Limiting the use of specialists is one of the highest priorities of managed care, which requires patients and their primary care physicians to focus on a health maintenance approach. Preventive medicine programs, encouraged by insurers and HMOs, theoretically reduce the need for expensive specialty care and thus lower overall costs. But where does this leave specialists and their institutions? Dr. John A. Kastor has studied two leading centers in specialty care, the Cleveland Clinic and the University Hospitals of Cleveland, to learn what these institutions are doing to survive in the current era. Using the findings of more than two hundred interviews with physicians, administrators, investigators, and trustees, the author describes in detail these rival organizations, their individual struggles against the economic pressures presented by managed care, and their sometimes bitter competition for patients. The insights that emerge from this struggle will be of value to anyone interested in how high-profile hospitals and academic medical centers operate, particularly in economically and socially challenging situations.