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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