Podcast Summary
Understanding the complexities of the eye: Learn about the basics of eye anatomy, common conditions, and treatments from an eye surgery expert, while debunking common misconceptions and gaining insights on preventing eye health issues.
The eye is a complex organ with many aspects that can impact our health as we age. Dr. Steven Dell, an internationally recognized leader in eye surgery, joined the Drive podcast to discuss the basics of eye anatomy, common conditions like nearsightedness, farsightedness, and presbyopia, and various treatments such as LASIK, PRK, and Smile. He also shared insights on preventing eye health issues, particularly myopia in children. Despite the importance of eye health, many people, including medical professionals, may have limited knowledge about the eye due to its compartmentalized nature. The discussion provided a nuanced understanding of the eye, demystifying common misconceptions and offering valuable information for maintaining eye health.
Ophthalmology: More Than Just Eye Surgery: Ophthalmology involves deep medical knowledge, collaboration, microscopic precision, and understanding the eye's connections to the body.
Ophthalmology, while primarily focused on eye surgery, requires a strong foundation in general medical knowledge and collaboration with other medical professionals such as optometrists. The eye is not a magical organ, but rather a complex system with neurological and vascular components. Ophthalmology training is intensive and surgical-focused, but there are non-surgical specialists like neuro-ophthalmologists. Ophthalmologists use tiny tools and work under microscopes, which may seem sedate but require great skill and precision. The ergonomic challenges of this work are different from those faced by other surgeons. The eye is an integral part of the body, and understanding its connections to other systems is crucial for effective diagnosis and treatment.
Exploring different specialties in surgery: The path to becoming a surgeon involves trying various specialties, encountering challenges, and acquiring comprehensive knowledge of the human body
Becoming a surgeon involves a long and diverse training process, even if you don't know exactly what type of surgery you want to specialize in at the start. The speaker's friend, for instance, trained as a cardiac surgeon but had to give up operating due to neck issues and then switched to cardiac critical care. The speaker himself didn't know he wanted to be an ophthalmologist until he tried it during a rotation and had a "eureka moment." During their training, the bulk of cases came from cataract surgery and treating retinal diseases related to diabetes. The eye functions like a camera, with the cornea acting like the covering on a watch and the pupil being the hole in the iris behind it. The lens is also part of the eye, but it's not the only component. Overall, the journey to becoming a surgeon involves trying different specialties, facing challenges, and gaining a deep understanding of the human body.
Understanding Eye Function and Vision Problems: As we age, our eyes may lose elasticity, leading to vision problems like nearsightedness and presbyopia, and eventually cataracts. Vision issues can also result from head trauma or certain conditions like diabetes.
Our eyes function by bending light rays so they focus on the retina, which is the part of the eye that sends images to the brain. In a healthy eye, images come into focus perfectly on the retina, which is the center of the bullseye. However, some people, like those with nearsightedness, have images that don't focus exactly on the retina, causing vision problems. As we age, the lens of our eye loses elasticity and we may need glasses or contacts to see up close. Eventually, the lens becomes hard and opaque, leading to cataracts. Cataracts are a natural part of aging, but they can also be caused by trauma or certain conditions like diabetes or steroid use. The eye, being part of the head, can be affected by head trauma, leading to cataracts even without direct eye trauma.
The human lens is relatively immune-privileged due to its avascular nature and protective capsule: The human lens's unique properties, including its avascular nature and protective capsule, make it less susceptible to systemic infections and changes in blood sugar levels, and a challenge to deliver pharmacological interventions.
The human lens, unlike other structures in the eye, is avascular and has a protective capsule that allows only small molecules to enter. This property makes the lens relatively immune-privileged and less susceptible to systemic infections and changes in blood sugar levels, which can cause osmotic changes and alter the shape of the lens, leading to vision changes. Additionally, researchers are exploring the use of lipoic acid choline ester as a potential treatment to soften the lens and delay the onset of presbyopia and cataracts. The lens's unique properties also make it a challenge to deliver pharmacological interventions, requiring the drug to penetrate through various layers of the eye to reach the lens. The pupil, the dark part of the eye, physically changes size during dilation and constriction, and pharmacological dilation is used during eye exams to provide a clear view of the back of the eye.
