Patient Care Lessons From My Garden
Sometimes on a summer Sunday I sit outside on my covered porch and gaze at my shady garden. During this time, I also think about my patients and the lessons my garden has taught me about them. It might sound strange to compare patients to plants, so let me explain.
Before we became physicians, and even before entering medical school, we were pre-physicians, studying basic biology as well as botany. In Biology 101, we learned about animal habitats and which animals thrive in which habitats, and which would not survive in those same circumstances. Some settings are suitable for some creatures, while others are not. Polar bears, for example, do well in cold weather and snow, while tropical birds and butterflies need the opposite conditions. Move those polar bears to the Amazon, and those polar bears will be gone. Many of us learned similar basic biology lessons much earlier just by visiting zoos.
Since most of us don’t keep polar bears in our backyards, I won’t stress this point and pontificate about animals and ecology. Better to talk about the gardens, which are more frequent.
What makes my gardens grow?
In the popular imagination, gardens need sun, along with good soil and the right amount of rain, so that roses and so many other beautiful, sun-loving flowers can grow. Still, I can look into my shady garden and see lots of other beautiful flowers that have been planted or potted. To my right are steps covered with caladiums, many different varieties. I wish I could list each species by name, but I can say for sure that all of their leaves come in a wonderful range of colors, with each leaf shaped like an elongated heart. Some are dusty red with green borders, and others are green with red borders. Some have green veins running through the reds, while others are white, with green stripes, etc. There are so many permutations to these shade flowers, and so many variations – but they share one thing – they need shade and can wither and die in direct sunlight.
A few meters above these steps is a balcony, surrounded by white fences, some of which remain in the shade and others extend into the sun. From these balustrades which rest above the caladiums hang scrolled wire baskets, filled with begonias. Some begonias are off-white, while others are pale pink, and even more are coral or a darker red that many might call vermilion. The colors and textures of the begonias play on the translucent shades of the caladiums below, although the shapes and sizes of the begonias are drastically different from the large elongated leaves of the caladium. But begonias and caladium have something in common: both prefer shade and cannot stand the sun.
While I applaud many advancements in our field that help patients lead more productive and enjoyable lives, I sometimes think we can help some even more by helping them find their own natural habitat.
If you’d like to put up with me a little more, let me mention another garden, right in front of me, in full frontal view, shaded by towering pines that drop sticky pine cones every fall. At this time of summer, hostas are in full bloom, getting wider and taller each year. These too come in many different hues and many different varieties, although each of them is a shade of green. A real horticulturalist could name each one of them, but I just call them each beautiful, without needing to know more just yet. In the sweltering heat of summer, they grow long stems with pale lilac flowers. In early spring, those same rows are occupied by pink daffodils which also thrive in shade, unlike their more well-known cousins which require full sun. I also adore these sun-loving daffodils, with their yellow and orange and gold trumpet crowns, which herald the start of spring.
I could go on and on about every plant, shrub, and flower in my gardens, but let me explain why I compare plants to patients.
Patients who have found their place in the shadows
As humans, we pride ourselves on believing that we can change nature and impose our wills on biology (despite hurricanes, wildfires and floods). Sometimes we can successfully change the course of nature, and often we should, but not always. Certainly, man-made irrigation systems made Israel’s deserts flourish, replacing sand with fruit trees to feed the people. Without surgeries, children born with club feet could end up with permanent lameness, unable to move completely. And so on. Yes, modern medicine has worked wonders for many, often resulting in longer, healthier lives. But how does psychiatry fit into this picture and how does this impact psychopharmacology in particular?
While I applaud many advancements in our field that help patients lead more productive and enjoyable lives, I sometimes think we can help some even more by helping them find their own natural habitat, even if we don’t. is not an environment envied by others. .
