Amanda: Hey guys. Welcome back to the podcast. I'm Amanda.
Laura: I'm Laura.
Kendra: And I'm Kendra, and today I wanna take it away. We have a very special guest with us, Dr. Al’ai Alvarez, joining us from sunny California. I actually had the privilege of listening to Dr. Alvarez at ACOEP Spring Seminar about, that was a little over a month ago. We were in Phoenix, Arizona and he brought two amazing lectures to the lineup, the symposium. But they really stuck out because for us here at The Whole Physician, it's a lot of what we're passionate about. And I actually had the opportunity to go up after his lecture and say hi, and talk to him a little bit about his work. Because it's obviously kind of the North Star, what we all probably want at all of our shops and just the work that Stanford has done to really set, you know, put the needle in the place where we all can kind of shoot for. So, he is a board certified EM physician and clinical associate professor of emergency medicine at Stanford University. He is the director of wellbeing and co-chair of the Human Potential Team. I love that, at Stanford. Like I said, he gave two lectures-Beating the Blame and Well for What it's Worth. Both resonated with me and like I said, really aligned with the work we're doing here at The Whole Physician. And one of the things that was super impressive was he also is the director of the first physician wellness fellowship, which is awesome. And we'll get a little more into that. So welcome, Dr. Alvarez. We're so happy to have you today.
Al’ai: Yeah. And I'm really grateful to be here. And again, call me by my first name. Otherwise I'm gonna be calling you Dr. Kendra, Dr. Amanda, Dr. Laura.
Laura: Awesome. Welcome, Alai. Thank you so much for being here. Can you just tell our audience a little bit about you, your training, background? Just tell us about yourself.
Al’ai: Yeah. So, as you heard, I'm an emergency physician. My training is that I was actually a little over the place. I couldn't figure out what major to do because I wanted to be a doctor, but I didn't really know how to get there. Nobody in my family has gone through this. I'm the first in my family, so I immigrated from the Philippines. I'm the first in my family to go to college here. And so my mom was very nervous about sending me to college and how to finance that. She's a single mom and so I got into a state school in New York which is great. I trained at SUNY Buffalo. I also, I'm terrible with my grades in terms of standardized tests, so I barely pass, I guess, if there's a passing score for MCAT. Which I didn't know was like the thing to do to get into medical school. And so I retried-I barely increased my score. And like long story short, I got into SUNY Buffalo. I deferred a year, mostly because I was actually waitlisted because I only got like two interviews to get into medical school and as emergency physicians now in looking back, I think that was the EM in me of trying to figure out like the plan B, plan C, plan D. So I got a job in Chicago. I did Americorp in Chicago. And then before that I got a summer job at Stanford. Actually, I never thought I would move to California, but that was the first time I visited California. And from there the rest is history. I trained at Jacobi, a very busy county hospital in the Bronx. And shortly after I moved to the Bay Area, not for Stanford. I actually did not know I was gonna work for Stanford. I applied to a county hospital because that was my training and I, deep in my heart, I'm a very county person. And then I found out during the interview that it was affiliated with Stanford. They did that on purpose because they didn't want to attract people to go to the county hospital and then transition to Stanford. They really want people to move to the county hospital, work at the county hospital and stay there. So I don't know if that was the answer you're looking for, but like, I think that kind of gives you a sense of how vulnerable I'm willing to be to share about myself because I, this is me, and hopefully it can get as much as you can from that lived experience that I have.
Laura: I love that. Thank you so much for sharing all that. Can you tell us about how you got into physician wellness and a little bit about your role as the director of the first Physician Wellness fellowship?
Al’ai: Ooh, yeah. I may forget the last part, so please remind me because I think just a wellness role itself, it's a little bit of a journey for me. So when I moved to the county hospital, in my mind then I wanted to learn how to make things better, faster, more efficient. The triple aim just started so to make the workplace environment better cost effective care, efficiencies of practice. And so I told my chair during the interview that I was applying for administrative fellowship and he offered me the position. To be a faculty and, well, I guess it's not a faculty, it's an attending position. And if I want, I can skip the fellowship parts and within a year he will promise to give me enough apprenticeship to become a medical director. So, and he was true to that. He said, I have to prove myself to the group and if I can, he'll gimme a title. And so within a year they gave me a director and education role. And then shortly after that, I was the quality education director. So I became an assistant medical director. And what this really gets to your question about how I got to wellbeing space, is that I caused a lot of burnout in my role. Because I'm like a new grad, I just learned all these cool things in the county like fighting the fight and making things better, more efficient. And so I would send people emails like, “Hey, tell me about this case.” Right? Like a lot of, like, in my mind it was just like a direct Bronx way of talking to people.
