E69: The Intellectual Domain of Stress

Katie: Welcome back to the "7 Domains of Women's Health." I'm Katie Ward, nurse practitioner and professor at the College of Nursing at the University of Utah, and I'm co-hosting the "7 Domains of Women's Health" podcast. And I'm here again with my friend, my teacher, and longtime host of this podcast, Dr. Kirtly Parker Jones, who's a reproductive endocrinologist and a professor in medicine at the University of Utah.

We're right in the middle of a series on the 7 Domains of Stress. And in this episode, we're focusing on the intellectual domain. Within this intellectual domain, we wanted to really talk about how education and stress interact, and I wanted to talk a little bit about health literacy as well and how education affects that.

Relevant to today's discussion, Kirtly and I have both been educators for a long time. Kirtly, how long have you been in this education endeavor?

Kirtly: Oh, gosh, it's been a long time. And, Katie, I really hope that when I was your educator that I didn't stress you out.

Katie: It was a good stress.

Kirtly: Oh, yeah. Thanks a lot. For me, it's been 50 years, and more intensely for 40 years. And I've seen the stresses for students change in ways that I had to come and understand better, and their reactions to educational demands change. So their responses to stress have changed really dramatically over the last 15 or 20 years.

It's working for me as an educator, now mostly a former educator as I'm retired, in trying to think of how to help them manage their stress.

Katie: Yeah. And I'm in an interesting situation. I've been an educator and I've been teaching at the College of Nursing for . . . I just passed my 24th anniversary here.

Kirtly: Whoa.

Katie: Yeah.

Kirtly: Yay you.

Katie: Nursing is kind of interesting because it's probably one of the few professions where . . . And this is actually changing, but when I was up and coming in nursing, you got your initial nursing degree and went out and worked in the world. And then if you wanted to go on in the profession once you had some experience, then you could apply to come back.

But that had some interesting implications because most people who are in graduate nursing programs, which is where I work, have been a nurse for a while. So they've gone out into the work world, been earning money, usually starting a family or getting involved in life outside of school, and then coming back to school with the burden of the other parts of their life. Nursing has some unique pressures for the graduate program in particular.

Kirtly: Oh, absolutely. I mean, the mature . . . what we used to call a mature student, in medical school, you can't have another job, and people sometimes do. And having the other job being three kids, you're already asking when someone is applying for them to commit to an 80-hour work week. That's the educational process. It takes a minimum of 80 hours a week. So if they're trying to do much of anything else, then that's a stressor.

And if they're trying to get by on less than 80 hours a week in terms of going to class, which is not nearly very much, but then actually learning and processing, they're either going to sacrifice how much they learn or they're going to sacrifice somewhere else.

So the mature student, it was easy when you have only yourself to look for. That's great. But if you have someone who's come back from the work world or come back with a family or come back with financial needs to work outside medical school, that's a toughie.

Katie: Yeah, it really is. And that's a thing I've been aware of both as an educator and also because I've lived that as a nurse and then going back to school to further my education.

For people thinking about going back to school or going back to school or thinking back on their education, we certainly have some data that getting an education, and beyond that, a graduate education, can be a buffer against some stresses. And I think that's the reason we save for our kids' college funds and our grandkids' college funds and dream of that, that more education is likely to lead to a place where you have better problem-solving skills and better coping mechanisms.

You may go to college and make lifelong friends through your affiliations with teams or clubs or the Greek system or something like that. And so all of those things can be buffers against the rest of your life's stresses.

And certainly, higher education may lead to a higher income, and that's going to reduce some financial stress in life. More educated individuals might have better health literacies, leading to improved health behaviors and potentially lower stress as a result of that.

Kirtly: I'm going to step in here, though, and just remind listeners whose kids may or may not want to go to college that what we used to call the trades, if we look at becoming an expert journeyman in either carpentry, or electrician or plumbing, those have an educational process, and then they often have an apprenticeship process. But people who are masters at this make over $100,000 a year if they're working full time.

