Laura: Hey guys. Welcome back to the podcast. This week's episode is part two of our interview with Dr. Al’ai Alvarez. Dr. Alvarez is a national leader and educator on wellness, and he is an emergency physician and clinical associate professor of emergency medicine at Stanford. Also, he's just an amazing person, so we hope that you enjoy the rest of this interview that we had with him.
Al’ai: You can also freely just ask me questions. I can just like, whatever comes up for you. However you think your audience will benefit. Because, I believe that each of you are making a very important role to not only empower people, but also to just make them feel seen. Right? We are dealing with a lot of crap, and oftentimes it's so hard to get that validation that we're experiencing is actually really not fun. Right? And, yes, we chose the hard path. But it doesn't take away the fact that it is a hard path, and maybe we can create environment spaces where we can talk and acknowledge those lived experiences.
So I'm all about happy hours if that's the place that we can do it. But I love the creativity that each of you are doing, which is reaching people on their drive to work, so that hopefully when you're about to see your next patient, you're reminded that what you're doing is important. You're mattering. And you can do that while also being a mom, being like a parents, being whatever else identity that you carry that oftentimes are invisible in our work as emergency physicians.
Kendra: Yeah, I think that's huge. And I think one of the things we talked about, even just recently at- when we gave our talk at the AAWEP pre-conference for LAC. We did talk about why, you know, some of the reasoning why. Burnout or just women walking away from medicine is a lot of that hidden work that you said, I think you said, invisible work. But we, I think we call it “silent suffering" because I mean, there's a lot more that women's…
Al’ai: We call it many things, right?
Kendra: So many more things. And so I think that contributes. I mean that- a hundred percent- that contributes, and that side's not even addressed. But I just so appreciate you even saying we have to take care of that part too. So, but just to flip the script a little bit, so tell us about this High Performance Resuscitation Team. I was actually very intrigued about this.
Al’ai: Oh yeah. It's another example of Stanford's creative serendipity. There's a group called the Mission Critical Team Institutes. And it's an invite-only group. It's their very exclusive. And it's comprised of elite teams, so NASA, sports teams. I'm not a ball sports person, so there's like big sports teams there that, that attends. The military attends, so the Five Eyes, so the special forces, FBI, and they have a website. I can give you their website. And also the medical team. So Stanford is one of the teams. Cleveland Clinic is one, and then now Mayo Clinic is one. And the reason why Mayo Clinic is one is that Dr. Colin Bucks, a dear friend of mine, I worked with him once when he was at Stanford.
He's actually famous for being that emergency physician that went to West Africa during the or East Africa during the outbreak of Ebola. West Africa. I'm blanking on exactly where, but and so he was the one that was in the New York Times and actually had to quarantine for a month when he arrived back to Palo Alto. Because we had no idea how to like, navigate life that he just brought back. But long story short, he led the Stanford team in the Mission Critical Summit. And I heard about it; it sounded pretty cool. And so I asked him if I can join, and he said, I'm sorry, I only have five tickets. And so it's usually reserved to his EMS fellow. So the, usually, EMS and tactical and disaster team go to this. Because, again, the whole point of this is to kinda anticipate big disasters, and how can we learn from each other in the high performance world.
Fast forward, I think a year later, I gave a Grand Rounds talk about my mistakes. So one of my lecturers that I give is on my mistakes as a, as an attending. So it's entitled “Rookie Mistakes, Things I Learned After Residency,” and it's really just being vulnerable and owning my mistakes, and what I've learned from that. And he came up to me and was like, wow, that was like, so powerful. That was great, like I…usually, this is what happens. People are like, oh yeah, I screwed this up. I missed this case and blah, blah, blah. And we're so tough on ourselves, right? And so, so then I forgot which started first, but he, I, we did not have a fellow that year for EMS. Just- I don't have a fellow next year for wellness fellowship. So, by the way, if anybody that you know is interested, please apply. It's a great program. It really is a fun program for me. And that's a very Stanford thing. Like we don't necessarily, we don't fight to have a fellow every year. Like we're very comfortable, actually, not having fellows because the mission is there. Like, I still do my job whether I have a fellow or not. Like the fellow is really there purely to learn about how to be that next level leader for their position.
So we didn't have an EMS fellow, and so I came up to him and was like, “Hey Colin, can I be that person now? Like to attend your conference?” And so he gave me the spots, and it was in New York City. And it's usually in New York City and then in California. And that year's in the FDNY. And so it brought back a lot of memories of, like, being in the Bronx and the work of the fire.
