Wellness Committee

Nature is good for us: Why I prescribe outside

Posted on Oct 1, 2021 in Wellness Committee | 0 comments

Nature is good for us:

Why I prescribe outside

A silver lining of the pandemic is that many of us have been forced to spend more time outside; we haven’t been able to do anything else!  I have been able to ditch my car and more safely pedal the 3.5 miles on pedestrian friendly streets to work.  One morning last spring, I was reflecting on how good the ride outside made me feel when I walked in to see Mr. T., a 68-year-old with several significant behavioral and medical problems.

Before I could say a thing, he jumped in as if in mid-conversation. “Dr Hass, I can’t thank you enough.  I swear that prescription you gave me mid- Covid lockdown saved my life!”  Nodding, I tried to hide the fact I didn’t recognize him and assumed he was talking about an antibiotic or some other medicine. 

“I was so depressed and isolated”, he said.  “You gave me a prescription to ride my bike to the marina and watch the sunset.  I have been watching that sunset almost every day until I got sick last week.  And the prescription is still on the fridge!  I can’t thank you enough!”

I have been giving out “old school” paper prescriptions for about 2 years now where I prescribe non-pharmaceutical  things that have been proven to make people healthier.  Apparently, I had given him one to get outside and take in the natural beauty of the sunset.

“Thank you, Mr. T.  that means a lot to me.”  I said, “Your feedback really helps!”

I had heard that nature can make people happier and healthier, but embarrassingly, revealing my bias, I envisioned it primarily for more “outdoorsy” people like me, whatever that means.  Also, I assumed it would just a slight bump in the happiness quotient.  Mr. T had shown me that I had underestimated both the impact of getting outside and who could be helped.

I became determined to dig a little deeper to understand the health benefits so I could do more with these prescriptions.

While much of the research has been done in the USA, Japan is where the science has been most readily embraced.  Starting with research on blood pressure and stress hormone levels in the early 2000’s, there is now a medical specialty in Forest Bathing and more than 25% of Japanese partake in the activity.  There are nearly 100 officially sanctioned forest where the benefits have been demonstrated and with guides to help visitors the get the most from their time in the forest. A measure of the Japanese commitment to health through nature is that the director of the ministry of forestry is a social scientist not a botanist.  Trees are seen more as a health resource than an extractable resource

What are the benefits?  Lower blood pressure, heart rate and stress, improved mood and immune function, better sleep and increased creativity.  There are surprising social benefits, too.   During early forest bathing experiments, Dr Qing Li found that after a couple hours in the woods, blood pressure went down an average of 5 points. The effects didn’t end once people left the trees; stress hormones were measurably lower for a week. After 3 days with 2 hours of forest bathing, markers of immune health showed improvement that last 7 days (researchers at the GGSC confirmed this finding in Yosemite!). And of course, almost all the people would say they just felt better, too!

What is forest bathing? It is essentially taking it all in – with all our senses.  In fact, looked at individually, all our senses have a role in nature’s restorative power.

Dr Qing Li’s group found that when people slept overnight breathing in essential oil from the sacred Japanese cedar tree, they reported better sleep and had lower stress hormone levels.  Since then, researchers at Vanderbilt have demonstrated nurses report less stress if this same oil is infused in their hospital workplace.

Sound researcher Joshua Smyth at Penn State has documented decreased the tension in our nervous system as measured by heart rate variability when people listen to songbirds.  It increases with rumble of cars and roar of airplanes.   Researchers with the Nation Park Service found their parks “look” worse when people hear man-made sounds and thus, view noise pollution as an important issue for the parks.  Man-made noise can be more than an irritant. Research in Bonn Germany found that kids at schools subject to a lot of airplane noise have a tougher time learning than those in control schools across town.

We are primarily visual creatures, so it is not surprising that simply looking at beautiful natural scenes makes us feel good.  A heart surgeon at Vanderbilt suspected it did more than that.  Looking at it closely, he found that his patients whose hospital room faced the forest healed faster than those who faced the parking garage. I never knew why hospitals are full of nature scene until I researched for this project.  Strange that this bit of data reached the architects, but not the doctors!

