Academic medicine is once more face-to-face with health care reform, which this time is being seriously debated and will at least be the subject of legislation. There is the possibility that the coming changes could unintentionally injure academic medicine; that is why academic medicine's leaders must be participants and constructive contributors to the discussion rather than simply being critics. The author describes the economic, social, and educational forces that have led to the present reform proposals, indicates the main proposals that are being made to respond to these forces, and states ways that academic medicine can effectively change to meet the coming reforms. For example, curriculum content can change (e.g., revise courses to strengthen the bridge between the basic and clinical sciences); there can be more public health emphasis; the educational structure can change (e.g., continue to modify the sites for clinical education); and academic medicine's philosophy can change (e.g., broadening the acute-care, biologically-based medical approach). The author also discusses risks of the proposed reforms to academic medicine (e.g., stagnant support of basic research; political pressures for the distribution of resources for prevention services research and other reforms; decrease in the support available for hospitals' examination of clinical activities), and emphasizes that academic medicine's traditional inertia is one of the greatest risks in the coming years. In conclusion, the author proposes that the university become the base of the medical school and that the health system become the base of the university hospital; an interactive federated relationship between medical schools and hospitals will allow academic medicine to stay flexible enough to effectively meet the coming changes.(ABSTRACT TRUNCATED AT 250 WORDS)