The Integration of a Hospitalist

“The doctor of the future will give no medicine, but will interest his patient in the care of the human frame, in diet and in the cause and prevention of disease.”

Thomas Edison, 1903

I knew I’d become a doctor when the first child died in my arms. In 1991, I took a sabbatical year from college to become a missionary in the Peruvian Andes. In the 1980–1990s, Peru was ravaged by a Maoist terrorist group called “The Shining Path.” Their goal was to burn the country to the ground and begin their version of “civilization” from the ashes. The killings produced many orphans without recourse. Medical care access was poor and often substituted by shamans. At the time, I thought I’d become a nun and work with the poor. As I worked with the children, one 5-year-old with large brown eyes, thick lashes, and ruddy cheeks became violently ill with fevers, he looked ashen and stiff. I knew there was something terribly wrong that required immediate action, but the doctor I called kept repeating “watch him, give him Tylenol, he’ll be fine.” He could’nt be bothered to come in and examine the child. Over the next 24 hours, I watched powerlessly as this child faded before my eyes, never seen by the physician. Afterward, it was my job to contact the widowed mother. She was too poor to bury her son, so we bought him a plain pine casket and buried him in a small hole in the ground. At that moment, I knew I’d work as hard as necessary, but I would never again lack the knowledge to help someone at death’s door. After entering medical school, I learned his symptoms were textbook meningitis.

My background is an odd mix of Italian on my mother’s side and Native-American-Chinese on my father’s side. At 33 years, after decades of suffering from a mystery illness with brain fog and fatigue, I was diagnosed with Celiac disease. One simple dietary change gave me my brain and my life back. Thus, my Italian genes gave me Celiac disease and my interest in the power of nutrition, and my Native-American-Chinese genes gave me an interest in Eastern Medicine and natural remedies.

After internal medicine training, I became a Hospitalist at UCSF, taught medicine in the wards, and co-managed patients in the bone marrow transplant service. While there, I learned of a highly effective treatment called ATRA-A for a deadly form of leukemia, which was based on the ancient natural remedy Arsenic, and Retinoic acid. Acute Promyelocytic Leukemia (APML) was once known to be the most fatal of the leukemias. It affects young adults in their prime, and they often hemorrhage to death as their platelets rapidly plummet to zero. Arsenic, a natural element that is considered toxic in high doses, has been used since the 18th century in both eastern and western medicine for a number of ailments including rheumatism, psoriasis, and even syphilis. A 1998 landmark Chinese study ¹ found that combining arsenic with trans-retinoic acid (ATRA-A) proved superior to all conventional chemotherapy for APML. By the time I served in the transplant service over a decade later, APML was transformed seemingly overnight from the most fatal to the most “curable” leukemia, a word almost never used in the oncology world. ² My interest in natural medicines was renewed.

Natural medicines are not the diametric opposite of drug therapies. We owe many drugs like aspirin, digoxin, and anthracyclines to natural substances. Therefore, any suspicion or animosity toward natural medicines is mostly due to a lack of knowledge about their functions. At a minimum, they can enhance the effectiveness of drug therapy, or help to reduce side effects. An understanding of the biochemistry of natural medicines can expand and improve our treatment options, as in APML.

Perhaps patients sense my inner nun, as they seem compelled to confess their life stories to me. As a Hospitalist, I only had 10 minutes to spend at the bedside, and the time felt inadequate. I hated cutting patients off to skirt away to discharge rounds but promised I would return in the afternoon to hear what they had to say. I was often the last doctor to sign out at night. If there were an award for “least efficient doctor of the wards” I could’ve easily won that distinction. When I learned that UCSF offered a fellowship in Integrative Medicine, a holistic field that incorporates natural remedies and lifestyle changes, I instantly applied and have been faculty there since.

As an integrative specialist, I now have 60 minutes to spend with my patients, and I can finally hear their story. I invite patients to start from the beginning, even if it means starting with their childhood. And then I shut up and listen. Their words begin to flow out in a rush like a dam that has burst open. Tears often flow as well. Over time, the words slow down until they come to a halt, and the patient ends in a hush, looking up guiltily for having taken so much of my time. Only then do I ask my clarifying questions. The average time for a physician to interrupt a patient is 17 seconds. My patients usually finish their entire life’s story within 20–30 minutes, which gives me plenty of time for the rest of my consult.

My goal with patients is to give them greater control over their health. I treat patients with cancer, fibromyalgia, IBS, chronic fatigue, autoimmunity, and hypersensitivity syndromes. They are often the “rejects” of our medical system. They have been swallowed up by the monstrous medical machine, chewed up by the sharp teeth of several specialists, and spat out as not having anything worth their expertise. By the time I see them, there is doctor trauma as well. I recommend a plant-based, antioxidant-rich, anti-inflammatory diet. I recommend supplements to cover any nutritional gaps in the diet, and to help with sleep, stress, fatigue, and other symptoms. I teach them breath techniques and stress reduction. Patients tell me, often tearfully, it’s the first time they feel heard, and the first time they feel hopeful in years.

My integrative oncology mentor Donald Abrams states that Western medicine focuses on expelling evil while integrative medicine focuses on supporting good. He teaches patients that cancer is like a weed, and your body is the soil. You want to make the soil as inhospitable as possible to the weed and tend to the garden to produce health. In my opinion, focusing only on disease misses half of the opportunities to create health. Western medicine takes a catastrophic, “find it, fix it” approach, while integrative medicine seeks to optimize health in every body. I give my patients a lot of information, I educate them, bring out charts, handouts, and pictures to engage their intellect. I show them books and often recommend one for them to read. And then I make some difficult asks—nothing short of a complete lifestyle overhaul. I am amazed at the change that follows. Last week, I had a follow up from a patient with numerous health issues, including migraines, obesity and sugar addiction. When I asked her to give up all sugar and to clean up her diet, I did not think that I would ever see her again. Three months, later she presented to report her progress. She cut out all sugar, endured a difficult chemical withdrawal, and joined Food Addicts Anonymous to support her recovery. She doesn’t miss sugar anymore. She started yoga, meditation, and breathwork. Her headaches and fatigue have subsided. There is power in listening first, asking last.

Patients want to hear from doctors what they should eat. Regrettably, many doctors don’t know, or don’t think it’ll make a difference, perhaps because they are not sufficiently trained. It’s unfortunate that nutrition is not emphasized in medical education. Patients want a doctor that has one foot in both worlds, that can recommend drugs but also lifestyle modifications, and natural treatment options if available.

My inner nun desires to take care of a patient’s mind and spirit, in addition to mending their bodies. I ask all of my patients what gives them strength, what gives them joy, if they have a meditative practice, or if they consider themselves spiritual. I end my interview with these questions. Sometimes this question completely changes the mood in the room, and I see patients visibly brighten as they speak of the activities that bring them joy, the communities and people that give them strength, the ways they connect to a higher power.

As a doctor, I could have easily diagnosed and hopefully saved the ruddy-cheeked Peruvian child. Yet even when a disease is incurable, it can be optimally managed to render quality of life. In the face of fatal illness, there is still the opportunity to improve symptoms, encourage patients to connect to their sources of strength, and seek joy in each remaining day of life. That is good medicine too.

ORCID iD

Carla Pia Kuon https://orcid.org/0000-0003-0723-3803