Racial Implicit Bias and Communication Among Physicians in a Simulated Environment

Importance

Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice.

Objective

To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias.

Design, Setting, and Participants

This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation.

Exposures

In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales.

Main Outcomes and Measures

Association between physicians' IAT scores and SP race with SP ratings of communication skills.

Results

In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased.

Conclusions and Relevance

In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Comparing scientific worldviews between allopathic medical degree and East Asian medicine degree students utilizing the thinking about science survey instrument (TSSI)

BACKGROUND

Integrative medicine has become a new healthcare model due to the growing evidence base for complementary and integrative therapies. However, some question whether complementary and integrative therapies can truly be integrated with biomedicine due to differences in underlying paradigms and theoretical bases. This study aimed to explore differences in scientific worldviews between students studying East Asian medicine and those completing an allopathic medical degree using the validated Thinking about Science Survey Instrument (TSSI).

METHODS

122 medical students from Albert Einstein College of Medicine (Einstein) and 48 East Asian medicine students from the Pacific College of Health and Science (Pacific College) participated in this study. Participants completed the TSSI, a 60-item Likert-scale instrument that quantitatively measures the sociocultural resistance to, and support for science. Item and category means were compared between each group using an independent sample t-test.

RESULTS

Distinct differences were seen between the two groups of students with regard to age, gender distribution and prior education. Einstein students were generally supportive of science and Pacific College students were generally supportive of/positively neutral to science. Einstein students more strongly affirmed the relationship of science in relation to the categories of Epistemology, Public Health, Emotion and Aesthetics, the Economy, and Public Policy. Pacific College students more strongly affirmed the relationship between science and the category Race and Gender. There were no differences in the categories of Environment and Resource, Science for All, and Religion and Morality.

CONCLUSION

This study suggests that there are differences underlying the scientific worldviews of Einstein and Pacific College students, particularly with regard to Epistemology and Public Health. Such differences may be related to the different theoretical knowledge bases and ways of viewing health within the two disciplines. Despite demographic and educational differences between the two groups their overall scientific worldviews were similar with neither group expressing disparate views. This suggests that both groups may be receptive to the value of other paradigms. Providing courses that focus on different therapeutic approaches and paradigms during medical training may foster interprofessional understanding and collaborative practice between health professionals of different medical disciplines.

Implicit Bias Recognition and Management in Interpersonal Encounters and the Learning Environment: A Skills-Based Curriculum for Medical Students

Introduction

Students desire instruction in skill development to address both their own implicit biases and bias perceived in the learning environment. Curricula to date achieve strategy identification through reflection and discussion but do not provide opportunity for personally relevant skill development and practice in implicit bias recognition and management. To address this gap, we developed and evaluated a skills-based elective in implicit bias recognition and management focused on learners' own interpersonal interactions, including patient encounters, and perceived bias in the learning environment.

Method

Fifteen first-year medical students completed the nine-session elective over three annual offerings. Each session lasted 1.5 hours. Curriculum development was informed by published frameworks and transformative learning theory. Direct observation of student performances in role-plays and other active learning exercises constituted the formative assessment. Program evaluation focused on the impact of instruction through pre- and posttests, along with analysis of notes taken by the investigative team, including notes on formative assessments.

Results

Students engaged with all aspects of instruction, including role-plays. Pretest/posttest results demonstrated increased self-reported knowledge and comfort in addressing perceived bias. Formative assessment demonstrated students' skill development in safely and respectfully addressing perceived bias in the learning environment without endangering their relationships with supervisors.

Discussion

Skills developed-addressing bias in interpersonal encounters and perceived bias in clinical and teaching encounters-are relevant to learners throughout their careers. This course is relevant to medical students and trainees at various experience levels and could serve as a template for novel, skills-based curricula across health professions.

How Assumptions and Preferences Can Affect Patient Care: An Introduction to Implicit Bias for First-Year Medical Students

INTRODUCTION

Instruction in implicit bias is becoming prevalent across the spectrum of medical training. Little education exists for preclinical students, and guidance for faculty to facilitate such education is minimal. To address these gaps, we designed and delivered a single session for incoming first-year medical students and developed a facilitator training program.

METHODS

One faculty member delivered a 1-hour, multimedia, interactive lecture to all first-year medical students. Students subsequently met in small groups with trained facilitators. Activities included reflection, guided debriefing, and strategy identification to become aware of when they might be making an assumption causing them to jump to a conclusion about someone. The program evaluation consisted of aggregated student strategies and facilitator feedback during postsession debriefs, both analyzed through thematic analysis.

RESULTS

We delivered instruction to 1,098 students. Student strategies resulted in three themes: (1) humility, (2) reflection, and (3) partnering. The postsession debriefs uncovered opportunities to enhance the session. Lessons learned included presenting material to an entire class at once, allowing students to engage in dynamic discussion in the small groups, eliminating anonymous polling in the small groups, and highlighting management of implicit bias as essential to professional development.

DISCUSSION

Our instructional design enabled first-year medical students to identify at least one strategy to use when implicit biases are activated. The large-group session was deliverable by one faculty member, and volunteers successfully facilitated small-group sessions after only one training session, making this model a feasible innovation to reach an entire medical school class at the same time.

Implicit Bias Recognition and Management: Tailored Instruction for Faculty

BACKGROUND

Implicit bias instruction is becoming more prevalent across the continuum of medical education. Little guidance exists for faculty on recognizing and debriefing about implicit bias during routine clinical encounters.

OBJECTIVE

To assess the impact and feasibility of single seminars on implicit bias and the approach to its management in clinical settings.

METHODS

Between September 2016 and November 2017, the authors delivered five departmental/divisional grand rounds across three different academic medical centers in New York, USA. Instruction provided background information on implicit bias, highlighted its relevance to clinical care, and discussed proposed interventions. To evaluate the impact of instruction participants completed a twelve-item retrospective pre-intervention/post-intervention survey. Questions related to comfort and confidence in recognizing and managing implicit bias, debriefing with learners, and role-modeling behaviors. Participants identified strategies for recognizing and managing potentially biased events through free text prompts. Authors qualitatively analyzed participants' identified strategies.