But now looking back, I mean, there were hurtful things, right? Imagine you're part of a case that didn't go well, and then you get somebody with a title emailing you about it with no context initially, other than, “Hey, tell me more about this case.” Which is not unlike somebody coming up to me when I show up at the shift and asking me like, “Hey, do you remember that case that you saw yesterday?” And then, I would get palpitations, I'd freak out, like, what did I do? And so, I learned a lot of that on the fly. And also I realized that the county had a ceiling. There's a lot of politics there and it was very hard to navigate. And I thought that that was gonna be my life. And then I realized like, you know what? Like I find more joy teaching residents and medical students because then I can make an impact on how they can change the trajectory of their work. And even like the things that I'm trying to change in the system, right? If it's like their work, then it becomes their QI project and they get credit for it. And also, I realize residents and medical students have more voice sometimes than faculty in certain environments. And so I leveraged that. And then shortly later, I was offered to become an assistant program director. Again, and this is after working at the county hospital for at least four or five years, and during that time I've really grown. I love the clinical space. The patients were fantastic, right? I felt like I was making a difference and also like there are real struggles working in a corporate management group. Real struggles working with navigating, like how do you pursue your passions when you're really just getting paid by the hour? And I can imagine people now looking back, right? I don't have a lot of invisible work at home, right? I get to go home and I can actually just like, turn on the TV and watch Ted lasso. I don't have to cook for kids or family members. Like, I don't have that. And so, again, I'm speaking out of privilege here, that I'm able to do a lot more things. But then I realized that I don't know if I really wanted the future that I was heading towards. And so when I became APD, I focused my energy in medical education. I found the need to like teach my residents everything that I learned at the county because they don't get as much of that certain aspects of it, like in a, in a big academic place. And then I caused more burnout. Like I drove the residents nuts. Again, I'm putting myself in a situation where a resident here, they don't know me, they've probably just worked a shift with me, or this is the first time they're working with me. And in my mind I'm like, I'm overcoming a ton of imposter syndrome, right? A ton of, like, I did not graduate in an Ivy League. I don't have the pedigree to work at Stanford, but I know clinical space, like I have worked in really austere environments and I can show them all these cool procedures that I've learned to do and I'm very comfortable doing. And then I realized that that was overwhelming for them. Which actually translated into like really crappy evaluations. I would get hurtful, like non-helpful, non-useful feedback that is anonymous about like, he's not a good program residency leader, right? It has nothing to do. Like it doesn't tell me, oh, if you do this, like you're gonna get better and it's all anonymous. And so I would get that at the end of the year and I remember to this day, in fact I'm giving a keynote on this on Saturday about, I have had many patients die on me as just part of the course of their disease process. Right. And, and I'm okay with that because for emergency physicians, that's part of the job. Like I signed up for this versus getting those bad evaluations, hurtful evaluations, like for me, they actually hurt more and they stumble more. And then I would get paranoid. I would look around, it's like, did you write this? And, which made me less effective. And so, in turn, I actually was struggling and how to like, own my space in this environment.
And so then I reached out, I went to, and this is a very Stanford thing. There's a bunch of these like free seminars and conferences and whatever. So I showed up because I'm truly curious. I was very interested. And one of the speakers was Patty Defreese, which I love, I adore. She's one of my good friends now, but I did not know her then. And she is this, like a superstar here at Stanford. And I emailed her and I said, Hey, what happens when these are my strengths? And also I'm getting feedback and anonymous evaluations that I'm overwhelming, like these two things. Like how do I coexist? Like how do I have the duality of like, I have a lot of personality, I have a lot of energy as you can tell. And also that's overwhelming to people. And in a true Stanford way, which is in some ways, Kendra, like, what, what we've had here. Like, you reached out to me, I was like, sure, why don't we meet?
