A major challenge for academic medical education is to sensibly balance the needs of students and residents for hands-on training with the rights of patients to receive the highest quality of care. Two aspects of the debate over this issue have received a great deal of attention: the appropriate degree of patient control over the makeup of the treatment team, and the proper role of supervision and accountability for attending physicians. Although the law has ostensibly resolved the conflict between the goals of student participation and the principles of patient autonomy and informed consent, the record of medical practices is too often inapposite. The divergence of law and reality is primarily a reflection of the law's flawed medical model, which poorly matches the dynamics of the physician-patient relationship and ineffectually attempts to reshape it. But the dissonance is also attributable to medicine's autonomous professional culture, which undervalues patient involvement and reinforces benign paternalism. Coherent policy requires a recrystallization of both the legal ideal and the medical reality. Lawyers and ethicists should loosen their rigid consumerist conception of medicine, and physicians should become more conscious of the infiltration of paternalism and instrumentalism into their decisions.