So the fire team, by the way, is part of the Mission Critical Teams. And the topic then was how do we select the best of the best? Right? And so then you get, like, Wharton School of Business talking about how they select their people. And then you get, like, the sports teams, how they select the best football players. And you get NASA, how they select the astronauts, right? And then I got to talk about how we select residents in Emergency Medicine. And then we learned about the ways that we decide who gets in and whatnot. And it was really an empowering conversation, right? A powerful conversation for me. And long story short, after hearing my talk on mistakes, he had this brilliant idea of “Hey, why don't we do Mission Critical Medicine?”
And so bringing all that, like, elite teams and focusing on problems that we deal with in medicine. And so that's what we did. We reached out to the Mission Critical Teams. We partnered with them. So they are collaborators for the High Performance Resuscitation Teams.nIt is not a simulation conference, which many people assume it is. It really is a gathering of people to learn about concrete problems that we deal with. They call it Rapidly Adapting Complex Environments. So for instance, like, how do we deal with the residue of working on a shift or working on a resuscitation, then quickly having to reset to take care of another patient, right?
That is a very real problem. I just resuscitated this patient. The patient died, and then the next patient yells at me for having waited like that extra five minutes or hour for their toe pain that like, that's been going on for 10 years. Right? Like, how do you quickly reset that?
In our inaugural conference, the first woman chief flight deputy officer from NASA was one of our speakers. Holly Ridings, who is an amazing human being. She talked about how leadership is actually very lonely. Like when you're a leader, nobody talks to you and people are scared of you. Which means that we have to be intentional about getting ideas from people. Oh, we got like Paddy Steinfort, who is now, he was then like, I think he was the coach for the whatever the one in Boston baseball team was. But, so now he is the executive performance coach for the Soccer Olympics team for Australia. So he was one of our speakers- again normal… And then we have the other person that we paired with him was the F1 performance director, F1 racing performance director to talk about like, how do you coach people with different personalities?
Because in emergency medicine we deal with this, right? Like we call it “swarm teams.” I have no idea who in the trauma team will arrive, and who in OB will arrive. But within a few minutes, we have to quickly establish who's running this? How are we gonna communicate with each other? How can we be kinder to each other when we're telling people tasks, like the nurses? How do they understand communication? Right? And so, that's why we brought in the sports team to help us unpack that. So yeah, so that is the High Performance Resuscitation Team.
So again, many of these things that I get to do are truly, like, passion work. I'm very excited about them. And I'm honored and grateful to be in a place where I get the support to do that. And most importantly, I think it's because of that, like, creative serendipity that Dr. Shenvi talks about. Like, I align it with the Human Potential Team because how do we focus not just on getting people, like, not burnt out, which is most of the narrative, right? How to prevent burnout. How do we fix burnout? How do we heal burnout? To how can we just, yeah, we need to do all of those, but how can we take care of the people who are getting by, who are actually doing well and have them do better, right? To really find that meaning in that sense of joy for them in the work that they do. Like for me, that is the High Performance Teams.
Both of them are important, but we need people to also talk about this aspect. That's what we get to do in the High Performance. And you are more than welcome to attend. That summit next year tentatively is gonna be in September. And this year, again, in design thinking, there's a concept of “fail fast, fail often.” And so we did it this year in Minneapolis. I'm sorry if you're from Minneapolis, but it's very hard to get people to fly into Minneapolis in April. And we're moving it to September. That was one of the lessons. And then we're moving it to San Diego because I think what I've learned, especially from ACOEP, people have CME money. Especially if you're an independent contractor, right? And so you can actually, like, tag in vacation and travel time with a quick CME course. And so, why not pick a nicer place? Not that Minneapolis is not nice, but people would like to be on the beach, like San Diego.
Amanda: Would you mind, we try to give our listeners, like, something that they can use immediately. Do you, are you able to share how to shake off that traumatizing death that just happened and then trying to get a five star with the next patient? That, really was something very frustrating for me when I felt like I was trying to just get a Press Ganey score, but I myself was devastated.
