EM-Bound Medical Students: Wellness

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Jan 2024 EM Bound newsletter

This time of the year offers us a moment to reflect on our past year’s challenges and accomplishments. It also provides us with the opportunity to think ahead, to wish for a brighter future. Many of us, no doubt, are thinking of the many New Year’s resolutions we hope to achieve in the year ahead of us.

By now, you also realize that you have done a lot more than you thought you did. For the #EMBound applicants, this moment also marks the final half-year of your medical school training. Within the month, you’ll finish your interviews, and shortly after, you’ll be finalizing your rank list and your away rotations.

It’s indeed an exciting start to the year. We are glad to share this time with you. As we bid our goodbyes to last year, let’s embrace this opportunity to forge ahead!

A dear colleague and friend at Stanford, Dr. Jennifer Kanapicki, shared the following tips on goal setting: Use SMART goals: As you think about what you want to accomplish for 2024 use this figure to help you.

  • Write them down: Take a moment to hand-write your goals down in ink. It sticks better than typing it.
  • Plan it out:
    • Reflect on your current state: Reflect on some feedback and evaluations you’ve received this year.
    • Visualize your future: Consider using #mindfulness practice. Set the stage for what success looks like for you.
    • Anticipate the obstacles that you’ll encounter to reach your goals. Think of the new skills you’ll need to reach your goal successfully.
    • Acquire new skills: Look at this as an opportunity to advance yourself by gaining new skills and building upon skills you learned from last year.
  • Take action today! Break it down into smaller steps so you can start taking action today.
  • Be realistic: Focus on the things you can control. Review goals weekly.
  • Make it public! To increase your accountability, sharing your goals with your friends and family will help you reach your goals.
  • Create habits: Tie steps of your new goals with existing habits.
  • Practice self-compassion: Be kind to yourself. Debrief and figure out why? Go back to the SMART framework and see how you can do better.
  • Embrace a growth mindset: With deliberate practice, you can do this!

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Nov 2023 EM Bound newsletter

Last month, national organizations in emergency medicine collaborated to launch the October #StopTheStigmaEM Month campaign to normalize the need to take care of our mental health as physicians and healers. We’ve learned a lot from doing this work–the stigma for seeking mental health, the discrepant access to mental health care, and the variable help-seeking behaviors of physicians.

Another important aspect of this campaign was highlighting the power of community. To put this in #EMBound perspective, many of you are going through interviews now, hoping to secure that residency spot. The process is intense, and because of the many known and unknown factors that influence your competitiveness as a candidate, it is very common for applicants to feel isolated.

And we know that several other contributing factors impact this sense of isolation. Experiencing an adverse event is an example. Yet, we often associate adverse events with challenging clinical cases–a patient dies, a bad outcome, or a medical error. The reality is that every day, we deal with challenges at work and within our home life, including managing our insecurities, doubts, and experiences of guilt and shame. The #StopTheStigmaEM campaign was helpful for me in highlighting that we don’t need to have a disorder to seek mental health support. Just like getting an annual check-up and preventative work with your primary care and your dentist, mental health care can have similar benefits. Practicing emotional self-care is just as important as preparing for that next interview or studying for that next exam. Additionally, there are many ways to acknowledge the challenges we encounter, and having a sense of community is a necessary resource.

We want to emphasize this. You don’t have to go through this journey alone. Reach out to mentors, colleagues, and friends. Celebrate the wins. Support each other. Be kind to yourself. This is just the beginning of a wonderful career in emergency medicine. #YouAreNotAlone

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Oct 2023 EM Bound newsletter

Growth mindset.

You’ve heard about it before. It’s the belief that one can develop their skills through hard work, deliberate practice, and feedback. It’s the opposite of a fixed mindset or the idea that one’s born with their talents. Dr. Carol Dweck has shown that having a growth mindset makes it easier to develop new interests, and one can also achieve whatever one sets their mind to accomplish.

In Emergency Medicine, this is a challenging concept. You look around and think that many are just born to work in the ED. Many are outgoing and have a can-do attitude. It also feels daunting to watch senior residents and attendings walking out of a patient’s room after only a brief encounter and already having a solid plan. In truth, you, too, can develop this.

We do not always articulate to learners how often we make mistakes in our judgment. We rely on heuristics, and heuristics are not infallible. In truth, part of our training and the practice of Emergency Medicine is the constant refinement of our practice patterns and heuristics. This requires seeing a lot of patients (hard work), reading and refining our mental models on pathophysiology and treatment (deliberate practice), and following up on our patients (feedback).

This means there’s no shortcut to developing broader differential diagnoses. It also means being kind to yourself. So on your next shift in the ED, and you miss a diagnosis, instead of being critical about your performance, remember the power of “yet.” You may not know this concept yet, though you do have the capacity to learn this. So get out there, and learn! Remember that we have very high standards in Emergency Medicine and that with effort, we believe you can reach them.