Right? And so that's what Patty did. She's like, do you wanna grab coffee? I don't drink coffee by the way. I'm like super hyper as it is. And so we grabbed tea and we figured out we were both activators. And that's actually the beginning of how my career in the wellbeing space started. In Dr. Christina Shenvi’s words, creative serendipity because we figure out we're both activators and we started giving lectures on gratitude because that sparks joy for me. And then shortly after they asked me to be the co-chair of the Physician Wellness Forum for Stanford WellMd. So, as you probably know, we have the first chief wellness officer that has ever existed in medicine. And we have, WellMd. And so now I get to run the Physician Wellness Forum which means like every month we get speakers that come in to talk about things like this. And like what sparks joy, what drives us nuts and how can we learn from each other? And then fast forward a couple of years later, and I was still an APD and we have actually a director of wellbeing. So this is not a new role for me, that was created for me. This is actually Dr. Corey Hoffenberg, who's an amazing human being who's done a lot of space in the wellbeing work at Stanford, especially in the emergency department. And I did not wanna step on her toes because again, I'm new to Stanford. I'm clearly getting bad evaluations. I'm struggling. And so I worked at the national level. I attended the wellness committee for, it was called resilience committee then, for CORD, Council of Residency Directors. And then I joined AAEM and then I joined SAEM. To now, I'm essentially like the chair for the wellness committee for both SAEM and AAEM, right? So that's how my work has been.
But when Dr. Hoffenberg left there was an opening for the Director of Wellbeing. And so I applied for the position and several other people applied and I actually did not think I was gonna get it. I was just more like I was interested in the role because it was certainly the things that I was doing already at the national level.
So when I was offered the position, I had to make a choice. And this was a rough thing for me because I just created this identity for me of being a medical educator from scratch, right? And then I was now being asked to let that go, to take on a new role. And I actually told my chair like, can I do both? And she flat out said, “no, you have to pick.” And so here I am, I'm in the Director of Wellbeing Space. And so part of that is the first ever EM Wellness Fellowship which was created, co-created by Dr. Corey Hoffenberg and Dr. Rebecca Smith Coggins. Rebecca is actually a colleague of mine and we were co-chair at the Physician Wellness Forum. So see, it's kinda like all connected. And so I guess the next transition to this is, and by the way before I forget, part of my role when I took this over, is to co-lead the Human Potential team which is an awesome team in our department. Our job is to really like understand, think, dissect, and break apart the dilemmas that we encounter in our practice. Not just clinical, but academic space. And not necessarily find solutions because there are dilemmas there's usually no solutions, but can we be creative enough to address parts of it that will at least make it easy for us to empower us to be better at our work and to find meaning in our work. So it is one of the best jobs that I've done that I'm doing because I am the front lines of the front lines. Like I get to be there, right? And so that transitions to my fellow, Dr. Amanda Deutch, who is an amazing human being. Also, she's graduating, very sad about this. Actually, she is going to be the inaugural director of Wellbeing at Thomas Jefferson Emergency Medicine. So they created a role for her because of the work that she's done. And most of her work really with me and part of the fellowship is to not just attend all the meetings that I go to, but really understand, like people usually associate wellbeing work with, I don't know, like happy hours and social events. And actually like when she was navigating different contracts and like traveling the country for positions, like we were very clear in our conversations. People will tell you you're gonna be leading this. Your job is not to be the social chair. There are so many other things that you can do to actually impact wellbeing rather than social events.
I support them, I attend some of them, right? But the reality is they're actually not that effective in many of the things that we need in our clinical space. And so most of my meetings actually show up to the medical director's council. And so when they ask us “oh, we need you to see more patients”. I get to be that voice. I get paid to be that voice to ask like, so how does this mean? Walk me through this exactly. Like the volume has increased. The space is the same. You want me to see more patients? How can I safely do that? And so then we can truly then get into the problem and then figure out like, oh, maybe we need to get more doctors to work at night.Oh, how does that work? Do you mean that you're gonna, I'm a nocturnist, if I have not said that I only work overnights. Which means if you send me to fast track, like I cringe because I hate fast track, right? I am like the worst in fast track. And so how can you, again, human potential, like how can you empower people to love to do the job that they love already whenever you can. And so then we created a nocturnist team so that the people who love overnight shifts, that's all we do. And so then if you're gonna add more shifts for the Nocturnists team, does that mean that we're expanding the nocturnist team? I'm actually proud to say that we have a waiting list in our nocturnist team because people love that, because we incentivize it, right? Like, and also there's a lot more efficient in the middle of the night than during the daytime when you have access to the bajillion consultants in the world who also expect to be called for some of their cases. I don't get to do that at nighttime because I know that they're sleeping. And if I call them, I really wanna make sure that I have a question for them. I'm rambling here as you can see, because I'm very passionate about this and also I hope that kind of give, answer the question of like, why wellbeing, how I got into it, and what I see my role now in the wellbeing space versus what people traditionally expects me to do, people still come up to me and ask me like, so what are you gonna do for this part? I'm like, I don't have solutions. Like I can't fix people's problems, but I can at least sit there, talk to you and understand, like, what is it about that, like a printer that's driving you nuts. If it's the color of the printer, like maybe we need to reframe this a little bit, but if it's constantly not working and you can't even print a prescription, then that's an issue. And then maybe we can refigure out a way for you to feel empowered so it doesn't just drive you nuts.
