CLINICAL INNOVATORS
Interview by
KATLYN NEMANI, MD
Addressing Disparities in Care:
An Interview with Paul S. Chan,
MD, MS
P
aul 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 nation al 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
ACC.org/CSWN
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
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