Permission to heal: An expert explains why we all need to rediscover “the lost art of convalescence”

I power through and I never learn. My last maternity leave was four weeks long. When people ask when I went “back to work” after having metastatic cancer, I explain that I never left. And this past winter, when I got a steamroller case of COVID, I tried repeatedly and insistently to rally — in between urgent visits to the medical center for chest x-rays. Nine months later, I’m still feeling the effects. 

So naturally, like a hoarder who self-soothes watching Marie Kondo videos, I was immediately drawn to Scottish physician and author Gavin Francis’s new book from the title alone: “Recovery: The Lost Art of Convalescence.” Doesn’t that just say it all? Don’t the words “recovery” and “convalescence” shimmer in your imagination like mirages? 

As Francis, whose previous books include “Adventures in Human Being” and “Shapeshifters: A Journey Through the Changing Human Body,” explains, bodies dealing with injury and illness need the one thing our culture places far too little value on — time. He traces the historical roots of convalescence, shares his own humbling healthcare experiences, and offers the reassuring, authoritative advice that truly allowing ourselves to get better helps us to stay better. It is a small jewel of a book, eloquent and humane and sensible. Weeks after finishing it, its wisdom has stuck with me like few other pieces of writing have in a long time.

Francis spoke to me recently from his office in Edinburgh about the roots of our quick-fix approach to healing, why good doctors should be gardeners instead of mechanics, and how overcoming our resistance to real recuperation is a win-win for everybody.

This conversation has been lightly edited and condensed for clarity.

There’s a phrase I’m sure you’ve heard, that people are being pushed through the healthcare system “quicker and sicker.” I wonder, did we not learn anything from the pandemic? Did we not learn anything, as medical systems, as workers, as parents, as caregivers? We went through this crisis where the consequences of illness should be pretty clear. And I feel like we learned not a damn thing.

I would beg to disagree, actually, from my perspective. I can see a lot more tolerance and a lot more kindness towards people who are suffering or struggling after following some kind of significant illness, not just from COVID. 

COVID affected everybody in some way. Everybody knows somebody who had COVID badly, or has heard of somebody who is struggling with fatigue weeks or months later. I feel like there is a greater willingness in society and among our patients generally to concede that there is a place for having respect to the process of recovery. There’s a greater respect for the process itself, because it’s so much more current.

One of the few silver linings of COVID — because it has been a catastrophe generally — has been that there’s a greater societal awareness of post viral fatigue and a greater societal awareness of the need to make time for and respect convalescence.

Let’s talk about time, because we are at the mercy of capitalism. I see many of us struggling to bounce back as quickly as possible, to just be at 100% immediately. That distances us from the concept of convalescence, which is a process. Talk to me about why we have to understand that illness and wellness are a continuum.

My impression as a family physician is that something major shifted in the mentality of humanity, certainly in the West, roundabout the ’60s, early ’70s. During the ’50s and ’60s, we had this explosion of brilliantly effective drugs. We started to have steroids, we started to have the wide availability of antibiotics, we started to have effective chemotherapies, we started to have drugs which were really effective in various mental health issues.

And so the old-fashioned notions of convalescence — of making time and space, and having somewhere clean and well-aired with a view of something green — that were time honored and self-explanatory to the Victorians, we just started to throw all that out and say, “No, all you need is the right prescription. Clearly, if you can just get the right drug, you’ll be fine.” That started to infect medicine and infect people’s expectations of medicine. 

The truth is that the drugs are wonderful. I wouldn’t like to go back to practicing medicine in a day before antibiotics, before steroids, before effective antipsychotics, for example. At the same time, there is a huge number of medical problems that we can’t properly cure definitively, that there isn’t a really effective prescription for. And these much older perspectives about giving time and respect and some self-compassion have to me being really neglected. 

Now it’s been 70 years since the early ’50s, when this drug explosion began. We can see that there are limits to the power of this scientific medicine approach. There are lots and lots of different illnesses and problems that I deal with as a doctor that don’t have a quick fix solution. And I really want us to move away from this idea of health as being some sort of golden zenith to which we all aspire to health actually being a balance between extremes, which will be different for everybody depending on their own personal circumstances.

I would like if this book could help people to reframe health as a balance, and something that’s achievable for everybody. Even if you have a condition which is ultimately incurable, there’s still health. It just means something different for you, then. Let’s let’s adopt some of those older principles and perspectives and not discard them just because we have a few really effective drugs these days.

