The new school sits between 40 acres of hilly farmland and the outskirts of an old mining town. There is an airy classroom building, several greenhouses, and a large community center that includes a restaurant and a gymnasium. The campus is built on earth scarred by draglines and scrapers, and the immediate surroundings have been replanted with solar panels and young pines.

The first-year students spend as much time tending crops and feeding chickens as studying biochemistry and pharmacology. The seniors are already staffing a network of small primary care clinics scattered throughout the valley. They spend less time in traditional medical settings than they do building relationships in classrooms, at local markets and basketball games. The school’s truly novel curriculum—rooted in principles of preventative medicine, environmental and nutrition science, and community engagement—aims to foster a new generation of healers focused less on treating disease and more on helping individuals and communities thrive.

The preceding decade has been one of upheaval in American health care and society. The Russo-Chinese wars of the late 2020s opened the door to a conservative austerity government that repealed the Affordable Care Act, shuttered Medicaid, and converted Medicare to a voucher system accessible only to the wealthy. An ongoing backlash against elite institutions led to the end of federal funding for Graduate Medical Education and within a few years only a handful of traditional academic medical centers, clustered in large, coastal cities and supported by private endowments, survive. An already fragile and fragmented healthcare system fractures and care becomes inaccessible to hundreds of millions.

After years of struggling to care for patients in a region plagued by public and private divestment, increasing environmental stress, and the opioid crisis, a loose collective of healers forms in the foothills of the Alleghenies. They garner funding from farming subsidies, state and local grants, and private philanthropy to establish the first Health Oriented Medical Education (HOME) program. It’s barely enough to purchase building materials, but local tradespeople contribute free labor and within a few years, the educational, clinical, and agricultural programs will become self-sustaining.

Over the next decade, HOME centers will spring up in both rural and urban parts of the country. Health professions graduates—a historically nomadic tribe—will put down roots and work alongside the people they serve to realize Wendell Berry’s vision1 that, “The community—in the fullest sense: a place and all its creatures—is the smallest unit of health and that to speak of the health of an isolated individual is a contradiction in terms.”

If only this dream were a reality.

It could be.

Einstein said that “No worthy problem is ever solved within the plane of its original conception.”2 In the pages of SGIM Forum and many scientific and lay publications, concerned physicians have scoped the problems that plague our disorganized, unequal, and ineffective healthcare system. But the scale of our industry and the powerful interests that support it discourage bold thinkers from sketching a future state conceived on an entirely different plane. I wonder how much I’ve been restrained by Upton Sinclair’s insight that it’s difficult to get a person to imagine radical change when their career and salary depend on not imagining it. How can we set our imaginations free?

Speculative fiction refers broadly to literary genres that depart from reality, including science fiction and fantasy. The term also applies to futuristic narratives more closely tethered to our present reality. In fact, many speculative fiction scenarios are not hard to imagine; it just takes a leap of faith—or a catastrophe—to realize those future states.

These narratives are often propelled by cataclysmic events or new technologies: a fertility crisis in The Handmaid’s Tale; a lethal pandemic in Station Eleven; a revolution in gene editing in Klara and the Sun. While recent data on Americans’ health outcomes3 may be less dramatic than a zombie apocalypse, it confirms that a more insidious disaster is already underway. So, what would you like to think comes next?

To confront immense challenges, Ursula K. Le Guin urged writers to become “realists of a larger reality.” In that spirit, I invite you to embrace (and to submit to Forum) your wildest imaginings for the future of healthcare; your unrealistic visions; your most embarrassing and impractical dreams. I know this community will take you seriously. We may even try to make the impossible happen.


  1. Berry W. Another Turn of the Crank: Essays. Washington DC: Counterpoint; 1995.
  2. Einstein A. Top 500 Albert Einstein quotes (2023 update). Quotefancy. Accessed October 15, 2023.
  3. Tikkanen R, Abrams MK. U.S. health care from a global perspective, 2019: Higher spending, worse outcomes? Commonwealth Fund. Published January 2020. Accessed October 15, 2023.



Mentorship, Advising, Sponsorship, SGIM, Wellness

Author Descriptions

Dr. Sgro ( is an academic hospitalist and clinical assistant professor of medicine, VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine.