Research advances and resource constraints: dilemmas facing medical education.

Public investment in health research is concentrated disproportionately in a limited number of United States medical schools: about 75 per cent of federal health-research expenditures occur in the "Top 40" institutions. The heavy resource demands of advanced research, coupled with constrained public investment in the foreseeable future, will cause a gradual shift of resources toward the already research-rich schools. The various implications of this shift in resources for different categories of medical schools are described under different assumptions for the future: growth, a steady state, and decline. These developments underscore a public-policy dilemma. The further concentration of health-research resources in centers of excellence, which is justifiable in terms of maximizing the potential scientific return on the public's investment, is apt to prove disruptive to medical education in many schools in the middle and lower strata of funded research activity.