New Year's Day for Trees

Jacob Schor ND, FABNO

Photo by Gilabrand via Wikipedia, used
under the Creative Commons License.

The 15^thday of the Jewish month of Shevat, or Tu B’Shevat, begins at sunset on February 7^th this year and marks the Jewish New Year for trees. In Biblical times, knowing the age of a tree was important because the fruit from a tree less than three years of age was considered inedible. This date was set to approximate when the earliest blooming trees in Israel ended their winter dormancy, but during the Middle Ages, Tu B’shvat grew to be an esoteric holiday.

In the middle of the 16^th century, the renowned Kabbalist Rabbi Yitzchak Luria of Safed and his disciples began to celebrate the day with a ritual meal. Each of the fruits of Israel was assigned symbolic meanings to represent concepts from the Kabbalah (the image of a tree is often used to represent the spiritual realms of the universe) and they were eaten in a ritualized order with the appropriate blessings and with adequate quantities of wine. It was believed that this would bring human beings and the world closer to spiritual perfection.

In more recent years, the holiday’s theme has shifted to reflect conservation and ecological themes, a concept that probably traces back to 1890 when Rabbi Zeev Yavetz celebrated the day by having his students plant trees in the agricultural colony of Zichron Yaakov. In the early 1900s, the Jewish National Fund devoted the day to planting eucalyptus trees in the Hula Valley to stop malaria and in 1908 the Jewish Teachers Union (and later the Jewish National Fund) copied their activities and turned the holiday into an annual effort to reforest Israel. This has grown into an annual day of tree planting; this year on Tu’Bshvat over a million Israelis will take part. This holiday provides a suitable excuse to review some recent research on trees and how they impact our well being.

Green Space and Mental Health

The idea that “green space” is fundamental to mental well being has become a popular research subject in recent years, to the degree that a recent Dutch paper employed the term, “Vitamin G” for green space, implying that it is essential for our health and sanity. [1] What is it about green space that is so healthful? It’s not what you might think – a 2008 study proved that green space proximity does not correlate with time spent exercising. [2]

Something about green space does change the way people perceive their lives. The further people live from open green spaces, the more lonely they perceive themselves to be and the fewer social contacts they actually have. [3] The closer one lives to a green space, the less of an impact the stressful events in people’s lives seem to have on them. [4] Though not proven as well as we might hope, there is a growing hypothesis that people need a minimum daily requirement of green space exposure to maintain a state of mental health. [5]

Forest Bathing

Photo by It's Just C via Flickr, used
under the Creative Commons License.

This brings us to recent research on a traditional Japanese practice called Shinrinyoku, translated as ‘forest bathing’ or ‘taking in the forest atmosphere.’ The practice entails just what it sounds like, walking quietly through a forest. That such a practice would leave someone feeling better seems intuitively correct, but the degree to which scientists have proven this is quite surprising.

We first noticed papers on forest bathing in 2007 when three separate journals published human trials. In March 2007, Tsunetsugu et al. reported that college students who either sat for 15 minutes admiring a forest view or walked for a similar period of time both felt better and also had lower blood pressure, heart rate and cortisol levels compared to doing similar activities in an urban setting. [6] In the same month Park et al. reported data on a similar experiment, finding that the forest not only lowered cortisol but prefrontal cortex activity as well. [7]

Other studies watched participants’ responses, finding that forest exposure was associated with significantly decreased scores for hostility and depression on personality testing and increased ‘liveliness.’ The higher the initial stress level in the individual, the more pronounced the benefit of forest exposure. [8] Further studies by Park et al. tested subjects in 24 different forested areas, finding that “The results show that forest environments promote lower concentrations of cortisol, lower pulse rate, lower blood pressure, greater parasympathetic nerve activity, and lower sympathetic nerve activity than do city environments.” All the different forests appear to have a similar impact. [9]

Unfortunately none of these (or the many similar) papers have yet explained the source of the benefit. Is it the sounds of the forest, the frequency of light filtered by leaves, the various chemicals that trees emit into the air, or that lack of urban discord? One can hypothesize that it could be any one of these factors, a combination or something yet unknown. Will an indoor fountain that mimics the sound of a forest brook have the same impact as being in a forest? Will abundant houseplants act as a trigger to relaxation? Could we bottle and aerosolize the odors given off by trees to our advantage? These questions remain unanswered. Suffice to say we humans feel better in the midst of trees.

