Editor’s Corner: Wellness 2.0

Alice Ma, MD
Professor of Medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill

We’re all talking and thinking about wellness.

You couldn’t miss the emphasis at the 2019 American Society of Hematology (ASH) Annual Meeting. There was the new ASH Wellness Studio, featuring microlearning sessions about various aspects of resiliency and wellness. Yoga @ The Park and treadmills and stationary bikes in the in the ASH Live: Remote Session Viewing area encouraged attendees to get their blood flowing. At ASH-a-Palooza, trainees were treated to three – count ’em, three! – separate “Blood Drops” mini talks about wellness (each repeated in case anyone missed it the first time). These talks were given by two experts in the field of wellness, Elaine Muchmore, MD, and Tait Shanafelt, MD, and me. With three days before my talk was due, I put together a PechaKucha-style presentation, heavily borrowing from Demotivator-themed images from despair.com (one of my favorite sites to browse when I have a few minutes to waste in between writing notes).

For attendees with children, perhaps better for wellness than any talk were the free child-care services provided at the meeting.

So, ASH and at least some health care systems have gotten the news: Wellness and efforts to fight burnout are in.

Unfortunately, increasing emphasis on work relative value units is also in. And electronic health record (EHR) foibles are perpetually in. Recently, I had a 1-hour WebEx conference with our EHR vendor about marking factor V Leiden and the prothrombin gene mutation results as “genomic indicators,” meaning they would be highlighted in the patient’s chart – just like the need for a flu shot. The EHR folks thought that these “genomic indicators” needed to be highlighted so that doctors would be instantly aware of them and “everyone would go on Xarelto or aspirin or something.” Sigh. I wanted to take a page from the National Rifle Association’s infamous tweet and tell the EHR people to stay in their lane, but that would just be the burnout talking.

Still, something good came out of this – potentially. I was able to get EHR and the laboratory team to agree to figure out how to ask clinicians who order factor V activity testing as part of a thrombophilia work-up if, in fact, they might want to order a factor V Leiden test instead. Damon Houghton, MD, MS, a former fellow at University of North Carolina and a current staff member at Mayo Clinic in Rochester, Minnesota, looked at this issue in a 2017 study.1 He found that, over a 6.5-month period, 159 factor V activity tests were ordered on 122 patients. Thirty percent of these patients had thrombosis, and, in nearly half of them, the factor V activity was not ordered appropriately. Moreover, half of the inappropriately ordered tests were misinterpreted to mean that a thrombophilia did not exist. Through our recent discussions, we might (fingers crossed) have been able to fix a systemic problem using the EHR. The temperature of the burnout flames just went down by 120 degrees.

Now that we’ve seen an example of wellness gone right, I want to address wellness gone wrong. (Warning: Ranting ahead).

You know who else has heard about wellness? Medical students. Medical school is stressful, but to quote a line from “The Princess Bride,” “You keep using that word. I do not think it means what you think it means.”

I just finished teaching the hematology block to a group of first-year medical students. A real comment I received on my teaching evaluation was: “We literally had to study every day, and I can speak for my fellow students when I say that this was detrimental to our wellness.” Really?

The block is 3 weeks long. I want to tell these students that, if studying for 3 weeks straight makes them unwell, there are plenty of opportunities to leave medicine and become yoga instructors before the unwellness gets too entrenched and their educational debt engulfs them (another common source of stress and burnout).

I am used to seeing our medical students using “wellness” as an excuse to not come to class, but now I’m seeing it used as an excuse to not show up for rounds on the wards. Through the grapevine, I have heard that students think it is acceptable to miss up to 12 weekdays during an 8-week rotation without penalty. Missing time to undergo surgery or for a family emergency is one thing. Missing time because you don’t want to work is another thing altogether.

I want to reference another video by physician and comedian Zubin Damania, MD (aka ZDoggMD). In his “Moral Injury, the Sequel” video, he calls on medical students to put in the work and the commitment to show that they have a calling before developing attitudes that make burnout a self-fulfilling prophecy. Their emphasis on their wellness is putting my wellness at stake – not to mention the wellness of their future patients.

Rant over.

Hope you all had a terrific ASH annual meeting, and best wishes for a happy (and well) New Year.

Reference

Houghton DE, Sud S, Moll S, Rollins-Raval MA. Perils in the thrombophilia workup: Frequency and circumstances of erroneously ordered factor V activity tests for thrombophilia. Vasc Med. 2017;22:527-8.