So why is the natural world good for us? The Biophilia Theory suggested that since we evolved in nature, our senses and body rhythms are best suited for that environment. According to biologist E. O. Wilson, there is an “innate emotional affiliation with other living organisms” that makes us calm and comfortable in nature.  The sounds, smells, sights are our evolutionary “happy place” where we can rest and rejuvenate.  We are deeply tied to a world from where have strayed, despite the comforts and safety of the modern world, there is a price to pay for urban living.

Other scientists espouse the Attention Restoration Theory, Rachel Kaplan at Michigan says the “soft fascination” with the beauty of the natural world along with its subtle mysteriousness draws us in.  It is “enticing but not demanding”.  fMRI data by her student Stephen Kaplan showed that looking at nature pictures let the hard-working executive function parts of the brain recover compared to looking at urban landscapes.

Emotion scientists like the GGCS’s own Dacher Keltner believe there is something else going on as well: awe.  It’s that feeling we get from seeing something vast, wonderous that challenges our comprehension; with it our jaw drops, and we get goose bumps as we say, “Awe-some.”  But more than that happens, we have the same physiological effects that are seen as we forest bathing where heart rate and blood pressure drop.  The “awe walks” the Dr Keltner recommends where one slows down and looks for the beauty as opposed to racing along are essentially a way to forest bathe.  Beyond the physiological there are pro-social effects of awe: less concern for self, increased generosity and more cooperation.  This might be why research suggests there is less violence when trees are incorporated into low income housing developments.

So, what do I prescribe now?  Researchers from Finland suggest that 5 hours a month is the minimum to have lasting effects (leave the technology behind or at least in your pocket).  It doesn’t have to be the forest; water, even urban parks, can be healing, too.   For those with the resources, I prescribe breaks to a quiet cabin or tent of at least 3 days once or twice a year.  I also recommend house plants for home and office, microbreaks of stopping work to look out the window or a nature video for one minute and a couple short 5-minute walks even if it is in an urban environment.

But how in our busy lives? Well, the pandemic has helped with that.  Many of us have taken our physical activities and social activities outside.  Skip the gym and coffee house.   A walk with a friend outside is a Greater Good “three-fer”: exercise, friendship and nature all at once.

We should also be thinking beyond of selves.  Access to the natural world is far from equitably distributed.  While access to green space is foundational in public health and urban planning, my country, the USA, is far behind, Japan, Korea, Singapore, and many European countries in efforts to integrate this idea into our society.  Yet through efforts of hard-working citizens, vets can get outdoor therapy for PTSD.  The SHINE program in the Bay Area is one of several park-healthcare collaboratives that get kids out of their tough city lives to nature once a week.  We should all be inspired by these efforts and find ways to advocate for green access as best we can.

We see the effects of this lack of access every day.  Last week, I was taking care of Ms. S, a 58-year-old woman with mental health and mobility issues complicated by poor social support.  She came to the hospital with abdominal pain.  Sitting down and talking to her I could see her mood and isolation were her biggest issues.  Notes in her medical record recommend psychiatric care and medications, but now I start with a different approach.  “What brings you joy, Ms. S?”, I asked.

“Well, I loved my flower boxes I had outside my apartment” she said.   “I planted herbs and flowers.  Tending the plants made me feel good, but the manager said it was a fire hazard and I have hardly been outside since they hauled them away.” Her comments are in line with data on the benefits of touch – hands or feet in the dirt – and wellbeing. There is also a large body of research on the positive social and health benefits of gardening.

Before she went home, our team gave her resources about community gardens and I gave a prescription to bus to Redwood Park and the lake.  While that felt insufficient, at least she felt buoyed that our health care team felt her garden was as important to her health as she did.

This is a lesson we all should learn from Ms. S: don’t underestimate the benefits of engaging with nature.  Researchers repeatedly found we tend to discount the wellbeing boost we get from nature. Coming out of this long public health crisis we all should cherish all the good we can.   I have tried to make this cognitive shift:  every episode outside is an opportunity to access the healing power of nature.  I try to see each tree as an incredible living being and forests, the shoreline and even my neighborhood park as sacred sites for communing with the wonderous natural world and restoring my body and mind.  And when I watch the sun set, I think of what it did for Mr. T.

