“We have two ears and one mouth so that we can listen twice as much as we speak.” Epictetus

TASK AT HAND: This week I’m thinking about the silent act of listening. This underused skill serves us in two major domains.

MINIMIZE SELF-TALK Self-talk comes in many forms – from self-deprecating jabs to words of encouragements – but its utility is limited. More often than not, negative self-talk can give way to dejection and apathy. Instead of turning to self-criticism, look for opportunities to listen to mind and body. This requires inner silence which allows us to gain insight and appreciate our levels of apprehension, anxiety, excitement or joy.

The effort to be silent and to listen to our emotions is crucial if we are to be “in the moment”. The act of being present, requires stillness so that we reflect what our emotions are trying to communicate to us. I have never found self-talk to be of any help. As the quote from Bob Proctor so nicely states, “Don’t be a victim of negative self-talk – remember you are listening.” On the other hand, an ability to remain silent and control reactionary forces is always of use and can guide us through turbulent times.

HAVE COURAGE TO LISTERN TO OTHERS Listening is a difficult and challenging skill. It takes courage to listen to others. Winston Churchill writes regarding this pursuit: “Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen.” We have archetypes of action and heroism but, let us not forget, the strength it takes to listen to others. To collaborate and effectively communicate, there must be a desire to genuinely listen, with both attentiveness and care. By the sheer frequency of times we turn to smartphones during encounters, you can see a significant weakness in our ability to connect.

As a call to action, go out this week and fight the desire to interject and interrupt. Be silent and listen, and you quickly come to appreciate the wealth of knowledge available to you. At the very least, follow the words of Epictetus and aim to listen twice as much as you speak.


MEDICINE & MACULA: It was a real pleasure to be on the Savvy Business Radio Podcast! You can check out my interview, which aired on Thursday August 17, here.

We talk about decisions, procrastination and effective entrepreneurial platforms. Check it out as well as all the other excellent past episodes available.


GRATIS: Last Sunday (August 13) Citrus Therapeutics, cofounded by Eric Chin and myself, were selected as finalists for the inaugural ASRS Winning Pitch Challenge.

We presented rationale for our new early phase therapeutic, CTX1, a novel agent for the treatment of age-related macular degeneration. Although we did not win, we are grateful for the feedback and honored to be on stage with a diverse group of innovative retina specialists. The “Shark Tank” atmosphere with a fantastic panel of judges and investors was a lot of fun and we look forward to more in the future.

For more info, check out the Citrus Therapeutics website here.


My best to you,

David Almeida


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“The arousing of prejudice, pity, anger, and similar emotions has nothing to do with the essential facts, but is merely a personal appeal to the man who is judging the case.” Aristotle


TASK AT HAND: This week I’m thinking about the logical fallacy of appeal to emotions. This occurs when emotion is manipulated to win an argument. Rather than presenting evidence or facts, emotion is used to persuade a desired viewpoint. In this fallacy of argumentum ad passions, emotion is used to weaponize opinion in place of reason. Consequently, the resultant logical construct lacks validity.

“Appeal to emotions is a logical fallacy that occurs when emotion is used to weaponize opinion in place of reason, resulting in argument without validity.”

Here is an example from the good folks at logicallyfallacious.com“X must be true because imagine how sad it would be if it weren’t true.” In reality, sadness has nothing to do with the statement for X being true or not because statements cannot, in of themselves, be sad (or happy). This fallacy is easy to spot because it will invoke emotions (e.g., sadness) for a belief in place of evidence.

Another example. Politicians argue that if you vote for their opponent, their opponent will cut programs that keep you safe. The appeals to fear and safety are being manipulated. Or, one we have all seen, commercials asking you to donate money as they show you a natural disaster or a scene of poverty. Now, there is absolutely nothing wrong with helping people after an earthquake or in desperate need; on the contrary, go out and help the downtrodden! But, as far as an argument goes, what you should be considering is the charitable organization, how much of donated funds actually get to the program in question, how well positioned the organization is for outreach in the affected area, etc. Emotional appeal distorts the argument because it preys on our desire to want to agree with a vantage point.

