ORIGINAL INVESTIGATION

Discrepancies in the Use of Medications

Their Extent and Predictors in an Outpatient Practice
Susanna E. Bedell, MD; Samer Jabbour, MD, MPH; Robert Goldberg, PhD; Helene Glaser, RN;
Susan Gobble, MBA; Yinong Young-Xu, MA; Thomas B. Graboys, MD; Shmuel Ravid, MD

Background: Misuse of medications is a major cause
of morbidity and mortality. Few studies have examined
the frequency of, and factors associated with, discrepan-
cies between what doctors prescribe and what patients
take in actual practice.
Patients and Methods: Patients’ medication bottles
and their reported use of medications were compared with
physicians’ records of outpatients seen between Novem-
ber 1997 and February 1998 in a private practice affili-
ated with an academic medical center in Boston, Mass.
Three hundred twelve patients from the practices of 5
cardiologists and 2 internists who were returning for their
routine follow-up visits were included.
Main Outcome Measure: The presence of discrep-
ancies based on comparing medication bottles with medi-
cal records.
result of patients taking medications that were not re-
corded (n=278 [51%]); patients not taking a recorded
medication (n=158 [29%]); and differences in dosage
(n=109 [20%]). Overall, discrepancies were randomly
distributed among different drugs and discrepancy
types with no discernible pattern. On multivariate
analysis, patient age and number of recorded medica-
tions were the 2 most significant predictors of medica-
tion discrepancy.
Conclusions: Discrepancies among recorded and re-
ported medications were common and involved all classes
of medications, including cardiac and prescription drugs.
Older age and polypharmacy were the most significant
correlates of discrepancy. The pervasiveness of discrep-
ancies can have significant health care implications, and
action is urgently needed to address their causes. Such
action would likely have a positive impact on patient care.

Results: Discrepancies were present in 239 patients

(76%). The 545 discrepancies in these patients were the Arch Intern Med. 2000;160:2129-2134

From Lown Cardiovascular
Center, Brookline, Mass
(Drs Bedell, Jabbour, Graboys,
and Ravid, Ms Glaser, and
Mr Young-Xu); The
Department of Medicine,
Harvard Medical School
(Drs Bedell, Jabbour, Graboys,
and Ravid), and the Division
of Cardiovascular Medicine,
Department of Medicine,
University of Massachusetts
Medical School (Dr Goldberg),
Boston; and the Department
of Medicine, Memorial Health
Services, Long Beach, Calif
(Ms Gobble).
I
N THIS ERA of polypharmacy, ex-
tensive literature has docu-
mented the growing problem of
adverse drug reactions, misuse of
medications, and significant cost
implications of drug-related morbidity and
mortality.1-6 While these problems affect
all segments of society, they are espe-
cially prevalent among the elderly, a group
that is especially vunerable because it com-
prises individuals who often have mul-
tiple medical conditions and therefore need
multiple medications.5,7-9 Errors and non-
compliance in the use of medications in-
volve all types of drugs, including those
that may be lifesaving, such as cardiac
medications, and the resultant morbidity
and mortality can be significant.10-15 Un-
derstanding the magnitude and cause of
medication misuse is essential to devis-
ing adequate strategies to control this prob-
lem. Understanding medication misuse is
especially important in the outpatient set-
ting, where there is opportunity to ad-
dress associated risk factors. Currently,
more is known about adherence to medi-
cations and less about discrepancy.16 The
present study was carried out in an out-
patient practice setting to assess the mag-
nitude of the discrepancies between what
drugs are documented in the medical re-
cord and the medications that patients ac-
tually take, to identify the types of dis-
crepancies, and to examine factors
associated with such discrepancies.
RESULTS
The study sample included 312 white pa-
tients; 48% were men and the mean age
was 62 years. Table 1 describes the clini-
cal characteristics of the patient sample.
We stratified the sample according to the
specialty of the responsible physician in
our office because the patient popula-
tions seen by internists and cardiologists
might be different.
Patients seen by internists were sig-
nificantly younger. There was a nonsig-
nificant trend toward an increased num-

