Hospitals and the communities they serve cannot afford poor physician-hospital relations. They need physicians and hospitals to ensure each other’s success and provide quality medical care. In many medical communities, these critical relationships between physicians and hospitals are plagued by lack of trust and poor communication. Add to that the myriad factors causing a fundamental lack of alignment of incentives between physicians and hospitals, and you have an untenable proposition to achieve trust and collaboration. These factors include financial misalignment as characterized by Diagnosis Related groups (DRGs) in which hospitals are paid a set amount prospectively for an episode of care from Medicare Part A and physicians are paid “per click” retrospectively from Medicare Part B. From a purely financial viewpoint, the hospital is incented to get the patient “out” and the physician is incented to keep the patient “in.” Consider the Emergency Medical Treatment and Active Labor Act of 1986, in which the burden for emergency department (ED) call is put on the hospital but can only be fulfilled by physicians (and you wonder why such rancor about ED call exists!). Or consider the National Patient Safety Goal of medication reconciliation. Once again, the burden is placed on the shoulders of the hospital, but the solution requires significant physician collaboration. The question arises, how do you spell alignment?