Medical education for the twenty-first century.

I T r WELL TO REMEMBER Til AT THERE IS NOTHI G IMMUTABLE ABOUT THE present structure of academic medical centers, whi h is not to ay that the sub tance of what they do will change, but their configuration may be different. All of you are familiar with the Flexner report and it impact on American medical education, so I will not repeat what you already know. But I would remind you of the prelude to Flexner's eminal report and the epilogue to tbe reforms catalyzed by Bulletin No. 10 of the Carnegie Foundation for the Advancemenl of Teaching. Ludemer has pointed out that active reform of medical education began in a few institutions years before the Flexner Report, and all of the changes he recommended were in place at Hopkins and a few other medical schools by 1910, as Flexner him elf conceded. It i quite likely that reform would have spread without FlexileI' , perhaps more slowly, but probably with the same result. I say this because the leaders of the medical profession wanted reform and wanted to be rid of the proprietary schools that were little more than diploma mills. And they wanted reform heeau e the science of medicine had be ome so impOltant, thanks to the advance ill physiology, bacteriology, and pathology made largely in Europe during the second half of the nineteenth century. Tlte epilogue is equally important, for today' a ad mic medical center with its array of profe ional s hools, its faculLy practice plan, aJld its largescale research establishment was not a part of FI ner' blueprint, the point being that there has been an almost continuous evolution of the academic medical center, nee medical school, during most of this entury. Further chaJlge will undoubtedly 0 ur, but it will be evolutionaI1', perhap accelerated a happen d at the b ginning of the century, but hru'dly a convulsive revolutionaJ'y change. ot only i incremental change our lyle, but there i enormous inertia in the pI' 'ent sySl III that, tog ther with the Vel) large amounts of money supporting our academic medical center, will impede rapid change. You will note that I said "academi medical center" rather than "medical education," for the education of medical student has b come, for most medical centers, a very ' mall part of what they do. The way in which the medical education establishm nt evolves may not change very much, but the impetus for change thi time will be very different from what it was at the b ginnjng of Ihe century. Then, it was the leader 'hip • Former President, ,Hilbank Memorial Fund, ell' York. Photograph by Jill Krementz