervous system and, you know, aberrations. That's a great point. You definitely will see your HRV being affected by your training habits. And so, you know, you kind of like, you can basically look at it like on a person to person basis. It's one of the strengths of whoop and essentially balance your, your strain to recover it to figure out what, what your optimal training should be. But it's not a perfect world. So sometimes you're going to be low recovered, but you're planning on hitting the gym hard. That's not the end of the world. But eventually, like, over time, if you're really overreaching and by overreaching, I mean your, your strain is far, like, greater than, than relatively, like where your recovery is, your, your heart rate variability is going to kind of kind of tank because of that, like in the subsequent days. And it's just basically your body saying, like, I need help. I need to run away. But, you know, hitting that, you know, like day in, day out is, and watching your heart rate variability change based off that is how certain people guide their, like, their rest days or, like, active recovery or, you know, maybe I won't hit a double session that day. Or, or on the flip side, like, you're really recovered, you have a high HRV, you're like, okay, today's the day I'm going to go for, you know, like a PR on some left or some benchmark workout or hit a two a day or anything like that. But it is very responsive to your training habits. And it's, it's hard because obviously at the same time you're under stress and things like that. So you got to weigh all of that and to really figure out what's causing that, you know, is that because you're stressed at work? Or did you hit the workout, like, really hard? And so you can actually answer that question a little bit using the loop journal. And so that kind of takes into account some of your lifestyle habits, like, you know, and it's customizable based off of, like, I think there's like 111 different variables that you can say, like, yes, no, too. You know, working late, eating late meal, did a hydrate today. Did I stretch? Did I use blue light classes? Did I use the sleep mask? And you can essentially run an unpaired tea test based off of your own work data to say, okay, when I say I did, like, a cold tub for recovery. You know, in the last 90 days, based off of my recovery, how did my HRV change with everything else being a constant? And so you can actually ask that. And so, you know, certain, some of the other variables that I'll read out is days that I was over X amount of strain, like a high strain day. You can use that as an independent variable. And so you can start to tease out, like, is this my training that's that's taking my recovery? Or is it like stress at work? Or, like, some of your lifestyle changes or modification that you make? Like, oh, is this helping or is this hurting? Like alcohol? If anybody's ever used whoop, they'll be able to know that alcohol is going to just drop your recovery, drop your HRV to, like, lowest levels you'll ever see. And then staying away from that, you'll be like, wow, these numbers are really good. And it, and it's real because alcohol is this precedent. And it's basically just going to drop that that variability factor. Yeah, to your point, man, it's, it's why I'm wearing the blue blockers right now with the whoop journal. I mean, it's the, it's the number one thing. It's increased my HRV by, like, 10% to 20%. So it's made the biggest difference in terms of recovery. But Alex, I wanted to ask you. So HRV, we know there's some genetic component to it, right? I mean, there's some individual basis. But then there's also some component of fitness. Now, I guess I'm asking this selfishly because I'm probably in that bottom, like, 20, maybe even 10%, I don't even know. But like 100% recovery for me on the whoop is probably an HRV of like 50. You know, and I mean, I'm pretty fit, you know, and I mean, I can run a mile under seven minutes. I can run 100, I could sprint 100 meters less than 12. I can lift pretty decent weight. So like, you know, for me at 50, is that worrying or is that something that's just genetics? And then my follow-up question to that would be, do you know base off the wearables like Aura ring versus whoop with the HRV stayed the same throughout that? So great question. Two parts of that. So your first part of the question is essentially, is my HRV of 50 mean like, is that bad? And the answer is no. All of your recovery scores are going to be calculated off of your personal baseline. So it'll be your change from baseline. It's why like for you, 50 might be very higher recovery versus for someone with a baseline of 150 is going to be low. And that does vary on a person person basis. So you can't compare my HRV to your HRV. It's apples to oranges comparison. What you can compare a little bit better between person to person is resting heart rate. And so that's something that you can kind of you can kind of look at and compare almost like level of fitness to some extent a little bit better. But your HRV is going to be a personalized metric. HRV will decrease