Dr. Matthew Strehlow (Host):

Today, we're diving into a critical topic: physician wellness. As emergency physicians, we work in environments that are fast-paced, unpredictable, and both emotionally and physically demanding. It's no secret that our profession can take a real toll on those of us caring for the many patients in our EDs and urgent cares.

In this episode, we'll take a closer look at what it means to protect our own well-being and that of our colleagues and explore strategies not just to survive but to truly thrive in emergency medicine.

Our guest, Dr. Al'ai Alvarez, is known for his work in wellness in emergency medicine. He's an emergency medicine faculty member at Stanford University where he focuses on physician well-being and creating a culture of belonging and psychological safety in high-performance environments. Dr. Alvarez, welcome.

Dr. Al'ai Alvarez:

Thanks, Matt. If it's okay with you, we can be first-name basis here.

Dr. Matthew Strehlow:

Works for me Al'ai. Well then let's launch into it. Where do things stand right now when it comes to physician wellness? How are we doing as a specialty? You and others have been drawing attention to EM physician and provider and wellness for a number of years now. Are we making progress?

Dr. Al'ai Alvarez:

Those are two different questions. I think the first one is, where do we stand? Unfortunately, since the pandemic, we are we have been number one in the highest burnouts across all specialties in medicine. Have we improved? I'd say that there's a lot of strides that have been done to focus on improving the system, improving our environment and also just increasing the awareness.

I know that at the national level, the conversation has really focused more on what can we do, not just to minimize burnout, but actually to find meaning in our work to increase professional fulfillment. And so, I think that is hopeful. And at the same time, I don't want to make that sound like we are so much better, because we continue, because of the challenges of our specialty and the work that we do. We continue to experience the highest burnout in medicine.

Dr. Matthew Strehlow:

You mentioned the challenges that are specific to our specialty, and I do really want to delve into those, but I also would like to know a little bit more about how our specialty - are we alone in this challenge, or is this a problem for most specialties in medicine?

Dr. Al'ai Alvarez:

When we look into, "Is emergency medicine alone in the experience of burnout?" No. I think as part of our common humanity, number one, we're just as human as everybody else, including our patients.

And so, we do feel the fatigue, the frustrations of a system that's not efficient. And also, we are impacted by the environment. The changes after the pandemic, the cultural changes that we're experiencing, the political changes, the finances impacting our work, and how we may be practicing. The perception of medicine right now, from our patients. The misinformation out there.

I think it's very clear that emergency medicine as a specialty just deals with a lot more of these strains because we are the first line for our patients we also see the impact on social inequities that happen. And it's on us to figure that out.

And for a while, I mean, you've probably experienced this, there's some thrill to solving those problems. And yet if you keep on doing that over and over and over again, and also realizing that many of these things have common patterns that do not just easily go away - that adds to that moral distress that we experience and that accumulation of moral distress, eventually…people have coined the of moral injury, for instance. And that's a tough one because that leads to burnouts.

Betrayal from the system that prevents us from doing the type of medicine that we want to practice, and also the betrayal of ourselves. We start doing things that we would not have done if we had the right resources, compromising our own wellbeing, for instance, compromising our own self, like cutting back on our sleep, skipping dinners, skipping lunch, just in service of the work that we do because we're emergency physicians.

We want to do the best thing for our patients. And that, I think, is a common thread across every physician that I get to work with.

Dr. Matthew Strehlow:

I would say that's a common thread across almost everyone I know in our healthcare team. And I love that about our work. But you mentioned this term moral injury, and I've heard this term before, but sometimes I have a hard time understanding exactly what people are saying when they use that term, and for our guests that maybe aren't as steeped in this as you are, can you define that?

Dr. Al'ai Alvarez:

Again, I like the idea of describing it as a double hitter. The moral betrayal that hits you from a systems level. So, a great example is at the beginning of the pandemic when we tried to see as many patients as we can despite the lack of access to PPE, there were folks who perhaps didn't even have the N95s or were asked to reuse N95’s for several days to two weeks.