Al’ai: Yeah. Right. And how do you deal with that? Thank you for asking me that question. It's one of my favorite things to do at work. I have a lot of favorites as you can, as you can see. But I tend to do them because I really believe in them. And so, and this is a very wellness in me. It's actually just a version of mindfulness. And so what I do is I pick a patient in my roster who I think would benefit from a sandwich. And I'm sure you have patients that would like a sandwich. And I can easily ask a nurse or a tech to do this, right? But I actually will do this myself. I would physically go to the refrigerator to pick up that turkey sandwich. And in that process, whether it's a minute or two minutes, I will think to myself, I'm gonna give this patient a sandwich. And he or she is gonna be happy, and he or she is gonna feel good about this. So I'm gonna think of that person receiving that sandwich, right? And if I'm really, like, that exhausted or emotionally drained, I'll sit with that patient. I'll talk to them briefly for like maybe a minute. Hey, talk. Like, how are you doing today? I'm so sorry you've been waiting here. Right? It connects me because that's why I went to medicine in the first place. To address suffering, and hunger is a good form of suffering. And so I can address that. All right, so then I chitchat a little bit.
Because then when I get back to that patient who has been complaining of their toe pain for 10 years, I can honestly and authentically show up and say, “Hey, I'm Dr. Alvarez. I'm so sorry. you've been waiting. I was in the middle of resuscitation. How can I help you today? What is your emergency?” Right?
Amanda: Love it.
Al’ai: But I've practiced that line, but the line is not as effective if I am coming in with all the baggage that I just left. And also it's not fair for that patient also, because it may be that they've been having this pain for 10 years. But tonight is their emergency, and it's not fair for them, for me to unload all of that crap to them. Right? They don't need to hear that. But I also expect them. Again, this is the whole point of relationship-centered care, not just patient-centered. It's about the relationship. We are doctors. There's a reason why we got trained to be doctors. And so I am bringing my doctor self in that room and telling them that like I am. As a human being, I just took care of this. Let me now be your doctor and then check in with you. But me, that doctoring also, that practical, like, steps that I do of, let me get that sandwich. That gives me enough time to even just think of something positive because there is a lot of science on gratitude.
So that person who's gonna thank me will make me feel good, but me also thanking people afterwards. Hey, thank you for this time, right? You didn't need to eat this sandwich, but like you took this sandwich for me, and this is exactly what I needed right now to connect me to a human being. So thank you. So me giving that thanks can actually make me feel good as well. Some people use washing their hands as a ritual. By washing their hands, they think of- I'm cleansing myself of all that trauma that I just experienced. And also, again, in design thinking. I know we're very busy, right? And there's always another thing that we do, but what would it look like if you just pause in that resuscitation, especially if that patient died, right? And that's what we do now in, in our shop. We pause and just acknowledge this is a human being that died. He or she, may be somebody's loved one, and this team just did this amazing.
And by the way, English is not my first language and so I actually fumble with this. So I have it in my phone. I read this out loud to them. Because I do shake. I'm very emotional in those moments. And I read that to acknowledge the team, to acknowledge the effort of the team, because I tell them, as soon as we get out of this room, as soon as we leave this room, somebody's gonna ask us about the urinal or that paperwork that we have to do, or that next patient is gonna yell at us, right? And then we just forgot that as a human being, we just took care of this patient that also just died. And there's a trauma that transfers to us, and we need to heal from that a little bit. And so, how might we design events within our department to actually honor that?
And so, we've created that and we also, now we do diffusing sessions. So like 10 to 15 minutes later, we expect the nurse to remind us if we forget. Hey can we do, can we just talk about what just happened? Like, that way we can have a shared narrative because your perspective with that resuscitation may be very different from my perspective of what happened. In my mind, maybe I'm like blaming myself. Man, like, I totally missed this. I didn't see this. I, that was an awful feeling. Versus like, this is usually what happens. And that's why I encourage people to do this. When you have a shared conversation, and again, not to do a QI process, cuz I know I have that hat sometimes. This is just to check in with people, right? Because we're all human beings. You'll find out that they're like, “Dr. Alvarez, I know you're being tough on yourself, but that resuscitation? That took 21 minutes, and the patient is now in the OR. You did that. Like you led that.” Right? And so I'm getting this goosebumps feeling as I'm sharing this with you right now, because it's good to be reminded of the good things that we do.
