But despite his concerns about the future of primary care, Goodman stops short of endorsing an increase in the supply of primary-care providers. "Primary-care physicians' effort can be as easily wasted as specialists'," he says. "So again, supply is not the answer to primary care."

Instead of simply ramping up the production of physicians, Goodman would like to see more-inclusive and better-organized workforce planning. Academic medical centers have dominated the discussion, he says, and that has resulted in a narrow focus on the role of physicians—excluding nurses, physicians' assistants, insurance companies, employers, and patients from the conversation.

Goodman also supports changes in federal funding of academic medical centers. He proposes enacting a competitive process for Medicare funds, similar in principle to the competition for research funding from the National Institutes of Health. "I believe that a competitive process has served us incredibly well in terms of research," he says. "And it could do the same in terms of promoting graduate medical education." Criteria might include, for example, what fields graduates enter, where they practice, and how well schools develop innovative training techniques. "I don't believe that training programs should be rewarded for producing ever more doctors just to practice in the most affluent communities in the country," he says.

For now, the future of the effort to increase the number of physicians remains unclear. In a survey conducted by the AAMC, almost all of the nation's medical school deans reported that their schools plan to expand; Salsberg thinks the goal of a 30% increase in M.D. graduates could be met by 2017. Osteopathic schools have also continued to grow, with first-year enrollment expected to surpass 5,000 next fall—a 40% increase over just the past five years.

Even Dartmouth Medical School has answered the call to grow. "Our senior class size a few years ago was about 68 to 70 a year, and in a year or two I think it will top out at about 83," says Nierenberg. "Something like 83 is probably what Dartmouth can do to help the country and still have the resources to do a superb job of training students."

Still, all that growth might not result in a significant increase in the actual number of doctors. Those medical-school graduates must go on to train as residents at teaching hospitals before

entering practice, and most of the funding for residencies is provided by Medicare.

But as part of the 1997 Balanced Budget Act, Medicare funding for this purpose remains capped at 1996 levels—about 80,000 residency slots—and it would take action by Congress to lift that cap. For now, at least, what seems likely to happen is that the growing number of U.S. medical graduates will displace some of the graduates of international medical schools, who currently fill about one-fourth of residency slots.

TDI researcher Elliott Fisher doubts that Congress will lift the cap anytime soon on spending for graduate medical education (GME). Russell Robertson, the chair of the Council on Graduate Medical Education, agrees. COGME has not officially revisited its stance on the physician workforce, but Robertson says at this point he doesn't recommend an increase in GMEfunding. "I'm increasingly convinced that lifting the GME cap isn't a good idea," he says. "I'm more and more convinced that what we're doing right now is probably going to produce a surplus of physicians."

The AAMC, however, has urged Congress to increase Medicare funding for residencies. That call seems likely to grow louder as medical-school enrollment increases.

Clearly, the debate over the physician workforce is far from settled. Goodman, for one, has no plans to stop asking the questions raised by his experiences two decades ago in Colebrook. The difference is that now, they no longer seem quite so heretical.