That is a systems-wide betrayal that you have to put yourself in danger in the service of others. But there's also the betrayal of ourselves, right? In many of these cases, we chose to take care of these patients because we felt really bad that these are patients who are dying, these are patients who are suffering by themselves.

And so, some of us, many of us would go into the room and hold their hands knowing that we may be putting our family and ourselves at risk. And so that betrayal, for ourselves is also hitting us. And the reason why I think it's important to understand, and I love the question, is that the solution for those betrayals is very different.

The solutions from the betrayal of the system require that reparation, that the acknowledgement from the system that we did this and here's what we're going do in order to improve your experience and improve your work.

We can do all of that, but without addressing the second part of the betrayal of ourselves, we're also not going to be completely satisfied. And that requires, I think, the self-compassion. We have to forgive ourselves. We have to be kinder to ourselves and know that we are doing the best we can in the circumstances that we are dealing with.

And it's not always perfect, but whenever we do those morally distressing compromises, it eats us up. And also, it adds to that residue that we accumulate over and over again and over the years as we know, each of us have these stories, we have graveyards that you alone will know.

And you kind of visit those patients that you have encountered. And you, you kind of say hi to them over the years, and nobody else will understand that, so as physicians, we carry those and I think we have to find ways to be kinder to ourselves. Because we chose to be here.

We chose to do this hard job.

Dr. Matthew Strehlow:

It's interesting to hear you talk about that. I reflect back on all the cases that stick with me. And a lot of times I think, oh, these are cases that, because they were particularly difficult with the outcome, or this or that.

But as you were speaking, I realized that a lot of the cases that I think about on a pretty regular basis have really [impacted me are cases where I was put in a morally compromising situation where what I ideally wanted to do and what the circumstances allowed for or up happening were things w here I couldn't make the decision that ultimately I would've had everything been optimal and that really brings it home for me. So, thank you for that.

Dr. Al'ai Alvarez:

I mean, that's very important, and that's why I share that, that, that story, right?

And I share that the way that I see moral injury. And at the same time, despite the best efforts, the best teams that we have, all the special tools that we have here at Stanford, patients do die. And I think that's just part of the impermanence of life.

And so, we have to again be kind to ourselves and to forgive ourselves. That it's not always because we made a mistake. It's actually just because sometimes it's just their time is up. And so how we honor them, and how we honor our team can have a significant impact on how we see the work that we do.

Because I've also been in situations where we were so busy that you call the time of death and then it's as if it was just part of the job, and you walk out and go see the next patient and probably get yelled at because they've been waiting longer. Because you are in that resuscitation. I think we need to pause and recognize.

Some of the work that we do at WellMD is to humanize us as physicians because it is important for us to pause, reflect, and recognize that our work is important and we need to also take care of ourselves so that we can take better care of others.

Dr. Matthew Strehlow:

You've done a lot of amazing work at WellMD at Stanford and advise people across the country and the world, around wellness, but also what we can do. And there is now a growing evidence base that I've heard you talk about, and so maybe you can share with us some of the most evidence-based interventions that organizations or individuals can take to improve physician wellness and wellbeing.

Dr. Al'ai Alvarez:

If your leaders are not supportive, if there is no psychological safety in a team, it eats us up. It's  this idea from a self-determination theory perspective, autonomy, belonging, competence, right?

It affects your autonomy, it affects your sense of belonging. And if you don't have the support to continue with your training to be better at your craft, then it affects your competence.

And then the second part of that is efficiencies of practice. If you're trying to take care of your patient and you just need to print out that prescription, and the printer is always broken, every time you print a prescription, you're reminded that the system is broken. And so, we need to figure out ways to improve our system from an efficiency perspective so that we can practice to the peak of our training again, there's that competence, the autonomy, and belonging again.

The third part - they actually shifted away from calling it personal resilience and instead calling it individual factors.

