Science. The very word for many of you conjures unhappy memories of boredom in high school biology or physics class. But let me assure that what you did there had very little to do with science. That was really the "what" of science. It was the history of what other people had discovered. What I'm most interested in as a scientist is the "how" of science. Because science is knowledge in process. We make an observation, guess an explanation for that observation, and then make a prediction that we can test with an experiment or other observation.
A couple of examples. First of all, people noticed that the Earth was below, the sky above, and both the Sun and the Moon seemed to go around them. Their guessed explanation was that the Earth must be the center of the universe. The prediction: everything should circle around the Earth. This was first really tested when Galileo got his hands on one of the first telescopes, and as he gazed into the night sky, what he found there was a planet, Jupiter, with four moons circling around it. He then used those moons to follow the path of Jupiter and found that Jupiter also was not going around the Earth but around the Sun. So the prediction test failed. And this led to the discarding of the theory that the Earth was the center of the universe.
Another example: Sir Isaac Newton noticed that things fall to the Earth. The guessed explanation was gravity, the prediction that everything should fall to the Earth. But of course, not everything does fall to the Earth. So did we discard gravity? No. We revised the theory and said, gravity pulls things to the Earth unless there is an equal and opposite force in the other direction. This led us to learn something new. We began to pay more attention to the bird and the bird's wings, and just think of all the discoveries that have flown from that line of thinking. So the test failures, the exceptions, the outliers teach us what we don't know and lead us to something new. This is how science moves forward. This is how science learns.
通过美国医学执照考试(USMLE examination)是赴美从医的必经的途径，大多数中国考生通过努力也能拿到不错的成绩，最后的一关是申请住院医的过程，在match申请和面试很多技巧都是有迹可循的。例如住院医面试，每个人去面试的program都不尽相同，但是有些面试的问题和回答都是可相互参考的，下面我们邀请Dr Huang老师从老师自身的回答经验分享出来供参考，可收藏，也可转发给身边需要的朋友。
Sometimes in the media, and even more rarely, but sometimes even scientists will say that something or other has been scientifically proven. But I hope that you understand that science never proves anything definitively forever. Hopefully science remains curious enough to look for and humble enough to recognize when we have found the next outlier, the next exception, which, like Jupiter's moons, teaches us what we don't actually know.
We're going to change gears here for a second. The caduceus, or the symbol of medicine, means a lot of different things to different people, but most of our public discourse on medicine really turns it into an engineering problem. We have the hallways of Congress, and the boardrooms of insurance companies that try to figure out how to pay for it. The ethicists and epidemiologists try to figure out how best to distribute medicine, and the hospitals and physicians are absolutely obsessed with their protocols and checklists, trying to figure out how best to safely apply medicine. These are all good things. However, they also all assume at some level that the textbook of medicine is closed. We start to measure the quality of our health care by how quickly we can access it. It doesn't surprise me that in this climate, many of our institutions for the provision of health care start to look a heck of a lot like Jiffy Lube.
There was once a time that our train was delayed, and before long we finally set off, we had an emergency broadcasting that a passenger needs help. As the only medical personnel around, I signed up and it was an old lady in her 70s, with history of diabetes, presented as lethargy, fainted with moderate dyspnea. She hadn’t eat anything in the last 8 hours, and she had 2 episodes of vomiting. With all the device at hand, I check her vitals, and did the physicals. As there was no further workup at that time, my best guess was electrolyte disturbance due to dehydration and vomits, but also cannot exclude a DKA. So I established a IV access and the patient was sent to hospital in the next stop.
The only problem is that when I graduated from medical school, I didn't get one of those little doohickeys that your mechanic has to plug into your car and find out exactly what's wrong with it, because the textbook of medicine is not closed. Medicine is science. Medicine is knowledge in process. We make an observation, we guess an explanation of that observation, and then we make a prediction that we can test. Now, the testing ground of most predictions in medicine is populations. And you may remember from those boring days in biology class that populations tend to distribute around a mean as a Gaussian or a normal curve. Therefore, in medicine, after we make a prediction from a guessed explanation, we test it in a population. That means that what we know in medicine, our knowledge and our know-how, comes from populations but extends only as far as the next outlier, the next exception, which, like Jupiter's moons, will teach us what we don't actually know.
