Teaching professionalism: passing the torch.

Changes in medicine brought on by health care reform will increasingly pressure physicians and physicians-in-training to adopt business or trade strategies in the name of cost containment and of competition in the health care marketplace. These strategies run directly counter to the professional standards and are a potential threat to medicine's status as a profession. A challenge for this generation of students is not to let this emphasis on finances erode medicine's professionalism. Medical faculty must ensure that their students properly understand the nature of the relationships that permit medicine to enjoy the benefits of being a profession (rather than a trade) and that they learn the appropriate balance between financial and professional considerations. Faculty can and should place financial considerations in proper perspective. Students should learn the basic components of professionalism, how physicians in the past have not always met the full criteria for professionalism, how the current emphasis on cost containment could threaten medicine's status as a profession, appropriate goals for health care reform, the need to form new alliances to meet those goals, and criteria for forming appropriate alliances. Armed with this knowledge, the generation of physicians now in training can understand the delicate balance that must be maintained between financial exigencies and professional imperatives. They will then be prepared to participate in the reform process, embrace its positive aspects, and argue effectively against its negative ones.

Changes in medical education: the community perspective.

The societal and economic forces driving change in medical education are affecting communities as well as universities. Each of the four authors of this paper is deeply involved in one of the components of their locale's well-developed community-based medical educational system, and each describes how change is influencing his role in that system, whether the role be managing a community hospital, directing a local Area Health Education Center, participating as a family medicine faculty member, or being a community preceptor. They agree on some common themes: (1) that it is good that medical students' education is moving into the community (e.g., this validates the importance of the community hospital to medical education, is an acknowledgment of the importance of generalism, and provides students invaluable learning experiences); (2) that educating medical students in the community is expensive, and more funding and resources are needed so that the area's hospitals, community faculty, preceptors, and support services can be fairly compensated for their commitment; and (3) that their community-based education system can no longer absorb the costs of training more medical students. This is not a criticism of academic medical centers, which are under tremendous financial pressures themselves, but is simply to state the community perspective and to urge fairness in the distribution of resources for medical education. Community institutions and academic medical centers will work individually to create their own integrated health care systems but must work together to create a better, more cost-effective system for educating medical students.