And for me, when I give talks, I talk less about the resilience part because as physicians there's actually evidence that we are,the most resilient workforce out there compared to any other workers. And at the same time, we also have the highest imposter phenomenon. We think that we're just faking it because of the work that we do. When things don't happen the way that we expect, we think that man, like. I'm not as good as I should be. That shoulda, coulda, woulda. And both of those require us to be kinder to ourselves. You can't be resilient  if you don't have self-compassion.

And at Stanford WellMD, Well PhD, we refer to it as self-valuation. The ability to accept our imperfections and have this growth mindset in order to be better. Right? But again, you can't do that if you're not kind to yourself.

And so, from an evidence-based perspective, if there's one thing that people can work on, it's just something that we've been working on in our department. It's really a big emphasis on psychological safety because the culture of wellness is the biggest driver that impacts burnout and professional fulfillment.

The second part is, is efficiencies of practice. Resilience is actually a lot less than that. It doesn't mean that it's not important, right? You can work in a place where you have all the bells and whistles that can make your practice smooth. And you can have the most supportive leaders, but if you are also not kind to yourself... as many of us are in this very perfectionistic world, in medicine, then we will, we'll never be satisfied. There's always going to be a better, should, coulda, woulda state for us.

Dr. Matthew Strehlow:

A lot of great stuff in there. And I think you mentioned psychological safety a couple of times, right? And I don't really know if people really understand what they mean or what is meant when we say the term psychological safety, right?

Can you just expand on what psychological safety is to you and the work you're speaking of?

Dr. Al'ai Alvarez:

Yeah, I think, for me, it's closely tied to that sense of belonging. If I can speak up for things that are not working and not have to worry about getting in trouble for that, I think that is an experience of psychological safety.

Right now, when we're having a conversation, I have great psychological safety. I can talk to you about anything, and at the same time, maybe in a different meeting, I'm going to be worried that you're going to judge me. I'm going to worry that you're going to reprimand me for something bad.

I don't think you will actually, but I'm just supposing that these are things that can happen, which means that, again, it really is on the leadership to continue to strive for that, and that requires a lot of work. And it's a constant work, including being vulnerable, being able to model mistakes, being able to model what it's like to argue that constructive conflict that we do a lot in the human potential team.

And also, understanding that we have to have accountability. Psychological safety doesn't mean that I can just say something, criticize you, and not have any ramifications from my end. I think for me, psychological safety is being able to call out something that I don't agree with, but make sure that both of us lead the conversation with dignity.

And again, that comes with that sense of belonging. You can do as a leader, you can do all the work to make me feel included. I may not feel included. That sense of belonging has to also actually come from me as well. So, it's mutual work. We think that belonging just is required for leaders to establish.

It actually means that we need to foster this sense of self-compassion. I need to be kinder to myself to accept who I am. To be able to show up as me and not have to worry about changing who I am in order to simply fit in. And I’ve been in many of these spaces before where I have to change the way I speak. I have to change the way that I talk or change the words that I would use in order to fit in. Versus in many meetings that I have with you, I can be truly me. I can mess up, and I know that you're either going to call me out, text me later on, call me, and just give me guidance .This is what it feels like to belong in a team that actually cares for each other.

I think that, for me is very, very important. And that's the difference between just saying psychological safety. We have psychological safety here, versus truly experiencing that and feeling like I can truly feel safe, bringing something up, and know that it may not be solved, but at least we can talk about it.

Dr. Matthew Strehlow:

Psychological safety is one of those things that is a two-way street, like you mentioned, or even just an environment. And I appreciate the way you describe that and bring it to tangible conversations. One of the other things I heard you allude to a couple of times in the last few minutes was around this idea of efficiency of practice.

And recently I was asked, how many physician providers would it take to staff an emergency department if we had this and that changes. You know, if we had all of these beds and we didn't have anybody boarding and things like that.

And I thought about it for a few minutes, and I was like, I have no idea. Really, I have no idea how many patients because all the physicians I know work really hard, right? And the nurses and everyone else is working really hard. I have no idea how many patients they could see in an hour and what their efficiency would look like if they were operating in an environment that allowed them to operate efficiently, yet still compassionately.

