Moving Medicine

Nigel Girgrah, MD, PhD, on well-being and top stressors physicians are facing right now

Jan 21, 2022

In this episode of AMA Moving Medicine with chief wellness officer at Ochsner Health in New Orleans, Nigel Girgrah, MD, PhD, discusses the state of physician well-being, how Ochsner Health is supporting physician wellness and the top factors contributing to physician stress right now. Accompanied by Dr. Girgrah is Nancy Nankivil, AMA director of practice transformation.

Speakers

  • Nigel Girgrah, MD, PhD, chief wellness officer, Ochsner Health
  • Nancy Nankivil, director of practice transformation, American Medical Association

Host

  • Todd Unger, chief experience officer, American Medical Association

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

Unger: Dr. Nigel Girgrah is committed to reducing burnout and improving physician well-being by understanding the mental health needs of the physicians at Ochsner Health. 

Dr. Girgrah: I think during the valleys, if I can describe them as valleys, we're just seeing a lot of stress around staffing issues, inefficiencies that result in longer hours. I think all of us are trying to get back to business as usual. There's been a pent-up demand for services, a backlog of procedures. And that's just very challenging given the current staffing environment.

Unger: Dr. Girgrah is a transplant hepatologist and chief wellness officer at Ochsner Health in New Orleans. In this episode, he speaks with Nancy Nankivil, AMA’s director of practice transformation, about Ochsner’s continued focus on the well-being of its workforce. Here’s Nancy. 

Nankivil: This is Nancy Nankivil and I'm honored today to be here with Dr. Nigel Girgrah. Dr. Girgrah is with Ochsner Medical System in New Orleans. He is a transplant physician, and also, their chief wellness officer. Nigel, it's just a pleasure to be with you today to have this dialogue about what's happening in your institution and your lens on what's happening with professional well-being during this critical time.

Dr. Girgrah: Thanks Nancy. It's just so great to be here with you. So, looking forward to the discussion.

Nankivil: Terrific. Well, first of all, I have to start by asking you, how are you doing? As a chief wellness officer, there's a lot on your plate and a lot on your plate in taking care of others but I just really want to know how you're doing and how you're replenishing yourself right now.

Dr. Girgrah: You mean on a scale of one to 10? I don't know. I guess it's been certainly an interesting 20 months and I think while I had a grounded interest in physician well-being prior to the pandemic, I think how I've reacted to the stressors has really been really illuminating for me and my team as we think about our strategy and our approach going forward. I'm doing well, Nancy, thanks for asking.

Nankivil: I'd love to hear you give some wisdom to other chief wellness officers in their journey. But what I'd like to talk about next is you're right, it's been a very interesting 20 months. None of us probably expected both the duration and the impact of the pandemic but I'd love for you to be able to share what you are seeing right now as top stressors with your physicians. They've probably gone from fear to fatigue to frustration to anger and back again. But what are you and your leadership and staff seeing as top stressors for your physicians, and as importantly, how are you looking at creating solutions to those stressors?

Dr. Girgrah: Yeah. I think you summarized it quite nicely, sort of the timeframe. I guess we've seen a lot of things. I think right now during the surges, just seeing exhaustion from just constant change and uncertainty. Particularly when I think of the fourth surge, which in Louisiana we sort of experienced in July and August, I saw a lot more anger from our health care staff. Sort of the sentiment that what we were seeing, maybe in part self-inflicted that it could have been avoided. I think that's dissipating a bit also seeing a lot more disruptive behavior particularly with our patients and their families.

And I know that's been very hard on our care delivery teams and I sort of liken it to sort of what our flight attendants are sort of putting up with these days with passengers. And that's kind of the surges. I think during the valleys, if I can describe them as valleys, we're just seeing a lot of stress around staffing issues, inefficiencies that result in longer hours. I think all of us are trying to get back to business as usual. There's been a pent-up demand for services, a backlog of procedures. And that's just very challenging given the current staffing environment. And I will say, what's been a little more unique to the south of Louisiana is Ida, Hurricane Ida. That was months ago but we still have many, many staff that are still recovering with respect to damages and expenses from that. So, a lot, we're feeling a lot and seeing a lot.