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 PATIENTS AND METHODS
STUDY SETTING
The practice setting was the physician offices of 5 board-
certified cardiologists and 2 board-certified internists, all
of whom were affiliated with the same academic medical
center. All but 1 physician had practiced for more than 15
years. In general, physicians saw their patients on an an-
nual or as-necessary basis. On average, they spent 1 hour
with a new patient and 30 minutes with established pa-
tients. Medication changes by the primary care or cover-
ing physician were documented in the medical record. A
cardiovascular fellow responded to patient calls after of-
fice hours and was instructed to document in the charts
any recommended changes in the use of medications.
DATA COLLECTION
The medical record of each patient contained a list of the
patient’s current medications, which was shared by all health
professionals involved in the patient’s care, both in the of-
fice and in the hospital. This list was reviewed and up-
dated at each office visit and became part of the medical
note dictated on the day of the patient visit. It was also up-
dated whenever prescriptions were renewed or added out-
side the office visit. This has always been the established
process in our practice. The expectation was that the drug
list would contain information about the use of over-the-
counter medications. An assistant to the 2 internists, but
ber of recorded medications in internal medicine patients
when compared with cardiology patients (6.2 vs 5.5,
P=.07). This trend was most likely the result of greater
use of nonprescription drugs. The majority of patients
had established long-term relationships with their phy-
sicians. Most patients were responsible for administer-
ing their own medications, and the majority had other
physicians who also participated in their care.
MEDICATION DISCREPANCIES
In 239 (76%) of the 312 patients, a total of 545 medi-
cation discrepancies were identified. Table 2 summa-
rizes patient characteristics according to the presence
of discrepancy.
Medication discrepancy occurred equally among men
and women. Overall, patients with discrepancy were sig-
nificantly older. The percentage of discrepancies in dif-
ferent age groups was as follows: younger than 40 years,
47%; 40 through 49 years, 85%; 50 through 59 years, 73%;
and 60 years and older, 82%. Patients who had other phy-
sicians participate in their care were more likely to have
discrepancies. This is not surprising, as these patients were
significantly older (mean age, 64 vs 49 years) and took
more medications (mean number of medications, 6.0 vs
3.9) (P,.001 for both). Similarly, patients cared for by
cardiologists were more likely to have medication dis-
crepancies, as they too were significantly older (mean age,
67 vs 53 years; P,.001). Patients with discrepancies
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not the cardiologists, at times verified the list of medica-
tions with the patient at the time of the office visit.
Information was abstracted from the medical record
about the patient’s sex, age, number of medications cur-
rently prescribed, person(s) responsible for the adminis-
tration and supervision of the medications, whether other
physicians participated in the patient’s care, number of years
the patient had been with the physician office, and date of
the patient’s last office visit.
Between November 1, 1997, and February 28, 1998,
all patients scheduled for a visit with one of the physicians
in the practice were called by a research assistant on the
day before their appointment. Each day, the patients of a
different physician, assigned randomly, were interviewed
so that there would be an equal opportunity to sample pa-
tients from all physicians in the practice. Patients were asked
to bring all their drugs (prescription and over-the-
counter) and medicated creams to the office visit. Ran-
dom samples of patients were selected from the practices
of all physicians.
The research assistant (H.G. or S.G.) specifically
asked patients to confirm that the medication bottles they
brought with them accurately reflected the name, dosage,
and timing of the drugs taken at home. She noted the
labels on the medication bottles but recorded the patients’
comments about what medications they actually took to
confirm the instructions on these labels. She compared
this information with the list of medications recorded in
the chart. She also determined whether the patient took
any additional medications that were not on the medica-
tion list and whether the patient was responsible for taking
had a longer association with our practice and a greater
number of medications listed on their medical records.
Most discrepancies, 278 (51%), were attributable to
patients taking medications that were not recorded. The
rest of the discrepancies were attributable to patients not
taking a recorded medication (29%) or to differences in
dosage (20%). The distribution of discrepancies accord-
ing to medication type is shown in Table 3. While over-
the-counter medications were the single largest category,
61% of discrepancies involved prescription medications.
Discrepancies in cardiac medications according to
subcategory and discrepancy type were noted (Table 4).
Inconsistencies for nitrates were the most frequent, fol-
lowed by diuretics, angiotensin-converting enzyme in-
hibitors, and b-blockers. Patients were as likely to have
a discrepancy owing to a difference in dosage, taking an
unrecorded medication, or not taking a recorded medi-
cation. Overall, discrepancies were randomly distrib-
uted among different drugs and discrepancy types, with
no discernible pattern noted.
PREDICTORS OF DISCREPANCY
We determined the association between any medication
discrepancy and demographic and clinical variables pre-
viously examined (Table 5). In univariate analyses, the
following covariates were associated with the presence
of any discrepancy: patient age, physician specialty, par-
ticipation of another physician in patient care, years with
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 his/her own medications. At the end of the structured
interview, open-ended questions were asked to evaluate
factors determining medication usage and to elicit pa-
tients’ concerns and comments about their medications.
DATA ANALYSIS
We defined medication discrepancy as the difference
between the list of medications in the medical record (re-
ferred to as recorded medications) and what a patient actu-
ally took based on medication bottles and on self-reports
to the trained research assistant (referred to as reported
medications). We categorized medications into 5 groups:
(1) over-the-counter medications, including vitamins/
minerals, acetaminophen, decongestants, and gastrointes-
tinal remedies such as antacids or histamine2 blockers; (2)
anti-inflammatory medications, including aspirin; (3) psy-
choactive medications, including sleeping pills, antide-
pressants, and anxiolytics; (4) cardiac medications; and (5)
other prescription drugs. Because of the importance of car-
diac medications in our large cardiology practice, we fur-
ther subdivided these medications into 8 groups: (1)
b-blockers; (2) calcium channel blockers; (3) nitrates (ni-
troglycerine and long-acting nitrates); (4) angiotensin-
converting enzyme inhibitors; (5) lipid-lowering drugs; (6)
diuretics; (7) warfarin sodium (Coumadin); and (8) oth-
ers, including antihypertensive agents (other than those
noted in categories 1, 2, 4, and 6).
For each medication group, we determined whether
there was a discrepancy in the type or dosage of medica-
tion. We noted whether the disparity occurred because the
the physician, and the number of recorded medications.
On multivariate analysis, patient age and the number of
recorded medications were the 2 most significant pre-
dictors of discrepancy. As expected, we found a signifi-
cant interaction between the number of medications on
the medical record and patient age, with older patients
taking more medications. We included this interaction
