EP. 67: STRESS AND THE MIND-BODY CONNECTION
WITH KELLY McGONIGAL, PHD
A health psychologist and bestselling author discusses our misconceptions about stress, how we can maximize the benefits of effective stress management, and how we can better care for our minds and bodies.
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Episode Summary
We live in a culture that vilifies stress. Stress, we are told, is unhealthy both physiologically and emotionally, and something to be avoided at all costs. But Stanford University health psychologist Kelly McGonigal, PhD believes that by suppressing or ignoring it, we're missing out on the benefits of effective stress management. Kelly is also a bestselling author whose work focuses on the mind-body connection and the psychology of compassion and mindfulness. In this episode, Kelly shares the personal experiences that led her to this work, the myths and misconceptions surrounding stress, the role of physical movement in promoting our wellbeing, and how even busy physicians can find space for self-compassion.
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Kelly McGonigal, PhD, is a health psychologist and lecturer at Stanford University, and a leading expert in the new field of “science-help.” She is passionate about translating cutting-edge research from psychology, neuroscience, and medicine into practical strategies for health, happiness, and personal success.
She teaches for a wide range of programs at Stanford University, including the Stanford Center for Compassion and Altruism Research and Education, the Graduate School of Business, and the School of Medicine’s Health Improvement Program. She has received a number of teaching awards for her undergraduate psychology courses, including Stanford University’s highest teaching honor, the Walter J. Gores award. Her popular public courses through Stanford’s Continuing Studies program—including the Science of Willpower and the Science of Compassion—demonstrate the applications of psychological science to personal health and happiness, as well as organizational success and social change. Through a wide range of conferences, workshops, university-affiliated programs, and consulting, Dr. McGonigal also provides continuing education and training to executives, teachers, healthcare providers, and other professionals.
Dr. McGonigal received her PhD in psychology from Stanford University, with a concentration in humanistic medicine. She received a BA in Psychology and a BS in Mass Communication from Boston University.
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In this episode, you will hear about:
• The early life experiences that led Kelly into a career in psychology - 1:55
• What health psychology is - 3:50
• How physical health impacts mental and emotional wellbeing - 6:13
• Why many physicians find it difficult to maintain physical health - 11:58
• The behaviors that can make a big difference in one’s physical and mental wellbeing - 15:06
• How Kelly helps physicians provide care to their patients while holding space for the exhaustion and frustration that can come with this work - 25:50
• Common misconceptions about stress - 38:39
• The importance of self-compassion for those working in high-stakes fields like medicine - 43:00
• Advice to clinicians on better supporting patients going through stressful times - 55:48
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] We live in a culture that vilifies stress. Stress, we are told, is unhealthy both physiologically and emotionally and something to be avoided at all costs. But Stanford health psychologist Dr. Kelly McGonigal believes that by suppressing or ignoring it, we're missing out on the benefits of effective stress management. Kelly is also a bestselling author whose work focuses on the mind/body connection and the psychology of compassion and mindfulness. In this episode, Kelly shares the personal experiences that led her to this work the myths and misconceptions surrounding stress, the role of physical movement in promoting our wellbeing, and how even busy physicians can find space for self-compassion. Kelly, Thank you so much for taking the time to join us and welcome to the show.
Kelly McGonigal: [00:01:53] Thank you for having me.
Henry Bair: [00:01:55] So you are a health psychologist, and we're going to spend some time exploring what that actually means. But for now, can you tell us what first drew you to a career in psychology?
Kelly McGonigal: [00:02:07] So I think it goes back to when I was a little kid. I dealt with both chronic pain that was unexplained and untreated intense headaches every day. And basically nobody believed me. And also, I grew up with an anxious temperament. You know, just from the day I was born, it's like I was filled with anxiety, existential dread, the kind of thing that also back then, when I was growing up, kids weren't in therapy. This was not something that people were actively looking out for kids mental health. So growing up, I had this, you know, day to day experience of really difficult inner states, pain and anxiety that nobody really took seriously because I was young. And I think that led to a couple of things. One is that it made me realize at a very early age that people can have stuff going on in the inside that's not visible to others but is real. It led me to an understanding that I call not surprised by suffering. So I'm not surprised when I find out that other people are in pain or struggling with depression or grief or addiction or anxiety. It makes sense to me that human beings struggle. And the other thing that it led me to is trying to find ways to deal with those difficult inner states that are hard to control. And that got me really interested in the mind body relationship and psychology. And so like a lot of people who get into psychology research, I was interested in solving problems that I had experience with.
Henry Bair: [00:03:50] So what is health psychology and what are some of the questions and issues you're interested in addressing?
Kelly McGonigal: [00:03:57] Yeah, so probably as a field health psychology is interested in both how psychological and social factors influence physical health and also the mind body relationship more generally. So I got started in Psychophysiology, which is like when you're angry, how does it affect your heart, your blood pressure, your immune system? I think the other part of health psychology that really drew me to it is this understanding that humans are embodied. We are biological, and to understand even psychological phenomena through the lens of biochemistry, what's happening in your brain, what's what, hormones are in your blood system. The idea that we're biological creatures is really interesting to me. So that's part of how I think about health psychology. But the questions that I'm most interested in answering, the things that I've looked at across all of my work, basically comes down to understanding the paradox of human nature. One thing that's been really clear to me is that human beings have competing instincts. For example, we are both motivated to protect ourselves and defend ourselves to be vigilant, to avoid. And also we're brave and we're courageous and we take risks. We have the desire for immediate gratification. We like to feel good now, but also we can invest in the future and imagine the future.