over time just with aging. But then you can also increase HRV with improvements in fitness and exercise tolerance. So you know, there's kind of a lot of factors that are going to go into that and you kind of got to figure out where you are on the curb. It's decreasing because you haven't hit the gym in six months or you know, aging happens at the same rate for all of us. So everybody's going to have a slow decline. But you know, if I look at my HRV from 2017 versus now, like what I expected to go down maybe, but that would only be if I said that my training has been constant throughout. But if I think that I've been getting in better shape, which I think that I have, that I would expect my HRV to be increasing from a training perspective, but maybe decreasing a little bit like weighing a little bit down from from just getting older. Now, the, the, the second part of your question is, how does that compare to oral ring and things like that other metrics of HRV? In short, I don't really know. It would, I think that they've done stuff looking at both of those in comparison. I'm just not someone that would wear a ring really. So it's never been appealing to me. But I know that that stuff has been done and also versus Garmin. Actually, one of my friends, who's a bioinformatics PhD down at Duke, she wrote a paper on basically heart rate variability and how well it's measured amongst different devices, both that are consumer grade and research grade. Pretty, pretty interesting results. The research grade is better at measuring at rest, the consumer grades are a little bit better at measuring it with exercise, kind of as you'd expect. In terms of HRV and what read out you get, I might butcher this, but I think that loop uses the root mean square 50. And I think that some of the other ones may use different HRV metrics. Because HRV could mean 10 different things. And this is like an electrophysiologic standpoint. It's like how you run the statistics. So there's probably going to be differences, but they should be internally consistent. Because if you say you had aura and you had a loop, you know, you should kind of see the same trends along both regardless of what type of HRV they're measuring. Now, one of the reasons I like whoop and I can't comment on when or bring how they run their measurements, but whoop will essentially standardize your HRV to the last five minutes of your last cycle of slow wave sleep overnight. Because you look at the data that time in slow wave sleeper or deep sleep, which is a form of restorative sleep along with REM sleep. And that time in deep sleep overnight, you are having the least amount of intrinsic stimuli like fluxes in your sympathetic or parasympathetic nervous system. And so it's just going to give you the cleanest read out of a standardized metric that you can compare to yourself from this night to the next night to the next night. I believe that aura probably does a similar calculation, but I just don't know the specifics of what when they do it. So you strike me obviously as a very analytical person who has an appetite for paying attention to these details, right, clearly with your PhD background and basically everything we've been ordering up for the last almost an hour. I mentioned that in 2017 when when first exposed to whoop, but you've been training for a lot longer than that, what metrics were using prior to this for recovery and how were you allowing those to guide your recovery. So my background going back to like high school and growing up was I played hockey and soccer, hockey being the main sport. I actually played hockey growing up with Robert Kowski and we went to high school together and he's one day older than me. So that's kind of a caveat there, but I didn't really pay attention to anything from a training perspective, like I was just going base off of feel. And so really you're just kind of like you're just kind of live and live in on the edge and and and find by the senior pants for, you know, to drop some cliches. But yeah, no, I really wasn't using anything. So I really was not, you know, like you said, I think that I'm a little bit of an analytical person, but I basically was it was just going by random chance of like, oh yeah, I'll work up today. Just really going off of my schedule, I guess, which is not like, you know, a way to optimize things sure might be like from a time management standpoint, but like, you know, you're trying to get more granular. And I figured out like, how can I unlock human performance better? Yeah, no, I love that. So now having a deeper understanding of it, though you probably come across maybe a lot of patients, right, who are interested in in performance. And maybe they're not necessarily interested in getting all the data and everything. And also there's there's a price tag to does something like this, right. Do you advise them to look at some of the basics in terms of metrics, right, is it resting heart rate, first thing in the morning, is it throughout their, you know, throughout their workout, that kind of stuff. What do you, what do you suggest? I think it's from a patient