Tell me what some of these principles are, because we do in the West think, “I’m going to take a course of antibiotics, and then I’m going to be right back out there at top of my game, better than ever.” What actually, should we be thinking about when we are recovering?

There’s various principles, and a conversation with a patient would elicit which ones are most important to emphasize. But I suppose the first really major principle is to make time and space and to respect the process of convalescence. Because if you don’t, you’ll do exactly what you just described and is far too common nowadays, people rushing back into work burning themselves out. If we don’t accept the fact that we’re operating below par, we’ll just push ourselves too hard.

What I see often in my patients that try and go back to work too quickly after a really challenging bout of COVID is that the just the end up retracting the recovery by quite a long way. If people were able to give themselves the permission to take longer to recover, I think that would help them. Respecting the process and giving yourself permission is connected to the idea of self-compassion. 

Another principle is travel. I’ve got a chapter in the book about travel, just because it’s a really time-honored approach, from the old Swiss sanatoria right all the way back through the medieval Christian tradition of pilgrimage. Many other faiths as well have a tradition of pilgrimage when you’re feeling unwell or you’re ill. Even if you don’t place a great deal of stock in the concept of faith healing itself, simply the journey to somewhere else into a new perspective, taking yourself away from the circumstances of home, from the other obligations of home which might be stressing you, can be profoundly helpful. But I’m very aware that it’s only really particularly privileged groups are able to do that. 

Another of the main principles that I try and encourage my own patients is to think about healing as a natural process, and think about nature. All our most effective drugs are derived from plants, and our bodies are part of the natural world. Healing is about a balance between extremes, rather than some sort of ultimate end in itself.

I often try and encourage my patients and my medical students to think of doctors and nurses as far more like gardeners than they are like mechanics. We don’t really replace broken parts. What we do is we try and create the environment for a natural process to flourish, which is much more of a gardening perspective than it is an engineering perspective. So that’s the third major principle, thinking about and involving yourself in the natural world in some way, even if that’s just having a window box if you can’t get out. If you can get out, think about getting fresh every day in some kind of natural space. 

Another principle is that there’s far more to treatment than just drugs and prescriptions. There are so many treatments. You know, sometimes the most effective treatment for somebody with chronic lung disease is to join a choir, for example. Some of the most transformative treatments I’ve seen people suffering all sorts of different problems for is simply getting a pet. Particularly a dog, because of the companionship and the love and the exercise that we then have to get. There’s a whole load of different kinds of engagements that you can do with your body and your life, which will help you and will be far more effective than just trying a different regime of pills. 

This idea of the recovery is not about sitting still and doing nothing. Explain to me what that difference is and what rest really means, opposed to the old-fashioned “rest cure.”

For me, rest is about learning a new language of the body and listening to it very, very carefully when your body’s telling you that you need to stop and take a bit of time. But it’s also being conscious of not letting your horizons shrink in too far. You alluded there to the famous Charlotte Perkins Gilman story whereby a woman is told basically to rest, but really it’s a way of shutting her up and silencing her. I think in the 19th and early 20th century, certainly women were pushed into this role far more often by this kind of perspective on medicine. 

Even today in the 21st century, we can see gendered approaches to convalescence. Whoever I’m trying to come up with a collaborative convalescence plan with, I would encourage to adequately rest when their body tells them to rest, but also to gently push at the edges of what’s possible and set achievable goals. The old-fashioned rest cures threatened to make your horizons completely shrink. People would get very anxious when they headed out; they would put on a lot of weight; they would lose all the social connections that sustain our lives. There were lots and lots of problems with this approach to the rest cure. When the rest cure was developed in the 19th century, they also developed at the same time this idea of the West cure, which only men were recommended, which was about going off and working on a ranch or something like that.

We do still see some evidence of that “rest cure” in how we care for the elderly, because it’s easier on the caregiving system for them to be quiet, and inactive. 

We have to find a way in our society to reframe the increasing age and frailty of our communities as a great success. People are living longer right now than they’ve ever lived in the history of humanity. If that is not a cause for celebration, then what is? How can we reframe this instead of being seen as a burden and a problem, as the corollary of some great, magnificent success? That’s really what it is. I’m delighted now that the worldwide life expectancy is now into the seventies. That’s amazing, it was down in the fifties at the start of the 20th century. We’ve got a lot to celebrate.

