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Dr. Susan Abookire, BSEE, MD, MPH, FACP, is an assistant professor at Harvard Medical School and a senior executive with two decades of experience leading healthcare organizations. She began her career as an electrical engineer in aviation systems. A graduate of Harvard, she trained at Brigham and Women’s Hospital, practises internal medicine and has taught nationally and internationally on patient safety, high reliability and systems design. Did we mention she’s also a trained forest therapy guide?
PaRx sat down with Dr. Abookire to learn more about her unique career path, the inspiring ways she’s incorporating nature therapy and prescriptions into her academic and clinical work, and her top tips for health-care professionals and patients on how to live and practise nature-connectedness.
I grew up in a middle-class Ohio suburb on Lake Erie. I didn’t grow up in a way where people went hiking—I didn’t have exposure to that—but I was simply drawn to nature. I always went down to the lake with my friends, and would sneak out of my house late at night back when people could do that, and I would be enthralled by the whipping winds and the trees. Sometimes it was rainy and cold. I felt so alive when I was there.
At 19 I moved to Seattle, Washington. I was in the middle of my college years and I discovered it was absolutely gorgeous, the mountains, lakes and ocean—and I discovered a sense of connection to place there I had never experienced. I felt like I was home. During those years I hiked with people who backpacked into the wilderness of the Olympic Peninsula and was so happy with that. I remember being on a ferry and somebody saying to me, “This is God’s country,” and I remember thinking, yeah, it was unspoiled, pristine beauty. That really rounded out my recognition of my own love of nature, being in a place where everybody valued it.
My childhood dream professionally was to do neural network modelling. I was fascinated by the brain and intended from a very early age to combine an engineering background with a medical one. So I became an aviation safety engineer and spent a good decade as a systems engineer.
I was still looking for a program where I could see patients and do brain research, so at some point moved to Boston to go to medical school, determined to find this dream. It’s too bad I don’t have more than one life to life, because I loved the west. But what I didn’t know during all those years as a girl growing up in the Midwest was that this field I was driven towards did not exist (laughs)—though now neural network modelling is just flying. So I had to reinvent myself, and I ended up fortunate enough to bring my love of systems design into health care.
To me these are all very related. A few years ago I started developing a curriculum to teach systems design to health-care executives. While I was doing the research I stumbled onto the concept of forest bathing. The minute I saw those words I immediately thought, “I want to do that. What is that?” So I decided to become a forest therapy guide.
I use nature as an exemplar in my curriculum, which comes from my intuitive understanding of systems and nature. Being in nature helps me experience the world and how it all comes back together in that bigger picture.
In one of my classes I used the example of murmuration in starlings, a symphony of birds flying in this one big beautiful pattern in the sky. I was trying to exhibit the point that there wasn’t a singular leader in that flock of birds. That whole principle of complex adaptive systems and the concept of emergence (where interactions between smaller entities give rise to larger entities with new properties of their own) is easier to see in nature.
That’s a really interesting question. No one’s ever asked me this question! I’m not sure that being a physician informs my approach to forest therapy, but the opposite is true: being a forest therapy guide informs my approach to being a physician.
The only way it might is when I am guiding a group, there is this feeling of holding the space of curiosity or liminality, of profound experiences. Perhaps being a physician has enabled me to do that in a way that feels very natural.
Guiding other physicians in a forest bathing experience is very special because you arrive at a place where you’re combining your history with each other, while being part of something greater and beautiful—an intrinsic part of a whole that doesn’t require the same kind of on-your-shoulders accountability that being a physician requires.
In forest bathing there are invitations to share what one is experiencing. The kinds of experiences shared by other physicians have a quality to them that I think is—it feels to me that it is unique. The quality is maybe a relief, of letting down.
Becoming a physician tends to teach us that the buck stops here, we’re accountable, we need to drive and determine the outcomes, be in charge. And I find that guiding physicians—the joyous relief of what they share comes from a deep immersion in a profession where control and directing things are the norm—but this is an escape.
When I was becoming a guide there was a period of my own development where I realized that I wasn’t in control of the experience that people had. At first if everyone came away saying, “That was amazing!” I patted myself on the back and said, I did a great job. But I really had to let go of the outcome of my participants and just trust the forest. “Trust the forest” is the term you hear in training. As a physician I thought, this is awesome, you lean on the forest to do the work.
I have a few irons in the fire right now.