Leif R. Hass, MD
Summit, Wellness Chair

Tragic Optimism vs Toxic Positivity

Posted on Sep 2, 2021 in Wellness Committee | 0 comments

Tragic Optimism vs Toxic Positivity – it is important to find meaning in hardship rather than try to gloss over life’s realities, especially when times are tough!

Ms. S is a 75 yo who recently lost a child to a violent crime and another to Covid and kidney complications. Now she lives alone and has just found out about a lung mass.  During one of our conversations she said, “God helps us find a way when there is no way.”  I got goosebumps, my body’s signal to me that I was in the presence of something awesome.

My younger defiantly atheistic self would have questioned the merits of that answer, but now I see the wisdom of it – even for those of us who don’t believe in a guiding deity.  We can find transcendence in suffering.

 I am a big fan of gratitude and looking for the positive in life, but to be human is to suffer loss.  A meaningful life is derived in large part by how well we grow during these inevitable times of hardship. Covid, climate change, political and economic uncertainty, we are all suffering now or have our heads in the sand.

How does gratitude fit into this idea of “post-traumatic growth”?  Gratitude should not be “I’m lucky for all I have”, but “I am grateful for what others have given me and for the opportunities life has presented for making a meaningful life.” With that comes a desire to give back, strengthen relationships, build culture and grow spiritually.  Gratitude researchers call this existential gratitude: being grateful for all that life brings, both the good and the bad.

Gratitude can help us appreciate the little good things at the fringes of our suffering and also help us face the suffering with a growth mindset.

Loss is a defining part of the human experience.  Fully feeling our losses can tie us to others who have suffered and those who have worked to lighten our burden.  As health care providers, we should all feel grateful for the opportunity we have to lessen the burden of those we care for.  We might not do it through a cure, it might just happen with an open-ended question and a quiet presence that invites sharing of hard-won wisdom.  We can learn from our patients about grace and gratitude – a gratitude with depth.

The day Ms. S went home I took her hand and thanked her. “Your grace amidst suffering is a thing of beauty.” I said.

“Your loving presence might be the best medicine I have on God’s journey.” She said

No Pollyannaish “lucky me’s” or blithely blind positivity.  Just some old fashion thanks for sharing ourselves with each other.

Leif Hass, MD
Summit Wellness, Chair

Summit Physician Wellbeing

Posted on Jun 1, 2021 in Wellness Committee | 0 comments

Cultivating Emotional Balance

  • An Important Strategy for  Coping with Stress and Finding Joy in our Work!

Our work is full of time pressure, life and death situations as well as amazing opportunities to see the depth of the human condition.  We are not taught any strategies the help us cope.  I have stumbled upon a great one.  Dan Siegel, a  Harvard psychologist,  developed this idea he calls  “Name it to Tame it”.

Simply naming an emotion is a great way to get control over it.  Functional MRI show that when we name an emotion the activity of the brain moves for the arousal areas of the limbic system where we really feel the heat of the emotion to the prefrontal cortex where appraisal happens and with this, calming neurotransmitters are released to sooth.   Simply naming the emotion helps put out the fire and gives us some control.  Moving our thoughts away from the source of the emotion to the emotion itself can help stop ruminative thoughts that can be fuel for the flames.

The first crucial step is paying attention to our emotions which, at least for me, I was not in the habit of doing.  Emotions are an embodied phenomenon.  We feel them.  Paying attention to our body is a good way to help us recognize what we are feeling.

Interestingly, when we are feeling positive emotions, naming them helps us appreciated them more; the good get amplified!

Give this a try.  It doesn’t take any extra time and with some practice I am sure you will notice the benefits!

The link below is to a longer essay I wrote on this for the society of hospital medicine.  In it, I describe how I used this technique on a tough day on our Covid unit last winter.


And look for more Celebrating our Physicians post in June!

Leif Hass, MD
Summit Wellness Chair

Patient Experience

Posted on Jun 1, 2021 in Wellness Committee | 0 comments

At ABSMC We Live a Life of Purpose!

