FINDING THE SILVER LINING WITHOUT THE GOLDEN EGGS

Despite the failure of Congress to enact comprehensive health care reform legislation, including the hard-won proposals on behalf of academic medicine, there is much reason for hope for the future. Academic medicine won major victories in having its proposals for a broad-based all-payer system of explicit supports for its various missions included in major reform bills. If the members of the academic medicine community can strengthen further the unity they achieved during the long debate, they will be well positioned to succeed if another opportunity arises in time to rescue academic medicine from a buyer's market that is indifferent to their needs. But prudence dictates that they not depend on being rescued and instead consider the faltering of legislative reform as a wake-up call, summoning them to focus on difficult issues within their own control as they engage the rapidly changing health-care marketplace. Academic medicine has grown phenomenally over the past few decades because its missions have been strongly supported by the public. Continued growth is unlikely, given society's numerous unmet needs and limited resources. Therefore, academic medicine not only must face squarely the challenge of restructuring its work to be more efficient and more productive, but must use the many opportunities that lie ahead to sustain and strengthen its public support by embracing public accountability and rededicating its efforts to meet public expectations. Among these opportunities are addressing the size and composition of the physician workforce; teaching and practicing more prudent use of clinical resources; emphasizing training in community-based sites; training generalists to assume a central role in the emerging integrated care systems of the future; fostering teamwork and mutual respect among all health care professionals; educating the public about the costs of education and research to secure adequate funding for these essential academic activities; eliminating financial barriers to entering the medical profession; and achieving greater ethnic diversity among practicing physicians and faculty. Despite growing tensions and preoccupations, academic medicine must also take every opportunity to reassert the primacy of education among its many pursuits. It must also find opportunities to emphasize outcomes and health services research, increase research productivity, reorganize the research process to be more efficient, and assess the value of new technologies more carefully before introducing them. The clinical enterprise of many institutions is already undergoing fundamental change, compelled by market forces, to align services with public need: costs are being reduced, integrated systems are being formed, and patient satisfaction is being enhanced. Overall, academic medicine must resist the temptation to place its own near-term interests above the public's interest, for only by maintaining public trust can it continue to qualify for the support needed to guide medicine to its true destiny.