Nankivil: You and I have talked about those things, and some of them are unique to New Orleans like Ida, but some of the things that you talked about, we are hearing regularly in our communication and work with other health systems. And some of the research that we've been doing is indicating when levels of stress remain high, work is now in overload, not resetting but still work overload. And then dealing with things that are actually starting to impact the integrity of providing care, maybe with people that aren't vaccinated or staff shortages, et cetera, it's quite the trifecta. And I'm wondering if you can comment on what you might be anticipating with regard to the workforce and intentions to leave. Are you seeing anything and are you working to identify some strategies in even different role types or just in general how you will continue to move forward?

Dr. Girgrah: Yeah. Going forward, I think, in 2022 we just had a chance to sort of present our strategic plan, Nancy, which sort of looks a bit like a hybrid of what our strategy was pre-pandemic and then how we had to adapt during the pandemic. I think by the essential issues around workforce retention. And I'm now not talking about just our physicians and APPs, I'm talking about our nurses and ancillary staff. I think it's impossible to create a strategy around physician well-being that doesn't look at the well-being of the whole care delivery team. So, what worries me most is the mental health sequelae of the pandemic.

I know you and I have talked a little bit about my background in Toronto. Having had the opportunity to experience SARS-1 in the earlier part of the two thousands, 2002, 2003, which was clearly much more limited in scope than what we're seeing now. But there were well studied long-term mental health outcomes in Toronto. And there were some changes that occurred as a result of that. So, I think as an organization, my team, certainly myself. I think I'll always be mindful of the importance of practice efficiency, how we train our leaders but I think anticipating the mental health outcomes, I think de-stigmatizing that conversation within the health care industry and being a little more nuanced in how we approach those individuals that need support during this time. I think these are some of the things that aren't honestly particularly well developed but certainly things that I'm thinking about a lot.

Nankivil: Absolutely. And let's dig into that a little bit. I know that you and I had conversations and I would call you from your experience in Canada. What are the best opportunities around peer support and breaking down the stigma around mental health, et cetera. And I know you all have put in, I think, some really innovative programs and thinking around this. Can you describe some of what you've leaned into, especially around individual resiliency and breaking barriers on mental health?

Dr. Girgrah: Yeah, sure. So, I mean, when we started into the pandemic, certainly we were a hotspot in March, April here in New Orleans. A lot of what we did was around out of necessity, crisis support, both at an organizational level and what our office of professional well-being was doing with our behavioral health team. So, I think as we, and I can get into that later if you want, but as we sort of emerged from the first surge, resilience was something pre-pandemic that I really did not want to focus on but I think it became clear that there was a need and there was an appetite for developing some resilience offerings. So, we've put together a number of things including a four-hour virtual course. We've created a number of YouTube videos that are about eight minutes in length.

And these have been very well received, high net promoter scores in terms of those that take them. But then starting to think a little bit more specifically beyond resilience but specifically around mental health. This gets back to your opening question. Back in 2020, I actually found myself of really languishing in July, August kind of in a darker place. I sort of recognize that July and August, traditionally, is a tough time for me. I recognize the triggers. It represents the anniversary of the death of a son. I lost a son to cancer many years ago but last year there just did not seem to be the compensatory things in place that usually allow me to cope with that.

Things like going up to Canada to visit my family and friends. I had a knee injury wasn't able to exercise to the extent that I would like to. And it was getting harder, and eventually I reached out for help and it worked out. But the reason I tell you this is that the learning for me and it was an obvious one was that that story isn't unique to me. I think most people I know, maybe everybody, has some version of that story or a story. And so that led me to think about more openly discussing that. Now, the office of professional well-being and my role as chief wellness officer, I have a quarterly open letter that goes out to all 30,000 employees.

And honestly, historically that had been a little sterile. It was just sort of a report out on what we were doing, activities that we offered in the previous three months. This letter, I decided to make it a little more personal. And the letter was primarily about myself and what I just described to you. And then discussing more broadly the issue of mental health stigma within our profession. So that letter went out. I was incredibly anxious about it because I didn't know how it'd be received. I didn't know how our executive team would receive it. I didn't know if the state licensing board would have something to say about it but what resulted was this overwhelming response, not just numbers of email replies but three-page email replies. Individuals expressing appreciation that that had been brought up.

I can remember one employee reaching out to me telling me that early in the pandemic he had lost his home and had been sleeping in his car since May of 2020. And he even described crying as he went to bed. And we were able to sort of put that individual in touch with the right resources. So, it seemed to sort of touch a nerve with the organization. And I think that that's some momentum that we're sort of trying to build on. And honestly, I started thinking that it goes back to before the story of my son, Bennett. I started thinking a little bit more in my history and I thought a little bit about my training, and even thought about going back to 1995, when I was a second-year resident in Toronto.

