Academic clinical medicine is widely believed to be in crisis. In particular patient-orientated research is notable for its almost complete absence from the research portfolios of many institutions. A number of recent reports have suggested ways to improve recruitment into clinical academic medicine. Here I argue that, in addition, we should realise that any such crisis is not just confined to medicine but affects most of the university sector. In medicine the situation is compounded by, first, our inability to recognise how much clinical advance occurs and, second, by a refusal to acknowledge the changing organisation and sociology of science. If academic medicine is to continue to be attractive to the brightest and most interesting minds institutional change is unavoidable.