Stakeholder Groups' Unique Perspectives About the Attending Physician Preceptor Role: A Qualitative Study

BACKGROUND

Attending physician preceptors are accountable to many stakeholder groups, yet stakeholders' views about what the preceptor role entails have not been sufficiently considered.

OBJECTIVE

To explore stakeholder groups' unique perspectives of the preceptor role.

DESIGN

Qualitative study with a constructivist orientation.

PARTICIPANTS

Semi-structured interviews were conducted with 73 participants from two university teaching hospitals between October 2012 and March 2014. Participants included representatives from seven stakeholder groups: patients and their families, allied healthcare providers, bedside nurses, nurse managers, medical students, internal medicine residents, and preceptors.

APPROACH

An inductive thematic analysis was conducted where researchers coded transcripts, abstracted codes into themes, and then mapped themes onto six focus areas: role dimensions, role performance, stressors and rewards, mastery, fulfillment, and impact on others. Two authors then identified "recurrent themes" (emerging in two or more focus areas) and compared them across groups to identify "unique themes" (emerging from a maximum of two stakeholder groups). "Unique thematic emphases" (unique themes that would not have emerged if a stakeholder group was not interviewed) are described.

KEY RESULTS

Patients and their families emphasized preceptors' ultimate authority. Allied healthcare providers described preceptors as engaged collaborators involved in discharge planning and requiring a sense of humor. Bedside nurses highlighted the need for role standardization. Nurse managers stressed preceptors' need for humanism. Medical students highlighted preceptors' emotional labor and their influence on learners' emotional well-being. Residents emphasized preceptors' responsibilities to multiple stakeholders. Preceptors described lifelong learning and exercising control over one's environment.

CONCLUSIONS

Various stakeholder groups hold unique and nuanced views of the attending physician preceptor role. These views could broaden formal role guidance for medical education and patient care. This study generated real-world, practical examples of what stakeholders feel are important preceptor skills. These skills should be practiced, taught, and role modeled in this clinical setting.

Understanding how patients perceive physician wellness and its links to patient care: A qualitative study

Despite increased interest in physician wellness, little is known about patients’ views on the topic. We explore patients’ perceptions of physician wellness and how it links to patient care. This exploratory, qualitative study employed semi-structured interviews with a convenience sample of 20 patients from outpatient care settings in a western Canadian city. Using inductive thematic analysis, interview transcripts were independently coded by two authors and then discussed to ensure consensus and to abstract into higher-level themes. Three overarching premises were identified. First, patients notice cues that they interpret as signs of physician wellness. These include overt indicators, such as a physician’s demeanor or physical appearance, along with a general impression about a physician’s wellness. Second, patients form judgments based on what they notice, and these judgments affect patients’ views about their care; feelings, such as trust, in their interactions with physicians; and actions, such as following care plans. Third, participants perceive a bi-directional link between physician wellness and patient care. Physician wellness impacts patient care, but physician wellness is also impacted by the care they provide and the challenges they face within the healthcare system. Patients’ judgments regarding physician wellness may have important impacts on the doctor-patient relationship. Furthermore, patients appear to have a nuanced understanding about how physicians’ work may put physicians at risk for being unwell. Patients may be powerful allies in supporting physician wellness initiatives focused on the shared responsibility of individual physicians, the medical profession, and healthcare organizations.

How evidence from observing attending physicians links to a competency-based framework

CONTEXT

Competency-based medical education frameworks are often founded on a combination of existing research, educational principles and expert consensus. Our objective was to examine how components of the attending physician role, as determined by observing preceptors during their real-world work, link to the CanMEDS Physician Competency Framework.

METHODS

This is a sub-study of a broader study exploring the role of the attending physician by observing these doctors during their working day. The parent study revealed three overarching elements of the role that emerged from 14 themes and 123 sub-themes: (i) Competence, defined as the execution of traditional physician competencies; (ii) Context, defined as the environment in which the role is carried out, and (iii) Conduct, defined as the manner of acting, or behaviours and attitudes in the role that helped to negotiate the complex environment. In this sub-study, each sub-theme, or 'role-related component', was mapped to the competencies described in the CanMEDS 2005 and 2015 frameworks.