And so, when you say efficiency of practice, I wonder if some people are hearing work harder. And can you talk a little bit about what the difference is between, hey, you just got to see more patients and work harder. Just don't take a lunch break, don't go to the restroom, don't do those things. And that's what we mean when we say efficiency of practice, right? Versus what I think you're saying when you say efficiency of practice.

Dr. Al'ai Alvarez:

Yeah. It's a great question. I haven't thought of it that way, but now that you reminded me, in my previous hat as an assistant medical director, you're right, I actually caused a lot of burnout when I wanted things to be faster, better, more efficient.

I'm talking about human-centered design. So, the people first; wellness-centered leadership is about making sure that the people come first. And so, in this context, in the world that we're in here at Stanford, an efficient shift for me would be not having to wait for the CT scans and not having to wait for transport, all these things that eventually will happen anyway.

And at the same time, actually allow me to take a break, like you mentioned, do human things provide time for us to be able to walk and talk, catch up with the nurses, maintain those relationships, because we know in emergency medicine, there's going to be that resuscitation that comes in.

And if we don't invest in those times, like taking a break, like going to the bathroom, it actually takes so much space in our minds that when we are in those resuscitations, we are not as effective, we're not as efficient with the cognitive load that we're dealing with. And so, for me, efficiency of practice is just again, the ability to be able to practice at the peak of our performance, at the peak of our training.

And the performance there is very important because performance doesn't mean that we have to see more patients. It's just that in order to have high performance, we can have dialogue, we can conversation. We can have debrief when things go well and things do not go so well. And also have a moment to reflect of what can we do better? I think the worst thing that we can do is make all those things work so well, like a factory. We don't necessarily need to make things work like an assembly line, and again, dehumanize the physicians, because then they will just feel like cogs in the wheel.

I think efficiency here is being able to take care of yourself in order to take care of other people better.

And for me, what I have seen is similar to what we do with the human potential team. Once people find alignment, once people actually find the meaning and are reminded of the meaning of their work, they're in their flow states. And so, time will just pass by so fast. I see you smiling, right? Because you know what that feels like. Your charts will just get done. You're going to see enough patients and at the end of the day, you're actually proud of what you've done. Instead of just exhausted, mad, I saw so many patients and I get yelled at left and right because I didn't have time for them.

Efficiency for me is to be able to connect with patients so that I don't have to order a lot of tests because we actually connected so well that we understood each other, including the limitations of what the emergency department is. And less about like, I don't have the time to talk to you, so I'm just going to order all these things in order for you to be satisfied.

And in the end, they're going to get the bill, and they're not going to be satisfied. Right? They're going to complain about it. Efficiency is actually being able to maximize the time that we have with each other, including our patients and not have to second guess that later on.

Dr. Matthew Strehlow:

There's these organizational efficiencies and changes to our practice environment that you've mentioned. Changes to our team performance, the way that we create a sense of belonging among the healthcare team, the emergency department team. But I'm going to ask you to bring it down to just the individual.

So, if you are counseling or mentoring or talking to a group and they ask you for three personal individual habits that an emergency physician can implement in the near future to sustain their wellbeing over the long haul. Give me three of those.

Dr. Al'ai Alvarez:

Okay. Number one, sleep. Sleep is…we are terrible at that, especially in emergency medicine because we're very guilty of this. Not because we don't care, but because we care so much that we try to be efficient with our time, including, right? We go into all these meetings during the day, and then a bunch of shifts after those meetings.

And so, then we compromise ourselves by not sleeping well. And then of course, when you wake up the next day, you're groggy. You know you're going to wake up the next day and then go to another meeting. You're not as efficient. And so that's one thing, I think if we can find time to really prioritize sleep.

One of the cool things that we have in our department is a dedicated nocturnist team making sure that continues and is preserved, because then that actually helps everybody else in the department. So that's one.

Number two, a simple thing that we can do is again being kind to ourselves, including creating...a way to, for me, when I have a very tough shift, I send thank you letters. I sent thank-you letters to the leaders in our department CCing the people who were involved, highlighting the work that they've done, because there's actually great evidence for gratitude, like the three good things, for instance.

