What I know about hubris, I learned from tomatoes.
I love to garden. Since middle school, I have spent the warm seasons tending to various fruits and vegetables with my grandmother. In college, with months of summer vacation time and little to fill it with, I really started to pick up the hobby on my own. My favorite plants to grow are tomatoes, which, while horticulturally mundane, I nevertheless find botanically very interesting. A member of the nightshade family with potatoes and peppers, tomatoes derive from an ancient vine. Today, some gardeners still grow a relative of this original species called Solanum pimpinellifolium, which erupts tiny red berries from a bushy habit, more similar to a clump of bamboo than the stock-straight tomatoes present on modern plots.
Tomatoes impress me because more than any other plant, I’ve seen how much their potential differs based on environment. Early in my gardening career, I strayed from my grandma’s teachings and decided to give my tomato plants more sunlight by planting them on our porch instead of the slightly shadier garden patch in our backyard. I bought six attractive, two-gallon pots that I knew would satisfy my mother’s decor requirements and happily transplanted a tomato start into each. The plants grew tall, stayed green, and soon started rewarding me with lovely red and yellow fruit. I was thrilled to harvest about two cups of cherry tomatoes over the course of the summer, not to mention a few pairs of handsome slicers. I understood tomato growing, I told myself. I enabled plants to thrive, and my tender care resulted in a bounty I was proud of.
Nothing I did that summer was strictly wrong. My plants avoided most diseases through the season, none suffered root decay or blossom end rot, and of course, I got a nice harvest. What was wrong was my hubris. I looked at my tomatoes and genuinely believed that they thrived before me, achieving their maximal potential.
Over the coming years, I learned more about gardening and what plants require to survive. I built a deep raised bed with my father and filled it with layers of old wood, leaves, aged compost, and topsoil. The final volume of the 6 x 4 x 1.5 ft bed was about 1000 liters, the equivalent of 135 two-gallon pots, and in it I planted eight tomatoes. By late June, the plants were taller than I was. In July, I’d picked several quarts of fruit. By August, fruits were falling off the branches onto the soil faster than I could pick them up. Now this was a tomato harvest.
In medicine, our goal is to help people thrive. We meet patients as they’re facing unimaginable hardship and use all the resources at our disposal to nurture them back to health. We challenge them to drink nutritional shakes despite horrific nausea from chemotherapy, climb stairs when only weeks ago a stroke made them nearly paralyzed, and show vulnerability in support groups about psychiatric illness that they themselves still don’t fully understand. When they finish their Ensure, climb 3 steps, or reach a new emotional breakthrough, we take pride in our success.
Positive developments merit feeling a degree of accomplishment. What I’ve realized I need to be careful in avoiding, however, is overconfidence in declaring success. As my garden taught me, success is conditional upon the environment, and hospitals are not, as I once believed, the ultimate substrate for recovery. Hospitals are excellent, but at the end of the day, they are designed for doctors. How often do we inadvertently limit our patients’ potentials by not providing the conditions they need to flourish? How often do we give our patients two-gallon pots?
During my medicine sub-internship, I was cross-covering a young man with terrible Crohn’s disease. He sat before me, wrapped in blankets and a hoodie but unable to generate heat, the act of shivering excruciating to his inflamed abdomen. Denied his usual home remedies of scalding tea and a hot bath, he pleaded to my resident and me for something to help his horrible abdominal cramping. We told him earnestly that antispasmodics are even better than his simple non-pharmacologic therapies and happily prescribed him Bentyl, breathing a sigh of relief when his nurse reported improved pain scores a little while later.
Throughout the night, I was woken nearly hourly to get his pain under better control. I scrambled up the staircase of painkillers recommended by his primary team, hoping to bring his breakthrough tens down to a six that he considered tolerable. Around 5:00am, paged once again but now at the end of the line with regard to stronger painkiller options, I went down to his room hoping that where medicine failed, maybe words could make a difference.
I saw him sitting next door in a family waiting area, the only awake soul on his wing of the medicine floor. His eyes showed the vicious thought spiral of the insomniac, the belief that relief from his waking pain will never come. At a loss for what else I could do, I went back to what he had asked for from the very beginning. Taking six hot packs from the supply closet, much to several nurses’ confused sleepy stares, I brought the patient to his bed and surrounded him with the soft white packets of warmth. Astonishingly, within minutes, he reported that his cramps were finally subsiding. I could see the hope grow in his eyes, that maybe he’ll actually get the sweet escape of sleep after all. He was finally relieved from the chilling hospital environment.
Much how a sprawling plant accustomed to growing on lush subtropical coasts will not thrive in tiny containers, a patient used to self-managing his chronic pain will not thrive when separated from the comfort tools he depends on. Through small environmental changes, we can accommodate individuals to set them up for achieving their maximum potential. A change as simple as increasing the temperature is all it took to bring my patient one step closer to a pain goal approaching the “true” best pain level he could hope for; not the six we settled on as tolerable, but perhaps a two or three that was possible in light of his other conditions.
How else might we be limiting our patients’ potentials? To start, we need to question the routine. Who are we serving by drawing morning labs before dawn, keeping operating rooms at 64 degrees, or guaranteeing that patients can always be found exactly where we left them (supine in bed)? Are there endpoints we’re not tracking because “hard” outcomes like falls or infections always take priority? Many hospital practices are rooted in excellent evidence, but as research in the nascent field of healthcare quality improvement is showing, some of these routines can be modified to patient benefit with hardly any friction to providers. Simply listening to patients when they point out that the ways in which they would care for themselves at home differ from the ways prescribed at the hospital may be all it takes to meaningfully optimize their environment for recovery.
Reflecting on my sub-I experience, I have to acknowledge the innate resilience of patients. We ask them—make them—recover, but do so in environments not suited for them to thrive. Humans are incredibly adaptable and readily make do with suboptimal conditions, but this does not mean that those conditions are acceptable. Whether through a deep garden bed or warm hospital one, we owe it to those we care for to provide environments not simply to survive, but to flourish. It’s time to crack the two-gallon pot.
Lev Krasnovsky is an MS3 at the Perelman School of Medicine.
