The Role of Accommodations in the Management of Visual Problems

Accommodations are modifications in the visual demands of a task with the intent of making the task easier. When visual problems are more severe, accommodations will be less effective or totally ineffective. The accommodations that I am going to address here are those that relate to the difficulties that students with healthy eyes have learning and while taking examinations.

The children who would receive that most benefit from accommodations are many children who have undiagnosed visual problems. These children have been able to cope with tracking, crowding, eye-hand coordination, focusing, and eye teaming problems, but school work could be easier for them and they could perform better if the print was bigger, the pages less crowded, they had frequent breaks, and they had more time to complete their work.

Children with diagnosed visual problems typically have more severe visual difficulties. While the above accommodations may still be appropriate, their effects will be limited.

This became personal for me lately due to the need for hip replacement surgery. Prior to the surgery and during the recovery, there were things that I just could not do regardless of accommodations. When I was able to “walk” with a walker and then for short distances with a walking stick, this was still far from walking automatically. I had to attend to walking. I was slow. There was little that I could think of other than walking due to the attention required and the associated discomfort. I fatigued quickly. Other parts of my body hurt from compensating. Student’s visual problems are no less incapacitating. I can look forward to putting this in my past. Without effective treatment, this will not happen for the children with significant visual problems.

A common example is a child who can keep their place much better when they point to each word with their finger. They cannot read without the finger and this can seem like a miracle, but it should not be equated with normal reading. It is similar to walking with a walker. It cannot be smooth. It takes longer. It is more tiresome. Attention is distracted from the reading material (comprehension) to the mechanics of reading. It is clumsy.

We will continue to recommend accommodations as appropriate. We don’t take crutches away from people who need them, but everyone who works with these children cannot forget that the effects of their problems have not been eliminated, even in the short-term.

Ironically, visual problems are less visible than many other problems. When I am walking with my walking stick, everyone knows that I have a problem and they do not expect me to function as if I did not have the problem. That can only happen when my problem is resolved. The same is also true for visual problems.

For More:

Crowding

Tracking

Eye-Hand Coordination

Visual Factors in Reading

Vision Therapy is Messy

In his book Messy: How to be Creative and Resilient in a Tidy-Minded World, Tim Harford provides examples of how extreme organization and structure, reduced diversity, and oversimplification makes things easier but constrain and compromise outcomes.

Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;

-eye alignment and movement,

-focusing,

-object perception, spatial perception, and guidance of movement

is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.

All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.

Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.

Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.

Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity.  The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits.  Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.

Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.

Superforecasting The Art and Science of Prediction

Philip E. Tetlock and Dan Gardner

We cannot avoid forecasting. Everything that we do is based on what we expect the outcome to be. Some forecasting is short-term and primarily preconscious such as planning a movement while taking into consideration the positions and movements of others around you. We have been making these kinds of predictions for millions of years and we apply the same processes to skills for which we have not evolved such as driving.

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We have immediate feedback on our accuracy of these forecasts enabling us to gradually improve. The transition to making conscious, long-range forecasts in our complicated world has not eliminated the often bewildering influence of our subconscious. Since these influences are subconscious, we are unaware of how they steer our decisions. And we can be deceived about our ability to make these forecasts accurately because we do not have immediate feedback. “Human thought is beset by psychological pitfalls, a fact that has only become widely recognized in the last decade or two.” P. 23

Philip Tetlock provides a readable and understandable review of these pitfalls at the beginning of Superforecasting and gives examples of how they influence our thinking and our forecasts. What makes this book different from dozens of similar books in this genre is that it goes on to demonstrate that we are not doomed to our fallibilities. His research has disclosed ways in which forecasting can be improved.

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Tetlock spent decades tracking the accountability and accuracy of the predictions of experts in various fields. When the results were published, people humorously summarized the findings with the statement: “The average expert was roughly as accurate as a dart-throwing chimpanzee.” P. 4 What was overlooked by considering only the majority is that some people were consistently better at making forecasts.

