UPFRONT
Art vs Science
Jason S. Slakter, MD

Over the years, we have all heard the terms �the art of medicine� and �the practice of medicine.� Decades ago, these terms were probably more accurate in their depiction of clinical medicine. In the 1800s, physicians learned medicine from apprenticeships with other physicians, thus gaining experience through �practice.� Although anatomy and physiology was understood, therapeutic treatment strategies were often employed through a trial-and-error process. The physicians who were leaders in the field often made discoveries and advanced treatment through innovative techniques � and occasionally through serendipity. These were the so-called leaders or �artisans.�

As science advanced, medicine began to rely more and more on hard data for determination of diagnostic and, more importantly, therapeutic approaches. Results of rigorous scientific inquiry into the efficacy and safety of treatments have led to the introduction of therapeutic modalities that have changed all of our lives. The cornerstone to this objective approach to analyzing treatment outcomes is the clinical trial. As physicians, we rely upon the integrity of the trials and a full presentation of the data to understand the safety and potential benefits, or occasionally lack thereof, for a particular treatment strategy. Transparency in clinical trials therefore, is crucial, and steps have been taken to introduce regulations that require registration and presentation of clinical trials. I am pleased to direct your attention to the guest editorial by Andrew Schachat, MD, editor-in-chief of Ophthalmology, who addresses this issue in depth.

Of course, not all of our practice patterns are determined by randomized trials. The clinical trials of ranibizumab for exudative AMD, the results of which are summarized and discussed in this issue, are excellent examples of well-designed studies with clear, comparative endpoints. On the other hand, there are many treatments that have evolved based upon collective experience in the medical community without such clinical trials. Such is the case with the treatment of macular holes. Initially, no controlled clinical trials were conducted, yet physician-reported experiences in the treatment of this condition resulted in one of the most successful vitreoretinal surgical procedures to date. The �macular hole story� is eloquently discussed by William Smiddy, MD, in this issue as well.

Maintain a Balance for Individualization

As we go about our daily practice, we carry with us the �science� gained from clinical trial data and pooled clinical experience from other retinal specialists. When dealing with a single patient, however, we often find ourselves basing our treatment decisions upon a combination of these data along with our own personal experience and expectations for that particular individual. Thus, although we have entered a new millennium, medicine remains a clear balance of art and science.