Just think of three things that we're grateful for each. By day four or five, we're more likely to start seeing benefits beyond those two weeks. And if you just do it for two weeks, the benefit actually lasts up to six months.

And there's even a study that they did a comparison with an antidepressant and, just a practice of three good things. And the benefits are the same, with no side effects and also, it's free, and I think one of the most important things that we can do is, again, being intentional about the practice of self-compassion. Because by practicing self-compassion, we're able to set boundaries. We're able to say no, and when it's actually dangerous, we're able to advocate for our patients better.

Also, I think for me, what is important is also we can celebrate the wins because oftentimes we do this wonderful resuscitation and then we leave the room immediately and we go see the next patient. Because we're constantly feeling the pressure of the next patient. But that moment of just, again, connecting it to gratitude and recognition, just little pauses and celebrating the wins means a lot.

Not just for you, but actually for the rest of the team, which is important again, for the culture of wellness. That is one of the biggest drivers for burnout and professional fulfillment.

So those three, I think, are important. I think plus one for that, that's attached to self-compassion and boundary settings is vacation. In emergency medicine, we are terrible with vacation time. I don't have the numbers in front of me, but it's less than 50% of us take more than two week vacations a year. Right, like consecutive two-week vacations, and actually I don't know how about you, but it takes me about 10 days to fully have psychological distancing from work.

The first couple of days, I'm thinking of the work that I just did. It takes me a couple of days to not care about the emails, and by the time it's 10 days when I wake up. I don't even think about work. I don't think about answering emails. I know I'm going to start working again in three days.

If I take two-week vacations, which means that you really have two solid days of true vacation in that two-week stretch. So, as emergency physicians, because we work in shifts, it's actually a lot easier to plan for this.

Because for me, what I've learned, and I've been taking two-week vacations,twice a year since intern year. Leaving the country, because for me, that is what, recharges me. If I think of what I'm doing now and I love all many of the things that I do, and also when I reflect on it and I'm struggling in one part or the other, I ask myself, in five months, will it still matter in five years, will it still matter? And most of the time, what I start regretting is not having those times with my friends, my family members. I'm getting to the age now that I'm saying goodbye to people because they're dying. And and unless we take the time to actually spend those times with our family, we're going to lose that.

And so, I... the three things that I mentioned, I think I do every single day, but I'm also very intentional about, looking ahead, looking at the next six months. What am I going do next? My birthday is next week, so I'm going to get a letter from myself that I sent at the end of the year.

Next week, I'm going to sit down, I'm going to write things, three things. What am I proud of? What have I accomplished over the past six months? Which is great because it's a great way for me to update my CV, but also, it's a great way to be reminded when I'm struggling that I actually accomplished a lot over the past six months.

And I also think about what am I currently dealing with? The problems that I'm dealing with, the things that's stressing me out, preventing me from sleeping. Because I have been doing this for several years now. When I get that email next week, I will think of that thing that I was stressing about six months ago.

And I'm like, I can't believe I was losing sleep over them because they're not that important in the longer scheme of things. And then I also think of over the next six months, what do I look forward to? What am I hoping to accomplish? Because then at least it's part of manifesting.

Did I do my best to actually reach that? And so, then when I get it, I'm like, oh my gosh, I did it. Or all right, well that didn't work out and here's one way for me to pivot. So, it's a lot more intentional. I think the perspective of time is a way to recalibrate the stresses that we deal with in emergency medicine.

Dr. Matthew Strehlow:

Well, I'm going to start with your advice by practicing self-compassion and recognizing that it's okay that I'm pretty terrible at all four things you mentioned, and I'm sure that my wife would grade me as a solid F in most of them. But I love that. So self-compassion. Gratitude, sleep, and vacation and a real vacation, not the partial vacation that a lot of physicians, and especially academic physicians, like to practice where it's like, it just means reducing your hours from 60 to 40 hours or something.