And at least in Canada training in medicine, I would say second year residency was the highest stress year. It was sort of the highest responsibility to knowledge ratio. It's the first time that you're really in charge of teams, of interns, medical students. Around that time, I had a death in the family. My grandfather passed away, and for some reason, it just all came burning down on me where I felt paralyzed, anxious. And I thought part of me thought that was going to be the end of my career. And I mustered up enough strength to go to my program director, who is one of those individuals I'll remember for the rest of my life.

His name was Dr. Herbert Ho Ping Kong. And I told him what was going on and he was compassionate. He was discreet and put me in touch with the right resources. And actually, a year later, he asked me to be a chief medical resident at The Toronto General Hospital, which was a very prestigious role at the time. I bring that up just that reaching out for help in this profession doesn't have to be a career stopper. It can make you stronger. It can open up doors and it's the right thing to do. So does that make any sense at all or ...

Nankivil: Well, it makes so much sense, Dr. G. And I can tell you in the qualitative data that we gain from working with health systems and the physicians who are willing to put a voice to it, they are looking for that kind of value from their system. Those values of being compassionate, being discreet, stepping into places that can be messy and hard but allowing the narrative to come forward. And I'm a believer that that is what is a part of the strategy for change and moving through this. So, I really commend you for being authentic and being brave and bold, and sharing that. I'm guessing that it will serve as a model for others to do the same. And I want to come back to a couple of things that you even expressed within that.

Again, what we learn from our survey work, residents have struggled through the pandemic. And I'm wondering if you have a lens on that. And also, if you have a lens and even some examples of how you might be looking at different specialties who may be harder hit from the pandemic and with burnout. Our data indicates that our physician colleagues in critical care are very fatigued and burned out. And I just wonder if you can give some thoughts on these different role types and actually different timeframes in people's careers. We're also seeing our female physicians, six to ten years in practice, who are dealing not only with work life balance, the intensity of work but then children unvaccinated or school from home. So just any perspective you have as a strategy as a chief wellness officer, how you're dealing with the variety that is within your health care setting.

Dr. Girgrah: Yeah. That's a lot to take on, but thanks, it's a great question. I think pre-pandemic, largely in collaboration with y'all in the Mini Z survey, we did get a chance to look at what the state of burnout was with our faculty physicians and APPs. And as you alluded to, burnout seemed to be higher in our female physicians and APPs particularly those maybe five to ten years in practice. And I don't think it's hard to imagine why. And so, as a result of that, I think we've been sensitive to it. We've developed a resource group or an affinity group where our female physicians can come together to talk about unique stressors. So that sort of has existed pre-pandemic and certainly, I'm sure, continues into the pandemic.

And again, we had the opportunity this past year. We were an alpha site with this sort of expanded Mini Z wellbeing index or organizational biopsy. So, we were able to delve into at a more granular level sort of drivers of professional fulfillment but of interest to me to look at depression, look at PTSD, look at those issues by department or service line and come to some conclusions. And it wasn't terribly surprising. And I think the numbers are low. So, I don't want to make any complete conclusion but the areas that we would've thought were most at risk for PTSD were our ER physicians and APPs, our critical care physicians and APPs, our hospital medicine physicians and APPs.

But in addition to those are our primary care folks and pre-pandemic, at least at our organization. I worry the most about our primary care physicians because they seem to be on the front line of every new initiative, whether it's a new population, population health initiative, whether it's a new patient experience initiative. So yeah, we're trying to be a little more targeted in our responses but you have to measure and I think we're sort of there or starting that discussion with some of the data that we've been able to put together.

Nankivil: Yeah. And pre-pandemic many organizations like you were measuring on more of an annual basis. Are you seeing a need to do that more frequently even if it's targeted areas or what is your measurement strategy now as we move through the pandemic and post?

Dr. Girgrah: Yeah.

Nankivil: Yeah.

Dr. Girgrah: Well, our commitment to measurement started before I actually took this role and actually led to the recommendations that this role, my role, be resourced and let our office be resourced. So back in 2017, for the first time we formed the well-being task force and we sent out the Maslach burnout inventory, which was kind of clumsy really, but helpful. And we looked at quantitative data from that survey. Importantly, I think you have to combine that with qualitative data, which was based on months of focus groups that I conducted across 2017, 2018 to sort of trying to inform a strategy and understand the state of burnout at least at Ochsner. Since that time, we continue to be committed to measurements.