So the process of being educated doesn't have to be the classic four-year college education. There are many educational programs for some of what we called the trades. I would call it the skills. And those are people who do very successfully. They often are their own bosses, or they can work with a group.

We're talking about a college education now, but there are other ways to be educated and make very good income and learn about the ways of the world without having to go to college.

Katie: Absolutely. I mean, I often recommend to up-and-coming nurses that they think about finding the easiest path to getting that license and then making an investment in lifetime education, because it makes sense to not get too deep into debt.

Kirtly: Oh, absolutely. That's one of those stressors caused by a pursuit of an education.

Katie: I also think for young men, and this is a podcast about women, so we won't go too deep into this, but for a long time, they would inherit the family business or the family line of work, and girls weren't getting educated at all. Their job was to be a wife and mother. I think that there is something in this century for both young men and young women of "the world is your oyster." You can be anything, and that paradox of having too many choices.

Kirtly: What do they say? FOBO?

Katie: Yeah.

Kirtly: Fear of a better offer.

Katie: Fear of a better offer.

Kirtly: Yeah. And I find students really stuck, very stressed, and I think, "Just pick one." It may not be perfect, but give it your best, and then you will find a branch point that will say, "Let's go this direction," and you'll take it. So it is okay. Just try one and do it well.

Katie: I mean, the sad truth is that physicians, dentists, veterinarians historically have had higher levels of suicide than the general population, although there's some evidence this is improving. But I wonder if you make that decision very young, that you're going to go into one of these high-paying fields, and so it's competitive to get in, and you have to perform well for a very long time in a training period.

Then you get out, and maybe it wasn't what you wanted to do, but you feel pretty stuck. You've become a doctor, and you've specialized in your one aspect of healthcare, and after all this investment, you discover you're not so happy there.

Do you think that plays into it at all?

Kirtly: Well, that could be. I think it's a combination that physicians, dentists, and veterinarians have access to very potent drugs. All these specialties can be highly demanding and can be stressful, and if you have access to very potent drugs, you might end up using them to get yourself going or to bring yourself down. And that is a spiral that it spirals down.

So of the many and unfortunate people I know who have committed suicide . . . I won't say it's many, but it's not women, surprisingly. It's all been guys that I've known. They were using alcohol and/or drugs to deal with the stresses in their life, and that's how they died. I don't mean that if they didn't have access to very potent drugs, they might not die.

But they're also a group of people who don't think you can tell them anything. And there's some shame and risk if they're already taking drugs to reaching out for help, because if any of these folks are known to be taking drugs, they can lose their license.

So it's a complicated thing where someone else that may not have access to drugs . . . Everybody has access to drugs these days, but they might reach out for help. But physicians are notorious, and I think that culture is definitely changing. We are trying at the very outset of medical careers, and that I'm sure is true for dentists and vets, that being stressed and acknowledging stress and that you're not coping well is not something to be ashamed of.

You should be proud of the self-actualization, of saying the self-awareness that, "I'm not doing well, and I'm going to get help," because notoriously, 20 or 30 years ago, they did not ever do that.

Katie: Yeah. And I think, unfortunately, we've had to sort of learn this lesson the hard way of seeing our colleagues suffer and then begin to respond to that.

One of the things I've liked about being a nurse and one of the reasons I encourage people to think about this field is you can change. I grew up at a time when my mother's dream for me was that I just got married and had children like that. In her mind, that was my highest calling. So she hadn't saved for college, and she didn't have any career ambitions for me.

But I needed to get a job, and I was still of that age, which I guess tells you a little bit about my upbringing, where the only viable careers for me as a female would be a nurse, a teacher, maybe a flight attendant, or a secretary. I couldn't type, and I didn't quite have the looks for a flight attendant job. I might have liked it. And so nursing seemed like the only choice for me. So I set my sights on nursing.

