Teaching hospitals, our academic centers of medicine, are struggling anxiously to develop a fiscally responsible plan to deal with the still-uncertain future of healthcare delivery systems. A struggle of equal, though less heralded, proportions is also being waged to maintain these institutions' commitment to research and training as an integral part of providing high quality health care. This latter struggle results in part from diminished clinical revenues, which have traditionally helped support these activities.

The academic mission is also facing enormous challenges with both the changing structure of teaching hospitals and society's perception of their role. The downsizing of medical centers has resulted in that traditional bastion of academic teaching and research - the inpatient facility - now being replaced by "hospitals without walls." New outpatient activities may extend dozens of miles from the medical centers and medical schools; with them must follow creative ways to teach, train, and conduct research.

With increasing public scrutiny, the academician is requested to take greater responsibility for prioritizing research and training and for providing justification that social benefits will likely arise from such efforts.

Although there will not be a single pathway to preserving academic medicine in the United States, I suggest that physician-scientists with combined M.D.-Ph.D. degrees can be one of the standard-bearers for this mission. They are most likely to be individuals who can be a bridge between the laboratory bench and the patient's bedside and develop creative approaches for a productive integration of medical care, training, and basic and clinical research.

The formal M.D.-Ph.D. program in American medical schools was established more than 30 years ago when funding from the National Institutes of Health was allocated specifically for these joint degree activities. It originated in the increasing rigor in scholarship at our clinical institutions and the beginnings of the biomedical research explosion that continues today. Thus born in the now perceived halcyon days of clinical investigation, the M.D.-Ph.D. took on the mantle of leadership for research in our teaching hospitals, particularly in basic research.

Abundant evidence has accumulated over the last decade demonstrating the extraordinary success of the M.D.-Ph.D. in the biomedical environment in the United States. M.D.-Ph.D.'s have led the list of federal-funded grantees and appointments to prestigious academic positions, have facilitated pathways up the academic ladder, and have become the role models of the physician-scientist, replacing that of the clinical investigator of a decade before.

These were times, however, when these outstanding physician-scientists carried out their work relatively unencumbered by fiscal constraints or societal scrutiny. Still, one can argue that these talented individuals, although no more tested by the new reality than their colleagues, are better prepared to deal with its consequences. As we demand more from the academician as a care giver and researcher, the M.D.-Ph.D. brings new flexibility to both cultures - that of the researcher and that of the health provider - adapting more easily to changes in either arena.

This group has readily perceived the necessity for a thorough understanding of integrated human physiology and pathology in our molecular era, and brings an ease to bench-to-bedside translational research that is essential to the maintenance of our leadership in medical knowledge and care. These individuals see translational research not as an abrogation of their research heritage, but rather as an extension of it. The M.D.-Ph.D. brings high credibility, a well-honed toughness in the research arena, and documented success in obtaining research funding.

It is also a hope of those involved in this educational pathway that obtaining the M.D.-Ph.D. degree will bring women and minorities into academic medicine with credentials that are undeniable, and thus help remove impediments to their leadership roles. Specific programs, such as the federal MARC (Minority Access to Research Careers) fellowships for minorities, provide an important resource to help achieve such a goal.

Past and present political leaders support the concept that medical research is a cost-effective investment. Society, in turn, has demonstrated that it values the products of medical research that emanate from such complex enterprises as teaching hospitals and other academic centers of excellence. To sustain this commitment in a time of diminishing resources, we must continue the pursuit of excellence in basic science investigation, but we must also acknowledge and rectify the significant deficits in patient-oriented research dealing with the fundamental mechanisms of human disease, and in the evaluation of the outcomes of our therapeutic interventions for such diseases.

To achieve these goals will require extraordinary and creative approaches in forging partnerships among hospitals, medical schools, the biotechnology and pharmaceutical industries, government, and health-care insurers. There is no more capable group to lead this initiative than those whose combined research and clinical training gives them the broadest perspective and experience. Academic centers should thus look to the M.D.-Ph.D. programs not only as a special expression of their educational mission, but as an important source for their future faculty. There, they will be rewarded with a group of individuals who have developed both a passion for caring and a science for curing.

Dr. Ausiello is Professor of Medicine and Director of the M.D.-Ph.D program at Harvard Medical School and the Massachusetts General Hospital.