We appreciate the comments on our recent article. Drs. Hammerschmidt and Barthel each raise the question of whether 1.5 years is sufficient for articles listed as "in print" to appear in print or in MEDLINE. The MEDLINE Department at the National Library of Medicine (Reference 2) has stated that the lag time from publication of a journal to its citation in MEDLINE is within a week of the publication date for the major clinical journals and within 30 days for obscure foreign journals. Thus, we feel that sufficient time was allotted. In addition, every effort was made to find publications using not only the usual compendia but also Ulrich's International Periodicals Directory, which is the definitive reference for the existence of journals. We agree that applicants may be naive and therefore may not know the difference between the terms "submitted" and "in press." We believe that it is the duty of the mentor of a trainee to teach students that distinction. Dr. Glick suggests that each individual trainee in our study found to have misrepresentations be contacted and asked to explain. He adds that this practice might result in fewer applicants with misrepresented achievements. We acknowledged in our report that, with the methods used, the percentage detected was at the highest end of possibility and that, even if the actual percentage were one half of that found, the problem would still be significant. We feel that it is beyond the scope of our article to try now to locate these persons and ask for explanations.

One of the difficulties we had during this study was the issue raised by Dr. Brar about the identification of trainees to their programs. During our study, we deeply considered the professional, legal, and moral aspects of this problem and sought counsel on these issues. With regard to the professional aspects, we were appalled to be told by some medical educators that "this paper cannot be published; it makes physicians look bad." With regard to the legal aspects, we obtained legal counsel and were advised that because no established professional standards addressed misrepresented academic accomplishments, we were in a murky legal area if we revealed the identity of applicants to their program chiefs. In fact, the astute reader may discern that, even in the published article, the applicant cohort has been masked because of this issue. With regard to the moral aspects, we strongly believed that this is an issue the medical profession needed to recognize and set standards for.

Our article brings attention to this significant problem and offers recommendations for minimizing this problem. Dr. Kimball's editorial provides the standard for the way in which individual cases of misrepresentation should be handled. Simply put, the professional, legal, and moral obligation now is that the applicant's program directors be informed of misrepresentation.

Finally, Dr. Nassar makes the important point that in our profession, integrity and self-discipline are required at all levels.