Our Duty

One is acutely aware of this here in Denver. We live in a place where trees do not grow naturally. Old photographs of homes in our neighborhood when they were first built show these structures standing alone in the middle of an empty prairie. The trees that line our streets and shade our yards are there only here because people have planted, watered and cared for them over the century.

Even with the value we might put on trees locally, 4,500 acres of forest disappear globally per hour, adding up to approximately 18 million acres of forest per year. [15] People in Sub-Saharan Africa, where trees have long been in short supply are burning wood for fuel at a rate that is 30% to 200% faster than it can grow back. Trees store carbon and destroying them hastens the carbon release that causes climate change.

Here in Denver we have a lovely organization called Denver Digs Trees that distributes free trees to residents for planting. I take pleasure in a lovely tree supplied by this group that my neighbor Bill and I planted a decade ago. The group supplies free trees for planting twice a year, Spring and Fall.

If you resonate with those bumper stickers that say “Think globally / Act locally,” then this program is for you. But if you really are the sort who wants to change the world, then you need to know about a group called Green World. As the name implies (and guessing from the context of this article), this group plants trees on a global scale. Their goals are lofty but their plan is simple. Donations are used to plant trees in parts of the world where they will do the most good.

Trees can enrich our lives. We would be far less without them. For this New Year Day I hope that you will take a moment to look about and appreciate the trees that do bring a bit of sanity to our world. I also encourage you to help plant a few more trees either in your own neighborhood or somewhere else in the world.


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1. Groenewegen PP, van den Berg AE, de Vries S, Verheij RA. Vitamin G: effects of green space on health, well-being, and social safety. BMC Public Health. 2006 Jun 7;6:149.

2. Maas J, Verheij RA, Spreeuwenberg P, Groenewegen PP. Physical activity as a possible mechanism behind the relationship between green space and health: a multilevel analysis. BMC Public Health. 2008 Jun 10;8:206.

3. Maas J, van Dillen SM, Verheij RA, Groenewegen PP. Social contacts as a possible mechanism behind the relation between green space and health. Health Place. 2009 Jun;15(2):586-95. Epub 2008 Oct 15.

4. van den Berg AE, Maas J, Verheij RA, Groenewegen PP. Green space as a buffer between stressful life events and health. Soc Sci Med. 2010 Apr;70(8):1203-10. Epub 2010 Feb 12.

5. Dean J, van Dooren K, Weinstein P. Does biodiversity improve mental health in urban settings? Med Hypotheses. 2011 Jun;76(6):877-80. Epub 2011 Mar 22.

6. Tsunetsugu Y, Park BJ, Ishii H, Hirano H, Kagawa T, Miyazaki Y. Physiological effects of Shinrin-yoku (taking in the atmosphere of the forest) in an old-growth broadleaf forest in Yamagata Prefecture, Japan. J Physiol Anthropol. 2007 Mar;26(2):135-42. Free full text http://www.ncbi.nlm.nih.gov/pubmed/17435356

7. Park BJ, Tsunetsugu Y, Kasetani T, Hirano H, Kagawa T, Sato M, Miyazaki Y. Physiological effects of Shinrin-yoku (taking in the atmosphere of the forest)--using salivary cortisol and cerebral activity as indicators. J Physiol Anthropol. 2007 Mar;26(2):123-8 http://www.ncbi.nlm.nih.gov/pubmed/17435354  Free full text

8. Morita E, Fukuda S, Nagano J, Hamajima N, Yamamoto H, Iwai Y, Nakashima T, Ohira H, Shirakawa T. Psychological effects of forest environments on healthy adults: Shinrin-yoku (forest-air bathing, walking) as a possible method of stress reduction. Public Health. 2007 Jan;121(1):54-63. Epub 2006 Oct 20.

9. Park BJ, Tsunetsugu Y, Kasetani T, Kagawa T, Miyazaki Y. The physiological effects of Shinrin-yoku (taking in the forest atmosphere or forest bathing): evidence from field experiments in 24 forests across Japan. Environ Health Prev Med. 2010 Jan;15(1):18-26.

10. http://www.fao.org/forestry/en/

2012: Be here now.