The credibility of our Intelligence Community was severely compromised by its prediction of the existence of Weapons of Mass Destruction in Iraq which triggered our invasion and all that has followed. Recognizing that they had to try to improve their predictions, Tetlock was invited to participate with his Good Judgment Project (GJP) in a research effort sponsored by the Intelligence Advanced Research Projects Activity (IARPA) which is the research arm of our Intelligence Community. “Thanks to IARPA, we now know that a few hundred ordinary people and some simple math can not only compete with professionals supported by a multibillion dollar apparatus but also beat them.” P. 91 The Intelligence Community of the United States employs about 100,000 people at an annual cost of $50 billion in an effort to keep us safe.

A surprising fact about superforecasters is that they are not distinguished by who they are but by what they do. “Superforecasting demands thinking that is open-minded, careful, curious, and – above-all – self-critical. It also demands focus. Only the determined can deliver it reasonably consistently, which is why our analysis consistently found commitment to self-improvement to be the strongest predictor of performance.” P. 20

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It is important to recognize that there are limits to forecasting. Even those things that can be forecasted to a high degree of probability, like the weather, become much less predictable the farther the prediction is made into the future. “One of twentieth century sciences’ great accomplishments has been to show that uncertainty is an ineradicable element of reality.” P. 127  “For superforecasters, beliefs are hypotheses to be tested, not treasures to be guarded.”P. 141 “Chance and fate do not mix. And to the extent that we allow our thoughts to move in the direction of fate, we undermine our ability to think probabilistically.” P. 149  “Knowing what we don’t know is better than thinking we know what we don’t.”  P. 245 “Meaning is a basic human need. As much research shows, the ability to find it is a marker of a healthy, resilient mind.” P. 148

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“Superforecasters may have a surprising advantage: they’re not experts or professionals, so they have little ego invested in each forecast.” P. 163 “John Maynard Keynes operated on a higher plane than most of us, but that process – try, fail, analyze, adjust, try again – is fundamental to how all of us learn, almost from the moment we are born.” P. 178 “The humility required for good judgment is not self-doubt – the sense that you are untalented, unintelligent, or unworthy. It is intellectual humility. It is a recognition that reality is profoundly complex, that seeing things clearly is a constant struggle when it can be done at all, and that human judgment must therefore be riddled with mistakes. This is true for fools and geniuses alike.” Pp 228 – 229 “Forecasters who see illusory correlations and assume moral and cognitive weaknesses run together will fail when we need them the most.” P. 229

As an example, Tetlock uses what I feel is one of the most powerful and beautifully written speeches ever created. “With firmness in the right, as God gives us to see the right, let us strive to finish the work we are in.” (From Abraham Lincoln’s Second Inaugural Address) The traps he discusses are traps that are common to all of us. The techniques to overcome them are not theoretical but have been proven through thousands of forecasts by hundreds of people who participated in the research. Forecasting is a learned skill just like reading, algebra, driving, manners, morality, attention, mindset, and grit. “I believe that it is possible to see into the future, at least in some situations and to some extent, and that any intelligent, open-minded, and hardworking person can cultivate the requisite skills.” P. 6

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Stumbling on Happiness

How We Learn: The Surprising Truth About When, Where, and Why It Happens

Grit

Visual Intelligence

Risk Savvy: How to Make Good Decisions

Gerd Gigenerzer

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We make many decisions every day. There is no data for most of the decisions that we make and when there is, there is a good chance that we interpret them incorrectly. Because important decisions about health and healthcare are made based on statistics, it is important to understand relative and absolute risks and what the numbers really mean. Here is what the author has to say….

Literacy – the ability to read and write – is the lifeblood of an informed citizenship in a democracy. But knowing how to read and write isn’t enough. Risk literacy is the basic knowledge required to deal with a modern technological society. p. 2

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Since the early 1960s, women in Great Britain are alarmed every couple of years by reports that the contraceptive pill can lead to thrombosis, potentially life-threatening blood clots in the legs or lungs. In the most famous scare, the UK Committee on Safety of Medicines issued a warning that third-generation oral contraceptive pills increased the risk of thrombosis twofold – that is, by 100 percent. How much more certain can you get? Distressed women stopped taking the pill, which caused unwanted pregnancies and abortions.

Just how big is 100 percent? The studies on which the warning was based had shown that of every seven thousand women who took the earlier, second-generation pill, about one had a thrombosis; and that the number increased to two among women who took the third-generation pills. That is, the absolute risk increase was only one in seven thousand, whereas the relative risk increase was indeed 100 percent. As we see, in contrast to absolute risks, relative risks appear threateningly large and can cause a great stir.