term in the regression models because we thought that
it was of clinical significance and had an impact on the
assessment of the effect of other variables. There was evi-
dence for a nonsignificant trend toward increased dis-
crepancy when the patient was female, when the man-
aging physician was a cardiologist rather than an internist,
and when another physician participated in patient care.
Finally, we examined factors associated with medi-
cation discrepancy, excluding over-the-counter medica-
tions and dosage discrepancies, separately and jointly
(Table 5). Age and number of recorded medications re-
mained significant predictors of discrepancy even though
the magnitude of effect for each of these variables changed.
Participation of another physician was the most signifi-
cant predictor of this type of discrepancy.
PATIENTS’ COMMENTS
Comments from patients were informal, rather than quan-
tified, but we did elicit meaningful responses about their
expressed concerns. We categorized patients’ feedback
about their medications into the following 4 areas:
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patient was taking a medication not listed on the medical
record or because he/she was not taking a documented
medication.
STATISTICAL ANALYSIS
We used t tests for 2-group comparisons of continuous vari-
ables, and x2 analysis or the Fisher exact test of statistical
significance for comparisons of proportions. To identify mul-
tivariate adjusted predictors of medication discrepancy, we
conducted 2 sets of analyses using different definitions of
discrepancy. The first regression model, which we used to
examine factors associated with medication discrepancy,
included discrepancies related to over-the-counter medi-
cations and dosage differences, while the second analysis
excluded these discrepancies. The rationale behind these
modeling approaches was to remove the effects of discrep-
ancies of lesser clinical significance. We used logistic re-
gression to identify factors associated with discrepancy, while
controlling for potentially confounding variables. Univari-
ate associations of independent covariates, such as age and
sex, with medication discrepancy were initially deter-
mined. Clinically relevant 2-way interactions were exam-
ined after the initial data categorization. Clinically rel-
evant or statistically significant variables, including
interaction terms, were entered into the final regression mod-
els. The most predictive and parsimonious models were se-
lected. Hosmer-Lemeshow goodness-of-fit testing was per-
formed on selected regression models, and likelihood ratio
testing was performed to compare different models. We used
a significance level of .05. All P values were 2-sided.
1. Desire for more information. Patients wanted
more details from their physicians about how the drug
they were prescribed would help their symptoms or how
it would interact with other medications.
2. Concerns about adverse effects. Adverse effects
that were important to patients were often vague, such
as “feeling blah” or “feeling not myself.” Some patients
worried that the dose of the medication they took was
“too much.” Specific complaints most often focused on
loss of libido or concern about liver toxicity.
3. Obstacles from convenience or cost. Conve-
nience in taking medications and filling prescriptions was
more important to our patients than medication costs. Even
patients on a twice-daily medication regimen asked to sub-
stitute it for a once-a-day medication. Patients wanted more
medications with each prescription to avoid the delay or
inconvenience of frequent refills. Some wondered whether
splitting a stronger pill would offer them savings.
4. Influence of multiple physicians. The majority of
patients’ comments focused on the problems of having mul-
tiple physicians involved in their care. Many patients com-
plained about lack of ready access to subspecialists and
that their primary care physician made medication changes
without consulting a specialist. One patient, for example,
said he had been “easing off” all his medications because
his primary care physician said that it would be fine to do
so as long as he “felt all right.” Medication lists were of-
ten modified after the patients were discharged from the
hospital, and patients were not always aware of the need
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 and the basis of successful outcomes.20 While the extent
Table 1. Demographic Data by Physician Specialty* of medication discrepancies in our study was higher than
in previous reports, this difference likely reflected the me-
Internal ticulous effort given to correct identification of medica-
Cardiology Medicine Total
(n = 205) (n = 107) (N = 312) tions taken and the uniqueness of our study in using the
patients’ medication bottles rather than patients’ diaries,
Age, mean (± SD), y 67 (± 14) 53 (± 16) 62 (± 16)
Male, No. (%) 136 (66) 15 (14) 151 (48)
computer printouts, or pharmacy records to verify the pres-
Participation of another 184 (90) 87 (81) 271 (87) ence of discrepancy.21,22 Consistent with the report of Mon-
physician, No. (%) son and Bond,23 we found that the more drugs a patient
Patient responsible for 173 (84) 101 (94) 274 (88) takes, the more likely that there will be a discrepancy.21
medication, No. (%) The existing literature on medication use and mis-
Family responsible for 30 (15) 1 (1) 31 (10)
medication, No. (%)
use has primarily focused on one aspect of discrepancy,
Years with physician 7.0 2.2 5.3 namely patient compliance, which assesses the failure of
office, mean patients to adhere to prescribed medications. Our study
Time since last visit, 7.0 4.1 6.0 highlights the larger picture of discrepancy and extends the
mean, mo previous work of Wagner and Hogan22 demonstrating that
No. of recorded 5.5 6.2 5.8
what medications a patient takes does not depend on vo-
medications, mean
No. of reported 6.7 5.7 6.4 lition alone. Other factors, such as miscommunication
medications, mean among physicians or between physicians and patients, can
play an important role, as suggested by other reports.21,24
*Differences were significant at P,.05 for all variables except number of Our patients were sometimes following another physi-
recorded medications. cian’s orders, frequently outside our office practice, when
they failed to take prescribed medications or took addi-
tional nonrecorded drugs. The differences between the defi-
Table 2. Patient Characteristics According nitions of noncompliance and discrepancy notwithstand-
to Presence of Medication Discrepancy ing, existing data on high rates of noncompliance are
consistent with the present findings.25-29 A unique aspect
Discrepancy Discrepancy
Present Absent P
of our study was that we took into consideration the pa-
tients’ perspectives; similar to previous reports about medi-
Age, mean (± SD), y 64 (± 15) 56 (± 18) ,.001 cation compliance, we observed that concerns about the
Male, % 48 49 .51
Physician type, %
convenience of taking medications, filling prescriptions, and
Cardiologist 82 18 ,.001 adverse effects were most important for our patients.
Internist 65 35 ,.001 Another method to determine the medications pa-
Participation of another 80 56 ,.005 tients actually take is to evaluate computerized drug da-
physician, % tabases, such as pharmacy records.23 While this method
Years with physician office, mean 5.7 4.2 .05 has the advantage of improving efficiency in larger stud-
Time since last visit, mean, mo 5.7 6.5 .45
No. of recorded medications, mean 6.2 4.4 ,.001
ies and can serve as a surrogate for pill counting, it may
No. of reported medications, mean 7.0 4.4 ,.001 be impractical to use in an outpatient setting where drugs
are obtained from multiple sources. On the other hand,
self-reporting of drug intake may be subject to recollec-
tion bias but provides the clinician with ready access to
to inform their physician in our office of changes that were important information if meticulously performed.
made in their regimen outside the practice.
FACTORS ASSOCIATED WITH
COMMENT MEDICATION DISCREPANCY