Below is a great graphic that illustrates the difference between fixed vs. growth mindset from FortitudeHP.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Sept 2023 EM Bound newsletter

Through our Wellness Corner, we’ve covered many tools and concepts to help you along your journey. Some important ones to consider during this time of transitions and change include the have-to/want-to perspectives, ways to prioritize yourself, and setting boundaries. These are all part of practicing self-compassion and understanding that we have the opportunity to control how we allow things to impact our lives, including how we react to things.

Another tool to consider is developing a generous interpretation of intentions and actions. Many of us have the natural reaction to think critically about an event with a negativity bias. After all, as Barbara Fredrickson (YouTube) highlights in her work, it takes at least three positive things to overcome one negative event. Negativity bias is not all that negative. It’s what allows us to survive and discern threats to our safety. However, left unchecked, this negativity bias also impacts how we work with others, how we trust, and how we take care of ourselves.

A way to apply generous interpretation is using the phrase, “just like me.” Just like me, you feel hungry, angry, and sad. Like you, I would feel anxious if I had not heard back from the residency program I wanted to interview. Normalizing these emotions can help us understand how we then interact with the other person. Just like me, I can imagine residency coordinators getting inundated with emails in the next several weeks about interview updates.

How then can I use this perspective when I communicate with them? Simple. Be kind. Just like you, no one wants to receive emails that are harsh or accusatory. Do they have all of your application files? Are they following the county release date for interviews? Just like you, coordinators are just doing the best they can, and just like you, they are also dealing with the pandemic, all the other events happening in the residency program, and their personal lives.

Just as well, when you don’t get that interview, be kind to yourself. Just like me, it’s never fun to feel like you’re not good enough. All the same, it’s essential to understand that perhaps you are better off not going to that program. By now, you’ve done the best you can, be somewhere that sees all the amazingness that you can offer, and where they can support you to be the best version of yourself.

It’s a stressful month. Next time you don’t get a response back from an email you sent, or someone snaps at you out of nowhere, breathe. Pause. Using generous interpretation, check in with them.

“I can only imagine how many emails you get every day, especially during the interview season. I wanted to follow up on the email about….”

“I’m sensing you’re upset. Is everything OK?”

Each of us has the capacity to change how we see things for the better. Each of us has the capacity to react to things that is kinder for ourselves and others. To be clear, feeling negative is not a bad thing. It’s OK to feel frustrated, angry, and feel ignored. And it’s also OK to respond with compassion and generous interpretation.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Aug 2023 EM Bound newsletter

Navigating the residency application can be confusing for us all and residency leadership across the country. With new changes coming along, we are also learning and adapting along with you. It is because of these changes that mentorship really matters.

Mentorship offers a unique perspective on the challenges in today’s application cycle. Specifically, you may be worried about the lack of research in your application. However, the summer that you’re applying may not be the best time to start new research. Your mentor can offer you guidance that truly highlights your strengths. I’m often surprised when a mentee shares a sparse CV only to realize there were so many things not listed simply because they did not think these should be included. Conversely, it’s also not uncommon to see CVs with so much padding and “fluff” that reviewers are very keen at noticing. With guidance, you can successfully avoid both extremes.

So how do you effectively structure your mentorship?

Have clear goals

  • Just like any successful meeting, having a clear agenda is helpful. During your first meeting, share with your mentor what you aspire to achieve, your dreams (yes, dreams!), your motivations, and what you need in order to get there. Mentors do not have all the solutions but they can be very creative in connecting you to someone who may help get you to where you want or need to be. Consider a mentor-mentee agreement (Here’s an example).

Schedule regular meetings

  • Mentorship is not a one-and-done thing. It is a relationship. Given the complexity of the application process, it’s important to break each step down into smaller chunks, which lends itself to several sessions with your mentor.

Develop action items AND set deadlines

  • Your mentor is busy, just like you. Offering a mutually-acceptable and realistic deadline allows for clarity of expectations and deliverables. By being explicit with the tasks, you can identify and anticipate roadblocks, and even role-play intimidating conversations such as asking for a letter.
    • Set reminders: Send a calendar invite to yourself and your mentor along with calendar reminders.
    • Schedule your next meeting: Especially with certain tasks–finishing your personal statement, letters of recommendation, CV, final review of your application, it’s best to put these tasks in your and your mentor’s calendar.

Clarify

  • Mentors may forget that from your perspective, some things may be so foreign–remember the eSLOE/oSLOE/nEMSLOE?
    • Ask questions: It’s better to clarify while you’re in the meeting than trying to do a task then realize you don’t really understand what you’re supposed to do.

