Nigel Girgrah, MD, chief wellness officer at Ochsner Health System, discusses strategies for creating a culture of well-being at your health care organization, including addressing mental health stigma, building a strong EAP program, employing an opt-out vs. opt-in approach and encouraging leadership to be vulnerable about their own burnout struggles.
- Nigel Girgrah, MD, chief wellness officer, Ochsner Health System
- Jennifer Mathews, practice transformation and sustainability, AMA
Introduction: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Mathews: Hello everyone. I am Jennifer Mathews, digital content specialist for AMA STEPS Forward®. Thank you so much for joining our podcast today. I'm very excited to welcome our guest, Dr. Nigel Girgrah, chief wellness officer at Ochsner Health System in New Orleans. Dr. Girgrah, thanks so much for joining us.
Dr. Girgrah: It is so nice to be here, Jen.
Mathews: Why don't you start by telling the listeners just a little bit about yourself and your background?
Dr. Girgrah: Sure, so I am a practicing transplant liver disease specialist. I did all my training in Toronto, Canada and actually worked in Toronto until 2007. In 2007, I moved to New Orleans. I joined Ochsner Health. Since that time I've had a number of, what I would call, traditional operational leadership roles. And then in 2018, assumed a less traditional role of chief wellness officer. So that's a little bit about me.
Mathews: Great. Well, we are here today, as you know, but our listeners don't, to discuss mental health stigma in health care and particularly your personal work in combating physician burnout and why it is so important, especially now. So why don't we start with you telling us a little about how your journey into mental health began, particularly as it pertains to health care?
Dr. Girgrah: Yeah, I'd be delighted to, I, you know, Jen, I don't think I've really thought of burnout or mental health in the health care setting until, I guess it was 2013 and in 2013, I went back to Toronto for a med school reunion and a friend of mine, Craig, wasn't there. And I found out that Craig had taken his life in the months leading up to the reunion. Now he was a pretty famous surgeon in Canada, famous to the point that you could Google him and find out things about him. And when I did Google him, there were some really disturbing descriptions, things like alcoholism in 2009, loss of his medical license, loss of privileges. And I was deeply affected and stressed. He was a kind, compassionate, funny individual. I'd matriculated into med school with him. And I became interested in this subject for all the reasons that many of you all would be.
I was touched as this had sort of hit me as a friend. And the more and more I thought about it, there just seemed to be a moral case to address this problem. So, health care draws in what we call, Jen, elite professionals. These are individuals that are usually deeply driven, highly conscientious, but prone to guilt and self-doubt. Now there's an upside to this, right. So, these individuals study hard, they work hard, they're there for their patients 24/7, they're fastidious. But there is a downside as well, and that's burnout, guilt about self-care, self-compassion. And when you study this, it's clearly a nurture versus nature thing. Matriculating medical students who've been shown to be less depressed, more resilient than other college students. But something happens after entry med school, but there's also what I would call a business case to address.
Well-being has been shown to be linked to improved patient experience, improved quality and safety outcomes, increased discretionary effort, decreased turnover, and, you know, improved financial performance. So, I would think of well-being as a leading quality indicator that's associated with all the good things that you want as a health system. So that's where it started. And then you can sort of fast forward to the pandemic, to the summer of 2020. And I found myself two summers ago, really kind of struggling, languishing, and, you know, I recognize the triggers for that. The summer represents the anniversary of the death of a son many years ago, but usually, I'm able to insert sort of compensatory measures. I'm usually up in Canada with friends and loved ones. I'm able to exercise. That year I'd had a knee injury. And I just thought things were kind of getting just a little bit out of control.
And eventually I reached out for help and, you know, sort of turned things around. But I guess my aha moment was that everybody kind of has their version of this story. And so, in September of that year, I sent an open letter to all 34,000 Ochsner employees. And historically that letter, we call it the chief wellness officer message, had been sort of a somewhat sterile report out, about things that we were doing in the office. But that year I shared a little bit about myself. I talked about that story. And then I talked more broadly about the issue of mental health in the health care sector. And the response was overwhelming. I think it was most opened executive letter, many responses, lengthy responses, people saying that they were now going to reach out for help.