This study demonstrates that there is considerable discrep-
ancy between recorded and reported medications in the ma-
jority of cases in our academic outpatient private practice.
The discrepancies include all medications, prescription and
nonprescription, and were of different types, including dis-
crepancies in dosages, not taking recorded medications, and
taking nonrecorded medications. One third of the discrep-
ancies involved over-the-counter drugs or herbal thera-
pies. Miscommunication about herbal therapies is rela-
tively common because patients often self-prescribe without
consulting or informing their physicians. Adverse effects
from such therapies are not necessarily trivial.17-19
The majority of discrepancies occurred with pre-
scription drugs and a full quarter with cardiac drugs. These
findings are especially striking because medical therapy
has been the foundation of medical care in our practice
Older age and a higher number of recorded medications
were strongly associated with medication discrepan-
cies. Consistent with a previous report, our findings dem-
onstrated that discrepancy was as likely to involve pre-
scription and potentially toxic medications as over-the-
counter medications.21 Our finding that older age is
associated with medication discrepancy seems plausible
clinically, but, to our knowledge, prior studies have not
evaluated the influence of age on discrepancy.21,24,30 In
fact, within groups of patients older than 65 years, older
age is associated with better compliance with antihyper-
tensive therapy and with treatment of congestive heart
failure.26,31 Reports on compliance or likelihood of ad-
verse drug reactions have not found an association with
advancing age.7,32-34 We found nonsignificant trends to-
ward increased discrepancy in cases involving female pa-