perspective, like for the people that I'm dealing with, I would say that I'm just happy if people are exercising in general. And I think that if having a wearable that gives you some biometric feedback is going to be helpful for that person, then I would recommend it. I'm not sure, you know, how deep I would go, like with like looking at particular data, but I think that, you know, if you wanted to look at one easy one resting heart rate is just I think the easiest to understand and track, because there's not going to be as much fluctuation on a day-to-day basis. But from a different patient population, I think more from the folks that you guys work with and I've worked with a lot of people, you know, kind of in coaching and crossfit that that use loop or use other wearables. I think that you can get a little bit more kind of in the weeds with the specifics of the data with them and I try to kind of teach them how I think about it and how I look at recovery and based off of HRV and sleep and things like that. You know, you're obviously trying to optimize all of them, but the question is like how and so for some people it's that their sleep habits are poor and maybe it's just the time and bad or maybe it's because they watch TV or maybe it's like the blue light blocking or maybe it's, you know, like other techniques that may help like using a sleep blanket or using dark night shaped curtains because they work nights. And so it really depends on the person, but I think if you have that conversation, you're like what's the what's the problem or you know, you have trouble sleeping, are you stressed at work? Do you not have enough time for things like what kind of workouts do you like? It really comes down to like what are your goals? Some people are trying to lift a lot. Some people are going for high endurance, like capacity, other people are doing crossfit and they're kind of in the middle of that. So, you know, I think that the beauty of these wearables is that you can tailor it from person to person and it's the same for that pro athlete, you know, it's the same data that they're collecting, but maybe they're using it a little bit different. And that's going to be the same for someone that just wants to sleep a little bit better and have that that feedback. And so I think that it's it's awesome to be able to, you know, such a wide diversity of people can can use the same device just in slightly different ways. Yeah, man, let's go, let's go into the applications now, right into medicine. I mean, you have a creative mind, you kind of thought about, well, let me start by saying this, I think a lot of the research in medicine. We tend to think of what can we do internally, right? Like what can we use within the hospital? Rarely do we think about how do we bring out the technologies from outside just healthcare and bring them in to see how can we collaborate and change healthcare altogether. Right. So talking about currently in the present moment, as well as the future, what are you starting to see wearables and their role in terms of different studies that are starting to come out. So I think there's a lot of interesting stuff with wearables. You can use it and I think about it in terms of buckets. So you have the kind of preventative measures. And whether that's like lifestyle prevention or exercise or whatnot or whether it's early detection of diseases, both from a diagnostic standpoint or prognostic standpoint or a screenings standpoint, particularly for screening, there was the Apple Apple study with with a fib and then Fitbit did one one recently. And so in really like the data was not very strong there. They they noted they were able to detect more arrhythmias, but it really didn't make a difference in clinical outcomes. So the question bears of how important is it to, you know, measure these maybe non clinically significant changes. And I think that that actually opens a larger conversation of like over screening and utilization of healthcare and whatnot, but also like sometimes that outcomes someone could detect a fit for a minute on their Apple watch, now they're out of blood dinner and then they come in with a GI bleed, you know, did that person need to be on that when they were perfectly fine at home before. Anyways, so then you can kind of use it as a, you know, a prognostic tool. So that that kind of gets into more of what I was speaking about with the S3 heart sounds and things like that. There's these multi parameter studies or devices that are usually implantable. One of them is heart logic with Boston scientific basically gives you like a score for a heart logic score for how likely you are to be hospitalized and things like that that can guide therapy with diuretics and guidelines directed medical therapies and outpatient and whatnot. And then there's kind of the, you know, the general consumer side of it where maybe you're not looking particularly at clinical outcomes. But I think that there was like a British medical journal article recently with. That actually correlated step count with mortality or something like that, which I was, which was pretty