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Type a behavior
134%
Letters
Allgemeines
to the
June 198.3 American Heart Journal
Editor
Wilfried Meyer, M.D. Joachim Neumann, M.D. Monika Nose Wilhelm Schmitz, M.D. Hasso Scholz, M.D. Jens Scholz, M.D. Jutta Starbatty Volker Steinkraus, M.D. Abteilung Allgemeine Pharmakologie Volker Doring, M.D. Peter Kalmar, M.D. Wilfried Riidiger, M.D. Abteilung fiir Herzund Geftisschirurgie Giinter Kliippel, M.D. Pathologisches Institut Universitiits-Krankenhaus Eppendorf Universittit Hamburg Martinistrasse 52, D-2000 Hamburg #20, FRG Peter Hanrath, M.D. II. Medizinische Abteilung Krankenhaus St. Georg, Lohmiihlenstrasse 5 D-2000 Hamburg #1, FRG
REFERENCES
Feldman MD, Copelas L, Gwathmey JK, Phillips P, Warren SE, Schoen FJ, Grossman W, Morgan JP. Deficient production of cyclic AMP: pharmacologic evidence of an important cause of contractile dysfunction in patients with end-stage heart failure. Circulation 1987;75:331. Schmitz W, Scholz H, Erdmann E. Effects of CX-and j3adrenergic agonists, phosphodiesterase inhibitors and adenosine on isolated human heart muscle preparations. Trends Pharmacol Sci 1987;8:447. Bruckner R, Fenner A, Meyer W, Nobis T-M, Schmitz W, Scholz H. Cardiac effects of adenosine and adenosine analogs in guinea-pig atrial and ventricular preparations: evidence against a role of cyclic AMP and cyclic GMP. J Pharmacol Exp Ther 1985;234:766.
that the MRFIT researchers “arbitrarily, without truly testing the coronary validity of their questions, employed ad-hoc, poorly chosen, inadequately trained, non-professional clerks to present them to 3110 of their MRFIT subjects.” This criticism reflects Dr. Friedman’s opinion and not anything we have said or published, and it is inaccurate on several points. Neither the publications nor the presentations of our research focused upon the interviewer selection process, which followed a detailed protocol.* MRFIT interviewers were screened, trained, and tested, and only 7 of 21 initial candidates were certified to be interviewers. Also, while one may debate the provoking strategy adopted for the delivery of questions in the MRFIT interviews, it is my opinion that the MRFIT interviewers were well-trained and consistent in following this strategy. A third point of concern is that Dr. Friedman’s Editorial maintains that our research addresses the reason that “MRFIT interviewers failed to predict coronary disease in the 3110 [MRFIT] subjects.” While I have stated that there is circumstantial evidence that measurement errors may have occurred in the MRFIT type A assessments: the same possibilities for error exist in many other structured interviews where the procedures for selection, training, and quality control are much less formal than they were for the MRFIT study. It is more accurate to say that we have been studying why the MRFIT study did not find a relationship between the assessment of type A behavior and CHD. Certainly, there are additional possibilities for this failure other than the differences in interviewer behavior. For instance, type A behavior may not be a risk factor in this sample because the more hostile, heart disease-prone individuals refused to volunteer for a study that involved possible long-term life-style changes. Larry Scherwitz, Ph.D. Dept. of Dental Public Health & Hygiene University of California, San Francisco 707 Parnassus, Room D-1012 San Francisco, CA 94143 REFERENCES
TYPE A BEHAVIOR To the Editor:
I am writing to respond to the Editorial by Meyer Friedman, M.D., entitled “Type A behavior: A frequently misdiagnosed and rarely treated medical disorder” (AMERICAN HEART JOURNAL, April 1988;115:930-6). I disagree with Dr. Friedman on several issues. First, in the Editorial’s criticism of the methodology of several studies that found no relationship between type A behavior and coronary heart disease (CHD), Dr. Friedman refers to research that my colleagues and I did on the assessment of type A behavior in two prospective epidemiologic studies-the Western Collaborative Group Study (WCGS) and the Multiple Risk Factor Intervention Trial (MRFIT). We conducted detailed research on interviewer question-asking techniques in both of these studies. Dr. Friedman correctly points out that our results showed that WCGS interviewers interrupted less; also they asked more questions and at a slower pace than did the MRFIT interviewers. I have also said before that the MRFIT interviewers appeared less engaging than the WCGS interviewers, but whether these differences have any bearing upon the predictive validity of the type A assessments, as Dr. Friedman maintains, remains an open question. Second, the Editorial incorrectly cites our research as stating
1. The MRFIT group. The MRFIT behavior pattern study. I. Study design, procedures, and reproducibility of behavior pattern judgments. J Chronic Dis 1979;32:293-305. 2. Scherwitz L, Graham L, Grandits G, Billings J. Speech characteristics and, behavior type assessment in the Multiple Risk Factor Intervention Trial (MRFIT) structured interviews. J Behav Med 1987;10:173-95.
