SICKBEDS AND GARDEN BEDS
Connie was sure her sister was plotting against Peyton Manning. She wanted to warn him, so she would yell, “Peyton, Peyton, watch out, she is coming for you!” when she woke up and as she collapsed into sleep. Her warnings went unanswered, so she knocked over a chair at her nursing home and threatened to keep knocking over chairs until the Denver Broncos’ star quarterback visited her. She needed to know he was safe. The overworked staff at her nursing home tried to soothe her, to redirect her, and to ignore her. Finally, they called a social worker from our hospital for an evaluation.
When he arrived, Connie was shouting threats. Having tried unsuccessfully to calm her, he placed her on a mental health hold, a form of involuntary psychiatric treatment. The sheriff transported Connie to our Emergency Room, where the on-call physician interviewed her. The physician had never met Connie and had no access to any records of her care, yet he was responsible for determining whether she had a mental illness and if, as a result of that illness, she was dangerous to herself or others. He diligently documented what he heard—Connie was threatening to kill her sister to save Peyton Manning’s life—and Connie’s fate was sealed: involuntary hospitalization on the psych unit.
I work every day on the unit, so I can tell you that real-life psych units bear little resemblance to the dimly lit places run by syringe-wielding sadists you see in the movies. Most resemble rented space at an office park. The modular carpeting is dark enough to hide the occasional stain. The walls are painted in muted earth tones and decorated with framed reproductions of soothing landscapes. When you look more closely, though, you can see signs that this building houses something other than business executives. Our framed pictures are bolted to the wall with recessed screws. Our windows are triple-paned and sashless, fixed in place. Our doors are locked with antiligature pull handles. You cannot take these pictures off the wall or open these windows. You cannot walk out these doors without a physician’s order.
The morning after Connie was admitted, I arrived on the unit and read her chart. She sounded dangerous and threatening. Then I saw her, a seventy-two-year-old kyphotic woman rounded over herself like a collapsed star, shuffling along a curved path with the assistance of a cane. She muttered that her older sister Rhonda would get to Peyton today. She begged us to call Peyton and warn him.
I did not know how to get Peyton’s phone number, so I asked Connie for Rhonda’s instead. When we called, Rhonda’s daughter told us that Rhonda had been dead for twenty years. If Rhonda posed a threat to Peyton Manning, he would need an exorcist, not a physician.
The report we got about Connie was simple: she had a long history of schizophrenia. We assumed, therefore, that she had experienced a recurrence after refusing her medication at the nursing home. Association slipped into causation, and the story was complete: Connie was psychotic because she was refusing medications.
I have learned to distrust completed stories, though, so I decided to approach Connie differently. She would not tolerate a full physical examination, but I found that she would walk with me and let me to listen to her heart and lungs as long I allowed her to remain upright. When Connie stood, she shook like a wind-blown tree, and something about her movement reminded me of a history book I had recently read.
The book, Rooted in the Earth, Rooted in the Sky: Hildegard of Bingen and Premodern Medicine, described the medical practice of Hildegard of Bingen, a medieval abbess. Despite her cloistered existence, Hildegard was a polymath who, in addition to working as an abbess, musician, mystic, and theologian, was also a gardener and an infirmarian who cared for the ill in her community’s infirmary. When the book’s author, a medical historian and physician named Victoria Sweet, analyzed the practical manuals written by Hildegard, she found that Hildegard’s infirmary, a sick house where the ill were diagnosed and treated, included an herb garden where Hildegard could grow medications and a pharmacy where she could compound them. Hildegard was equally at home in the clinic and the garden, and she tended ill bodies and ill plants with the same care.1
As I examined Connie, my wind-blown patient, I wondered what treatment I would give her if I emulated Hildegard and acted as a physician-gardener.
. . .
Victoria Sweet’s second book, God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, recounts her own attempts to adopt a version of Hildegard’s practice. In the memoir, Sweet described practicing medicine at Laguna Honda, a public almshouse dedicated to rehabilitation and skilled nursing services for a diverse and underserved population in San Francisco. Most of her patients were impoverished and cycled in and out of area hospitals whenever they experienced an acute crisis. Every time they were admitted to area hospitals, they were treated according to the evidence-based algorithms of industrial medicine. They always received life-saving care. They were also always discharged back to the streets of San Francisco. In those inhospitable environs, their health inevitably deteriorated, and they were hospitalized again to start the cycle anew.
