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Studying Abroad in the USA
Foot prints of life. Anecdotes from studying abroad:

  There is rise and fall in life. Some memories will never be erased but may in turn enlighten your path.

  I was offered the opportunity to study abroad on a government fund during my second year of being an attending physician. I recommended myself, presented my resume, and chose 2 famous hospitals in the United States of America – Massachusetts General Hospital of Harvard Medical School and Mayo Clinic. Even though there was still an opening at Mayo Clinic and I could start there immediately while Harvard required a year of waiting, I chose the latter because I wanted to go to what I consider the best school and hospital.

  April of 1983, I flew from Taipei to Los Angeles via Tokyo where I switched to a domestic flight to Boston. At that time I was the first Taiwanese to receive post-doctoral training for researchers at the Pulmonology Department of MGH. Before me there was a Prof. Zhu Yuan-jue form Beijing Union Medical College Hospital who had just completed a short course of training and had returned to China.

  Dr. Cheng Ming Chi, a neurologist, a senior colleague serving at Tri-Service General Hospital, was already at Harvard’s Brigam Women Hospital at the time. He came to pick me up. But I arrived during holidays, so we weren’t able to arrange my housing. That very afternoon Dr. Kao KP, another physician from Taipei Veterans General Hospital that was training at MGH, dropped by. The three of us watched a NBA game together but I didn’t get to enjoy the match as I was preoccupied with my housing.

  The next day, Dr. Cheng suggested that I first settle down at a hotel, so I chose the YMCA Hostel which was the cheapest option available. There was only a small bed in the room. Common bathroom and TV. It was after checking in that I realized that all the guests were dark skinned. I realized I was actually the lightest of them all in the shower room. All of these tall guys with really white teeth scared me in the beginning.

  Being in the United States is when I officially came in contact with dark skinned people. The only image of dark skinned people that I had from the start came from stereotypes seen in movies, but after a while of hanging out with them, I realized they were really nice-better than some white people dressed in suites who deemed themselves superior to everyone else.

  My stay at YMCA was for approximately 2 weeks. I looked for a place to lease on the newspaper and called to try and set an appointment daily. Unfortunately, the owners that I called would always end up hanging up on me before I was done speaking. I assume it was because my English wasn’t fluent that they had difficulty understanding me, or maybe it was because they knew I was not an American that they didn’t want to rent their properties to me. I ended up looking up the addresses and presented myself directly at their door steps. There was one late snowing night when I got lost in a house hunt. Even though I was wearing adequate clothing, my hands and feet were still freezing from the cold. I needed to find a store with a heater so that I could continue walking. I walked into the ghetto, saw drunks spread across the street, groups of people shouting taunts, graffiti sprayed all over the walls, broken glasses on the floor, and some cars with busted windows that terrified me.

  My first week in the United States alone was the most difficult. The language barrier, lack of adjustment, no friends to lend me a hand, and no suitable housing made me homesick. I wanted to go home, but, my study was funded and I was the first to be accepted at MGH. Not only could I not be discouraged, I had to become one of the best. So I had to overcome all these obstacles no matter what. I forced myself to watch TV, chat with colleagues if I got the chance, and study the language. The concept of tourism was still underdeveloped in Taiwan during that period of time. There was only business inspection. There was no internet, information of each country wasn’t readily available as it is now, so everything must be done one step at a time and only when you encountered it. For example: I opened a bank account but I didn’t know how to use an ATM card, so I had to ask for instructions. If I wanted to use the metro, I also had to ask and figure out how to read the map and then decide which line to take and how to buy a ticket.

  Eating was another lesson to learn. The hospital had its own restaurant. I had to learn how to get in line, see how other people grabbed a plate and silverware, and how they ordered food. I also had to pay attention to the name of the food and also how it looked. Guessing was not an option. I had to make sure it suited my taste because the food was not cheap and even though it looked good it didn’t necessarily taste good. Part of the funding only provided me with 500 USD per month (the exchange rate was 40 NTD for 1 USD), so I was on a rather tight budget. In the beginning I thought American food was not at all tasty. It was either salad or boiled vegetables. Fish was rarely fried but stir-fried or steamed. There wasn’t any soy sauce or special spices and seasonings. If I really needed to add some flavor to my food I had to either add salt or A1 sauce or ketchup. Supermarket didn’t exist in Taiwan. There were only traditional markets which were rather messy and filled with a mixture of different odors. It was in the US when I first walked into a supermarket, spacious with goods categorized and stacked up neatly on shelves. Different varieties of apples were stacked up neatly as well. All this impressed me. Apples were rather expensive back home since they were imported and each one cost 50 NTD or more, so back then getting 1 slice was more than enough. By contrast, in the US apples were big and cheap. I thought I was able to have one apple a day as breakfast, but, I was done by the end of one week. I couldn’t stand eating apples anymore. It even took me a couple of years after returning to Taiwan to begin eating apples again.

