Several caveats about this paper should be noted. First, the results of this small study should be confirmed by other institutions and expanded to additional specialties and subspecialties. We do not know the true scope of the problem and must resist the temptation to generalize from the limited data reported in this study. Second, the authors' warning that the methods used in their study put estimates of misrepresentation at the high end of probability must not be forgotten. Verifying research experience in the absence of objective publications is difficult and open to interpretation. The authors were correct to focus primarily on publication claims that can be readily documented. Third, it should be emphasized that although 30% of applicants who claimed to have publications and presentations misrepresented their accomplishments, the frequency of misrepresentation is much lower (about 7%) when the total applicant group is the denominator.

These issues aside, this report is a troubling commentary on the current status of professionalism among our colleagues. In addition to the cited cases of Drs. Alsabti and Slutsky, other similar misdeeds have been documented. In one study addressing this issue [2], the certification status of physicians in Yellow Pages advertising was misrepresented in 12% of all entries. Another study called attention to a 5% rate of falsified credentials in applications for employment in a large managed care organization [3]. In the past decade, the American Board of Internal Medicine (ABIM) and other certifying organizations have accumulated several dozen cases of fraudulent certificates that were presented by physicians seeking clinical privileges or employment by health care institutions. Over time, the ABIM has developed a standard method for handling cases of confirmed misrepresentations that routinely includes revocation of board eligibility and certification and notification of the appropriate State disciplinary boards.

Sekas and Hutson do not describe the actions taken by the administrators of the gastroenterology fellowship program upon their discovery of credentials misrepresentation. However, the authors do present useful recommendations for the manner in which institutions and the profession should respond to the problem: They should insist on adequate documentation, require an affirmation of accuracy, and, most important, reinforce the obligation of medical schools and training programs to emphasize the importance of professionalism to students and residents. We should not assume that trainees either know or fully understand the basic principles of professionalism or what constitutes unprofessional behavior. The Hippocratic oath simply does not cover all the situations faced by contemporary physicians.

Early in 1995, the ABIM published Project Professionalism, a document that was sent to more than 2000 internal medicine and subspecialty program directors, department chairs, and medical school deans [4, 5]. This document provides guiding principles, a working definition of professionalism, and specific examples of unprofessional behavior, among which is a case study of credentials misrepresentation. Incidentally, one of the stated goals of this project is to remind program directors of their responsibility to verify the credentials of their trainees. In other efforts to promote these values, the Residency Review Committee for Internal Medicine, responsible for accrediting all training programs, has outlined specific expectations about professionals and professional accountability [6]. One educator has also described a core curriculum for teaching professionalism to resident trainees [7].

Fraudulent credentials have the potential to harm patients because they misrepresent a physician's skills and competence to colleagues and the public. Viewed in this context, the authors' dilemma about violating the confidentiality of candidate applications are difficult to understand. Curricula vitae may be personal, but they are not confidential; even if confidentiality were requested, the best interest of patients should take precedence. Who should be informed about misrepresentation? Most important, of course, is the person who presents false information; he or she must be confronted and made to realize that misrepresentation is unprofessional and unacceptable. Program directors and department chairs in the applicant's institution should be informed because they have an obligation to be involved with any plan for remediation. Persons who recommended the individual also have a right to know about the misrepresentation. Finally, given its responsibility to certify the ethical and humanistic qualities of a diplomate, the ABIM should be apprised of the problem and the plan of remediation.

Credentials fraud is destructive to the ethical principles of our profession and undermines the public's trust in doctors. When misrepresentation is uncovered, it must be handled in a manner that leaves no doubt about our personal and collective standard of integrity.