Ms. Jung raises several important issues about physician compliance with clinical practice guidelines. We purposely used the term compliance because it is commonly applied to "conformance" with guideline recommendations. Our point was that before one assumes that physicians simply refuse to follow recommendations and are therefore "noncompliant," a more in-depth review is required. I believe that Ms. Jung and we are in complete accord on this issue.

Compliance rates for cardiologists, internists, and a combination of these two significantly differed. Compliance with the guideline was higher (84%) when internists alone cared for patients than when cardiologists alone (58%) or internists with cardiologists cared for the patient (53%; P = 0.001) [1]. We have no data to support or refute the idea that cardiologists might be less adept at managing comorbid conditions outside their domain.

We believe our study supported the concept that physician-to-physician feedback was effective. We cannot comment on whether cardiologist-to-cardiologist or internist-to-internist feedback would be more effective.

If physicians are using the literature and an evidence-based medicine approach to guidelines and pathways, substantial consensus about best practice (in well-studied areas) is likely. An evidence-based medicine approach should help avoid "biased" guidelines, whether they are developed by subspecialists or other groups. The issue of apparently equally efficacious treatments is best resolved by direct comparisons in rigorous clinical trials. In addition, if a team is attempting to develop guidelines and has good evidence supporting two different approaches, it is not unreasonable to offer a choice of management strategies to the caregivers and patients.

Finally, measuring outcomes of care coupled with optimal processes according to guideline recommendations should provide the best quality of care.