Let me provide 2 patient examples to dramatize this point. Let me call one “Ms. A” and the other “MB” Ms. A was already a lawyer, although she hated reading and writing, and especially arguing. Yet she chose the law on the advice of her parents, who rejected her wish to become a baker, oblivious to the wonderful creations she made for her friends and family. Ms. A did well in elementary school, high school and university, well enough to be admitted to law school. Still, her focus waned as she studied legal details that didn’t interest her. A local doctor diagnosed her with Attention Deficit Hyperactivity Disorder and put her on stimulants, despite having no early history of attention problems, and apparently without inquiring about her interest in the subjects she was dealing with. she was studying. With these pharmaceutical aides, she earned her JD, passed the bar, and was hired by a mid-sized law firm in midtown Manhattan. Although her parents were delighted with her apparent success (her analogue in the sun in a garden), she was unhappy sitting at a desk, staring at a computer screen, when she wanted to cook.
Because she was so unhappy, she went to every happy hour after work and quickly developed an alcohol use disorder. She started arriving late for work when she wasn’t calling to be sick. Fortunately, the bar association offered help to its members and referred her to treatment, which at the time included antidepressants as well as appetite medication. We also added behavioral activation to encourage him to engage in enjoyable activities (and to increase the chances of overcoming depression, as shown in New England Journal of Medicine.1
Instead of slowing down her after-work hours at local water points, she signed up for cooking classes. Her mood cleared up enough and her focus cleared up enough that she decided on her own to complete a culinary certificate and change careers. As she said, she preferred to “knead the dough” rather than do more. No longer sitting in a chair for hours, she could wander at will in a commercial kitchen. She decided that she no longer needed the stimulants prescribed for her to push her into an education she despised. In short, she found her shade garden where she could not only survive, but thrive, even if it wasn’t the sunny rose garden her parents recommended.
MB’s situation was somewhat different. Always a shy man, Mr. B found solace in his college computer classes which required limited human interaction and which also promised a bright financial future. It’s no surprise that he landed a high-paying coding job after graduation, but it was an unpleasant surprise when he became paranoid while working in a large open space rather than in a confined cabin. Soon enough, he accused his colleagues of plotting against him and engaged in enough arguments to lose the job. He never had any frank auditory hallucinations – only barely audible intermittent whispers – but, in hindsight, his evolving symptoms seemed worrying. It was easy enough to find another job, given his high-level coding skills and the high demand for such skills, and it was surprisingly easy to crush these emerging psychiatric symptoms with a low dose of an atypical antipsychotic.
Everything might have worked out fine if he hadn’t developed involuntary facial contractions from his new medication. To avoid worse consequences in the future, he reluctantly agreed to stop the drug, even though he had relieved him so much. We have replaced cognitive behavioral therapy techniques and watchful waiting. Then, Mr. B was literally saved by the pandemic. Everyone in his office was forced to work from home. Without the untenable closeness to his colleagues, his paranoid symptoms abated, even in the absence of medication. The erratic whispers evaporated. Even his productivity improved and his supervisor praised him. When the owners of the business talked about reopening the office, we chose to apply for housing under the Americans with Disabilities Act, which would allow her to work from her family’s home. Better to work from home than to end up in the hospital, if her rudimentary symptoms reappear and progress to a full-blown schizophrenic rupture, which could impair her cognition in the future and interfere with her employability. For Mr. B, his home office was his shade garden, where he could survive and thrive.
Is there a moral to this story and a special message to psychiatrists? Yes there is. These 2 cases of human ecology demonstrate interactions between humans and their environment.
I wish I could claim to have discovered the concept of human ecology, but I can’t. This term was coined several decades earlier. Although we discuss the impact of climate change on human well-being, human ecology is not a concept we typically discuss in contemporary psychiatry, but it is perhaps worth considering. The concept of human ecology goes back to Carl Linnaeus, MD, whose name we heard in those premedical biology and botany courses taken while we were on the way become doctors. Linnaeus is best remembered as a taxonomist who categorized both animals and plants, but he was much more than that. Linnaeus was both a botanist and a physician who probably would have appreciated how much looking at the gardens can add information about the treatment of patients.
Dr Packer is Clinical Assistant Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mount Sinai, New York, NY.
1. Park LT, Zarate CA Jr. Depression in primary care. N English J Med. 2019; 380 (6): 559-568.