I enjoyed reading the most recent issue of HealthcarePapers centred on the lead article by Jeff Lozon and Robert Fox. Having written one such lead article myself, I can appreciate what they describe as the "humbling and unnerving experience" of reading a large number of commentaries by learned, experienced people, all focused on what you had to say.

As one of the drafters (with Scott Rowand) of the 1995/96 ACTH/ACMC papers on Academic Health Science Centres/Networks, it is clear that not a lot has changed in the last six years despite all the discussion by the major "players" represented in the ACTH/ACMC. That it has not is, in my view, entirely our fault. By ours, I mean those of us who were and are in positions of leadership within these curious beasts. I agree strongly with a number of the commentators, notably Schneller and Ward (and to a lesser extent Ludmerer), who make the case, in different ways, that AHSCs are slipping into the "victim" category because we have not been able to come to grips with our own internal complexities, inflexibilities, and the resistance to change of all manner of folks on whom we are dependent. We have not developed those clear statements of vision Schneller refers to or come forward with the innovative new approaches to practice, to education, and to research Ward says(rightly) governments need - primarily because we can't get our own folks internally to agree (or, if they agree to the statements, to behave accordingly).

I remember well the intense and seemingly interminable arguments in Kingston as we developed the Alternative Funding Plan. They all came down to the question, would you rather do something yourself or have something (probably worse) done to you? And it was always in the context that the status quo was just not an option (unless you considered going out of business an option). Bad as things are in AHSCs throughout the country, I fear they are not yet bad enough to drive the principal resistors of change (primarily physicians and unions) into accepting structural and functional changes that would allow people like you to really lead the transition of St. Michael's from a teaching hospital to a founding constituent of a genuine, speaks-with-one-voice Academic Health Sciences Network.

I love your quotation from Kennedy and agree with it but my too long experience tells me that our whole society, including the inhabitants of our AHSCs, have come to think of the past and present as the "golden age" and as a consequence will not pick up the hammer to re-roof until the downpour is really bad and unrelenting. It is a sad commentary and not one this life-long optimist has come to happily.

I must stop but would venture one more point (to get it off my chest, once again). Rigid and inflexible as teaching hospitals and AHSCs are, universities are worse. Once thought of as society's principal agencies of forward, innovative thinking as well as repositories of the most advanced knowledge and wisdom, I believe most people who know enough about them to venture an opinion consider universities to be measured among the forces of reaction. Just as AHSCs are rapidly losing their one-time monopoly on high technology and sophisticated procedures to large community hospitals, so universities are fast losing their knowledge-creation monopoly to teaching hospitals, industrial labs, think tanks, etc., and their educational monopoly to all kinds of industrial/business in-house programs and to private sector courses (e.g., their own "off-line" Executive MBA programs put on by their Business Schools). Yet universities continue to present themselves to anyone who will listen as "precious," an argument Ward convincingly rejects from AHSCs. He is right to ask, "show me that you are leading the way and then I will treat you as a precious resource." Leading the way is always tough and it is really tough when the folks who have to do it in AHSCs and universities don't want to change from the way they did business in the "good old days."

Enough ranting and raving. Good set of papers. As you can see, I enjoyed reading them.

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