As a physician at a safety-net hospital for the urban underserved, I see this cycle every day. Patients are stabilized in the hospital, discharged to places where they cannot maintain their health, and return within weeks or months. Sensing a kindred spirit, I eagerly read Sweet’s memoir.
Sweet observed that when people grow ill, they enter hospitals whose purpose and architecture were defined hundreds of years before germ theory and the discovery of the genome. When people receive care as patients or work in these hospitals as practitioners, Sweet showed, they unknowingly follow scripts written by our premodern predecessors. Sweet had trained as historian, so she could see the premodern scripts underlying our contemporary hospitals as if they were “shadow texts that could sometimes be discerned beneath another text.”2 Sweet wanted patients and practitioners to bring some of these premodern texts out of the shadows, out of the recesses of our thoughts and desires. She wanted us to reclaim them for our daily use.
To do so, Sweet engaged Hildegard’s concept of viriditas. Hildegard understood all of her seemingly disparate activities as unified under this Latin word, which means, literally, “greening.” For Hildegard, viriditas is always a divine gift, the invigorating force of life that animates the body just as sap animates a tree. Without viriditas, the human body is mere matter, either inert or decaying, like a plant without sap. As this simile suggests, Hildegard understood the sickbed and the garden bed as analogues of each other. Viriditas animated both human beings and plants, and therefore both could be healed by its renewal. So Hildegard tended to the ill in her infirmary as she cared for the plants in her community’s garden—by observing the environment in which a patient’s body was situated, removing the obstacles to the renewal of viriditas, and encouraging the body’s ability to heal by giving, say, less or more food, drink, or rest.
Sweet so admired Hildegard’s approach that she put it into practice at Laguna Honda. As Sweet followed Hildegard’s model of looking for ways to repair or strengthen the viriditas of her patients, she noticed a change in the way she approached them. Instead of acting like a technician searching for the broken part to fix or replace, she began encouraging the self-healing of her patients, as a gardener would encourage her plants.
As she began approaching patients like a gardener, she found renewed meaning in the practice of medicine. She found a medicine in which “the body was not imagined as a machine nor disease as a mechanical breakdown,” and the physician could appreciate the wonders and mysteries of the bodies of her patients.3 Sweet argued that while a physician-technician looked for fixes—I thought of treating herniated discs with discectomy, obesity with gastric-bypass surgery, or rapid mood swings with mood stabilizers—a physician-gardener helped a patient resolve these illnesses organically. A physician-gardener might advise learning new habits over time, like daily stretching, dietary changes, and coping strategies.
After adopting some of Hildegard’s practices, Sweet also found that her perception of time changed. And as her perception shifted, she stopped feeling frantic and alienated from her patients. Indeed, Sweet found that time itself was the critical ingredient in their care. She described one patient, Terry Becker, who needed two and a half years to be restored to health. Two and a half years is an eternity in today’s hospitals, where efficiencies are celebrated.
Sweet knows this, knows the many obstacles to prescribing “tincture of time” in contemporary medicine. Administrators insist upon brief patient encounters that can be billed at the maximum level. Insurers demand rapid discharge. Regulators standardize care. There are many demands upon the time we physicians might like to give patients. When I spend more than the usual time with a patient, panic sometimes grows in my gut, as I worry about where these extra moments will have to be borrowed from the remainder of my day.
This is a shame, because Sweet is right: many patients are able to heal only when physicians give them a sufficient period of time to heal themselves in a supportive environment. There are, of course, pragmatic considerations, which Sweet acknowledged. For acute conditions like appendicitis, sepsis, or myocardial infarction, physicians should still act like efficient technicians. Remove the appendix, treat the infection, stent the heart. Fix the broken part. In chronic conditions, like the dull abdominal pain that presents six months post-appendectomy, the lingering fatigue following sepsis, or the vague depression after myocardial infarction, physicians should act like wise gardeners by prescribing watchful waiting and considered observation. Instead of rushing to diagnostic tests, imaging, and treatments, physicians should follow the patient over the seasons and cycles of time.
