Reflections on the medical deanship.

In 35 years, being dean of a medical school has changed dramatically. Thirty years ago, the dean's world was still the medical school and its affiliated hospitals, but soon this world was transformed by new emphasis on research (and the resources to conduct it) and the increase of specialty medicine. The medical school became larger and the affiliated hospital more complex. They consolidated into the modern academic medical center, which then became more diverse and self-contained and eventually became an island of special expertise and achievement in medicine, the biomedical sciences, and clinical care. Fifteen years, ago, the academic medical center began to be transformed again, this time by its competition with or incorporation into managed care and other health care delivery systems. The medical school dean now operates in an environment far different from that of the 1960s. Deans spend 90% of their time on five major issues: too few resources, isolation and division of activity within the institution, poor management, excessive traditionalism, and too few people with too much to do. In addressing these issues, the dean has several powerful levers, including the appointment and promotion of faculty, appointments to committees and task forces, assignments of budget and space, and controlling the agenda and leading the debate in the institution. Another but less tangible issue is the dean's attitude. Another but less tangible issue is the dean's attitude, which has enormous impact on what happens at the medical school and in its programs. The deanship will continue but in the new context of a health care delivery system-with variations on the same five problems and with the same ten levers available to address them. The responsibility is old; only the context is new.