Academic health centers (AHCs) face an unfamiliar new world of competition. It is true that they have always competed with one another, seeking the same faculty, students, donors, research grants, and even patients. Today's competition is more complex. It involves the emergence of relatively new outsiders (eg, freestanding specialized outpatient departments, dialysis units, day surgeries) offering niche products. Unlike AHCs, these competitors do not have a social contract with society. They perceive no obligation to provide a complete package of services designed to address the total health needs of the entire community, educate and train tomorrow's practitioners, and develop more effective therapies through research.