Kelly McGonigal: [00:05:21] We can be both violent and aggressive and hostile and also incredibly kind and cooperative and compassionate. So when you look at the interventions that I've designed or the books that I've written, I think they basically all look at that paradox of how do we hold the opposites of human nature? And I'm like really interested in helping people tap into what is good in human nature, not just from some kind of moral point of view. Like, wouldn't it be great if we were all brave and kind and investing in the future? But because when I was looking at those questions like, how do I deal with my anxiety? How do I deal with the fact that I have physical pain every day that I can't control? Actually, it was often it was those things helping others, imagining a better future, these positive human capacities. They were the things that actually helped me deal with, reduce or transform things like chronic pain or anxiety. And so I feel like that's the perspective that I bring to everything that I do is this idea that we can actually transform pain and suffering by turning to what is good in human nature. It's actually like a coping choice we can make.
Tyler Johnson: [00:06:39] You know, I'm really glad to hear you say that stuff. We promised our listeners last week that in ten minutes you were going to give us the secret for perfecting human nature. So did you really?
Kelly McGonigal: [00:06:47] Is that was that the pitch?
Tyler Johnson: [00:06:48] That's that's actually a lie. But it would have been cool if we had done that. And then I would just start a stopwatch and we would just, you know, wait and see what you said. Let me ask you this. So, you know, I think the idea of studying psychology is so interesting for a lot of reasons, but one of them is precisely because what you mentioned. Right. I think all of us when we're young and many of us even still when we're old, because our psychology, like what happens inside of our hearts and brains, is just hardwired into the way that we experience the world. I think most of us are not even aware that anything is happening, right? It just is us. Like the idea of analyzing it doesn't really make any sense because, I mean, you have to realize that there is a thing to be analyzed before you can even really talk or think about it, Right? And so then for someone like you who spends their life studying psychology, it's sort of like you have to drop down into your own brain or other people's brains and sort of, you know, it's like a kid opening up a toaster or something, right? To see how it works inside and to like figure out what does this do and what does this do and how does it all fit together. So I guess and you started to speak to this a minute ago in your answer to Henry's last question. But as you've now spent many, many years sort of taking apart the toaster of the human brain and trying to understand these things that might help you with the problems that plagued you when you were young and by extension, then help other people. What do you feel like are some of the most important insights? Like as a person who's been down there looking at the toaster and now you're coming back to tell everybody else sort of, Oh, boy, this is the thing that I learned. Like, what are some of those?
Kelly McGonigal: [00:08:34] I think one is that you have to take care of your physical body and your physiology, edgy and not often in the ways that people are told to. So, you know, people are told have a healthy weight, have healthy blood pressure, then you won't, you know, have heart disease. But I think of it more as now.
Tyler Johnson: [00:08:52] Don't, don't, don't, you know, talk down on the weight and heart disease. These are two doctors. Okay. We like talking about.
Kelly McGonigal: [00:08:58] I'm just kidding. Right. But it's this idea that, like, your body is this thing that you're dragging around and it's it's you have to take care of it if you want to be alive. I think that's how a lot of people feel like they are.
Tyler Johnson: [00:09:10] Talking, though that does tend to be true.
Kelly McGonigal: [00:09:12] But and I think of it as your your life. You experience life through your biology. And what we know about human beings is everything from your mood, your personality, your stress, resilience, how social you are. They're influenced by things like what you eat and how physically active you are and what you're exposed to in your environment. You are a physiological creature and human beings thrive when we are taking when we take care of ourselves in some really basic ways. So as you know, I'm very focused right now on physical movement and physical activity as one of the most important things that that a human being can do, not only for their physical health, but for their mental health and for their ability to find community and connection. So I really I feel like so many people hear messages about taking care of their body that are based on either shame about what the body looks like or just fear of physical states and conditions we don't want. And not enough time is spent explaining that what you eat this morning is going to affect your mood. It's going to affect how well you get along with others that you are. You are in a sense, creating who you are and your experience of life through how you take care of your physical state and that its sleep too. I mean, it's it's a lot of things.
Kelly McGonigal: [00:10:29] So that's one of the the big takeaways that I've had is if you want to experience more joy, more connection, more meaning, more more psychological strength, more creativity, all of that, to not pretend that you aren't a biological. Being who needs a biology that supports all of those things. And then the other key takeaway, I think, is that it's that humans are so obviously social and both our worst instincts and our best instincts are related to the fact that we are interdependent and we depend on other people and to find a way to embrace the fact that we need other people and influence other people and experience joy through our social connections and contributions. That is the other key takeaway. Time and time again, when I talk to people about anything, you know, whether I'm asking people how they've recovered from the most difficult experiences in their lives to what brings them joy to even why do you exercise the things that people tell me they always come back to connection community and and making a difference. Feeling like you can say my existence matters in some way and that is, you know, that social. It's very hard for someone to say my existence matters without talking about the what they do or who they help or who they love.
Tyler Johnson: [00:11:58] So we'll come back to that hugely important idea about connection and community in a minute. But first, let's go back to the your biology influences the way that you experience reality. So. Dirty little secret: Doctors, for all of our discussion about, you know, having a good weight so that you don't get heart disease, it can often be immensely challenging for doctors, especially doctors in training to take care of their bodies.
Kelly McGonigal: [00:12:26] Oh, I know you.