A version of medicine that depicted the body as a wonder rather than a machine: the physician as a gardener rather than as a technician, and the hospital as a garden rather than a factory. I found this vision entrancing.
After even a few years of seeing much, the practice of medicine becomes routine. You start to recognize patterns. One of the patterns I see is a person with a known psychotic disorder who stops taking his or her meds and subsequently experiences psychosis. So the story the admitting physician told about Connie raised no eyebrows. Connie has schizophrenia, an often-devastating and progressive disorder that remains poorly understood, even though it affects 1 percent of the world’s population and causes 10 percent of the world’s disabilities. She has an extensive medical record that dates back to her first episode as an adolescent, and she has been in and out of psychiatric hospitals, and on and off medications for most of her life.
There are many ways to account for schizophrenia. One neuroscientific explanation is that it is a sensory-gating stimuli disorder, an inability to sift through the stimuli that surround us: the tastes of foods, the touch of other people, the sounds of the city, and all the other stimuli in our worlds. Most of us learn to filter through the various stimuli unconsciously and focus on a particular thing or a task at hand. People with schizophrenia often struggle to do so. They are unable to shut out a thought, a smell, a taste, a sight, or a sound that the rest of us can ignore as we go through our day.4 When people with schizophrenia become paranoid, it usually means that they have overinterpreted some stimulus in their life. They might fear people they know or the environment in which they live or what they hear discussed. In the 1960s, people with schizophrenia were often paranoid about Communists. Today, they frequently fear terrorists and government surveillance or become obsessed with celebrities and athletes like, well, Peyton Manning.
In Denver, however, not just psychotics but rabid fans as well are obsessed with Peyton Manning. And while paranoia certainly occurs during a psychotic episode, it is a symptom of many ailments; it can also occur when a person is sleep-deprived, anxious, or taking (or withdrawing from) any number of licit and illicit drugs. Another trigger for paranoia can be delirium, and I wondered whether that could be the case with Connie. When people are delirious, they are confused, struggle to follow conversations, and have trouble navigating even familiar environments, let alone unfamiliar environments like a psychiatric ward. The irony is that when they most need a familiar, soothing environment, they are admitted to the purposeful bustle of a contemporary hospital, where the many movements and noises can be provocative.
. . .
Sometimes the assumptions we make through seeing much are wrong. Sometimes physicians overinterpret the available evidence. I suspected that we were fitting Connie’s story into our expected patterns. So when I evaluated her, I decided to try something different, to engage her as if I were a gardener-physician.
I sat at the nursing station and watched Connie for a few minutes. I wanted to see how she moved through the room. She sat for a moment, rose from the chair, approached the nurses to say, “I lied,” and then began organizing the chairs in an unhinged semicircle, as though they faced an unseen fire. As she moved, her gown flapped in the breeze, revealing her bare chest.
At this point, I decided to approach Connie, offering her a shirt to cover herself. She received it from me wordlessly, then stepped into the shirt’s armholes as though it were another pair of pants. She was evidently confused, so I started over and introduced myself. I asked Connie her name. She knew it. She knew her birthdate as well. So I asked for that day’s date. “Red.” She struggled with memory, unable to remember a few common objects after a minute or two. She became irritable when I assessed her level of attention by asking her to spell a word backward. She could not name the president. I asked her to hold my finger and, as I spelled out a word, squeeze it whenever I said the letter A. Instead, she simply squeezed my hand every few seconds. Connie was paranoid to be sure, but she was also delirious.
The causes of delirium are numerous. Infection, dehydration, or various medications are common causes, and physicians have lists of questions to help them assess for each possibility, but Connie could not answer many questions, so we needed to examine her body for clues. As we examined her, I tried to envision her body as a storm-battered though once-sturdy tree. Was her problem in the bark (her mottled skin), the leaves (her brittle hair), or the branches (her deconditioned limbs)? I looked for signs of past or present pests. Her glasses were crooked, her hair unkempt, and she favored her right foot. Her pants smelled of urine. Watching her gave me a few clues, and the gradual gathering of them had reassured Connie enough that she finally allowed us to sample her blood and urine for further study.