Artificially manipulating pupil size improves near vision for presbyopia: Researchers found a way to narrow pupils to enhance near vision for presbyopia, which surprisingly benefits distance vision too. Effects last 6-8 hours and don't harm far vision.
Researchers have discovered a way to artificially manipulate the size of the pupil to improve near vision in individuals with presbyopia, a condition that makes it difficult to focus on close objects. This is achieved by narrowing the aperture, which filters out scattering rays and allows for clearer vision of nearby objects. Contrary to common belief, this process actually improves distance vision as well. The effects of these eye drops last for six to eight hours and do not compromise far vision. This discovery offers a simpler solution to presbyopia compared to more complex methods aimed at addressing cataracts. Additionally, the evolution of different eye colors, such as brown and blue, may provide protection from UV and visible light. These findings could lead to the commercial availability of new presbyopia treatments in early 2022.
The Retina and Visual Processing: The retina, a light-sensitive tissue, converts light into electrical signals, which are sent to the brain for processing. The retinol pigment epithelium protects the retina from damage. The midbrain handles some visual processing, while most occurs in the cortex.
The retina, a metabolically active tissue in the eye, is constantly bombarded with radiation and light, making it prone to free radical formation. The retinol pigment epithelium, a pigmented layer behind the retina, shields the vascular supply from this damage. The retina contains rods and cones, specialized cells with photoreceptors that convert light into electrical signals. These signals are then sent to the brain via the optic nerve, with most visual processing occurring in the cortex. The midbrain handles some aspects of visual processing, such as pupil responses and autonomic functions. The left and right hemispheres process visual information from each eye, with some cross-processing occurring. Damage to the visual system can be localized by observing the effects on the visual field, with problems in front of the optic chiasm affecting one eye only, and those behind it affecting both eyes.
The Value and Significance of Human Vision: Human vision is crucial for survival and evolution, but requires maintenance to avoid vision threats.
Our sense of vision is a valuable asset for humans, both in terms of personal importance and evolutionary significance. The discussion highlights how our intelligence and technology have allowed us to excel in vision compared to other animals, despite our limitations in senses like smell and hearing. This advantage has been crucial for our survival as hunters and hunted beings. Additionally, the conversation touched upon the importance of recognizing and addressing potential vision threats, such as brain tumors, which can significantly impact our daily lives. The anecdote about the hunter and the elk illustrates the narrow margin of error when it comes to vision, emphasizing the significance of maintaining good eye health.
Young people are at a higher risk for vision loss due to trauma: Prioritize safety measures to minimize eye injuries and consider advanced laser vision correction for enhanced visual performance.
Young people are at a higher risk for vision loss due to trauma rather than age-related causes. Blunt trauma is the most common cause of vision loss in this age group. The eye is relatively well-protected, but certain objects or accidents can directly impact the eye and cause irreparable damage. It's essential to prioritize safety measures, such as wearing protective goggles during outdoor activities or handling sharp objects, to minimize the risk of eye injuries. Additionally, modern laser vision correction offers the possibility of improving vision beyond 2020, providing athletes and individuals with better visual performance, potentially enhancing their abilities in their respective fields. However, contact lenses, despite their convenience, may not offer the same level of optical performance due to the body's reaction to them as foreign objects and the constant movement during blinking.
The shape and length of the eye impact vision: The cornea's shape influences astigmatism, while the eye's length determines nearsightedness or farsightedness. Adaptations to visual environments can impact eye development.
The shape of the eye, specifically the cornea, can impact vision and lead to conditions like astigmatism. Astigmatism occurs when the cornea is not perfectly spherical, causing different meridians to require different lens prescriptions. Astigmatism is common, affecting around 60% of people with glasses prescriptions. The length of the eye, particularly the anterior-posterior length, is the primary determinant of nearsightedness or farsightedness. If a person's visual environment consists mainly of close objects, their eye may grow longer to bring those objects into focus. This process, known as emmetropization, can occur over a period of months. Factors like deprivation from outdoor light and near work can contribute to the development of nearsightedness in children. These findings show how the eyeball can adapt to its environment, and the consequences of modern visual habits on vision health.
Going outside reduces risk of nearsightedness in children: Exposure to natural light outside decreases risk of myopia, while staying inside increases it up to 16 times. Blue light is crucial for preventing myopia and promoting attention.
