Some of the most important things a physician leader should do won’t appear in a job description: Be vulnerable. Openly acknowledge your mental health issues. Seek treatment when necessary. Normalize mental health problems and treatments.
That’s the insight of Nigel Girgrah, MD, PhD, a transplant hepatologist and chief wellness officer at Ochsner Health in New Orleans, based on his own experience.
In the first summer of the pandemic, Girgrah felt the stressors stacking up on him. As New Orleans suffered through a COVID surge, unable to exercise because of a knee injury and unable to seek comfort with friends and family in his native Canada because of travel restrictions, he was dwelling on the death of his son several years earlier.
“I had my own struggles with anxiety, as many did, and I knew that I needed help,” he says “I got help and recognized that the story wasn’t unique to me.”
Girgrah began speaking more openly about mental health challenges and the stigma about mental health that pervades the healthcare sector. Then he wrote a letter describing his own experience and emailed it to his 34,000 Ochsner colleagues.
That email got the highest ever “open rate” of any executive communication at Ochsner. Many of his colleagues responded, expressing their gratitude and citing his message as a call-to-action to seek help for their own mental health challenges.
Ochsner’s CEO was inspired to write a similar letter, sharing his own struggles with mental health. As a result, Ochsner leaders are incrementally changing the health system’s culture to one that acknowledges the reality of mental health issues and treatment. “That sets the tone,” Girgrah says. “I want to underscore the importance of leading with vulnerability because vulnerability builds trust.”
The Crisis at Hand
Burnout, marked by emotional exhaustion, a lack of empathy for or negative attitudes toward patients, and feelings of decreased personal achievement, is not a mental health diagnosis, but it is a serious condition that, if unaddressed, can lead to mental health problems.
The healthcare sector was alarmed when, in 2011, the first comprehensive national physician burnout survey found that 46% of physicians suffered at least one burnout symptom. While burnout rates dropped a bit before the pandemic, the situation is worse now. The latest survey, published in Mayo Clinic Proceedings, found that 63% of physician respondents reported at least one symptom of burnout in late 2021 and early 2022.
Meanwhile, half the physicians responding to a survey for Medscape’s 2022 Physician Burnout and Depression Report said they felt more burned out than they did a year earlier. Nearly a quarter — 24% — said they suffered clinical depression.
“Unfortunately, last year the nation saw a rebound in the number of physician suicides nationally across specialties and across practice environments,” reports Stefanie Simmons, MD, vice president of patient and clinician engagement at Envision Physician Services, a multispecialty medical group of more than 25,000 physicians and advanced practice providers across the country.
An estimated 300 to 400 physicians in the United States die by suicide each year, according to the American Foundation for Suicide Prevention. Depression is a major risk factor in physician suicide, along with bipolar disorder and substance abuse.
Lorna Breen, MD, an emergency physician at NewYork-Presbyterian Allen Hospital in Manhattan, had never experienced any of those problems; however, after contracting COVID-19 during New York City’s first wave and lacking adequate support in treating patients in the emergency department, she suffered a mental health crisis that prompted her family to admit her into an inpatient psychiatric unit.
In an AAPL SoundPractice podcast interview, her brother-in-law, Corey Feist, said stigma surrounding mental health treatment may have contributed to her death. The majority of state licensing boards require physicians to report past or current mental health treatment in their licensure applications. Breen feared that because she had received mental health treatment, she would lose her medical license.
“Lorna started calling saying she was feeling better, but that (we) needed to recognize that now that she’d received mental health treatment, she was going to lose her license to practice medicine, and she would never be able to practice again… . She was convinced beyond any doubt that this was going to impact her ability to practice medicine…. After about a 10-day stay in the inpatient psych unit, she was discharged. She was doing a lot better. And then tragically on the 26th of April, she died by suicide.”
Shortly after her death, Feist, chief executive officer of the University of Virginia Physician Group, and his wife, attorney Jennifer Breen Feist, established the Lorna Breen Heroes Foundation to reduce burnout among healthcare professionals and to safeguard their well-being and job satisfaction.
Reducing the Stigma
The tragedy is that Breen was misinformed about the threat to her career. New York does not ask physicians to report prior mental health treatment as part of their licensing protocol. The myth is so pervasive, however, that many physicians live in fear, says Envision’s Simmons, a member of the Breen Foundation board of directors.
Indeed, a 2022 survey conducted by the Physicians’ Foundation found that nearly 40% of those interviewed said that either a colleague or they personally avoided seeking mental healthcare for fear that the treatment would need to be disclosed on licensure, credentialing, or insurance applications.
The Lorna Breen Foundation has identified 31 states, as well as the District of Columbia, that require applicants to disclose past mental health issues or to explain why they have taken breaks from work.
Those questions imply that past mental health issues or treatment puts patients at risk, Simmons says. Instead, licensing boards should look at mental health issues the same way they view physical conditions. “If you have a clinician who has diabetes, you don’t care whether they have diabetes, you care whether their diabetes is stable and allows them to practice medicine in a safe way,” she explains. “It’s the exact same thing with a mental health issue. It needs to be diagnosed, it needs to be treated, and the clinician needs to be able to attend to their care. And there is a significant chilling effect on all three of those aspects if you’re asking people if they have a history of any mental health condition or treatment.”
