Many in academic medicine agree that its future will be very different from its past. Transformation, not tinkering, is needed if academic health science centers are to survive the challenges posed by federal and state budget constraints, the intense price competition of managed care, and the wide dispersion of information via the Internet. Academic medicine is like an ocean liner, stately and slow to turn from its charted course. But those who captain the huge, slow ship have seen the tip of the iceberg that looms in its path, and must turn to a new course now. The author presents a possible scenario of the future that describes new relationships among academic health centers, new roles for deans and department chairs, and a more collaborative approach to learning. In the scenario, set in the year 2002, the writer looks back on the changes of the period 1996-2005 and describes the relationships, management, priorities, and reward systems of the institutions responsible for health care, medical education, and biomedical research.