Tyler Johnson: [00:12:28] Yeah. So I'm sure that you have some idea of this. But just to paint the picture a little bit so somebody graduates from college, they want to become a doctor. They spend a couple of years in medical school where it's probably fine. They can take care of themselves. Fine, because it's kind of like an extension of college. But then you get to the third, what traditionally is the third year. Some places it's second or whatever. But anyway, you get to the year of your clinical rotations in the hospital and in effect, for a period of anywhere from 4 to 10 plus years, depending on what kind of doctor you want to be when you grow up, you just sort of disappear, maybe not 100% of the time, but at least for months at a time and often for years at a time. You're just sort of swallowed into the hospital. Right? And during that time, you may be working 80 to 90 or 100 plus, in some cases, hours a week. You might be working 30 plus hour shifts. You might be routinely not sleeping at all every fourth night and then getting relatively little sleep on the other nights. You may routinely be tempted anyway to eat hospital cafeteria food because that's what's on your way down the hall. You may have a distant memory that there was a thing called exercise that you once upon a time did. And it can be very, very challenging. Right?
Kelly McGonigal: [00:13:47] You forgot to mention having to pee when. So I've done interventions in hospitals with all levels of medical professionals. And, you know, we had to have serious conversations about when are you going to pee like that? Level of inability to take care of your physical body. I also learned very quickly that if you said you were hosting an event or training for medical students or doctors, they would give you food and they would bring really unhealthy food. And I had to, like go to the mats and be like, Could we feed people something actually nourishing? Since we're talking about self-care and self-compassion, it can be brutal. And I also I know that there are ideas about that brutality being a part of how you train physicians to overcome certain instincts that actually can get in the way of providing effective care in the moment. Now, I'm sure you all would have a better argument on that. But I also understand sort of some of the heritage around that, thinking about why you need to enter a state that doesn't really allow you to slow down and think about what you're doing in order to achieve certain levels of ability to go into places where people are suffering and do what needs to get done.
Tyler Johnson: [00:15:06] So let me ask you this question, because, you know, obviously this conversation needs to happen and I think is starting to happen on two levels, right? So one is the systemic level, which is what you're sort of alluding to there at the end. Right. Which is that a lot of people, a lot of non medical doctors who I talk to about my training, by the time I get finished, they're just like, you did what? Like, why would they do that to anyone? Right. And so there is a level on which I think we have to have a discussion about whether this even makes sense. But since we're not sitting in the rooms where those decisions are made right now, let's put that aside for a moment. Here's the question that I want to ask you. If you were going to have like a one on one consultation where you sat down for an hour with a medical student who's on their surgery rotation or an internal medicine resident who's in the middle of intern year or whatever it is, somebody who is really right in the hottest part of the crucible of whatever part of their medical training. And they were to say to you, Look, Kelly, like I don't have very much bandwidth. It's everything I can do just to stay standing and remember how to repeat potassium or whatever. I just need you to distill all of this wisdom you've gained about how to take care of your biological organism to facilitate flourishing. I need you to distill that down into some super concrete suggestions about like if you could only do a little, here are the things like the the few things that you can do that would really make a big difference within the constraints that life presents you. What would those look like?
Kelly McGonigal: [00:16:43] Number one, because it's subtractive, it doesn't require time is stop using mind altering substances that allow you to dissociate or distance yourself from the reality of your life.
Tyler Johnson: [00:16:55] A la?
Kelly McGonigal: [00:16:56] A la, Like drinking? Is that what you mean? Like what? Or.
Tyler Johnson: [00:16:59] Yeah, like seriously? Like which. Which specific things are you talking about? I want to be really granular.
Kelly McGonigal: [00:17:03] I mean, you know, I would say anything what you do is at the end of the day, you find yourself taking a substance to try to undo the reality of your life. This is not just for physicians or physicians in training, but this is sort of one of the biggest risk factors for every experience you don't want, whether it's burnout or divorce or depression or addiction, that habit and it often it starts often in these pressure cooker kind of situations where people are trying to find a way to keep going. And many people will find this kind of dissociation or avoidance, this state change that's available through drugs or alcohol is a short term fix that leads to some really negative consequences. So if you were going to ask the first thing that would be if you have an opportunity right now to not go down that route, now is not the time to think like, Oh, this will be just how I get through. The second would be to start cultivating mindsets or mental practices throughout the day that allow you to see and appreciate the good that is meaningful to you. Whether that is the meaning of your work, seeing some sort of positive consequences of what you're doing, even the stuff that's not fun and that's hard, whether it's feeling connected to coworkers and colleagues, whether it's feeling a right fit, like the thing that you're doing.
Kelly McGonigal: [00:18:33] Oh, I was born for this part of the work to start noticing those things because that is the mindset when you look at things like burnout over time or satisfaction in medicine and joy in medicine, it's the ability to notice those things because you can't control the rest of it. I mean, you can argue about whether the system is getting worse or worse and worse. I think everyone always feels like it's always getting worse and worse. So I think you could reliably predict it might not be getting better and better and better then to. Start to cultivate this mindset that is going to provide you those moment to moment experiences that help people persist and and not say, I wish I hadn't gone into this profession. Being physically active in doses as small as a couple of minutes seem to be sufficient to help boost energy and mood, even if you're sleep deprived. Even if you're stressed out, I always say combine it with music because music is another incredibly powerful biological state change that doesn't have some of the harmful effects of getting drunk. In terms of your ability to to keep going and take care of yourself. So finding ways to be physically active. You know, it's not going to be after that. It's not going to start sounding super surprising.
