I agree with Seifer and colleagues that we must consider the broader context of health care delivery when determining how best to preserve and enhance professional values, attitudes, and behaviors [1, 2]. These professional values, attitudes, and behaviors are learned and reinforced explicitly through formal educational structures (for example, bedside rounds, lectures, and seminars) and implicitly through the influence of role models, mentors, and the "silent curriculum." Perhaps most important is the cultural context of medicine, with its socialization pressures and internal rewards.

Academic medical centers have a unique culture that combines research, the delivery of specialized patient care, and the education of health professionals. This culture differs from that of a managed care organization, a group practice in rural America, or a private physician's office. How can professional values, especially as they relate to putting the patient first and service to society, be instilled when academic medical centers and managed care organizations must compete in an environment that places less emphasis on trust in the doctor-patient relationship than on a greater market share [3]?

Ways to preserve professionalism within the academic medical center and the broader context of health care reform do exist [1, 2]. One strategy is for academic medical centers to develop programs that serve their neighboring communities more directly [4, 5]. Another is through continuous quality initiatives designed to enhance excellence in patient care and at the same time reduce costs to the system. It is essential that we remind the economists and health policy makers that the public expects that physicians will act in their best interests. Maintaining medicine as a profession dedicated to the welfare of others must be at the forefront of health care reform, whatever form it takes.