RESULTS

Many role-related components from the Competence element were represented in the 2015 CanMEDS framework. No role-related components from the Context element were represented. Some role-related components from the Conduct element were represented. These Conduct role-related components were better represented in the 2015 CanMEDS framework than in the 2005 framework.

CONCLUSIONS

This study shows how the real-world work of attending physicians links to the CanMEDS framework and provides empirical data identifying disconnects between espoused and observed behaviours. There is a conceptual gap where the contextual influences of physicians' work and the competencies required to adjust to these influences are missing from the framework. These concepts should be incorporated into learning both broadly, such as through an emphasis on context within curriculum development for the workplace (e.g. entrustable professional activities), and explicitly, through the introduction of novel competencies (e.g. the Conduct role-related components described in this study).

An orientation to wellness for new faculty of medicine members: meeting a need in faculty development

OBJECTIVES

To evaluate the format, content, and effectiveness of a newly developed orientation to wellness workshop, and to explore participants' overall perceptions.

METHODS

This was a mixed methods study. Participants consisted of 47 new faculty of medicine members who attended one of the four workshops held between 2011 and 2013. Questionnaires were used to evaluate workshop characteristics (10 survey items; response scale 1=unacceptable to 7=outstanding), intention to change behavior (yes/no), and retrospective pre/post workshop self-efficacy (4 survey items; response scale 1=no confidence to 6=absolute confidence). Mean scores and standard deviations were calculated for the workshop characteristics. Pre/post workshop self-efficacy scores were compared using a Wilcoxon signed-rank test. Participants' written qualitative feedback was coded using an inductive strategy to identify themes.

RESULTS

There was strong support for the workshop characteristics with mean scores entirely above 6.00 (N=42). Thirty-one of 34 respondents (91%) expressed intention to change their behavior as a result of participating in the workshop. The post workshop self-efficacy scores (N=38 respondents) increased significantly for all four items (p<0.0001) compared to pre workshop ratings. Participants perceived the key workshop elements as the evidence-based content relevant to academic physicians, incorporation of practical tips and strategies, and an atmosphere conducive to discussion and experience sharing.

CONCLUSIONS

  Participants welcomed wellness as a focus of faculty development. Enhancing instruction around wellness has the potential to contribute positively to the professional competency and overall functioning of faculty of medicine members.

How physicians identify with predetermined personalities and links to perceived performance and wellness outcomes: a cross-sectional study

Background

Certain personalities are ascribed to physicians. This research aims to measure the extent to which physicians identify with three predetermined personalities (workaholic, Type A and control freak) and to explore links to perceptions of professional performance, and wellness outcomes.

Methods

This is a cross-sectional study using a mail-out questionnaire sent to all practicing physicians (2957 eligible, 1178 responses, 40% response rate) in a geographical health region within a western Canadian province. Survey items were used to assess the extent to which participants felt they are somewhat of a workaholic, Type A and/or control freak, and if they believed that having these personalities makes one a better doctor. Participants’ wellness outcomes were also measured. Zero-order correlations were used to determine the relationships between physicians identifying with a personality and feeling it makes one a better doctor. T-tests were used to compare measures of physician wellness for those who identified with the personality versus those who did not.

Results

53% of participants identified with the workaholic personality, 62% with the Type A, and 36% with the control freak. Identifying with any one of the personalities was correlated with feeling it makes one a better physician. There were statistically significant differences in several wellness outcomes comparing participants who identified with the personalities versus those who did not. These included higher levels of emotional exhaustion (workaholic, Type A and control freak), higher levels of anxiety (Type A and control freak) and higher levels of depression, poorer mental health and lower levels of job satisfaction (control freak). Participants who identified with the workaholic personality versus those who did not reported higher levels of job satisfaction, rewarding patient experiences and career commitment.

Conclusions

Most participants identified with at least one of the three personalities. The beliefs of some participants that these personalities enhance professional performance may reinforce the harmful behaviors associated with poor wellness outcomes. Future research should further explore links between physician personality, perceptions of performance and actual performance, and more definitively address whether the perceived benefits offered by identifying with the workaholic personality are enough to counter the potential costs to physician wellness.