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 Table 3. Detailed Medication Discrepancies by Drug Type and by Subspecialty

Over-the-counter Prescription Sleep Cardiac Aspirin/Anti-inflammatory

All
Not Not in Not Not in Not Not in Not Not in Not Not in Types,
Dose Taking Record Total Dose Taking Record Total Dose Taking Record Total Dose Taking Record Total Dose Taking Record Total Total
Cardiology 2 20 112 134 19 17 50 86 10 5 20 35 46 33 39 118 10 7 13 30 403
Internal 2 15 22 39 9 31 13 53 3 15 2 20 4 6 6 16 4 9 1 14 142
medicine
Total 4 35 134 173 28 48 63 139 13 20 22 55 50 39 45 134 14 16 14 44 545

Table 4. Cardiac Medication Discrepancies by Type Table 5. Crude and Multivariate Predictors
of Medication Discrepancy*
No. (%)*
Discrepancy for
Not in Dose Recorded Any Discrepancy Prescription
Record Discrepancy Not Taking Total Medications
b-Blockers 3 (2) 10 (7) 4 (3) 17 (13) Crude OR Adjusted OR Only†, Adjusted
Calcium channel 1 (1) 3 (2) 4 (3) 8 (6) Factor (95% CI) (95% CI) OR (95% CI)
blockers Age, 10-y 1.36 (1.16-1.60) 1.60 (1.14-2.24) 1.47 (1.08-2.00)
Nitrates 10 (7) 6 (4) 9 (7) 25 (19) increment
ACE† inhibitors 2 (1) 11 (8) 6 (4) 19 (14) Sex 0.98 (0.58-1.65) 1.73 (0.83-3.58) 1.05 (0.58-1.93)
Lipid-lowering 5 (4) 6 (4) 5 (4) 16 (12) Physician being 0.40 (0.24-0.69) 0.44 (0.12-1.65) 0.61 (0.18-2.10)
Diuretics 5 (4) 10 (7) 8 (6) 23 (17) internist
Warfarin sodium 5 (4) 1 (1) 2 (1) 8 (6) Participation of 3.11 (1.51-6.40) 1.45 (0.63-3.38) 2.49 (1.14-5.44)
(Coumadin) another
Other 14 (10) 3 (2) 1 (1) 18 (13) physician
Total 45 (34) 50 (37) 39 (29) 134 (100) No. of recorded 1.21 (1.10-1.33) 2.28 (1.47-3.53) 1.74 (1.20-2.53)
medications
*Some percentages are not true totals because of rounding.
†ACE indicates angiotensin-converting enzyme. *OR indicates odds ratio; CI, confidence interval.
†Excluding over-the-counter medications and dose discrepancy.