Show up

  • Nothing irks mentors more than mentees not holding up to their end of the relationship. We’re all busy. Let us know if something has come up. This is not the time to ghost your mentor. See the mentor-mentee contract above.

Thank you

  • This is simple, yet often forgotten. Remember, mentors have choices on who their mentees are. They’ve chosen you. A quick acknowledgment of this goes a long way. For me, one of the best thank you’s is a quick update email highlighting what my mentee has been doing. It reminds us that what they do matters.

Goodbye

  • This can be awkward. Your needs may not be something that your mentor is able to meet, or that you may have outgrown them. Similarly, thank them for what they have thus far offered you. This is a great time to check for compatibility and best suit: mentor vs. a coach vs. a sponsor. If it’s an assigned mentorship and you are not able to switch, look for shared interests and see if you can further develop a skill or obtain a relevant connection to someone else. Whatever you do, be kind.

The process of getting into your dream EM residency is daunting and overwhelming. You don’t have to go through it alone. Your mentors are there to guide you, recalibrate expectations, celebrate your successes along the way, and be there with you to strategize when unexpected things happen. The best mentors are the ones who are able to tell you when you are astray. Each of us needs more than luck in our journey–we need guides who can help direct us to the right path.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in July 2023 EM Bound newsletter

Now that July is here, and you’ve crossed another milestone! Congratulations! Dr. Carol Dweck’s Growth Mindset often comes up in medical education.

While we celebrate our #EMBound friends and colleagues, you now carry the distinction of being one of the most senior medical students in your school. There is a lot of pressure inherent to this. In addition to simply doing well in your advanced rotations, a more junior medical student may be working alongside you. How do you take this newly minted responsibility? How do you teach them the ropes of clinical medicine while ensuring you are also catching up with your own learning?

Breathe.

Armed with scaffolding in your medical knowledge, you will soon start noticing more inefficiencies in our clinical practice. You will come up with fantastic ideas to make this better, fast, and more efficient. While this is exciting, this can also be a great source of frustration. How do you navigate this without negatively impacting your performance? This is a common source of burnout in medical trainees and physicians.

One way to avoid the downward cycle of helplessness is to understand what is within and beyond your control. In their latest book, Big Feelings: How to Be Okay When Things are Not Okay, Liz and Mollie discuss the withins and the beyonds. They talk about navigating uncertainties by understanding what is within our scope of control and the beyonds. Once we are clear about our withins, find a moment to reflect on how you plan to address these challenges. What skills will you be using? What skills do you currently have, and what skills will you need to develop? Who can help you? Understanding this gives you the power to formulate your course better. “I need to set aside time to study for this test.” “I will ask my senior resident how to handle the syringe better when I inject lidocaine to control the needle better.”

Just as well, knowing the beyonds can be empowering. Let go of trying to change the beyonds. “I cannot change the weather outside,” or things that have already happened in the past, “I did not do well on my Step 1 test.”

Applying self-compassion allows you to start today and focus on what is within your control. I wish I had known this when I was a medical student. I wish I had known this when I was a resident or junior faculty. I am now able to be kinder to myself. With finite time and energy, I can dedicate myself more to challenges and opportunities within my control.

How might you apply this perspective to your next EM shift?

Moises Gallegos, MD MPH
Clerkship Director
Stanford Emergency Medicine
Originally published in June 2023 EM Bound newsletter

I recently had the opportunity to speak in front of our EM interest group during a story-sharing event. Having been a part of so many interesting patients encounters over the last several years, I was struggling to settle on what story I would share. Unable to choose just one, I decided instead to speak about the concept of slowing down in EM, a concept you wouldn’t think fits the hustle and bustle of the ED. Truth is though, that many of the patients we see in the ED will benefit more from our time and connection than any medication or treatment we could offer.

One of the stories that I shared was of an older patient who passed away under my care in the ED during the early months of COVID. Visitation rules were at their strictest, and I had been communicating with family outside of the building, coordinating and understanding the goals of care. Although I had several other patients on my mind as well, it hit me at some point that I needed to slow down and fully commit myself to this patient that would likely pass before the end of my shift, especially since I was functioning as the point of contact with family. I asked the family if there was anything I could say or do for their loved one in the ED and was asked to play a specific song that was known to be her favorite. Working with the patient’s nurse, we coordinated to focus on her comfort, we began to play the song in the room, and I expressed some messages of love that the family had asked me to convey. Before the nurse and I could leave the room, the song came to an end. Almost simultaneously, the patient took her last breath. Some might say it was coincidental. I like to think it was that the patient found calm and peace after hearing the words of her family and the song they played for her. Looking back at that night, I am glad that I took the extra minutes to connect with the patient and her family. Sure I was stressed by the growing list of tasks and new patients piling up, but it was important for me to slow down in that moment for them.