This single scare led to an estimated thirteen thousand (!) additional abortions in the following year in England and Wales. Not all unwanted pregnancies were aborted; for every abortion there was also one extra birth. Ironically, pregnancies and abortions are associated with a risk of thrombosis that exceeds that of the third-generation pill. pp. 5 -6

The quest for certainty is the biggest obstacle to becoming risk savvy. The problem is that false certainty can do tremendous damage. As we will see, blind faith in tests and financial forecasts can lead to misery. p. 21

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A rule of thumb, or heuristic, enables us to make a decision fast, without much searching for information, but nevertheless with high accuracy. A heuristic focuses on the one or few pieces of information that are important and ignores the rest. One might think that the study of smart heuristics must be a central activity in many fields. But it isn’t. Oddly, most theories of rational decision making, from economics to philosophy, still assume that all risks are knowable. pp. 29 – 32

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An intuition, or gut feeling, is a judgment:

-That appears quickly in consciousness,

-Whose underlying reasons we are not fully aware of, yet

-Is strong enough to act upon.

It is a form of unconscious intelligence. To assume that intelligence is necessarily conscious and deliberate is a big error. p. 30

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A 50-year-old woman, no symptoms, participates in routine mammography screening. She tests positive, is alarmed, and wants to know from you whether she has breast cancer for certain or what the chances are. Apart from the screening results, you know nothing else about this woman. How many women who test positive actually have breast cancer? What is the best answer?

-9 in 10

-8 in 10

-1 in 10

-1 in 100

I will now give you the relevant information to answer the question about the chance of cancer after a positive test. First, I’ll present it in the way that is customary in medicine, in probabilities.

The probability that a woman has breast cancer is 1 percent (prevalence).

If a woman has breast cancer, the probability that she tests positive in 90 percent (sensitivity).

If a woman does not have cancer, the probability that she nevertheless tests positive is 9 percent (false alarm rate).

The best answer is one in ten. That is, out of ten women who test positive in screening, one has cancer. The other nine women receive false alarms. pp. 162 163

Reporting in the news does not explain this and most health professionals are not well-versed in interpreting these statistics. If you are faced with this type of situation, it is important to have someone interpret the statistics for you before you make important decisions. This is one area in which intuition is not reliable.

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How We Learn: The Surprising Truth About When, Where, and Why It Happens

How Vision Therapy Changed My Life: A Letter From a Doctor to Her Optometrist

Let Them Eat Dirt

Thinking, Fast and Slow: Daniel Kahneman

Daniel Kahneman received the Nobel Prize in Economic Sciences for his research in psychology about how we make decisions. Economic theories, and other models of how we think, assume that we make rational decisions on important matters. Kahneman’s very readable book explains how this is not how we think and decide even though we are convinced that this is the process that we use.

He explains that we have two systems for making decisions and describes them. System 1 is fast, intuitive, and emotional; System 2 is slower, more deliberate, and more logical. He exposes the extraordinary capabilities – and also the faults and biases – of fast thinking, and reveals the pervasive influence of intuitive impressions on our thought and behavior. Knowing this is a step towards improving our decision-making.

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I have made reference to prior blogs in the following excerpts….

Decisions are not only made in our minds. Our bodies are also involved. While we are making a decision we may feel tense and our pulse and blood pressure may change. In turn, how our bodies feel can influence our decisions. We feel anxiety and fear in our bodies and these feelings influence our decisions. The word “feelings” often communicates better than the term “emotions”. (See Action in Perception)

Our perceptions are selective. Vision is our primary sense and we cannot process all that we see. Looking puts some objects in focus and filters others but we are unaware of what is filtered and also unaware of the process. (See The Invisible Gorilla and Active Vision)

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“You can do several things at once, but only if they are easy and undemanding.” P. 23 This is multitasking which is essential to efficient functionand is dependent on working memory. If tasks are more demanding or draw upon the same processing, we must shift from task to task which consumes a great deal of effort and is prone to errors. This process is better described as split-tasking. (See The Distraction Addiction)

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“Our comforting conviction that the world makes sense rests on a secure foundation: our almost unlimited ability to ignore ignorance.” P. 201 Living requires plans and planning is based on predictions of the future. But our confidence in our predictions of the uncertain is an illusion. “The core of the illusion is that we believe that we understand the past, which implies that the future should also be knowable, but in fact we understand the past less that we believe we do.” P. 201 Our vulnerability is disappointing but ignoring is can have serious consequences.