Going outside and being exposed to natural light can significantly reduce the risk of developing nearsightedness (myopia) in children. This protective effect is likely due to the release of dopamine from the retina, which inhibits eye growth. Staying inside in a dimly lit room and performing near tasks, on the other hand, increases the risk of nearsightedness up to 16 times compared to children who go outside. The importance of natural light has been further supported by studies showing that children who engage in noontime outdoor activities have better outcomes than those who are outdoors at less illuminated times. Additionally, blue light, which is often associated with negative effects, is actually critical for preventing myopia and promoting wakefulness and attention. Myopia is not just an inconvenience of wearing glasses or contact lenses; it's also associated with various eye diseases such as cataracts, myopic macular degeneration, and glaucoma. From an evolutionary perspective, our ancestors in non-literate societies had excellent vision and no nearsightedness, suggesting that there is a genetic component as well as an environmental trigger for myopia development. Parents who don't wear glasses but expose their children to long hours of near tasks, such as reading or using electronic devices, are more likely to contribute to their children's risk of developing nearsightedness.
Impact of Outdoor Time and Illumination on Nearsightedness: Nearsightedness can be prevented or reduced by spending time outdoors and ensuring good lighting. Cataracts, an age-related vision issue, are not preventable but can be treated effectively with cataract surgery. Early signs of cataract formation include changes in night vision, glare, halos, and contrast sensitivity.
Near work and lack of outdoor time can contribute to the development of nearsightedness, while good illumination and regular breaks for outdoor activities can help prevent it. Hunter-gatherer societies, who spend all their time outside, do not develop nearsightedness but may develop other vision-related issues as they age. Cataracts, a common age-related vision issue, are not preventable but can be effectively treated with cataract surgery, which is typically a one-time procedure. Early signs of cataract formation include changes in night vision, glare, halos, and problems with contrast sensitivity. The decision to undergo cataract surgery is usually left to the patient based on their individual visual needs and preferences.
From couching to intraocular lenses: A journey of vision improvement: The development of intraocular lenses revolutionized cataract surgery, enabling clear vision and correction of various refractive errors
The evolution of cataract surgery has seen significant advancements, with the introduction of intraocular lenses in the 1980s being a game-changer. Before this, methods like couching, which involved pushing the lens backward, allowed some light to enter the eye but did not provide clear vision. The use of gold needles to poke the lens and make it detach was a common practice in ancient civilizations. Fast forward to the post-World War II era, and ophthalmologist Harold Ridley discovered that shards of plexiglass from aircraft canopies, when implanted in the eye, were biologically inert and did not cause harm. This discovery paved the way for the development of intraocular lenses as we know them today, which not only replace the cloudy lens but also correct various vision issues like astigmatism, nearsightedness, farsightedness, and presbyopia.
Revolutionizing cataract surgery with PMMA lenses: PMMA lenses transformed cataract surgery with smaller incisions, foldable implants, and improved biocompatibility, making it a common procedure for vision restoration
The discovery and development of intraocular lens implants, made from polymethylmethacrylate (PMMA), revolutionized cataract surgery. Initially, the idea of replacing human lenses with PMMA lenses was considered heresy due to bad outcomes in the early days. However, as technology advanced, smaller incisions became possible, and foldable implant lenses were introduced. The importance of a small incision lies in minimizing astigmatism and healing time. PMMA lenses are still used in joint replacements due to their biocompatibility. Cataract surgery, once a significant event, is now a common and relatively non-eventful procedure for restoring vision clarity. While there are risks associated with cataract surgery, such as infection and pressure issues, the benefits of improved vision far outweigh these risks for most patients.
Cataract Surgery: More Than Just Replacing Clouded Lenses: Modern cataract surgery offers vision correction beyond clouded lens removal, increasing spectacle independence for some patients. Premium lenses can be costly but prioritized by many. Patients need realistic expectations, careful education, and thorough assessments.
Cataract surgery involves more than just removing clouded lenses and replacing them with new ones. Modern technology allows for the correction of various visual defects, resulting in increased spectacle independence for patients who value it. The cost of premium lenses can be significant, but many patients prioritize their vision and independence over the expense. It's important for patients to have realistic expectations and for doctors to carefully educate them about the capabilities of these advanced lenses. Additionally, the condition of the cornea and the use of contact lenses can impact measurements and calculations, making careful assessment necessary.
