A study reported in the Dartmouth Atlas of Health Care 2008 decsribes The remarkable variation in the way academic medical centers manage chronic illness is testimony to the weakness in the scientific basis of medicine. The neglect of the evaluative sciences— those sciences whose mission is to evaluate medical theory, understand patient preferences, and establish the cost-effectiveness of clinical practice—has left the nation unprepared to deal with unwarranted variation. The consequences for public policy should be obvious. Further the authors of the sudy say “the nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care”. However the country cannot focus just on the cae of chronic disease without also changing the entire system to a focus on affordable, accessible, coordinated primary care. This will require different teaching goals in academic centers which must turn away from a focus on basic research and move toward a focus on patient care and effective efficient outcomes of care.