Why Doctors Hate Science 1064
theodp writes "A 2004 study found some 10 million women lacking a cervix were still getting Pap tests. Only problem is, a Pap test screens for cervical cancer — no cervix, no cancer. With this tale, Newsweek's Sharon Begley makes her case for comparative-effectiveness research (CER), which is receiving $1 billion under the stimulus bill for studies to determine which treatments, including drugs, are more medically sound and cost-effective than others for a given ailment. Physicians, Begley says, must stop treatments that are rooted more in local medical culture than in medical science, embrace practices that have been shown scientifically to be superior to others, and ignore critics who paint CER as government control of doctors' decision-making."
Re:paps with no cervixes (Score:5, Informative)
Re:Evidence-based medicine (Score:5, Informative)
I'm 53 and my physician makes a regular practice of PSA tests for men my age, actually I started having them @ 50. Also just had my first colonoscopy recently and good thing as I had one tumor removed that was pre-cancer.
This is rule of thumb, and Dr. Merenstein should have known this.
Actually the previous poster is right. Population based studies suggest that more harm than good is done by screening for prostate cancer.
The evidence goes like this. Once you have an elevated PSA, you see the urologist who orders a biopsy. Biopsies and treatments for prostate cancer carry risks like bleeding and infection, urinary incontinence and impotence. Now most prostate cancers will not kill you or cause problems in your lifetime. So investigations and treatments for prostate cancer cause more harm to people than the cancer does. This makes sense in a population, but not to the guy who got a bad cancer.
The current guidelines do not suggest PSA's in all men over fifty, but rather that you discuss the risks and benefits of screening, plus potential harm of further workup of a positive screen vs. the harm of developing prostate cancer. In practice, there is no patient who can actually understand enough of this to truly make an informed decision. Many docs haven't heard of the 'new' evidence and continue screening. The ones who do know of that evidence often ignore it because it's hard to explain, and patients will love you for finding an early cancer, even if it would never have affected them.
As far as your colon cancer screening comment, what you describe is standard of care.
The other thing to consider is that medicine in the US is HUGELY biased by the litiginousness of US culture. US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient. A lot of those investigations are not recommended in socialized health care systems because they are not cost effective, nor do the benefits outweigh the disadvantages.
The system favors compliance over logic (Score:5, Informative)
2. There is a case to be made for anal Pap smears, because HSV also causes anorectal cancer in people who participate in anal sex. Unfortunately, because it's not standard of care, private insurance won't pay for that either. (We don't even need to talk about Medicare or Medicaid because they don't pay for preventative visits.)
Re:I'm torn on this (Score:3, Informative)
While I like the idea of reinforcing what works and discouraging what doesn't, the fact is, this is a federal study, and likely the well-intentioned results will be some government panel or body controlling what doctors can and cannot do, regardless of the patient's circumstances, all in the name of "science" and "efficiency".
I think you're confusing "federal studies" with "federally funded studies".
The reality is that most trials are done by pharmaceutical companies and not impartial non-government organizations.
You can call the status quo a success, if you want the winners to be big pharma's profit margin. Unfortunately, big pharma has one goal: to get the next blockbuster drug (or variation of a previous one) approved by the FDA. Personally, I can't help but observe that the 'free' market has obviously failed "we the people" because there is no incentive for private companies to transparently share their negative results or to conduct tests showing the relative merits of new (expensive) treatements vs out-of-patent (generic, cheap) treatments.
Here's two articles, which just happen to have been written today, that highlight exactly what I'm talking about:
http://www.upi.com/Health_News/2009/03/01/Seroquel_maker_denies_hiding_side_effects/UPI-17851235928556/ [upi.com]
http://blogs.wsj.com/health/2009/02/26/another-drug-company-accused-of-hiding-negative-study-results/ [wsj.com]
Re:paps with no cervixes (Score:1, Informative)
I bet next they give mandatory prostate exams to women too!
Well, in the UK, you can file a complaint when your doctor refuses to screen you for cervical cancer. Even though you're male: http://docs.google.com/Doc?id=d22v96t_15cv5m8cfr [google.com]
Re:Smart move (Score:4, Informative)
There are a few reasons for what you're talking about. I am a primary care provider myself, a nurse practitioner, and the BIGGEST reason we give out the drugs the reps bring us is because when we give out the drugs we get as samples there is no cost to the patient. You would probably be shocked at how many people can't afford a $4 wal-mart prescription. If this means I give aciphex instead of prilosec I'm going to jump on that pretty quickly.