And I happened to land in an aspect of nursing that I have loved, but my job has been different every few years. There's a new opportunity. I've gone back to school multiple times and changed sort of what I do within nursing. But I also always talk to people looking at this field. If you don't like pediatrics, you can go to geriatrics. You can be inpatient, you can be outpatient. You can fly, you can stay on the ground. You can sit at your computer. There are so many ways to be a nurse. And so it felt like a good investment.

Well, I didn't know this at the time, but now I can look back and say it's been a great place to be able to not feel stuck in any one thing.

Kirtly, what was your education path like, and how stressful was it for you?

Kirtly: Well, I was born a student, I think. I had a drive for cognition, which actually some people who are psychologists look at drives and personalities. I had a drive for cognition when I was little.

And my life course was complicated by the early death of my father and the economic challenges at home. So things were challenging at home, and I was made very lucky. I had an academic scholarship that paid my way all the way through college because I was a good student. And I never cared about grades because they just came, so it wasn't stressful.

Importantly, I had lived around the world, but college and medical school brought the greater world and its joys and sufferings right to my eyes. And although I'd experienced a fair bit, it was always about me. And then I realized every day that people all over the world are more stressed than I am for really good reasons. As I became a clinician, most everybody I saw was having a worse day than I was.

So real life in the working world or in the educational world can teach empathy if you're willing to receive it. The gift of empathy is the perspective that another personal lived truth is as valid as yours. And that really helps it not be all about you when you get into a stress spiral.

It doesn't always work, but when I have residents who are pretty stressed out, and they should be, it is hard, but I try . . . We're OBs. I try to then remind them that a single parent of three small children who's trying to make enough money to get by and doesn't have enough really for childcare, and she's got three kids, you look at those people and they're stressed out. Take a deep breath and try to live their life in your heart for a little minute, and your life's going to look pretty lovely.

So for me, whenever I feel stressed out, I have to do a little reality check. And I used to have a sign on my door during the Rwandan genocides. I had a sign on the inside of my office door, not the outside, that says, "This is not Rwanda."

So when people would want to come in and talk to me, when they closed the door, there were two signs. One is from Abraham Lincoln, who said, "I have come to the conclusion that people are just about as happy as they allow themselves to be." And number two was, "This is not Rwanda."

Now, that may be a little cruel, and I wanted to be empathetic to this young person's stress because their lived experience is as valid as mine. But boy, oh, boy, there are some people out there in the world who are having a hard time.

Katie: Yeah. And at the same time, I know certainly in nursing, and I think it's true in medicine as well, we have been actively recruiting a more diverse workforce in healthcare. I know it's been a challenge in my world as an educator. We want to recruit nurses from the communities that they serve.

And so that's meant that we've had to adapt a little bit to realize that people are coming back to . . . As we were talking about earlier, you're coming back to school with some other burdens as far as a family to raise and being accustomed to earning money and maybe being accustomed to being out in the world where you were at the top of your game at whatever you were doing.

Then you come back to school, and if you're accustomed to being really good at what you do, and now you're back in school and somebody's redlining your paper and taking points off your test because you didn't answer it just right, it's hard. And I know that personally.

Kirtly: I think medical school can be rather profoundly infantilizing if someone isn't able to sort of grasp ahold of who they are truly and what an apprenticeship is really all about. If you feel infantilized, it may feel that way. And we're not always so good at helping people raise up in their lack of knowledge and their lack of experience and their lack of skills.

How do you help people not feel like infants when they truly are professional infants? Even though as adults, with a phenomenal background of their own, but in this world, they are like children. So that's a balance.

When someone's been really good at something before they come to this work or come back to the university to get . . . when they were really, really good at what they used to do, and now they're not.

Katie: Yeah, I think it takes, as you were talking about, some empathy and some careful thinking and understanding, taking a minute to put yourself in their world.

When you were training, did you feel like you developed any particular problem-solving skills or things that helped you manage your stress?