The Importance of Cornea Shape in Vision Correction: A precise cornea shape enhances vision correction with implants, while advanced technology accurately measures eye dimensions for lens calculation. Game-changing tech could be a lens that adapts to focus on near or far objects. Corneal pathologies like dry eye can impact vision and require treatment.
The more perfect the shape of the cornea, the better the calculation for implanting a lens to correct vision, especially with advanced multifocal lenses. Current technology can accurately measure the length of the eye and predict the power of the implant lens based on this and other eye dimensions. However, a game-changing technology would be a lens that can change its shape or position to zoom focus seamlessly from near to far. Corneal pathology, such as abrasions or dry eye, can significantly impact vision and require attention. Dry eye is a common issue in society, caused by various factors including medications, hormonal influences, and a lack of tears. The lack of testosterone is believed to be the primary cause of dry eye in women.
Understanding Dry Eye: Causes and Solutions: Dry eye is a complex condition with multiple causes, including gland dysfunction and inflammation. Manage symptoms with eye drops, consider high-dose omega-3 and omega-6 supplements, and protect eyes from UV light. Combine strategies for effective dry eye treatment.
Dry eye is a complex condition with various causes, including dysfunction of the meibomian glands and inflammation. The application of eye drops, whether in the form of drops or sprays, can help manage symptoms. High doses of omega-3 and omega-6 fatty acids, particularly gamma linoleic acid, may also be beneficial due to their anti-inflammatory properties. The importance of light exposure is still debated, but it's generally recommended to wear sunglasses to protect against excessive UV light. Dry eye treatment often involves a combination of strategies, including artificial tears, supplements, and lifestyle modifications.
Protecting Eyes from UV Light: Darker eyes have natural UV protection, lighter eyes need sunglasses. UV protection delays age-related eye conditions. Sunglasses, clear spectacles with UV protection effective.
Protecting your eyes from UV light is crucial for maintaining eye health and potentially delaying age-related conditions such as cataracts and macular degeneration. Darker eyes have more natural protection due to increased pigment, while lighter eyes let in more light and require more protection. Sunglasses are an effective way to shield your eyes from harmful UV rays, even on cloudy days or during eclipses. Polarized lenses can be helpful for certain activities like fly fishing, but the primary benefit comes from UV protection. Clear spectacles with UV protection can also provide the same benefits as sunglasses.
The Debate Between Contact Lenses and Laser Eye Surgery for UV Protection: Glasses provide consistent UV protection with no risks, while contact lenses and laser eye surgery have potential infection and surgical risks, respectively.
When it comes to protecting your eyes from UV damage, glasses or spectacles are the safest option as they provide a consistent barrier with no associated risks. However, the debate continues between contact lens wear for potential infection risks and laser vision correction. The advent of laser eye surgery, such as LASIK and PRK, began in the mid-90s, and the technology was revolutionary due to its ability to etch or cut human tissue with minimal heat generation and scarring, resulting in improved vision without detectable surgery. The first successful human procedures were performed in New Orleans by Dr. Marguerite McDonald.
Laser eye surgery to correct vision: PRK: PRK is a laser eye surgery that involves removing the epithelium layer to reshape the cornea, allowing for improved focus on the retina. Unlike LASIK, PRK does not create a corneal flap and is suitable for those with thin corneas or certain eye conditions.
PRK (Photo Refractive Keratectomy) is a type of laser eye surgery used to correct vision, particularly for those with nearsightedness. The procedure works by removing a thin layer of cells from the front of the cornea, the epithelium, to expose the underlying tissue. A carefully calibrated laser is then used to reshape the cornea, making it less curved and able to focus light more effectively on the retina. This process is similar to sanding down the center of a piece of wood to make it flatter. The epithelium grows back, allowing the eye to heal. Unlike LASIK, PRK does not involve creating a flap in the cornea, making it a good option for those with thin corneas or certain eye conditions. The procedure is typically done while the patient is anesthetized and lying down with their eyes held open. The removal of the epithelium layer is temporary and the eye drops used to do so are similar to isopropyl alcohol. Overall, PRK allows for the correction of refractive errors by changing the curvature of the front of the eye, making it a valuable tool in improving vision.
Mapping the entire optical pathway for precise laser correction: Advanced laser eye surgery uses digital mapping and real-time tracking to ensure accurate and safe correction of vision distortions, reducing the risk of complications.