Actually, I do not have a dramatic story that direct me into medicine. You see, there are a string of experiences, small things just like this that makes my choice seems so nature. Also, the outstanding doctors that I’ve worked with; the patients that I learned so much from; and the simple joy learning the knowledge, the thinking process, differential diagnosis and so on. I just never feel tired and enjoy it, so why not turn my interest into my career.
Now, I am a surgeon who looks after patients with sarcoma. Sarcoma is a very rare form of cancer. It's the cancer of flesh and bones. And I would tell you that every one of my patients is an outlier, is an exception. There is no surgery I have ever performed for a sarcoma patient that has ever been guided by a randomized controlled clinical trial, what we consider the best kind of population-based evidence in medicine. People talk about thinking outside the box, but we don't even have a box in sarcoma. What we do have as we take a bath in the uncertainty and unknowns and exceptions and outliers that surround us in sarcoma is easy access to what I think are those two most important values for any science: humility and curiosity. Because if I am humble and curious, when a patient asks me a question, and I don't know the answer, I'll ask a colleague who may have a similar albeit distinct patient with sarcoma. We'll even establish international collaborations. Those patients will start to talk to each other through chat rooms and support groups. It's through this kind of humbly curious communication that we begin to try and learn new things.
As an example, this is a patient of mine who had a cancer near his knee. Because of humbly curious communication in international collaborations, we have learned that we can repurpose the ankle to serve as the knee when we have to remove the knee with the cancer. He can then wear a prosthetic and run and jump and play. This opportunity was available to him because of international collaborations. It was desirable to him because he had contacted other patients who had experienced it. And so exceptions and outliers in medicine teach us what we don't know, but also lead us to new thinking.
Now, very importantly, all the new thinking that outliers and exceptions lead us to in medicine does not only apply to the outliers and exceptions. It is not that we only learn from sarcoma patients ways to manage sarcoma patients. Sometimes, the outliers and the exceptions teach us things that matter quite a lot to the general population. Like a tree standing outside a forest, the outliers and the exceptions draw our attention and lead us into a much greater sense of perhaps what a tree is. We often talk about losing the forests for the trees, but one also loses a tree within a forest. But the tree that stands out by itself makes those relationships that define a tree, the relationships between trunk and roots and branches, much more apparent. Even if that tree is crooked or even if that tree has very unusual relationships between trunk and roots and branches, it nonetheless draws our attention and allows us to make observations that we can then test in the general population.
I told you that sarcomas are rare. They make up about one percent of all cancers. You also probably know that cancer is considered a genetic disease. By genetic disease we mean that cancer is caused by oncogenes that are turned on in cancer and tumor suppressor genes that are turned off to cause cancer. You might think that we learned about oncogenes and tumor suppressor genes from common cancers like breast cancer and prostate cancer and lung cancer, but you'd be wrong. We learned about oncogenes and tumor suppressor genes for the first time in that itty-bitty little one percent of cancers called sarcoma. In 1966, Peyton Rous got the Nobel Prize for realizing that chickens had a transmissible form of sarcoma. Thirty years later, Harold Varmus and Mike Bishop discovered what that transmissible element was. It was a virus carrying a gene, the src oncogene. Now, I will not tell you that src is the most important oncogene. I will not tell you that src is the most frequently turned on oncogene in all of cancer. But it was the first oncogene. The exception, the outlier drew our attention and led us to something that taught us very important things about the rest of biology.
专有名词释义：Diabetes：糖尿病、Lethargy：嗜睡、Dyspnea：呼吸困难、electrolyte disturbance：电解质紊乱、DKA：Diabetic Ketoacidosis 糖尿病酮症酸中毒 、IV：Intravenous therapy 静脉治疗
Now, TP53 is the most important tumor suppressor gene. It is the most frequently turned off tumor suppressor gene in almost every kind of cancer. But we didn't learn about it from common cancers. We learned about it when doctors Li and Fraumeni were looking at families, and they realized that these families had way too many sarcomas. I told you that sarcoma is rare. Remember that a one in a million diagnosis, if it happens twice in one family, is way too common in that family. The very fact that these are rare draws our attention and leads us to new kinds of thinking.
