The practice of physiatry in an acute hospital setting is evolving into a new system of care. Responding to unpredictable and unregulated health care reforms, the physiatrist’s traditional role as clinician, administrator, educator, and researcher is going through a metamorphosis. There is a sense of urgency in dealing with the three Ms: Medicare, Medicaid, and managed care. To survive and continue to thrive, physiatrists are shifting their paradigms of practice.