Advanced laser eye surgery is a precise process that utilizes digital mapping and real-time tracking to ensure accuracy and safety. The fear of accidentally disrupting the procedure is common, but the technology is designed to prevent such mishaps. The procedure involves mapping the entire optical pathway of the eye to identify distortions and adjust the laser correction accordingly. The laser is programmed to track the eye and will not fire unless it is within its range. The surgery itself involves vaporizing tissue to change the shape of the cornea and can take varying lengths of time depending on the prescription and distortions present. Valium is sometimes used to alleviate anxiety during the procedure, but the technology and safety measures in place significantly reduce the risk of complications.
Two Types of Laser Eye Surgeries: PRK and LASIK: PRK involves removing the cornea's protective layer and takes longer to recover, while LASIK uses a laser-created flap for quicker recovery and is more commonly performed.
PRK (Photo Refractive Keratectomy) and LASIK (Laser-Assisted In Situ Keratomileusis) are two common types of laser eye surgery used to correct vision, but they have distinct differences in the procedure and recovery process. PRK involves removing the epithelium (the outer protective layer of the cornea) and applying a contact lens to aid in healing. The recovery time is around 4 days for the epithelium to heal, but full visual recovery takes several days longer. LASIK, on the other hand, uses a femtosecond laser to create a thin flap in the cornea, lifting it to access the underlying tissue. The laser is then used to reshape the tissue, and the flap is replaced, allowing for quicker visual recovery, often achieving 20/20 vision the next day. The choice between PRK and LASIK depends on individual factors, including the desired recovery time and the specific eye condition being treated. In the United States, approximately 80-85% of corrective eye surgeries are LASIK, with PRK accounting for a significant portion of the remaining procedures. While both procedures have risks, the risks are different – PRK has a higher risk of infection due to the epithelium removal, but LASIK introduces the risk of flap complications.
LASIK vs PRK: Two Types of Laser Vision Correction Procedures: LASIK and PRK are two laser vision correction procedures with different approaches. LASIK creates a thin corneal flap, while PRK directly reshapes the cornea. Each has advantages and disadvantages, including temporary dry eye with LASIK and more post-operative care with PRK. Costs are similar, but exclusion criteria vary. About 15% of people choose PRK.
LASIK and PRK are two common types of laser vision correction procedures, each with their advantages and disadvantages. LASIK involves creating a thin flap in the cornea to access the underlying tissue, while PRK directly reshapes the cornea's surface. The flap creation in LASIK can lead to temporary dry eye and potential complications if not performed correctly. However, PRK requires more post-operative care due to its more invasive nature. Night vision issues were once a concern with LASIK due to the limited treatment diameter, but advancements in technology have significantly reduced these complaints. The cost of these procedures is generally similar, although prices may vary depending on the surgeon. Exclusion criteria include certain corneal conditions, irregular astigmatism, and autoimmune diseases, among others. Despite these differences, about 15% of people still opt for PRK, particularly those with deep treatments or thin corneas, pre-existing dry eye, or specific military backgrounds. Overall, the choice between LASIK and PRK depends on individual circumstances and the expertise of the surgeon.
Laser eye procedures for perfect vision and diagnosing glaucoma: Individuals can achieve 2020 vision or better with advanced laser procedures. Glaucoma diagnosis requires accurate intraocular pressure measurement, preferably through indentation methods.
For individuals aiming for careers requiring perfect vision, such as pilots or aviators, achieving 2020 uncorrected vision after laser corrective procedures like PRK or LASIK is typically achievable. These procedures have advanced to the point where they can often provide vision that is even better than 2020. However, age-related presbyopia may still require the use of reading glasses. Another topic discussed was the Smile procedure, a single-laser method that has gained traction outside the US. Its primary purpose was to reduce dry eye and provide Lasik-like recovery times, but its effectiveness compared to LASIK is still debated. Regarding eye examinations, measuring intraocular pressure is crucial for diagnosing glaucoma, a condition characterized by damage to the optic nerve. While air puff tonometry is a common method, it's not considered a gold standard due to potential inaccuracies from quick blinks. Instead, methods that physically indent the cornea are preferred. Glaucoma itself is a complex condition, with various causes leading to optic nerve damage and potential vision loss. Symptoms may not always be noticeable, emphasizing the importance of regular screenings.