That said, there was a recent ethics thing where drug reps can't give us pharma schwag (I'll miss getting my viagra clock every year...) anymore, nor can they take us out to dinner at expensive restaurants. *sniffle*
In conclusion, even if you don't have a cervix it makes sense to get a pap of that area, because if you don't have one it probably means that you had all those bits removed for some reason, and the dysplasia or cancer may be present in the areas immediately adjacent to what was removed. Sometimes it doesn't make sense, but sometimes it does.
Re:The assumption here (Score:5, Informative)
Re:The assumption here (Score:1, Informative)
For instance, when you go in and get a checkup and they listen to your heart with a stethoscope, guess what that's for? Nothing. But everybody does it.
Are you serious?! Of course they're listening for something. They're listening for a LOT of things actually, and if you'd like I can write you a list. And guess what? Listening with a stethoscope is a hell of a cheap screening tool. Yes, if they hear something funny like an holosystolic murmur, they'll likely refer you out for an echocardiogram to verify their diagnosis and further their evaluation. Does that mean that listening with a stethoscope is not useful? No. First, the physician is able to screen ALL of his/her patients without having to perform an echo on EVERYONE, which saves a hell of a lot of money. Second, there are many reasons why a murmur or a gallop would be EXPECTED or even irrelevant, and may not require further work-up. Even hearing normal heart sounds rules out a ton of possible diagnoses in most cases.
So unless you plan on taking all your medical advice from this economist in the future, try not to take everything you read in a book so seriously. Because honestly, what the hell does he know about the practice of medicine?
Jonathan Blackhall, medical student
Re:EBM vs. the Art (Score:4, Informative)
>I'm sure if you did a study of "average" gastroparetics you could say "due to evidence-based medicine, everyone should take medicine X", and this might be fine for 60% of the patients while forcing 40% into ineffective treatment. Medicine needs to address the individual needs of patients.
Exactly! To bring up a further point about patients as individuals, the Government just announced that testing PSAs for men over 75 is pointless. Which is ridiculous; their entire line of reasoning is based on the odds of the patient dying of something else before they die of prostate cancer. And now let me bring up my father, who had his PSA tested around the age of 75. Unlike most of America, he eats right, exercises nearly every day, has never smoked and has drank alcohol sparingly. He is the perfect candidate to get further PSA testing, because he is less likely than your average American to die of "something else" in the case he has an indolent prostate cancer. Which, in fact, he did - an intermediate-high grade (Gleason 7) prostate cancer that was still local and eminently treatable. But following the Government's advice today for "Best Practices", he would have stopped testing, and this malignancy would have metastasized and in all likelihood killed him.
Evidence-based Professional IQs (Score:3, Informative)
The truth is doctors aren't geniuses. They sat next to you in high school. Some of them copied your answers on the math test. They are average everyday people that have been trained (hopefully well) to do a specific job.
MDs have a median IQ significantly higher than all other measured professions [iqcomparisonsite.com]. That is to say, the average, everyday median MD IQ at ~125 is already halfway to official "genius" level.
The notion that "Doctors Hate Science" is absurd.
VA - Pretty Good (Score:5, Informative)
Go talk to someone in the military about that whole free government provided healthcare...you get what you pay for...
I agree that the VA is underfunded relative to its size and patient population but, given its funding limitations, it's actually the best performing health system in the US [www.cmaj.ca] when measured [annals.org] objectively [jamia.org] in terms of patient outcomes [washingtonpost.com].
Re:Evidence-based medicine (Score:5, Informative)
To throw in a real world data point to back your claim, my healthy, active and vibrant 82 year old grandfather went in to have an operation to deal with prostate cancer, his doctor suggested that as he was in such good shape if he got rid of the cancer he could live on for quite a while longer.
He died suddenly in the hospital from internal bleeding caused by the surgery a few hours later. Now the cancer might have gotten him eventually, but how long, five years? ten? He was 82 and healthy and happy so it was kinda pointless operating really.
He thought so too, but let himself be talked into it by his doctor.
