Business as usual is not the answer these days. But how do you create a new paradigm for academic educational and research endeavors? There is increasing pressure to separate the costs of providing care to patients from those of educating students and residents. It is evident already that we will not enjoy the flexibility of the past to cross-subsidize the academic effort. Presented here is a case study--a joint venture between Harvard Medical School and Beth Israel HealthCare created to sustain the academic mission, as distinct from its clinical business, and promote innovation in medical education and research through intellectual leadership, dedicated state-of-the-art facilities, and a focused development effort.