So we've used Mini Z survey. That went out for the first time to the group practice in, I think, April of 2019. The second survey went out in 2020. And then the third survey, which was the more expanded version of the survey, I think we were the first health system to offer, that went out in June, July as it turned out to be just right during the fourth surge of the pandemic. So yeah, we're committed to measuring it. I had the opportunity to report to the board the results of the survey. So, I think it all just starts with measurement and being able to make sure that everybody in the organization including our board of directors knows what the state is.

Nankivil: I love that. And I'd love for you to comment on your leadership commitment, your board of directors and your executive leadership team to supporting the well-being of your human assets. And I'd love for you to comment on where have been some of the pain points, some of the barriers you've had to push through as I know leadership and board look at revenue. And also, where are the bright spots? What has surprised you from your leadership during all of this in support of the work you and your team do?

Dr. Girgrah: Well, I think the biggest bright spot for me is I don't think there's any area within the organization that this subject doesn't touch individuals. So, there's been no shortage of grassroots enthusiasm to supporting some of the initiatives that have come out of the office of professional well-being. I would say the other thing, maybe you could call it a silver lining. I'm not sure that's the right word but clearly workforce retention and workforce well-being has sort of emerged as no longer just a top five strategic imperative but probably the number one strategic imperative for the organization.

So, it has the full attention of our CEO and our executive team. So, I mean, that's a good thing. I think everybody's, not just our organization, is just trying to understand where the whole workforce, engagement workforce turnover, workforce retention issue is going to go. There's obviously a moral case to address that but there's a clear business case, in terms of agency costs and what's costing the bottom line. So, I think that that's been an upside. I think we've struggled, honestly, during the pandemic is initiatives that are focused more around practice efficiency and promoting advanced team-based care.

We had a lot of momentum pre-pandemic but those sorts of things have really, I would say, required more collaboration across business units. And I think particularly early in the pandemic it was, as everybody was being pulled in different directions, it was sort of hard to together multidisciplinary teams. Practice efficiency is clearly so important. I think it's the number one driver of physician professional fulfillment. So that's going to be clearly in our crosshairs as we emerge from the pandemic, if we ever emerge from the pandemic, is sort of refocusing on practice efficiency.

Nankivil: And are there any priorities in that space? Again, I think you hit the nail on the head, a lot of people had to put those things, not to the side but the focus became something very different with the pandemic. And we do know that workflows and processes and even teams got disrupted. Are there some priorities on what, I hesitate to use the word, but the reset. I know we may not go back to normal, but do you have some priorities whether it's with the EHR or workflows or training up your support staff?

Dr. Girgrah: Yeah. So we spent a lot of time, Nancy, trying to identify not just primary measures of success but secondary measures of success and actually process metrics. One of the big, important, I think, secondary metrics of success was measuring pajama time or work outside work. We've been continuing to do that. Identify physicians and APPs that are struggling the most in this area. Trying to understand which areas of the EHR they're struggling in the most post whether it's making notes, whether it's in basket work, et cetera. And we've been trying to bring those individuals to sort of EHR coursework on our time, not on their time. That got sort of paralyzed a bit just because we had a lot of positions approved and then positions were frozen early in the pandemic but now we're sort of doubling down on that and trying to get our most struggling physicians, EHR help.

And then the goal is to actually have all of our physicians undergo sort of annual EHR sort of retraining, I think, which is best in class. That's sort of one area. Things like establishing a pharmacy refill clinic. Things like so how do we take things off the plates of our primary care physicians? So that's something we've been collaborating with pharmacy is sort of automating that, taking message refills away from our primary care physicians. As it turns out, 75% of them can be automated with the help of our pharm Ds and that in doing so you can give back 25 to 40 minutes back to a busy primary care physician. And so, I guess it's no one particular thing. It's just sort of you always hear the term death by a thousand cuts. How do you start chipping away at those thousand cuts one by one? And I think that's what we're getting to.

Nankivil: Well, it sounds like you have an eye on they're more than the fundamentals but they are the things in the workflow that can make the greatest difference in hopefully in the quickest fashion. So again, kudos to you for focusing on those things that matter. And you're right, they're more than pebbles in the shoe right now but they can create a day and a life of a physician that's less than desirable. And so, I want to ask you a question because I do know a little bit about you. I know you've got two sons that are, I think, not yet out of high school and some older kids as well. But what would you say to young people about the profession, especially when we might have a workforce in peril and we may have physicians that are retiring before they want to and unfortunately from burnout? What would you say to your own sons about the profession of medicine and would you encourage them to step in and be a healer?