The use of emotion and persuasive language is a deceitful approach to discourse and seeks to succeed on the back of an emotional-based strategy. Don’t get emotional! Emotions are highly personal and, as grounds for an argument, cannot be verified. The biggest perpetrators are appeals to the negative emotions of fear, anxiety, anger and sadness and the positive emotion of hope. These are emotions we strongly associate with and thus create an opportunity for exploitation by those seeking to sway us.

On today’s Sunday Surgical Scrub, the call to action is to recognize that emotions are powerful and can evoke great appeal to your argument; however, it must be in the context of logic and evidence. Together, evidence and emotion are superlative. But, without evidence, you have a baseless appeal to emotion that is devoid of real meaning.


MEDICINE & MACULA: I’m at the American Society of Retina Specialists (ASRS) 35th Annual Meeting in Boston this weekend.

Later today, we will be presenting one of our studies: “Efficacy of Intravitreal Sustained-Release 0.7mg Dexamethasone Implant For Diabetic Macular Edema Refractory to Anti-VEGF Therapy: Meta-Analysis”. Alexander Ringeisen, first year vitreoretinal surgery fellow at VRS, will be presenting. Many thanks to our coauthors Zainab Khan, Robin Kuriakose, Maryam Khan and Eric Chin. This study provides further insight into the benefits of multi-modality therapy for diabetic macular edema, the most common cause of vision loss in working age individuals.


GRATIS: Also later today, Eric Chin and I – cofounders of Citrus Therapeutics – were selected as finalists for the inaugural ASRS Winning Pitch Challenge.

This will take place in the main auditorium and we will be presenting our new therapeutic, CTX1, a novel agent for the treatment of age-related macular degeneration. Stay tuned for updates!



My best to you,

David Almeida


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“Things are not quite so simple always as black and white.” -Doris Lessing


TASK AT HAND: This week I’m thinking about the concepts of moral relativism and moral absolutism.

Let me digress for a few sentences.

This past Wednesday, I was watching one of my kids play soccer and intrigued by how little the score and the eventuality of a “winner” or “loser” was to the kids playing. Sure, they understood that whatever team scored the most goals was the winner, but the purpose of the event was beyond the outcome of a binary winner and loser.

Moral absolutism refers to a set of ethics or principles that are fixed in time. In this system, there are principles that are always right or wrong and beyond debate. There is always a winner or loser based on defined criteria. Contrasting, moral relativism holds that nothing is intrinsically right or wrong, black or white; winner or loser depends on context. To the relativist, circumstances are crucial to uncovering the character of a person or conflict.

The debate between absolutism and relativism – whether it be philosophical or cultural – is centuries old, and despite our best efforts, we will not solve it here. Instead, the goal for today’s Sunday Surgical Scrub is to make you aware of these powerful differing views that permeate significant portions of our headspace.

On the one hand, the pursuits of life are beyond simply a winner and a loser. Limiting yourself to transactional interactions risks being devoid of fundamental insight into the machinations of motive and meaning. However, at the same time, one must be weary of having no absolute ideals and default to rationalizing any act. The latter has been the calling card of many oppressive societies.

“Limiting yourself to transactional interactions risks being devoid of fundamental insight into the machinations of motive and meaning.”

So, what do we do?  

In my opinion, the sanguine approach is to beware the limits of binary absolute outcomes and embrace the diversity of relative viewpoints. This allows to circumvent the curt effect of a black and white world while at the same time still allow for the questioning and query essential for a just existence.

Agree? Disagree? Let me know.


MEDICINE & MACULA: Many thanks to the Journal of VitreoRetinal Diseases and the American Society of Retina Specialists for publishing one of our recent reports, West Nile Virus Chorioretinitis With Foveal Involvement: Evolution of Lesions on Optical Coherence Tomography (Gary L. Yau,  Eric K. Chin,  D. Wilkin Parke, Steven R. Bennett & David R. P. Almeida).

It was published in the March 2017 issue of the journal and describes the clinical course of foveal West Nile virus chorioretinitis.

You can find the publication here.


