A serendipitous path to Yale

“In surgery we have a saying: It’s better to be lucky than good,” said Veronica Chiang, MD, HS ’00. Clearly, however, as director of the Yale Gamma Knife Center, professor of neurosurgery, and a 2019 recipient of the Yale Cancer Center Award for Excellence in Clinical Care, Chiang exhibits plenty of the latter quality as well.

Still, her journey has been an unusual one. When she was only a year old, Chiang emigrated with her family from Hong Kong to Australia, in part to escape the hypercompetitive Hong Kong education system. Dreams of a career in medicine didn't take root at that time, but a love of discovery did. “I remember as a child when I had nothing better to do, I had a pile of basic medical books sitting around that nobody else would read,” Chiang said.

Chiang did well in school and was admitted to study medicine at the University of Western Australia in Perth. “[In Australia] back then you entered medical school right out of high school,” she said. “It was not really a choice one thought too much about. It was more an opportunity.”

In her sixth year she had another opportunity: to travel anywhere in the world for an away medical rotation. Her brother was at MIT at the time, so Chiang took advantage of the chance to visit him. “I wrote to Harvard. Back in the day we didn't have the internet; we were still writing handwritten letters,” she said. “Harvard swears that they sent me an offer letter but I never received it.”

Not easily dissuaded from her goal of studying in the United States, Chiang applied to Yale. Serendipity promptly arrived: “When you come from Australia you only know a couple of names, and the next school down on the list was Yale, given it was only a few hours away from Boston,” she said. Internal medicine rotations were not available to non-Yale students, so though she planned to become a medical intensivist, Chiang settled for a rotation in neurosurgery. She figured she would never do it again. Later, as Chiang explored residency options overseas, Yale notified her of a vacancy. “In the spirit of ‘Let’s give it a try,’ I came for a year,” she said. “And then I never left.”

Around the same time, the concept of radiosurgery using imaging-based radiation was coming into use in the United States. The Gamma Knife, designed by a Swedish neurosurgeon in 1967, found specific applications for targeting lesions in the brain. “Radiation to the head prior to Gamma Knife was really just radiation to the entire head,” Chiang said. “Being able to use a 3D system to target radiation specifically to lesions in the brain that you saw on an MRI was a relatively new concept.”

Despite its novelty, the Gamma Knife lacked the glamour of traditional neurosurgery because it wasn't real surgery. As such, it was not Chiang's first choice. “As the most junior person, I got relegated [to] this newest tool,” she said. Quickly, though, she learned to embrace it.

“Neurosurgery is hard core,” Chiang said. “It's tough, psychologically and physically.” Radiosurgery offered a less intense focus on outpatient treatment—which proved particularly valuable when she started a family. Chiang also appreciated the multidisciplinary environment of radiosurgery. “Neurosurgery is intensely solitary. You do a lot by yourself, and some people like that,” she said. “With radiosurgery, it’s a team-based effort, which I enjoy.”

Yale’s Gamma Knife Center has long been home to pioneering neurosurgery research. “We’re always interested in that multidisciplinary interaction: Do we provide the best care to our patients by ourselves as neurosurgeons, or could we do better with collaboration with other specialties? In which situations are the tools we have best used?” Chiang said. “We don’t like to admit it, but even neurosurgeons need help! Multicentered multidisciplinary research, especially in the care of patients with brain cancer, helps us work this out.”

As she did as a child with a pile of textbooks, Chiang said she loves the process of discovery that research affords. At Yale, she enjoys the opportunity to pay it forward with medical students, residents, and fellows. “I like to look at data, and then I like to be able to share the process of working out how that data changes the way we might think about how we do what we do,” she said. “I like to share with somebody who’s learning and to see them get it. Then, in the future hopefully they’ll be able to ask their own questions, gather their own data, and then move their field forward, too.”

Chiang herself has witnessed considerable forward progress. “When we started first with the Gamma Knife, we were just able to treat a single brain lesion, or two or three lesions at most per patient,” she said. “[Now] we have treated as many as 51 lesions in a patient in support of those patients entering clinical trials for cancer.” The Gamma Knife has also become a first-line rather than salvage treatment. “We now put whole-brain radiation therapy aside for a time down the line when a patient really needs it, and often use radiosurgery only,” Chiang said. “It’s been a complete turnaround in the field.”

As technology, science, and human ingenuity evolve and intersect, the ability to understand and provide treatment expands, which Chiang finds an interesting aspect of the surgical field. “One of the really cool things that we do in neurosurgery is develop new tech,” she said. “We're moving from what is sometimes seen as a very invasive field into a more minimally invasive field.”

Chiang is one of the first in the United States to employ a new cutting-edge technology to treat radiation necrosis: MRI-guided laser thermal ablation. Participating in its development has been another process of discovery. “It’s kind of like I got to experience the back end of the Gamma Knife development and the front end of the laser development. It’s been a real eye-opener,” Chiang said. “By the time I started in Gamma Knife, most of the technical challenges were well on their way to being worked out, but with the laser there are so many changes still needed to make this tool easier to use and more clinically reliable.”

“I think in the surgical field, one of the most exciting things that’s going on is this huge growth in computing power, and people are into engineering like they never were before,” Chiang said. “While we are still not completely sure how that fits into patient care, it’s very exciting.” Though growth in technology contributes significantly, product development still involves a trial-and-error process. After all, research and development often contain their own instances of serendipity.