Universities and medical education have been allied since the Middle Ages. In the United States, proprietary medical schools began to unite with universities at the turn of the century. At the end of the century, this traditional alliance is being questioned, even threatened, by marketplace demands, and medical schools and their universities continue to deal with internal struggles regarding teaching and research goals, and funding. In this paper, the author defines and discusses the origins of university-medical school tensions, provides a brief review of the history of university-based medical education in the United States, and describes some of the advantages and disadvantages of the alliance. Finally, he makes a case for why medical education must continue to be grounded in universities.