hospices in the Middle Ages emphasized charity and hospitality. Monasteries ministering to the sick and the insane incorporated an arcaded courtyard where they could find the some shelter, sun, or shade in a human-scale, enclosed setting. In the 18th to the 19th century, the increased need for hygiene during treatment led to the acceptable uses of "sanitary reforms" such as cross-ventilation, access to sunlight and gardens. The 20th century ushered in the discovery of germ theory, advances in medical science theories, the biomedical model, and improved technology in the medical sciences. The biomedical model, derived from Louis Pasteur's germ theory of disease, became the predominant conceptual model used by physicians in diagnosing disease. According to the biomedical model, health constitutes the freedom from disease, pain, or defect, thus making the normal human condition "healthy". The biomedical model of health focuses solely on biological factors, and excludes psychological, environmental, and social influences. This narrow focus rationalized and streamlined not only medical diagnosis but also medical processes. Infection reduction, cost effectiveness and operational efficiency became the norm in the design of medical facilities. "Pressure from insurance companies to minimize hospital stays have largely worked against the provision of actual usable gardens in new or refurbished medical complexes.". At this time, gardens were no longer perceived as settings that could contribute to the restoration of the patient's health. Nature and gardens were relegated to the beautification of entrances; small "pocket" areas were used as focal points; sidewalks and even parking areas. In response to the reductionistic scope of the biomedical model, several medical researchers and scientists such as George Engel strongly believed that "…a medical model must also take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physical role and the health care system. This requires a biopsychosocial model." Since then, the impact of the physical environment on the well-being and health of the patient has received extensive academic research and attention. In 1984, Roger Ulrich conducted a ground-breaking study comparing the positive effect of views of natural scenery, i.e., trees, on the recovery of patients from surgery to patients in similar conditions who were exposed to a view of a brick wall. He was the first to use the standards of modern medical research—strict experimental controls and quantified health outcomes—to demonstrate