A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study

BACKGROUND

Walk-rounds, a common component of medical education, usually consist of a combination of teaching outside the patient room as well as in the presence of the patient, known as bedside teaching. The proportion of time dedicated to bedside teaching has been declining despite research demonstrating its benefits. Increasing complexities of patient care and perceived impediments to workflow are cited as reasons for this declining use. Research using real-time locating systems (RTLS) has been purported to improve workflow through monitoring of patients and equipment. We used RTLS technology to observe and track patterns of movement of attending physicians during a mandatory once-weekly medical teaching team patient care rounding session endorsed as a walk-rounds format.

METHODS

During a project to assess the efficacy of RTLS technology to track equipment and patients in a clinical setting, we conducted a small-scale pilot study to observe attending physician walk-round patterns during a mandatory once-weekly team rounding session. A consecutive sample of attending physicians on the unit was targeted, eight agreed to participate. Data collected using the RTLS were pictorially represented as linked points overlaying a floor plan of the unit to represent each physician's motion through time. Visual analysis of time-motion was independently performed by two researchers and disagreement resolved through consensus. Rounding events were described as a sequence of approximate proportions of time engaged within or outside patient rooms.

RESULTS

The patient care rounds varied in duration from 60 to 425 minutes. Median duration of rounds within patient rooms was approximately 33% of total time (range approximately 20-50%). Three general time-motion rounding patterns were observed: a first pattern that predominantly involved rounding in ward hallways and little time in patient rooms; a second pattern that predominantly involved time in a ward conference room; and a third balanced pattern characterized by equal proportions of time in patient rooms and in ward hallways.

CONCLUSIONS

Observation using RTLS technology identified distinct time-motion rounding patterns that hint at differing rounding styles across physicians. Future studies using this technology could examine how the division of time during walk-rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow.

Shifting perceptions: a pre-post study to assess the impact of a senior resident rotation bundle

BACKGROUND

Extended duty hours for residents are associated with negative consequences. Strategies to accommodate duty hour restrictions may also have unintended impacts. To eliminate extended duty hours and potentially lessen these impacts, we developed a senior resident rotation bundle that integrates a night float system, educational sessions on sleep hygiene, an electronic handover tool, and a simulation-based medical education curriculum. The aim of this study was to assess internal medicine residents' perceptions of the impact of the bundle on three domains: the senior residents' wellness, ability to deliver quality health care, and medical education experience.

METHODS

This prospective study compared eligible residents' experiences (N = 67) before and after a six-month trial of the bundle at a training program in western Canada. Data was collected using an on-line survey. Pre- and post-intervention scores for the final sample (N = 50) were presented as means and compared using the t-test for paired samples.

RESULTS

Participants felt that most aspects of the three domains were unaffected by the introduction of the bundle. Four improved and two worsened perception shifts emerged post-intervention: less exposure to personal harm, reduced potential for medical error, more successful teaching, fewer disruptions to other rotations, increased conflicting role demands and less staff physician supervision.

CONCLUSIONS

The rotation bundle integrates components that potentially ease some of the perceived negative consequences of night float rotations and duty hour restrictions. Future areas of study should include objective measures of the three domains to validate our study participants' perceptions.

The effect of a biofeedback-based stress management tool on physician stress: a randomized controlled clinical trial

BACKGROUND

Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations.

OBJECTIVE

To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress.

DESIGN

Randomized controlled trial measuring efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness.

SETTING

Urban tertiary care hospital.

PARTICIPANTS

Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians' lounge and throughout the hospital.

INTERVENTION

Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team.

MAIN OUTCOME MEASURE

Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200).

RESULTS

During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change -14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change -2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change -8.5, SD 7.6; p < 0.001).

CONCLUSION

A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.

Food for thought: an exploratory study of how physicians experience poor workplace nutrition

BACKGROUND

Nutrition is often a casualty of the busy work day for physicians. We aimed to explore physicians' views of their nutrition in the workplace including their perceptions of the impact of inadequate nutrition upon their personal wellness and their professional performance.

