We agree with Dr. Kuhn that much more attention needs to be paid to assessing medical students and residents for their suitability and fitness to practice medicine, and that failure to do so is a breach of the fiduciary responsibility of schools and hospitals. These are issues that the Association of American Medical Colleges and specialty boards should address.

However, Dr. Kuhn's dismissal of the need for additional testing is diametrically opposed to every specialty board's strong (and, we think, laudable) initiative to develop much more rigorous and effective assessment of physician performance. Although we are sensitive to the fact that rural practice clearly has unique accountability issues, the ability of physicians to learn and maintain personal standards is not one of them. There is neither an ethical nor practical justification for accepting lower standards for physicians in rural areas.

We disagree that our data do not justify our estimate that at least one third of physicians will need help at some time in their career. The finding that performance problems are not confined to a small fringe of practitioners is a central point of our paper. Sadly, most compromised doctors do continue to practice, often with dire consequences for their patients. This is the problem that we seek to remedy.

The diametrically opposed views of Dr. Gold and Ms. Frost-Pineda (who advocate for preemployment and random drug testing of physicians) and those of Dr. Donohoe (who raises associated "ethical, legal, and policy questions") illustrate the controversial nature of this issue. Clearly, the practice warrants further study and testing.

Drs. Gifford and Crausman and Mr. McIntyre make the important point that not all physicians participate in hospital credentialing processes. However, credentialing is a good place to start improvements because a mechanism and a requirement already exist. If we can develop effective early identification and assessment practices for physician performance in hospitals, they should be adaptable to office, clinic, and ambulatory surgical settings.

Although we applaud these 3 correspondents' call for expanding the role of licensing boards to support remediation programs and agree that these entities should set standards, we do not share their enthusiasm for having state boards actually perform the credentialing process. We also do not believe that insurers and managed care plans should play a role in reviewing physician performance. We believe most physicians would agree that these duties are the profession's responsibility.