The points that Dr Hirsch raises are ones commonly expressed by physicians who have not had much actual experience with audit.A low number of deficiencies found was cited. It is important to understand the difference between a deficiency and a variation. Variations from established criteria might include such things as a complication that prolonged hospital stay, a justification for surgery that is legitimate but was not included in the original criteria, or a postoperative death that occurred despite good operative and postoperative management. All of these problems are discussed in detail in each audit, and deficiencies are recorded only when care or judgment were not optimal. In our community, more than 97.5% of all surgical procedures are performed by fully trained surgeons who are board-certified in their specialty in most instances, and we certainly expect and hope that deficiencies in care will be kept at a minimum.