IN THIS section 2 years ago, we described a process of "curricular ferment" that was occurring in US medical schools.1 This characterization was supported by evidence of comprehensive educational change at a number of medical schools, in part stimulated by an influx of funding from private foundations. On balance, the outlook for medical education at that time was essentially positive. While medical education was being influenced by internal and external pressures, it appeared to be in control of its own destiny.
During the past year, a less optimistic scenario has emerged as the external pressures have intensified. Health system reform, a phrase that stands for fundamental changes in the organization and financing of health care, has been a major topic of discussion among policymakers and the media. Although it is not clear at this writing what form health system reform will eventually take, all the options that have been