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AMA Update
Reducing burnout and mental health stigma for physicians with Nigel Girgrah, MD, PhD
Mar 30, 2023
Featured topic and speakers
Happy Doctor's Day! March 30th is National Doctor’s Day—to mark the occasion Nigel Girgrah, MD, PhD, chief wellness officer at Ochsner Health in New Orleans, shares how his health system works to reduce burnout and prioritizes physician well-being every day. AMA Chief Experience Officer Todd Unger hosts.
Learn how the AMA is #FightingForDocs and access resources from the AMA Recovery Plan for America’s Physicians.
Speaker
- Nigel Girgrah, MD, PhD, chief wellness officer, Ochsner Health
Transcript
Unger: Hello and welcome to the AMA Update video and podcast series. In honor of National Doctors' Day, today we're talking to one health care leader about how his health system works to reduce burnout and celebrate physicians. I'm joined today by Dr. Nigel Girgrah, chief wellness officer at Ochsner Health in New Orleans. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Girgrah, welcome back, it's been a while since we last talked.
Dr. Girgah: It's been a little while, I think, about three years. It's so great to be back with you, Todd.
Unger: I still have our AMA magazine with you on the cover on my desk. So I think about you a lot and all the work that you're doing down there at Ochsner. We're having this conversation today to recognize National Doctors' Day. But in truth, every day should be doctors' day when it comes to making sure that physicians feel valued and fulfilled in their work. And I know this is an important mission for you professionally but also personally. So let's just start off by talking about why.
Dr. Girgah: Yeah. So March 30 is Doctors' Day. And really, every day should feel like Doctors' Day. It's the best profession in the world. It's one of the most trusted professions in the world. But unfortunately, for many, March 31 and April 1 isn't going to feel like Doctors' Day.
There should be joy in medicine. Every day we come to work, every day should be a reminder of the calling that we chose to—we enlisted in this profession to be a healer, to be a clinician, to be a scholar, to be a teacher. Physicians are so innately purpose-driven.
But unfortunately, there's an increasing duality in our roles. There's the profession I just described, the one that we signed up for. And then another sort of area of our work, the increasing economic regulatory, clerical part of our jobs. It's sort of pushing many folks past their emotional limits. And as I said, every day should be Doctors' Day. But this is resulting in more burnout. That's important to me personally, but this is a professional crisis at a national level that needs to be addressed.
Unger: We're going to talk more about that, because I know a lot of those things that you just mentioned there. Those burdens are outweighing the time you get to spend doing what you love to do, which is taking care of patients.
This focus on well-being became important to you. At the same time, it became a priority for Ochsner. How did that intersection and timing help shape your involvement and approach there?
Dr. Girgah: Yeah. So I don't think I'd even heard of burnout until 2013 when I returned to Toronto, where I went to med school for a med school reunion. And I found out that one of my close friends from med school had died by suicide a couple of months earlier. He was a very prominent physician. Because he was prominent, you could—he has his own Wiki page. You could Google a little bit about the circumstances.
And when I did, it was really horrifying. So 2009 documented issues of alcoholism, substance use, loss of licensure, the fall in your credentialing, a criminal court case, with even witness tampering. And then incredibly, bizarrely, the Toronto Star had a piece about this high-speed police chase across rural Ontario and then, unfortunately, his death. So I was deeply affected. And I think that's when it became personal to me.
And then over the course of the next few years, I started thinking about burnout more from the perspective of an organizational leader. So well-being is certainly a quality indicator that leads to other things that we want—patient experience, quality and safety outcomes, even discretionary effort and financial performance. It's aligned nicely with our diversity, equity and inclusion imperative.
And I had several conversations with Dr. Hart, our chief medical officer, and I know he agreed. So around 2017, when he sent a letter out to the group practice, I think that was really the defining moment in terms of organizational intent.
Unger: It's hard to imagine, just 10 years ago, where that was not a top of mind concern. Of course, a lot's happened in between those times, including a pandemic. Your story is particularly resonant, because I know when we especially didn't really know a lot of are thinking about this, that was hard to even recognize burnout. And maybe like your colleague, your ... some physicians may just be doing a good job at hiding the fact that they're struggling.
What should leaders and other physicians be watching out for in their colleagues? And what implications can it have for organizations if it's left unaddressed?