One solution for an ailing and tired-appearing patient like Connie would be to take the analogy between physicians and gardeners literally and prescribe Hildegard’s herbal medicines. Some admirers of Hildegard take her medical manuals as recipe books rather than inspirations. They plant, compound, and consume the herbal preparations Hildegard described: fennel seeds to ease indigestion; lavender wine to increase understanding; aloe and myrrh to relieve headaches. The books dedicated to the literal reclamation of Hildegard’s medicine are full of premodern generalizations. In one of those recipe books, I read, “People with green eyes are good craftsmen and very good at learning a new trade. Other characteristics include stability and cunningness.”5 As a green-eyed physician, I can be cunning, but I struggle to learn new trades. This kind of generalization explains little about me, but it reminds me of how much separates us from Hildegard.
Hildegard lived before Darwin, Newton, even Copernicus. She thought the position of the earth was settled in the sky and that the sun, moon, and stars rotated about the fixed earth. Their rotations generated not only time and the changing seasons, but the components of health and illness of plants and people alike. To reclaim Hildegard’s medicine literally, you need more than a well-loved herb garden. You need premodern astrology and biology. But most practitioners of what is called contemporary and alternative medicine proffer treatments from the premodern garden without endorsing the premodern understanding of nature. Advocates chew fennel seeds but keep time like the rest of us, assuming that our planet rotates about the sun and that time can be exchanged for money.
Thinking of Connie as a tree was an inspiring analogy but not a useful recipe for her care.
. . .
Victoria Sweet does not encourage physicians to become herbalists who re-create the medicines Hildegard compounded. Sweet appreciates and employs contemporary allopathic medicines. What she wants is for contemporary physicians to prescribe their medications within a physician-patient relationship like those that Hildegard developed with her community members.
Contemporary physicians so often begin and end patient encounters with medications that healthcare executives often call physicians “prescribers.” So when Connie visited her physician every three months at our local mental health center, the visit was aptly described as a “fifteen-minute med check” because the questions were all about the efficacy and adverse effects of the medications. Not so for Hildegard, who began the medical encounter with a careful observation of the patient, followed it with an examination, and only then might offer a prescription. Hildegard’s prescriptions included both a regime and a medication designed to maintain (not simply restore) health. The regime encompassed rules for living that addressed the most healthful quantity and quality of emotion, exercise, food, and sleep, and it was personalized for each individual’s humors, age, and climate. Hildegard’s infirmary was no factory.
Sweet believed that contemporary physician-gardeners could also prescribe both a regime and a medication. Instead of simply prescribing a medication or performing a procedure—what physicians are encouraged to do by contemporary billing practices—physicians could modify a patient’s internal and external environment to fortify his or her ability to heal. Instead of, say, prescribing olanzapine to a child who acts out, a physician-gardener would design behavioral and educational interventions and follow the child through his or her developmental stages. Instead of prescribing testosterone cream to a faltering man, a physician-gardener would help him improve his energy levels through exercise and rest. Instead of operating on aging knees, a physician-gardener would teach the patient ways to strengthen the muscles surrounding them. This might sound radically opposed to contemporary medical practices, but by the standards of evidence-based medicine, there is actually little reason to recommend antipsychotics to irritable children, testosterone to aging men, and knee surgeries to the middle-aged. There are, however, financial incentives for recommending each intervention. Sweet wanted to incentivize physicians differently so that, like Hildegard, they approached the body as a plant that could heal itself gradually, within realistic limits.
Yet Sweet developed her ideal at some remove from Hildegard’s garden and infirmary. Sweet practiced in a contemporary hospital, while Hildegard lived in a premodern monastery. Sweet cared for the patients admitted to her service, while Hildegard cared for fellow members of her Benedictine community. In a cloistered community, the therapeutic alliance between physician and patient was established well before a medical relationship was initiated. They shared a common life and lived by a common rule; their common rhythm was a sung hymn.
Do we need to restore such communities or therapeutic alliances to reclaim hospitals as gardens instead of factories and make physicians gardeners instead of technicians? That would be a dramatic reconfiguration, but perhaps we can still work to reenchant medicine with some of the mystery that has been lost in the modern world.