  Fast-food was found everywhere in the US. Fast and cheap. Like McDonald’s, pizzas, muffins, and donuts. These were the first American food that I got used to.

  It still snowed during April in Boston and the air was dry. I only knew that I should bring appropriate clothing but I didn’t expect that the dryness could cause my lips to chap and skin to itch. My American colleague suggested that I buy chap stick and lotion. On my first day off, there was a bit of a drizzling outside, and I took the metro and went to pick up things like an umbrella, socks, a chap stick, lotion, and other daily products. After I seated myself on the metro on my way home, a dark skinned man who had just gotten off came back and told me that the umbrella was his and he wanted me to return it. I refused, explaining that I had just bought it. The young man immediately called the police, who asked me for my receipt which I didn’t have. The police requested for my ID and left after seeing my hospital issued ID, but the dark skinned man was still spattering foul language from outside the car. This showed me that Americans value a person’s credibility. They believe that a physician who works at one of the finest and prestigious hospitals would not commit theft. With this incident I learned the importance of conserving all my receipts. It also made me feel that being a foreigner, you didn’t have a firm base and insecurity would follow you around. Finally towards the end of my training, my performance was on the top of the line and the hospital wanted me to stay permanently, but I decided to return because my country had invested in me and it was my duty to return and contribute. Even though the Ministry of Defense also got in contact with me stating that they would assist me if any difficulty presented itself, I still refused as I was determined to return. Till this day I still despise those who take advantage of the opportunity to go abroad and reside there illegally in the hope that someday they will become an American citizen.

  Two weeks after my arrival in the US, I met a Mr. Situ from Hong Kong. He offered to rent me a loft with only a bed and a desk for 100 USD monthly. This loft was actually an unapproved construction and wasn’t even tall enough for me to stand straight in. Common shower and toilet. Since I couldn’t find anything better and YMCA charged 30 USD per day which stacked up to something pretty significant in a month, I accepted and moved in to Mr. Situ’s house. At least I got to have my own space.

  There wasn’t a kitchen but there was a basement that had an outlet for me to plug in a cooker (kind of like crock-pot) so I could cook rice and braise food. So I started visiting Chinatown to buy ingredients and soy sauce, pork, and eggs. I would braise these once a week then cook rice or noodles. That was my dinner. At least it suited me better. Breakfast for me was muffin or donuts and unlimited coffee offered at the hospital. Speaking of coffee, I picked up this habit after going to the US. Coffee was not popular in Taiwan back then and there weren’t as many selections as there is now like instant, cans, Americano, etc. Today I need a cup of coffee and a cup of tea in the morning to wake up.

  My second day in the US, I reported to Chief of the Department Dr. Homajon Kazemi. By looking at his name I knew he wasn’t native. He is Iranian and studied medicine at London before he went to Harvard. He was also a fellow classmate of Johon B. West, famous in the world of respiratory physiology. He assigned me the role of a nonmedical post-doctoral researcher. At first he took me to the animal room to pick up a dog and proceed to the animal lab. First I had to shave the dog’s leg, inject anesthesia into its vein, insert a central venous catheter, add more anesthesia, then insert a cardiac catheter into the pulmonary arteries, measure the cardiac output and pulmonary artery pressure, heart rate, blood pressure, and other hemodynamic values. Then I went on to inject radioactive, stable isotope labeled amino acids into the vein to then obtain a brain tissue after 4 hours to analyze the levels of the radioactive isotopes to predict the materials that may be transmitted through respiration.