But that's the kind of things that I get to do to create a sustainable change instead of just like one-offs. Like, all right, the printer is broken, let's fix that. Because the more you fix problems, the more problems show up. And so how can we create an environment that people actually feel empowered, heard and also feel comfortable being vulnerable when they say, like, I don't feel comfortable doing this, or what you're asking me to do is actually scary or dangerous.
Laura: How many people raise your hand if you would like someone with this position at your shop?
Al’ai: I definitely love that for me, right. And I also can say that Because there's a human potential team. I also have problems, so I get to bring up my, like, the things that I personally experience. I do clinical shifts. I still do work, right? And so I know when it's tough, and I can empathize when it's really like not working. I also wanna commend like the leaders in my team, like in my, in my department, like my medical director, Dr. Ryan Ribeira, again, we're first name basis. So Ryan, when he works, when he implements something, like when he implemented these new overnight shifts to decompress the volume in the waiting room. The first three overnight shifts, he worked those as a medical director because he wants to know exactly the logistics that he's gonna encounter, right? Like people not knowing that there's actually an extra wing now that we're gonna be that we're gonna be running, and like the logistics of the staffing for that. And so he had to understand that like first hand first, so that when I do those shifts and I complain like, Ryan, this doesn't make sense. I know that he understands the problem that I'm experiencing. And if he doesn't, he at least can ask me the right questions knowing that this is not foreign for him. And so what I'm trying to say is that we try to, in as much as we do a lot of interventions, we try to also live that true lived experience. So that's, we can't just ask people to do certain things and then expect them to get there without giving them the right tools to be successful in that environment. That to me is the human potential.
Kendra: Love that. Yeah, I love that. I love how you say, Or just that you elaborated on some of the processes cuz just so much more than just, I hate this shift, I hate these patients, I hate this. You know what I mean? Yeah. I really spiral in the vortex, but this past just few minutes listening to you has been, this is like what it all is about like having a human potential team because you are seeing that there's processes, there's people and there's protocols and like all of those, there's something to do about one or all of those at any given time. And does it fix it? No. But do we always have to fix it or do we just have to make it a little bit better or give someone a little bit of hand in the process to get it to where it needs to go? Like what is it? How much do we need to go a hundred percent or can we go 70% on the process and go 80% on the protocol and 60% better for everyone or whatever, you know? So I love that. I love how you just totally like that was for everyone listening. That's what it is like, breaking it down, figuring out that there isn't just a happy hour or some pizza or donuts that is gonna exist.
Al’ai: I bring pizza by the way, at work, just so you know. So like I'm guilty of that, but I also, there's a design for me bringing food at work. We can go to that by the way. Cuz that is like a love language for me. Like it's a passion for me.
Laura: The, the word I heard you use that I think is key though, is you wanna empower people and that is at the heart of so many EM docs burnout is just feeling like they have no power, lack of autonomy.
Al’ai: Yeah. I've learned it from Dr. Greg Guldner who's an amazing human being. You know Greg?
Kendra/Amanda: Yeah. We had him on the podcast.
Al’ai: Oh yeah. I feel very honored about all the people you guys are naming. I was like, I am part of the crew now.
Amanda: That's what he spoke about on our podcast and autonomy. That's right.