METHODS

This is a qualitative study of a sample of 20 physicians practicing in a large urban teaching hospital. Semi-structured open ended interviews were conducted to explore physicians' views of workplace nutrition. The same physicians had agreed to participate in a related nutrition based wellness intervention study that compared nutritional intake and cognitive function during a day of usual nutrition patterns against another day with scheduled nutrition breaks. A second set of interviews was conducted after the intervention study to explore how participation in the intervention impacted these views. Detailed interview content notes were transcribed and analyzed independently with differences reconciled by discussion.

RESULTS

At initial interview, participants reported difficulty accessing adequate nutrition at work, linking this deficit with emotional (irritable and frustrated), physical (tired and hungry), and cognitive (difficulty concentrating and poor decision making) symptoms. In addition to identifying practical barriers such as lack of time to stop and eat, inconvenient access to food and poor food choices, the physicians described how their sense of professionalism and work ethic also hinder their work nutrition practices. After participating in the intervention, most physicians reported heightened awareness of their nutrition patterns and intentions to improve their workplace nutrition.

CONCLUSIONS

Physicians report that inadequate workplace nutrition has a significant negative impact on their personal wellness and professional performance. Given this threat to health care delivery, health care organizations and the medical profession need to address both the practical and professional barriers identified.

The Introduction of an Electronic Patient Care Information System and Health Care Providers’ Job Stress

In this paper, the authors explore how the introduction of an electronic Patient Care Information System (PCIS) relates to changes in health care providers’ (HCPs’) perceptions of computer use, quality of patient care and job stress. Data were collected using a mixed-methods case study approach over a 20 month period following the introduction of this system. Initially stress levels appeared to increase, but over time declined significantly. After 3 months, the majority of HCPs reported they spent more time entering, retrieving and searching for patient information than before; however, these increases in computer use were unrelated to HCP stress. The potentially negative impact of the system on the quality of patient care was highly correlated with increased job stress. After 20 months, HCPs reported spending less time searching, entering and retrieving patient information, but these indicators of computer use were now highly correlated with stress. While some negative perceptions of the impact of the PCIS declined over time, HCPs reported ongoing stress related to concerns about quality of patient care even after 20 months of use.

Physician nutrition and cognition during work hours: effect of a nutrition based intervention

Background

Physicians are often unable to eat and drink properly during their work day. Nutrition has been linked to cognition. We aimed to examine the effect of a nutrition based intervention, that of scheduled nutrition breaks during the work day, upon physician cognition, glucose, and hypoglycemic symptoms.

Methods

A volunteer sample of twenty staff physicians from a large urban teaching hospital were recruited from the doctors' lounge. During both the baseline and the intervention day, we measured subjects' cognitive function, capillary blood glucose, "hypoglycemic" nutrition-related symptoms, fluid and nutrient intake, level of physical activity, weight, and urinary output.

Results

Cognition scores as measured by a composite score of speed and accuracy (Tput statistic) were superior on the intervention day on simple (220 vs. 209, p = 0.01) and complex (92 vs. 85, p < 0.001) reaction time tests. Group mean glucose was 0.3 mmol/L lower (p = 0.03) and less variable (coefficient of variation 12.2% vs. 18.0%) on the intervention day. Although not statistically significant, there was also a trend toward the reporting of fewer hypoglycemic type symptoms. There was higher nutrient intake on intervention versus baseline days as measured by mean caloric intake (1345 vs. 935 kilocalories, p = 0.008), and improved hydration as measured by mean change in body mass (+352 vs. -364 grams, p < 0.001).

Conclusions

Our study provides evidence in support of adequate workplace nutrition as a contributor to improved physician cognition, adding to the body of research suggesting that physician wellness may ultimately benefit not only the physicians themselves but also their patients and the health care systems in which they work.

Not all coping strategies are created equal: a mixed methods study exploring physicians' self reported coping strategies

Background

Physicians experience workplace stress and draw on different coping strategies. The primary goal of this paper is to use interview data to explore physicians' self reported coping strategies. In addition, questionnaire data is utilized to explore the degree to which the coping strategies are used and are associated with feelings of emotional exhaustion, a key symptom of burnout.

