The need for real evidence in physician workforce decision making.

The analysis by Barbara Starfield and colleagues has serious methodological and conceptual shortcomings. Despite the reference to "evidence" in the title, there is little evidence to guide the health care community or policymakers. The paper faults specialists for most of the ailments of U.S. medicine and fails to recognize the critical role of specialists in improving Americans' health status. A variety of factors, including organizational and financing systems, discourage effective use of both primary care and specialty physicians. The nation would be better served by developing an evidence base on the relationship between outcomes and education, training, and specialty.