The changing medical care system: some implications for medical education

In summary, the medical care system is undergoing the most widespread and significant changes in a generation. Individual hospitals, the basic delivery units of the past, may fast be disappearing as mergers, acquisitions, and a variety of multi-institutional arrangements become the dominant form and as a host of free-standing medical enterprises spread out into the community. Fee-for-service medicine and cost-based hospital reimbursement, each with its service-maximizing incentives, are being replaced--the former by prepaid capitation systems and the latter by discount pricing and all-inclusive admission charges. The hospital, until now a "farmer's market" of diverse programs and activities serving a broad patient population, increasingly has become a provider of intensive services to a narrowing and more ill patient base. The major teaching hospital, formerly a complete educational resource within itself, may soon become simply one of a number of educational settings, all of which are equally essential for providing a total medical education. Finally, after years of change driven by biomedical discoveries and centered in the academic medical centers, there is a new locus of innovation within the delivery system itself, and those in the forefront are not academicians. It is important, therefore, that just as in the past, when the academic medical center took the lead in bringing to the delivery system what it was learning in its laboratories, it must now take what is being learned in the marketplace and bring it back into the classroom.