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In Reply: Drs Rabkin and Cook argue that medical workforce planning is bound to fail without medical financing reform that addresses the perverse incentives of fee-for-service reimbursement. I agree. The evidence is also robust that a greater infusion of public dollars to expand graduate medical education is likely to lead to more fragmented care and higher costs without improvements in access, quality, and outcomes.^1-3 Less widely discussed, the additional physician capacity will adversely affect the pace and direction of health care reform. It is hard to imagine a more efficient and coordinated health care delivery system evolving during an era when teaching hospitals greatly expand the training of subspecialists.

Dr Perkins asks whether there is evidence that the tectonic movement away from physicians training in primary care is a problem for patients. A more salient question is whether the substitution of a potential primary care physician by a cardiologist, dermatologist, . . . [Full Text of this Article]

David C. Goodman, MD, MS
david.goodman@dartmouth.edu
Dartmouth Institute for Health Policy and Clinical Practice
Dartmouth Medical School
Hanover, New Hampshire

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