The past few decades have seen great change in the capabilities of medical care. The next decade will emphasize great change in its delivery, driven mainly by the necessity of containing costs presently running at more than 13% of the gross national product. The current perception is that two of the principal causes of the excessive cost of medical care in the United States are the price of new technology and the fact that much of the care rendered is by specialists. In fact, most surgical care can be rendered by general surgeons, and the coming changes will revitalize the demand for and self-esteem of general surgeons. Managed care will recognize this by using general surgeons and keeping patients "down on the farm," a line drawn from the World War I era song entitled "How can you keep them down on the farm after they've seen Paree?" But some things are still unique to the medical equivalent of Paris, perhaps including more complex forms of treatment, the acquisition of knowledge, and teaching. The questions are: what should we decentralize and how do we discriminate what should remain decentralized in the community for economy, and what might be concentrated to good advantage in the centers? I would like to offer the pancreas as a paradigm in thinking about these issues.