GRATIS: “Changing the game is a mindset.” -Robert Rodriguez


My best to you,

David Almeida



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“I’m a culture vulture, and I just want to experience it all.” -Debbie Harry


TASK AT HAND: This week I’m thinking about what it means to be a culture vulture. This is a term that I have comes to admire with great esteem! I was born in Portugal, grew up in Canada, did a PhD in Hungary, an MD in Canada, and an MBA in the USA. I did my vitreoretinal surgery fellowship in Iowa and now I am proud to be part of VitreoRetinal Surgery, PA and call Minneapolis-St Paul, Minnesota my home.

Throughout this extended journey, I have had the privilege of experiencing different cultural mores and philosophies. Some that I like and some that I don’t. Parts which I emulate and others I prefer to distance myself from. This has been a wonderful and expanding learning experience allowing me appreciation of cultural breadth. Needless to say, over the years, I have enjoyed being a culture vulture!

Within the Urban Dictionary, one of the  definitions of a Culture Vulture is “a person who loves art, music, movies, and dance, and all forms of culture so much that they consume whatever they find.” The consumption of culture is a bona fide way to open yourself to a myriad of experiences.

Now, there is one issue that we must note; the mass consumption of culture can be confusing if you curate without context. While I have no issue with exposure to all forms of art or culture – both good and bad – you still need to be cognizant of that which you are incorporating into your practices. A degree of discernment, a slice of skepticism, query and questioning always need to be present.

As we close out the month of July, here in the western hemisphere, we find ourselves in the depths of summer. In this season of sun and adventure, I encourage you to enjoy the rest of the summer and be a culture vulture! Go out experience a wide range of contexts. Curate experiences outside your comfort zones. Take bites of the extensive palette in front of you.


MEDICINE & MACULA: A special thanks to Dr Parnian Arjmand MD, a senior ophthalmology resident from the University of Ottawa (Ottawa, Ontario, Canada). She visited us here at VitreoRetinal Surgery, PA in Minnesota in July for a research elective. Dr Arjmand analyzed outcomes in challenging cases of proliferative vitreoretinopathy (PVR) which is an ongoing active area of study for us. Additionally, she collaborated on developing a novel vitreoretinal surgical technique for optic pit maculopathy. We will keep you posted on the exciting findings from these studies!


GRATIS: “If your friend is already dead, and being eaten by vultures, I think it’s okay to feed some bits of your friend to one of the vultures, to teach him to do some tricks. But only if you’re serious about adopting the vulture.” Jack Handy (Deep Thoughts)


My best to you,

David Almeida


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“The light obtained by setting straw men on fire is not what we mean by illumination.” ―Adam Gopnik


TASK AT HAND: This week I’m thinking about the straw man fallacy. This is one of the most common logical fallacies that I see occurring in media, television, social commentary and public discourse. Touching everything from science to religion, entrenched in politics and ethics, the straw man fallacy is a hurtful and dishonest approach to discussion.

The straw man fallacy occurs when someone attempts to rebut a discussion by diverting the argument to an unrelated topic. For example, someone purports that A leads to B. The other person then attacks by bringing forth argument C. The perpetrator of the straw man fallacy, instead of opining about the argument that A leads to B, attacks position C which us unrelated and designated as the “straw man”. In practical terms, the straw man fallacy causes gross distortion of the original position by misrepresenting it with another point.

“In practical terms, the straw man fallacy causes gross distortion of the original position by misrepresenting it with another point.

I am disenfranchised by how often I see individuals attack straw man with loud voices, distasteful words, and erroneous opinions. See, the problem is, people love to attack the straw man because the straw man does not fight back. It is unrelated to the original argument which sometimes catches the first person off guard. Now, the attacker of the straw man proclaims victory in the argument but, all the while, not realizing that the straw man attack is unrelated to the original position. In actuality, the original argument is untouched by the gauche comment.

It is important to realize that, at times, there may be nothing wrong with the argument created by the one attacking the straw man – it might be correct or accepted as fact. However, it is unrelated to the original argument and therefore lacks correct context. The straw man fallacy is an easy logical fallacy to catch and many times takes the form of a counterargument beginning as “well, how about…” or “but, how about…”. What frustrates me most is the few times this logical fallacy is called out.