Dr. Girgah: Oh, that's a great question. So I think there's been more of a national conversation. So I would say, understanding your comments that more and more physicians are actually just opening up and saying, "Hey, I'm burnt out, I'm emotionally exhausted, I'm not finding work terribly satisfying." But if that's not the case, I think it's important to pick up on other cues, like a shift in personality, folks become less talkative, less presence, less responsive, maybe more cynical, sarcastic, frustrated.
Leaders can look at electronic health record data to see if folks are spending more time after-hours on the computer—we call that pajama time—or struggling with documentation. Sometimes the one over leader will make comments. But often, I found, you can hear things from the ancillary staff, medical assistance, nurses, just describing disruptive behavior or unusual behavior. So those things can be cues.
And in terms of the importance, it goes back to what I said in my last comment, that we know burnout will take away from the patient experience, will lead to poor quality safety outcomes, worse discretionary efforts and turnover. So very important.
Unger: And potentially, very serious outcome for the physician as well. So it's so important that, like the AMA, Ochsner has been working to address burnout and improve physician satisfaction for a long time now. Back in 2017, you established a well-being task force. Talk to us a little bit about what that task force does and how it's changed over time.
Dr. Girgah: Sure. Well, I mentioned the organizational intent when Dr. Hart sent a letter out in May of 2017 about the organization commitment to well-being. So he had asked me in July of that year, two months later, to chair the well-being task force.
And that task force was essentially about 20 different stakeholders, many physicians. We had project management support, input from HR. And we were very deliberate about assembling data, so both quantitative data. We did the mass burnout inventory for the first time. We looked at our engagement survey data. We looked at our culture safety survey data.
And so we combine that with qualitative data, comments from the surveys. I did a number of focus groups across the organization. And then we tried to distill that down to themes and a voice of the customer. And essentially, there were five themes.
One was in the area of providing our physicians the fundamental tools to do their job, either staff or stuff. Another was promoting advanced team-based care and having everybody on the care delivery team practicing at the top of their license. A third was around respecting time, so getting folks off the computer and getting them home or in front of their patients or in front of their colleagues.
A fourth theme was around more consistent positive messaging. And also, a last theme was around clarifying priorities. We know there's about a hundred important things that a health system has to do. But how can we make that simpler for our frontline physicians in terms of how they approach work?
So at the end of that, I made a series of recommendations to our executive team the following year. One was to resource the role of chief wellness officer. And the second recommendation was to resource the office I now lead, the Office of Professional Well-Being.
Unger: So when you look back at the work you've done, and you explore more deeply the drivers of burnout, I'm sure you've learned a lot over time. Can you share some of the key takeaways about maybe how those drivers are evolving?
Dr. Girgah: Yeah. I mean, that's an interesting question. So there's probably about a hundred different drivers. And drivers can be unique to different specialties at different facilities. But I think the three broad themes or the three most important drivers I've seen are—one is around practices in efficiency or workflow. We know that over time, that is probably the second or the biggest driver of professional dissatisfaction.
A second theme would be around the quality of leadership, the one over leader. We know that the quality of the one over leader taking an interest in job-crafting discussions. Does the physician feel heard? Is his input important? We know that's a very important drive for professional fulfillment. And a lack of leadership quality is a driver of burnout.
And then a third big bucket to me is around lack of mental health support and basically the stigma around mental health that exists in the health care sector.
Unger: Well, speaking to a couple of the themes that you just mentioned, especially around leadership, we know that COVID influenced the work in the area of burnout in a number of ways. And during this time, you wrote an open letter to your staff that had the highest ever response rate to an Oschner health executive communication. So tell us more about that letter, why you did it, and why it resonated so well.
Dr. Girgrah: Well, that sounds a bit braggadocious in retrospect. But as a background, pre-pandemic, our work had been heavily focused on practice efficiency and leadership development for the reasons I just mentioned. With the pandemic, we had to adapt and get into crisis support resilience.
And then in the summer of 2020, between the effects of the pandemic and seven hurricane threats in New Orleans, I found myself in a funk. A big funk. And every year, I go through a funk. July 26 represents the anniversary a long time ago of the death of my son Bennett. But usually, I'm able to recognize those triggers and compensate by planning a trip to Canada. Obviously, I couldn't do that in 2020. I'd had my first significant orthopedic injury. I wasn't exercising.
And by August, things seemed to be spiraling out of control. Eventually, I reached out for help and everything was good. But my moment of recognition was that many of us, if not all of us, have some version of that story. So early in September, with the support of someone on our executive team, I wrote an open letter to all 34,000 employees, where I described that story that I just described with you, Todd, and then discussed more broadly the issue of the stigma of mental health in health care.
