THE TSUNAMI HAS BEEN used as an apt metaphor to describe the coming impact of changes in American health care. (1) Those of us in health care are walkers on a beach unaware of the danger and destruction that is bearing down upon us. One might well object that most of us are anything but “unaware” about changes in health care these days. but our knowledge is not the same as foresight. Do we really see what dangers lurk on the horizon? Even the most knowledgeable person can be surprised when cataclysmic events occur suddenly and seemingly without warning. Journalist Hedrick Smith, a long time Moscow correspondent for The New York Times, admitted that he did not foresee the sudden collapse of the USSR, despite his many years of living in and reporting on that country. (2) If such a historical and cultural “tsunami” can catch even the most knowledgeable and astute observer by surprise, how comfortable can we be about our future?