Nearly every contributor to this month’s issue refers to the presumption of confidentiality as essential to the patient-physician relationship—its cornerstone. And nearly every one of them admits that confidentiality has never been absolute. These writers then plumb the meaning of limited confidentiality. What patient expectations can be satisfied? What breaches are justified? How can medical records support clinical decision making, assist coordination of care, provide a business record and legal protection, conserve data for research, and fulfill requirements for accreditation and regulatory approvals while protecting the privacy of patient information? This clear-eyed reality check on a hallowed tenet of medical professionalism yields many surprises and much reassurance.