We’re not islands, we all exist within broken systems that do not facilitate the kind of healing that you’re talking about. We work in broken systems, where asking for time off is frowned on. And it feels like our systems are becoming less and less accommodating. What do we do about that, when we are all going to need these resources? We all are going to need time to heal.

Because it’s funded in such a radically different way, a lot of the problems with the U.K. health system can be ultimately traced back to neglect from politicians and from managers who’ve cut it and cut and cut it and cut it. Because we have one NHS which is all funded through taxpayers and contributions, for many years now they’ve been taking money out of the capital budgets just to keep the frontline services going. So we have a system now that’s really on the edge of collapse. 

In the U.S., I know you’ve got very different systems, many tiers depending on your levels of insurance cover and many different kinds of organizations involved from top to bottom. 

I love the sentiment of the founder of the U.K.’s NHS, a Welsh politician who came from a mining community. He really strongly believed that ultimately, we should judge a society by how they treat their sickest and most vulnerable people. Have we become a rich, powerful, technologically advanced civilization? I think we have. What is the point of that if we can’t use those riches, that power, that technology, in order to help the people of those communities that are most vulnerable? 

The vast vast majority of illnesses, people do not bring upon themselves. They happen to them. They are misfortune, they are bad luck. And if we can’t use all the power and the resources of these very wealthy 21st century societies in order to help people that are the victims of this kind of bad luck, then I think we’ve got our priorities wrong. 

I would really like to see much more unbiased reporting about health. I think journalism has a really amazing part to play in a functioning democracy in terms of properly laying out the facts to the electorate. I would really like to see a reframing of our aging and frail population as a success. And I would like to see some very frank, honest examinations of the costs involved and how they could be paid for in different ways. How the U.S. moves towards a system with a more compassionate approach to people who are in a low income, I don’t really know.

Some people would argue that in the U.K., one of the reasons the NHS is struggling is because ultimately, that postwar consensus where people felt very strongly that we’re all in together is starting to break up. Ultimately, if people who are wealthy are less willing to subsidize the healthcare of people who are poor, the system breaks.

Perhaps that’s, deep down, the problem. As we’ve moved further and further from the postwar decades, the wealthy are less willing to subsidize the care or the education of the poor. But I would really like to see this reframed in a way where you could say, “Look at the huge benefits for the rich of having a society in which the poor are well cared for, and anybody can end up moving both ways up and down the ladder.” You might be wealthy this year, but you might not be next year.

It is in everybody’s interests to have a healthy society that uses its power and its technology and its resources to look after most vulnerable. It’s in everybody’s interests, top and bottom of the ladder. 

One of the arguments that you’re making in this book is that this is not just about benevolence. It’s about making a good bet on ourselves and our society.

Yes, because illnesses and misfortune can happen to anyone, and how we look after that is ultimately how we’re looking after ourselves, because any of us could end up in that situation. My argument is that if you learn this new language of the body and learn how to to be kind to yourself and to convalesce properly, you will convalesce much better. The word convalescence means grow in strength, so you will emerge stronger from the experience.

A bitter pill to swallow is the fact we’re all going to get sick, we’re all going to get injured. You talk about your own sicknesses and injuries in this book and how they were managed. So what do we want for ourselves when that moment comes?

How compassionate a society do we want to ultimately build? Did you hear that your chances of staying out of a nursing home as you get older are directly proportionally related to how many daughters you have? One of the things I tried to touch on in the book is the pressures on carers, which can be extraordinary. 

The greatest thing this book does is to affirm, you have permission to be sick, and you have permission to heal. That’s challenging for a lot of us to hear and accept. For the person who is struggling today, who got those telltale lines on their COVID test or who just broke their arm, what do you want them to know about dealing with their condition right now?

Just what you said so concisely. I would like them to know that they have permission to be ill, that it’s not their fault. It’s a misfortune, and that there are time honored ways in which you can give yourself the best chance of recovering and to look into those. To try to find a clinician or carer that you can trust. To allow yourself to rest but gently push at the edges of what’s possible. To not compare yourself to others because everyone’s different. To set small, achievable goals and work towards them steadily, and not get too downhearted when you fall backwards.