The medical school and the practicing physician.

I am proud to be invited to write an essay for the special issue of the Yale Journal of Biology and Medicine honoring Dean Vernon Lippard. The Association of American Medical Colleges first brought us together in 1946 and during the years that have followed his counsel and friendship have steadily added to my store of significant memory. The subject for this essay has always been one of our mutual concerns, and now that our national medical establishment is passing over the threshold of great change, a review of the relationship between those who teach and those who practice is very much in order. Thanks to the scholarly article by Dr. John Gordon Freymann, which appeared in the April 4, 1964 issue of the New England Journal of Medicine' there is little need to do retrospective research upon the historic background of this subject. In his article, Doctor Freymann points out the well-known fact that the primary reason for establishing the American Medical Association was to strengthen medical education. This explains why, for the first 70 years of its existence, the leadership of the AMA and of the medical schools was in the hands of the same individuals. But shortly after World War I, increasingly entrenched behind a system of full-time appointments, the leaders in medical education began to withdraw from this responsibility for those in practice, and the AMA began to turn into itself, progressively becoming more preoccupied with the security and prerogatives of the practicing profession than with the changing needs of society. Wrote Doctor Freymann: "Owing to blindness and selfishness on both sides, a schism between practicing and academic physicians . . . jeopardized the profession's control of its own destiny." But Doctor Freymann did not write his article merely to criticize medical practitioners and educators for not working together. His primary purpose was to point to what he called a "third force"-the many thousands of physicians who had been trained and certified in one of more than twenty specialties since the end of the last great war. These individuals,