Despite all the questions that continue to surface about the future effectiveness of health reform, U.S. physicians can do more now to help patients than at any other time in our history. Yet, a dichotomy remains within health care that makes this reality anything but an undisputed success story. The American health care system has pockets of extraordinary excellence that often sit in a sea of mediocrity and wastefully high costs. At its best, the American health care system is an international destination for those who want to learn from and be treated by us. At its worst, that same system is a target of ridicule and scorn—a prototype for waste and inefficiency run amok. It is hardly a surprise then that health care reform needs to focus not on our pockets of excellence and the things we do well, but on the efficient functioning of the entire system. That is our mandate for change.