A 54-year-old man presents to the Emergency Department (ED) with crushing chest pain and is found to have an ST-elevation myocardial infarction (heart attack). The patient needs a heart catheterization with likely stent placement, but he insists on leaving the ED. The emergency physician is unable to convince him otherwise despite confirming that he understands the risks and consequences of his decision. He leaves and returns via ambulance several hours later in cardiac arrest. Could this story have ended differently? Quite possibly, yes.  But not with skills that are taught in medical school. Now consider a host of other conflicts: from interdepartmental turf wars, to poorly designed agreements between hospital systems and insurance providers, to the difficulties encountered in aligning hospital goals and incentives with those of contracted physician groups.  In these and many other interfaces within our health care system, the limitation is neither incompetence nor ill intent, but rather a dearth of negotiation skills and acumen.