So, then honestly, you know, when I think even earlier, I go back to 1993, when I was a second-year medical resident and, at least in Canada, that part of your training, there's probably the highest sort of responsibility to knowledge ratio. And I remember being in the ICU, my grandfather died, and again, I felt just kind of anxious and things a little bit out of control. And I mustered up the courage to talk to my program director, Dr. Ho Ping Kong. And I honestly thought, Jen, that was going to be a career ender. I thought, this is it. And he was compassionate. He steered me in the right direction. The following year, he asked me to be his chief medical resident, which was, you know, a pretty important job there. And I just bring that up because seeking help does not need to be a career ender. It can actually make you more resilient and, you know, build character, I think.
Mathews: Yeah, definitely. How did you make the connection from reaching out for help personally, and then deciding to share your experience with all of your colleagues in that letter? What led to that decision?
Dr. Girgrah: I honestly thought that our senior leaders, and this was happening, needed to be a little more vulnerable and authentic in their communication style. And I think there has been a shift in what I call leadership behavioral norms. Leaders being more open to sharing when they don't really have their A-game, showing some of their warts. And I think that creates an environment that's more permissive for employees to seek help earlier. So that was sort of where I was going with that letter. But honestly, I did not know was what was going to happen. I didn't know whether the state licensing board would come knocking at my door. It felt a little risky, but I think it was the right thing to do certainly, at that time and for our employees.
Mathews: Clearly and yeah, a risk worth taking, obviously. So, you said the response was overwhelming. What shift have you seen in general in the culture since you shared that letter and, you know, in your larger organization in terms of how you're addressing these types of issues?
Dr. Girgrah: Well, I think we've been talking more intentionally about mental health and it seems to me that we've sort of developed, Jen, a sort of four-pronged approach to tackling mental health at Ochsner Health. The first part of this is actually measuring the state of mental health. So, you know, we've done this in terms of measuring annually physician engagement. Pre-pandemic with the help of the American Medical Association, we began to measure burnout year over year and be able to benchmark ourselves with other health care systems. This past year we were an alpha site for an expanded mini-Z survey or an Organizational Biopsy®, so we were actually able to delve into things like post-traumatic stress disorder and depression. And this year, we've been a little more intentional about trying to measure burnout with all our employees.
So, I think it starts with measuring what's going on. And then, I think, being more focused on education, raising awareness, talking about it more largely. The third area would be destigmatizing mental health at Ochsner, a bit of that I touched on with sort of communication styles. This year we’ll be launching a mental health resource group, which we hope will sort of, more broadly destigmatize mental health here. And then, so that's what we're doing internally. And then I think externally there's an opportunity to influence credentialing agencies, regulatory agencies. And then lastly, what we're doing with our mental health offerings. We're trying to be a little more upstream, a little more on demand, be willing to experiment with different things. Sort of doing PDSAs, scaling interventions or initiatives that work and eliminating those initiatives that don't work. So that's kind of where we're going. I think in the mental health space.
Mathews: You touched upon already about what Ochsner’s doing to help really put more of a focus on mental health. Did you see a specific shift in the intent of Ochsner once the pandemic hit? Were the building blocks already in place for you to then naturally segue into a public emergency, kind of like, crisis mode or did you have to make adjustments?
Dr. Girgrah: A couple of things happened. So, I've had this role since 2018. Pre-pandemic, the office I read, which is called the Office of Professional Well-Being, was focused on a few things, but largely improving practice efficiency, developing our leaders, supporting organizational culture that promotes well-being. And we had large workgroups. We were sort of building momentum in those areas and then the pandemic hit and that changed a few things. The first thing it changed was our scope had to broaden. So, we were no longer just an office of professional well-being that supported our physicians and APPs. We became an office that supported, more broadly, the well-being needs of all our employee staff. Then secondly, you know, while practice efficiency and leadership development continued to be very important, it became apparent that we had to really get down Maslow's hierarchy of needs. Our clinicians, our employees can't really focus on their critical roles in the community if there are concerns that their basic safety and physiological needs aren't being met. So, yeah, as an organization, Jen, we were very intentional about communicating early on things like access to PPE, that there would be enough ventilators around, that compensation would be protected, that colleagues would not be furloughed. I remember one weekend in March of 2020, over the course of a weekend, we stood up childcare for all our employees that needed childcare. So that is what was going on with the organization more broadly.