Al’ai: The ABC, autonomy, belonging and competence. Right? Yes. And, and I would add to that, that I think it's important to understand when we talk about empowerment, to understand the “withins” and the “beyonds”. So, I'm borrowing this from Liz and Molly's book, “No Hard Feelings”. Understanding what is within my control and the beyonds of my control is very important because if you tell me the constraint, I can't do this, then I get to explore. Again, the human potential team will look at that and say, so we can't do this. Does that mean that we can do this then? Maybe the question is not, does that mean that we can do this? The question would be, again, using design thinking. That's my background. How might we, knowing the constraints, do this because the goal is still X, Y, Z. And so that's how creative ideas actually, I wish people get to see us in our meetings because it's one of those meetings that's very like cup filling for me. Like I feel very good at the end of those meetings because we tackle dilemmas and yes, we don't have a lot of solutions for them. But, the dynamics, the people feeling like there's actually things that we can think about, or at least we can narrow down. Like, we can't do this. This is like a no star for us because most of the time people are frustrated because they don't even know what they can and cannot do. Right? Like, that's the autonomy part. Because you're not sure, like, what am I following rules? I'm a rule follower but tell me the rules explicitly. Tell me what that means. Right? And so I'll give you another example of how the human potential team helps with this. At our shop, there's an expectation to publish because, you know, like we have a name and, and that's what we're expected to do in an academic program. So one, one of my first roles actually in the human potential team and director of wellbeing was to understand clarity, right? Because I'm making assumptions here. And so if I can get rid of assumptions, like how many papers did you expect me to write? So for real, like I asked my chair, I was like, what does that mean? And so she said, “two to three papers per year.” I was like, two to three papers per year. I'm a clinical educator. I don't publish. Like, I don't know how to do that. And also, do we even have the infrastructure to do that? Like do we have people in the department that will help us submit IRBs and stuff? Right. And so then it was decided that it was actually very impossible. I mean, I'm sure it was possible, but just not nice and cruel to people's lives to expect that. And so then we learned and we actually like invested a ton. So we hired research managers and teams, so we developed an entire infrastructure for the research team, which I'm so proud of. Like Dr. Maya Yiadom is leading that because that's what we needed because we're clinical instructors. So the educators, when we were hired, we were initially told that we didn't need to publish to now all of a sudden the new expectations, right? So that's one. And then still, like, there's still the uncertainty. It's two to three. And so then we had a nice discussion, and discussion meetings, like multiple meetings. Right, because that's just the reality of things. And I accept that because that to me gives me a better handle on relationships. Like, what is it really that's driving you to get us to do X, Y, Z? And so for our department right now, it's advancing research because there's so many things that we can actually impact, including the wellness space that we're trying to work on, right? Like you wouldn't have heard about the human potential team if I didn't present that. But that's not published anywhere right now. And so we need to actually put this on paper so other people can learn from us. So I understand why we need to publish and at the same time, I don't have all the skills to do that, so I need the support. And so long story short, cuz I, I can go on and on about this. We now at Stanford Emergency Medicine, it's written as part of, like, this is the baseline faculty expectation amongst many things. It's written that we are expected to publish one paper on average per year over the course of three years. Like, how cool is that? Number one, know that okay, I'm expected to publish one paper, but also there's an on average that we designed intentionally because we understand that parents go, faculty go, on parental leave, right? We're moving into the generation that the new term is the sandwich generation. Like our generation will be the ones that will have kids and also our parents are gonna be older. And so they're gonna be dealing with new processes that they had to do, which we had to take care of them, right? And so now how do we navigate that to be successful clinician, to be successful academician. It's also just a successful human being. So we added the “on average" to make it kinder for people that on one year, maybe I don't publish anything because I am dealing with so many other crap that life expects me to handle. And so those are the kinds of things that we tackle in the human potential team.
Kendra: Love it. Well, thank you so much Al’ai for being with us today. This has been such an inspiring time and I honor you for the vulnerability that you show every time you show up. There's just that common humanity that you spoke of. Thank you very much for what you do.
And we had such a fun time doing our recent free class. “Too Much To Do and Not Enough Time, said every doctor, every day.” We had a great time. But if you missed it, scroll down now to the bottom of the show notes and click the link to watch the replay. Also, if you wanna claim CME for listening to this episode today, scroll down, click the link at the bottom of the show notes and you can get CME.
So until next time, you are whole, you are a gift to medicine and the work you do matters.
