Crushing the commercial spirit in academic medicine: a crusade that failed.

The struggle between academic values and the practice opportunities in clinical medicine has continued throughout the present century. The reformers who prevailed in bringing clinical teaching into the university as a full-time occupation were persuaded that only university ideals--academic rigor, high professionalism, and full-time service in teaching and research--could create the kind of environment in which clinical science and effective clinical teaching could flourish. Their victory was never complete, and much of America's clinical establishment resisted the change, arguing that it was not commercial gain but concerns over teaching medicine in a narrowly academic enclave that motivated them. For the first two thirds of the century, the commercial spirit in academic medicine, while never completely crushed, gave way to an academic ethos that honored academic recognition and research honors over making money. Events of the past 30 years have reawakened the commercial spirit with a vengeance. In the years since Medicare, managed care, and HMOs have become prominent, faculty practice has become a principal means of maintaining teaching hospitals, high professional salaries, and medical teaching. In the present crisis, the author believes, only an unprecedented, all-out effort on the part of medical faculties and their allies to separate out medical education from other health care concerns and secure strong support from government offers any long-range hope for success.