Worst thing was he was completely lucid, happy and rational minutes before he died, it was very sudden and unexpected.
RTFM (Score:3, Informative)
There's a quick way to tell if someone has actually managed to motivate themselves enough to click, and that's if they epically fail to check a link to see the original source:
Figure 12 of Hauser, Robert M. 2002. "Meritocracy, cognitive ability, and the sources of occupational success." CDE Working Paper 98-07 (rev). Center for Demography and Ecology, The University of Wisconsin-Madison, Madison, Wisconsin. The figure is labelled "Wisconsin Men's Henmon-Nelson IQ Distributions for 1992-94 Occupation Groups with 30 Cases or More" and is found at http://www.ssc.wisc.edu/cde/cdewp/98-07.pdf [wisc.edu]
Why do you hate social science? [google.com]
Re:But CER is government control (Score:2, Informative)
Let's take the little issue of pap smears after hysterectomies. If you had a hysterectomy for actual cervical cancer, then you ARE supposed to keep getting pap smears (at some unknown frequency). That's because cancerous tissue doesn't necessarily stop growing the moment it wanders off it's initial tissue base. That's why it's a cancer.
Thanks you for posting this. My wife had a hysterectomy after cervical cancer, and IS supposed to continue to get them (less frequently, of course). She knows much more about this than I do, but when I told her about this article, she said it was irresponsible to suggest after cancer is removed you no longer need to get paps. She was a surgical tech, worked in an OBGYN office and grew up around family working in medicine. She doesn't know everything, but she did her homework on this when we were dealing with it. Anyone out there who deals with this, your life is worth more than this sound-bite critique.
Re:Evidence-based medicine (Score:3, Informative)
US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient.
Actually one of the big reasons that EM diagnostic evaluation is more aggressive than usual is that (shock) patients actually do have a hint of what is important. That is, if you take a random person who goes to his family doc with chest pain versus one who goes to the ER the former is less likely to have significant coronary artery disease. So its not surprising that if you compare ER with primary care, it is good medicine to be more aggressive with diagnostic evaluations in the ER.
That said, hell yeah as an ER doctor I sometimes practice defensive medicine. If you place me in an environment where people can effectively sue me for what I might make full time in 20 years for a bad outcome that happens despite me practicing medicine that meets the standard of care in my practice environment I sure as hell am going to practice defensive medicine. The fact that I don't always do aggressive diagnostics in every patient is either me being a Pollyanna or perhaps taking my patient's best interests at heart. I'm willing to put my neck on the line somewhat to avoid a CT in a toddler who just has overprotective parents, but your fat, diabetic, smoking, sedentary, litigious ass is just not cute enough to get the my sympathy.
I'm comparing US emergency medicine guidelines with Canadian emergency guidelines. A lot of the US based CME will even directly admit in their lectures that their recommendation is based more on protecting against potential litigation.
I'm not criticizing defensive medicine either. 98% of my charting is done solely to protect myself in case of a law suit. Very little of it is clinically helpful.
I practice mostly in primary care, but I do ER work as well. Most of my EM CME is US based. My comment is not intended as a slam at all, just a realization that we practice medicine in different environments.
(and thanks to my EM training I picked up two subtle acute coronary syndromes recently that my partners missed. Direct admit from clinic to the ICU baby! Sometimes it pays to be aggressive)
Re:While a bit alarmist... (Score:3, Informative)
Yep. Ingrown toenails aren't too bad. I've had a few removed by a doctor, but once I did it myself. All you really need are some small CLEAN scissors, some CLEAN pliers, something to disinfect the tools with, antibiotic cream, some gauze/bandages, a really good pain tolerance, and a whole lot of paper towels to soak up the blood. I prefer the brief pain of cutting it and ripping it out myself to the doctor's method of giving me three local anesthetic injections in my toe before removing the ingrown. Each shot felt like it went to the bone, even after the others started to kick in. To me, that hurt worse than the ingrown. Of course, I haven't had any ingrowns since I went up a shoe size, so prevention is the best strategy of all.