By Michael Cronin, ND
AANP President 

I invite you to ‘take a deep breath’ and appreciate our Naturopathic profession for a moment with me. We are a relatively small profession with strong institutions and deep roots, we have: nearly 4,000 ND licenses in the U.S., five U.S. colleges, legal recognition in 16 states (plus D.C., Puerto Rico and The U.S. Virgin Islands) and full scope in eight of those states. Meanwhile, the profession in Canada includes another nearly 2,000 NDs and an international Naturopathic community is taking form in India, England, Australia and New Zealand. Our community in America is growing and we have a distinct professional identity.

As people recognize that they must take more personal responsibility for their health, they will come to understand the advantages of our medicine. Our patients appreciate our expertise and clinical work: our doctors are in demand with successful practices and innovative approaches. There is a growing body of work that supports the methods we use and we are working to increase the amount of evidence of ND effectiveness.

It is essential to build a stronger and more effective professional community in 2012 in order to license new states, expand laws to full scope, improve how we educate the public, manage our media affairs and recruit patients for our members.

In the area of government affairs, an urgent and immediate opportunity for the AANP is the Affordable Care Act (ACA), which was signed into law last year. The inclusion of the term “licensed CAM (Complementary and Alternative Medicine) provider and integrative health practitioner” could be a game-changer for our profession as well as our patients, if NDs are included in the pending rulemaking process. Short of having NDs specifically mentioned, we believe there may be opportunity to ensure against insurance caps on CAM services. It is my belief that the Obama Administration, despite this being an election year, is working to determine the rules and regulations surrounding the implementation of the ACA.

I note, however, there is a legal challenge to the ACA by 26 states that will be heard by the United States Supreme Court. This suitchallenges the mandate that every person not covered by a government or corporate policy must purchase private health insurance. Once the Justices make a ruling on whether the mandate is constitutional, the issue of severability remains a question. However, it is possible the other sections and definitions of the ACA will stand.

The most important component of the ACA may be section 2706 on non-discrimination, which is planned to go into effect January 1, 2014:

Providers - A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law.

There are other sections of law that recognize “licensed complementary and alternative practitioners and integrative health providers” and their involvement in (1) community health teams (2) national prevention, health promotion and public health council (3) the national health care workforce commission, (4) patient centered outcomes research, and (5) demonstration projects concerning individualized wellness plans. For a summary of the components of the Affordable Care Act, take a look at this guide at theintegratorblog.com

Outside the ACA, the AANP’s Government Affairs strategy includes seeking ND eligibility for tuition forgiveness in rural health care and recognition of NDs within the Veterans Administration or Department of Defense.

2012 brings challenges we plan to use as opportunities. I encourage all NDs to be involved with your state associations and the AANP. I invite you all to join our DC Federal Legislative Initiative (DC FLI) on May 5-7, 2012 to engage with the Federal legislative process so we as a community shape our future.

Holiday Cheer in Trying Times

By Lise Alschuler, ND, FABNO
AANP Past-President (2008-2009)

Photo by CCAC North Library via Flickr, used
under the Creative Commons License.

‘Tis the season to be jolly! … A whole season to be full of joy, conviviality, glee and laughter.  I reflect on that as I think about two patients. One is an extremely vivacious, fast-talking, go-and-get-‘em young woman diagnosed with ovarian cancer. She concluded integrative therapy early this Fall. She felt great and her motivation to continue to live healthfully was strong. She even took her mile-a-minute self into a Tai Chi class and is learning to love the peaceful gracefulness of this exercise. And then, a follow-up scan just before Thanksgiving found several new tumors in her liver.  Just after Thanksgiving, she began a new round of chemotherapy. She understands that her that her prognosis is guarded and yet, her jolliness has not diminished in the least. She ends every email with a salutation of love and gratitude. She wishes her providers good health and happy Holidays. Her sense of exuberance in daily living continues to reverberate in her being.

The other patient is a woman that I have had the honor of providing naturopathic care to for the past 2 years.  She was diagnosed with triple negative breast cancer with an inflammatory breast cancer component. This is an ominous diagnosis, to say the least. Over the past two years, she has had sequential chemotherapy, surgery and radiation therapy. She has also maintained a comprehensive regimen of diet, exercise and supplements. She has exemplified health and radiance throughout her treatments, amazing all of her care providers. In September, she was without evidence of disease. Then, the week after Thanksgiving, a follow-up evaluation revealed metastasis in her bones and more inflammatory breast cancer. Upon hearing what, for most people, would be a devastating blow, she absorbed the news and, as she put it, “picked up the shattered pieces of myself and got right back into the saddle.”  She too, continues to shower her care providers with gratitude and well-wishes. She understands the seriousness of her situation and, at the same time, has managed to focus on the opportunities, the hope and the love around her.

