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Price competition and other aspects of the changing health care environment are threatening many academic health centers (AHCs) and causing them to reassess their education and research missions. In order to design effective AHCs for the next century, medical leaders must define the unique competencies needed by tomorrow's physicians and describe the educational enterprises required to produce physicians with these competencies. Two of the most important of these competencies are the ability to manage the uncertainty associated with creating clinical paradigms and the ability to manage the uncertainty associated with managing care delivery. Creating clinical paradigms involves (1) developing knowledge about disease categories and (2) developing knowledge about the most appropriate therapy for a disease in a particular category. Both these tasks involve uncertainty. The second type of uncertainty is associated with managing care delivery and is largely a matter of optimizing current clinical paradigms. The challenges are (1) to correctly assign patients' diseases to existing disease categories, and (2) to correctly choose and manage the delivery of the most appropriate therapies to these patients. Currently, AHCs are more competent in managing--and educating students to manage--the uncertainty involved in creating clinical paradigms. But there is an increasing demand for physicians who manage the second type of uncertainty associated with care delivery. The authors conclude that in order to remain viable, AHCs, and particularly their medical schools, must broaden their educational goals so that students can learn to manage both forms of uncertainty.