Kirtly: Well, not so much when I was training. I mean, training is just being all in. And luckily, although I was married . . . Well, for most of my training I wasn't married. My now husband was my live-in boyfriend, and he had to get used to being ignored, or it was too bad for him.

But later on, I think it was being . . . as you get to move on up the academic scale or any workforce scale, you come into conflict all the time. I sought out conflict-management training, and it was really important.

I saw conflict around me between physicians and nurses, and between physicians and staff, and physicians and physicians. And being able to step back, getting the skills to step back and learn how to solve a problem by helping everyone get to "yes."

I think people often think that the pie is only so big. So if you get more, I get less. It's you or me. It's yes or no. And in fact, good problem solving for yourself, your own self, and for others is understanding that the pie can be made bigger with good problem solving. There are more goodies out there to divide up, and it's not always so clear that it's yes or no.

So the core of being a good physician, I think, is exactly that. I may have my ideas about how things can go, but it's not about me. I'm the purveyor of information, but how it's sorted is by the patient.

I think conflict resolution helped me look more carefully and listen more carefully to what my patients were saying. And it's been grateful for me because I took the very same skills to my own inner voice. So when there was conflict in my own home, I could step back and start trying to listen carefully.

And then when I have conflict, stress in my own head, I say, "Can I believe this voice inside me? I mean, I'm feeling stressed out because I'm hearing this version of the world that I'm in and this version of me. Is it true? And can I really trust the voice that's lying to me in my own voice?"

I think that conflict resolution really helped me deal with my own stress, me deal with how to help things be smooth in my family and at work. Really useful.

Katie: Yeah. Maybe that'll be my next education. I tend to be pretty conflict-averse, I think.

Kirtly: Oh, me too.

Katie: So we're talking about this particular space where people are in school. Because of our experiences in healthcare, but I think you can apply these things to whatever learning you're doing, there are a bunch of things that we can talk about as just practical strategies for enhancing your intellectual health and thereby managing your stress.

And so I think we've kind of touched on one already, which is that just automatically going to college is not going to fix your stress. Do it if it's your dream and it's a good fit for you, but look at both sides of that. There's, as we've talked about, the expense and the emotional parts of being a student. And there's a lot of data that getting education is a hard thing to do.

But no matter what you do in that intellectual pursuit, I think there are some important lessons that we can take away. One, and it's something that comes up in the research around students and stress, is self-efficacy and self-awareness. Those are skills that help you manage the stress of anything, education or training.

Time management. That's probably the biggest lesson that I've been learning, is just how to look at my day and figure out what are the hours in the day when I'm most productive and what are the hours when I'm not, and that's where I'm going to put more my leisure activities. But making sure I have time for those leisure activities and just really looking at my day and saying, "Okay, I need the leisure, and I need to get this work done. So how am I going to balance that?"

Kirtly: And maybe even keeping a little log of where you are spending your time. If the average adolescent and young American is spending five hours on their phone on social media, or some number . . . And Katie, you might know that number better than I do. But between TV and social media, TV maybe for older people, and social media for younger people, it soaks up . . . And not that these aren't good stress relievers to just mind-numb yourself into something, some great TV show or a sports show, but it takes time to do all that.

Katie: Yeah, and that's where I think it's an exercise of looking at your day, your week, your month, and kind of saying, "All right. I've got to spend a certain amount of time sleeping." That's really important to get your sleep. And you've got to spend some time exercising. That's also really critical to stress management.

So I think it is worth the investment in mapping that out and saying, "Here are my 24 hours in a day. I'm going to commit to sleeping and exercising."

And then what I've done is look at my day and said, "Well, I'm most productive early in the morning. So that's going to be when I'm going to do my high-thinking kind of work."

As the day wears on, then I become a little bit less effective at things that require my best brain. But then that's a good time to exercise, and that's when I know I can unwind, that I get a little bit of TV time or screen time in the evening. Other people are kind of night owls, and that might be their best work time.