tients, in cases involving patients managed by cardiolo-
gists as compared with internists, and in cases in which
there was participation of another physician in patient
care. A long-term patient-physician relationship did not
diminish the likelihood of medication discrepancy.
We expected a lower number of discrepancies, con-
sidering that our patient population was well educated
and of high socioeconomic status. To our knowledge,
there is no information in the published literature that
indicates how socioeconomic status may affect medica-
tion discrepancy, and the relationship may be more com-
plicated than we expected.
STUDY LIMITATIONS
There are several limitations to the present observational
study. First, while the study sample was representative of
our practice as a whole, our results might not be gener-
alizable to other clinical settings, to patients enrolled in
health maintenance organizations, or to patients of low to
moderate socioeconomic status. Second, our data did not
allow us to separate discrepancies that were caused by im-
proper practice in our office from those resulting from a
lack of communication from an outside physician or those
resulting from patients acting independently. Third, we
did not collect information on comorbid illnesses and
thereby did not assess their influence on discrepancy.
Fourth, we may have found fewer discrepancies had we
assessed medications in the medical record after a physi-
cian visit rather than before. However, the discrepancies
we identified reflected the realities of day-to-day use of the
medical record in patient care. Also, if the charts were to
be reviewed after the patient visit, physicians aware of the
study may have attempted to take a more accurate medi-
cation history, thereby introducing bias. Finally, this study
did not assess the impact of medication discrepancy on
patients’ outcomes. However, studies on noncompliance
have clearly documented the association between medi-
cation misuse and adverse health outcomes, in both the
outpatient and the inpatient settings.4,35-39 This medica-
tion misuse may have a major impact on outcomes for many
illnesses, including cardiovascular disease.11-13,15 For ex-
ample, discontinuing certain cardiac medications, such as
b-blockers, may be detrimental to patients with coronary
disease, triggering potentially life-threatening arrhyth-
mias or myocardial infarction.13
RECOMMENDATIONS
There are several possible solutions to improve medica-
tion accuracy. Our findings suggest that a compulsive, spe-
cific, and systematic review of the patient’s medication
bottles should become a standard element in the patient’s
care. Although this system may seem time consuming and
cumbersome, it is unlikely to outweigh the cost of medi-
cation misuse for patients with chronic or comorbid ill-
nesses. It will ensure accuracy and identify any change in
medications, whether initiated by an independent or non-
compliant patient or by a physician who fails to commu-
nicate his/her adjustment of medications. Critical review

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of the medication list should emphasize the simplest, most
parsimonious prescribing regimen.40 Communication
among primary care physicians and subspecialists, such
as cardiologists, clearly needs to improve to achieve greater
accuracy in medication use and instruction.
Other proposals that have been developed in the past
to enhance medication accuracy include a telecommuni-
cations system for monitoring drugs,41,42 continuous elec-
tronic monitoring of medication containers,43 follow-up by
pharmacists,44 computerized prescribing,45 “one-write” non-
carbon prescription forms,46 or use of a standardized drug
questionnaire.47 We hope to initiate a program of phar-
macy bar code labeling into our practice so that drugs can
be mechanically recorded at the time of each visit and
printed up for the physician to review. This system allows
physicians to track changes in medications initiated by other
physicians or during hospitalizations. Patients’ input should
be carefully sought before adopting any solution to en-
sure feasibility and relevance to patients’ preferences.
CONCLUSIONS
Discrepancies among recorded and reported medica-
tions were common in our study; they occurred in 75%
of the patients. Discrepancies involved all classes of medi-
cations, including cardiac and prescription drugs. Older
age and an increasing number of prescribed drugs were
the most significant correlates of discrepancy. The per-
vasiveness of medication discrepancy may have signifi-
cant health care implications that deserve further study.
Action is needed to address the variety of causes that may
have an impact on discrepancy. Such action would likely
have a positive impact on patient care, patient-physi-
cian relationships, and long-term outcomes.
Accepted for publication January 11, 2000.
This study was supported in part by the Lown Cardio-
vascular Research Foundation, Brookline, Mass, and by the
Grimshaw-Gudewicz Charitable Foundation, Fall River, Mass.
Reprints: Susanna E. Bedell, MD, Lown Cardiovascu-
lar Center, 21 Longwood Ave, Brookline, MA 02446 (e-mail:
Bambil@tiac.net).
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