For me, these two courageous women personify the true meaning of holiday cheer. They have taken being joyful and jolly to a whole new level. They are giving life a big bear hug and are squeezing every drop of its vitality into their attitude, communications, actions and ultimately, into the lives of those around them.  So, in the spirit of the season, and with deep love and admiration, I thank them for their splendor. 

President's Message: A Final Farewell

By Carl Hangee-Bauer, ND, LAc

AANP President

Winter is upon us as I write this, my last blog as AANP President. It is a time for drawing inward, reflection and preparation for growth as well as new things to come as the light begins to return and Spring is right around the corner. We see this season reflected in our microcosm of the AANP, with our Executive Director of the past nine years having moved on, Board members departing (Thank you so much, Trevor Holly Cates and Corey Resnick!), Helen Healy finishing her term as HoD Speaker, and other changes in AANP staff. It is truly a time of great change and with that change comes challenges and opportunities.

AANP's renewal is already taking shape, like an early Spring thaw. Terri Deerr has stepped into the role of Chief Operating Officer (COO) and will manage the association during the interim period as we seek our next ED. Michael Cronin takes the reins of AANP President on January 1st and brings vigor, passion and new ideas for moving the AANP and profession forward. Bruce Milliman is stepping up as the next HoD Speaker, and the Board welcomes new member Michelle Simon. 

As I like to say, "Change is the order of the Universe." I believe these changes are timely and I'm optimistic about the growth and future of the AANP. We must embrace change if we are to adapt and grow.

Please renew your AANP membership or rejoin if your membership has lapsed. We have so much to accomplish with regards to changes in the federal health care landscape, state licensing and scope of practice issues, PR & Branding, member support and a host of other ongoing projects. We need your help, your active participation and your support if we are to meet the challenges ahead. Your actions and your voice are a vital part of this process.

In August, I gave my farewell speech to those gathered at our annual Awards banquet. As I re-read it, it still reflects my thoughts and observations as I finish my term as AANP President. I have reprinted it below: 

"Last year the AANP celebrated its 25^th anniversary. At the gala we formally recognized those who founded this association, our past leaders and award recipients and my speech envisioned what the next 25 years would bring to this profession and to the AANP. It was a very formal event befitting of the time and venue.

This year I am going to be less formal and speak more from my heart and share a few of my experiences and insights. I have served nearly four years on the Board and my last year as AANP President is coming to a close. It has been a very interesting, challenging and, as I tell many who ask, a growth experience. There have been moments of great joy as well as moments of struggle and conflict.

It’s said that change is the nature of the universe. It is certainly true for the naturopathic profession. Over the past year we’ve suffered losses with the passing of Dr. Konrad Kail, Friedhelm Kirchfeld and others who have led, taught and inspired us. We’ve learned that our next naturopathic medical school will open in San Diego in 2012; meanwhile our other naturopathic colleges are growing as we’ve never seen before. We’ve seen another state licensed with more poised to follow. We’ve been inspired by how one man, Dr. Dennis Godby, with great personal sacrifice and dedication is acting to change the world by running across the United States to raise awareness of naturopathic medicine and how it can improve the health of all Americans. The AANP membership has grown and surveys show member satisfaction with the AANP is very high.

We bear witness to the renaissance of naturopathic medicine in the US.

Change is also on the horizon for the AANP.

We have a dynamic board dedicated to making naturopathic medicine a household name and have elected new board members who are stepping up as our future leaders.  

The House of Delegates has worked diligently to improve its process and has set an ambitious agenda as well as the work the House and the Board will do together will move this profession forward. 

Our next president, Michael Cronin, a long time pioneer and leader in Arizona and founding board member of the AANP, takes office in January at a time of great challenges and changes at both the federal and state levels, and I believe he is ready and up to the task. 

Our executive director, Karen Howard, who has dedicated herself to serving this profession for the past 9 years has decided that it is time to move on to the next challenges and opportunities that life presents and we will sorely miss her. With the support of her professional and dedicated staff, she has worked tirelessly to make naturopathic medicine known on Capitol Hill and the houses of Congress, to build bridges with other professions and coalitions, to support the growth and success of our members and to build our organizational structure, finances and resources so we can meet our goals as the national association representing naturopathic physicians. Please join me in thanking Karen and wishing her much success wherever her future takes her.

