The four horsemen of the apocalypse. Study of academic medical center governance.

Governance of academic medical centers is in a process of change. This essay reviews some of the historical factors that have affected the present status of academic medical center governance and describes the functions of the four individuals who are most involved in the operation of academic medical centers: vice-presidents for health affairs, deans of relationships between these four individuals are analyzed, and points of conflict are identified. Some suggestion about how these individuals can work together more effectively are made.