Clinical Innovators: Addressing Disparities in Care: An Interview with Paul S. Chan, MD, MS | Interview by Katlyn Nemani, MD

CardioSource WorldNews | Paul S. Chan, MD, MS, is professor of medicine at the University of Missouri-Kansas City School of Medicine, and is an internationally renowned cardiologist and clinical research scientist known for his expertise in cardiac arrest, quality and appropriateness of care, and disparities in care. Dr. Chan received his medical degree from John Hopkins Medical School and went on to complete joint training in internal medicine and pediatrics at Brigham and Women’s Hospital and Boston Children’s Hospital. He then went on to pursue cardiology fellowship and a Masters in Biostatistics at the University of Michigan. Dr. Chan has a particular interest in studying the care of traditionally vulnerable populations, including minorities and uninsured patients. He has over 100 peer-reviewed publications and serves on national committees for the American College of Cardiology and the American Heart Association.

You emigrated from Hong Kong to the Lower East Side of New York at the age of six and decided at a young age to dedicate your life to service. How did your experience as an immigrant impact your decision to go into medicine and care for the underserved?

I did not decide on medicine as a career and a vocation until late in college.  However, my years of growing up as an immigrant in a New York City tenement shaped my perspectives on poverty, social justice, and compassion for the marginalized in our society. My mother worked in the garment industry, getting paid 25 to 75 cents per piece of clothing she produced, and I remember her working long hours into the night to provide for my brother and me. She even sold sweet hot cakes on the streets of Chinatown in New York for $1 a bag to try to generate more income for our family. The experiences were formative ones, and I still to this day remember and can empathize with the hardships both immigrants and citizens in the U.S. share as they struggle for a better livelihood for their family.

It was in college where my eyes were opened.  I lived in two different homeless shelters during my undergraduate years at Harvard, and I was immersed in the struggles of the working and unemployed poor. I worked as a full-time volunteer for 2 years teaching high school drop-outs in Appalachian Kentucky and as a lobbyist for Bread for the World on hunger legislation in Washington DC. I started working with children in war-torn countries in Central America, where, for the first time, I met physicians who were spiritual and physical healers of their communities. These individuals inspired me to pursue a career in medicine that would be married to activism and social justice.

After completing residency in internal medicine and pediatrics you served as a primary care physician in the Navajo reservation in northwest Arizona before pursuing further training at the University of Michigan. What was your experience like on the reservation, and how did you decide to become a cardiologist?

I spent 4 years living in the most remote of the Navajo hospitals, in Chinle, AZ.  It was a humbling 4 years, and I learned a lot about my own limitations, the limitation of my first-world academic training, and the invisible challenges faced by native peoples in our country. Imagine anywhere in the US where 50% of the population does not having running water or electricity in their homes—this would be scandalous. There were also no specialists at our hospital, and I had to learn on the fly how to reduce fractures when I did shifts in the ED, drain peri-rectal abscesses, and a wide variety of other procedures. There was no CT scanner at our hospital, and the closest CT scanner was 160 miles away in Flagstaff, AZ.  And there was only one fixed-wing plane to transport patients in Chinle.  If I sent a patient for a CT, the plane would be gone for 4 hours. The remote location and lack of facilities at this hospital forced me and my other physician colleagues to hone our clinical skills and make decisions without the most basic of technologies with which we had been trained.

For Navajos in our community to see a board-certified cardiologist, they would have to travel to Tucson (400+ miles), Phoenix (320 miles) or Albuquerque (240 miles).  Since I had a lot of exposure to cardiology from my days at the Brigham, it felt natural for me to take on many of the cardiology patients there. I relished the opportunity to build long-term relationships with this panel of patients, and I taught myself how to interrogate pacemakers and evaluate some of the more complex cardiac cases. In the end, I realized I was not cut out to be a primary care physician on the reservation, but as I loved cardiology, I decided to pursue training in this specialty.

