Nigel Girgrah, MD, discusses crisis fatigue contributing to physician stress

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 update, AMA Chief Experience Officer Todd Unger talks to health experts about how health systems are supporting physician wellness during the COVID-19 pandemic, and the top factors contributing to physician stress right now, including crisis fatigue; stress around politics and racial violence; and anxiety about the potential for a second wave of the pandemic during the fall flu season.

Learn more at the AMA COVID-19 resource center.

Speakers

• Nigel Girgrah, MD, PhD, chief wellness officer, Ochsner Health
• Amy Locke, MD, co-director, University of Utah Health Resiliency Center
• Bryant Adibe, MD, system vice president & chief wellness officer, Rush University System for Health

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're discussing how health systems are supporting physician wellness, during the pandemic, and beyond. I'm joined today by Dr. Nigel Girgrah, Chief Wellness Officer at Oschner Health in New Orleans, Dr. Amy Locke, Co-Director, University of Utah, Health Resiliency Center in Salt Lake City, and Dr. Bryant Adibe, System Vice President, and Chief Wellness Officer for the Rush University System for Health, in Chicago. I'm Todd Unger, AMA's Chief Experience Officer, in Chicago. Dr. Girgrah, let's begin with you. Tell us about the top factors contributing to physician stress right now.

Dr. Girgrah: Yeah, it's interesting when I think about that. Back in March, New Orleans was a real hotspot with COVID. And I I think then, it was perceived as an acute threat, like a hurricane, and we're pretty good at managing acute threats. There's an adrenaline surge. People were worried about things like vents, PPE, having enough critical care staff, daycare for their children. And there was a real clarity at that time that a lot of the usual economic and regulatory considerations evaporated, and it was all about the patients, and the community. And now, we're in September. I think there's been that surge. Capacity of adrenaline has dissipated a little bit, and there's a bit of crisis fatigue now. And I think we have this situation where it's both business as unusual, and business as usual. And I think that's a little hard for us to grasp.

Unger: Dr. Locke, is that what you're seeing?

Dr. Locke: Yeah, I think we're seeing the just extreme fatigue of month after month of thinking about how to do things slightly differently, combined with worries about our families, and quite a lot of stress around politics and racial violence. And so, I think, all of those things combining are just creating a really tremendous level of stress.

Unger: Dr. Adibe, we continue to see some progress here in Chicago. I saw that we just passed through another gate. What is the stress looking like for physicians right now, relative to what it was in the spring?

Dr. Adibe: I think, as you all know, it's been a busy summer here in Chicago, and a busy year. But, I think here at Rush, at least, we were really impacted pretty heavy, pretty early on. So, really, I think a statistic that puts it in context is at one point, at the max of the surge, one out of every four, so 25% of all critically ill COVID-19 patients in the entire state, were being seen here at Rush. So, we were obviously kind of leading the charge, relative to that early push. I think, like so many of my colleagues have said so far, I think that that comes with a cost, long-term. And so, there's certainly that fatigue. And, I think the other piece that we're certainly seeing is that anticipatory anxiety, as we head into this fall flu season, of a potential second wave, and we're certainly beginning to prepare for that.

Unger: Dr. Adibe, what wellness efforts did you have in place prior to COVID, and how have you pivoted in response to the pandemic?

Dr. Adibe: We were fortunate. We were fortunate in that, I think, we had a very forward-leaning leadership team here that had already made wellness a priority. And what that enabled us to do was, very early on in the pandemic, we were nimble, and able to respond. So prior to the pandemic, we already had our office, the Chief Wellness Office here that I lead. We also had what we call our Wellness Council, which has representation across our system. And a number of initiatives, and programs, including our 24/7 system-wide, what we call, Rush Wellness Assistance Program to support the mental health and wellbeing of our community. When the pandemic hit, we knew we needed an additional layer of leadership around this. And so we convened a interdisciplinary wellness task force, where we were able to bring in our department of psychiatry, behavioral sciences, our social work and population health departments, as well, under a central command, essentially. And what that allowed us to do was really tailor the efforts of our organization around wellness.

Unger: Dr. Girgrah, Oschner has had a strong focus on physician wellness. Had the opportunity to work with you on the AMA side, around this. Can you tell us about where have you been on the journey with your programs about physician wellness, and how have you had to pivot those?