interesting. And so all of that, you know, that conglomerate of wearables, I think is, you know, it's one part of the digital health revolution. But I think it's a pretty large part. And in part because people can see themselves wearing it, you know, like it looks, I think it looks cool, but like the, you know, the apps and stuff like that. We're already on our phones all the time. Like why not allocate a little bit more time to improving your health and improving your wellness and really just improving your lifestyle in general. Yeah, well, the whoop commercial with the pat was pretty awesome. And there was, it was pretty, pretty cool that they did that. So, but it's funny. It's funny. You mentioned, you know, like just look at patients. I think about this all the time ever since wearing whoop last year in the PM in our setting. Right. I mean, we have patients who are very stable who do physical therapy, occupational therapy every single day. Right. And I'll see both sides of spectrum where it's like, oh, I didn't really get to do much. I could have done more or you see very motivated patients, right. That really want to get back to walking and things. You'll see the opposite side of the spectrum. They're like, I can't do physical therapy today. I'm not feeling well or the next day, I'm too sore and I would just love right to see them have a whoop. Unfortunately, I mean, I guess what takes three to four days to get a baseline and sometimes our patients are out by then. But I mean, you know, even two weeks to a month and just kind of see and like, man, like, are you are you actually good to do PT today, right. I just I just think that would be a cool thought experiment, at least. Yeah, or or guide like the amount of, you know, you know, you know, we always talk, oh, they can they go to a cute rehab all can this person like tolerance. We have a judgment call you're like, yes or no, but like, what is that really rude off of like spend like 15 minutes with the patient. So if you had like days and weeks or the data during an inpatient stay and you can monitor their progression and then you can see how that improves or, you know, gets worse with with rehab. I think that that's great for any injury rehabbing, but also cardiac rehab. It's like that obviously. You've asked your system. Right. I feel like that that would be like a phenomenal, you know, thing to look at with how you can guide therapies, you know, whether it's rehab or, you know, meds and whatnot. Because like all of these things are tied into your physiology. Yeah. Josh, to your point, I will jump in and say, so that would be challenging. I mean, it would be certainly cool to see. I think from a clinical perspective, the subjective portion in those settings, I think outweighs the objective data, right? And when somebody's in the acute inpatient rehab setting. And like, okay, so historically going back and I think folks in the performance sector, like if you have a good coach or if you even have a personal trainer or something like that. And a lot of what they'll do is if you go to them and they'll ask, hey, how are we feeling today? Are you ready to crush it? Or are we not, right? So it's your readiness score subjectively on a scale of zero. I don't feel like being here at all. I can't believe I got a bed to 10. I'm ready to just load up this and go for a PR like Alex was talking about, right? That's your subjective readiness score. So I think when it comes to the inpatient rehab aspect and the clinical aspect, I mean, that means a lot. And I think in an in an era where we didn't have any of these devices, like Alex was talking about, like just the, I think this has been validated actually just getting a resting heart rate, right? But also again, willingness to really get after it for in the elite athletes, particularly is a good bark overall for kind of recovery essentially. Right, I agree. And I think that having that data, especially for those performance athletes, you know, it just kind of gives it's it's not, you know, you can't just look at one number. You know, you've taken that ensemble. There's days when my recovery is high, but I feel shit. I mean, that's just life. But I think the overall correlation is pretty good. Awesome, Alex. I kind of want to tie this all back together, man, with the inception of whoop and that that study that you kind of brought to life in terms of wellness. Take us through some of the preliminary data. I know not all of it's kind of red, but if you are able to tell us what you're finding. Yeah, so it's it's really interesting. So the initial pass through through some of it. You know, we're kind of looking at how much people are sleeping and whatnot. And there definitely seems to be like major fluctuations based off of which rotation you're on, which I think is what we expected. But it's really cool to see that data across, you know, 30 plus participants. And then the same thing with HRV and also resting heart rate and whatnot. I think what we'll end up seeing is that there's probably going to be like maybe not one variable that directly correlates with because what we did