Represented by a young couple "dumping" grandpa for the weekend, so that they can have a few days to themselves, or by the admission of alcoholics and derelicts who would otherwise have nowhere to go-has already been reduced and will soon be eliminated. One can say this with some confidence because in every case the rationale is economic, not philosophical. Hospitals are becoming so expensive that financial considerations will soon become the paramount determinant of function.

Less certain are those new tasks and responsibilities that the hospital will assume in the future. Here, the pressures are largely social, and their manifestations not easily anticipated. Perhaps the clearest-and most general-trend is the hospital's notion of an extended responsibility, which goes beyond the confines of its walls. A teaching hospital such as the Massachusetts General now sees its job as dealing both with the hospital patients and with the surrounding community. It defines this new role in two ways: discovering those patients who need hospitalization but are not receiving it, and treating other patients so that future hospitali-zations will be prevented.

But the hospital is going further. It is spreading its research and its knowledge beyond the local community to a broader population. In the past, it did this in the form of research papers printed in scientific journals. That form persists, but more directly the hospital now uses television and computer programs to disseminate its knowledge and its resources.

For the patient, something rather paradoxical is happening. Broadly speaking, the whole thrust of enlightened medical thinking is directed toward getting more care to more people. The problem is as enormous and as important as curing any specific disease process. In examining the situation, both doctors and patients express the fear that the individual may cease to be treated as a person, that he may become merged into some faceless, very lonely crowd. Yet at the same time, the hospitals, which have traditionally been the most impersonal elements in any health-care system, are more concerned than ever about tailoring the hospital so it treats every patient individually.

For medical education, the impact of changes in hospital function may be considerable. For the last half century, medical education has been almost exclusively in-patient education-the emphasis has been upon care of the patient who is in the hospital and not outside it. But as the hospital reaches outside its walls, so will medical education.

There is another point about medical education, not often considered in formal discussions. It is a problem, a fact of medical life, which can be dated quite precisely in terms of origin: it began in 1923, with Banting and Best. The discovery of insulin by these workers led directly to the first chronic therapy of complexity and seriousness, where administration lay in the hands of the patient. Prior to that time, there were indeed chronic medications-such as digitalis for heart failure or colchicine for gout-but a patient taking such medications did not need to be terribly careful about it or terribly knowledgeable about his disease process. That is to say, if he took his medicines irregularly, he developed medical difficulties fairly slowly, or else he developed difficulties that were not life-threatening.

Insulin was different. A patient had to be careful or he might die in a matter of hours. And since insulin there has come a whole range of chronic therapies that are equally complex and serious, and that require a knowledgeable, responsible patient.

Partly in response to these demands, partly as a consequence of better education, patients are more knowledgeable about medicine than ever before. Only the most insecure and unintelligent physicians wish to keep patients from becoming even more knowledgeable.

And when one considers a medical institution, such as the hospital, the importance of a knowledgeable public becomes still clearer. Hospitals are now changing. They will change more, and faster, in the future. Much of that change will be a response to social pressure, a demand for services and facilities. It is vital that this demand be intelligent, and informed.