  After a month, I was in charge of leading a dog from the animal room to the animal lab daily, anesthetizing it, and watching it until the cycle completed. Then the German-American would ask me to take all the tissues that contained radioactive components and get the levels measured. I felt like I might not be able to learn much and I was more like a servant being directed to do labor. So I gathered all my courage and asked to speak to the chief hoping to give myself a shot at something better. Even though my English was not very good in the beginning, after hard work and practice, I was more capable of communicating now. So I told the chief that I was here to see clinical trials and learn how to research and how to write and publish articles with the expectation that when I returned to my country I could perform independent research. Dr. Kazemi understood me but perhaps he doubts my ability or any Taiwanese’s ability as a matter of fact, so he suggested that I propose a research plan and he’d decide thereafter. I was really happy at this point. I had been in the library looking up articles for about a week and thought about the possibility of devising a new theory or even discovering something new. Eventually I came up with using hypoxia or increasing CO2 levels to stimulate respiration and investigating any changes in neurotransmission that might occur in the central nervous system, which might enable me to hypothesize the relationship between nerve transduction and respiratory control. The idea seemed feasible, so I proposed this to the chief and Dr. Kazemi approved, so I started my own research.

  I was very active and dedicated to performing this experiment. If I had time I would go watch clinical practice. I saw how they did bronchoscopy. The resources and devices were very new and came in a complete set. The newer X-ray equipment didn’t require the patient to flip around in bed because the C-arm of the X-ray equipment could rotate and the image resolution was quite high. You could see with more precision the clamp of the biopsied tissue or villi of the brush cells. At the same time they had an anesthesiologist performing general anesthesia with music in the background to help the patient relax. However, I felt they weren’t as skilled. Maybe Taiwanese people were more adroit perhaps. I had performed over thousands of bronchoscopy in Taiwan, so I had more experiences to fall back on.

  At around 7:30 in the morning the attending physician would visit the ward. Clinical researchers of the Pulmonology Department would first report medical history of newly admitted patients, then everyone proceeded to look at any available imaging at the Imaging Department and discussed with the attending physician on call, and lastly went visit all the hospitalized patients. Their strongest quality was that their knowledge was vastly expanded. They could finish reading related articles quickly, and immediately analyze and determine while eliminating what was not possible and finally verifying what might be the possible cause and then suggesting what other diagnostic tools could be helpful in making a definite diagnosis and assigning the patient his appropriate treatment regimen. Their professionalism and the ability to analyze and their motivation to study related articles were something worthy of our attention. Every single one of their attending physicians was specialized in what they did and had published articles, therefore any one of the students that were taught by what I would like to call a Master became a subject of interest for all other hospitals.

  In the ICU of Pulmonology, a resident physician would first report the hemodynamic values like blood pressure, heart rate, pO2 or PaO2, PaCO2, respiratory rate, pH, food and liquid intake with urinary output, and orientation, to decide whether the patient was stable or was improving. Then he reported about other organs and associated values to see if there was any change. The pathologist and intensive care control team, respiratory therapist, pharmacist, nutritionist, physiotherapist, and so forth would provide their suggestions and opinions along with the opinion of the chief resident. Lastly they all gathered with the attending physician to evaluate the patient together and make a final decision.

  Here I learned that in clinical studies you must have all the appropriate equipment and work as a team where each and every one member has their own function in providing health care whether it is to have a strict control over infection, intubate the patient, use ventilators, venous injection, venous or cardiac catheter, nasogastric tube, and urinary catheter. If any of this may cause discomfort in the patient, then anesthesia performed by an anesthesiologist is warranted to spare the patient suffering. I once was the Director of the Association of Critical Care Medicine and felt that in Taiwan we lacked resources on planning a budget for investment in a team and system for 24 hour vigilance, equipment, computer imaging, and infection control. Under the terms of payment devised by the National Insurance, hospitals lost money through ICU for critical care so they were not likely to invest. The condition of a critical patient may change in any second so it requires an immediate action coursed by a physician. But due to the low payment terms of the National Insurance, not only is the quality of life for the attending physicians low, but it is also a job that can provoke medical dispute so readily that a lot of physicians are not willing to go down this road. Pulmonology Department, other than providing clinical care for in-patients, holds a lot of academic meetings like a weekly clinical topic discussion where attending physicians take turns or invite specialists to give a lecture. These contributions to clinical science are not something that can be calculated with the terms of National Insurance.