As a student, you often become the primary point of contact for your patients and their families. You may have the opportunity to spend more time at the bedside than other members of the team. As you enter the next few months, marked by away rotations and sub-internship roles, try and stay open to the times where it’ll mean a lot, for both you and your patients, to slow down and take in the moment.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in June 2023 EM Bound newsletter

As Match is behind us, we welcome the #EMBound Class of 2024! For the Class of 2023, congratulations! The latest Match outcome brings light to the growing challenges our specialty faces. EM’s fast-paced and unpredictable nature of the job makes it exciting and stressful. EM is a vibrant, incredibly rewarding specialty with lots to offer.

Change is inevitable in all aspects of life, and medicine is no exception.

Emergency new technologies, treatments, and diseases add to the exciting field. This requires that we continue to be open to learning and being adaptable, including learning new skills, accepting new ideas even if we think you have already learned the material, and trying new approaches. It is also important to acknowledge that there are variations of practice in medicine, coupled with one’s version of balancing science and art.

These variations in practice and the ever-changing landscape of medicine added to the very nature of your undergoing your own transition as you level up can be challenging and even uncomfortable. The transitions may require stepping out of your comfort zone, taking on new responsibilities, and working in unfamiliar settings. Sometimes, it may feel like you’re balancing your safety over your patient’s. As you embrace the change, grow as a person, and develop your identity as a medical professional, know that you are not alone in this experience and that your residents and faculty also underwent many transitions to get to where they are now. Lean into this as you remind yourself that you are still learning, still growing.

The upcoming residency application process is no different.

Face it with a sense of openness and a willingness to embrace this change. You’ll be surprised by what you discover about yourself, your passions, and your limitations. As you prepare for your away rotations, study, and plan your summer, pause. You don’t have to figure it all out all at once. Set up a meeting with your advisor and your mentors. Don’t forget to contact some graduating medical students and ask them for tips. What did they learn? What were some lessons they took away from last year’s cycle? If they had to do it again, what would they do differently? What would they do again? They are your closest source of real-life experience from an applicant’s perspective.

For those who just matched, again, congratulations!

Now you will likely face the challenge of maximizing the remaining time you have in medical school. While it’s probably too late to join an international rotation, ask yourself: In 5 years or 10 years, what would I remember more from the last month of free time before becoming a full-time professional emergency medicine doctor? Do you stay local? Do you travel?

For some of you, this means traveling and spending some time with the friends you made during medical school. For some, this may mean finishing up your research or capstone project. And for some, you’ll start opening up the books and online resources to prepare for the internship year. Whatever you decide, pause. Enjoy knowing that you’ve finally arrived at a point where you were so worried about where you would end up this time last year. Revel in this. You’ve earned it.

May you go through transitions with ease and grace.

All the same, may you continue to find ways to enjoy your time as a medical student. We’re excited to welcome you to Emergency Medicine, with all its imperfections, and we look forward to building a better future that includes you in it.

Tatiana Carrillo, DO
Clinical Assistant Professor
University of Pennsylvania

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine

Originally published in May 2023 EM Bound newsletter

Several leaders in emergency medicine shared their perspectives on transitions. How have you managed transitions? What goes through your mind? Excitement? Trepidation? A mix of both? It wasn’t until the past couple of years that I learned about the idea of imposter syndrome–that persistent self-doubt or feeling like you don’t belong. Transitions have a way of exacerbating these feelings.

Understanding your locus of control is essential, as transitions are moments in our lives where we feel we do not have control over things.

  • You have control over your mindset. Understand that you’re not alone in this experience and that each and everyone surrounding you also go through transitions and the challenges and excitement inherent in transitions. When you start your away rotation or your first shift as an intern, remember that this was the day you’ve been looking forward to and that you’re finally here! In a year, how will you describe this moment to someone else who will be in your very same shoes?
  • Lean into your friends, family, and mentors. Just as everyone else is going through their own struggles with transitions, you can be that senior resident or attending you wish you had. Be kind. Be patient. To yourself. And to others.
  • Don’t forget your dentist. Dr. Cassandra Brady shared this experience to remind us that there are vital logistics we need to arm ourselves with as we embark on this journey. These support teams will help us be our best selves–your primary care physician, mental health specialist, and car repair person. We don’t often need them every day, and yet when we do, wouldn’t it be easier if we already know who they are? “Take care of yourself,” as Dr. Edgar Ordonez summarizes.
  • Be you; be authentically you. Often, we try to change ourselves to fit in–some even would change their name or the pronunciation of their name just to belong. While at first, it feels comforting, this is an act of betrayal to your own self. Dr. Sree Natesan shares how being authentic and true to yourself can go a long way. After all, you are there for a reason, and “who you are was enough to get you through the door.”
  • It’s OK not to be OK. Dr. Josh Mugele shares that when he is in crisis mode, he “writes out on a piece of paper the things that are important to [him].” Whatever you do, “don’t let imposter syndrome make the decision for you.” — Dr. Joel Moll

And remember, as Dr. Bradby points out, “It doesn’t get easier; it just gets different,” so take care of yourself. As Dr. Lexie Mannix shares, “If I don’t take care of myself, I will not be able to also show up and be my best.”

