June 2016

burnout pile of papers

“I have a theory that burnout is about resentment. And you beat it by knowing what it is you’re giving up.” Marissa Mayer, Chief Executive Officer, Yahoo!

 

TASK AT HAND: This week I’m thinking about burnout. I’ve received a lot of emails about this recently and, when you consider the most recent data, US worker burnout rates are as high as 45%. So, let’s define burnout, uncover what makes you susceptible to burnout, and – most importantly – how you can avoid it.

What is burnout? This is a difficult concept to grasp and ranges from excessive work load to erosion of motivation and worth from one’s occupation. Personally, I believe that burnout goes beyond work load and is actually based on a balance between drive and work load; specifically, when work load is greater than your drive or motivation to complete it, you get into burnout territory. Burnout is a chronic condition and should not be equated with acute stress. Acute stress can be an excellent driving force but, if excessive and prolonged, can lead to burnout. As balance is lost, more work piles up, and motivation dips further. The cycle of burnout quickly gets out of control and resentment becomes a dominant sentiment. This resentment hinders both personal satisfaction and meaningful relationships.

What makes you susceptible to burnout? I have found there are two key characteristics that increase your likelihood of burnout. First, if you are the person that says “yes” to every request – be careful! Now, please realize, I am this type of person: I want to say yes to every request but, this is not a sustainable strategy! Start saying no and you will see how liberating it is. Every time you say yes to a task you are saying no to everything else: to time with family, to time with friends, to time with activities that renew you. David Allen wrote, “Much of the stress that people feel doesn’t come from having too much to do. It comes from not finishing what they’ve started.” If you say yes to every request, you will start having difficulty finishing it all. Second, isolation is a major risk factor for burn out. Isolated individuals are more likely to get caught in the cycle of dipping motivation and increased workloads because they lack positive external forces to help identify this.

So, what can you do to minimize burnout? Once again, I must emphasize that stress is not burnout; stress is acute and usually for a short period while burnout is a prolonged chronic condition. For stress, I really like Lee Iacocca’s advice: “In times of great stress or adversity, it’s always best to keep busy, to plow your anger and your energy into something positive.” However, if the stress is endless and burnout has started – mostly because your motivation and drive are fading – you need to change your strategy. This is where I really like the Mayer quote: always know what you are giving up! This way, you will learn to say no and remain focused on your priorities and principals. Finally, meaningful activities and relationships are paramount. Do not isolate yourself from loved ones, friends, or new experiences. Renew your motivation hourly and realign your focus constantly!

 

MEDICINE & MACULA: Interesting study in the journal Eye on patient perspectives in the delivery of treatment for neovascular age-related macular degeneration. Survey of 87 patients found the most important factor to patients was: (1) having good vision, (2) one-stop service, and (3) less frequent follow up. The least important factors were label status of the drug, cost to the health service, and grade of the injector. Drives home what I see in clinic every day: patients want to preserve the best possible vision in the most convenient manner.

Check out the study here.

 

GRATIS: I attended the WAVE Ocular Imaging Conference this week (June 22-25) in beautiful Vail, Colorado. It was a wonderful meeting delving deep into complex and challenging vitreoretinal topics. I presented, Surgical Techniques and Outcomes for Retinal Detachment Secondary to Viral Retinitis (below is a preoperative and postoperative photo of one of the patients), and grateful to my colleagues for the fantastic discussion.

RS Figure ARN

 

My best to you,

David Almeida

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time

“Success is simple. Do what’s right, the right way, at the right time.” Arnold H. Glasow

 

TASK AT HAND: This week I’m thinking about time. Specifically, how to decide on timing for optimal execution of strategy; in other words, what is the right time for a given action?

When considering strategy, and within the paradigm of planning and execution, timing is crucial to the latter. You have to ask yourself, when do I have to act? What is the optimal time for me to achieve the outcome I desire? You may know how to act, but the question here is – when to act? The key then is deciphering how much time you have. We will quickly see that this is not always possible, and in fact, morphs into an existential question in its broadest extension – how much time do I have left? But that is for another day…

 

You can decipher how much time exists by deconstructing this strategic element of decision making into 3 scenarios.

1)  Defined time period. This is the easy one and applies to a large share of your strategic decision making. This applies to scenarios where you have a defined timeline (e.g., decision is due in 10 days). In these instances, it is best to allocate the minimum resources to achieve the goal within that time frame. Use the time you have!