Posted on Apr 6, 2021 in Wellness Committee | 0 comments

Walking toward our Covid unit at 7:30 on a Saturday morning, I passed a very ill patient being urgently transported on a gurney.  With an RT bagging and couple of all PPE’d-up nurses   pushing, this frantic caravan moved the patient towards the ICU.  When I arrived at the nursing stations a moment later, the team there had just figured out the staffing for the day. “Linda and Marina, thanks so much for staying over and working a double” called out Tola the charge, “And Claire, thanks for staying over to help with that Rapid Response call.” Even the nurses who just arrived already look tired with their glasses steamed up and their shoulders hanging low.

They turned and got to work as I stood still taking it in. These exhausted nurses were getting at it because there was work to be done.

“I wish you all could see it with my eyes.” I said, “You are all amazing and you might not even realize it.  Well, I have to tell you.  Our community thanks you.  The medical Staff thanks you.  Your nursing colleagues thank you.”

“As thanks, let me offer you this.  Something so obvious we tend to forget it around here.  You live a life of purpose! You believe in taking care of the elderly, the sick, the disenfranchised.  You believe that people take care of people, because that is what human beings do, because that is how we build a just and beautiful society. You sweat and hustle and breathe all day through N-95s because that is what a nurse has to do to serve in the pandemic. Looks like we need better staffing and you could all probably use a cup of coffee, but I offer you this because you should have great pride in what you do!  Tell your friends and family that you live a life of purpose.”

A little embarrassed by my preachiness, I then shut up. But I felt compelled to tell them. It is true and it is something we all need to hold in mind as we grind through this awful pandemic. I tried to slink away but the team was energized now. “You are right; we don’t think about it and people don’t often remind us of it either. Thank you so much!”  Phones came out and we did socially distanced selfies.

I had been feeling crispy myself the week before when I got a text from my friend Ray. Ray is a wonderful human being and a person whose life is inseparable from his faith.   Every couple of weeks, I get a text from him.  On that morning the text said, “Have a great day on purpose!”  I had heard that playful pun-like phrase before, but going to work, to work caring for some of the sickest and most vulnerable people in the east bay, it didn’t feel trite that morning; it felt profound.   My purpose was my path to make a potentially tough day a work into a “great day”.

That night, I started doing a little reading about purpose and got even more fired up!  Dacher Keltner who co-teaches UC Berkeley’s class on happiness says, “a sense of purpose is possibly the best predicter of a life well lived.”  Developing a sense of purpose is one of the keys to happiness.  Nothing predicts performance and satisfaction at work as much as having a sense of purpose.  An entire industry has developed to help people find a sense of purpose at work. Why had I lost sight of this sense of purpose in my work?

Turns out that perhaps I had started to fall into common trap. I started to equate wellbeing with thoughts about one’s self. While working on ourselves is necessary, it could be a life time before I get myself “dialed” just right. It seems those community focused, hardworking ideals that got me into medicine in the first place, ideals that seem naïve at times now, are fact right.  Our years of study and training to earn the right to care for the most vulnerable in our community is something to be very proud of and should be a driver of our wellbeing.

Purpose is energizing and motivating.  Purpose won’t empty your inbox or get the OR to run on time, but it can put gas in our tanks, and we all need that from time to time.

Perhaps the purpose in our work is so omnipresent we lose touch of it.  Perhaps it is the relentless emotional content of the work or the irritating administrative tasks that blind us to it as well. Perhaps there is an important sense of humility, too.

Yet we can hold these notions in our minds and hearts at the same time: Ours is a life of service and purpose.  We accept the responsibility with humility and a tender heart. As an institution we should have a sense of full-chested pride.  And with each other, we should remind each other of our purpose.  When we have those late-night phone calls, those tough conversations with patients and those grueling days we need that pride in our purpose to turn our sacrifices into a great day.  Thank you for living a life of purpose and all you do to serve our community!

Leif R. Hass, MD
Summit Wellness Chair

Two ends of the Covid Cove

Posted on Feb 1, 2021 in Wellness Committee | 0 comments

Two ends of the Covid Cove

Ms. A was an 85-year-old woman who always clutched her rosary and had a traditional Central American shawl on her bed.  My Spanish is not great, but I understood her prayer when I entered the room.  She had come in the night before with cough, fever and shortness of breath.  She had tested positive about 7 days before – so had all the people in her multigenerational home.  Her o2 sat was 95% on 5l nasal canula, so over the phone, I felt comfortable reassuring both her and family that she would likely do well.  All the time Ms. A said she just wanted to go home.