Reading Sweet had reminded me of Max Weber’s observation that our rational modern world, with our ability to generate evidence-based guidelines and standardize best practices, came at the cost of an enchanted view of the world. Premodern people, Weber wrote, understood the natural world as a mystery, governed by “mysterious incalculable forces” in which they participated.6 When we perceive the world as made up of materials (including the body) that we can enumerate, manipulate, and control, Weber wrote, mystery and wonder are replaced by technical means and calculations. If we could reenchant medicine, perhaps we could move away from the model of physicians as technicians controlling the failing parts of a patient and allow them to be more like gardeners tending to patients. Physicians would understand themselves and their patients as part of the natural world that remains, for all our scientific knowledge, mysterious.
My training taught me to see the body as a machine made up of parts. I learned that physicians identify themselves by the part of the machine for which they are responsible. We are consulted when our part of a patient’s body falters, and we sign off on the case when we cannot think of how to help that part further, even if the patient remains ill. We see the body as a collection of interrelated problems. We might say something like, “Connie has an infection in her urinary tract that has caused delirium in her brain.” But there are at least two difficulties with that sentence.
The first difficulty is that by our own measures we struggle to understand why an infection in the bladder and kidneys could profoundly impair the brain. We believe that dehydration and shifts in essential minerals like sodium and potassium are involved. We know that neurotransmitters like acetylcholine and dopamine are altered. We believe that inflammatory cytokines are involved. We know that, in the year after developing delirium, 35–40 percent of patients will die. Yet all we can conclude is, as stated in a review article I read while caring for Connie, “The pathophysiology of delirium remains poorly understood.”7 We physicians struggle when the parts of the body are interrelated in complex ways.
The second difficulty is that it posits the body as primarily a problem. Reading Sweet, I thought of the poet Christian Wiman and his observation that “existence is not a puzzle to be solved but a narrative to be inherited, and undergone, and transformed person by person.”8 Given the limitations of our science, it seemed more apt to engage Connie’s delirium as a narrative that could be transformed through a therapeutic relationship than to treat it as a disease and send her on her way.
. . .
We began with the fixes. She had too little potassium, so we ordered supplemental potassium. She had E. coli bacteria growing in her urine, so we administered an antibiotic. She was psychotic, so we ordered an antipsychotic.
Then we addressed her habits. Connie had become accustomed to taking medications for which we could find no indication, and we pruned them from her medication list. She was up all night, circling the unit in loops that never closed; we established clear times for being asleep and awake. She confused the date with the color red, so we oriented her each time we met her. Then we tried to form a therapeutic alliance with her, but Connie was not interested. She still wanted the Broncos rather than the shrink squad.
I wondered whether the only way to build a therapeutic alliance might be to provide literal enchantment. That ought to be easy in Colorado. The windows of our unit look out upon the Rocky Mountains erupting from the plains, but the steel safety wire cross-hatched into each pane of glass obscures the view. The view out those windows is encumbered rather than enchanted. The unit is, like a factory or an office park, designed for the standardized encounter, for safety, for efficiency. You have to work to find enchantment on the unit. Ours is a hospital for the poor, where a literal garden would be an unfunded luxury, an inefficient use of scarce space, a pretense—or a place where the methadone patients would sell their doses. Instead of a garden, we have a little landscaping near the entrance. It has flowers, a water feature, some bushes, and a few young trees, but the whole area takes up no more space than the backyard of a suburban home. Among the trees, emaciated girls from the eating disorder unit sit sullenly in their wheelchairs while trauma patients lean against the branches of their IV poles while balancing cigarettes between the yellowed fingers of bandaged hands. When I visit this space, I feel little enchantment. I wish we could give our patients more of the enchantment of the natural world—a garden, a forest, an expanse of green—but the cost is prohibitive. I have to translate Sweet and Hildegard, become a metaphorical gardener.
