"Your gestures are rapid," Dr. Meyer Friedman says, leaning back from his desk and lacing his fingers. "That's a sign."
The reporter, who thought she was cloaking it pretty well, looks embarrassed.
"Two," Friedman says, "twice you 'uh-uh'ed me, as I started to wander in a senile fashion. 'Course, you have a story to write, and obviously Dr. Friedman is sitting there orating and flitting non sequiturs at you."
He smiles. Very gentle and calm. "The third thing is, you have a little, what we call 'grimace.' This." He lifts the corners of his mouth and drops them again. The reporter is aghast. She does that? "Four, you have head-nodding. I mentioned your speech was rapid. How many is that? Six? Your eyes blink more than 25 beats a minute. Your gestures are rapid, purposeful. Bang, bang."
Friedman looks pleased with himself. All in vain, reading the studies and remembering the signs he might watch for -- don't jiggle your knee, don't interrupt his sentences, don't hunch at the edge of the chair as though poised for the starter gun. All in vain. Meyer Friedman knows Type As, he likes to say, five minutes after they walk through the door.
Maybe you remember the list: You brush your teeth, read the newspaper and listen to the morning news at the same time. You find restaurant and bank lines excruciating. Slowed traffic, or inefficient driving, infuriates you. You keep count of things -- how many patients you saw last week, how many articles you wrote, how many miles you ran. You wave your hands when you talk. You chafe at people who speak slowly or fail to get to the point. You walk fast, clean your plate before anybody else (including your teen-age kid on the basketball team) and drop truculent Hemingwayisms about the daily struggle that pushes the victors to the top.
And you are prime material, Meyer Friedman says, for a heart attack.
It has been 10 years since Friedman and his then-associate Dr. Ray Rosenman helped make "Type A" a kind of national slang for the harried, hostile, achievement-obsessed personalities who champ and bark their way through the modern workplace. "Type A Behavior and Your Heart" is still in print; editions have been translated into Spanish, German, Dutch, Portuguese and Finnish, and in what might be viewed as a distressing byproduct of the quest for industrial supremacy, plans were recently completed for getting a copy into Japanese.
But many practicing cardiologists have never really embraced the central tenet of the book -- that what Friedman and Rosenman called "Type A behavior" causes internal physiological changes that may be even more dangerous to the heart than commonly accepted perils like smoking and high serum cholesterol. The idea was by no means dismissed outright; the American Heart Association makes qualified reference to Type A behavior in its list to physicians of risk factors contributing to coronary heart disease. Even physicians who found merit in the Type A idea, though, were stumped as to what to do with it. So a Type A barges into your office, glancing at his watch and muttering about sales figures -- what good does it do to calm him down?
This month, with his new book, "Treating Type A Behavior -- and Your Heart," Friedman presents his answer. Armed with the three-year results of a five-year study, the summary of which made up the lead article in the August American Heart Journal, Friedman and his coauthor Diane Ulmer say they have shown that Type A heart patients can help fend off future heart attacks by learning to ease up -- to slow their driving, to speak kindly to their families. By learning, in effect, to conduct themselves like the milder-mannered Type Bs.
As might be expected, this is not such a simple proposition. In laboriously recruited groups from all over the San Francisco Bay area (the patients are no longer almost all men -- the new book includes an entire chapter on the Type A woman), Friedman and his colleagues spent scores of two-hour sessions teaching Type As behavioral skills as elemental as smiling. They had a hard time learning to smile, Friedman says. "That they'd rehearse in front of us, because sometimes the smile looked like this." He bares his teeth, looking momentarily wolflike.
The counselors told their Type As -- each equipped with a small looseleaf notebook to check off completion of assignments -- to leave their watches home for a day. They told them to move deliberately into the longest line at the supermarket. They told them to contemplate aphorisms such as "Common sense is only wisdom applied to conduct" or "Eagles do not prey on flies." They told them to examine trees or plants and to linger at the table after dinner and to read novels and great works. (Friedman used to recommend that his patients read Marcel Proust, the languid seven-volume "Remembrance of Things Past" being the antithesis of Type A literature, until he found out that the only patient who actually finished all seven volumes was a major general who likened the experience to surviving the Korean War. Now Friedman suggests Greek classics or a volume from Will and Ariel Durant's "The Story of Civilization" instead.)
The researchers combined their "Type A counseling" with an overall plan that included more traditional cardiologic advice about diet, exercise and general medical information. At the same time, a second group of recruited Type A heart disease patients received only this traditional counseling, with no advice on how to modify their Type A behavior. The overall result, Friedman writes in the opening chapter to his new book, was a "marked, even startling success." Although many of the 862 patient-volunteers dropped out before the end of the study, the researchers determined that 13 percent of the patients who got no Type A counseling suffered repeat heart attacks -- a rate almost twice as high as that of patients who had been counseled on changing their Type A behavior.
"We know now beyond any doubt what we suspected before," Friedman writes, "that Type A behavior can be treated effectively, that reduction or elimination of Type A behavior can reduce the incidence of second heart attacks radically, and that Type A behavior can now be regarded, alone among risk factors, as a primary causal agent in the pathogenesis of coronary heart disease."