Kelly McGonigal: [00:19:50] It's about doing what you can in a system that makes it hard. And I find myself saying that to people. I mean, so just to give you some perspective, outside of medicine, one thing that I've observed over and over and talking to people who work in law and education and public service and government and you name it, the military, when I talk to people about what they do, if they're doing anything that matters, I hear the same stuff. The system makes it impossible to be our best selves. It's getting worse. We're under extraordinary levels of pressure. We often are vilified by the public. This seems to be the state of the world right now. And so part of me wants to be very pragmatic about it and say it's not like other people out there are having radically different experiences and like, you picked the wrong profession or you're not cut out for it. There's something about the way the world works right now that is creating that experience for a lot of people. You know, the pragmatic thing for me is to say, okay, well, if I choose this life, I continue to choose this life. My task is to do what I can and to find ways to maybe make it better for those who are coming after me.
Tyler Johnson: [00:21:04] One thing. I just want to go back and be clear about this because I think this is really important. I know when I was a resident, as I sort of alluded to earlier, oftentimes the idea of exercise felt so overwhelming because it was like, you know, it's like it takes 15 minutes to get to the gym and then you have to change and find a place to put your clothes and then you exercise and then it takes 15 minutes to get back. And so it's like a half an hour plus of transit time plus whatever time working out. But what I think I hear you saying is that even if you're on like a busy call day and you honest to goodness, just like go outside in the sunshine for a minute and I don't know, do jumping jacks or push ups or sit ups or something even that is helpful.
Kelly McGonigal: [00:21:41] Shadow box run up and down stairs, do some stretches someplace, go hide somewhere and do some stretches. Yeah, it's a yes. And also, I should say, I mean, I, you know, depending on where you are in your career, things may seem more or less impossible. But of course, you know, I've got plenty of physicians and people in health care in my fitness classes like it is possible at some point in your life to choose activity that is intense and of a sufficient duration to feel like it's an incredible break in your day, an incredible stress reliever. So it's a yes and you do what you can. And I also you know, I'm always encouraging people, there's going to be a time when you can go for an actual hike, do it. This is the research is really clear on this, that it's a very low dose that's required to give you some benefit in terms of outlook and health and also greater duration. Higher intensity is going to pay off incredibly for every potential benefit, physical, psychological or social. So I feel like and that's not necessarily true with everything, but yeah, with movement.
Tyler Johnson: [00:22:47] And and again, just to be granular on the music piece, is there a particular kind of music that works.
Kelly McGonigal: [00:22:54] Better? Yes, it's the kind that you love. You know, one of the areas of research that I've looked at a lot is the use of music in medical procedures for pain and anxiety. And people always think like, you know, there's this one research study that tried to create the most relaxing piece of music based on music principles, and they found that did not work as well as just telling people to listen to a song they love. You know, music is so powerful because it evokes emotions and memories and identity. So if you want to hear somebody rapping about how incredible they are and it makes you feel hype, that could relieve your pain. Or if you want to listen to someone singing gospel and spreading the good news and that makes you feel uplifted, that could reduce pain or give you energy. You know, it's truly the power of music lies in its ability to make you feel a certain way about yourself and about life. So that's so isn't that that makes it so much easier. You don't have to go find like the perfect score or like the, you know, the exact right BPM.
Henry Bair: [00:23:56] Going back to your first piece about substance use. You know, I realized just now that for all the conversations Tyler and I have had with other doctors about burnout and stress, substance use isn't something that has come up. So I looked into it.
Kelly McGonigal: [00:24:11] Did you just look it up now?
Henry Bair: [00:24:13] Yeah, just just a quick search. And it appears that between 10 and 15% of physicians report struggling with substance use.
Kelly McGonigal: [00:24:22] That's actually that is that's pretty on par with the general population.
Henry Bair: [00:24:27] Right. And and I wouldn't be surprised if this number is underreported. So, yes, it is a problem.
Kelly McGonigal: [00:24:36] That's interesting. So, you know, one of the reasons I'm aware of it is when I was getting my PhD in psychology, I was also doing an academic concentration in humanistic medicine, which is a lot of thinking about how human factors influence medicine. And I heard so many conversations from folks in the medical school then actually about substance use and alcohol and addiction when people were talking about. There are direct experience that came up a lot, and it's also something that I see. I think it's because my first big, like, well known book was about willpower. And one of my arguments is that everyone struggles, that it's not a moral failing. I think people view me as someone who has a lot of empathy for substance use and addiction, which I do. So I hear from a lot of folks about their own uncertainty, about how they use alcohol and other substances and whether it's on that line or crossing the line of what really is going to let them live the life they want.
Henry Bair: [00:25:50] The other thing I wanted to draw out was what you mentioned earlier about the fascinating duality of human nature. Humans can be aggressive yet kind. Impulsive, yet meticulous. In medicine, one of the ways this manifests is in how doctors might behave when they are tired and overworked. Despite the stated mission of altruism that most physicians genuinely hold on to, when you are in the thick of it, working long hours and taking care of the sickest patients, it can be really easy for physicians to be callous to patients. Almost to a degree that would surprise you. You talked about how you've developed interventions for helping people navigate those dualities and finding the right balance moving forward. How would you counsel a physician who is struggling with this?