On a more personal level, serving as AANP President has been one of the greatest challenges and opportunities of my life and I have had a few insights along the way I want to share with you now.

Some of you in this room who know me know I love the outdoors and our garden. Often if I’m stressed out or feel overwhelmed with everything, I’ll make time to get out into my backyard, repot some orchids, pull some weeds, prune a few plants and get my hands dirty. There’s something about getting my hands in the earth that I find grounding. During these activities I often reflect on problems and issues I’m dealing with and something about gardening helps me step back and get the bigger picture.

In these moments, one train of thought I’ve followed recently is how the naturopathic profession is alike and different from other health professions. For example, allopathic medicine, for all of its great strengths and weaknesses often favors a mechanistic approach and relies on specific diagnoses to treat disease; prevention, for example, often focuses on vaccinations or screening tests. It has produced major advances in medicine and surgery to be sure, but can sometimes miss the forest for the trees.

We naturopathic physicians are most like gardeners in the care of our patients and we must apply these principles in our professional associations and in our interactions with one another. We must nurture our community like we nurture our patient’s health.

We must focus on the soil.

In Metchnikoff’s discussions with Pasteur, he argued that “it’s not the germs but the soil” that is most important to focus on in health care. As NDs we learn how to improve our patients’ health by laying the foundation with proper diet, exercise and play, adequate hydration and sunlight. We check for mineral levels, pH and indications of imbalances. We focus on achieving health and wellness as much or more than disease itself.

The AANP, our state, specialty and other associations as well as our colleges prepare the soil and the environment for the growth of our profession by educating our doctors, passing licensing laws, creating board exams, nurturing federal recognition, and other steps to insure that naturopathic care is available for all Americans and that the sprouts of our graduates have the opportunity to grow, thrive and become fruitful. Our corporate partners help us nourish the soil by their support for our goals and our programs.

We care for and tend our gardens.

Naturopathic Physicians are trained as systems thinkers. In patient care, we are wholistic in our approach even while focusing on specific health issues. Even while we help our patients manage or overcome their challenges, we encourage their growth, vigor and hardiness through preventive strategies and by dealing with health problems in context with the individual in all our aspects-body, mind and spirit.

As an association the AANP nurtures the growth and robustness of our profession.

We companion plant by building coalitions with our natural partners and creating deep ties with external organizations with mutually supportive goals. However effective as we are, we know that we cannot do this alone.

We pay attention and we tend the garden of our profession. When we are engaged, focused, thoughtful, attentive and have our vision, we produce beautiful and productive ecosystems in balance with nature. If we don’t pay attention or have a plan, we see a few plants thrive, many struggle to survive, our soil become deficient and the weeds take over.

We are the gardeners and it’s our responsibility to take care of the land.

Sustainability depends on good caretaking. If we are good caretakers, our harvest will be the health of our patients and the health of this profession. How well we do this will determine our yield. We must work together, knowing that while we may have differences of opinion and approach, we are all working toward the same goals and ends. Respectful debate and listening will yield better solutions. And we must take care of each other and nurture one another, because our greatest strength is our community and our relationships with one another. We are a small and growing health profession yet together we are much greater than the sum of our parts. Our strength does not lie in our numbers but our connectedness to each other.

In closing, I want to thank you for the good work you all do everyday to benefit the health of your patients and this planet and for your dedication to this profession. And from my heart, I want to thank you for the honor and privilege to serve as AANP President."

Here's An Easy Tip For Curing Cancer

By Shiva Barton, ND, LAc
2011 AANP Physician of the Year

Photo by esmtll via Flickr, used
under the Creative Commons License.

So now that I have your attention, you hopefully know that there are no natural cures that have been researched well enough to state that they can cure cancer of any kind. Yes, isn't it interesting that there are no known natural cures for ANY TYPE OF CANCER! Is this because there is nothing out there that works or because the scientific/medical community hasn't put the resources into finding the cure? I don't know the answer to that. Time will tell.

However, there are definitely things that you can do to improve the outcomes and help the survival of cancer patients. I am focusing on one of those treatments, below. If you are like me, you probably see many patients who have cancer. Some of you choose to treat people with cancer and some of you don't. I encourage all of you to treat these patients because there is so much that we can do to help these patients have better outcomes. Sometimes EXTREMELY better outcomes. That is what I want to share with you now.