Kirtly: Yeah, and knowing your chronotype. We did a 7 Domains of Chronotypes, and it's worthwhile knowing whether you're a morning person or an evening person. Without doing any fancy testing or doing a questionnaire, most people know that they get up early or they stay up late, if it's not related to a job, and understand that you're most effective either whether you're taking a test . . . Unfortunately, tests are often on someone else's schedule. But when is your brain the best?

It turns out what your gut is doing really affects your brain's happiness. And an education in nutrition isn't something that we get in nursing school. Maybe in nursing school you get it. We certainly don't get much in medical school. But looking at kinds of foods that will make you sleepy and bring you down, paying attention to that and knowing how tired it will make you if you have a great big cookie and then . . .

Katie: A warm milk?

Kirtly: Yeah. Well, warm milk is good for bedtime. But how you eat, how you space it out so you're never too full and never too hungry also helps you be more efficient and think more clearly.

Katie: Yeah, absolutely. Not having those big spikes in blood sugar. I've learned to eat a lot more protein at breakfast than I used to.

Our brains need both things, right? Being productive feels really good, but you can't stay productive for 16 hours a day straight. And so I think it is important to recognize that there are moments where your brain really needs that time to kind of check out. The reason our phones are so appealing and draw us in is playing Candy Crush or scrolling the internet doesn't require a lot of brain power.

And so a technique I learned . . . I tried to take up a musical instrument a long time ago as an adult, and I never got very good at it. But when I was trying to learn it and master it, one of the things my teacher taught me was to practice for 10 minutes. I was going to remember the first thing I worked on and the last thing I worked on. But much more than that, I was going to lose the middle. And so he would have me do just short 10 minutes of practice rather than try and just work on it and make the same mistake over and over again for an hour.

Kirtly: Well, the same thing is true about exercise. If you decide to do something that's moderately high intensity for 10 minutes, you can get a pretty good workout. And the "New York Times" wants you to see how many incredible workouts you can get in 7 minutes or in 10 minutes.

You can work out hard and get a cardio in just 10 minutes, and then maybe if you do two to three a day, you have gotten a lot of exercise for your health. A walk does other things. A walk out in nature is a whole different story of how it's restorative to stress, but you can get a lot of work done, exercise-wise, in 10 minutes.

Katie: So we're talking about short bursts of exercise, but it does come to me more in my role in trying to learn something, whether it was learning an instrument or as a student. It's the closest I get to a flow state sometimes. It doesn't always come easily, but sometimes words just flow out of me, and I write a whole paper or a podcast or something interesting. Once I start that, then I really get into it.

And I think that's one of the things I like about being a lifelong learner, is finding those moments of really getting into that flow state where I'm doing this and really enjoying it, and the rest of the world sort of falls away. I get that with exercise, too.

Kirtly: Oh, yeah. But learning something new, learning about a new plant, or learning something about the reproductive strategies of an animal, or for me, because I've been deep into geology over the last five years, learning what's been happening over the last four billion years, it's a deep dive and you can get so engrossed. But when you wake up out of that, you think, "Wow, this doesn't really matter, does it? I am no longer so stressed about this tiny little thing." Oh my goodness.

Katie: Yeah. I don't know that much about geology. I always want a geologist on a hike with me, though. "Tell me what this rock is." But just being in nature and sort of seeing how the world works, that definitely helps me relieve my stress.

So I think that's the value of going out for a walk, is not just going for a walk, but taking a minute to notice how the light filters through the trees, or how that tree looks in different seasons, or where the sun is on the horizon, or what you see in the sky. Just taking a minute and appreciating the world that you're seeing, that's a big stress reliever for me. And it's critical. It's critical to my day to have that experience.

In the education world, there's research about, for students, feeling like you belong is important. And I think that that has been something that's been a little cracked through the pandemic, because we've really retreated into our own spaces and the internet and the screens have filled up some space. I feel like the world is a little bit more fearful.

And so that actually, I think, is something we have to really work at, is repairing the things we've lost through the pandemic and being afraid of each other.