Computer skill for the medical system?
Now, many of you may say, and may rightly say, that yeah, Kevin, that's great, but you're not talking about a bird's wing. You're not talking about moons floating around some planet Jupiter. This is a person. This outlier, this exception, may lead to the advancement of science, but this is a person. And all I can say is that I know that all too well. I have conversations with these patients with rare and deadly diseases. I write about these conversations. These conversations are terribly fraught. They're fraught with horrible phrases like "I have bad news" or "There's nothing more we can do." Sometimes these conversations turn on a single word: "terminal."
Silence can also be rather uncomfortable. Where the blanks are in medicine can be just as important as the words that we use in these conversations. What are the unknowns? What are the experiments that are being done?
Of course, I’m quite sophisticated with the basic software like words and PowerPoint. As I’m working as an USMLE instructor, so I’m expected to be able to present an interesting and organized PowerPoint every of my lessons. With the previous clinical experiences of US, I took the courses and am very handy at using the Epic system. I also working on statistical analysis software like SPSS, so I can take the advantage of the data base and make some progress on my research.
Do this little exercise with me. Up there on the screen, you see this phrase, "no where." Notice where the blank is. If we move that blank one space over "no where" becomes "now here," the exact opposite meaning, just by shifting the blank one space over.
I'll never forget the night that I walked into one of my patients' rooms. I had been operating long that day but I still wanted to come and see him. He was a boy I had diagnosed with a bone cancer a few days before. He and his mother had been meeting with the chemotherapy doctors earlier that day, and he had been admitted to the hospital to begin chemotherapy. It was almost midnight when I got to his room. He was asleep, but I found his mother reading by flashlight next to his bed. She came out in the hall to chat with me for a few minutes. It turned out that what she had been reading was the protocol that the chemotherapy doctors had given her that day. She had memorized it. She said, "Dr. Jones, you told me that we don't always win with this type of cancer, but I've been studying this protocol, and I think I can do it. I think I can comply with these very difficult treatments. I'm going to quit my job. I'm going to move in with my parents. I'm going to keep my baby safe." I didn't tell her. I didn't stop to correct her thinking. She was trusting in a protocol that even if complied with, wouldn't necessarily save her son. I didn't tell her. I didn't fill in that blank. But a year and a half later her boy nonetheless died of his cancer. Should I have told her?
专有名词释义：Epic system：美国大部分医院或诊所使用的电子病历系统、SPSS：Statistical Package for the Social Sciences 社会科学统计软件包
Now, many of you may say, "So what? I don't have sarcoma. No one in my family has sarcoma. And this is all fine and well, but it probably doesn't matter in my life." And you're probably right. Sarcoma may not matter a whole lot in your life. But where the blanks are in medicine does matter in your life.
Tell me about USCE
I didn't tell you one dirty little secret. I told you that in medicine, we test predictions in populations, but I didn't tell you, and so often medicine never tells you that every time an individual encounters medicine, even if that individual is firmly embedded in the general population, neither the individual nor the physician knows where in that population the individual will land. Therefore, every encounter with medicine is an experiment. You will be a subject in an experiment. And the outcome will be either a better or a worse result for you. As long as medicine works well, we're fine with fast service, bravado, brimmingly confident conversations. But when things don't work well, sometimes we want something different.
A colleague of mine removed a tumor from a patient's limb. He was concerned about this tumor. In our physician conferences, he talked about his concern that this was a type of tumor that had a high risk for coming back in the same limb. But his conversations with the patient were exactly what a patient might want: brimming with confidence. He said, "I got it all and you're good to go." She and her husband were thrilled. They went out, celebrated, fancy dinner, opened a bottle of champagne. The only problem was a few weeks later, she started to notice another nodule in the same area. It turned out he hadn't gotten it all, and she wasn't good to go. But what happened at this juncture absolutely fascinates me. My colleague came to me and said, "Kevin, would you mind looking after this patient for me?" I said, "Why, you know the right thing to do as well as I do. You haven't done anything wrong." He said, "Please, just look after this patient for me." He was embarrassed -- not by what he had done, but by the conversation that he had had, by the overconfidence.