Kelly McGonigal: [00:26:39] Yeah, the primary intervention that I did on this topic was through the Stanford Center for Compassion and Altruism, Research and Education, and we had developed this 8 to 10 week training that initially was was meant to help people explore the limits of their own empathy and compassion, including especially actually for themselves, the ways that people are hard on themselves or neglect themselves and develop mindsets that would allow them to choose empathy and compassion for themselves and for others and like a really skillful and strategic way. So, for example, the the thing that people always remember from that particular intervention of everything we we do, people will come back to me and say, you know, I still say to myself when I'm looking at a patient or family member or stranger on the street and I'm feeling disgust or irritation or resentment or whatever it is, just like me. And then that's a short form for just like me. This is a human being who wants to be happy and wants to be free of pain and suffering and also sometimes suffers and is doing the best that they can. I mean, you can keep going on that. But the Just like Me is the shorthand and it's often about rehumanizing people in situations where either the circumstances or the time pressure or interpersonal conflict can lead us to feel less than human or see others as less than human. And I was just actually looking at a paper last night for a different project, and it was a study that asked patients in ICUs and palliative care to pick a photo or if the patient was unable to, for their family members or loved ones to pick a photo that represents how they would want to be viewed by their health care team.
Kelly McGonigal: [00:28:33] And so patients pick this photo or the families pick the photo and it's put near the bed of the patient. And the thing that was really interesting is how much it helped the care team that like for the patient, it was like, I want to I want to be seen as somebody who has a reason to live. I want to be seen as something beyond just a set of symptoms or prognosis. I'm a human being and I matter. But for the care team, it often helped them feel more connected in the moment to not just the patient, but the meaning of their work. The interventions we developed involved things like that, things in the moment that allow you to reconnect in a very basic way to seeing another person as human and also viewing yourself as human and coming to recognize the obstacles to that which may be in the system that you're in. It may be in the ways that time, pressure and high stakes can really make us a version of ourselves that is less civil to one another. It's not it's not just patients, you know, So often I hear about collegial incivility in in medicine and in other professions that can really make you feel less supported in the environment that you're in, so that it's more like you're kind of doing it all on your own rather than being part of a system that cares and is producing these amazing outcomes.
Tyler Johnson: [00:30:02] Hopefully. Yeah. You know, so I am one of the principal faculty members for teaching medical students during their first two years. And one of the things that we spend a lot of time doing is learning to distill down a person with really complicated physiologic problems into what amounts to sort of a matrix of those problems in a very systematic way that then allows us to understand the problems as part of a holistic medical circumstance and then figure out how do we approach each branch of what's going on and teaching that and watching other people learn that and then watching as we apply that in more advanced and subtle ways when I'm when I'm attending in the hospital is a really beautiful, amazing thing, right? Because it's this because it's a sort of an act of intellectual wizardry to be able to take this person with all of these super complicated problems and then figure out how to work within the constraints that are imposed by that person's body to get the person feeling better. But it is also the case and, you know, and as an educator, that's like one of my favorite things is the moment that I start to see the light bulb go on in my learners and I can tell that they're really figuring out how to do that, that's maybe my single favorite thing to teach when I'm when I'm attending or what have you. At the same time, though, what has become really, really clear in our conversations on this podcast and now that we've had these conversations, just as I observe sort of in the medical world, is that we run the risk of defaulting into the assumption that once we have learned to do that rigorous mental work to figure out how to sort all the problems and then address all of them simultaneously, then we're done.
Tyler Johnson: [00:32:02] Now we know how to be a doctor, and now we can go solve all the problems and make everybody better. And it may be true that a person who is in that place can do a really good mental job of figuring out the problems and figuring out how to get them better. But what has become clear is that if that's the entirety of how you approach it, first of all, it leaves the patients feeling dehumanized because you don't need to think of them as people in order to do all of that stuff that I was just saying. And secondly, it ultimately leaves you as the health care professional dehumanized because you have, in effect, converted yourself into a very complicated kind of machinist or technician. And this is nothing about machinists or technicians, but most people go into medicine not because they want to be engineers, but because they want to help other humans. Right. And you have to figure out ways once you have mastered all of that intellectual piece of it, to then add back the humanity of the people that you're taking care of. And that I think Henry and I have talked about this, and we both agree that if we had to factor out one lesson that has come across more clearly in all of the episodes of the podcasts that we have done, and it sounds like you're echoing a very similar theme. It is that that we have to rediscover, once we've learned the technical aspects of whatever our given field is, we then have to rediscover how to honor the humanity of the person that we're taking care of.
Kelly McGonigal: [00:33:31] Yeah, I think so. And this is making me think of two things. One is that from the patient or the family point of view, when a health care team can actually solve the problem, this is not so much of an issue, right? Like if you can diagnose me and you can treat me, you can do this, and it works. I actually don't really care that much about whether or not you're dehumanizing me if it's all going very quickly and effectively and wow, thank you. The problem is when things are less clear, longer, maybe it can't be fixed. And these are the problems that got me interested in health, psychology, things that are intractable and difficult. And people often have to learn to live with, like chronic pain or anxiety or recurrent depression or grief. These are things that that often a surgery doesn't fix or a single medication doesn't fix. And so I'm really interested in those situations that that interaction with health care team and health care providers, the interactions that make things worse or make things better. You know, last summer I was going through a very long process of trying to figure out what was causing a new and unusual pain, and we never figured it out. Nobody could agree. Does she need surgery? What is that? And at the end of the day, the one thing I remember is one specialist who just said, Wow, this must be really frustrating for you. I am so sorry that nobody can even agree on what's happening, let alone suggested a treatment yet. And that was the last appointment I went to. And it was fine, you know, it was.