  I still think about events that occurred in MGH after my return. Besides being impressed by these Master physicians, I remind myself constantly that there are sacrifices that should be made so I may see over 100 outpatients and don’t eat lunch or go to the bathroom. I ask my team to absorb new knowledge and gather patient information for clinical research. Every week a researcher will report results from the research done in pulmonology and we discuss and propose ideas to improve the module. There is also a reading report every week where a senior resident physician will choose an article and comment on the positive and negative qualities of said article,and then the attending physician and other researchers discuss about it and list out a new possible direction for further research. This also helps me learn how to read a vast variety of articles and come up with new and unique hypothesis for scientific research.

  The clinical death case symposium of the Internal Medicine Department of MGH is even more interesting. They invite clinical specialists to discuss the medical record and analyze all possible causes, conclude a final possible diagnosis, where a Pathology specialist announces the report and explains the underlying pathophysiology. This is a classic move and should be used as reference for any clinical teaching of the world. All of these discussions are published in the renowned New England Journal of medicine. A lot of medical centers use these articles to train the diagnostic skills of clinical practitioners.

  It was after my arrival in the US that I found out MGH was actually older than Harvard Medical School. It is also the first hospital in the US to use ether to anesthetize a patient as demonstration to other hospitals. Until today they preserve this section. The entire hospital is an architecture of combination of new and old buildings. The underground passages are like a maze. It is a great way to conserve history and also demonstrate the beauty of the modern world.

  There is a beautiful green field outside of MGH that is suitable for people to lie on for a break or lunch. The hospital’s interior decoration is also artistic with famous paintings hanging on the wall. It does not give off the cold feeling most hospitals do. Unlike Taiwanese hospitals that consist of a building with spacious front, MGH interior is divided into sections by departments with warm lighting giving off a warm feeling. You may see visitors who pay to come visit the hospital and they even have a tour guide, so it is easy to see that MGH does have quite a reputation.

  For the next year, during my independent research, I used different levels of hypoxia to stimulate and obtain tissue samples to observe amino acidic neurotransmitter changes and discovered that glutamic acid increased while GABA decreased. This suggested that these 2 components might be linked to respiratory control. I presented this result to the director and he was pleased. He asked me how I was going to prove the link and I told him that hypoxic stimulation was made possible by 2 hypoxic chemoreceptors, so destruction or interruption of these might do. He agreed with me and encouraged me to go on. This meant that Dr. Kazemi went from doubt to approval of my abilities.

  I continued performing animal experiments, but owing to the presence of muscles and big vessels found in a dog’s neck, I couldn’t find a deep nerve unless I cut through the muscles to avoid major vessels. This was a challenge for an internist. I reported back to the director and asked him if he could guide me on how to perform such a task. Dr. Kazemi hadn’t done any experiment in a laboratory for over 20 years but he was willing to come in and teach me how to destroy the hypoxic chemoreceptors. All there was to it was peeling off the nerve plexus found on the outer layer of the aortic body (found on the aortic arch) and the carotid body (found on the carotid artery), then providing a hypoxic status (switching oxygen to nitrogen) and observing if this hypoxic stimulus could completely truncate the response by increase of respiratory rate. If respiratory rate did not change, then that meant the chemoreceptors were completely destroyed. Ever since Dr. Kazemi personally helped me, everyone in the department approached me in a friendlier way. The research assistant who never offered to help me in the past now helped me prepare animals and calibrate all recording equipment. All I could do was to thank them because I still had to reply on myself so working independently after returning home wouldn’t be a problem. I was deeply convinced that one must be independent and show what one is capable of when opportunities present themselves since it is the only way for others to see why you are different and pay you respect. Education is spoon-fed in Taiwan. Students don’t dare to ask questions. However, I believe education should be a two way street. Basic knowledge can be handed down but anything that has room for discussion should be left for the student to think and research on for an open discussion to be held at a later point. This way you can train his independent thinking and ability to solve a problem.