Down the hall was Mr. D; he was an 81-year-old former Vietnamese “boat person” refugee.  He had experienced cognitive decline and weakness for a couple of years and went into a snf 6 months before the “lockdown.”  He had come in 3 days prior to my coming on service.  While he didn’t talk even with an interpreter, he ate well and had looked comfortable for days on 45% O2.

Each day the hard-working nursing staff on the unit, donned their sweaty blue plastic robes, face shields and N-95s and worked to feed, bathe and provide medicines.   And of course, we all relied upon the RTs who essentially managed the all-important oxygen for us.

Ms A’s o2 needs crept up each day as did her anxiety and the plaintive tenor of her prayers and enquiries about going home.  I got a priest to visit, not for last rites but just for some support.  I backtracked on prognosis with the family. 

4 days into her stay she needed 95% O2 and with that her pO2 was only 70.  I told her family it seemed the virus would likely claim her life shortly.  I said we could see how she did on 60% – that’s the max she could get at home with hospice.  If she did ok with that, she could get home which was clearly her wish.  I called them after 2 hours on 60% to tell them she was up eating and despite a low sat and slight increased resp rate, she looked ok.  “Can you guarantee that she would not make it if she stayed in the hospital? “

“I am sorry, but this is such a new disease, I can’t say that for certain.” I replied.   Feeling bad about it, the opted to have her stay in the hospital.

Down the hall Mr. D had stopped eating.  First it was dinner and now it had been a day and a half without food; also, his sats dropped as did his bp.  A nurse exited his room; despite the mask and steamed up glasses, I could read her body language.  “That poor man is dying.’ She said.  I told her I agreed and called the family with the news and to offer them a chance to visit and to talk about home hospice. 

“He has not seen any of us in 10 months. We would love to visit and talk about bringing him home on hospice.”  The next morning 4 of his 9 kids showed up with a quart of jook, an Asian rice porridge, for him and pastries for the staff.

They left the room smiling an hour later. “He ate all the jook and he smiled!  Yes, let’s work on home with hospice.”  That night he bp was better and we were able to move him to 8 liters oximizer and the staff agreed he looked much better.

The next day Ms. A was less responsive with sats in the 80’s, but still had this great sense of warmth and dignity about her.  Family was able to visit and when I walked in the room, Spanish catholic hymns were playing on a phone, her two children each had hand and, on an iPod, there was a chorus of tears.  20 family members were all crying on a Zoom call.  Together this made the most beautiful soundtrack to an end of life I have ever heard. I tried hard not to join the chorus as we talked about turning off the oxygen to help limit her suffering.

With the help of Sara, the RT and Kamal, the nurse, we added a bolus of morphine to her drip and removed the oxygen.  She looked so much more beautiful and peaceful without it.  Briefly, she closed her eyes then opened them, her breathing calmer.  And with the hymns and the chorus of her crying family, she lived another 20 minutes in the loving presence of her big family.

Meanwhile, down the hall, Mr. D’s family arrived in great spirits armed with more food for patient and staff.  He was to go home later that day with hospice.  When they saw him up in the chair without the oxygen, they said, “It is a miracle Dr Hass!  He is going home on hospice but having beat Covid!  We can’t thank you enough!” 

“Don’t thank me!  He was cured by love and jook!  What a lesson for us all.  Sometimes there is no better medicine than food from home and love!”  All bursting with joy, we shared some “elbow love” and took some pictures before he was wheeled home.

Back at the nurse’s station, there were tears. Sometimes life is so full of emotion that it is hard to give it a name – joy? grief?  Our bodies almost pulsing, our minds searching for words, it is as if an ancient process is marking a time and place in our souls.  “This is what it is to be a human being living with love and creating meaning” the experience seems to be telling us.

All I can say is “Well everybody, thank you all for your efforts. And isn’t this amazing work!”

Leif Hass, MD
Summit Wellness Chair