As the national debate continues over spending, deficits, taxes and the fiscal direction of he country, one point of general agreement is that fundamental change to the American healthcare system is needed: healthcare costs must be brought under control. As hospitals grapple with ways to adapt, physician leaders have a critical role to play. Only clinical input can ensure that such efforts reflect the latest evidence-based medicine, and strike the right balance between efficiency and clinical flexibility. Success will require a few key tools for physician leaders as they guide their organizations to less expensive operations.