Methods

This mixed methods study explores factors related to physician wellness within a large health region in Western Canada. This paper focuses on the coping strategies that physicians use in response to work-related stress. The qualitative component explores physicians' self reported coping strategies through open ended interviews of 42 physicians representing diverse medical specialties and settings (91% response rate). The major themes extracted from the qualitative interviews were used to construct 12 survey items that were included in the comprehensive quantitative questionnaire. Questionnaires were sent to all eligible physicians in the health region with 1178 completed surveys (40% response rate.) Questionnaire items were used to measure how often physicians draw on the various coping strategies. Feelings of burnout were also measured in the survey by 5 items from the Emotional Exhaustion subscale of the revised Maslach Burnout Inventory.

Results

Major themes identified from the interviews include coping strategies used at work (e.g., working through stress, talking with co-workers, taking a time out, using humor) and after work (e.g., exercise, quiet time, spending time with family). Analysis of the questionnaire data showed three often used workplace coping strategies were positively correlated with feeling emotionally exhausted (i.e., keeping stress to oneself (r = .23), concentrating on what to do next (r = .16), and going on as if nothing happened (r = .07)). Some less often used workplace coping strategies (e.g., taking a time out) and all those used after work were negatively correlated with frequency of emotional exhaustion.

Conclusions

Physicians' self reported coping strategies are not all created equal in terms of frequency of use and correlation with feeling emotionally exhausted from one's work. This knowledge may be integrated into practical physician stress reduction interventions.

Physician wellness: a missing quality indicator

When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality health care. We review the work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to the individual and to health-care systems. We show that health systems should routinely measure physician wellness, and discuss the challenges associated with implementation.

Location of residence associated with the likelihood of patient visit to the preoperative assessment clinic

BACKGROUND

Outpatient preoperative assessment clinics were developed to provide an efficient assessment of surgical patients prior to surgery, and have demonstrated benefits to patients and the health care system. However, the centralization of preoperative assessment clinics may introduce geographical barriers to utilization that are dependent on where a patient lives with respect to the location of the preoperative assessment clinic.

METHODS

The association between geographical distance from a patient's place of residence to the preoperative assessment clinic, and the likelihood of a patient visit to the clinic prior to surgery, was assessed for all patients undergoing surgery at a tertiary health care centre in a major Canadian city. The odds of attending the preoperative clinic were adjusted for patient characteristics and clinical factors.

RESULTS

Patients were less likely to visit the preoperative assessment clinic prior to surgery as distance from the patient's place of residence to the clinic increased (adjusted OR = 0.52, 95% CI 0.44-0.63 for distances between 50-100 km, and OR = 0.26, 95% CI 0.21-0.31 for distances greater than 250 km). This 'distance decay' effect was remarkable for all surgical specialties.

CONCLUSION

The present study demonstrates that the likelihood of a patient visiting the preoperative assessment clinic appears to depend on the geographical location of patients' residences. Patients who live closest to the clinic tend to be seen more often than patients who live in rural and remote areas. This observation may have implications for achieving the goals of equitable access, and optimal patient care and resource utilization in a single universal insurer health care system.

Association of postoperative complications with hospital costs and length of stay in a tertiary care center

BACKGROUND

Postoperative complications are a significant source of morbidity and mortality. There are limited studies, however, assessing the impact of common postoperative complications on health care resource utilization.

OBJECTIVE

To assess the association of clinically important postoperative complications with total hospital costs and length of stay (LOS) in patients undergoing noncardiac surgery.

METHODS

We determined total hospital costs and LOS in all patients admitted to a single tertiary care center between July 1, 1996 and March 31, 1998 using a detailed administrative hospital discharge database. Total hospital costs and LOS were adjusted for preoperative and surgical characteristics.