Kelly McGonigal: [00:35:12] Which is often how sometimes people have to learn to live with a body that is vulnerable. But I think about how nice it was to receive some kind of empathy for the fact that not. Every situation is going to be clear cut and solved. And that actually gave me the ability to just deal with what was happening. The other thing that made me think about is over the years, being in a number of training situations to work with specific types of patients or populations. And to that, that really I always remember one was people with terminally ill cancer and the other was with parents whose children are dying. And I remember in both of those contexts the trainers saying something very similar. This is not what you say to them, but it's the mindset you have for the the people with terminal cancer. You have to have a mindset of hope that is not tied to their cancer being cured. But as you have to be able to have an interaction with these people where you believe their life is not already over or wasted, that your time is a waste, that there is something that is worth living for and it's possible in this moment and you don't know to hold a certain kind of not knowing uncertainty. About what the future holds or you should not be helping this population or working with this population. That was really interesting because it requires you to be both realistic, but also to live in that state of being willing to appreciate what the moment holds, even if you can't fix the problem. And then with the the parents whose children are dying.
Kelly McGonigal: [00:37:00] I remember the trainer was just so adamant. If you don't think that it's possible to turn this level of suffering into something good, you should stay the hell away from these people, is what he said. And it's not that you tell them, Oh, ten years from now you're going to have learned and grown from this experience. And it'll all these like the things we talk about, post-traumatic growth. You don't say this to the parents, which is cruel, but you have to believe it. There's something about your state of mind that views human beings as adequate to the life that they're given, including the worst things that happen to them. And to have some kind of deep knowing in you that this is not going to define whether or not happiness is ever possible for them or life is ever meaningful for them. And that those when I think about what it means to humanize a situation, it's often it's that kind of mindset. And back when I was looking at helping physicians embody compassion, it was interesting to me that when you ask patients what were the behaviors that were most predictive of whether or not they felt like their their health care provider was compassionate, it was expressions of hope that was driving it. I think that that's you know, that's different. Sometimes people are trained in empathy to really focus on connecting to what is awful, but that the idea that just your own base level hope and not knowing in a positive way can be. Deeply humanizing and received as a gift by the patient or the family.
Henry Bair: [00:38:39] In the first half of this conversation, we've spent a lot of time talking about how taking care of your physical body can benefit your emotional and mental well-being. I'd like to talk about the flip side of it, which is how your mental state can actually affect your body and your behavior. This brings us to something you've written and spoken widely about stress. Can you tell us what stress is? And what are some of the most common misconceptions around it?
Kelly McGonigal: [00:39:11] Yeah. So I define stress as what arises in your brain and in your body when something that you care about is at stake. And, you know, going through my initial training, I was always told that was synonymous with the fight or flight response. I'm sure lots of folks here were given a similar kind of training, that there's essentially one stress response system. It typically reacts in the same way to every type of stress, whether you're worried about your taxes or you're worried about your kid or your, you know, feeling self-critical, that all of these things produce this exact same physiological response, that your brain and body are releasing, cortisol and maybe adrenaline and it's toxic. It's only good if you are preparing for battle right in that moment. This idea that we have a stress response, that it really doesn't meet the moment of modern life for most people, and over time, the consequences add up in a way that is harmful and predisposes us to everything we don't want from from heart disease to depression and dementia. Right. That's the so that was what I was trained in. Let me pull back a little bit and say I don't think that's what the research supports. So the way that I think about stress is, again, it's what arises when something that you care about is at stake.
Kelly McGonigal: [00:40:29] But recognizing that human beings have a stress response system and systems that produce really interestingly, diverse biological and psychological and social reactions to moments that matter. It's not just fight or flight or fright. It also is you can have a challenge response that looks a lot like what happens when you're in a flow state or when you're physically exercising that it looks very different in terms of what stress hormones you release, the effect on the cardiovascular and immune system much healthier. You can have a tend and befriend response, which is really about priming you both physiologically and psychologically to connect with others, to be willing to ask for help, to experience more of a warm glow. When you are around others, you also have a kind of plasticity built into your stress response system that enables you to learn from stressful experiences and that can lead to both positive outcomes like stress inoculation and resilience and also things that that look more like the traditional negative effects of stress, like post-traumatic stress disorder. But I think that understanding the diversity of our stress responses, it's really important when you do not live a life in which you can avoid or reduce stress, which I feel like is everyone I ever talk to, I never talk to anyone who's like, Thank goodness you finally told me stress is harmful.
Kelly McGonigal: [00:41:55] I didn't know I will just cancel the stress in my life and continue to pursue a life of meaning and love and joy and fun and challenge. And people can't do that. So I feel like this particular message that it is not the case. That every time you experience anything that you would label as stressful, you enter a toxic state that turns you into the worst version of yourself and produces this irrevocable harm on your physical and mental health. That's the story that most people believe, and therefore the only solution is to avoid or reduce stress. That message is deeply disempowering and not scientifically accurate. And so what I spend a lot of time trying to do is help people think, okay, in a moment when I'm stressed. What is the best possible response? How can I harness some of the the really helpful capacities I have as a human being to respond in a moment that matters and not only focus on just trying to avoid or escape stress.