in the study was essentially compare whoop data to subjective assessments of wellness or not depression. And then in the setting of, you know, people are switching rotations and whatnot. So we look at all those outcomes. And I think that what you'll see is that well, one, not everybody's the same. So there might be people that are more or less resilient to some of these changes. We actually use the angelic doctors resilience. You need to have score as one of the baseline characteristics so we can actually answer that question. But, you know, so people are going to be different. But I think that the some of the general trends, I think, will be powered to say that OK, X, Y and Z does seem to correlate with for wellness or improved wellness or, you know, like more line depression scores or whatnot. So we've all felt it like from an acute standpoint, but also from a chronic standpoint. And, you know, I, you know, I feel like it's not really talked about a lot, but I think there's a lot of people in medical training that get down to the doldrums that are, you know, they would score high in a pH unite. You know, they probably are depressed. And, and I think we don't really do a good job of figuring out like what to do with that, you know, we get thrown, we get wellness modules thrown at us. And it's like you need to do this now all caps, like otherwise, like what was holding your next paycheck or well, here's like a. I mean, like that'll, that'll, that'll make your 80 hour a week for the last three years, like, you know, go ahead and they give you like a water bottle for like, you know, it's, it's, it's resident, it's resident appreciation on Friday. So I get some candy bars. There you go. Yeah, I mean, I mean, it's tough because because wellness is such a subjective thing and my wellness might be different than someone else's wellness. Someone else just may want to go home and read a book or go and walk with their family, whereas I might want extra time to go to the gym. And, and you know, you're so busy during residency, you're working a lot of hours and I don't think that that's really something that we can change based just off of the structure of the system. Got a whole nother question about medical training that I don't really want to like tackle right now, but in the department that we have, I do think that there are things that we can, we can do better. One of those is potentially looking at some of these metrics and figuring out like what where we're bad at it, you know, and then, okay, well, maybe like we know the ICU is bad. Maybe we can figure out like a better rotation structure to make that a little bit, you know, so to improve that or, you know, like scheduling people. So they're not doing like ICU and then like floors, floors, floors, floors, floors. People just get burned out from that, you know, you got to, I mean, the six plus two or eight plus two, four plus two models work really well with that. But maybe there, maybe there are better ways, better ways to structure that, like, you know, not give you three hard rotations in a row. Kind of almost do like a point system like three to one and, you know, you don't want any block to be greater than a certain number and whatnot, kind of like have all this calculated out and whatnot for some of our study parameters. But I think that that would be really neat. And I think that program directors, I think, hopefully once we publish results, I think that I hope that they give it a serious look as a tool to actually improve wellness beyond, you know, modules and pizza parties. So, you know, I'm trying to dig into the why a little bit more was your hope when you started this project to say, hey, like where can we, because in order to get buy in right at an institutional level, you need to pit something where you can make actionable change, right. And so was the hope that, hey, if we can figure out how people are responding or quote unquote wellness, maybe we can formulate the rotation structure a bit better to opt for lack of a better word, optimize wellness. Is that is that kind of what the purpose was? Yeah. Yeah. So it was the lead on everything based off of my data. The person that that bought in and kind of supported it was one of our program directors, Andrew Tinsley, he's in GI also was on board with loop. He's a big golfer and, you know, it's actually is pretty big in the golf community. So he had heard about it. We were sitting in the ICU one day on a weekend. And I was like, hey, I looked at all my preland data. I think that there's really something here to do. It was about to like scope someone was like a massive GI bleed and we're talking about it. And, you know, we were like, yeah, like, why don't I, I'm just going to submit the IRB will figure this out. I think that it's certainly worth a shot and seeing, you know, we can get funding and whatnot. And from the statistical standpoint, one of the reasons why I was actually confident that we can ask these questions and, and, and like do the, you know, properly powered study and whatnot was, I was basically practicing analyzing my data with with the whole