RESULTS

We received 116 completed surveys from 203 participants (57% response rate). Participants self-reported confidence and comfort increased for all questions. Qualitative analysis resulted in three themes: looking inward, looking outward, and taking action at individual and institutional levels.

CONCLUSION

After a single session, respondents reported increased confidence and comfort with the topic. They identified strategies relevant to their professional contexts which can inform future skills-based interventions. For healthcare organizations responding to calls for implicit bias training, this approach has great promise. It is feasible and can reach a wide audience through usual grand rounds programming, serving as an effective early step in such training.

Survey analysis to determine the impact of evidence informed practice education upon East Asian medicine faculty clinical instruction and students' skills, knowledge, attitudes and behaviors within a master's degree program

BACKGROUND

Between 2013 and 2018 Pacific College of Health and Science (formerly Pacific College of Oriental Medicine) trained faculty and developed curriculum in evidence informed practice (EIP), with support from a grant from the National Institutes of Health (NIH). A three-credit (45 h) Foundations of EIP course, and online EIP learning modules (developed as part of a previous NIH R25 award), were used for faculty and student training. In addition, EIP was incorporated into 73% of the East Asian medicine degree program. Clinical integration of EIP in the College clinic was enhanced by improving access to reference sources, including additional EIP-related questions to the patient intake forms, requiring the use of a patient-centered outcome instrument, and assessing students' clinical EIP competencies.

METHODS

Master's degree students' self-reported EIP skills, knowledge, attitudes and behaviors were assessed before and after taking the Foundations of EIP course using a 17-question paper-based survey with an additional open-ended comments section. The survey was administered in 29 courses across all three Pacific College campuses. Clinical faculty self-reported EIP instruction, focusing on the EIP content and instructional approaches that were utilized, was evaluated on the New York City campus using a paper-based survey before and after changes were made to enhance the clinical integration of EIP.

RESULTS

A total of 1181 completed EIP-course surveys consisting of 657 pre-EIP course surveys and 524 post-EIP course surveys were analyzed. There was a statistically significant improvement in students' EIP skills, knowledge and behaviors after completing the EIP course. Students' perception of the importance of EIP was high before and after the EIP course. Little change in Faculty's EIP-related clinical instruction was evident following the EIP-related changes that were made to the Clinic.

CONCLUSION

Our study suggests that the three-credit (45 h) EIP course was effective at improving the EIP skills, knowledge and behaviors of this group of East Asian medicine students who were undertaking a master's degree that qualified them for licensure in acupuncture in the US. These students also demonstrated a high level of recognition for the importance of research and EIP both before and after the course. Training faculty clinical supervisors and providing greater access to evidence sources in the College clinic did not appear to increase EIP instructional activity.

Validity evidence for a novel instrument assessing medical student attitudes toward instruction in implicit bias recognition and management

BACKGROUND

Implicit bias instruction is becoming more prevalent in health professions education, with calls for skills-based curricula moving from awareness and recognition to management of implicit bias. Evidence suggests that health professionals and students learning about implicit bias ("learners") have varying attitudes about instruction in implicit bias, including the concept of implicit bias itself. Assessing learner attitudes could inform curriculum development and enable instructional designs that optimize learner engagement. To date, there are no instruments with evidence for construct validity that assess learner attitudes about implicit bias instruction and its relevance to clinical care.

METHODS

The authors developed a novel instrument, the Attitude Towards Implicit Bias Instrument (ATIBI) and gathered evidence for three types of construct validity- content, internal consistency, and relationship to other variables.

RESULTS

Authors utilized a modified Delphi technique with an interprofessional team of experts, as well as cognitive interviews with medical students leading to item refinement to improve content validity. Seven cohorts of medical students, N = 1072 completed the ATIBI. Psychometric analysis demonstrated high internal consistency (α = 0.90). Exploratory factor analysis resulted in five factors. Analysis of a subset of 100 medical students demonstrated a moderate correlation with similar instruments, the Integrative Medicine Attitude Questionnaire (r = 0.63, 95% CI: [0.59, 0.66]) and the Internal Motivation to Respond Without Prejudice Scale (r = 0.36, 95% CI: [0.32, 0.40]), providing evidence for convergent validity. Scores on our instrument had low correlation to the External Motivation to Respond Without Prejudice Scale (r = 0.15, 95% CI: [0.09, 0.19]) and the Groningen Reflection Ability Scale (r = 0.12, 95% CI: [0.06, 0.17]) providing evidence for discriminant validity. Analysis resulted in eighteen items in the final instrument; it is easy to administer, both on paper form and online.

CONCLUSION

The Attitudes Toward Implicit Bias Instrument is a novel instrument that produces reliable and valid scores and may be used to measure medical student attitudes related to implicit bias recognition and management, including attitudes toward acceptance of bias in oneself, implicit bias instruction, and its relevance to clinical care.

It Can Be Done! A Skills-Based Elective in Implicit Bias Recognition and Management for Preclinical Medical Students

PURPOSE

Students perceive bias in learning environments. Curricula targeting implicit bias recognition and management increase student awareness and achieve strategy identification, but fall short of actual skill development to address bias. In light of this gap, the authors developed and evaluated a skills-based elective to recognize and manage implicit bias in the learning environment.

METHOD

Nine 1.5-hour sessions were delivered to 15 first-year medical students from 2017 to 2019. An evidence-based conceptual framework and transformative learning theory informed the instructional design; it incorporated active learning exercises. Skills assessment occurred through direct observation of student performances in role-play exercises. Using thematic analysis, the authors conducted a program evaluation based on focus groups with students and data from notes taken by the investigative team.

RESULTS

Students engaged with all aspects of instruction, including role-plays. Authors identified 3 themes from the program evaluation: (1) Student engagement can be enhanced, (2) Instruction is empowering, and (3) It (addressing bias in one's own and witnessed encounters) can be done! Analysis additionally highlighted opportunities for improvement and lessons learned.