2)  Undefined time period. Now it’s getting harder… With an undefined time period, you have time competition. With no known timeline, you have to allocate resources in a judicial manner to achieve your desired outcome with external time competition present. In these cases, you almost always gain an edge by executing promptly! This is more significant if you are in a novel market with possibility for a first-mover advantage – the advantage gained by the initial occupant of a market segment. If you have the possibility for technological leadership, you need to move fast!

3)  Asymmetric time period. This is the most complex situation and relates to decisions with external competition as well as internal factors; it also most analogous to surgery where – at any time – there can be total destabilization forces (complications). In these instances, decision analysis has to find the “window of minimal conflict” which designates the optimal timing for execution.

For example, cataract (clouding of the natural eye lens) extraction was initially performed as “couching” where a needle was use to push the lens out of the visual axis into the back part of the eye. As you can imagine, this provides terrible visual results and was riddled with complications. This technique operated within a window of maximal conflict: you perforated the eye without a proper wound, you did not control the inflammation, and you failed to replace the refractive element of the eye. Instead, modern cataract surgery relies on proper wound construction, excellent visualization, etc. to find the right time to remove the cloudy cataract – using minimal ultrasonic energy within a stable eye – at a time of minimal conflict to achieve the best possible outcomes.

There is another benefit to operating within a window of minimal conflict. If you happen to execute the wrong decision, damage limitation and error correction are simpler. Contrastingly, high stakes – or decisions made within windows of maximum conflict – requires you to take on excess risk and need to be carefully leveraged.

 

Next time you have a decision, deconstruct and decipher the time window you are operating in; then, execute the right way at the right time!

 

MEDICINE & MACULA: Our new case, Distinguishing optic pathway glioma and retinitis pigmentosa with visual field testing, reviews the challenging issue of visual field defects in retinitis pigmentosa (an inherited retinal disease) and optic glioma (a brain cancer). It was published in Canadian Journal of Ophthalmology (Volume 51, Issue 3). Check out the study here.

RP

 

GRATIS: Happy Father’s Day to all those who have served, and continue to serve, as role models and teachers. Thank you!

 

My best to you,

David Almeida

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blurry

“The focused mind only picks up on those aspects of a situation that are needed to accomplish the task at hand. It is not distracted by other thoughts or external events.” The Inner Game of Tennis by Timothy Gallwey

 

Task at hand: This week I’m thinking about the concept of cognitive burden. We know from cognitive psychology that cognitive load refers to the total amount of mental effort being used in the working memory. Cognitive burden can be thought of as an excess load on our mental effort – I attribute this undue burden to mostly meaningless or inconsequential items. We all want the personal freedom to choose: to choose a place to call home, to choose a partner, to choose a career. However, do we want to make every possible decision and have every choice? Personally, I don’t want to have to choose when to breathe, when to take the next walking step.

Do we want to burden ourselves with the construct of every action? Yet, our lives are increasingly filled with inconsequential decisions – from cell phone plans to social media posts – it’s easy to lose clarity. Thus, we arrive at the point of today’s scrub: remain focused on what is important to you and minimize cognitive burden. There are two main strategies I use for this.

The first one applies to extrinsic inconsequential items. You have to strip these decisions away. Einstein had multiples of the same suit and shirt so he never wasted any time on this trivial matter. He was right – you shouldn’t waste any of your mental energy on this! I’m a believer of the morning routine: wake up, exercise, nutrition and don’t burden your brain until executive functions are actually required. For these inconsequential items, try to create as many possible routines as possible. I really don’t want to use any of my processing power for these mundane musings; I want to save them for creativity and problem solving.

 
The second item is related to intrinsic cognitive burden. This is a major component, and the one I find hardest to minimize. First, you have to realize that there are two parts to your being: a physical part that executes movements and actions and a cerebral part that perceives and processes. Unfortunately, these two seem to be in constant battle with each other. Your cerebral part is constantly burdening you – the voice ruminating and contemplating – eliminate it so that it does not undermine what you desire.

 

Minimize your cognitive burden – both the extrinsic inconsequential happenings and the intrinsic personal trappings – so that in clarity you can fulfill your potential.

 

Medicine & Macula: Interesting article in JAMA on the resurgence of syphilis in the United States. Syphilis is caused by infection with the Treponema pallidum pathogen and can cause a myriad of systemic and ocular manifestations. While there were fewer than 4 cases per 100 000 by the year 2000, this has been increasing every year since that historic low.