I was very nervous when I sent out that letter. By the end of the day, I received scores of replies. I think at the end of several weeks, 100 replies, lengthy emails. People saying this was going to be their call to action to reach out for help. So I think it did resonate. And for some, they may have felt timid about coming forward. I think it was a way of normalizing the discussion around mental health, seeing a leader open up about their struggles.
Unger: Well, it's an incredible story. As you've moved out of the acute phase of the pandemic, how do you carry through the learnings that we've had over the course of these years and the sense of being at it all together as you return to more of business as usual, so to speak?
Dr. Girgrah: Yeah. That's a challenge and that's a great question. When I talk to physicians I work with, the theme is back to the future. It really should be back to the past. Back to basics. And that is it's been great to and very important to work on mental health resilience. But let's get back to practice efficiency. Addressing the administrative burden of the clerical burden.
And that really, Todd, requires shared accountability. So not just physicians working on this, but everybody all within. The corporate units, the EHR IT folks. Everybody within the health system locked in and improving physician well-being, health care workforce well-being.
Because I think the lack of well-being is really an existential threat to achieving what we desire to as a profession.
Unger: And that's a perfect message for Doctors' Day, the themes that you've pointed out here. Number one, addressing these structural issues. The system level ones that are just creating so much burden for physicians but also really opening up yourself and for others a pathway to ask for help when they need it, especially having been through the trauma of a pandemic.
Talk to us a little bit, in closing, about reducing those burdens again. How have you done that? What's been the most significant step in the eyes of your physicians, and how have they responded to that?
Dr. Girgrah: Yeah. That's another great question. I think any success we've had has been through the strategic and put strategy over tactics. That being said, I think our physicians need to see quick wins. About three years ago, we did the tap and go with the EHR, where you could save time by not having to log in endlessly.
And it's a series of quick wins. A couple of years ago, we established a pharmacy refill clinic where pharmacists and pharmacy technicians working with software and AI could basically remove 70% of messages around refills from our physicians. That, on average, saves 30 minutes.
Last year, we started a working group around reducing best practice alerts. Reducing BPAs by over 70%. That saves another 15 to 20 minutes. So it's not going to be one thing. It's going to be a series of accomplishments or initiatives that will reduce the clerical burden.
Unger: I love those stories. Quick wins are so important and just listening to the minutes that you were outlining there, they add up. Not just in a day, but over the course of a year and really have an impact.
Dr. Girgrah: I actually heard one story. One of our primary care physicians after we enrolled that pharmacy refill clinic says that he went home at 5:00. And his wife had thought that he'd been fired from work because he was home 45 minutes earlier than usual.
Unger: That's amazing.
Dr. Girgrah: Pretty hilarious. Pretty sad.
Unger: Anything on your radar screen that's the big thing you want to still accomplish for the coming year?
Dr. Girgrah: Yeah, I think there's still a lot of work to be done in the area of mental health stigma and mental health support services. I think Ochsner along with other health systems can be a catalyst for change. I was really delighted to hear a couple of months ago that our state licensing board in Louisiana had eliminated questions around mental health substance use. I'd like to think that we were an influencer, so it's still a lot of work to be done in that area.
I worry about all our physicians, but I'm really worried about our primary care physicians and the administrative burdens. They're really starting to dig deep in their workflows and try to improve their workflows over the next few years. Really another area really to experiment with new models of care—advanced team-based care models, and there's a lot of work to be done in that area.
And I think there's a lot of work still to be done in articulating the business case around well-being to a CFO or to somebody who works in the corporate business units. I mean, it still remains fluffy. People can get the business case around turnover and the cost of recruiting, ramping up. But I think we can do a better job of really attaching dollars to discretionary effort. Attaching dollars to patient experience. Attaching dollars to quality and safety outcomes. So I think there's more work to be done. I'd like to think there's a lot more work to be done in these areas.
Unger: Dr. Girgrah, thank you so much for joining us today. I know it's been an honor for the AMA to be working with you on physician wellness efforts at Ochsner. And I think you've had a huge influence on physicians across the nation at the same time. Thanks so much and a happy Doctor's Day out there to all the physicians who are listening. At the AMA, we certainly value the work that you do.
That's why reducing physician burnout is a key part of the AMA's Recovery Plan for America's Physicians. I urge you to take a look at that at ama-assn.org/recovery. We'll be back soon with another episode. You can catch all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Take care.
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.