CONCLUSIONS

This innovative course achieved skill development and practice for medical students in implicit bias recognition and management as it pertains to 3 facets of clinical care present at every stage of a health professional's career. These include interpersonal encounters, advocating for patients when bias is perceived in witnessed encounters with peers and supervisors, and addressing comments made by others within the learning environment. Outcomes could inform novel, skills-based curricula across the spectrum of health professions training and practice.

Developing, Integrating, and Implementing Evidence-Informed Practice Curricula Throughout a Chinese Medicine Degree Program

Objectives: To train faculty and develop curricula in evidence-informed practice (EIP) within a Chinese medicine degree program.

Setting: Pacific College of Oriental Medicine (New York).

Design: Faculty EIP training was undertaken through utilization of online EIP modules, and development and completion of a 3-credit (45 h) online Foundations of EIP course. This was supplemented by faculty meetings and one-on-one support from department chairs. Curriculum development was undertaken by an EIP Curriculum Committee. The committee followed a modified Delphi process to develop EIP course learning outcomes (CLOs), and to make changes to the College's clinic policies and procedures. EIP assignments were developed for each course in accordance with the CLO.

Results: Ninety-one percent of the faculty and 97% of clinical supervisors received formal EIP training. Thirty-five percent of all didactic faculty, 38% of faculty teaching courses with EIP incorporated, and 30% of clinical supervisors completed 10 or more h of EIP training during this project. Faculty also received informal EIP training through participation in department and general faculty meetings. Seventy-three percent of the Master's degree curriculum, inclusive of 40 didactic courses and fifteen 60-h clinic shifts, were modified to incorporate EIP. EIP CLOs and corresponding assignments were developed. Clinic intake forms were modified to facilitate undertaking EIP in the College clinic. Issues related to how EIP is defined in conjunction with the nature of available scientific research in Chinese medicine required discussion and resolution.

Conclusions: Training faculty and developing curricula in EIP within Chinese medicine colleges has unique challenges that must be factored into the strategies and processes. Factors that contributed to the success of this project were having faculty drive the process, integrating EIP content within existing curricula, gradual exposure, identifying champions, relating EIP to practice building, and openly discussing opposing perspectives.

Interdisciplinary Relationship Models for Complementary and Integrative Health: Perspectives of Chinese Medicine Practitioners in the United States

OBJECTIVES

The combination of biomedicine and traditional and complementary medicine (T&CM) is often referred to as integrative medicine. However, the degree to which the medical disciplines are integrated varies between medical settings, and it is believed by some to be impossible due to epistemological and paradigmatic differences. Clinicians' perspectives are important determinants of how different medical disciplines are used together. This study explores the perspectives of experienced Chinese medicine practitioners when asked about the most ethical model (opposition, integration, or pluralism) for the relationship between biomedicine and T&CM.

DESIGN

Thirty-one Chinese medicine practitioners, undertaking a doctoral upgrade program at the Pacific College of Oriental Medicine, participated in this study. Participants were asked to read a publication discussing three models (opposition, integration, and pluralism) for the relationship between biomedicine and T&CM and then discuss, via an online forum within Moodle learning management system, the most ethical model. An inductive content analysis of the forum posts was undertaken to identify common themes, followed by member checking.

RESULTS

The data were found to contain six major and six minor themes. There was a clear preference for pluralism. The Chinese medicine practitioners expressed reservations about the integrative model, and, above all, cared about the quality of patient care. Much dialogue occurred around issues related to a power imbalance within health care, and possible cooptation issues. Paradigmatic differences and a lack of compatibility between biomedical research models and the practice of Chinese medicine were seen as problematic to the validity of research findings. Interprofessional education was viewed as critical for the development of respect, shared patient care, and referrals between clinicians from different disciplines.

CONCLUSIONS

This study provides insight into the issues associated with combining biomedicine and T&CM that are perceived by Chinese medicine practitioners. Such insights are important for the development and management of clinical settings that provide complementary and integrative health care, especially as the provision of insurance coverage for T&CM increases.

How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development

PURPOSE

To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management.

METHOD

Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts.

RESULTS

Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development.

CONCLUSIONS

Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.

Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development

OBJECTIVE

Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived.

METHODS

The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory.

RESULTS

Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions.

CONCLUSIONS

Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias.

PRACTICE IMPLICATIONS

Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

Survey of Chinese Medicine Students to Determine Research and Evidence-Based Medicine Perspectives at Pacific College of Oriental Medicine

CONTEXT

Research literacy and the practice of evidence-based medicine (EBM) are important initiatives in complementary and alternative medicine (CAM), which requires cultural change within educational institutions for successful implementation.

OBJECTIVE

To determine the self-assessed research and EBM perspectives of Chinese medicine Masters degree students at Pacific College of Oriental Medicine, New York campus (PCOM-NY).

DESIGN AND METHODS

A survey with 17 close-ended questions and one open-ended question was administered through Survey Monkey to students at PCOM-NY.

RESULTS

The survey was sent to 420 Masters students and 176 (41.9%) responded. Students in all four years of the Masters degree indicated a generally high degree of interest in, and support for the value of research. However, increasing years (one to four years) in the program was associated with lower interest in post-graduation research participation and entering the doctoral program, and the fourth year students reported low levels of interest in having greater research content and training in their Masters degree programs. Students who responded to the open-ended question (23% of respondents) expressed enthusiasm for research and concerns about the relevance of research in Chinese medicine.

CONCLUSIONS

Consistent with findings in similar studies at CAM colleges, interest in research, and EBM of the PCOM-NY Masters students appeared to decline with increasing years in the program. Concerns around paradigm and epistemological issues associated with research and EBM among Chinese medicine students and practitioners warrants further investigation, and may be an important challenge for integrative medicine.

The Evolution of an Elective in Health Disparities and Advocacy: Description of Instructional Strategies and Program Evaluation

PROBLEM

Health disparities remain pervasive in the United States. Training future physicians to address health disparities requires attention to both systemic and provider causes of disparities, but comprehensive curricula are lacking.

