In their editorial, Drs. Sandy and Schroeder [1] used our position paper [2] to continue the debate about the size of the physician work force. This issue retains its immediacy, despite a legislative lull, because the pipeline of young physicians wanting training has never been larger and because a surplus of physicians in all areas, including primary care, has never been more obvious [3, 4].

The Association of Subspecialty Professors has taken no position on the future number of international medical graduates entering the United States because controlling the size of the physician work force is a logistical decision that should not be confused with training excellence. It is in the best interests of our health care system to train physicians of the highest quality in training environments of the highest caliber, regardless of where trainees received their degrees. We emphasize a need-based approach to determining size because the assumptions start with an assessment of what is best for patient care, not what is best for business. Making subspecialty medicine more affordable rather than less available is a functional bridge between need-based and demand-based (insurance-or payer-determined) approaches.

Members of departments of internal medicine have made major contributions to biomedical science. Most of the research areas that Drs. Sandy and Schroeder believe were slighted by our position paper are actually integral parts of research programs in many disciplines. We welcome the research contributions of all academic scholars. Although unlinking physician training from research risks the scientific literacy of our trainees, cutting subspecialty training positions to some extent should not greatly affect the productivity of established research programs. Most of the extramural research dollars flowing to departments of medicine go to only a few institutions, implying that there are two kinds of departments: those that have the legitimate means to train new physician-scientists and those that do not. Across-the-board cuts to all departments of medicine would therefore be inappropriate. Further, a shortage of successful investigators can be found throughout medicine, and establishing dedicated training paths for producing physician-scientists should be a priority for all parties in this debate.

Because the United States is processing more physician graduates than it needs [3, 4], the moral obligation for using public training monies is distributed over many disciplines, including primary care. This obligation also requires that we seriously look at new methods for collective birth control. It is equally unfortunate to continue lumping together all specialties of medicine during these discussions. Substantial surpluses exist in only a few disciplines, an appropriate training rate exists for some, and genuine concern about an inadequate future physician work force exists for a few (for example, seven states in the United States are without a pediatric nephrologist).

The Association of Subspecialty Professors believes that only when medical schools, hospitals, and professional organizations with the capacity to reshape work force distributions set aside some of their special interests will society obtain what it really needs: a properly sized physician work force that operates in the interest of patients. No one will attempt such manipulations without legislative indemnification. We welcome the advice of the Robert Wood Johnson Foundation in these matters.