Now, how can this help your strategy?

When you are faced with someone attacking the strawman, DO NOT shift to their argument. Call out the fallacy, and return the discussion to the original topic. You must avoid the incredulous feelings that give rise to perplexing anger. Simply call out the fallacy and redirect them to the initial point.

This simple tactic will exhaust the ability of your counterpart to attack the straw man by diverting the discussion to the original point. The burden of proof is not on you to defend the straw man because he has no place in the argument. Your gamesmanship is to re-direct the argument to the proper context. Do not fall victim to the straw man!


MEDICINE & MACULA: The power of placebo is a real effect! A 2014 knee pain study found that 74% of patients who underwent placebo knee surgery described deriving some benefit. This was as effective as the actual elective surgery about 50% of the time. The routine of fasting, anesthesia, fake incisions – independent of actual surgery – seems to have a dramatic effect in patients undergoing elective surgery.

FiveThirtyEight.com has a fantastic piece on this (check it out here). You can find the study, Use of placebo controls in the evaluation of surgery: systematic review (BMJ 2014;348:g3253) here.

Sham or placebo surgery is a controversial topic in medical ethics but studies like this show that, without well designed placebo controlled trials of surgery, ineffective treatment may continue.


GRATIS: “A straw vote only shows which way the hot air blows.” -O. Henry


My best to you,

David Almeida


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“If ever it’s necessary to ride the bandwagon, it’s done with one leg swinging out and eyes scoping the fields.” ― Criss Jami (Killosophy)


TASK AT HAND: This week I’m thinking about what it means to jump on the bandwagon. The phrase is from the mid-nineteenth century and attributed to Phones T Barnum who, as a circus owner and showman, would urge audience to jump on the wagon that carried the circus band (a literal bandwagon). In the modern lexicon, “jumping on the bandwagon” usually refers to individuals supporting a person, team, idea or activity after it is popular or successful.

There is nothing wrong with supporting a movement or idea; in fact, you should curate movements that align with your mores, challenge your beliefs, and allow you to develop as a thoughtful creature. My issue with the pursuit of merely popular or successful people or ideas is that they limit your ability for independent thought. To join a collective for the mere sake of popularity, limits choice, and aggrandizes mass effect.

There is convenience in joining a bandwagon. There is instant common ground that, while at times merely superficial, allows connection and fabric to take hold. But, and you know how I fell about convenienceit breeds complacency – and this is where trouble begins. As you become complacent, history shows us with a multitude of examples that it becomes easier to succumb to groupthink and lose objectivity amidst the loud voices of a large group.

Be wary of bandwagons and, as the existential philosopher Criss Jami so nicely summarizes above, if you must ride a bandwagon, do so with one leg out the cart and be ready to move. Look for a landscape that challenges you as an individual. Realize that autonomous pursuit is lost on the backs of most bandwagons.


MEDICINE & MACULA: Check out one of our recent publications, Novel Technique for Submacular Hemorrhage Removal Using 27-Gauge Pars Plana Vitrectomy and Recombinant Tissue Plasminogen) Activator (Kunyong Xu MD MHSc, Eric K Chin MD, John B Davies MD & David RP Almeida MD MBA PhD).

Many thanks to the Journal of VitreoRetinal Diseases for publishing our work!

You can find the study here.


GRATIS: “If you see a bandwagon, it’s too late.” -James Goldsmith


My best to you,

David Almeida


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“Nothing’s beautiful from every point of view.” -Horace

TASK AT HAND: This week I’m thinking about points of view. Perspective is the context for processing information. Very little – if anything – is black and white. Actions and consequences rarely exist in a vacuum. Instead, there is nuanced context to words in a conversation, lines on a page, and in the decisions we act out.

We have previously talked about perspective here on the Sunday Surgical Scrub (March 2017) but, today, we are going to go beyond defining perspective and I will present 3 pearls to points of view that you need to consider for effective strategy.