APPROACH

Albert Einstein College of Medicine in Bronx, New York, offers a 13-session health disparities elective to first-year medical students. The curriculum covers three main content areas: background, provider contributions to health disparities, and systemic contributions to health disparities (i.e., social determinants of health). Teaching methods included didactic and multimedia presentations, reflective discussions, and skill-building seminars (e.g., addressing subconscious assumptions and advocacy training).The authors evaluated the course in 2010-2013 by comparing students' summary scores for knowledge, attitudes, and self-reported confidence on pre- and postintervention tests. They investigated associations between students' sociodemographic characteristics and changes in summary scores.

OUTCOMES

Scores increased significantly in each domain: Mean knowledge scores increased from 63.6 (± 10.0), out of 100, to 76.4 (± 12.8); mean attitudes scores increased from 16.7 (± 1.9), out of 20, to 18.2 (± 1.1); mean confidence scores increased from 10.7 (± 1.5), out of 16, to 14.4 (± 1.7). Younger students (< 24) had greater changes in confidence than older students. Other sociodemographic characteristics were not associated with changes in any domain.

NEXT STEPS

Exposure to health disparities instruction is important for medical students. The authors' experience provides insights for incorporating such material into the compulsory curriculum. Future evaluation of outcomes from similar curricula should include measures of clinical behaviors (e.g., through clinical examinations).

Faculty survey to assess research literacy and evidence-informed practice interest and support at Pacific College of Oriental Medicine

CONTEXT

Educating healthcare practitioners to understand, critically evaluate, and apply evidence to the clinical practice of complementary and alternative medicine has been an important initiative for the National Institutes of Health National Center for Complementary and Alternative Medicine.

OBJECTIVE

To determine the self-assessed research skills and interest of faculty at Pacific College of Oriental Medicine (New York campus) and their likely support of, and participatory interest in, an evidence-based medicine (EBM) training program.

DESIGN

The survey was administered in Survey Monkey. All questions were close-ended with 5-point Likert answers, except for one open-ended question at the end of the survey.

SETTING

One of three campuses of Pacific College of Oriental Medicine (PCOM), the largest Chinese medicine college in the United States.

PARTICIPANTS

102 faculty employed at PCOM.

RESULTS

The response rate was 88.7%. Responses illustrated a generally high degree of interest and support for research, EBM, and institutional participation in research activities. Faculty who responded to the open-ended question (19.6% of respondents) expressed concerns about the relevance of research to Chinese medicine and the possibility of co-option by biomedicine.

CONCLUSIONS

While faculty were overall supportive and interested in research and EBM, the results are consistent with the hypothesis that success of EBM training programs could be enhanced by soliciting and addressing faculty concerns and by being inclusive of approaches that honor the traditions of Chinese medicine and its own forms of clinical evidence.

Implicit bias and its relation to health disparities: a teaching program and survey of medical students

BACKGROUND

The varying treatment of different patients by the same physician are referred to as within provider disparities. These differences can contribute to health disparities and are thought to be the result of implicit bias due to unintentional, unconscious assumptions.

PURPOSES

The purpose is to describe an educational intervention addressing both health disparities and physician implicit bias and the results of a subsequent survey exploring medical students' attitudes and beliefs toward subconscious bias and health disparities.

METHODS

A single session within a larger required course was devoted to health disparities and the physician's potential to contribute to health disparities through implicit bias. Following the session the students were anonymously surveyed on their Implicit Association Test (IAT) results, their attitudes and experiences regarding the fairness of the health care system, and the potential impact of their own implicit bias. The students were categorized based on whether they disagreed ("deniers") or agreed ("accepters") with the statement "Unconscious bias might affect some of my clinical decisions or behaviors." Data analysis focused specifically on factors associated with this perspective.

RESULTS

The survey response rate was at least 69%. Of the responders, 22% were "deniers" and 77% were "accepters." Demographics between the two groups were not significantly different. Deniers were significantly more likely than accepters to report IAT results with implicit preferences toward self, to believe the IAT is invalid, and to believe that doctors and the health system provide equal care to all and were less likely to report having directly observed inequitable care.

CONCLUSIONS

The recognition of bias cannot be taught in a single session. Our experience supports the value of teaching medical students to recognize their own implicit biases and develop skills to overcome them in each patient encounter, and in making this instruction part of the compulsory, longitudinal undergraduate medical curriculum.

Developing a multidisciplinary model of comparative effectiveness research within a clinical and translational science award

The Clinical and Translational Science Awards (CTSAs) were initiated to improve the conduct and impact of the National Institutes of Health's research portfolio, transforming training programs and research infrastructure at academic institutions and creating a nationwide consortium. They provide a model for translating research across disciplines and offer an efficient and powerful platform for comparative effectiveness research (CER), an effort that has long struggled but enjoys renewed hope under health care reform. CTSAs include study design and methods expertise, informatics, and regulatory support; programs in education, training, and career development in domains central to CER; and programs in community engagement.Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center have entered a formal partnership that places their CTSA at a critical intersection for clinical and translational research. Their CTSA leaders were asked to develop a strategy for enhancing CER activities, and in 2010 they developed a model that encompasses four broadly defined "compartments" of research strength that must be coordinated for this enterprise to succeed: evaluation and health services research, biobehavioral research and prevention, efficacy studies and clinical trials, and social science and implementation research.This article provides historical context for CER, elucidates Einstein-Montefiore's CER model and strategic planning efforts, and illustrates how a CTSA can provide vision, leadership, coordination, and services to support an academic health center's collaborative efforts to develop a robust CER portfolio and thus contribute to the national effort to improve health and health care.

In it for the long-term: defining the mentor-protégé relationship in a clinical research training program

PURPOSE

To define the characteristics of effective mentor-protégé relationships in a Clinical Research Training Program (CRTP) and to assess the agreement among mentors and protégés regarding those attributes.

METHOD

The authors administered an anonymous survey to protégés who completed the Albert Einstein College of Medicine's CRTP during its first seven years (2000-2006) and their mentors. Statements included aspects of mentoring thought to be important within the program, such as availability (Statement 1) and oversight of the thesis process (Statements 2-4). Additional statements were related both to career development (e.g., looking out for the best interests of the scholar and assisting in negotiations for a faculty position after program completion [Statements 5 and 6]) and to the expectation that the mentor would continue to be a resource for the protégé in years to come (Statement 7). The authors assessed overall agreement among mentors and protégés, using matched pair analysis.