To the Editor:
The following comments are in response to Dr. Friedman’s Editorial, “Type A behavior: A frequently misdiagnosed and rarely treated medical disorder.“’ When the Multiple Risk Factor Intervention Trial (MRFIT) was organized in 1972-73, results from the Western Collaborative Group Study (WCGS) indicated that the type A behavior pattern, assessed at baseline by a structured interview, was associated prospectively with a twofold increase in risk of coronary heart disease after adjustment for age, blood pressure, cigarette smoking, and serum total cholesterol.2,’ A similar association was observed’ when type A behavior was assessed by the Jenkins Activity Survey, a self-administered, Address correspondence to Dr. Richard B. Shekelle, School Health, University of Texas, Health Science Center at Houston, 20186, Houston, TX 77225.
of Public P.O. Box
Letters
Allgemeines
to the
June 198.3 American Heart Journal
Editor
Wilfried Meyer, M.D. Joachim Neumann, M.D. Monika Nose Wilhelm Schmitz, M.D. Hasso Scholz, M.D. Jens Scholz, M.D. Jutta Starbatty Volker Steinkraus, M.D. Abteilung Allgemeine Pharmakologie Volker Doring, M.D. Peter Kalmar, M.D. Wilfried Riidiger, M.D. Abteilung fiir Herzund Geftisschirurgie Giinter Kliippel, M.D. Pathologisches Institut Universitiits-Krankenhaus Eppendorf Universittit Hamburg Martinistrasse 52, D-2000 Hamburg #20, FRG Peter Hanrath, M.D. II. Medizinische Abteilung Krankenhaus St. Georg, Lohmiihlenstrasse 5 D-2000 Hamburg #1, FRG
REFERENCES
Feldman MD, Copelas L, Gwathmey JK, Phillips P, Warren SE, Schoen FJ, Grossman W, Morgan JP. Deficient production of cyclic AMP: pharmacologic evidence of an important cause of contractile dysfunction in patients with end-stage heart failure. Circulation 1987;75:331. Schmitz W, Scholz H, Erdmann E. Effects of CX-and j3adrenergic agonists, phosphodiesterase inhibitors and adenosine on isolated human heart muscle preparations. Trends Pharmacol Sci 1987;8:447. Bruckner R, Fenner A, Meyer W, Nobis T-M, Schmitz W, Scholz H. Cardiac effects of adenosine and adenosine analogs in guinea-pig atrial and ventricular preparations: evidence against a role of cyclic AMP and cyclic GMP. J Pharmacol Exp Ther 1985;234:766.
that the MRFIT researchers “arbitrarily, without truly testing the coronary validity of their questions, employed ad-hoc, poorly chosen, inadequately trained, non-professional clerks to present them to 3110 of their MRFIT subjects.” This criticism reflects Dr. Friedman’s opinion and not anything we have said or published, and it is inaccurate on several points. Neither the publications nor the presentations of our research focused upon the interviewer selection process, which followed a detailed protocol.* MRFIT interviewers were screened, trained, and tested, and only 7 of 21 initial candidates were certified to be interviewers. Also, while one may debate the provoking strategy adopted for the delivery of questions in the MRFIT interviews, it is my opinion that the MRFIT interviewers were well-trained and consistent in following this strategy. A third point of concern is that Dr. Friedman’s Editorial maintains that our research addresses the reason that “MRFIT interviewers failed to predict coronary disease in the 3110 [MRFIT] subjects.” While I have stated that there is circumstantial evidence that measurement errors may have occurred in the MRFIT type A assessments: the same possibilities for error exist in many other structured interviews where the procedures for selection, training, and quality control are much less formal than they were for the MRFIT study. It is more accurate to say that we have been studying why the MRFIT study did not find a relationship between the assessment of type A behavior and CHD. Certainly, there are additional possibilities for this failure other than the differences in interviewer behavior. For instance, type A behavior may not be a risk factor in this sample because the more hostile, heart disease-prone individuals refused to volunteer for a study that involved possible long-term life-style changes. Larry Scherwitz, Ph.D. Dept. of Dental Public Health & Hygiene University of California, San Francisco 707 Parnassus, Room D-1012 San Francisco, CA 94143 REFERENCES
TYPE A BEHAVIOR To the Editor:
I am writing to respond to the Editorial by Meyer Friedman, M.D., entitled “Type A behavior: A frequently misdiagnosed and rarely treated medical disorder” (AMERICAN HEART JOURNAL, April 1988;115:930-6). I disagree with Dr. Friedman on several issues. First, in the Editorial’s criticism of the methodology of several studies that found no relationship between type A behavior and coronary heart disease (CHD), Dr. Friedman refers to research that my colleagues and I did on the assessment of type A behavior in two prospective epidemiologic studies-the Western Collaborative Group Study (WCGS) and the Multiple Risk Factor Intervention Trial (MRFIT). We conducted detailed research on interviewer question-asking techniques in both of these studies. Dr. Friedman correctly points out that our results showed that WCGS interviewers interrupted less; also they asked more questions and at a slower pace than did the MRFIT interviewers. I have also said before that the MRFIT interviewers appeared less engaging than the WCGS interviewers, but whether these differences have any bearing upon the predictive validity of the type A assessments, as Dr. Friedman maintains, remains an open question. Second, the Editorial incorrectly cites our research as stating
1. The MRFIT group. The MRFIT behavior pattern study. I. Study design, procedures, and reproducibility of behavior pattern judgments. J Chronic Dis 1979;32:293-305. 2. Scherwitz L, Graham L, Grandits G, Billings J. Speech characteristics and, behavior type assessment in the Multiple Risk Factor Intervention Trial (MRFIT) structured interviews. J Behav Med 1987;10:173-95.
To the Editor:
The following comments are in response to Dr. Friedman’s Editorial, “Type A behavior: A frequently misdiagnosed and rarely treated medical disorder.“’ When the Multiple Risk Factor Intervention Trial (MRFIT) was organized in 1972-73, results from the Western Collaborative Group Study (WCGS) indicated that the type A behavior pattern, assessed at baseline by a structured interview, was associated prospectively with a twofold increase in risk of coronary heart disease after adjustment for age, blood pressure, cigarette smoking, and serum total cholesterol.2,’ A similar association was observed’ when type A behavior was assessed by the Jenkins Activity Survey, a self-administered, Address correspondence to Dr. Richard B. Shekelle, School Health, University of Texas, Health Science Center at Houston, 20186, Houston, TX 77225.
of Public P.O. Box