With economic pressures restricting campus budgets and healthcare policy issues capturing national attention, facilities managers at university-affiliated hospitals and other healthcare entities say they feel more urgency than ever to provide cost-effective services to patients, providers, medical researchers, and students. Managing facilities at a university-related medical center is, in many ways, much like doing it on an academic campus--except in the many ways it isn't, and that's what makes their positions as facilities directors at major medical institutions particularly challenging. But it is also exciting, according to several APPA members who hold those positions. "Life and death," literally, is how they describe the principal difference between their management responsibilities at medical and non-medical facilities. Given the responsibilities and accompanying stresses of their jobs, facilities officers at university-affiliated healthcare institutions say they have learned lessons about how to do their jobs well.