RESULTS

Overall response was 70.7% (133/188), with fewer matched pairs (n = 50, 50%). Seventy-five percent of respondents agreed strongly or somewhat with all statements. Analysis indicated significant agreement with Statements 2, 4, 6, and 7. Median scores from protégés did not differ whether their mentor responded (paired) or not (unpaired); however, mentor-protégé pairs had significantly greater agreement with Statements 3-7 than unpaired mentors and protégés (P < .01).

CONCLUSIONS

Mentors and protégés seemed to agree that mentors within a CRTP demonstrated effective mentor attributes, including fostering a long-term relationship with the protégé.

Defining translational research: implications for training

Because translational research is not clearly defined, developers of translational research programs are struggling to articulate specific program objectives, delineate the knowledge and skills (competencies) that trainees are expected to develop, create an appropriate curriculum, and track outcomes to assess whether program objectives and competency requirements are being met. Members of the Evaluation Committee of the Association for Clinical Research Training (ACRT) reviewed current definitions of translational research and proposed an operational definition to use in the educational framework. In this article, the authors posit that translational research fosters the multidirectional and multidisciplinary integration of basic research, patient-oriented research, and population-based research, with the long-term aim of improving the health of the public. The authors argue that the approach to designing and evaluating the success of translational training programs must therefore be flexible enough to accommodate the needs of individual institutions and individual trainees within the institutions but that it must also be rigorous enough to document that the program is meeting its short-, intermediate-, and long-term objectives and that its trainees are meeting preestablished competency requirements. A logic model is proposed for the evaluation of translational research programs.

Epidemiology 101: toward an educated citizenry

Epidemiology, as the core science underpinning public health, encompasses methods and concepts that are fundamental to understanding health-related information and health policy. Thus, understanding these concepts would enhance the lay public's ability to make informed decisions with respect to health and prevention, and teaching epidemiology at the undergraduate level would be consistent with the goal of creating an educated citizenry. While epidemiology has traditionally been taught largely within graduate schools, there has been experience at the undergraduate level as well. This experience has demonstrated that such courses are popular and effective. While there may be some challenges inherent to teaching Epidemiology 101 at every college and university, this is a worthy and important goal, and most challenges can be successfully overcome with creativity and effort. Perhaps the greatest barrier is instinctive resistance to this idea, since most faculty with epidemiology training received such training in graduate schools. It is up to us to cast off those preconceptions; if one explores the notion of undergraduate epidemiology teaching with an open and unbiased mind, the logic, feasibility, and importance of this effort becomes clear.

A call for higher standards of evidence for dietary guidelines

Dietary guidelines, especially those designed to prevent the diseases of dietary excess, are a relatively new phenomenon in the United States. National dietary guidelines have been promulgated based on scientific reasoning and indirect evidence. In general, weak evidentiary support has been accepted as adequate justification for these guidelines. This low standard of evidence is based on several misconceptions, most importantly the belief that such guidelines could not cause harm. Using guidelines against dietary fat as a case in point, an analysis is provided that suggests that harm indeed may have been caused by the widespread dissemination of and adherence to these guidelines, through their contribution to the current epidemic of obesity and overweight in the U.S. An explanation is provided of what may have gone wrong in the development of dietary guidelines, and an alternative and more rigorous standard is proposed for evidentiary support, including the recommendation that when adequate evidence is not available, the best option may be to issue no guideline.

Diabetes and stress hyperglycemia associated with myocardial infarctions at an urban municipal hospital: prevalence and effect on mortality

Municipal hospitals in large cities provide care for patients from immigrant and mixed ethnic communities that are at high risk for diabetes. Both diabetes and stress hyperglycemia increase the risk of adverse outcome after myocardial infarctions, and the impact of stress hyperglycemia on the outcome of myocardial infarctions in this particular setting has not been previously studied. We therefore undertook a retrospective cohort study to determine the prevalence of diabetes and stress hyperglycemia in patients presenting to a university-affiliated Bronx municipal hospital with myocardial infarction, and the relationship of these conditions to the extent of coronary disease and mortality. We obtained data on 106 consecutive patients from July 1998 to April 1999 with a diagnosis-related group diagnosis of either myocardial infarction or acute coronary syndrome, in which myocardial infarction was confirmed by serum enzymes or characteristic electrocardiographic changes. Patients were followed until March 30, 2001. Measurements of clinical parameters and results of catheterization were obtained for all patients. Death rates were determined by laboratory database, direct patient contact, or data from National Death Index. Eighty percent of the cohort had either a diagnosis of diabetes (n = 45, 42% of cohort) or evidence of stress hyperglycemia (defined as serum glucose greater than 126 mg/dL at the time of admission without prior diagnosis of diabetes, n = 40, 38%). In-hospital mortality for patients with diabetes, stress hyperglycemia, or normal glucose was 20%, 15%, and 14%, respectively. Eighty-three percent of the cohort received beta blockers, and 61% of hospital survivors had catheterization. Left main or triple vessel disease was common in both patients with diabetes (52%) and patients with stress hyperglycemia (32%). Mortality at follow up (maximum follow up 3 years; mean follow up 19.6 months) was much higher in patients with either diabetes (42%) or stress hyperglycemia (52%) than normal subjects (24%). Kaplan-Meier analysis of the difference in mortality between patients with high glucose on admission and normal subjects was borderline significant (P = 0.06). Multivariate regression demonstrated that age (P = 0.020), increase in admission serum creatinine (P = 0.001), and reduction in either ejection fraction (P = 0.016) or admission systolic blood pressure (P = 0.005) were significant predictors of mortality. Glycemic status and sex were not independently associated with death after controlling for these other factors. These results show that the prevalence of both diabetes and stress hyperglycemia on presentation with myocardial infarction is strikingly high in this immigrant, mixed ethnic, urban population. Patients with diabetes and stress hyperglycemia had advanced disease on presentation and much higher mortality at 2 to 3 years than those with normal blood glucose. The mortality difference is the result of older age and more advanced disease rather than hyperglycemia per se.

