a need for new leaders who are able to function effectively in and lead complex delivery systems.

Finally, there are implications for the training and development of nonclinical administrative and management personnel, as well as governance. By making budgetary and resource decisions for health care organizations, these groups, with input from and in collaboration with the clinical community, influence priorities and the pace at which they are implemented. For example, the administration of a hospital can provide sufficient resources to support the implementation of medication order/entry systems that help clinicians provide safer care, or they can slow the pace at which such systems are implemented by not ensuring sufficient resources or training. Training and development for both management and governance should recognize the important role these groups play in collaborating with clinicians to make possible the types of changes needed for the health system of the 21st century.

There have been many prior examinations of clinical education, particularly medical education. The structure and form of medical education were set through the Flexner report of 1910. That report called for a 4-year curriculum comprising 2 years of basic sciences and 2 years of clinical teaching, university affiliation (instead of proprietary schools), entrance requirements, encouragement of active learning and limited use of lectures and learning by memorization, and emphasis on the importance of problem solving and critical thinking (Ludmerer, 1999; Regan-Smith, 1998).

More than 20 different reports followed Flexner’s, each calling for the reform of medical and clinical education. The striking feature of these reports is their similarity in the problems identified and proposed solutions. Christakis (1995) reviewed 19 reports and found eight objectives of reform among them: serve changing public interest, address physician workforce needs, cope with burgeoning knowledge, foster generalism and decrease fragmentation, apply new educational methods, address the changing nature of illness, address the changing nature of practice, and improve the quality and standards of education. Enarson and Burg (1992) reviewed 13 studies of medical education and summarized the recommended changes under the categories of (1) methods of instruction and curriculum content (including the need for a broad general education, definition of educational objectives, acquisition of lifelong learning skills, and expansion of training sites); (2) internal structure of medical school (including integration of medical education across the continuum of preparation, control of education programs in multidisciplinary and interdepartmental groups, and definition of budget for teaching); and (3) the relationship between medical schools and external organizations (including integration of accreditation processes, assessment of readiness for graduate training, and use of licensing exams).

Many believe that changes in medical education are needed. In their survey of medical school deans, Cantor et al. (1991) found that 68 percent believed



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