The past several years have witnessed a profound upheaval of many elements of Western civilization. Not since the changes catalyzed by the industrial revolution has society undergone such drastic reorganization, yet the pace of today's changes is infinitely more rapid. Relations between individuals, economic classes, races, age groups, and the sexes are being radically revised. Clinical investigation has not been immune from the current pressures and I believe that it may be of some interest to attempt to identify the major forces currently acting on our field. One of the themes on which my predecessors have focused attention during the past few years is the relationship between clinical investigators and the federal government, which may be considered the major purchaser of biomedical research. They have pointed out the ultimate societal dividends likely to accrue from the investment in biomedical research, have decried the inadequate support of research in recent years, and have also encouraged investigators to assume more active interest in the development of government policy that affects the welfare of biomedical research. I will choose a different theme and not look primarily at our external milieu, ie at the relations between the federal government and our academic institutions, but rather examine our internal milieu, ie, the basic organizational units in which clinical research is actually conducted. We take for granted that the vast bulk of clinical biomedical investigation in this county is carried out in medical schools, and most of us would find it difficult to imagine a system in which teaching, research, and patient care are not inextricably intertwined. However, it may be well to remind ourselves that there is nothing sacred or binding about this partnership between biomedical research and the medical schools. Indeed, the great European research institutes, such as the Max Planck, were deliberately established to be freestanding; similarly, the institutes of the Soviet Academy of Sciences andof its Academy of Medical Sciences have relatively little relation to that nation's universities and medical schools. Even in this country and the United Kingdom, large, outstanding biomedical research lab-oratories operate under the auspices of pharmaceutical houses or under governmental auspices at the campuses in Bethesda and Mill Hill, without formal connections to academic institutions.

However, shortly after World War II, a conscious decision was made to carry out the bulk of this coun-try's biomedical research effort in its universities and medical schools. Clinical investigation, in particular, has been carried out almost entirely in medical schools and their closely affiliated teaching hospitals. These institutions have provided a hospitable soil for the nurturing and ultimately the flowering of clinical in-vestigation. As this plan has been implemented during the past three decades, the benefits to the research endeavor have been enormous. The constant influx of bright, energetic, and enthusiastic young investigators