That sort of declaration, like the insistence with which Friedman and Rosenman presented their earlier findings on the nature of the Type A personality, has been met with what might be called highly cautious mixed reviews from other physicians. "Whether they're right or wrong, they have made a great contribution in that they've made us all look and face up to these issues of stress," says cardiovascular epidemiologist Dr. William P. Castelli, who heads the Framingham Heart Study, a long-term research project that for 34 years has monitored the health histories and heart attack rates of thousands of residents of Framingham, Mass. "But I think we still have a good way to go in getting what we call the hard data. I'd like to see this reproduced in two or three dozen studies all around the world."
"A lot of people have taken note of this," says Dr. Dorothee Perloff, a veteran cardiologist and clinical professor of medicine at the University of California at San Francisco. "A lot of people don't believe it. Others are sort of amused by it, and the terms 'Type A' and 'Type B' are thrown around . . . We know so much about other risk factors -- high blood pressure, high cholesterol, family history, hypertension, maleness and age -- that this just doesn't compare, somehow."
Reservations like these bring snorts of something like contempt from both Friedman and Rosenman, who says he split with Friedman in the early years of this study because he disagreed with Friedman's research methods. "They're frightened of it," says Rosenman, now a senior research physician at Stanford Research Institute. "Cardiologists, the younger they are, and in general, are very Type A. Number two, being so rushed and Type A, they can't take the time to go and learn about new things. Number three, cardiologists are trained to treat people -- they know nothing about prevention of disease."
And what of the long-held conviction (long-held chiefly by dedicated Type As) that time-obsessed frenzy makes successes of people? Friedman likes to answer that, in part, by pulling out some of his taped interviews -- this one with a patient so adamantly Type A that even after the man's heart attack Friedman was unable to convince him to join the counseling program.
"Let me explain to you how I drive a car," Type A says on the tape, in one of those voices that carries all the way across a restaurant. "It is a constant strategy never to get in the lane that is bottled up. It is a constant strategy battle on my part never to -- never. I know that the right-turn lane in this block is legal, so you're going to get held up in the right lane by the pedestrians in the crosswalks. I'll never be in the right lane where the right turn is permitted. I'll be in the right lane where the left turn is permitted, where that other lane is going to get slowed down."
"Notice how he's struggling as he's talking about it?" Friedman says. "And he gets so upset at just recalling this that he stops breathlessly."
"Lots of times I'm not even going anywhere," Type A says. "Lots of times I'll get there early, so I'll just have to sit and wait for my appointment when I get there . . . And then my driver, if I am being driven, if my driver makes a bad decision and gets in the wrong lane, I have a very difficult time biting my tongue so I don't say, 'You -- stupid -- ' " Type A's voice cracks. "And he doesn't have this sense of urgency that I have at all -- "
Friedman's quiet voice breaks in on the tape. "Now, the behaviorists, the behavior psychologists," he starts to say.
Type A is not listening at all. "But that's why I'm the general counsel," he cries triumphantly, "and he's the driver!"
Friedman smiles and switches cassettes. He says it is a tricky matter, determining people's personality types just from their answers to questions -- sometimes the interviewer must watch how they respond rather than what they say. On this tape Friedman is deliberately shuffling through a question with a languor that would make a frustrated Type A break in with his answer. "By the way, sir, most executives get up before, uh, 7:30," Friedman says, "that is, Monday, Tuesday, Wednesday, Thursday, Friday -- Saturday, Sunday, they sleep later -- in your case, uh, what time do you usually, on the weekdays, what time do you usually, uh, uh, uh, uh -- get up, sir?"
The other voice is patient, polite, waits for the doctor to finish rambling. "About 6:30," it says.
Is this man successful in his work? "Chairman of a multinational company employing well over 50,000 people," Friedman says. "Type A is only anger and impatience. It has nothing to do with success . . . General Omar Bradley, Type B. General (George C.) Marshall, Type B. Viscount Montgomery, Type B. Winston Churchill, Type B. Probably slept through the bombing raids -- he had to have his nap. Truman, Type B. Ford, Type B. Reagan, Type B. Chairman of General Foods, Mr. (James L.) Ferguson, Type B."
Phil Donahue is a Type A, Friedman says. Henry Kissinger is a Type A. Former president Jimmy Carter is a Type B, but Alexander Haig is a Type A. The whole "MacNeil/Lehrer NewsHour," on PBS, is Type B. Walter Mondale looks like a Type B, but he's really a Type A, Friedman says -- "strained. Inside, he's seething." Meyer Friedman, a small 74-year-old man with a fine half-crown of gray hair, is a Type A -- but reformed. "I was called 'Cannonball' in the Army. As a doctor, to be called 'Cannonball' is not very nice," he says. He says he began to worry about his impatience during the early years of his research, when the chance comment of a wistful San Francisco Junior League woman helped direct him to what became the central focus of his work. " 'If you really want to know what is going to give our husbands heart attacks, I'll tell you,' " he recalls the Junior League woman saying. " 'It's stress . . . Why, when my husband comes home at night, it takes at least one martini just to unclench his jaws.' "
Friedman himself reads Proust (the whole seven volumes, three times through so far, he says). He rambles gently through an interview, particularly when his questioner is determined not to interrupt him. He says he has stopped trying to criticize his wife, that he no longer lectures his children, that he maintains a lively interest in "the three Ps, I call it -- Pets! Plants! Persons!" And he put a tape deck in his car so the traffic jams that used to aggravate him would turn into listening sessions instead. "I've learned all nine symphonies of Beethoven -- don't like the mass in the Ninth -- I enjoy Joan Baez now, and Liza Minnelli and trying to figure out how she's like her mother," he says. "I've been stopped twice on the road by the police for going too slowly, even on the outer lanes."