The purpose of my short essay was to place the issue of "using the science we know, reliably," squarely on our professional agenda as physicians by connecting it directly to a strongly held professional value: autonomy. That using the science we know would improve patient outcomes and would also increase the time physicians desperately need to perform the artful custom-crafting of care that each patient requires resonates deeply with another core professional value, that of patient-centered altruism. These are the keywords for an internal professional debate, and perhaps for a much-needed revitalization of medicine. They were not intended to support any external political agenda.

The intensity of interest in these topics (for example, evidence-based medicine and safety) in the external political world is perhaps a symptom of our historic inability to address them within the profession itself. It is in our interests, and our patients' interests, to lead the conversation about how to address these problems, even if we have to confront some cherished values such as our attachment to individual physician autonomy.

I agree with Dr. Horner that patients neither know nor care about implementation of guidelines. What they (and those who claim to represent patients' interests in legislative, regulatory, and payer arenas) do seem to know and care about are unexplained geographic variation in supposedly scientific practices; disturbing safety risks from unreliable, poorly coordinated care processes; and the hurried nature of most physician visits, among other problems. Our professional failure to use guidelines and protocols is but one among many mechanisms through which these results have been produced. The key thrust of my essay was that we should take steps as a profession to address these larger problems, because if we don't do this for ourselves as physicians, someone else will do it to us (if they aren't doing so already). Guidelines aren't the core issue. Effective practice, safety, and the art of medicine—and how these matters are entwined with our attachment to individual physician autonomy—those are the core issues.