RESULTS

Of 7,457 patients who underwent noncardiac surgery, 6.9% developed at least 1 of the postoperative complications. These complications increased hospital costs by 78% (95% confidence interval [CI]: 68% to 90%) and LOS by 114% (95% CI: 100% to 130%) after adjustment for patient preoperative and surgical characteristics. Postoperative pneumonia was the most common complication (3%) and was associated with a 55% increase in hospital costs (95% CI: 42% to 69%) and an 89% increase in LOS (95% CI: 70% to 109%).

CONCLUSIONS

Postoperative complications consume considerable health care resources. Initiatives targeting prevention of these events could significantly reduce overall costs of care and improve patient quality of care.

Utilization of a preoperative assessment clinic in a tertiary care centre

OBJECTIVE

To describe the utilization of a preoperative assessment clinic (PAC) by various surgical divisions, and the types of consultations sought by those divisions.

DESIGN

Cross-sectional descriptive study of PAC utilization.

SETTING

A large university-affiliated tertiary care centre.

PATIENTS

All patients who underwent surgical procedures by selected surgical divisions between July 1, 1996, and Mar. 31, 1998.

MEASUREMENTS

The number of patients referred to the centre's PAC, utilization by surgical division, and the types of consultation obtained (general internal medicine, anesthesia, cardiology, intensive care). Adjusted rates of consultations were determined by logistic regression, controlling for age, sex, comorbidity and major versus minor procedure.

RESULTS

Of 9603 surgical cases, 5725 (60%) were referred to the PAC. The adjusted rates of PAC utilization ranged from a low of 46% for cardiovascular and thoracic surgery to a high of 72% for general surgery. The adjusted rates of general internal medicine consultations ranged from 5% for oral surgery to 33% for otolaryngology. For anesthesia consultations, the rates ranged from 6% for orthopedics to 39% for general surgery. Increasing age (odds ratio [OR] = 1.14 for 10-year age increments), female sex (OR = 1.23), major surgery (OR = 1.94) and a number of comorbidity variables were significant predictors of PAC referral on multivariable analysis.

CONCLUSIONS

PAC utilization varies across surgical divisions and in the types of consultation sought, even when controlling for age, sex, comorbidity and type of procedure. The potential exists for standardized PAC referral guidelines to reduce these variations.

Effectiveness of the Quick Medical Reference as a diagnostic tool

A number of computer-based systems with diagnostic capabilities have been developed for internal medicine. Quick Medical Reference (QMR) is one such program. The authors describe key features of QMR and report on their study of its effectiveness as a diagnostic tool. They investigated how frequently the correct diagnosis would appear among the 5 highest ranked diagnoses generated by QMR. The charts of 1144 consecutive patients admitted to a teaching unit were retrospectively screened. Eligible cases included those referred for investigation of an undiagnosed illness with an objectively proven final diagnosis (n = 154). Two physicians familiar with, but not experts in, the use of QMR entered clinical information abstracted from the patients' charts into the program. Physician A obtained the correct diagnosis in 62 (40%) of the 154 cases, and physician B was successful in 56 (36%) of the cases. The authors use study cases to illustrate QMR's strengths and weaknesses.

[Congestive heart failure in the elderly. Value of Doppler echocardiography]

Fifty-eight consecutive elderly patients (seven men and 51 women, mean age 84 +/- 6) admitted for congestive heart failure were prospectively investigated by doppler echocardiography in order to 1) define the prevalence of cardiac failure with normal left ventricular systolic function, 2) estimate the role of abnormalities of left ventricular filling (diastolic dysfunction), 3) evaluate echodoppler parameters for assessment of diastolic function: ratio of early peak on atrial peak of filling velocities (E/A), mitral deceleration time (MDT) and isovolumic relaxation time (IRT). Of the 58 patients, 32 (55%) had normal left ventricular systolic function and 26 (45%) had systolic dysfunction. Of the 32 patients with normal systolic function, diastolic function could not be evaluated in nine patients, was abnormal in 16 and normal in seven. Congestive heart failure with normal systolic function is very frequent in the elderly subject. Sensitivity of clinical data being too low, doppler echocardiography is the easiest noninvasive technique for defining abnormalities of both left ventricular systolic and diastolic function. In the elderly, MDT and IRT are more sensitive parameters than E/A for the diagnosis of diastolic dysfunction.