A handful of surgical facilities are still willing to purchase new capital equipment just to keep the requesting surgeon happy, but the breed is near extinction. Facing pressure on the bottom line, and having had the experience of purchasing "must-have" capital equipment that never got used, most facilities now have tight budgets and daunting, tedious approval processes for capital equipment requests that discourage impulse buys. Facilities carefully vet virtually every proposed purchase for its economic impact, and if the piece won't increase efficiency, bring in new business or replace something already in use, the request usually won't get granted. Some physicians still threaten to take their cases elsewhere if they can't get what they want, but few follow through. Most don't make such threats, either because they've accepted the financial realities or because they have no place else to go.