Academic medicine in North America has been highly successful in many ways in the last 50 years, including being able to resist change while unprecedented and fundamental changes are taking place in the practice, technology, and financing of medicine. This stance places academic medicine at risk of being bypassed by events. To prevent this, what balance between rigidity and flexibility should be sought? The author addresses this question by first reviewing the history of academic medicine and then defining in detail three current problems in medical education and two in biomedical research, two of academic medicine's domains. All these problems have in common some form of harmful dissociation of endeavors: for example, in education, there is a dissociation between both the teaching and academic clinical practice of medicine and the health care needs of the public. The author then proposes solutions to the problems, based on his examination of three major principles that motivate academic medicine. For example, he maintains that the teaching of all the medical sciences should be part of, and equal in quality to, the overall program of sciences in a university, and that the interdependence of medical schools and universities should be nurtured. He also maintains that the narrow conceptual framework of medicine that focuses on mechanisms of disease must be expanded to include rigorous attention to such areas as prevention, technology assessment, and organization of care.(ABSTRACT TRUNCATED AT 250 WORDS)