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Tenure in American medical schools is a personnel policy which exists in relation to institutional policies and realities. It is related to the functions of academic institutions and their capacity for carrying out these functions, and it arises from the needs of an open society to sustain critical and innovative roles for its universities, the necessity for universities to support and protect their faculties, the optimization of their capability to react to new opportunities, and the demands of ever shifting social circumstances. The relation between society and its universities and the balance among the various roles of the universities have not been stable in the past and will not be so in the future. Tenure policies will continue to be modified. The leadership of institutions needs to be aware of the fact that the modifications will occur and of what might be termed the plasticity of tenure.

Approximately two-thirds of all U.S. and Canadian medical schools have provisions for the evaluation of their departments on a periodic or ad hoc basis. Most of these institutions have initiated the departmental review process since 1970. It appears that use of the practice is increasing and is becoming an important tool in providing guidance for departmental activities, programs, and leadership. Departmental review may be conducted in a variety of ways with varying levels of intensity, flexibility, and skill, depending on the environment, resources, dean, department chairmen, faculty, and attitudes of university administrators. Departmental review may be employed to identify, elaborate, document, and/or contribute to the resolution of current and potential organizational concerns. When carefully administered, the process can be a stabilizing rather than a disruptive force; however, by itself, it does not solve major institutional problems.

This paper reports the results of a Delphi probe of the perceptions of medical school deans regarding the most significant changes in medical education and in the health care system which they expect to influence medical education over the next 20 years. The study, conducted in the first quarter of 1974, included an analysis of 54 potential changes distilled from over 440 suggestions. A composite view of the probability of occurring, impact on the system and percentage of deans favoring the change are presented. In general, the future is believed to hold more positive changes than negative ones, and those most likely to occur will come about in the near term. The results disclose few surprising conclusions but provide a structural description of areas of consensus and disagreement among deans.