Tyler Johnson: [00:43:00] So building off of those comments, I want to introduce a mindset that I think is common, I'm sure in many professions, but especially in medicine and in a really dramatic, heightened way. And then ask you to talk about one thing that I think is important in response to that. So everybody knows that people who go into medicine tend to be people who have done really well in school. Right? Because that's just kind of part of the price of entrance. So you take that, then you get them into medical school and then for the first two years, you teach them over and over and over again that medicine is, in effect, largely an intellectual puzzle that has a right answer. Right. And so having gotten 95% on all of their tests for their entire lives, right, then they start to apply this same thing to the work that they do in the first two years of medicine. Then they get into the clinics and not only do they have all of that background, but then in addition to all of that background, they are told from the day they enter clinic the way that you do on your clinical rotations and the evaluations that are written about you afterwards are going to be the main thing that determines where you get to go for your residency, right? Which for many medical students that feels like the be all end all.
Tyler Johnson: [00:44:10] It shouldn't be, but that's how it feels. And then you put on top of all of that, that and oh, by the way, when you and your team are trying to figure out what's wrong with a patient and what to do to fix it, the life or limb, sometimes literally, sometimes metaphorically of the patient that you're taking care of depends on you doing it right and getting the right answer right. So you can imagine that with all of that as background. And I know that you already know this, but I still think it's helpful to sort of articulate it, to bring it up to the surface. You can imagine that with all of that as background. It happens at a different time and in a different setting for everybody. But everyone who goes into medicine has the experience of a patient where everything seems to be going right and then all of a sudden everything goes wrong. And a person that you thought was getting better instead gets sicker. And in some really dramatic examples, the person dies. Right? Maybe that's on the operating room and they bleed out in front of you. Maybe that's from an overwhelming infection on the bone marrow transplant unit.
Tyler Johnson: [00:45:16] Maybe it's an old person who goes into kidney failure because you just couldn't get her kidneys turned around fast enough. Whatever the thing is. Somebody at least gets really sick or hurt, and sometimes people actually die. It is difficult to articulate the burden of guilt and shame. I mean, it just feels like you have violated the very purpose of your existence, right? Like here you've been training for however many years to do this one thing, and instead you let this person, it feels like you let this person slip through your fingers and now they're whatever hurt or dead or have a dysfunctioning organ or whatever the thing is. So with all of that as background, and I imagine that just that description probably has a lot of listeners hearts racing already, right? Because it's so like visceral to, I think pretty much all of us who are in medicine. I know that one of the things that you're most known for talking about is self-compassion. And so I'm hoping that with that very serious context that I just provided that you can talk a little bit about what self-compassion is, first of all, and then what self-compassion might look like in that kind of a really difficult setting.
Kelly McGonigal: [00:46:30] Yeah, I relate to this very much. You know, this sort of thing happens in a lot of the professions that I care about and am connected to. Also, you know, one of the other examples that comes to mind for me is an animal rescue. And the veterinarians who are charged with taking the lives of animals who can't be adopted, which is another kind of situation where you feel enormous guilt and shame about what you're doing. And yet it's also connected to the work that matters most to you. So the thing that that I think is really important about this is when you're in a role where this is the case. That there is a tragic gap between what you and others are trying to do and what will happen because of the reality and the complexity of life. The first thing is, although we are talking about self compassion, I really believe in structural compassion first. There needs to be conversations about this that scaffold the experience for people who are going through it for the first time. Conversations that let people know this is a part of the process it doesn't define. The entire experience. And we've all been through it with some wisdom, some real perspective to say something like the guilt and shame that you feel right now are because of two things One, you care, and two, you actually do have the capacity to make a difference. And if there was no benefit to what you do, you have no agency and no skill set, you wouldn't be feeling this overwhelming kind of guilt and shame.
Kelly McGonigal: [00:48:18] And if you didn't care, you wouldn't. It would be something else. But that does not. The intensity of that emotion is not equivalent to. The degree of culpability or sort of unique failure. It can still be something that happened that is a tragedy or part of life and not doesn't say something about what is uniquely wrong with you or what you did or what you are capable of. And to separate the two that the intensity of that emotion. And this is true in so many professions where you have the ability to create change or do good and day to day, you're going to be confronted with the inevitable limits of that, that the intensity of the emotion and that being able to live in that tragic gap is what the job is often. And to not isolate and to turn your attention to the next opportunity to reengage in a way that matters, that it's, you know, to the degree that you internalize it and disconnect makes that experience more all defining and all encompassing. This is a process that requires you to reengage again and again and to focus on the next patient, the next opportunity. You know, I really meant what I said. That first thing about creating structures that give people a way to understand this is kind of cruel. To leave people to try to figure this out on their own or to focus only on the let's move on to the next thing. Like, life happens, this happens. Let's move on, which I think sometimes is a coping mechanism that that people experience.
Henry Bair: [00:50:09] So what might structural support for these kinds of situations look like?
Kelly McGonigal: [00:50:14] Conversations, mentoring conversations. There's a intervention called meaning in medicine that looked at creating structured conversations where people are required to tell stories like tell me about a clinical failure or disappointment. And people are guided in how to tell those stories and how to listen, which is a little different from like the problem solving version of it, like the debrief where you're trying to just figure it out so it doesn't happen again. Creating these these contexts in which people are required to talk about the human aspect of it. Um, you know, thinking about the people who have some kind of responsibility over folks who might be going through this for the first time. You know, they're the ones who should be thinking about the one on one conversations that you might have with whom and when those conversations can happen. You know, maybe it's built more into the curricula. But the programs that I've worked with, it's primarily happened through intentional conversations.