Re:Evidence-based medicine (Score:1, Informative)
Realistically, the MD salary needs at least a $50,000/year premium to not have a negative effect on the talent pool. The reason for this is that for someone who went to a private undergrad and medical school, you are talking about $300k in costs to reach MD and another $300k or so that someone of that intelligence could make working during the 8-10 years of extra school. With compounding of interest (either on loans or in investments that would have been made instead), this becomes closer to $750k by graduation. Using a mortgage calculator, to just break even on this sacrifice over a 30 year career would require that they make ~$50,000 more per year than they otherwise would. I have no problem with doctors being millionaires then given that many invested or had invested on their behalf nearly the equivalent of $750,000 by their late 20's.
The free market does not guarantee a healthier populace because the populace has control over their own bodies and can choose unhealthy habits (fast food, smoking, etc). This is the way it should be - we own ourselves and our own labor.
As to your applause of 90% income tax rates, that would be during the post WWII years when pent up consumer demand from the war years allowed a boom despite those tax rates. There is less incentive for businesses to expand (especially small businesses) under those conditions than with lower marginal rates. I also seem to recall that both the Kennedy and Reagan era cuts in the top marginal rate produced even more tax revenue. I guess it comes down to whether the goal of taxes should be to fund government expenditure or as a means of leveling out income.
Another example of Americans screwed on healthcare (Score:3, Informative)
A doctor gave us a prescription recently for our newborn's acid reflux with the words: "try this, see if it helps her". The prescription was for 30 tablets (30 days). When I got to the pharmacy, I learned, that the 30 tablets cost $190, and that insurance will only cover $120 (for some reason or the other).
We had similar with our first baby. Its a common problem and many things may help. Did your doctor suggest anything else in addition to drugs? Antacids are cheap and over-the-counter, so the doc probably prescribed a PPI (proton pump inhibitor). The only reason it cost us a bit, was paying the pharmacy to make a suspension. The cost for the tablets was negligible, as they just ground up three adult tablets to make enough suspension to last the baby a month.
Re:Smart move (Score:4, Informative)
In France, we actually have a dual system.
Public hospitals and private clinics.
Everyone is covered and can go to the hospital. 'The rich' as you qualify them, will go to the clinic and thus pay more, getting things such as a personal room instead of a shared one in the public hospital.
Doctors can get the money from working at the clinic because they also have to work part-time at the hospital.
No 'bribing' involved. Just some common sense and both parties are satisfied.
This is very *very* dangerous (Score:4, Informative)
Yes, we all know that (arguably) most docs don't keep up with the literature. Or they choose a treatment and stick with that because it worked the best at one point and they like it because they trust it. Problem is, that research is ongoing and new things are found all the time. In fact, on one of my clicking adventures on-line, I found out that Lithium Carbonate was being used to treat refractory depression (as an adjunct), OCD, cluster headaches and even ALS (the one that Stephen Hawkins has) to name a few. All that in *low* doses. Yet, most docs still consider this a horrid drug refusing to realise that in low doses Lithium Carbonate does _not_ require close monitoring.
So, this sort of study could be very beneficial.
HOWEVER, it's things like this that HMO's really *really* like. They'll probably use it to force doctors into treatments that are cheaper alternatives regardless of that particular patient. Because, as with many things, certain disorders, etc, have different drugs to treat them. Different drugs for different sets of symptoms, different severity of symptoms, etc, etc, etc. So, patients will likely get cheated out of drugs that would be more effective for them simply because there HMO won't pay for the one that is best for them and the one that is best for them isn't in there price range. Especially, for the more complicated disorders.
And what happens when next week happens and this changes. How often is this list going to be updated? How often are the HMO's going to be updating from the research?
Quite frankly, while I fully believe that this thing is undertaken with the best of intentions, it is ripe for abuse. In the end, it is my opinion, that it'll likely lead to more harm than good.
Pap Smear Also Screens For Vaginal Cancer (Score:2, Informative)
Why kdawson hates doctors (Score:5, Informative)
HMOs and federally mandated employer-based healthcare was proposed and signed into law by President Nixon. In fact, there is an infamous tape [youtube.com] of Nixon and his adviser discussing the plan as proposed by Edgar Kaiser of Kaiser Permanente where they blatantly talked about how the emphasis would be on profit (for the HMO) and "providing less care."
What we have today wasn't the result of some master-plan hatched in a secret lair in the lower recesses of an evil University by bleeding heart liberals or whatever you've been told. No, our entire employer based healthcare system is the result of special interest pork legislation written by the industry and pushed upon the public by a Republican administration. It's the DMCA of 1971.