Thanks for those. Those are wonderful. You know, there's a lot of hope in that. And looking ahead, what gives you hope around the future of physician wellness in emergency medicine? What changes do you think that we need to implement to get there?

Dr. Al'ai Alvarez:

What gives me hope is that we, I mean, this specialty is super cool, right? There's not a lot of specialties out there that really allow us to meet people, at the worst times and also make a big difference. For me, what gives me hope is that. We continue to have the conversation, not just to talk about burnout, but actually find meaning in our work and also trying to be creative.

If anybody can figure this out, it's going to be emergency physicians, because we deal with a lot of stresses already. We're very creative with very limited resources. What gives me hope is now all of a sudden, we're talking about vacation and publishing about that. Why that is important.

What gives me hope is that there's many things that we get to do and also, um, we get to celebrate. I mean, we just survived the pandemic and that is not a simple thing. And our department, for instance, I just saw we're now the fifth largest NIH grant receiver in academic emergency medicine. That's a big deal. And we did that in what, six years? I was told you don't have to do research here at Stanford. And then now I'm publishing, right?

From a growth mindset perspective, we can actually change for the better if we find alignment in our work. And so, whatever that is, I think what is important is that we always have a choice.

And also, that you don't have to go through this alone, that sense of belonging is, is really powerful. And so, for me, what gives me hope is that I don't have to do this alone. That I don't have to always figure it out. That we don't always have to have the answers, and at the same time, we can pause, reflect on it, and actually do something about that.

That is so powerful because otherwise it feels like we're just stuck here trying to figure this out all the time. But when we actually pause as we're doing now, we're exchanging some ideas that is so powerful. That gives me a lot of hope.

Dr. Matthew Strehlow:

Yeah, I think that what I'm learning is that it's about individual weakness. We are still resilient, we are still committed and passionate. The system is challenging, but if we take that resiliency, that commitment, that passion, that energy, and focus it on. Making the system better for our patients and ourselves. Then wellbeing will follow. Right? Wellbeing will follow, and each of us can contribute to that. Again, you don't have to be the chair, the executive vice chair. Each of us can ask you what can we do?

Dr. Al'ai Alvarez:

I think that's a great modeling of how we can truly advance our specialty, to find professional fulfillment better. And also, in turn, minimize the burnout. I don't actually truly think we're going to get rid of burnout. As emergency physicians, there's a lot of those things that we have to do, right?

Like depersonalization. I do it all the time. I have to be able to quickly go from one room, maybe shed a tear, when we're in resuscitation and then smile to the next person because they don't deserve to see me weighted down when they're also dealing with their own stressors.

I would call that compartmentalization. And some people might think that that's a bad thing, but I think we are very adaptive, we're very resilient people in emergency medicine.

And so, I think it's less about feeling the burnout and more about truly that, finding that meaning and finding that professional fulfillment.

Dr. Matthew Strehlow: Well, we like to end our podcast on a lighter note. So, one final question for you. What's a non-healthcare book you think everyone in healthcare should read?

Dr. Al'ai Alvarez:

Ooh, you know, I do a lot of book clubs in our department, so I have a lot of non-healthcare books. I think to honor the conversation that we’ve had, the book by the Heath Brothers, The Power of Moments, because I think it's when we see things that are working well, we can actually take the time and pause and acknowledge that, and if we can celebrate that.

We, each of us, experience peaks and valleys in our careers, in our work, in our lives. And if we can find a time to highlight those peaks, I think that can mean a lot for people because that gets to, again, the sense of belonging. that then, cultivates that psychological safety that cultivates the culture of wellness that we talked about earlier.

Dr. Matthew Strehlow:

Well, I learned a lot of that by watching you, so thank you.

And that's a wrap for today's episode. A huge thanks to Dr. Alvarez for sharing his insight and expertise. There's still so much more to explore in this important space, and we hope to have him back soon as our understanding of and strategies for improving physician well-being continue to evolve.

Thanks for tuning in. We'll see you next time. Until then, keep taking care of anyone with anything at any time.