Kirtly: I think they're really working hard at the medical school here to try to help people manage their stress. And they decided maybe six, eight years ago to divide the student body into small groups.

So this is a medical school student body of 12, and they stay together for four years, and they learn clinical skills in these small groups, but also social skills. They meet once a week.

And when I would help out with one of these groups, the students would start a session with check-in. I didn't suggest this. Are you kidding? I'm a boomer. I don't do that. But they were wonderful because they'd say, "Okay, let's check in."

It's an open mic time where students can talk about their stresses with people they know who are going through what they're going through and will be at their side for four years. They can share their stresses and how things work to make them better. A burden shared is a burden halved is what I . . .

And that is so wonderful in terms of making a big, sometimes impersonal, medical school process become very personal, and you've got your own made-for in-group. You can create your own in-group, of course. But making one that's a small educational community with a steady mentor at the top or at your side, maybe not at the top, has really been fabulous.

Katie: Yeah. And you mentioned something. You're a boomer. That's a thing I know we've been working on a little bit in nursing, is thinking about what are the strengths.

I actually get the different groups . . . I can't remember who's who. That's not always a good classification system for me, but I am aware that I came up at a time when life was a little bit different. And I think that it's an effort throughout the world that we live in. Maybe that's the reason we classify students by millennial or boomer or Xers. I can never remember where the boundaries are.

Kirtly: Yeah, I can't either. And I'm not sure how . . . I mean, I always self-identify myself as a boomer, but I think now with the diversity that we're seeing in the educational spaces, we need to take each person as themselves. You can't call someone whose family is refugees who this is the first kid going to college a millennial because their whole life experience is not millennialoid. It's different. So I'm committed to meeting every student where they stand and not their age.

Katie: Yeah. At the same time, I think we have to really be aware that in certain fields, stress is still greater on female students and anybody that comes from various minority backgrounds, whether it's racial, ethnic, financial, or gender diverse or LGBTQ. These are groups that have a different experience than you or me. And in building that community, to make sure that we're reaching out to everybody and finding safe spaces for everyone. That's felt challenging, especially in the last couple of years, at least where I work.

Kirtly: Oh. Well, what are we going to do about this, Katie?

Katie: Wherever you're employed, a lot of larger employers and even smaller ones have an employee assistance program. That's always a place where I encourage people to at least start, is checking their human resources and see if they have an employee assistance program.

Often, it's not your company that's doing this. It's outsourced to a bigger company that includes counselors and mental health professionals. And they are really experts at helping people through short-term stresses, like divorce, job changes, financial troubles, substance use. So that's always a great place to start that may be a free benefit to people who are employed in the community.

Kirtly: And every university and college has, in their student life or student resources building, people specifically to help students who are really struggling with stress.

Katie: Yeah, and we've invested a lot in ours, especially post-pandemic, recognizing that that was a unique stress on everybody. I think that the services have really been strengthened, and you can see that in the university. They've been making a big investment into mental health, and that includes just stress and burnout. So those are important things to recognize.

One of my favorite books is a book entitled "Burnout" by Emily and Amelia Nagoski. It's specifically aimed at women, but so is this podcast, so I'm going to give them a shout-out because I think that's a nice book about stress and how that affects you in how you present in your life and feeling burned out. It has a nice workbook with some exercises.

So hopefully those are some helpful suggestions here from the "7 Domains of Women's Health," and this particular intellectual domain of stress.

Certainly, if you haven't listened to the rest of the series, we hope you'll take the time to listen to those. You can binge all seven or take them one at a time. You can find the "7 Domains of Women's Health" wherever you get your podcasts, or we've got our own site that is womens7.com.

Kirtly, thank you so much for talking about this with me.

Katie: Oh, thank you, Katie.

Kirtly: And having you as a teacher has been one of the great privileges of my life.

Katie: And having you as a student has been one of the great successes of my life. So there you go. Hang in there, guys.