With regard to your child's heartburn, you need to start asserting yourself as a patient and parent. Take an active role in your child's health and specifically ASK your doctor for generic prescriptions. I'm going to go out on a limb and guess that your doctor prescribed Nexium or some other namebrand Proton Pump Inhibitor. The generic, Omeprazole, is available Over-The-Counter, costs a fraction of the price, and works virtually identically. Call your doctor and ask him or her if this is appropriate for your daughter. No doctor I've ever met would mind a call such as this. In fact, I think most would welcome it. Fifteen seconds of his or her time for one potentially satisfied, engaged patient is what you call a clinical no-brainer.
-Grym
Only "scientists" who get their "facts" wrong! (Score:4, Informative)
A few facts first:
1) Pap smears still make sense in women after a hysterectomy. It is then called a vaginal vault smear. It is meaningful at the very least in women who had abnormal smears prior to hysterectomy, because abnormal cells can have spread to the surrounding vaginal wall
2) Some surgeons leave a stump of the cervix behind when they perform a subtotal hysterectomy. Not common practice any more, but used to be very common in many countries and can have some advantages for the stability of the pelvic floor. Not all women who had a hysterectomy know whether they still have a cervix stump or not.
3) When the hysterectomy was performed for malignancy, eg cancer of the uterus, the vaginal vault smear can be useful to detect early recurrence
Hence. some women may not need pap smears after a total hysterectomy - but in many women this is still a meaningful and cost effective procedure - which is why even public health systems are still happy to pay for them.
The article does not seem to take this properly into account - because most scientists have only a very limited insight into medical problems. I should know - I did a science degree first before becoming a MD.
Re:Politics of health care (Score:4, Informative)
There already is a lot of competition driving health care costs down.
Yes but where is the competition to bring the standard of care up? There is some. Some employers will offer multiple health plans, but it's more like Verizon vs. AT&T than figuring out where to eat lunch. The McCain plan was an obvious, painless, and timely way to improve health care for Americans. All Obama has delivered, to this day, is promises.
Re:Smart move (Score:3, Informative)
I'm in a country where we have national health care and there's no bribery going on so I have no idea where you'd get the idea that that would happen.
We get a fairly decent, bog-standard level of health care which means everybody can afford to get checkups and advice. Sure, you'll have to wait a while to get an appointment for checkups since they're not exactly an emergency but it's possible to do. There's also the option of going private if you have the money. I don't see a problem with this as it doesn't mean the "poor" are deprived of health care, it's just that those with more money can get a faster and more personal service. Just like in any other service industry.
Most people here complain about the health service, it's bureaucratic and full of middle managers sucking funds away from the actual service. However, when it comes down to it, if I'm sick or injured I can get seen and treated in a decent manner and time frame, no matter who I am, how much money I have or if I have health insurance or not.
Re:Smart move (Score:4, Informative)
The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.
All the points being made here are very pertinent, but one factor I have been dealing with (handling my elderly mother's medical care as she is no longer capable of keeping track of things) is that doctors today just have too heavy of a workload. They are juggling so many patients that they cannot possibly devote the time they really need to every individual case. The tendency is to just diagnose and order tests/prescribe drugs based on the most common knee-jerk diagnosis that comes to mind. The House M.D. depiction of a group of doctors having the time to sit around and debate diagnoses with intricate knowledge of every exotic possibility and with ready knowledge of all the latest medical research simply does not happen in most hospitals.
Example: for over two decades, my mother has dealt with achalasia, a swallowing disorder. It is not a common problem, but certainly not some exotic rare disease that no one has heard of. She does have a very capable gastroenterologist, and the problem is currently under control, but it does rear its ugly head now and then. When my mother has been hospitalized and treated for other problems, the achalsia is still a factor as it affects her diet and eating schedule. You would be amazed at the number of attending physicians to whom I have had to explain and define what achalsia is and how it should be handled. Different doctors will all come and go in the course of her stay, none of whom seem to talk to each other at all, or have any inclination to inquire of her gastro doc about the problem, and all of them skeptical at best and disdainful at most of this "layman" son of hers trying to tell them how to do their job. When the achalasia begins to manifest (usually because they ignore or are clueless about the standard recommendations for diet), they keep automatically attributing it to nausea or reflux or some other unrelated condition and try to treat her for that. I can't sit in her room 24/7 waiting to intercept any random new doctor that happens to breeze in at odd times for one of their brief drive-by visits to "educate" them about achalasia (and somehow this information either never gets into her chart, or gets overlooked by these doctors in their overworked haste), so she ends up getting unnecessary treatment for problems she doesn't have. And this is not in some hellhole of a hospital -- this is in the highest-rated, most modern facility in our metro area.