1) Sensitivity Requires Perspective. Being aware of differing points of views provides sensitivity to the fact that we are all different people, from different cultures and with different mores. Sensitivity, and the ability to detect differences, aligns with one’s ability to be cognizant of diversity. Looking at a situation from the perspective of another, is empathetic and contributes to the fostering of collaborative relationships.

2) Do Not Substitute Perspective for Understanding. There is a strong desire, due to the bias of rationalization, to bend perspective to “fit” with your own thoughts and actions. Avoid this! Look to differing points of view as an empathetic tool but do not distort strategies to fit your unchanging perspective. “A point of view can be a dangerous luxury when substituted for insight and understanding” (Marshall McLuhan). The later quote is essential learning because we must remind ourselves that perspective can both help or hinder our understanding of actions. Cataloging the different points of view relevant to a certain situation are only one component of understanding.

3) Find the Vantage Point. It is possible to, when considering points of view, to ascribe to a perspective that is clear and concise. This is the Vantage Point. Vantage simply means a positon affording a good view. Think of the vantage point as a position of balanced and informative perspective; the point of view uncluttered by bias and most free of rationalization.

Try to find the vantage point of a conflict as a means to ascertain the key variables for all the parties involved. Find the vantage point for a decision you are pondering to offer you the needed perspective of consideration and avoid the collusion of bias that is so tricky whenever points of view come into play.


MEDICINE & MACULA: Many thanks to Judy Hoberman for having me on the Selling In A Skirt radio show! Judy has incredible insight into the gender differences that we should all understand and embrace instead of feeling unable to communicate about. We discussed entrepreneurship, my book Decision Diagnosis and, of course, gender differences.

You can find our July 2017 episode here.


GRATIS: “Men are disturbed not by things, but by the view which they take of them.” -Epictetus


My best to you,

David Almeida


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“Beware the barrenness of a busy life.” -Socrates

TASK AT HAND: This week I’m thinking about “the busy life”. When I ask friends how they are doing, the most common answer I get – irrespective of whether they work in medicine, business, entertainment or sports – is: “busy!”.

How’s the day going? -Busy!

How was the weekend? -Busy!

How’s the week looking? -Busy!


I hear it so much, I am reminded of this Henry David Thoreau quote multiple times a day: “It is not enough to be busy. So are the ants. The question is: What are we busy about?”

Our language has a powerful effect on how we frame our relationships and strategy. Descriptors, like “busy”, create a disconnect from actions we perform. One is less able to extract meaning from an act that is defined in an impersonal manner such as “busy”. For the descriptor of “busy”, a strategy is simply to finish the event. Unfortunately, this is a rudimentary process because, in the end, what have you achieved? Completed a busy day? Almost always, the tasks have much more meaning that simply of being “busy”. You are living more than just a “busy life”.

For example, I see patients and perform surgery. There are days with more patients than others, some days with more complex cases, etc. I have three fantastic kids under 6 years old. Some days are marathons while others are sprints. Some days I enjoy the hectic pace while others I like the pauses for reflection. If I am left describing each of these different days as a homogenous “busy”, there is the deleterious effect of disconnecting me from what it is I am doing during those very different days. Instead, if you re-frame how you look at these “busy” actions, you can open the door to more engagement.

The call to action on today’s Sunday Surgical Scrub is to avoid using the word “busy” as a descriptor. Re-frame how you look at your tasks and actions.

How was your day? -It was a day with challenges that required me to…

How’s the week looking? -I’m looking forward to…

By simply changing the language you use to describe what you do or how you go about your days, has a demonstrative effect on your level of engagement. This approach allows you greater insight into managing challenges and resolving conflicts.


MEDICINE & MACULA: A few months ago, I had the privilege of being on a panel looking at best practices of the surgical technique of the dexamethasone intravitreal implant (Ozurdex). These events always remind me how much I learn from my wonderful colleagues. Many thanks to Seenu M. Hariprasad MD, Kimberly Drenser MD PhD, Sunir Garg MD and Bruce Saran MD!

For those interested, check out the publication here.


GRATIS: Happy Canada Day! Happy Independence Day!