So go out there! Embrace all the emotions attached to transitions! You don’t have to go through it alone.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in March 2023 EM Bound newsletter

Live in the moment.

Match Day is the most highly anticipated day in medical school–far more than the White Coat ceremony or the first day of clinicals. It’s a culmination of grueling years of late-night studying, countless hours of devouring pages and pages of knowledge, showing up to demanding clinical rotations, and constantly having to prove yourself on challenging exams. In a way, it’s a day when all graduating medical students, including #EMBound students just like you, collectively expect to find out where you will spend the next 3 or so years of training to be that emergency physician you’ve written about in your personal statement, and talked about during your interviews.

So, here’s to acknowledging that March is stressful for graduating medical students like you. The anticipation and excitement surrounding this day can be overwhelming, and it’s essential to remind yourself to live in the moment and appreciate all that you have accomplished thus far.

Match Day is a significant life event, and it is easy not to remember it all because of multiple strong emotions simultaneously. We often hear about living in the moment, and with the Match Day around the corner, plan on being fully engaged in the present moment without worrying about the future or dwelling on the past. This way, we can be present to the fullest and embrace everything it offers. I still remember the trepidation of opening that envelope in front of friends and family. Looking back, beyond finding out where I matched, that day was a blur. Maybe that’s a good thing, but in retrospect, isn’t Match Day supposed to be the most highly anticipated day and something I would want to remember?

Match Day is a time of celebration and joy, but it’s also a time of uncertainty and transition. Like many medical students, it’s normal to feel unsure about what the future holds, especially since Match Day can also feel like a critical decision is being made about your career and life. In these moments, it’s essential to remember to appreciate all you have accomplished thus far, reflecting on all the hard work and sacrifices you’ve made to get to this point. Maybe this can help you to shift your focus away from the future and onto the present moment and allow yourself to enjoy and savor this special day fully.

Mindfulness can be as simple as taking a few deep breaths or focusing on your senses. You can close your eyes and feel the weight of your clothes or the air hitting your skin. Focusing on these sensations can redirect your mind to appreciate the present moment fully. To stay present, you can also take the time to take in your surroundings. Look at the faces of classmates, professors, and loved ones in the audience. Take note of the decorations, sounds, and venue. These details help ground you in the present moment and enhance your experience.

Medical school training has been challenging. The challenges and obstacles you had to overcome helped shape you into the emergency physician you will become. So take a moment to recognize and honor these struggles and hard work that led you to this momentous occasion.

Take pride in your achievements and use them as inspiration and motivation as you move into your next home, your residency program.

Match Day is not the end of their journey; it’s just the beginning of a new one.

Tomorrow will be another day. So as you think about Match Day, plan on savoring this special moment, and celebrate your success! At ALiEM, we are celebrating your success! Congratulations, future #EMDocs!

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Feb 2023 EM Bound newsletter

For #EMBound medical students, February can be more stressful. Clinical years are more physically, mentally, and emotionally challenging. You’re not memorizing facts; you’re applying your medical knowledge to disease processes that impact patient care.

For graduating #EMBound, you now must consolidate everything you’ve learned about programs you interviewed, decide on your rank list, and hope you match somewhere within your top 3. For those in their first year of clinicals, you’re expected to summarize your life into ERAS in a few months, craft the perfect personal statement to highlight all the things you’ve done and experienced, and cross your fingers you’d get enough interviews–all the while wading through clerkships.

So now that February is here, you’re faced with big decisions.

Listening to a podcast interview by a performance expert and neuroscientist, Dr. Huberman, with Dr. Alia Crum, an expert on stress and mindset, Dr. Crum speaks of stress from a growth mindset perspective. To be clear, no one is advocating for us to seek more stress. Dr. Crum’s work highlights the concept of the stress-is-enhancing mindset and how this mindset helps us respond better to threatening and challenging stressors… like agonizing about the rank list.

To summarize this episode, Dr. Crum shares why we often stress about something because it affects what we care about, what matters to us, and our values. Therefore, the goal is not to manage or cope with stress but instead to leverage and work with the stress.