With the office of professional well-being, we started a few things in the crisis support area. We developed, in partnership with our behavioral health service line, unit-based rounding. So, we would go intentionally to the units that were most affected by COVID. So, hospital medicine, the emergency room, ICU. So, what we call that unit-based rounding. Secondly, we developed structured team debriefs with psychologists that could either be in person or virtual. We developed decompression zones where employees would've access to mindfulness opportunities, digital apps, things like that. We developed leader focus guides, or rounding guides, to help our leader support their direct reports. And then lastly, we developed a peer support group. We call that COVID Connect, where our employees who tested positive for COVID could connect with those that had gone through it and sort of feel less isolated in the process. So those were some of the things that we did very early on with the pandemic.
Mathews: That's great. That's amazing. So, as we've been moving through the last two years, collectively as a society, but especially in the health care community, and we're starting now to shift out of the high level of public emergency that COVID had generated for so long. What are some of the after-effects that you're seeing or that you anticipate seeing in health care workers, care teams, clinicians, at Ochsner and beyond? And how do you think we should help address as people are coming out of the adrenaline-fueled emergency phase and are now trying to process what the last two years has been?
Dr. Girgrah: Yeah, that's a great question. So, I was in Toronto back in 2003 for SARS-1, which was much smaller in scope, clearly, than COVID-19. But there were well-documented mental health sequelae in Toronto with health care workers. And this reaches out to three to four years after SARS-1. So, we have to anticipate that while we may be emerging from the pandemic, clearly, the mental health sequelae are going to be long-lasting. I guess we are trying to make mental health more of an opt-out discussion rather than an opt-in discussion. This concept sort of came about over 2020 when we actually saw our EAP utilization go down. Now, Jen, I think we've got a very strong EAP program and I think there may be many explanations for that. People may have been overwhelmed, just very busy, but it seemed clear that most people sort of access EAP during an acute crisis. And I think we needed to get upstream.
When I did rounding on units, I would hear individuals talk about this concept again, of wishing that there were more opt-out offerings rather than opt-in. And so, I think we've been trying to develop those thinking outside traditional EAP. We've been experimenting with and partnering with a few mental health startup companies. We've been trying to develop various resilience offerings, whether they're bite size YouTube videos that are seven minutes long or for our virtual resilience courses, we're working with a company called Happy, which is a mental health startup that is essentially an army of 2,500 empathetic support givers armed with a 1-800 number that can do outbound calls to our employees and schedule follow up calls. So, you know, being more on-demand and available.
And I think going forward, we just have to kind of engineer and develop a culture that really supports well-being. Making check-ins just a part of the one-on-one meeting process. Engineering intentional pauses during the day where folks can sort of recover at a micro-level. Being very intentional about not disturbing our employees when they're not at work, allowing them to decompress and sort of being consistent with what we tell folks as an organization. It's one thing to sort of say, we want you to support your own mental well-being or personal well-being, but if then I start calling you after hours or texting you, that sort of, I think, sends mixed messages, if that makes any sense.
Mathews: It makes perfect sense. I think that's something that people are struggling with across the board is that a lot of practices and health care systems are becoming more aware of how important it is to prioritize the well-being of their care workers, yet how they go about doing that is pretty important. Right. And I'm glad you brought in the opt-in versus opt-out philosophy because I think sometimes just having to reach out to ask for help feels too overwhelming for someone who really is, you know, stressed. And so having someone come to them versus them having to reach out, even just shifting your thinking in that regard can make a huge difference.
Dr. Girgrah: No, absolutely. And clearly, we have, like many health systems, you know, capacity issues with our, you know, behavioral health, and psychiatrists and psychologists. But wouldn't it be amazing if just part of the routine is that, every six months, I have an appointment scheduled with a psychologist? It sends a message that this is just a normal part of the conversation. Rather than letting things bubble up to the point I'm in distress and I need to make an appointment.
Mathews: I love that idea. You know, we have in any sort of career capacity, there's usually built-in performance reviews. What if there could be like mental health reviews, right? Where you just check in, and like you said, it's just part of the process. I mean, it eliminates the stigma right out of the gate. Right. Because it takes away that risky aspect that you had mentioned earlier a couple of times where you had felt this could be potentially career-ending and it felt like a huge leap of faith to do. Just erasing that element of it, I would imagine, would be a huge game-changer for a lot of people.
Dr. Girgrah: I absolutely agree.