As you may know, (if you have attended any recent Clinical Anecdotes sessions that I have moderated at either the AANP or NHAND conferences) I am very interested in periodic fasting for health improvement. I am particularly interested in periodic fasting to improve outcomes of patients who are undergoing cancer treatments, specifically chemotherapy. There is emerging research that doing alternate day fasting or a pre-fast before chemo enhances the effectiveness of the chemo while protecting the normal cells and reducing the side effects. This is what I have been doing with my last few cancer patients with great success. Here's an example with my latest case:

A 50 year old man came to see me 2 weeks after being diagnosed with stage 4 duodenal carcinoma that had spread to the liver. Prognosis for survival was 2 months (Christmas 2011). He was scheduled for 4 rounds of chemo (once every 2 weeks) which would have taken him to his drop dead date. Clearly, his oncologist didn't have much hope but thought something should be done. The patient had one chemo treatment before seeing me. After learning what chemo he was getting I suggested some of the supplements recommended in Lise Alshuler's book, The Definitive Guide to Cancer. (This is an indispensable book and I strongly urge you to get a copy.) In addition, I recommended that he fast for 24 hours, starting from 24 hours before the end of his chemo the following day. To clarify, his chemo infusion ends on Friday at 2pm. I recommended that he fast from Thursday at 2pm until Friday at 2pm. In addition, I recommended that he fast daily from after dinner until noon the next day.

So, here is what happened. A PET scan was taken at the 6 week mark. The tumors had shrunk "significantly" (30 -50%). The oncologist was stunned (said they never see that kind of result), the patient was happy (doh!), and I was inspired to write about it in this blog. Now, I can't say for certain that it was the fasting that had the biggest part in the response. But it is a potentially powerful tool that is non-toxic, inexpensive, "easy" to do and mimics our natural prehistoric seasonal cycle of times of plenty (building cells) and times of famine (breaking down cells). Sounds uniquely naturopathic to me and it could save many lives. That’s why I am encouraging all of you to treat patients with cancer and to use this treatment to improve their outcomes of their chemotherapy. It could help to change lives.

Carnage of Symptoms

Photo by D'Arcy Norman via Flickr, used
under the Creative Commons License.

By Lise Alschuler, ND, FABNO
AANP Past-President (2008-2009)

If you were to walk into my study, you might think that an enormous massacre had taken place. A duck lays across a chair, its beak dangling over the edge of the seat. Below the duck, a monkey can be found sprawled on its back with a rooster, a look of alarm on its face, oddly resting its head on the monkey’s belly. Across the room, there is a red bird unceremoniously toppled to its side. A few feet away lies a giraffe, long legs tangled helplessly. And then, towards the back of the room sprawls the hunter, exhausted after this convincing display of prowess, legs and ears all comfortably splayed on the ground.

Despite the fact that the subjects of the scene of carnage are stuffed animals and the hunter is my dog, it is eerie nonetheless. As I look out on this scene, I think about how cute it is and enjoy a swelling feeling of pride in the playful delight of my dog. And yet, the scene really is rather horrific. As I continue to survey the landscape over the rim of my computer, I am struck by how much I can determine about how my dog has spent her time, just by looking at the display of critters. I can tell which ones she snuggled with, which ones she ignored and which ones she chewed on. I can imagine her making her way from one to another until she finally gave into the pull of happy exhaustion.

In many ways, the symptoms that our patients manifest, like these animals littering my study floor, are the end-results of various processes – processes linked together, perhaps by their own narrative, but often not. We often must draw upon our training and clinical experience in order to piece the symptoms together and to generate a pathway from one to another. Our sequence of events ends with the patient sitting before us and presents an explanation for their current state. And then, very much like I am about to pick up these animals and return them to their proper box, we physicians apply our therapies and attempt to remove each symptom from the landscape of the patient’s life. We often dig deep and have to do some major rearranging to get at the root of certain symptoms, but if we are persistent and attentive, we can successfully restore a more serene state of health in our patients.

This may seem like a silly analogy, but as I reflect on this, I find it oddly reassuring. Things are messy, sometimes the way they get messy is rather fun, tenderly sweet or perhaps not. The consequences can be distressing, perhaps even dangerous, but we are trained and capable of restoring order. And, unlike my dog and her toys, we can also empower patients with the tools that they need to effectively pick up after themselves.