Several research projects you have lead have examined regional variation in cardiovascular care and outcomes measures across the U.S. What are some of the main findings that cardiologists should know about?

There have been several important lessons for me.  First, medical care is like education. The environment in which your patient is located has a lot to do with what type of care he or she will receive. Patients who live in geographically poorer areas are less likely to receive timely care at the community or hospital level.  So while racial differences can be described for a variety of different cardiovascular procedures and conditions, a good proportion of it is due to the environment in which patients get care. We found this to be case for bystander CPR for out-of-hospital cardiac arrest. Patients who have this type of cardiac arrest in a poor or mostly black neighborhood are much less likely to receive bystander CPR than in a wealthier or non-black (white or integrated) neighborhood.  In another study, we found that patients who are black are much less likely to receive bystander training than white patients because BLS training is less likely to be done in non-white neighborhoods.  We have also found that patients with an in-hospital cardiac arrest at hospitals with lower socioeconomic status or higher non-white race composition have lower survival rates, regardless if the patient is black or white.

Second, it is not enough to just describe racial disparities in care anymore. Unlike 3 decades ago when this was a rather novel finding, we have too many disparities studies which sit on academic shelves and not enough implementation research on how to reduce disparities. And it is not a simple solution. Unless one has lived the life of a patient in the inner city, they will not realize that health care is often not the first, second or third priority of a recently hospitalized patient.  Rather, the priorities are food, housing, employment, and heat in the winter. Only after these fundamental rights are taken care of—especially for one’s children—can a patient can focus on his or her heart failure regimen, salt restriction and diet management. I have watched way too many discharge instructions by trainees and physicians who are oblivious to the challenges faced by patients with few means.  Patients are labeled “non-compliant” and we assume that they do not take their health care seriously. Often, it is really that they had more important concerns to attend to at home once discharged, or their instructions were provided at a health literacy level way beyond their comprehension.

In addition to socioeconomic differences that may account for patients’ adherence to treatment, there may be differences at the provider level as well. How do socioeconomic differences impact provider adherence to guideline-recommended preventive treatment? Where should efforts be focused to reduce this disparity?

We need a smarter approach.  It has to be comprehensive, community-based, and patient-centered. We can take a page out of work done in resource-poor countries.  We now know that hospitals in developing countries are relatively ineffective in reducing disease. They may treat disease but they see the same patients over and over again for the same conditions. Interventions that have a much larger impact--for a fraction of the cost—include the provision of potable water and the training of community health workers who live in the villages wherein they provide medical care. This model of community health workers has not been adopted by the U.S, but I think it is the next logical step. We need community workers to walk in solidarity with poor people to ensure they understand the health care directions they receive and the medications they take, conduct home visits to understand what other challenges impede a patient’s ability to focus on his or her health, assist in providing transportation for patients to ensure medical follow-up, and connect patients to social services which exist but are often overlooked. In short, we need community workers to be passionate advocates.

We cannot expect poor patients to have the same resources as our suburban upper and upper middle class families, whether these resources are time, money, affordable child care, health literacy, or leisure time. If we are serious about improving guideline adherence among the poorest of our poor in the U.S., we need to walk with folks throughout the entire health and illness journey and not just within the hospital.  Otherwise, we will be setting them (and ourselves) for failure.  And more often than not, we will blame the patient as ‘ignorant’ and ‘non-compliant’, or label them as a ‘frequent-flyer’. My mentor at the Brigham, Paul Farmer, has shown that when we walk in solidarity with the poor, we can accomplish First World cure rates of multi-drug resistant TB, antiretroviral adherence rates for HIV, and comprehensive human development in rural Haiti, the slums of Peru, Rwanda, and other regions of the world written off as hopeless. We can only expect good results in the inner cities and rural regions of the U.S. if we work with patients both in and outside the hospitals.

You have been involved in a number of health organizations in developing countries, particularly in Central America. What are some of the projects that you currently have underway?

