After 50 years of accelerated development, universities and medical schools have entered a period of uncertainty and instability. The Flexnerian paradigm of medical education, rooted in biomedical science and conducted under the aegis of a university, reached its apotheosis by the late 1960s and the early 1970s. Fuelled by the introduction of comprehensive, government-sponsored health care insurance and advances in technology, the demand for health care professionals and for access to facilities increased sharply. Medical education, research and advanced clinical services expanded dramatically aided by the emergence of academic health sciences centres and accompanied by a wave of medical curriculum reform. Now medical schools must strike a dynamic balance in responding to the continued expansion of knowledge and technology, the demand for social equity and the exigencies of prolonged fiscal constraint. They must also balance the biological and sociological approaches to medicine in establishing the foundations for the future development of Canadian medical education.