The task force finds that there is net benefit of screening for syphilis infection in nonpregnant persons who are at increased risk for infection. Screening allows for identification of infected individuals which can then be treated. Treatment of early syphilis with single-dose intramuscular administration of penicillin G is highly effective and has the advantage of assured adherence and can prevent significant morbidity of untreated disease. After seeing multiple patients this week with syphilis, I am reminded of the need to increase awareness of this great masquerade!

Check out the study here

US Preventive Services Task Force.  Screening for syphilis infection in nonpregnant adults and adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. doi:10.1001/jama.2016.5824.

 

Gratis: Check out Timothy Gallwey’s The Inner Game of Tennis: The Classic Guide to the Mental Side of Peak Performance (where the opening quote comes from). This book is about much more than tennis and is a wonderful short read on cognitive clarity and enhancing your ability to reach your potential in any situation.

 

My best to you,

David Almeida

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wrong way

“The years teach much that the days never know.” Ralph Waldo Emerson

 

Task at hand: This week I’m thinking about negative outcomes. Times when life gives us the proverbial lemons… Surgery and life mirror each other in the interplay between action, reaction, and consequence. Sometimes – despite our best efforts, despite our best strategy, despite our best analysis of the situation – there are negative, untoward, unfavorable outcomes. In surgery, these are complications. In life, more commonly, these are hurdles and stumbling blocks that hinder our relationships and goals.

 

The question then, becomes, how do you effectively deal with these negative outcomes that invariably come our way?

 
There are three main attitudes that I use to deal with negative outcomes – whether they be in life or in surgery. First and foremost, do not over-react! What is done now is history, so you have to immediately start planning for the next step. The idea of not over-reacting is absolutely crucial, and almost guarantees your ability for damage limitation. You must stay calm, stay focused, and try to assess what just happened. In surgery, you will sometimes encounter a complication. If you are not careful, your rush “to fix” this first complication that instant, can cause you much bigger difficulties. I can’t stress this enough: the idea of not over-reacting is paramount.

 

 
This brings us to attitude number two: Take inventory of the perceived negative outcome. Is this a decision that’s been poorly executed? Have you offended someone? People tend to over-react and speak endlessly in these situations… Don’t do this! Instead, hold space. “Holding space” is a concept that I’ve come to appreciate. The idea is that you take inventory of the situation by actively listening and consciously processing information. You don’t have to say anything. You don’t have to do anything, but you have to consciously be there. For example, if someone comes up to you and says, “You did this wrong”, it’s very easy to get defensive; it’s easy to start talking, to start moving in a counter direction (usually defensive). Instead, try holding space. Hold that moment there, and you’ll see that the silence, and the pensive aspect has a powerful effect – it can diffuse tension and allow you to empathy in stressful momemnts.

 
The final one is – and I’ve said this before – plan and execute. This is always your go-to strategy. You have to plan. Then you execute. You have to develop a strategy, followed by its application. What was the negative outcome? Was there an unhappy patient? Was a co-worker offended in the way that you dominated a meeting? Was it a friend who feels abandoned? Whatever it is, you make a plan, and you execute the correction.

 
These are the three attitudes I have found to successfully mitigate negative outcomes. There’s no way to avoid conflict or complications: these are the crucible of character that you will encounter, undoubtedly, many times. The adage that calm seas don’t make for a skilled mariner – it’s the storm that brings it out – rings true. Remember: don’t over-react! Instead, hold space, and plan your escape.

 

 

Medicine & Macula: Interesting article in the open access journal, Medical Practice & Reviews, on Computer Vision Syndrome (CVS). It can affect anyone who spends three or more hours a day in front of computer monitors and – worldwide – up to 70 million workers are at risk for CVS (risk factors include prior ocular history and poor ergonomics). The most common symptoms include headache, eye strain, double vision, dry eyes (burning, foreign-boy sensation), and eye fatigue.

While a better understanding of the pathophysiology underlying CVS is necessary, I try to always remind patients that when you are in front of a monitor, you blink approximately one-third less than normal. Consequently, artificial tears and lubricating drops are excellent to maintain a happy ocular surface and the integrity of your cornea-tear film interface.

Check out the study here

 

 

Gratis: Our new case, Central retinal artery occlusion in a young HIV-infected patient on Highly Active Anti-Retroviral Therapy (HAART), has been published online ahead of print by Retinal Cases & Brief Reports. Thank you for all the positive feedback! Check out the paper here

HIV CRAO

 

My best to you,

David Almeida

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