And so, in fact, one of the things that I shared to my residents- and Kendra, I think I may have shared this in that talk- is focusing on these goosebumps moments. Right? So you asked me again, Amanda, like what other practical things. I'm in this resuscitation. And their resuscitation may not have been the best, but you know what? It was the best that we could have offered. And this patient survived. Like literally, there's blood in the, like, in the hallway. We took the patient to the OR, and I can still picture my residents looking at me. And I was like, man, that was awful. I wish we did this. I wish we did that, right? And I looked at him and I said, “Hey, can we just pause for a moment because I'm getting these goosebumps. And I don't know if you feel this, but for me, this is what it feels like to save a life, right?” And then just pause on that, because we don't pause on the good things. We usually just move on. It's like we, maybe we do a quick high five and then we move on. But like, how often we actually feel the feels of like good resuscitation? Feel the feels of giving that sandwich to that patient who truly needed it, or listening to that person that you just delivered, like, that they have cancer. Right? How often do we actually get to, to feel all of those emotions that like yeah, they're lucky to have you that day because you took the time to actually take care of them.
Kendra: Right. And I think that is so important. I just heard so much of…you talked about the vulnerability a little bit ago, but we're bringing the personalization, the humanity...
Al’ai: Yeah!
Kendra: …to medicine because man, and especially I think our trade. Being EM docs, I think one of the most protective things we do is we are supratentorial. We just, we own it, and we do the thing. And we are awesome at compartmentalizing. And next job. And next job. And we don't always want to pause because not only do you… I mean, I love how you just talked about the good feelings of saving a life, but we sacrifice that to not feel the terribleness when we have that pediatric code that doesn't go well and you know, so. So I feel like we don't do the positives because we also just don't wanna feel the negative and mandatory.
Al’ai: Well we feel the negatives for sure. Yeah. We actually do the negatives a lot more. Yeah. May I expand on this? Because this is actually a very important point, and I learned this from the Mission Critical Teams. There's a concept that they call “residue.” And they didn't make this up. Actually, actors make this up. And so, Tom Hardy. Bane, one of his characters is Bane. I think he came up to Preston Cline, who's the director of Mission Critical Teams. And he said, why don't you guys talk about residue? And he's like, tell me more about it. But essentially like for actors, when they take on the role of Bane or when they take a role of like- I don't know, like, a sniper- they have to really get to know like the, in the psyche, like their mannerism. So like when you take on Abraham Lincoln, you are Abraham Lincoln to your family members. You talk like Abraham Lincoln. For months as you're doing the recording, right? And then what happens when your next role is Mahatma Gandhi. You're gonna be the weirdest Mahatma Gandhi if you have, if you have the Abraham Lincoln. And so what they talk about is there's the residue that they carry in each of the experiences that they have, each of the roles that they have.
Similarly, as emergency physicians, we have the residue of taking care of our patients. And so over the years, these accumulates on us, and unless we know how to take care of that, the good and the bad. But I think what I'm trying to say here is that we need, in as much as we're experts at compartmentalizing, because that's how we are effective, we need to actually acknowledge that there is a role for us to tend to ourselves. Because I don't know about you, but I know that I have a lot of cemeteries, like graveyards in my backyard at the end of my career. And even now, I look out, and think of the many people that I have lost. And how do we honor them, and how do we take care of ourselves honoring them?
And I think that, I think, is very important that we don't often get to do because we're so busy. That's why I'm taking a sabbatical in September to fully understand this more, so I can really understand what are the ways for me to understand the residue, take care of myself. Because many of you probably are familiar with the book The Body Keeps The Score. Yes. These things will come up, like physically, they'll actually manifest in us. And so when we talk about burnout, how much of this is because of the constant trauma that we deal with as we take care of people at the worst times. Right? And they're not always bad for us, but we just need to at least pause and realize you know, this is very important.
Al’ai: I talk again a lot, and I just realize the time. And so I'm sorry!
Amanda: I love it.
Al’ai: But all this
Laura: No, we love it. Love it.
Al’ai: Thank you for the work that you do.
Kendra: Wow. This, I mean, it is amazing though, just to have you on and just to share. And you know, as we all think, gosh, can't we all have a shop at Stanford? Or can we all just do this? But it just really,
Al’ai: Why not?
Kendra: I know, why not?
Amanda: That's what we're trying to do.
Kendra: We just gotta, yeah. We gotta start somewhere. And also we gotta know that every little step. I mean, you started somewhere and are here now.
Al’ai: I told you I got rejected to Stanford twice. Like I, I didn't have the grades to get in. Right?