morph thing, which I know you mentioned. At the beginning, Darshan, we didn't really get into it. All of that really played a role like my initial like passed my data in half with the residency scene. I don't sleep a lot seeing that there's correlations. And then, you know, kind of going through and figuring out logistically, how do I make this happen? I wrote a bunch of grants and got funding for a project and then got bind from, from the department and from the program. And then, you know, just ran it by the institutional IRB and the rest of the rest was history. That's exactly what it was. We kind of had a bunch of different ideas and I kind of mentioned some of the scheduling changes or, you know, like even something like does the ICU rotation need to be a month long. I think that once you hit three and four, you know, you're kind of like beat up. And I feel like that could easily be swapped into two two week rotations, like we do the rest of ours. I mean, this is more specific for us at Hershey. And so we kind of had all these ideas. And, you know, I feel like when we talked to the program, you know, they bought in because, you know, having objective data to ask and answer these questions was something that they were interested in. And, you know, I'm glad that they did because I feel like now we have a very large data set to hopefully make improvements off of. Awesome. Well, dude, this has been absolutely incredible. I am having a difficult time processing the fact that you just came off a 24 hour shift. I thought this afternoon. So like, I mean, I, okay, fair enough. You got a little bit more recovery in your system before you jumped on here, man. I can't thank you enough. This has been so, so amazing and highly informative for myself. Before we let you go, I do want to know, man, and you got this inquisitive mind, right? You're extremely knowledgeable. What's next for you, man? And whether it's in clinical aspect, whether it's, you know, it doesn't have to be medicine, your own personal life, fitness related. What's coming up for you? What are you excited about? Oh, excited about a lot. I'm excited about, you know, continuing on in fellowship, you know, kind of like passing the halfway point here in first year, which is a little bit busier. So eventually, it'll kind of lighten up. We can focus a little bit more on, you know, the extracurriculars, whether that be research or gym or whatever. My eventual training and career path, I hope to go into advanced heart failure and transplant. So that would be another year fellowship after three years of general cardiology fellowship and then, you know, stay in academics and be faculty somewhere. And really, the rest of it is just continued training, kind of pushing the envelope, seeing what I can do in the gym, whether it's like lifting or, you know, benchmark workouts or the CrossFit Open is around the corner. So last year was in the quarter finals, so we'll see how that goes. And yeah, I mean, I guess it's just like a lot of exciting stuff. It's really, it's really pleasure to work with like really bright minds. You know, your guys' insights on some of these and the questions that you ask are really important questions in terms of like, how can you help patients, how can we help ourselves? You know, and really because you need to take care of yourself in order to help others, you know, it's kind of like that, like, you need to put your mask on on the plane before putting it on self-analysis. Yeah. Well, hey, Alex, man, I also want to say thank you, man. It's been a pleasure getting to know you. Glad you could come on here. So truly appreciate that. You didn't get to delve too much in the Merf, but we're going to link that article in the show notes that you have, man. Because dude, if I did something like that, I probably would have torn like all the muscles of my body, maybe my 10, that's just absolutely insane that you were able to do that. That's all right. You know, I got you. I fixed you up. Yeah. That's right. That's how we got all of it. Honestly, that was a huge thing because I was basically doing Merf and I was like, I came here with rotation, I was on. But I was sitting there and I would just, because the gym was closed and this was COVID. Yeah. Well, I would literally do Merf and then I would go and I would sit and analyze the data and then I would write these wound grants and I was designing this study. So like, it was, it was pivotal. And honestly, what I was doing, it was like an hour a day, the whole time I was doing it alone. So the whole time, I remember just running and being like, oh, man, what are, what are, what are the rest? Like, do we have for this? So like, it's actually like pretty instrumental. And why ended up doing this? Because it was just me and my boss. And I was just like, man, this is like, this can be big. I hope that like, you know, we can do it. And, you know, we did it. So it's solid. Yeah. That's, that's awesome, man. Big it was. And, you know, also in the show notes, I'll put all your social. So people know where to find you. I know you're big on Twitter as well with, with