The American health care system is changing rapidly and radically. The Patient Protection and Affordable Care Act (P.L.111-148) was set in motion by an unsustainable growth in medical expenditures that eventually consumed 16% of our gross domestic product or nearly $3 million annually. Left unattended, this would nearly bankrupt our economy.1 In addition, the Affordable Care Act will allow the enrollment of nearly 20 to 30 million currently uninsured Americans into expanded Medicaid and Medicare programs. Coverage to many additional patients will become more marketplace driven through the establishment of health insurance exchanges.2 These expanded programs, in concert with the rapid increase of Americans that are older than 65 year of age, and the now 13-year freeze of Medicare support for graduate medical education, are expected to produce a projected shortfall of some 91,000 physicians by 2020, including a nearly 7% decrease in such critical surgical subspecialties as urology, thoracic surgery, and rural general surgery.3 and 4