Kendra: Yeah. But I mean it's the work that comes out of passion that cannot be denied. And even though you get a no, you're still passionate about the work and bringing it to the community where you impact. So it's all of us taking what we can from everything that you've said here and doing something. Like just grabbing a little bit of that passion and starting somewhere. Cuz you know, I know that at my shop, I would, I want a High Performance Team. I want a Human Potential Team. But I know I'm gonna start somewhere to move in that direction, and we'll see where we are in a year or whatever.
Al’ai: But I'll just also add the idea of 1%. There's a lot of expectations sometimes. So do the big thing. And again, like, what is the 1% that you can do to make a difference? What is the 1% that I can stop doing to make your life better? Because maybe it's like the stopping that's important, right? And so I think that is an important perspective to also understand.
Laura: Yeah.
Amanda: That's actually our podcast this week is on taking smaller steps, like just get on…
Al’ai: Oh, yay!
Amanda: Yeah. So you're hitting like all the things that we talk about.
Kendra: Yeah.
Al’ai: That just means you're in the right path. That what you're working on is really something that's important.
Amanda: Oh, thank you.
Kendra: Well, yeah, this has been so amazing. Al’ai, like, we definitely need to have you on back because I think we could take several pathways from this and have episode 1, 2, 3, however. So it's been such a joy. Any closing thoughts that you have for us?
Al’ai: I think if I can leave you one thing. I think it's the idea that each one of us has the capacity and the ability to make a choice of what is within our control, what is beyond our control, and what do we want to do with all the things that are facing us. And I hope that people will feel that sense of empowerment, Laura, about the many things that they cannot do. But maybe, making a choice that is aligned with their values. What is truly aligned with myself, my core being, and focus more on that, and do more of that.
There are many things that I do that actually sucks energy for me. And I try to do very well of not including that in my calendar. And I really, I reflect back which of these can I take away? And I fill myself for more events like this. Like me talking to the three of you is, like, it fills my cup. Because it actually makes me truly believe that the work that we're doing is important.
And I hope that you know that. And I hope that it'll also inspire people to think about ways to be kinder to yourself. Because then, as much as we try to be kind to everybody else, and do all the good things for other people, we often forget ourselves. And if there's, the one thing that I can leave you, is that all of my work is really rooted in self-compassion.
How can we show up for others by taking care of ourselves in a way that is healthy?
Laura: Yeah, I love that.
Kendra: Amen.
Amanda: People are gonna want to reach out to you. How would they get in contact with you?
Al’ai: I am the worst with emails. I really am. And so I am on social media, on Twitter. I don't have Instagram because I'm old school like that. And so for as long as Twitter will continue to exist. I'll be there. And I do respond to Twitter a lot.
Kendra: Yes, he does. I attest to that. He does respond.
Amanda: Guys. His Twitter handle is @alvarezzzy with three Zs. I love it. I especially love it now that the young kids are talking about rizzz all the time. You might have to be alvarizzzy. But if you don't mind, are there any favorite books that we should be looking at or,
Al’ai: Oh my gosh, a lot.
Amanda: You share nuggets all the time. It's the best question.
Al’ai: Yeah. And social media. I use that actually. It's, I know people like. So Kendra, thank you for mentioning that, by the way. I have a lot. I'm a slow reader. And so for me actually the things that I post on social media are reminders for me. And not just for other people. But the one that I'm finishing right now, which is very powerful, is Michelle Obama's. The Light We Carry is a fantastic book because she talks about just showing up for who you are. And in the conversations that we had here earlier about mattering and the invisible work, like she touches upon these things. And it was just one of those things, like, when you hear somebody say the lived experience that you have, you're like, oh yeah, I am not alone. Which is really part of compassion, right? That common humanity, that just like you, I struggle with this. And just like me, I can understand how it feels to go from one resuscitation, Amanda, to the next. And then feeling like you're betraying yourself from not even taking care of yourself because another patient needs you.
Amanda: I love it.
Kendra: Yeah. That's awesome. Well, thank you so much Al’ai for being with us today. This has been such an inspiring time, but I just want to really honor you for the work that you've done. I honor you for the vulnerability that you show every time you show up. There's just that common humanity that you spoke of. There's a connection there, and I just wanna say thank you for that because I know that's gonna really resonate even though we're doing this as a podcast. So thank you so much for just showing up, and for being vulnerable, and for connecting with us and our listeners, and really doing that every time that you do your daily work. So thank you very much for…
Al’ai: Thank you.
Kendra: …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.