Several states are working to change their medical board renewal questions, and Simmons encourages physician leaders to advocate that their own states do so. Meanwhile, many hospitals need to amend the questions on their credentialing applications to de-stigmatize mental health issues and treatment.
“The biggest issue, honestly, is inertia,” Simmons shares. “So it’s important to get in front of the hospital leaders who are responsible for those changes. At Envision, we’re using our wellness champions at many of our sites to start that conversation with our hospital partners and raise awareness of why it’s important and work to support clinicians’ mental health and well-being.”
Preventing the Problem
Mark Greenawald, MD, vice chair of the Department of Family and Community Medicine at the Virginia Tech Carilion School of Medicine in Roanoke, Virginia, had been active in physician leadership for years when a bad obstetrical outcome threw him off his stride. It took him a year to seek professional help.
“During that year, on the outside, I had it all together, and nobody would have known what was going on, but on the inside, I was a hollow, empty shell,” he says.
Therapy relieved his suffering. “I thought, ‘If it took me a year to reach out for help, what’s going on for my colleagues who might not have the same kind of support?’ ” he remembers.
That question sparked his interest in the intersection of physician leadership and physician well-being. He has chaired the American Academy of Family Physicians (AAFP) Physician Health and Well-being Conference for the past four years, serves on the faculty for AAFP’s 10-month Leading Physician Well-being program, and co-chairs his department’s well-being committee.
In 2020, independent of the pandemic, he launched PeerRxMed, a free, peer-supported program that helps physicians and clinicians prevent burnout by building an intentional relationship with a trusted peer.
“Nobody wakes up one day burnt out — that’s something that has happened over a long period of time,” Greenawald says. “So how can we prevent burnout in the first place, knowing that healthcare is really challenging and takes an emotional and a physical toll on anybody who is practicing or leading it?”
A PeerRXMed participant recruits a partner or “buddy” with whom to go through the process. Greenawald sends email prompts reminding partners to have a brief, once-a-week check-in — maybe just 90 seconds — by phone, text, email, or in person. There is also an accompanying weekly blog that can take the conversation deeper.
Prompts are also sent to encourage a monthly check-in — 30 to 90 minutes is suggested — during which participants discuss their progress on personal or professional goals. Once each quarter, Greenawald prompts PeerRxMed partners to commit to a 90-minute dialogue into a deeper topic, such as “How are you living out your values?” or “What’s your next vacation/adventure?”
The PeerRXMed premise is that having regular check-ins with a trusted peer diminishes the likelihood of getting burned out or worse.
“It’s because you have somebody who you can immediately begin to process things with so you don’t carry them with you and start on that downward spiral that often leads to burnout and distress and depression,” he says.
Changing the Culture
Girgach started recognizing the danger that comes from the stigma around mental health problems and treatment in 2013, when he learned that a friend from medical school — a surgeon with an international reputation — had died by suicide.
Fast forward a few years, and he chaired Ochsner’s Provider Wellbeing Task Force, which made several recommendations, including these: Create a chief wellness officer position and establish an Office of Professional Wellbeing.
In 2018, Girgach accepted the CWO assignment. He and an executive dyad partner with a background in human resources now manage a small team that collaborates with colleagues in Ochsners’ IT department, the electronic health record implementation team, the leadership development institute, the pharmacy team, and others.
“The idea that six or seven FTEs are, by themselves, going to change the well-being of all 35,000 employees is not realistic,” he acknowledges. “It quickly became clear that this must become an office of influence.”
The two biggest drivers of professional fulfillment for physicians are practice efficiency and their relationship with their immediate supervisor.
“So, it’s important to develop our physician leaders, not just with the hard skills of leading a department, but also with the soft skills: How do you meet with your patient-facing physicians? How do you have job-crafting discussions? How do you make your physicians know that they are cared for by the organization?” he says.
The Ochsner wellness program includes four components, the first of which is raising awareness about mental health broadly across the organization.
“The second component is actually measuring mental health — not just engagement, not just burnout, not just well-being but measuring depression and PTSD, which we have started to do,” Girgach says.
Another component is de-stigmatizing mental health problems and treatments by changing the traditional leadership behavior — “I’ve got it all together” — to model vulnerability and willingness to seek treatment when necessary.
Fourth, Ochsner is broadening the range of support it offers to its employees beyond the employee assistance program. “We need to get upstream and think about different ways to meet the mental health needs of our physicians and all our employees,” he says.
A resource, or affinity, group was launched to give staff members who have been affected personally by mental health challenges or have a struggling family member an opportunity to talk openly about the situation. The goal is to normalize mental health as a topic of discussion.
Ochsner also started Schwartz Center Rounds, a regularly scheduled time period that gives clinicians an opportunity to talk about distressing clinical cases. In addition, Ochsner provides a digital mental health platform that allows employees to participate anonymously in group therapy sessions led by a licensed behavioral health specialist. It also hired a company to call all staff members to offer emotional support and be available for round-the-clock inbound calls from staff members who want someone to listen.
“There’s not going to be a silver bullet, so we are just trying different things and scaling those things that are working,” Girgach says.