Dr. Girgrah: Yeah. Coming into 2020, I think our Office of Professional Wellbeing had presented, I think, a pretty solid evidence-based strategy to promote physician wellbeing, helped a lot by some of the thought leaders in the AMA, and that strategy focused on things like practice efficiency, leadership development, advanced team-based care, and a little bit on personal resilience. Then COVID hit, and it became clear. Two things, I think, became clear to us. One, is that we had to broaden our scope. So we were no longer an Office of Professional Wellbeing, for just our employed physicians, and APPs. But we're now at a necessity, an Office of Professional Wellbeing, for all our employees. The second thing is that we kind of had to move down the Maslow's Hierarchy of Needs. So a lot of our pre-COVID efforts were looking at the top of Maslow's Hierarchy of Needs.

Dr. Girgrah: So, developing a sense of self-actualization in the workplace, a sense of belonging. But we have to really think about physiological safety in the workplace. People can't do a good job if they're worried about their own safety in the workplace. Whether their children are going to be safe at home. Whether their compensation is going to be safe. Whether their colleagues are going to be furloughed. So there was a very strong effort, initially, to allay people's fears. I remember, one weekend in March, in 72 hours, we put together, with collaboration with other services, daycare for all our employees that needed child daycare. And I think those things were just absolutely essential.

Unger: I've heard many times from our different guests on the program, that it literally is, to begin with, about food and shelter, and some of those, just, basic needs of support for physicians, and the whole medical staff. Dr. Locke, can you tell me a little bit about the creation of the Resiliency Center, and the work that you're doing with the AMA, and for your staff?

Dr. Locke: Yeah, so we began thinking about this in 2016, and with the help of the AMA, did a system wide survey of providers, which really helped, I think, galvanize interest and focus. We subsequently designed and implemented the Resiliency Center through the Office of the Chief Wellness Officer. And I think that that ability to really work across groups, and bring people together, put us in a really strong position when COVID did hit, because we already had a great network of relationships and collaborative projects across many entities in the health sciences, and in the hospital.

And so, then, in the spring with COVID really looming, it was an opportunity to pull together a COVID resiliency work group with people from Patient Safety, Human Resources, Chief of Nursing, Quality, our CMO, and experts in resiliency to really think about how to support people, just as my colleagues were saying, thinking not only about the day-to-day of being a physician in terms of self-actualization, but also, really, tangibly, how are we doing with personal protective equipment? Where are we sending our kids? How are we going to cover for each other when people are not available? And then, really, just making sure there's that strong support system.

So if you look at our numbers of providing either one-on-one, or group, as support, we've more than doubled usage in the last six months. So just really being able to have conversations, and get out the word about how to support teams and each other.

Unger: Well, you all have mentioned the issue. We're already experiencing a sense of fatigue right now. There's fear about what's coming in the fall. As you think about preparing now, for the potential long-term mental health impact the pandemic may be having on physicians, what are you thinking? Dr. Adibe, will you start?

Dr. Adibe: Absolutely. I think the one advantage of having gone through a spring surge is we do at least have some understanding of what to anticipate, and how to prepare, and I'm sure my colleagues would agree. There are some great lessons learned.

Part of what we did was we built out a framework for how we'll respond, relative to the wellbeing of our clinical team. Some of which have been mentioned, I think. So the ideas of supporting the bio-psycho-social needs of our community. Whether that be through onsite daycare support, etc.

One of, probably the biggest hits, believe it or not, of our wellness response team, which is bringing foods to the units, right? So that people had meals to eat, and they felt that they were physically cared for. But the other was central to our core strategy here at Rush, our wellness response team, which was an interdisciplinary group. As I mentioned, made up of psychiatrists, psychologists, nurses, physicians, and others that were able to provide in the moment, onsite assessments for any staff that were having issues.

And what that allowed us to do was, instead of allowing issues to build over time and to have to be dealt with downstream, they were able to provide in the moment, real time, support and care. That's something that we will certainly plan on reactivating as needed, heading into this second wave.

Unger: Dr. Locke, how are you thinking about the longer term impact?

Dr. Locke: Well, I think that one of the bright sides of COVID, if there are any slight silver linings, is just the increase in conversation around these topics. And I think it really serves to de-stigmatize mental health and stress as a general concept, particularly among high-achieving physicians, and other health professionals. And so my hope is that this... You've now come and chatted one-on-one or you've had a group debrief session, or you've started doing group check-ins with team meetings. That those things might continue beyond COVID, as the comfort with those interventions increases.

The other thing that I think we'll transition is we've had a peer support program now, for a number of years, but I think growing that program, instead of waiting until someone talks to risk management and has a crisis, but really, this idea of a culture of support that's embedded in our day-to-day conversations. I think it just allows us to continue furthering that conversation.

Dr. Girgrah: You know, can I just add, I was in Toronto for SARS-1, back in 2003, which was much less than this, obviously, and one of the silver linings, as Amy pointed out, was there was a real conversation after SARS-1 about de-stigmatizing mental health amongst our health care professionals.