Snowball in a Blizzard:A Physician’s Notes on Uncertainty in Medicine

Steven Hatch, MD

Considering uncertainty is important in many areas of our lives. Steven Hatch, a physician and medical educator is concerned about how uncertainty is misunderstood or ignored which leads to bad decision-making on the part of healthcare providers, patients, and their families. Discomfort with uncertainty is natural. We discount the role of randomness in our lives and develop narratives, after the event, to explain why things happened that we could not have predicted. Despite our impressions and statements in the media, there are few decisions in medicine that lead to guaranteed outcomes without a possibility of complications.

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The nature of this subject makes the book difficult to read at times. Since the math involved in statistics is not that sophisticated, it would seem that our intuitions would be correct, but we have difficulty handling more than a couple of numbers at a time and tend to put too much value on the figures that we are considering at the moment and those that have the largest emotional impact. As the author states, decisions in other aspects of life are difficult because they cannot predict the future. In healthcare, the current data often do not even present a clear view of the present.

A significant part of the problem is due to how healthcare information is presented in the media. Whether through misunderstanding or the need to attract readers, the media presents medical information with far too much certainty while the reality is like seeing a “snowball in a blizzard”. Steven Hatch emphasizes that there are few things in healthcare which are as certain as: Exercise more, Eat less, and Do not smoke. “That is because most Americans die from cardiovascular disease and diabetes (which is why you should eat moderately and exercise) or emphysema and lung cancer (which is why you shouldn’t smoke).” P. 15 But it is difficult to make this news exciting.

Hatch emphasizes the importance of keeping the “spectrum of certainty” in mind at all times which he diagrams as follows.

Benefit ————————————————————– Harm

High confidence – reasonable confidence – pure speculation – reasonable confidence – high confidence

Evidence

Strong – moderate – weak – none or contradictory – weak – moderate – strong

Technology can deceive us through its precision. Technology, such as mammograms, can find cancers much earlier. When these are treated, the patients (and doctors) have the satisfaction of having saved lives; but have they? The cure rate goes up. Relatively fewer people are dying who were diagnosed with cancer, but is the absolute rate of death from that cancer going down? The media frequently use relative statistics when absolute statistics provides a more important perspective. “The precision with which we can make diagnoses is profound, but precision is not the same things as certainty.” P. 24 After test information is considered and a diagnosis is made, we then treat that diagnosis as it is the unquestionable truth which leads to overdiagnosis and overtreatment. We now realize that many of us harbor cancers which will never impact our lives and detecting these cancers does not benefit our health or longevity. There is an analogy to the stock market. Technology now enables us to follow the value of stocks continuously, but do these moment-to-moment values provide information about the long-term value of that stock?

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Steven Hatch repeatedly reminds readers that there is a huge difference between the values of screening mammograms in a population of women who are unlikely to have cancer compared to mammograms in women who have recently detected a lump in their breast. The statistics are completely different and he wants to make sure that this information is not misunderstood or misquoted.

It is important that we look at the appropriate outcomes. Hatch discusses this relative to blood pressure, blood sugar, and cholesterol levels but emphasizes that it is true in many other areas of health as well. The outcomes which are important are not lowering these numbers, but the mortality and quality of life of these people. Research confirms that lowering these findings places us at the left eye of the spectrum of uncertainty when the figures are very high to start. The potential benefits are significant and the risks are low. As we attempt to continue to lower the numbers, the added benefits become questionable and the risks continue to rise as more medications are needed. Also, in the case of blood pressure for example, there are significant risks of blood pressure being too low. Fainting is a common problem caused by low blood pressure with associated broken hips in older people. “The one-year mortality following a broken hip is probably between 10 and 40 percent – at least as bad as or worse than many cancers.” P. 97

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Hormone replacement therapy is an example of a combination of the medicalization of our society and the effects of the media. Loosely collected impressions “seemed ever more convincing, so by the late 1980s the vast majority of physicians had become sufficiently sold on the many benefits of hormone replacement therapy. Eventually, hormone replacement therapy became part of the national primary care guidelines.” P. 174 When a trial by the National Institutes of Health was stopped in 2002 because “a steady accumulation of data suggested that not only were hormones not beneficial but they were harmful” p. 176, the news hit the media. Many women stopped taking the hormones and many doctors stopped prescribing them. “Yet the harms posed by prolonged hormone use were in fact relatively small” and there were associated benefits.