academic stuff. So two last questions for you. I don't think any conversation is fully over unless you asked Dr. Alice Hadshek about the bills. So, you know, almost, almost made it this year. But what are your hopes next year for Josh Allen and the crew, man? That's a great question. What are you thinking? Well, so they opened up as a plus 750 to win the Super Bowl next year. And I believe that they were tied with the Chiefs for that. So they're kind of like cold favorites with the Chiefs. So I would say statistically speaking, according to Las Vegas, they're up there. Obviously, like, I walk into every year saying that they're going to win the Super Bowl. But we have to get that to that point. But I do believe they're truly knocking on the door. You know, 100%. Here's a being of bills fan and a Sabers fan. I mean, we had a 17 year drought of no playoffs for the bills. And the Sabers are still in the Doldrums. But the bills are basically talking about improvement of wellness. Like the whole city of Buffalo is heavier when. And honestly, Allen is no one, you can't argue. Like he's obviously the real deal. And he's like a great guy. Like they raised a ton of money for like Buffalo Children's Hospital and stuff like that. And so like happy to have him as the as the figurehead of the team. I mean, I got to stay optimistic and say that that 2023 is our year. But that's why they play the games. I will hopefully be celebrating a Super Bowl at some point in my life. Oh, yeah. No, I think I think they'll most definitely happen with the bills, man. I think Casey's on the way down. I don't think Joe Barrow makes another Super Bowl hot take right there. So I really do think it's it's a bills bills to get there. Last question for you that we ask all our guests is how do we put the health back in health care? Oh, man. This could have been like another power on the podcast. Yeah. Honestly, I feel like we've kind of been talking about this premise indirectly the whole time without answering that question. You know, I think that really it's it's patient first. And that that's that's the key to everything. And I think that everything else revolves around that. And when you when you put aside all the you know the BS that we deal with, you know, all of the administrative tasks, all of the scheduling difficulties or getting off for weddings and all these things that express us out. And you kind of like realize like why you're there in the first place. You know, when you're a little kid and you decided you want to be a doctor, maybe that path was different. And you know, you figured it out somewhere along the way. I think, you know, really leaning into that reason for taking care of people. It's one of the most humbling experience to, you know, fix someone. You know, I'm sure you guys experienced plenty of that. And it honestly is like like a tearjerker. You're sometimes like, I can't believe that my job or, you know, my life is devoted to, you know, being able to help these people. It's such an honor. And, you know, you go through a lot of training. And it can be difficult at times, but it's all worth it in the end to see those smiles on those, those people's faces. And, you know, watching them walk out of the hospital and things like that or, you know, fixing them up in clinic and making a difference. That's how you put the health care. Like just bringing it down to the fundamentals. Always, always going back to those fundamentals of why we did this in the first place. Love it. Thanks Alex. Thanks guys. Well, the future is here, especially when we talk about wearables technology in healthcare. I mean, there is such a boom happening right now in terms of this integration between using technology and using it to a different metrics so that we can provide better healthcare to patients. Now, if you found this episode fascinating, you can definitely check out the show notes. Take a look at Alex's Twitter. He posts a lot about the data in the cardiology world, but also about his personal journey and how he's using Woop to optimize his fitness. And again, if you want to support the efforts with his ongoing battle in Ukraine, definitely check out the two links below where you can check out Dr. Hatchek's story, but also support the GoFundMe page that he has set up. And of course, if you've enjoyed this series, we had the last three episodes here have been about cardiology. Please let us know. You can send us an email at medretabinedatgmail.com and be sure to share this episode with anyone who you think could benefit from it. And be sure to subscribe as well so that you can stay on top of our episodes weekly. All right. And now, time for the medical disclaimer. Anything in this podcast is for educational purposes only. It does not constitute the practice of medicine, and we are not providing medical advice. No physician patient relationship is formed, and anything discussed in this podcast does not represent the views of our reports. We recommend that you seek the guidance of your personal physician regarding any specific health related issues. And we will see you next week with a lessons learned.