Revolutionary changes in the nature and form of medical practice institutions are likely to reverberate backward into medical education as leaders of the new practice organizations demand that the educational mission be responsive to their needs, and as these demands are increasingly backed by market power. In the face of this pressure, medical education's traditional response - that it should have autonomy in defining its mission - is no longer viable. Instead, more explicit, formal, and systematic linkages between practice and educational institutions are inevitable. The crucial question is whether these linkages will reflect the values of the market, oriented by economic self-interest, or the values of medical professionalism oriented by the obligation to sacrifice economic self-interest in the service of patients. The authors maintain that the realization of the normative ideal of professionalism in medical education within the emerging market environment requires that a vision be articulated that is distinct from that of either autonomy or the market, and that combined lay - professional institutions be established to integrate - and perhaps merge - education and practice, and to foster responsiveness to lay values and community needs. The authors conclude by briefly describing examples of current efforts in this direction.
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