Teaching clinical skills through videotape review: a randomized trial of group versus individual reviews

BACKGROUND

Video review is a valuable educational tool for teaching communication skills. Many studies have demonstrated its efficacy with individual learners, but few studies have addressed its use in a group format.

PURPOSE

To assess the educational benefits of group versus individual video review of standardized patient encounters through the evaluations of 4th-year students at the Albert Einstein College of Medicine.

METHODS

Students (128) who participated in a 7-station, standardized patient, clinical competency exam were randomly assigned to an individual or small group video review of selected segments of these encounters in 2000-2001. Students filled out an anonymous 13-item questionnaire assessing the experience and provided open-ended responses.

RESULTS

With both review formats, most students had a positive learning experience (80%), found it less stressful than they expected (67%), and would not have preferred to do the review the other way (84%). Students randomized to individual reviews had a significantly higher level of satisfaction with the amount of time for the session (91% vs. 78%, p < .05) and the amount of feedback they received (95% vs. 79%, p = .01) and were more likely to view the session as a positive learning experience (88% vs. 73%, p < .05). Students in the individual review format were more likely to choose self-assessed weak segments (63% vs. 49%, p = .01). Students' comments indicated that they appreciated the value of peer review in a group setting.

CONCLUSIONS

Although both group reviews and individual reviews of videotaped standardized patient encounters were received well by the students, there were several statistical differences in favor of the individual format.

Community-based screening for cardiovascular disease and diabetes using HbA1c

BACKGROUND

Persons from inner-city immigrant and mixed-ethnic communities are known to be at high risk for cardiovascular disease and diabetes. Such communities may also be underserved for preventive medical care. The authors hypothesized that hemoglobin A1c (HbA1c) could be used as a screening test for a community-based program to detect new cases of diabetes and persons at risk for diabetes and cardiovascular disease.

METHODS

Screenings took place in churches, group homes, shelters, community centers, and street corners of the Bronx. Screening data included history of diabetes, age, ethnicity, body mass index, blood pressure, lipid panel, random glucose, and HbA1c. Data were analyzed for number of cases of new diabetes (HbA1c > or =7%), for patients at risk for diabetes (HbA1c 6%-6.99%), and for associations between HbA1c and other variables. The effect of location of screening and self-reported ethnicity on outcome variables was also analyzed.

RESULTS

Seven hundred four persons were screened in 25 different sessions. HbA1c and lipid profile were obtained on 539 persons, which formed the cohort for analysis. Mean HbA1c for the cohort was 6.00%. Thirty-two percent of the cohort had HbA1c of more than 6%, and 11.4% had HbA1c of more than 7%. Excluding known diabetics (13% of cohort), 24% had HbA1c of more than 6%, and 3.4% had HbA1c of more than 7%. HbA1c was significantly correlated with total cholesterol, triglycerides, low-density lipoprotein, systolic blood pressure, body mass index, and age; in all cases, correlation coefficients were higher with HbA1c than with random glucose. In addition, significantly higher cardiovascular disease risk factors were found in persons with HbA1c of more than 6%; 6% may be a threshold value for the metabolic syndrome. Mean HbA1c was higher in persons from the South Bronx (which has a higher poverty rate) than the North Bronx (6.08% v 5.74%, p=0.013). There were no statistically significant differences between self-reported ethnic groupings.

CONCLUSIONS

There was a high prevalence of undiagnosed diabetes, and of patients at risk for diabetes, in this community setting. Community-based screening can be used as a method for identifying high percentages of patients at risk for diabetes or with undiagnosed diabetes in an inner city, immigrant, mixed-ethnic population.

Using the case-discussion method to teach epidemiology and biostatistics

Medical students must learn the principles of epidemiology and biostatistics to critically evaluate the medical literature. However, this subject has traditionally been difficult to teach. In 1997 at the Albert Einstein College of Medicine, the required first-year course in epidemiology and biostatistics was revised to use the case-discussion teaching method. In preparation for the course, experienced faculty participated in an intensive, two-day training workshop. The course, taught to 163 first-year medical students, was structured in two parts: (1) three lectures complemented by a detailed syllabus, followed by a multiple-choice midterm exam; and (2) six case-discussion seminars, followed by a short answer/essay final exam. There were seven case-discussion groups with 23-24 students each. The program was evaluated using subjective faculty feedback, examination scores, and student evaluation questionnaires. Faculty noted excellent student preparation and participation. Multiple-choice exam scores were comparable to those from earlier years, and a short answer/essay exam demonstrated good student mastery of the required material. Student evaluation was overwhelmingly positive, and significantly improved from prior years of the course. Positive student evaluations of the course using this teaching method continued over the next four years; National Board of Medical Examiners examination scores indicated success in mastery of the material; and student assessment of the course improved on the AAMC Graduation Questionnaire. This favorable experience suggests that case-discussion teaching can be employed successfully in teaching principles of epidemiology and biostatistics to medical students.

The internal medicine subinternship: a curriculum needs assessment

Despite broad acceptance of the internal medicine subinternship rotation by the undergraduate medical education community, only a small fraction of programs provide students with explicit learning objectives. To design a curriculum for the medical subinternship, we surveyed 3 different groups of educational stakeholders--subinternship directors, residency program directors, and housestaff--in order to identify and prioritize the competencies that should be learned during this rotation. This study provides a starting point for the development of a structured curriculum for the fourth-year subinternship rotation.

Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study

OBJECTIVES

We investigated prospectively the relationships among falls, physical balance, and standing and supine blood pressure (BP) in elderly persons.

BACKGROUND

Falls occur often and adversely affect the activities of daily living in the elderly; however, their relationship to BP has not been clarified thoroughly.

METHODS

A total of 266 community-dwelling elderly persons age 65 years or over (123 men and 143 women, mean age of 76 years) were selected from among residents of Coop City, Bronx, New York. Balance was evaluated at baseline using computerized dynamic posturography (DPG). During a one-year follow-up, we collected information on subsequent falls on a monthly basis by postcard and telephone follow-up.