Here are 3 steps Dr. Crum provides:

  1. Acknowledge that you’re stressed. This requires self-awareness and owning this. We all have stress. Just like you, I would be stressed about the rank list, too.
  2. Welcome stress. Dr. Crum explains, “Stress is connected to what we care about.” Therefore, we should seek out why we feel stressed and what values or goals it affects. Reconnect with that value or goal that you really care about–you want to belong, or you want to go to a prestigious program, or you want to live near the ocean.
  3. Utilize your stress response. Instead of getting rid of the stress–ignoring it, pushing it away, agonizing over it–use this stress to help you get what you really care about, which is getting clarity on what matters most to you and how that can help you work through your rank list.

You overcame a lot over the past 2 years, and I have no doubt this month will be stressful.

Dr. Adam Grant once tweeted, “Adversity isn’t always a test to conquer. Sometimes it’s a struggle to endure… All your scars may not make you stronger, but they do remind you of your strength.”

We all stress over things. Our profession expects us to manage uncertainty well. The Match is just another example of uncertainty. I hope you know that you’re not alone in this experience. Talk to your mentors. Talk to your friends. Talk to your family. They can help you see your goals and values. And no matter what happens next month, you’re almost there! Emergency Departments across the country are looking forward to welcoming you as part of our family.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Jan 2023 EM Bound newsletter

I started 2022 after having just recovered from COVID-19. I reflected a lot about dualities–being both a physician and a patient, a caregiver, and someone who also deserves to receive care. As many of you look back on 2022, I can imagine there are joys, moments of struggle, and even regrets. And as we start 2023, just like you, the allure of a New Year’s resolution offers the opportunity for a do-over and hope for the better.

I recently learned about the work of Alex Elle of InsightTimer. She shares some perspectives on re-centering in times of uncertainty, specifically, the concept of “I can… And Still…”

  • I can focus on becoming a better clinician and still make time to rest and play.
  • I can take care of patients who either refuse to believe in science or refuse to take part in their care and still show them compassion.
  • I can make mistakes and still learn from them.
  • I can love someone and still prioritize my needs.

Dualities allow us to accept the intersectionalities of our identities. It also offers us grace for ourselves as we navigate uncertainties, make mistakes, and grow. As a concept, dualities also allow us to look into 2023 with more #selfcompassion.

The activist Alok was recently interviewed for Vogue magazine, where they shared their perspective on New Year’s resolutions. They shared that one of the beauties of resolution is that we can always try again next time, which is part of our “perpetual state of transformation.”

I love this outlook as it helps us break away from the self-inflicted restrictions we often fall into the goal of being better.

  • I can focus on self-improvement, and still accept who I am, and embrace my many imperfections.

Alok, instead, reminds us of resolution as a continued goal of recalibration, where we can embrace a growth mindset.

And so, our wish for you for 2023: May you embrace dualities. May you continue to strive to be better and still be kind to yourself along the way.

As a dear friend wished me, may 2023 exceed your highest expectations!

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Dec 2022 EM Bound newsletter

Last year, we tackled surviving the holiday season in this newsletter. TLDR: It is essential to pause and practice mindfulness and relish the simple moments that the holiday season brings–seeing friends, holiday dinners, potlucks, and secret Santa presents.

Patient volume and ED boarding are at an all-time high for many of us. To make it more challenging, we are now in the middle of what’s being called the Tripledemic–COVID + influenza + RSV season. We’ve dealt with each of these surges before, yet now, we have to manage patients with sometimes 3 of these at once.

How can we preserve our well-being?

In any given challenge, it is vital to understand the withins and the beyonds of our control. Prioritizing our safety is something we have control over as we care for our patients. Let’s look at the physician’s hierarchy of needs. Whether working clinical shifts or traveling to see friends and family, you must also attend to your body’s needs. Eat healthily, exercise, prioritize sleep, take some vitamins, including some sunlight and other sources of vitamin D, get vaccinated, wash your hands, and wear your mask. Your pediatric patient will likely sneeze or cough at you (beyond your control). However, if you at least attend to your safety and needs (PPE, vaccination), you are more likely to minimize getting sick yourself. Oh, and take a moment to relax. When you relax, you allow yourself to replenish and heal. Remember, the goal here is for your growth and fulfillment and not just for survival.

As we shared before, while it has been a long pandemic, and we’re about to embark on new challenges, we at ALiEM EM Bound wish you the very best this holiday season, and may you find moments of awareness to savor these experiences.

Alana Harp, MD
Chief Resident
Stanford Emergency Medicine
Originally published in Jan 2023 EM Bound newsletter

January is a weird time to be a fourth-year medical student. Many people, the kind that isn’t staring down the barrel of finishing medical school and starting residency, are focused on New Year’s resolutions and fresh starts. However, those of you with the MS4 title are compulsively opening up your NRMP rank list trying to figure out what you want the next 3-4 years of your life to be like. While I can’t possibly tell you how to rank your future, I’d like to pass on a bit of wisdom for how to survive your end.