Pre-COVID, our organization announced our commitment to elevating the overall health of our state, and part of that is mental health. And that starts with our physicians, and our employees. And I think there's two aspects to this. One is removing real, or perceived barriers to having conversations about this, and these are things like questions on licensure applications, or credentialing applications. And then the other thing is creating a true belief system, that it's okay to talk about these things. And that starts with our leaders doing storytelling, talking about their own struggles. I think patient-facing physicians are going to feel uncomfortable talking about this, unless they start seeing their leaders have discussions about this.

Unger: Well, you all hold leadership positions that are focused on physician wellness, and your programs are now up and running. Is this something, at this point, you see as relatively widespread among health systems, and how is it important for systems and practices to create positions, and even departments, focused on physician wellness, like you've established? Dr. Girgrah?

Dr. Girgrah: Yeah. I'm not sure how widespread it is, but I think it's sort of catching on. I think we've recognized here at Oschner, that physician wellbeing is a leading quality indicator. It drives other things, like quality and safety. It drives patient experience. It drives financial performance for the organization, and it's just the right thing for a compassionate organization to do for its physician staff. So it's a vehicle to execute on, I think, our bold strategy. And to do that, you have to make investments. You have to invest with FTEs. You have to invest in programs. You have to measure the state of wellbeing. And so it has been a priority here. And I think we are making a difference at Oschner.

Unger: Dr. Girgrah, how are you measuring?

Dr. Girgrah: Well, pre-COVID, we used things like the NASDAQ Burnout Inventory, which I think is kind of cumbersome. After partnering with the AMA, in April of 2019, and then more recently in June of this year, we've used the AMA Mini-Z survey, which I think is a much more nimble survey, that actually gets to the root of unique drivers amongst our physicians and APPs. So, we also use our Gallup Physician Engagement survey as well. But the core has been our Mini-Z survey.

Unger: Dr. Locke, do you have any advice for other health systems and practices that are looking to promote physician wellness initiatives, or advice for physicians who are struggling?

Dr. Locke: Well, I think from a system perspective, it's important to remember that we all want the same thing. We all want excellent patient care. We want our systems to have great reputations with research and education, and that's included in our mission. And we want to serve our communities, and we want a sound financial platform for our health systems. And so, looking for ways that, considering wellbeing, can help meet those needs, I think, can really make sure that we're putting our resources in the right space to make that happen. I think when an individual person is really suffering, it can be hard to see the forest for the trees, and it can really just... I sometimes call it being in the puddle. Like you're just sitting there waiting for a rescue. And so, really just trying to think about, what are the strengths that that person brings to their career, and really maybe working with them to find that, kind of, edge of how they can start to see a potential way forward. But I think you do need that ground-up and that top-down approach to really meet the broadest needs possible.

Unger: Dr. Adibe, any advice for health systems and practices?

Dr. Adibe: Yeah, I think there's a few. One is, at least our position here would be, I really think it's imperative that as physician leaders, we take advocacy stances and really use these roles, and our positions as anchors of our communities to send a message, really, to ideally create a future of health care that we can all believe in. You know, Todd, I think this is such an historic time for our country and really, for health care, and never before, has wellness been more important, and luckily, never before have more people been listening. You know, when I think about the obligation that we have in kind of leading through this time, I think we as a collective, don't need to think of a future where these conversations around addressing burnout, and mental health, and de-stigmatizing getting help for those who need it, isn't something new or different or unique.

It's the norm. I believe in a future in which trainees are brought into our profession in such a way that concepts of respect, and equity, and civility are really the expectations, and are what are modeled on our clinical floors. And also believe, I would say, in a health system in which we're all respected, regardless of our backgrounds and our given roles. And I think, as you would agree, being here in Chicago, that's something that I think we've seen throughout the summer. And it's certainly been a narrative that folks all around the world have supported.

And so something that we believe very deeply in: this was pre-COVID, during COVID, after COVID, something I'll continue to fight for is, in many states in our country, physicians still have to declare if they are seen by a mental health provider. They still have to declare if they do what they're really recommended to do, which is seek help when they need it. I think it's wrong, and our institution has taken a stance on that. And we believe that those who help, who need help should be able to get it, when and how they need it, and that's something we'll continue to fight for.

Unger: Well, that is an excellent perspective. Thank you so much, Dr. Adibe, Dr. Girgrah, Dr. Locke, for being here today. For all the work that you're doing to support physician wellness. That's it for today's COVID-19 update. We'll be back soon with another segment for updated resources on COVID-19, including resources to help physicians manage their own mental health. Go to ama-assn.org/COVID-19. Thanks for joining us, and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.