RESULTS

One or more falls occurred in 60 subjects (22%) during the one-year follow-up. Women fell more frequently than men (28% vs. 16%, p < 0.03), and fallers were younger than nonfallers. Fallers (n = 60) had lower systolic BP (SBP) levels when compared with nonfallers (n = 206) (128 +/- 17 vs. 137 +/- 22 mm Hg for standing, p < 0.006; 137 +/- 16 vs. 144 +/- 22 mm Hg for lying, p < 0.02), whereas diastolic BP was not related to falls. Falls occurred 2.8 times more often in the lower BP subgroup (<140 mm Hg for standing SBP) than in the higher BP subgroup (> or =140 mm Hg, p < 0.0003), and gender-related differences were observed (p = 0.006): 3.4 times for women (p < 0.0001) versus 1.9 times for men (p = 0.30). Loss of balance, as detected by DPG, did not predict future falls and was also not associated with baseline BP levels. Multiple logistic regression analysis demonstrated that female gender (relative risk [RR] = 2.1, p = 0.02), history of falls (RR = 2.5, p = 0.008) and lower standing SBP level (RR = 0.78 for 10 mm Hg increase, p = 0.005) were independent predictors of falls during one year of follow-up.

CONCLUSIONS

Lower standing SBP, even within normotensive ranges, was an independent predictor of falls in the community-dwelling elderly. Elderly women with a history of falls and with lower SBP levels should have more attention paid to the prevention of falls and related accidents.

Age-associated changes in diastolic filling: Doppler E/A ratio is not associated with congestive heart failure in the elderly

Although left ventricular filling tends to occur in late diastole in the elderly, the clinical significance of this change is unclear. To determine the prevalence of diastolic filling delay and its relationship to congestive heart failure (CHF) in the elderly, we studied 114 community-living elderly volunteers (median age 75, 37% male). Clinical history, physical examination, chest x-ray film, and Doppler echocardiogram were obtained in blinded fashion. CHF was diagnosed by a previously validated clinico-radiographic scoring system. Diastolic filling was assessed by the Doppler ratio of early to late transmitral flow velocity (E/A). The standard clinical definition of diastolic filling delay (E/A < 1) was met by 94 subjects (82%), and median E/A was 0.72; for this study, diastolic filling delay was defined at the median, although both approaches yielded similar results. Systolic function was normal (ejection fraction > or = 0.5) in 97%. There were 22 subjects (19%) with definite or possible CHF. Older subjects were more likely to have CHF, but not more likely to have an E/A ratio below the median. Subjects with diastolic filling delay were no more likely to have CHF than those without. Mean E/A was not different between CHF groups, and there was no significant correlation between E/A and CHF score. There was still no association after controlling for age, history of hypertension, and other potential confounders by multiple logistic regression. Although diastolic filling delay is common in the elderly, it does not correlate with signs and symptoms of CHF. Determination of its prognostic significance requires a prospective follow-up study.

Low incidence of stroke in ambulatory patients with heart failure: a prospective study

The current study was undertaken to determine prospectively the risk of cerebral thromboembolism and the prognostic significance of left ventricular thrombus in ambulatory patients with chronic congestive heart failure. A total of 264 ambulatory patients (mean age 62 years, mean left ventricular ejection fraction 27%) were followed prospectively for 24 +/- 9 months to determine the incidence of nonhemorrhagic stroke, transient ischemic attack, and mortality. Two-dimensional echocardiographic studies, performed for clinical indications other than previous systemic thromboembolism in 109 patients, were analyzed to relate the presence of left ventricular thrombus to subsequent outcome. Nine cerebral thromboembolic events occurred in 264 patients during the two-year mean follow-up period, yielding a rate of 1.7 thromboembolic events per 100 patient-years of follow-up. Known risk factors for stroke (hypertension, diabetes mellitus, and/or atrial fibrillation) were present in all nine patients with cerebral thromboembolic events. The 109 patients with echocardiographic studies had more severe heart failure than patients without echocardiographic studies (functional class 2.6 vs 2.1, p < 0.01), greater risk of a thromboembolic event (2.4 vs 1.4 events/100 patient-years of follow-up, p < 0.01), and higher mortality (21.3 vs 5.5 deaths/100 patient-years, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Lung cancer in patients with immunodeficiency syndrome

We report adenocarcinoma of the lung in seven patients with human immunodeficiency virus (HIV) infection. We compared age, clinical findings and survival data with a sex-matched control group of HIV-negative patients with adenocarcinoma of the lung. Median age of HIV-infected patients with lung cancer was lower than in control patients with lung cancer. The HIV-infected patients had more systemic symptoms and abnormal physical findings than control subjects. Both groups had smoking histories. Laboratory data were similar but control subjects had lower blood oxygen tensions than did HIV patients; HIV patients had more abnormalities on chest roentgenograms and computed tomography scans than did control subjects. All HIV-infected patients were stage IV. Median survival was 4 weeks. For control patients, 50 percent had stage IV disease; median survival was 25.5 weeks. Thus, patients with HIV infection develop lung cancer at a younger age than sex-matched control subjects and undergo a more fulminant course with shortened survivals.

Prognosis in ischemic heart disease. Can you tell as much at the bedside as in the nuclear laboratory?