I’ve talked to many applicants this year, and the question I’m probably asked the most is, “how is your work/life balance?” This is a great question, but my work/life balance has absolutely no bearing on what yours can and will look like. I would argue that how you keep yourself sane as a resident is a practice that can start right now. Yes, I know you have a couple of very stressful months coming up with the ranking, matching, and moving. Still, it’s no more stressful than learning how to practice actual medicine, and now would be a good time to rediscover those small joys that make you a person outside of the hospital.

As I sit here, a PGY-4 about to go off into the world of attending-hood, here are some habits I rebuilt during those 6 months you are about to embark on, which I still do today to help me keep some of that illustrious balance we all speak of:

  • I read a little bit every single night before bed
  • I cook at least one night a week because it comforts me
  • I workout (semi-regularly) and pretty much never regret it
  • I go to see that movie I’ve been waiting for (even if it’s by myself for a weekday morning matinee)
  • I call my mom at least every few days just to talk about nothing
  • I say yes to the post-shift happy hour, even when I’m tired and think I don’t want to. Because yes, actually, I did want to, and there’s nothing like time with friends to recharge you after a tough day

This is what has worked for me, and I’m able to make time for myself even now because they are habits I have built.

This will look different for everyone, but try pondering these questions for yourself:

  • What food do you love that makes you feel better?
  • What activity makes you feel more like yourself, and how can you make time for it?
  • Who do you reach out to when you are feeling down or have good news to share?

Maintaining your happiness and wellness is a skill that requires practice and honing, just like any procedure or clinical skill you will learn in the years to come. More importantly, this is something you can start working on now. So go on and enjoy this last bit of medical school, make some time for yourself, and congratulations to you all for making it this far.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Nov 2022 EM Bound newsletter

Last month, national organizations in emergency medicine collaborated to launch the October #StopTheStigmaEM Month campaign to normalize the need to take care of our mental health as physicians and healers. We’ve learned a lot from doing this work–the stigma for seeking mental health, the discrepant access to mental health care, and the variable help-seeking behaviors of physicians.

Another important aspect of this campaign was highlighting the power of community. To put this in #EMBound perspective, many of you are going through interviews now, hoping to secure that residency spot. The process is intense, and because of the many known and unknown factors that influence your competitiveness as a candidate, it is very common for applicants to feel isolated.

And we know that several other contributing factors impact this sense of isolation. Experiencing an adverse event is an example. Yet, we often associate adverse events with challenging clinical cases–a patient dies, a bad outcome, or a medical error. The reality is that every day, we deal with challenges at work and within our home life, including managing our insecurities, doubts, and experiences of guilt and shame. The #StopTheStigmaEM campaign was helpful for me in highlighting that we don’t need to have a disorder to seek mental health support. Just like getting an annual check-up and preventative work with your primary care and your dentist, mental health care can have similar benefits. Practicing emotional self-care is just as important as preparing for that next interview or studying for that next exam. Additionally, there are many ways to acknowledge the challenges we encounter, and having a sense of community is a necessary resource.

We want to emphasize this. You don’t have to go through this journey alone. Reach out to mentors, colleagues, and friends. Celebrate the wins. Support each other. Be kind to yourself. This is just the beginning of a wonderful career in emergency medicine.

#YouAreNotAlone

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Sept 2022 EM Bound newsletter

So I just got back from vacation and was thinking about what to write on the wellness corner. During my time away, I had moments when I was disconnected from work, my emails, and even text messages! It gave me a chance to reflect on the past academic year, the distance I’ve traveled, and what lies ahead on the horizon.

So how does this relate to you, #EMBound students, many of whom likely just submitted your ERAS application? I can imagine this is not the time for vacation for many of you. As you plan your next day off, however, you may have this overwhelming sense of responsibility to catch up on things you’ve put off–from the mundane lists of doing laundry and other chores to studying for your shelf exam or that article you were hoping to read, or that presentation you have to do at the end of your rotation. And yet, just like me, I bet whenever you get that day off or the “golden weekend,” there’s this hope for something extraordinary–seeing friends, a quick getaway, a nice dinner.

The allure of the day off suddenly becomes dreadful if not morphing into just another nonclinical yet work-filled day. During my vacation, there were undoubtedly moments like this. Maybe during my flight, I will try to squeeze in a paper. Perhaps I’ll answer that one email. Then soon enough, I find myself immersed in trying to beat yet another deadline, overwhelmed, in paradise.

I remind myself that this is an all too common experience. I’m not alone. It’s a timely reminder that we don’t always have to be “on” for work. It’s ok to take a break. Because it’s as if “busy-ness” equals a strong work ethic. It does not.