If you are particularly interested in uncertainty as it applies to breast cancer, prostate cancer, and chronic fatigue syndrome and Lyme disease, I would recommend that you read the book. Any summary that I make will be incomplete and potentially misleading but I would like to mention two things in closing. One is the natural tendency to not pay attention to those things which did not happen which can be more important than those that did (the dog that didn’t bark in the nighttime). Public health measures have had a huge impact on mortality and morbidity. Seat belts and safer cars save thousands of lives each year. Antibiotics have a similar impact. Decreases in the number of people who are smoking has had a much larger impact on emphysema and lung cancer than medical care. Vaccines are another example. Vaccines have one of the best track records in medicine by being at the far left end of the spectrum of certainty but they have been a target of the media and special interest groups. The flu vaccine, for example, has a very low risk of significant adverse side effects and, while only 60 percent effective, it saves thousands of lives each year in the United States. Exotic influenzas make the news while most people think that the flue is like a bad cold. “Yet influenza is a killer: since 1976, when the Center for Disease Control began systematically tallying influenza mortality, the estimated number of annual deaths from the flu has ranged from about 3,000 to 50,000, with a typical year resulting in about 25,000 deaths.” P. 202

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How Doctors Think by Jerome Groopman

The stated purpose of How Doctors Think is to help understand how doctors gather information and combine it with their medical knowledge and experience to arrive at diagnoses and treatments. Understanding this may improve our ability as patients to work with doctors to facilitate diagnoses for ourselves. This problem-solving process is not unique to medical care and the book’s message has broader applications. Decisions are actions derived from our predictions of the future. When the decisions are about people they are more complex. Attitude and communication (which includes listening) may be as important as the decision. Expectations influence outcomes. The placebo effect is not limited to medicine. Might you be more effective as a parent, teacher, coach, doctor, tutor, therapist or other professional if you have empathy and a positive attitude? In the author’s words…

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Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the canon in many hospitals. Treatments outside the statistically proven are considered taboo until a sufficient body of data can be generated from clinical trials. Of course, every doctor should consider research studies in choosing a therapy. But today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers. Statistics cannot substitute for the human being before you; statistics embody averages, not individuals. Numbers, can only complement a physician’s personal experience with a drug or a procedure, as well as his knowledge of whether a “best” therapy from a clinical trial fits a patient’s particular needs and values.

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Groopman extensively discusses the importance of communication and the patient feeling comfortable with the doctor. How much of our wellness or sickness is based on our attitudes, reactions to stress, support from our family and friends, and confidence in our caregivers? How much can patient outcomes be enhanced through good communication and caring? How much do these factors influence non-medical interactions as in the following?

Few of us realize how strongly a physician’s mood and temperament influences his medical judgment.

At each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong.

Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct. But as we hear from a range of physicians, relying too heavily on intuition has its perils.

Judy Hall, the social psychologist, has focused further on the emotional dimension of the dialogue between doctor and patient: whether the doctor appears to like the patient and whether the patient likes the doctor. She discovered that those feelings are hardly secret on either side of the table. In studies of primary care physicians and surgeons, patients knew remarkably accurately how the doctor actually felt about them. Much of this, of course, comes from nonverbal behavior: the physician’s facial expressions, how he is seated, whether his gestures are warm and welcoming or formal and remote.

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Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes.

One of the most celebrated statements in clinical medicine comes from a lecture delivered by Dr. Francis Weld Peabody of Harvard Medical School in 1926: “The secret of the care of the patient is in caring for the patient.”

Moreover, “The narrowest subspecialist, the reasoning goes, should also be able to provide this range of medical services. This naïve idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases….Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem.

Our behaviors evolve based on our experiences, age, and new information.