Dr. Girgrah: Well, wow. So I grew up with a old world. I was born in the Middle East and my father was pretty traditional, and in his eyes... I was a very good student. So, in his eyes it was, "You're going to be a professional and you're going to be a physician." And actually, that turned out to be the best ... I mean, he was right but in terms of my own perspective, I just want my four children to be happy. That's the most important thing. I really, Nancy, don't care where they find happiness but I want them to be happy. And in the sort of last chapter of my career, I always hate talking about using adjectives like last and words like chapter.

I just want to get this profession in a better place so that I can more enthusiastically recommend this as a choice for my teenage kids. I get the sense that my 12-year-old is sort of most interested in mirroring my career path but well, I'm sure it's not the ringing endorsement that you want to hear. I primarily am a dad. I want them to be happy and I'm certainly not going to push them into any profession but I always talk about how rich this career that spanned several decades has been for myself but I'm not sure it's for everyone.

Nankivil: Right. Right. Well, I think it would be good to have more Dr. G’s out there in the profession and really serving in the way you have. And I'm going to tap into you for maybe a couple of more comments from your wisdom as a chief wellness officer. And when you and I met, which is now still less than a handful of years ago but there were not that many chief wellness officers in the country. And I remember our early conversation and, again, you were one of a handful, that were stepping into this place that's been without much of a roadmap. But now today we are seeing far more chief wellness officer positions emerging, and organizations making a commitment to wellness strategies, not in just resiliency but really strategies that change culture and drive new ways of working. And hopefully again, more and more value, joy, purpose and meaning to the profession. So as a wise, now, elder chief wellness officer—

Dr. Girgrah: Right. Yeah.

Nankivil: What might you share to those that are either wanting to get into this space, being asked to step into this space? What might be the top words of wisdom from you to them?

Dr. Girgrah: Yeah. Well, a couple of rambling thoughts. It's an incredibly gratifying role to be in. I think I remember I reported out our recommendations to the executive team in 2018 and one was to resource this role. And then I was asked to take on this role, and honestly, I was really not clear that I wanted to take this role on because my professional identity was sort of more immersed in more traditional operational leadership roles but it's certainly a role at a national level. It's getting a lot more interest. I'm so committed to Ochsner but out of interest, clearly, just in terms of emails from recruiters looking for chief wellness officers, it's clearly something that other organizations are identifying as a strategic priority.

So that's one thing. I guess when you take on the role if you do take on the role, I would just sort of advise individuals to really try and be strategic and thoughtful. I think physicians are generally impatient so they don't understand why burnout can't be solved in two months with enough organizational will. But it's very important to put strategy before tactics to measure and to influence other business units. So those would be some recommendations, maybe not the answer you wanted Nancy but that's my answer.

Nankivil: It's always a good answer. And let me also ask you, you've seen and help shape our work at the AMA. We really do see it as a collaboration with people like you and organizations like yours. We hopefully bring things to the table but we learn so much from the experiences that you all are engaged in. What might be things that you would say to us at the AMA to either keep doing or to take on to support this work and people like you in these roles?

Dr. Girgrah: Well, first of all I have to say, and I've said this before, so we have a partnership with the AMA but the help extended by the AMA, anti dates any relationship that I knew Ochsner Health had with the AMA. So, I tell the story of being lost in my role as the chair of the well-being task force before I had this role. And I didn't know if there's a roadmap, if a roadmap could exist. And honestly, when I reached out to you, I wasn't sure I was going to get a reply. And I think I was on the phone with y'all within a couple of days. So, you all have been extraordinarily helpful in shaping my strategy. You have several resources. I haven't been on the Steps Forward website recently but that was a website I was on constantly on in 2018 as I tried to put together a strategy.

Nankivil: Thank you all for listening today. And thank you, Dr. Girgrah, not only for an authentic conversation together today but also for your ongoing commitment and leadership to the profession. It's greatly appreciated. And hopefully you are one of many who are moving medicine.

Dr. Girgrah: Thank you so much, Nancy.

Unger: You can subscribe to Moving Medicine and other great AMA podcasts anywhere you listen to yours. Or visit ama-assn.org/podcasts. I'm Todd Unger and this is Moving Medicine.


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.

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