Dear Readers, It is Saturday morning at a small community hospital. An 81-year-old woman with hypertension arrives by ambulance after experiencing recurrent syncope. She has frequent episodes of symptomatic sinus arrest in the Emergency Department. The on call cardiologist admits her to the intensive care unit and, unable to identify a reversible cause, starts her on dopamine. The cardiologist consults an electrophysiologist, who agrees that an urgent pacemaker is indicated. Before leaving home, the electrophysiologist calls the patient’s nurse and asks what the mechanism would be to implant a pacemaker at this small hospital on the weekend. The nurse responds that the cardiac catheterization on call team could be summoned and the pacemaker could be implanted in the cath lab within the next hour. When the electrophysiologist asks the nurse who one needs to call to activate the cath lab and to notify a representative from the pacemaker company, the nurse states simply “oh, we’ll take care of that for you.” After evaluating the patient in the intensive care unit, the electrophysiologist finds the on call team in the cath lab setting up the equipment. The device representative mentions that she had just come from another small hospital where she supported an emergent pacemaker implant in the operating room. Within an hour the patient has a pacemaker. She is discharged home Sunday morning. Now imagine the same physician trying to implant a pacemaker on a Saturday at a large tertiary care medical center. First of all, who would one call? Certainly the nurse taking care of the patient is not going to be able to arrange for a pacemaker. Which administrator would one call? The operating room administrator? The cardiology administrator? Because pacemakers are often implanted at large academic medical centers in dedicated EP labs using staff that do not take emergency call, the only available on call cardiology team is the cath lab staff, who are not familiar with permanent pacemaker implantation. Therefore, the typical route when an urgent pacemaker is needed at a large medical center is to place a temporary pacemaker – either at the bedside or by activating the cath lab staff — and implanting a permanent pacemaker on the next weekday. Is this always in the best interest of the patient? Small community hospitals are feeling pressure to merge with large hospital systems. “In health-care circles, the summer of 2010 may be remembered as the end of small, independent hospitals in Central Florida.”1 There are many potential advantages to large hospital systems. The benefits of size include the power to negotiate more profitable contracts with third party payers and the ability to negotiate lower supply costs. But what are the advantages of a large hospital system for patients and physicians? Larger hospitals have large administrations and a thicket of policies and procedures that can serve as roadblocks to the delivery of good health care. Getting things done for a patient at a small hospital can certainly be easier at times than at a large hospital. As the size and complexity of hospitals grow, it will be critical to promote good judgment, focus on the fundamentals, and strive for simplicity where it matters. Everything matters at a hospital, but not everything matters equally: nothing should matter more than preserving the ability of health care providers to efficiently and effectively provide timely, appropriate medical care. There are no health regulations, hospital policies, or printed protocols that are more important than common sense and facilitation of appropriate medical care. The small hospitals still seem to get that right.