The mission, indeed the very existence, of the traditional academic health center is under siege. Changes in the financing and delivery of health care threaten the clinical revenue used to subsidize the tripartite mission of education, research, and patient care. Market practices, driven by the growth of managed care, will intensify the impact of declining revenue to threaten the actual patient base necessary to sustain these endeavors. The survival of academic health centers depends on their ability to change. This change will not be easy, and the size of the collective academic medical establishment will decrease. Successful enterprises will be those that go beyond incremental, reactive adjustments. Nothing short of organizational redesign, creation of strategic partnerships, and adopting a cybernetic model of continuous measurement, improvement and adaptability will suffice. Using the elements of a strategic planning exercise, this paper reviews the background issues that have produced the current predicament and explores the strengths and weaknesses inherent in academic institutions. Elements of an 'idealized' academic health center are postulated and, finally, specific strategies that might be considered in creating a relevant and secure future are proposed.
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