BACKGROUND--While the resting left ventricular ejection fraction (LVEF) predicts prognosis in ischemic heart disease, clinical evaluation is also useful. METHODS--To compare the prognostic value of LVEF by resting radionuclide ventriculography with that of clinical signs and symptoms of congestive heart failure (CHF), 170 patients with suspected ischemic heart disease were followed up in this prospective study. Patients had a standardized history and physical examination performed by a study cardiologist immediately before the nuclear scan. Chest roentgenography and radionuclide ventriculography were performed in a standard manner. The diagnosis of CHF was made by validated clinicoradiographic criteria based on the Framingham study. Mortality was determined by means of the National Death Index; median follow-up time was 3 years. RESULTS--There was CHF at baseline in 70 patients, and baseline LVEF was low (< or = 0.4) in 63 patients. Low LVEF was significantly associated with CHF. During follow-up, 55 of the subjects died (overall mortality, 32%). Subjects with CHF had a significantly higher risk of death than those without CHF, and subjects with low LVEF had a higher mortality than those with preserved LVEF. Both CHF and LVEF were independent predictors of mortality. In a Cox model, each percentage increase in LVEF was associated with a 2% decreased mortality, while subjects with CHF had a mortality 2.5 times higher than that of those without CHF. Also, CHF with preserved LVEF had a better prognosis than CHF with depressed LVEF, but this prognosis was worse than that in subjects without CHF. CONCLUSIONS--The clinical diagnosis of CHF, based on clinical evaluation and chest roentgenogram, is a valid predictor of mortality and provides information independent of the radionuclide LVEF in determining prognosis in patients with ischemic heart disease.

Left ventricular hypertrophy in black and white hypertensives. Standard electrocardiographic criteria overestimate racial differences in prevalence

OBJECTIVE

To assess racial differences in the accuracy of standard electrocardiographic (ECG) criteria in the diagnosis of left ventricular hypertrophy (LVH).

DESIGN

The sensitivity and specificity of standard ECG criteria were compared in blacks and whites using echocardiographic LVH as the reference standard.

SETTING

Eight worksite-based hypertension clinics in New York, NY.

PATIENTS

A sample of 122 black and 148 white hypertensive patients.

RESULTS

The prevalence of ECG-LVH was two to six times higher in blacks than in whites, depending on the criteria used (range, 6% to 24% in blacks vs 1% to 7% in whites; P = .0005 to .19 for black-white comparisons). The difference in prevalence of echocardiographic LVH [corrected], however, was less striking and did not attain statistical significance (26% in blacks and 20% in whites; P greater than .2). The sensitivity of the ECG was low (range, 3% to 17%) and did not differ significantly between the two races for any of the conventional criteria; specificity, however, was lower in blacks for all criteria (range, 73% to 94% vs 95% to 100% for whites; P = .0001 to .09). The predictive value of a positive ECG was consistently, although not significantly, lower in the black subjects. Black race was the strongest independent predictor of decreased ECG specificity in multiple logistic regression analysis that also considered age, gender, body mass index, left ventricular mass index, and smoking.

CONCLUSIONS

Commonly used ECG criteria for the detection of LVH have a poor sensitivity in both black and white hypertensives and a lower specificity in blacks than in whites; this may lead to a greater number of false-positive diagnoses in black patients, as well as to an overestimation of black-white difference in LVH prevalence.

Teaching clinical epidemiology to medical students using a collaborative learning model

Epidemiology and biostatistics are difficult to teach in medical school. To determine the feasibility of applying a collaborative learning model, we randomly assigned one section of an epidemiology and biostatistics class to use this teaching model. Students in this section did not attend lectures or follow the regular curriculum but instead learned epidemiologic concepts by identifying clinical problems of interest to them and reviewing relevant journal articles, with the group leader functioning as facilitator. All students took an identical examination and anonymously evaluated the course. Examination performance was comparable between the study group (mean 72.1%) and the other students (mean 73.5%). However, the students' evaluation of the study group method was more favorable, especially in their perceived mastery of specific cognitive skills. The data suggest that this model can be successfully applied in teaching epidemiology and biostatistics to medical students.

Clinical diagnosis of congestive heart failure in patients with acute dyspnea

The validity and utility of physical examination maneuvers were determined in diagnosing congestive heart failure (CHF) in patients with acute dyspnea. Fifty one patients presented to the emergency room with the chief complaint of shortness of breath. History and physical examination were obtained independently, and the physical examination included hepatojugular reflux and the Valsalva maneuver. The diagnosis of CHF was made by predetermined criteria, and was compared with the diagnosis of the emergency room (ER) physician and with the response to bedside maneuvers. The hepatojugular reflux and Valsalva maneuvers were valid in the diagnosis of congestive heart failure in acutely dyspneic patients. Although these maneuvers rarely added to the routine assessment of patients in this study, they may provide a useful, noninvasive adjunct to clinical diagnosis in problematic cases.

Diagnostic heterogeneity in clinical trials for congestive heart failure

There are no uniform diagnostic criteria for congestive heart failure. To determine the pattern of diagnostic criteria used, reports of 51 randomized, double-blind, placebo-controlled, clinical drug trials published between 1977 and 1985 were reviewed. Only 23 (45%) of the trials specified objective diagnostic criteria beyond treatment history, clinical diagnosis, or functional class. Of these, there were two trials each for digoxin, hydralazine, amrinone, and metoprolol; for each pair, only one study showed therapy beneficial. Of the amrinone pair, the positive study required a lower ejection fraction (less than 30% compared with less than 45%) and selected patients with more clinical severity. Conversely, for metoprolol, the positive study specified a higher ejection fraction (less than 49% compared with less than 35%) and selected patients with clinically milder disease, suggesting that conflicting results may relate to differences in study population. Many studies of congestive heart failure are done without explicit diagnostic criteria. Criteria lack uniformity, and such discrepancies may explain conflicting results.

The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria

There is no uniformly accepted clinical definition for congestive heart failure (CHF), although criteria have been published by various groups. There is also no reference standard for CHF, although left ventricular ejection fraction (LVEF) gives a quantitative assessment of systolic function and is useful in predicting prognosis. To determine the relationship between LVEF and clinically diagnosed CHF, we compared resting LVEF determined by radionuclide ventriculography with diagnosis of CHF by clinical criteria in 407 patients, based on clinical data collected by a cardiology fellow. Of 153 patients with a low LVEF (less than or equal to 0.40), 30 (20%) met none of the criteria for CHF. Conversely, of 204 patients with normal LVEF (greater than or equal to 0.50), 105 (51%) met at least one of the criteria. We conclude that different criteria for CHF will have varying utility depending on the population being examined, and that a combination of clinical features and an objective measure of cardiac performance is needed to diagnose CHF.