The work of the Prince of Wales Hospital (POWH) surgery group by Parasyn et al. has opened up and given form to a very necessary discussion. Many of us in surgery, and general surgery in particular, chose careers in surgery because of the opportunities that were provided for immediate and expert involvement in immediate health needs of members of our community. The personal professional satisfaction derived from being regularly involved with emergency surgical assessments and interventions, doing that work well and successfully passing on the skills to our trainees remains uniquely strong for most of us. But deep satisfaction also comes from exercising our skills in scheduled patient consultation and planned surgery. Our desire to deliver excellent care in both of these practice realms has become a source of tension, as the costs have escalated, the resources have not grown to match the costs, administrative strategies have multiplied in an effort to manage the mismatch and surgeons have become alienated from the decisions and processes.