FEW RELATIONSHIPS ARE as complex and dynamic as the hospital-physician relationship, and even fewer are as critical to maintain for the future benefit of healthcare delivery in the United States. Joseph Bujak and Chris Howard speak well to the complexities of this relationship and offer helpful suggestions as to how we might improve on them. It has been my privilege over the years to observe Bujak develop his theories on hospital-physician relations, and, with minor exception, I find myself in substantial agreement with his concepts and approaches. I believe his comments for the greatest part are reflective of the historical context of practicing medicine and medical staff relations. With that said, I make the following observations. Whereas physicians have historically been the people ultimately accountable for patient outcomes, recent practices and court cases seem to indicate a shared responsibility among the physician, hospital, and patient for those outcomes. This is especially true when catastrophic events occur that are often the result of defective system design as well as human error. A movement toward team approaches to patient care and individual patients' responsibility removes some of this burden from physicians but simultaneously makes physicians and others more interdependent. At the same time I believe the loss of this autonomy and control is one of the contributing factors to physician dissatisfaction. In a recent presentation to the American Hospital Association's Health Care Systems Leadership retreat, Lawrence Casalino (2003) cited the following as examples of the emotions and feelings that are being experienced in physician practices: general anger, discontent, distrust, breach of professional-society contract.... These and other factors are as much a result of loss of control or autonomy as of economic issues. We need to demonstrate more mutual respect between physicians and hospital leadership and build on our interdependency. Bujak's comment on the medical staff organization and structure are representative of the experiences many hospitals and medical staffs are having and does raise valid questions about the value of the medical staff to the individual physician and to the hospital. Many hospital executives and physician leaders are in fact evaluating new ways to bring greater relevancy to the medical staff structure and create greater value for all involved. His recognition of medicine being both a profession and a business is also valid, and recognition that physicians have legitimate economic needs that are driving many of their actions needs to be given serious consideration. Physicians also need to develop a better appreciation of the fact that hospitals must remain financially as well as healthy for the benefit of both patient and community and that erosion of hospitals' stability is in one's interest, especially the patients'. I mention healthy because too many healthcare organizations lose sight of their while pursuing their margin. This concern can grow even more as hospital margins erode while physician participation increases in specialty-owned hospitals and ventures that affect hospital earnings to the point that the repeated concept of no margin, mission becomes a reality. Casalino (2003) reported that in the area of physician-owned ambulatory surgery centers, 585 were created in the past two years...[as compared to] 166 in the prior eight years. Although one can argue the relative value to the healthcare delivery system of this trend, one must also acknowledge the potential negative impact on hospital missions and their relations with physicians with this type of activity. As Bujak also points out, all physicians are not alike when discussing strategies, and it is important that executives recognize that most physicians do evolve from an culture and as such are independent thinkers. What I do question is whether the expert culture is strong enough to overcome the group think or collective, which I believe can exist in physicians as well as executives. …