Much as I would like to see some form of universal health care soon, this phenomenon will just be exacerbated by suddenly adding 30 or 40 million new formerly uninsured patients into the system. Doctors already do not have the time to give each patient the time and care they need. Unless they train or import a whole lot of new medical talent quickly, it's just going to jam up the system even more, and there will be an even greater tendency for doctors to make diagnoses and treatment decisions "on the fly" as they breeze through on their way to their next patient.
Why is govt-provided health care worse? (Score:5, Informative)
I've experienced both systems first-hand -- I'm an American living in Britain. Government-provided health care is FAR superior to what I received in the USA. Easier to get, cheaper, and of equivalent quality. No comparison.
buy a dictionary; read it. (Score:1, Informative)
No, anecdote implies that the information is second-hand, can not be verified, and is therefore unreliable.
Actual scientific data is first-hand and verifiable.
No, it does not imply that.
An anecdote is a short tale narrating an interesting or amusing biographical incident. It may be as brief as the setting and provocation of a bon mot. An anecdote is always based on real life, an incident involving actual persons, whether famous or not, in real places.
People may embellish anecdotes, and they may falsify data, but it is not implied that all data is falsified and all anecdotes are embellished.
Real Title: Why One Journalist Hates Doctors (Score:2, Informative)
The fact that the medical system has struggled to implement evidence (ie, science) based medicine over the past 20 years is not evidence that physicians hate science. Its evidence that the science is poor, the process is hard and there are tremendous incentives against it. Its just damn difficult.
Think physicians hate "science"? Try explaining to a patient why they should take the drug that is 10% less effective than the competitor but half the price. Or explain why the diagnostic procedure that saved their best friends life is unlikely to find anything in their case, wouldn't hurt them -- but is "worthless" from a cost efficacy perspective. We all struggle with cost efficacy - no one wants to get something less than the best, patients even less than physicians.
Besides which, "doctor" means teacher, not medical practitioner. So exactly why does this journalist think that teachers hate science? And how does citing a Senator help? Yes, Coburn is a physician (albeit an obstetrician which is one of the fields that has struggled the most to integrate hard science appropriately due to the overwhelming malpractice issues), but Coburn doesn't believe in science in the first place - famously calling global warming a "bunch of crap."
Garbage.
Re:Why is govt-provided health care worse? (Score:3, Informative)
By the Gods, that must mean the US healthcare system really sucks!
Re:Why is govt-provided health care worse? (Score:3, Informative)
Yeah...like that happens ALL the time here in the US.
If your kid is in trouble...no ER in the country will refuse you service. The kid will get tx, and you don't take them home to die.
Re:"Over-investigating?" (Score:3, Informative)
As a neurologist, I agree 100%. Just ask for the amount of people that want an MRI after a common headache. And many of them don't do it the polite way.
Re:Smart move (oh god, I'm replying to AC) (Score:3, Informative)
As an ob/gyn, I don't relish the idea of ill-informed beaurecrats telling me how to practice medicine. The beaurecrats want to automate the practice of medicine so they can pigeonhole all diagnosis and treatments into cubby holes and check boxes in order to analyze and arrive at such statistics as pap smears per hour and state--as if it means something--"Dr B does a pap smear for $3.97 while Dr C charges $3.99." Therefor, we're only going to pay $3.97 for any and all pap smears. Think it sounds funny? That's exactly how Medicare pays, without regard to how easy or difficult it may be to perform a pap smear on various patients. You might just as well say you can reduce all of programming to a universal automated system, plug in a description of inputs and desired outputs and some algorithm generates perfect code. There are many aspects of programming that could be considered an "art form". The same is true with medicine, law, research and a host of other disciplines.