My best to you,

David Almeida


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“Adulthood brings with it a pernicious illusion of control.” Juan Gabriel


TASK AT HAND: This week I’m thinking about control. The desire for control is commonplace and, overall, we hope to exert positive or beneficial control in the actions and events that take place in our lives. The hope is that we can “guide” strategies towards desired outcomes. Control becomes a surrogate for ends and outcomes.

You can see this is a reasonable and somewhat rationale thought process. However, let me introduce you to the cognitive bias of the illusion of control. This is a habit where we overestimate our ability to control events. The effect is named by psychologist Ellen Langer and has been demonstrated in numerous different experiments.

“The illusion of control is a type of cognitive bias where we overestimate our ability to control events.”

As we find ourselves in stressful and competitive situations, this type of bias increases significantly. Sports are common examples where a participant “believes” that he or she can make the basket or score the goal. In reality, once that ball leaves the shooter’s hands or launches from their foot, all control is foregone. There is no control that can be exerted beyond that action. Another example is financial markets where an investor is “sure” they can make a profit on a particular trade. For the latter, he or she has almost zero control over the outcome of that stock price or bond dividend.

So, what does this mean for our strategies and plans?

Do we just relinquish all control?

No, as with all types of biases, we need to learn to detect it and minimize it’s deleteriously effects. For the illusion of control, one can overcome this type of bias by focusing on processes rather than prediction of outcomes. I like reminding myself of the adage, “the ends do not justify the means”, to realize that I cannot control ultimate ends but I can influence the means and processes via a conscientious connection with acts. This liberates you from the stress of trying to control the outcome and allows you to deliver the best possible action or strategy. Try it!


MEDICINE & MACULA: Many thanks to Jim Beach (@entrepreneurjim) for having me on the School for Startups Radio! Jim’s philosophy on entrepreneurship is refreshing and you can hear me on his June 22 episode here.


GRATIS: “If everything seems under control, you’re just not going fast enough.” -Mario Andretti


My best to you,

David Almeida


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“Nowadays I don’t want a perfect face and body – I want to wear the life I’ve lived.” Pat Benatar


TASK AT HAND: This week I’m thinking about scars. We normally think of scars as negative manifestations of past trauma. Sequels of serious harm. Instances where circumstances went beyond our ability to repair and restore our normal constitution. Whether they be physical, psychological or spiritual, scars are commonly unwanted tattoos of dramatic life events.

But this view is nearsighted.

As the insightful Pat Benatar quote echoes above – you, your body, your face and your smile – are reflections of the life you live. The scars you collect speak volumes of the miles you travel, the milestones you achieve, and the pain you reconcile. These are, whether negative or positive, the greatest hits of your life. The scars you collect are essential elements of your constitution; consequently, they should be celebrated for, so strong an effect they have, they change you forever.

“The scars you collect speak volumes of the miles you travel, the milestones you achieve, and the pain you reconcile.”

Don’t hide from your scars! There is no need for that “perfect face and body” Benatar alludes to above. Instead, embrace scars, imperfections, and stains. Actually, let me go one more: welcome the opportunity to develop new scars! Challenge your character and choices in ways that provide opportunities for personal growth and the ability to foster new relationships.

When life pushes you, push back.

When you are held down, the only next move is to get back up.

When you are questioned, answer in the affirmative. Answer without fear of scars.


MEDICINE & MACULA: Check out one of our recent publications, Dysfunctional Autonomic Regulation of the Choroid in Central Serous Chorioretinopathy by C Nathaniel Roybal, Elisabeth Sledz, Yasser Elshatory, Li Zhang, David RP Almeida, Eric K Chin, Brice Critser, Michael D Abramoff & Stephen R Russell.

It was published in the June 2017 issue of RETINA. You can find the study here.

We describe the effect of changing perfusion pressures on retinal and choroidal structure in central serous chorioretinopathy (CSC). In this study, we found that choroidal thickness increased in response to increased perfusion pressures in patients with CSC and not in normal controls. These findings likely represent an autonomic dysregulation of choroidal blood flow in patients with CSC.


GRATIS: Happy Father’s Day to the selfless individuals who, without fear, serve as mentors and role models!


My best to you,

David Almeida


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