As I was a last-year student, I've got hands-on clinical experience, which is very precious opportunity for IMG, I was required to work as M4 students with same task and schedule, in both inpatient and outpatient care. Besides the basic skills and understanding to the system, I also learned how to communicate efficiently and responsibility or role in the medical team. After get familiar with the system, I started to ask for task and learn how to be an intern. The attendings and residents are very dedicated for medical student teaching. The faculty are supportive and are willing to give me more autonomy. For example, I was able to take over the newly-admitted patient from ER totally on my own.
So I performed a much more invasive surgery and had a very different conversation with the patient afterwards. I said, "Most likely I've gotten it all and you're most likely good to go, but this is the experiment that we're doing. This is what you're going to watch for. This is what I'm going to watch for. And we're going to work together to find out if this surgery will work to get rid of your cancer." I can guarantee you, she and her husband did not crack another bottle of champagne after talking to me. But she was now a scientist, not only a subject in her experiment.
By the last of my rotation, I was capable of handling the work assigned to me. I even had the time and ability to supervise and oriented the M3 students. From that I can tell how much I have been matured and progressed in the last year. What I have learned will help me become a competent doctor in your program.
And so I encourage you to seek humility and curiosity in your physicians. Almost 20 billion times each year, a person walks into a doctor's office, and that person becomes a patient. You or someone you love will be that patient sometime very soon. How will you talk to your doctors? What will you tell them? What will they tell you? They cannot tell you what they do not know, but they can tell you when they don't know if only you'll ask. So please, join the conversation.
专有名词释义：IMG：International Medical student 国际医学生、M3/M4: Third / Fourth-year medical student 美国3 / 4年级的医学生
Any questions about this program?
Every team has its culture. And I realize I tend to incorporate part of the culture or spirit from every previous educational experiences. So, how do you characterize the culture of this program, or what common feature is shared by the successful graduate from this program? What do you see the program in the next 5 years? I’m considering being a Chief resident in the fourth year as I think it will be a bright spot on resume and I am definitely interest in developing my leadership. What do you think is the most important quality for a chief?
What if you got pregnant again when you were resident?
Every program is expected to be supportive if a resident gets pregnant. And it would be very inappropriate for any faculty to ask a question with the potential of sexual discrimination, like this one.
What would you do if your senior resident proscribed a medication which would harm the patient?
First, I would hold the medication if no one is around for consultation. Then contact the senior immediately. Once any adverse event arises, I would have to ask the senior to report to the authority and explain it to the patient.
What would you do if your patients were not compliant with the treatment?
First, I would explore his/her understanding for the current condition we are dealing with. I will also explore the reason behind that led to the incompliance and list other options, for example, a long medication list could be confusing for a senior, a regular dose of insulin could be embarrassing for a teenager hanging out with his friend. Last but not least, I also keep in mind that the patients do have a right to refuse treatment.
What can you do for this progra？
I take a great pleasure sharing medical knowledge and have a passion for teaching. I used to lead the international student studying group of our school and now working as USMLE instructor. And I noticed that this hospital is affiliated to xxx school which means there gonna be medical students coming over. I think I will be a great teacher when I become the senior. That’s my way of giving back to this program and I think I’m going do great here.
Why do you want to be a resident in US？
Based on my personal experience and insights from alumni, there is the training I desire here. And it will lay a solid fundation for my future career and a brilliant next step for my previous endeavor. It took me a long time and many efforts to be here, but I think it worth every second even just fo rthe possiblity to become a better doctor. I'm fully aware that there must be more of the challenges, but I'm a problem solver and an adaptor, and I'm ready.
Planning for the next five year？
After receiving my training which is the upmost important thing for me right now, my interest lies in hem/onc. My goal is to become a competent doctor that can care for the patients, I also wish to have the resources and ability to reah out for some underserved community. I once served in the Youth volunteer organization of our school and one of our campaign was to coordinate with the hospital and arrange free medical consultation in impoverished area. I realized that many people are deprived of their chance to change their lives because of lacking of medical care and knowledge.