As a young man out of college, I spent a summer in Guatemala doing art therapy with kids who were traumatized by recent violence during their civil war. There, I fell in love with the people, culture, and opportunities to improve health.  Over the past 26 years, I have returned to Guatemala many times. So far, I think I have had more of an impact in my work there than as a physician. I am a big believer in approaching a community as equals.  I was President of an organization whose acronym is ALDEA (advancing local development through empowerment and action). We approach communities and ask what their needs are. Invariably, it is almost always the need for safe, potable drinking water. Imagine having to walk 3 to 4 hours each day just to fetch unsafe water to drink and cook with. When we bring water into a community, it frees up time for women to pursue productive economic pursuits (making crafts and jewelry, farming) and girls to go to school. Girls, in turn, are more likely to have smaller families with more education. Our organization then works with community leaders to erect latrines, identify and provide supplementation to infants with severe malnutrition, train community health workers to provide key preventive and curative care, implement micro-credit projects to improve disposable income among families, and increase their self-reliance and confidence.

I also serve on the board of Church World Service (CWS), a network of 37 Protestant denominations that do rural development work (like the type described above with ALDEA) and refugee and disaster relief work. I love this organization because there is no missionary component. I am not even Protestant! But we believe in a world that can only be healed with solidarity, grassroots development, and peace and justice. So CWS does all of this and more. Every year, we do a fundraiser for CWS, where I and my group walk 50 miles in the Grand Canyon going from one rim to the bottom to the opposite rim and then all the way back (see: https://www.crophungerwalk.org/kansascitymo/GrandCanyonHikers). We trek these 50 miles within one 24-hour period with no stops except to eat, climbing 11,000 feet in total and descending 11,000 feet.  And we have built a community of supporters who believe in our vision of a better world where it is just not enough to do our daily jobs. And as a physician, I believe I have a unique opportunity (and might I say, responsibility) to promote social justice and equality for those with no voice in our society.

What are some of your research and clinical goals in the coming years?

I am a big believer in mentoring, and not just in research but in life.  In research, we have to not be afraid to shake things up sometimes. When we published our paper on rates of appropriate and inappropriate PCI in JAMA in 2011, I was not very popular with many inteventional and non-interventional cardiologists.  I received angry emails and some folks yelled at me in person. Five years later, rates of inappropriate PCI have plummeted, in part because of the growing awareness of how to choose this treatment wisely. I think we have to be creative in our research.  I would like the disparities research field to move beyond simple descriptive epidemiology to wholesale engagement and involvement in a community to actually reduce disparities. The goal in any research would, ideally, promote excellence in patient care, and this will require better engagement of patients in more informed decision making about procedural benefits and costs.

Admittedly, I am more excited about what can be done in global health in the future.  I recently was involved in donating a substantial amount of money for a mutual fund for water projects in resource-poor countries. Imagine if the next water project did not depend on having to raise another $3000. An organization called water.org (of which Matt Damon, the actor, is co-founder), recently launched a mutual fund investment with a guaranteed return of no more than 1% (basically, no monetary return on investment). In return for your money locked up in the mutual fund for 7 years, it would be loaned every 6 months as micro-credit for poor people to access water. These loans get re-paid (at a 98% rate), and the money is re-invested in the next micro-credit water loan. Over 7 years, your initial investment is loaned 14 times, multiplying the impact of your donation 14-fold. At the end of 7 years, the donor gets his or her money back, and it is a win-win for everyone.  I have never been happier to part with my money. I am now focused on inspiring our youth. Over the past 2 years, I have taken high school students from the Kansas City area to learn about sustainable, grassroots development. Our goal is to learn from the villagers and to return to the U.S. with a healthy concept of how to engage communities in change. These high school students from an elite private school will serve on their parent’s charitable foundations, and my hope is that they will give lavishly to organizations which move beyond charity which creates dependence to development which empowers.

Read the full November issue of CardioSource WorldNews at ACC.org/CSWN

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