A few big-city hospitals and other nonprofit enterprises have stepped into the fray, and while not perfect themselves, have performed the best by many accounts, bringing a sense of mission to the work.

A typical big-city hospital might have five or six serious birth injuries a year, he said.

Small transplant centers feared that the new rules would put them out of business by steering organs to larger, big-city hospitals.

You walk into the emergency room of a big-city hospital - the kind where patients on gurneys moan in the aisles waiting for flimsily curtained cubicles to become available.

Self-taught in English and acupuncture, he was offered a slot at an elite medical graduate program in the mid-1990's, an opportunity that could have secured him a job at a big-city hospital.

The building is an example of the suburbanization of big-city hospitals as they compete with major local hospitals that are updating their outpatient clinics with the latest technology and treatments.

David E. Kelley of "Picket Fences" will create a pilot episode for a possible series about a big-city hospital.

But opponents of the regulations say that patients who do not want to travel to big-city hospitals for specialized care should be able to find similar services closer to home.

The hospital's average charge under the new rate order is $3,629, compared with $5,853 at Yale-New Haven Hospital and $5,000 to $8,000 at other big-city hospitals.

I remembered the slight change in Jess O'Shea's face when I'd asked him how the big-city hospital had been different from the tiny one in Bartley.