The first one, a forest bathing experience, is embedded into an inpatient month at the Brigham (and Women’s Hospital) where all the internal medicine residents rotate through the Integrated Teaching Unit. It’s a highly intense clinical rotation with, for example, pancreatitis patients crashing, but the unique thing about the ITU is that it’s more team oriented, which is why I wanted to do it there. I’ve been working on making it happen all year. There’s intense pressure to teach more than there’s time to teach, so trying to get something into the curriculum can be a challenge—but we are starting officially on March 23rd!
Part of it is guided forest therapy, and we supplement that with other facilitated, more didactic teaching. My goal is simply to inspire in the residents an understanding of how the kinds of properties they see and experience in nature—properties of resilience and residence and reciprocity—how those characteristics could be applied in health care, either in the design of teams or even in the care of patients.
The second thing I’m doing in the ambulatory care block is a lecture on the health benefits of nature and how to prescribe it.
I also have developed a CME (continuing medical education) session about the benefits of nature that I’m hoping will be offered to all of the physicians in the state through the Massachusetts Medical Society. It includes a forest bathing experience—I’m going to guide the physicians first, then teach it. If I’m trying to impress upon someone the benefits of nature and how to prescribe it they need to experience it.
The fourth thing is that I’ve applied for a grant at the Brigham that’s focused on the entire department of medicine, over 1000 physicians. The first phase is guiding and offering a forest therapy experience to up to 300 faculty. The second phase is forest therapy for faculty that’s more focused on leadership and teamwork; I do that focus through the invitations.
I’m using the word leadership with a little L, not a capital L; as physicians we lead teams, we set the tone for how interactions with the patients and staff will go. Leadership doesn’t only mean being an executive. When you’re out in the forest you can’t really point to leadership—is this tree the leader of the group of trees? How does that work? As we develop our skills as leaders, some of the embodied authenticity and trust we experience in the forest can be translated into our own development as leaders. Ultimately we need to be true to ourselves and find the leader within us.
I would love to bring the same curriculum to leaders running health-care systems. I think it would be a phenomenal improvement in some ways. The hierarchical structure we place into our organizations is designed to promote siloes: the marketing department does this, and the finance department does that. Everyone has the great idea that it’s collaborative, but ultimately it gets into siloes. Then we end up having this hierarchical siloed structure expressing itself in the kind of care we can provide to patients—I believe that firmly. If executives could understand the complexity of the systems they’re in, and understand how to allow the complexity to breathe and to be resilient, then we would probably have much more healthy organizations.
One of the things I really think would help to shift the paradigms for people would be to experience forest bathing. The observations people make are so profound. I say, “I couldn’t teach that myself in a million years.” There’s no way I could bring someone to that observation if I tried.
I just go out whenever I can. I like to hike in the woods and I like to go sit in my sit spot. I’m a fly fisher, and I actually have a little camper. I leave it in Montana and I go there and camp and fish—I love to be near and in the rivers. But I didn’t go fly fishing this year because I didn’t go anywhere! I’m bursting at the seams to go this year, hopefully.
I’m really fortunate that I live in Boston on a pond. It’s part of the nature conservancy, so I can walk out my door to trees and a beautiful pond with ducks and geese. I’ve been doing that every day, walking one to three miles per day in my own tiny little world here.
The pandemic has definitely shrunk my world, but I have really appreciated the intimacy of knowing one place extremely well—knowing each tree and watching it change over the year, you know what I mean? When you’re younger you want to see new, new, new places, but now I really appreciate the familiarity.
If I was giving advice to an individual physician it would just be encouragement to take the time. It doesn’t take much time to prescribe. I have found that patients are somehow delighted when they get a nature prescription, and say, “Oh, this is cool!”
And you as a physician may not be able to exactly tie what you prescribed into their lower blood pressure, better control of diabetes, better sleep, better mental health. You may not always be able to connect the dots between what you prescribed and the anticipated benefits. That’s true of a lot of things; we don’t always get to connect the dots. But the benefits of nature are far-reaching, particularly in this era of COVID. People are cooped up, and they need the connection and wellbeing nature offers.
It doesn’t matter how small or close to home it is. Any time you feel the desire for a small break, or being uplifted—even if you just step out your back door and smell the night air, you don’t have to go far.
When you interact with the natural world, of which you are a part—even for 10 minutes, I’m a little wimp when it comes to the cold weather—you can bundle up, you can get an umbrella if it’s raining. Even if you just step out the door it’s worth taking that little tiny bit of effort to get yourself outdoors. You don’t need anything fancy like a wild forest.
Being in nature, and sharing this part of ourselves, is an important part of being physicians.
Check out the Harvard Health Blog for more of Dr. Abookire’s insights on nature, forest therapy and health.