Dr. Nathalie Martinek shares that we all need solitude to “reflect on our needs, values & what matters in life to return to purpose,” which could mean “a few minutes/day & longer periods.” When we’re overwhelmed, Dr. Brené Brown discusses her research in her book, Atlas of the Heart, about nothingness being its only cure: “nothingness is the only way to really reset after overwhelm.”

To be clear, I’m not advocating for you to put off time-sensitive work. What I’m suggesting is perhaps, during your moments of stillness, you can explore and reflect upon what’s causing you to procrastinate in the first place. And maybe then, you’ll realize that you have other unmet needs that also call for your attention. Attend to them.

And so, my wish for you:

May you discover the power of stillness and nothingness and still feel you are enough.

Because you are enough.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in Aug 2022 EM Bound newsletter

As you apply what you’ve learned about the withins and the beyonds, it’s also important to now consider the role of self-advocacy. Self-advocacy is an example of self-compassion and may come in many forms: the act of standing up for yourself, putting your name on the ballot, and marketing your work. Self-advocacy also can mean setting boundaries and prioritizing yourself and your well-being.

We’ve said it before. Practicing self-compassion is not easy. The more I talk about it, the more I hear why practicing it in medicine is challenging. “I don’t want to sound x,” with x being lazy, selfish, or sounding like you don’t care. But it’s the opposite. Limit-setting, for instance, allows you to understand your limits and also what you’re able and capable of doing.

Recently, volume and acuity in the ED have been high. While it’s great for learning, it’s also challenging when boarding patients are everywhere. Limit-setting, I learned, is being able to set limits on how many patients I’m going to pick up so I can safely manage them vs. going out in the waiting room, picking up several new patients on my own, and then not having the space and time to see them all. Ultimately, the patients end up waiting longer, and my patients and I are more frustrated, all while regretting the same altruistic and can-do attitude I set out to manifest. Learn from my mistake.

What if, for instance, you realize the waiting room is crowded, and instead of going solo and picking up as many patients, you pause and briefly huddle with the charge nurse and your senior resident on who to see next and reorganize priorities? You will still safely be able to care for the sickest patients hiding behind the level 3 acuity pile.

This is no different from taking on multiple projects and opportunities. So many opportunities look great and will undoubtedly be good for your career advancement. But at what cost?

What if, instead, you can sit down with your advisor or mentor and discuss all the opportunities you’re considering? Wouldn’t it be helpful to have a sounding board to reflect upon your progress, assess gaps in your ERAS application, and then reprioritize goals and action plans?

I wish I knew this when I was a medical student, resident, or even an attending. I still fumble over this once in a while. So now, I effort harder on limit-setting. What can I realistically accomplish? What skill do I need to achieve this? What support is available to me? All this while also keeping in mind that I have to take care of myself, including finding time to cultivate my relationships with my family and friends. I know this is not easy. But we can all start somewhere.

Al’ai Alvarez, MD
Director of Well-Being
Stanford Emergency Medicine
Originally published in March 2022 EM Bound newsletter

Mindfulness has taken a bad rap in wellness interventions. People associate it with yoga and meditation, and not as a tool to clear the mind, but as a punishment for not being resilient. As someone who trained in the Bronx for Emergency Medicine, mindfulness and meditation certainly were not part of my formal or even hidden curriculum. But there is an argument for mindfulness in developing resilience.

Mindfulness is really developing self-awareness. Wouldn’t it be helpful if you know you are getting hyperactivated when a consultant is asking you questions? How about when you’re suturing or putting an IV and your attending is watching you? Knowing that you are getting nervous, even subconsciously–your heart rate goes faster, your hands’ tremor–that there are ways to actually overcome this? Mindfulness allows us to deal with the situation.

Before we can talk about solutions to handle the nerves that we experience, it is important to develop the skill of being present in the moment. Mindfulness and meditation train our minds to be present. There are several ways to develop a daily habit of meditation. Start small, even a few minutes a day, and anchor it to something you do every day already–brushing your teeth, showering, or walking to your car or the subway.

There are several benefits to mindfulness, including the awareness of what is happening in the present. So in that scenario when your heart starts racing because you’re feeling nervous, try box breathing. As your heart rate increases, your ability to focus diminishes. You develop tunnel vision. By slowing down your breathing, you will be able to slow down your heart rate, which then will help manage the tremors, and also have a better focus on how you should handle the situation. Try it next time!

Al'ai Alvarez, MD

Al'ai Alvarez, MD

Section Editor, ALiEM Medical Student Home Page
Clinical Associate Professor
Director of Well-being
Co-Chair, The Human Potential Team
Department of Emergency Medicine
Stanford University School of Medicine