  Three months later I concluded my experiment and wrote an article published in the renowned Journal of Applied Physiology. Director Kazemi appreciated my work and asked me if I could continue the next step of the research which was proving if Glutamic acid and GABA really played a role in influencing respiration. I told him sincerely that I could only continue for 3 more months and then I must return to Taiwan. I might not be able to follow through. He said it was fine and I could leave the rest to other Research fellows. So I took these 2 neurotransmitters that possibly participated in respiration and infused them into a cerebral chamber and found that glutamic acid could increase respiration whereas GABA decreased respiration. Finally I wrote these in an article again and published it in the same journal and simultaneously reported this result in the Annual Symposium of Pulmonary and Critical Care medicine.

  Of the Research Fellows who were training in MGH at the time, some didn’t have results while some only published one article. I was the only one with 2 articles. I was awarded 1st place and received a tie with MGH crest on it from the director who kept on insisting that I should stay in MGH. I was still an attending physician at Tri-Service General Hospital ranking Major. My patriotism and commitment made me reject this once-in-a-lifetime chance. It was after my return that I found that a lot of my fellow practitioners who were presented with an opportunity would stay abroad and maybe return after 20 years. Now that I think about it, I am not sure if my decision was correct. If I had stayed abroad in an environment that was so good for research, I might have yielded better academic achievements and might someday become an Academician. But being in Taiwan is still preferred because this is my home.

  Lifestyle in the US is very different from that in Taiwan. There are no houses in the city. Most people live in the suburbs. Some people may need to drive up to 2 hours to got to work. I lived in a Jewish neighborhood in Brooklyn. It was safe and I get to see Jewish men with their Kippah walking around. I took the metro every day. First I took the green line then switched to the red line. It took me about 40 minutes to get to the hospital.

  Among my colleagues, I got along best with 3 of them. They took care of me. I have been to Taylor Tomsons, house for BBQ and beer. We had a great time and hung out like brothers. He is now the Director of ICU of Internal Medicine at MGH and also a Professor at Harvard University. His most representative research involves the ventilator which is essential in saving a patient’s life but if the Tidal wave is set for too high a value, lung damage may result in a patient who already has an acute lung injury. This can be considered a classic in clinical medicine. In the year 2011, I was the President of Taiwan Society of Critical Care Medicine and I invited him to deliver a lecture during our annual symposium. For different critical patients and criteria for the use of ventilators, he surely is a specialist.

  Jay Ryu, a Korean-American, was the closest I was with. He was very welcoming. Perhaps it was because we were both Orientals. He was also the one that studied the hardest among the Americans. At the time he researched about Pulmonary Immunology especially concerning the Killer cells. This article was published in a Thoracic Medicine journal. He was probably going to stay in MGH as an attending physician, but his girlfriend who was also a Sweden-American physician wanted to return to Mayo Clinic. So he returned to Mayo Clinic in Minnesota. Currently he is also a Professor at the Mayo Clinic Teaching Hospital. He is very well known for research on pulmonary fibrosis. While I was in Boston, I would run into him at the hospital every weekend or during holidays. Any questions regarding the English language or computer, he was the person I would go to. Computer was not popular in Taiwan and Machintosh offered a 50% discount for students at Harvard, so MGH used Mac. Jay Ryu also taught me how to use statistic software to calculate data. I remember on one Christmas he cooked a turkey meal for his girlfriend. I did not want to go as third wheel but he insisted on having me over and it turned out to be the most unforgettable Christmas I had in my life. After my return I also invited him to come and give a lecture on pulmonary fibrosis, took him to Bei Hai coast for a week to enjoy the scenery, and eat fresh seafood by the Fuhji fishing harbor. Foreigners are not familiar with live seafood and never had seafood this fresh. There is a Cape Cod in northern Boston famous for 1 big crab that can fill you up, but it’s probably not as tasty as the seafood in Taiwan.

  Another one of my good friends is Meinhard Knusell from Medical University of Vienna in Austria. He first went to Montreal Medical Center in Canada and then continued a higher degree education in MGH. He had a great humor. He was very easy to get along with and popular. He was the richest among our group of friends and he bought a car. The day of my departure, he drove me and other colleagues to bid me farewell. I believed I became part of their lives as they were willing to accompany me to the airport. Although it was a sad moment, we all had our own goals and future to pursue. In 2010 I invited him to lecture about pulmonary embolism.

  Studying abroad in the US for a year taught me a lot of things. How to research, team work and division on clinical studies, enjoying analysis and mode of thinking taught by masters, learning English, experiencing a different lifestyle, and making new friends who are now famous professors.

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