Understanding Glaucoma: Causes, Detection, and Prevention: Glaucoma, a common cause of vision loss, results from overproduction of aqueous fluid and increased eye pressure. Regular eye exams starting in your 50s aid in early detection and prevention. Risk factors include aging and family history. Limiting UV exposure and wearing sunglasses can help reduce risk.
Glaucoma is a common condition that can lead to vision loss if left untreated. It is primarily caused by chronic open angle glaucoma, which results from overproduction of aqueous fluid inside the eye and increased eye pressure. The condition can lead to a visual field defect, which is not reversible once damage has occurred. Regular eye exams, starting in your 50s, are crucial for early detection and prevention of further damage. While the exact causes of glaucoma are not fully understood, it is not directly linked to diabetes or hypertension. Some factors that may increase your risk include aging and family history. It's important to note that there is no surefire way to prevent UV exposure, but limiting exposure and wearing sunglasses when possible can help reduce the risk.
Protecting Our Eyes from More Than Just the Sun: Antioxidants like lutein and zeoxanthin may help delay macular degeneration, but their preventative effect is not definitive. Exposure to blue light from screens in the evening can disrupt sleep patterns, so using software to adjust screen color temperature is recommended.
While hats are important for protecting our eyes from sunlight, they are not enough on their own. Excessive light, especially blue light from screens, can lead to eye problems such as macular degeneration and disrupted circadian rhythms. Antioxidants, specifically lutein and zeoxanthine, have shown some promise in delaying or reducing the progression of macular degeneration, but their effect on preventing the condition is not definitive. UV radiation from screens is not a significant risk for macular degeneration or cataracts. However, exposure to blue light from screens, especially in the evening, can disrupt our sleep patterns. Using software to adjust the color temperature of computer and phone screens to reduce blue light exposure in the evening may help mitigate this issue.
Proper contact lens care and eye health: Remove lenses nightly, avoid extended wear, use protective measures, replace implant lenses if needed, ensure prescription stability, and don't delay necessary eye procedures.
Proper care of contact lenses is crucial to maintaining eye health. This includes removing them nightly, avoiding extended wear, and using protective measures like sunglasses and artificial tears. Another takeaway is that cataract surgery is not the one-time procedure it once was, and advancements in technology have made it possible to replace implant lenses if necessary. Additionally, prescription stability is important for successful laser eye surgery, with the cornea and length of the eye typically finishing their development in the early 20s. It's important to note that the lens in the eye continues to change throughout life, but cataract formation is usually not a concern until later in age. The fear of cataracts should not delay necessary eye procedures, as they can lead to significant vision improvements and potentially correct other age-related visual changes.
The eye's transparency offers a unique opportunity for early detection of health conditions, particularly diabetes.: The eye's transparency allows for direct observation of the capillary network and lens, revealing damage like diabetic retinopathy and potential glucose leaching. Changes in the eye could indicate higher red blood cell turnover and potential health issues.
The eye, as a transparent organ, offers a unique opportunity for early detection of various health conditions, particularly those related to diabetes. The eye's transparency allows for direct observation of the capillary network and the lens, which can reveal damage such as diabetic retinopathy and potential glucose leaching. These findings could serve as a non-invasive screening technique for diabetic disease and other microvascular issues. Furthermore, the eye's sensitivity to excessive glycosylated hemoglobin suggests that changes in the eye could indicate higher turnover of red blood cells and potential health problems. Although the technology to measure glucose in the lens does not yet exist commercially, it holds promise for earlier and more accurate diagnosis of various health conditions.
Ophthalmology's crucial role in diabetes care: Ophthalmology reveals microvascular damage in diabetes, even with normal A1C levels, providing valuable insights for improved diabetes management.
Ophthalmology plays a crucial role in diagnosing and managing diabetes, even when a patient's A1C levels may indicate good control. During a discussion on the importance of ophthalmology in diabetes care, it was emphasized that changes in the retina, such as fluid exudates, hard exudates, and microaneurysms, can reveal uncontrolled diabetes despite normal A1C levels. These signs of microvascular damage are not just indicative of eye health issues but also systemic health problems. The ability to directly observe the brain and vascular tree in ophthalmology is unique and valuable, making it essential for better diabetes management. The integration of ophthalmology into medicine as a whole is encouraged to improve patient care and outcomes.