Mathews: Well, shifting to some exciting news. When you and I talked before, you mentioned that Ochsner was just awarded a grant to build workforce mental health and resiliency. Why don't you tell us a little bit about that and what your plans are for it?
Dr. Girgrah: Sure. Well, we've talked a lot about this discussion that delivering health care, Jen, is inherently stressful. It's probably the most stressful of all industries that I can think of and recognizing that Ochsner’s invested heavily, pre-pandemic, in the well-being of our physicians and APPs, as I said earlier, focusing on leadership development and practice efficiency, and these will continue to be a focus going forward. But, as I mentioned, since the pandemic, our scope has broadened to all our employees, and we've recognized that we need to develop and offer programs that meet our team members where they are at to survive and, ideally to thrive. And so, the HRSA cooperative agreements is one that really focuses more exclusively on bolstering the resilience and mental health of our health care workforce and helping us scale some existing initiatives and begin some efforts, primarily around mental health with speed and depth that, honestly, we wouldn't be able to achieve without the help of the grant.
You know, a few things that we're doing. There is a mental health startup that we've been working with pre-pandemic, even health, that has a platform cabana, which is a very interesting concept. This is group therapy with a licensed behavioral health specialist that is truly anonymous. You can create an avatar of yourself. You disguise your voice. And different topics are offered on things like struggles with parenting, struggles with the pandemic. We were the first health care system to work with Cabana. Now other health systems are doing this. So, there will be the ability to network, in an anonymous fashion, with other health care workers that are dealing with the same stressors that we're dealing with. So, the funds from this grant will allow us to move from, sort of, beta-site to fully implementing this at Ochsner.
We're developing a lot of initiatives, Jen, around resilience training, being able to scale this, being able to work with our nurses, our nursing leaders. You know, when I was in medical school, I learned a lot about medicine but virtually nothing on how to play the long game in health care. And I suspect that's true of most health disciplines and it's time to change that. And then I think a lot of the funds will be helping us to destigmatize mental health. We, as I mentioned earlier, we are launching a resource group that will be focused on the mental health of our employees. We have started something called Schwartz rounds, which brings health care workers together to be able to talk about situations that have been associated with a great deal of emotional labor. So those are the sorts of things that I think over time will help sort of expedite, you know, the resilience and support the mental health of our workforce.
Mathews: Wow. That is so exciting. That's really good to hear. There's so many great initiatives and ideas there. One last question before we close up our time. Something you said earlier really stuck with me, particularly about the story you told when you were in med school and you know, taking a risk at such a vulnerable point in your journey in health care and reaching out and talking about how you were feeling. Ochsner is really kind of setting the bar in a lot of ways for how to approach well-being. And I think that you've given so many great examples to health care leaders about how they could start to lay the groundwork for some of these things in their own organizations, if they haven't already. But I'm curious what your advice would be to a med student or a physician today who was feeling similarly to how you felt, you know, before you wrote that letter or even how you felt in med school. What if they're not greeted with compassion or what if they don't feel like they have a path of where to go to? What advice would you give them to do?
Dr. Girgrah: I guess, you know, just don't stop with the first person. This is an incredibly normal part of being a health care provider, being a physician. It's okay to reach out for help. It is something that should not be a career-ender. It is something that should build your own personal character. You know, these are the qualities that we value in our health care providers. Individuals who have a history of mental health challenges are usually more empathetic. They've certainly developed grits. They have many of the attributes that we want as a health care organization. So, I'm not sure I'm answering your question well, but that—
Mathews: No, I think that's a great answer, but I mean, first of all, just reaching out, which you've already emphasized. And second of all, if you don't get the response that you feel is helpful the first time, then reach out again. It's a scary prospect. So, I know that that is sometimes difficult for people to do, but I think it's important for everyone to hear. Physicians are put in the positions of caring for other people, and just like parents and other caregivers, they often give everything they have to others, and they don't keep a lot in reserve for themselves. So, I think even just giving the advice of reaching out and reaching out again, and potentially even reaching out again and not giving up and prioritizing your own health is important to hear.
Dr. Girgrah: You're preaching to the choir, Jen.
Mathews: I know I am. Well, thank you so much, Dr. Girgrah, for being with us today. It was so great to hear about all the amazing things that you've already put into place at Ochsner and that you have planned for the near future. And for our podcast listeners, if you would like more resources on combating physician burnout and managing well-being, please visit us at our website, stepsforward.org.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.