Tyler Johnson: [00:51:20] Yeah. One thing that I think is just as the senior doctor on the call and Henry and I have actually talked about having an episode dedicated to this, I know that the Nocturnist, which is another medical podcast, just had an entire series on this, but I don't want to let this moment pass without saying that as a person who I think, you know, I consider myself to be a very thoughtful doctor who's very dedicated to my work. I try to really think deeply about the patients that I'm taking care of. And that has always been the case. And I think I, I generally do a pretty good job. But I will just I'm just here to tell you that I have spent a lot of time. Grappling with my own perceived inadequacies and feeling entirely responsible for the what at the time appeared to me to be inadequate outcomes of my patients, including patients who have died. Like I have spent nights in my office alone crying because I felt like a patient's death was my fault and greater experience and hopefully now seasoned with a little bit of wisdom have helped me to know that. To your point, Kelly. We. There's a myth that we tell ourselves as doctors, which is that we can fix every problem and it's just not true. Bodies break down, cancer advances, Some people die and they will die with or without medical professionals helping them. And part of the moral risk of being a doctor or any health care professional is being there when people get sicker and when they die.
Tyler Johnson: [00:53:08] And so, yes, there is an appropriate way to look back on your care if you have an unexpected outcome and say, was there anything that I could have done different? And if there was, then great identify it and do it different next time. And even then, the only people who get to be doctors all turn out to be imperfect humans. So, you know, there are going to be places where we fall short and and even in those cases, we need to have self compassion. But in the vast majority of cases, it's not because someone fell short. It's because the people that we are taking care of have bodies. That right? Entropy is entropy. Everybody's body is breaking down to some degree or another. And we forestall that breakdown as much as we can for as long as we can. But we're not going to be able to do it perfectly and we're not going to be able to do it ever. And some people are going to get sicker and some people are going to die. And the fact that we're willing to be there when that happens, to your point, I think actually says a lot about how much we care. And we can't allow ourselves to be usually falsely convinced that that means that we're not doing a good job.
Kelly McGonigal: [00:54:10] Yeah. And I also I think that when someone enters medicine, they are entering a profession that requires them to be in contact with some of the worst human suffering, like the grief of the family when when someone dies. And it is. You know, in a way there's a way of engaging with that that is respectful. Part of part of your own guilt or shame about that is even when it's not 100% accurate, it is a way of paying tribute and respect to the family and others who are suffering. And I think there's a way of working through your own suffering around situations like this where you can see yourself as part of a moment that is really hard. And you are sharing to some degree in that you don't have to fix it or make it go away. It's part of what people take on, and I hope that doesn't. I'm not saying people should wallow in the guilt or the shame, but I think it's part of acknowledging I mentioned one of the most important things we can do is acknowledge not being surprised by suffering and also our interdependence and your your willingness to be a part of this process that will have negative outcomes is a tremendous courage. And gift. And it comes with those moments. And not everyone can do that.
Henry Bair: [00:55:48] Kelly, thank you so much for sharing all this valuable advice for how we as clinicians can better take care of ourselves. With the last few moments we have here, I'd like to ask what advice do you have for clinicians on how we can in turn better help our patients navigate through moments of stress in their lives?
Kelly McGonigal: [00:56:09] You know, my first thought is actually it's so much more micro than that, which is to create a moment in a clinical encounter where they feel seen as a human being. You know, to be like a kind of detective for every person you encounter what they're wearing, something they say, maybe something that's in their history or their chart that allows you to ask them about their life beyond the surgery that's coming up. Maybe a clue to something that they love, that they're a fan of. To look for an opportunity to have a moment within this conversation that is about something else and maybe something positive. It's a way of modeling sort of how one approaches something really stressful, like a treatment or surgery or an illness. There can be these moments where you just connect over someone you love or something you love or something that you're doing. You can model that. There can sort of be both at the same time. We got to, you know, focus on this and make sure this goes well and handle what's hard and also in this moment. But then I also think like if you have the opportunity to ask patients, you know, are you thinking, you know, how this is affecting the rest of your life, Are there people who can support you? You know, this is because this is not my actual job, right? I'm trying right now in the moment, I'm thinking, like, what? What would you say or what would one want to hear? And maybe I'm not the best person to to suggest a specific script.
Kelly McGonigal: [00:57:40] I think even just knowing that and having the idea a lot of what we a lot of what mindset research shows us is that what you are thinking about and what you are aware of allows you to engage in an authentic way that can help another person. So just even knowing that what they're going through might be affecting their relationships, just knowing that they might be more nervous about this than you are because this is their first time and they have no idea what it's going to be like or how it goes or, you know, it's their entire life. It's not just one appointment of the day. It's their entire life. Even just having these mindsets available to you, I think can allow you in the moment to be more responsive, perhaps receptive to questions that they have, or even just leave the space for them to ask questions.
Henry Bair: [00:58:26] Well, with that, we want to thank you again, Kelli, for taking the time to join us and for sharing your stories and insights.
Tyler Johnson: [00:58:33] Thank you, Kelly. Thank you.
Henry Bair: [00:58:37] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctor's Art.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:58:56] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments. I'm Henry Bair. And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Dr. McGonigal is the author of several books, including The Willpower Instinct (2012), The Upside of Stress (2015), and The Joy of Movement (2019).
Watch Dr. McGonigal’s popular TED talk on stress management.
You can follow Dr. McGonigal on Twitter @KellyMcGonigal.