More often I feel like a factory farmer. The goal of commercial agriculture, like that of the healthcare industry, is to maximize yields. But the analogy breaks down when we think about what each industry is creating. Factory farmers can simply cull underperforming crops and focus their attention on the high-performing crops. We do not cull, but in the healthcare industry it is common to neglect the indigent ill in favor of healthy, well-insured patients. (When a neighborhood becomes impoverished, hospitals relocate to wealthier neighborhoods and call it an effort to change their “payer mix.”)
I think Sweet is right that physicians are charged to care for the indigent ill—we cannot neglect these patients in favor of the healthy and well-insured—and it makes sense to understand a physician as more akin to a gardener than a factory farmer. But being a physician-gardener in today’s hospital cannot mean copying Hildegard’s recipe books and declaring that green-eyed people are cunning. It requires translation.
For Connie, the enchantment we could offer was the hospital’s therapy dog. He proved remarkably effective. As Connie caressed his shaggy coat, her shoulders relaxed and her eyes cleared. She could sit still in his company. Despite her delirium, she had a capacity for joy in the presence of her fellow animal. He provided enough enchantment for her to form an alliance.
Sweet describes her proposal for medical reform as “slow medicine,” an analogy to the slow food movement. At the same time that people are turning away from mass-produced and standardized food in favor of locally grown and craft-produced meals, Sweet wants physicians to turn away from standardized medicine. Reading Sweet, I thought back to my reservations about Famous Factory Meatloaf and tried to imagine a medical practice that adopted some of the commitments of the farm-to-table and locavore food movements. Could the practice of medicine be particular to specific places and seasons?
When we hear about variations in medical care, it is usually in the form of a criticism, identifying a deviation from the norm. The most trenchant criticism comes from the Dartmouth Atlas of Health Care. The atlas combines zip code–level records of Medicare claims overlaid onto a finely detailed map of the United States. With the click of a few buttons, you can find out how the rate of particular surgical procedures, the availability of physicians, or the use of prescription drugs varies across a state or region. The Atlas’s intuitive graphical interface makes it easy to access data that were previously squirrelled away in a thousand government records. It is startling to see how much variation occurs and how the key variant appears to be whether a particular service is available. If physicians can profitably perform a medical intervention for the patients in their zip code, they seem to do so, irrespective of the medical necessity of the intervention. The curators of the Atlas rightly describe it as a critical tool for improving “understanding of the efficiency and effectiveness of our health care system” and note that “this valuable data forms the foundation for many of the ongoing efforts to improve health and health systems across America.”9 In their description, they situate the Atlas as a worthy advance in Cochrane’s reorientation of medicine around effectiveness and efficiency on the population level. And, as in Cochrane’s work, the Atlas describes variations in care as inefficiencies to be identified and eliminated.
I admire the editors’ aim, but worry that the Atlas neglects other kinds of regional variations, some of which seem desirable to me. Who wants every place to feel like no place at all? In medical school, I met physicians who belonged specifically to North Carolina. They had grown up, trained, and practiced in the area. They had courtly manners and uncommon names. Axalla Hoole. Georgette Dent. Jacob Lohr. Their accents were as particular as their commitment to the Goodliest State and its research university. As physicians and teachers, they listened to stories and told stories. When students joined Jacob Lohr’s service, he asked them to tell a story. You belonged to his team if you could tell a story well. Physicians like Jacob Lohr moved slowly but with purpose.
The best physicians share this ability to form a relationship with a patient that develops into a story. The first time I saw a child with failure to thrive for an unknown reason, I could not get the child to stay still long enough for an examination. But Jacob Lohr asked a few questions of the child’s parents, played a small game with a child, and got him or her to relax so that he could perform the examination. By the end of an encounter, the examined child would be calm, the parents charmed, and Lohr had integrated all the known information into a narrative diagnosis and prescription. The parents thanked him, and I stood in the corner, wondering how he did it.
Since Lohr never acted like a technician following a script, when he attended on the wards the hospital felt more like Hildegard’s garden than like a factory for the efficient diagnosis and treatment of disease. Time did not press upon him, but was rather part of the treatment. Lohr would sit with patients. Listen to their stories. Communicate his findings and counsel in stories of his own. His service was a master class in forming therapeutic relationships. So now, when I see patients like Connie, I call upon the craft I learned from physicians like Dr. Lohr. I look for a story we can share.