How will Newton-Wellesley Hospital (NWH) preserve its private practice tradition while remaining effective and competitive in a healthcare industry demanding increasing integration between physicians and hospitals? This is the decision facing Newton-Wellesley Hospital president Mike Jellinek in 2009, as several trends-higher costs and lower revenues, shifting workforce demographics, and changing reimbursement models-threaten to disrupt NWH's organizational model. Similar to other U.S. community hospitals, NWH has historically been staffed primarily with private practitioners; however, in recent years Jellinek has taken several steps toward further integration, such as hiring primary care physicians and hospitalists, and even proposing formation of a physicians' organization (PO)-a move its veteran private practitioners sharply oppose. In 2009, NWH is renowned for high-quality care and is financially strong; yet, given external pressures, most at the hospital agree that reforms are needed to improve the hospital's and physicians' profitability while maintaining highest-quality patient care. Diverging opinions over how to improve the hospital has exposed differences between some private practice physicians and the administration. The crux of their disagreement centers on one question: how to make the organizational changes required to keep NWH effective and competitive in the face of a diminishing revenue growth rate, while honoring its tradition of physician independence.