In 2009, the entire clinical faculty of the Department of Neurosurgery of the University of Louisville School of Medicine elected to become employees of a nearby community hospital. This took place in the context of the financial burden of caring for the indigent, declining reimbursement, clinical demands for neurosurgical coverage of a level 1 trauma center, rising salaries for neurosurgeons, and competitive pressure on hospitals. The author, who was dean of the school of medicine at the time, would not accept the abrupt withdrawal of these clinicians from the faculty practice plan, single-point contracting, and academic governance of clinical work assignments. Politicians, the press, and accreditation bodies quickly weighed in as the university, the school, and the public good were placed in jeopardy. The motivations for this event-the community hospital defending its market share and physician recruitment and retention pipeline, the dean defending principles of academic governance and the faculty practice plan-and the responses of the participants offer an instructive case study for academic medical management. The author concludes that one might view the protagonists of this episode not as defenders of principles but, rather, as pawns in a larger drama playing out related to a perfect storm of economic and social pressures in American medicine.