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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mnfl final

Task at hand: This week I’m once again thinking about decision making; specifically, decision analysis and how to achieve success in your decision making process. As you know, I like to borrow from the spheres of medicine, science and business when constructing my models and frameworks. When diagnosing a patient, physicians will investigate “associated factors” –  what are the related symptoms, history, or other issues that may be contributing to the suspected underlying diagnosis? Similarly, when looking at the decision or conflict at hand, spend some time deciphering the associated factors. These are always pertinent to the outcome you are trying to achieve.

 

Let me use a simplified example for you here. With spring in full swing, let’s say you are trying to decide on a particular plant for your garden. Our simplified desired successful outcome of this decision is to pick a plant that will not only grow – but thrive – through the seasons. Consequently, we can quickly deduce that the “associated factors” will include environment (weather, rain, soil quality), resource availability (how much time do you have to tend to the plant, what is your budget for seed), and appearance (do you want a pretty flower or a unique plant).

 

The best method I have found to uncover the associated factors of a particular decision is through visualization. The concept of “visualization” is common ranging from sports to cognitive-behavioral therapy. Here, I am ascribing visualization as an act to appreciate all the forces acting on your decision. I’m always surprised at how much I uncover through this process and realize that our decisions are heavily indebted to a lot of extraneous influences: it is usually not possible to remove these factors so one would be wise to figure them out!

 

I actually use a lot of visualization in surgery as well – many times, the surgeon’s view is compromised secondary to many possible factors. In these challenging instances, my visualization of the problem at hand and the role of my immediate environment allow me to continue without being deviated in a negative manner. So, next time you are pondering a difficult conflict – visualize the relevant associated factors – and give yourself some clarity on your way to success!

 

Medicine & Macula: The first US universal newborn ocular screening initiative was recently published in the journal Ophthalmology. It showed that fundus hemorrhages are common in healthy newborns, especially in those born by vaginal delivery (9 times more likely) and in forceps assisted delivery. While the long-term consequences of retinal hemorrhages on visual development remain unknown, it is important to have empirical knowledge that these are common. The issue of child abuse and shaken baby syndrome are a natural extension of this topic, and key points of differentiation (vitreous hemorrhage, retinal hemorrhages in multiple layers, traumatic retinoschisis) in the latter need to be emphasized.

Check out the study here

 

Gratis: Thanks to American Journal of Ophthalmology Case Reports for recently publishing our study on Delayed fungal endophthalmitis secondary to Curvularia.

Curvularia

Check out the paper here

 

 

Happy Memorial Day!

My best to you,

David Almeida

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choroidal rupture

Task at hand: This week I’m thinking about strategy. We all have some strategy – some series of actions we employ to achieve a desirable outcome. One question that I am frequently asked is, “What makes a strategy successful?” My answer usually is, “If it works, it’s successful!” I am joking, but only half so. Ultimately, your strategy has to work and you have to achieve your goals; otherwise, I would seriously consider switching strategies.

In today’s Sunday Surgical Scrub, I’m going to give you my two tenets of any successful strategy: Planning and Execution. I plan like an economist, but execute like a surgeon. In planning, you have to employ some sort of analysis; whether it’s a simple pro/con list or a formal SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis, you have to bring your decision out of your personal vacuum and into context and consequence. Then, when all planning is done, go out and execute it. A personal example for me is in surgery where there is absolutely no time for uneasiness or hesitation – one has to fix the problem at hand – and it has to work! Similarly, when you have devised your plan, go and execute! I don’t much care for extraneous pressures when the time for action has arrived.

Critiques I have heard of this strategy is that it lacks a “reactionary” component when the environment changes. My response to this query is that I will take a good decision today over a perfect one tomorrow every time (thanks General Patton!). I know too many smart and gifted people who have become trapped by the creation of the perfect plan. Napoleon Bonaparte wrote: “Take time to deliberate, but when the time for action has arrived, stop thinking and go in” – this beautifully summarizes the strategy.

So, no matter what goal you are trying to achieve, I say Plan and Execute! Don’t let time from one deviate the path of the other.

 

Medicine & Macula: A JAMA study released this week showed exercise is great at cancer prevention! The National Cancer Institute confirmed that exercise lowers the risk of many types of cancers. The study looked at 26 types of cancers in 1.44 million people and found that leisure-time physical activity was associated with lower risks of many cancer types. It is important to emphasize that most of these beneficial associations were evident – regardless of body size or smoking history – and thus should be encouraged for most people.

Check out the study here.

 

Gratis: Last week we launched the new website, davidalmeidamd.com, and I want to thank everyone for their support! Thanks to all the emails and interest in my research, speaking, medicine/ophthalmology/retina, and leadership – it was the main driver for the creation of the website. Let us now go and innovate together!

 

Always feel free to drop me a line with feedback or questions.

My best to you,

David Almeida

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Task at hand: This week I’m thinking about decision making, problem solving and conflict resolution. Before making any decision, you need to properly define or characterize what that decision is. In medicine, when elucidating a problem from a patient, a physician commonly describes the “character” of the problem; for example, what is the character of the pain? Is it a dull ache, sharp pain, or boring soreness? Continue reading Sunday Surgical Scrub: May 15, 2016

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Task at hand: This week I’m thinking about actions and experiences after being reminded of the Oscar Wilde words: “Experience is the name everyone gives to their mistakes”. In living one’s life, there is perhaps no better barometer of engagement than the merriment of the experiences one amasses over time. Fear of mistakes or failure are never an adequate reason to shy away from an experience that may allow us to learn and grow. In fact – seek out experiences that are outside of your comfort zone regularly – and you will be rewarded multiple fold. I have come to appreciate that, fear of mistakes is nonsensical, and instead, I urge myself to ask questions and then to test them in the many spheres of life. An empirical life allows the days to become a series of experiments and life a collection of experiences. Continue reading Sunday Surgical Scrub: May 8, 2016

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“Before each and every case, a surgeon scrubs and disinfects his hands. At the same time, he or she becomes solely focused on the task at hand – preparing to navigate a complex surgical path – and ready to confront any difficulties that lie ahead. Here, on the Sunday Surgical Scrub, I bring you what I’m pondering for the week ahead.”

David Almeida MD MBA PhD

Task at hand: This week I’m thinking about how we, as humans, interact with our environment. A large study of over 2000 participants found that the average human has an attention span of 8 seconds; contrastingly, this was 12 seconds in 2000 before the smartphone revolution. For comparison, goldfish are believed to have an attention span of 9 seconds. Many will argue that our ability to multitask has improved so these 4 seconds lost may not be as significant. Continue reading Sunday Surgical Scrub: May 1, 2016

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