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 it
s affiliated hospitals, but soon this world was transformed by new emp
hasis on research (and the resources to conduct it) and the increase o
f specialty medicine. The medical school became larger and the affilia
ted 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 me
dicine, 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 h
ealth care delivery systems. The medical school dean now operates in a
n environment far different from that of the 1960s. Deans spend 90% of
their time on five major issues: too few resources, isolation and div
ision of activity within the institution, poor management, excessive t
raditionalism, and too few people with too much to do. In addressing t
hese issues, the dean has several powerful levers, including the appoi
ntment and promotion of faculty, appointments to committees and task f
orces, assignments of budget and space, and controlling the agenda and
leading the debate in the institution. Another but less tangible issu
e is the dean's attitude, which has enormous impact on what happens at
the medical school and in its programs. The deanship will continue bu
t 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 ad
dress them. The responsibility is old; only the context is new.