Sunday Surgical Scrub

“Asynchrony – relationships occurring at unrelated times – offers the opportunity to thrive amidst change and turbulence.”


TASK AT HAND: This week I’m thinking about the concept of asynchrony. Asynchrony is a common term in computer science where it refers to events occurring at different times that are independent of the primary program. In biology, asynchrony pertains to the ability of a species to fluctuate in their evolution over time. As Bluthgen and colleagues have shown, asynchrony affords animal or plant communities the ability to fluctuate beyond biological diversity (Nico Bluthgen, Nadja K. Simons, Kirsten Jung, et al. (2016) Land use imperils plant and animal community stability through changes in asynchrony rather than diversity. Nature Communications 7, 1069. doi:10.1038/ncomms10697). The authors write: “The more the species in an ecosystem fluctuate in their evolution over time, the less they are likely to falter.” Think of these fluctuations as asynchronous behaviours.

So, what is the relevance of asynchrony for us here on the Sunday Surgical Scrub?

I define the term of asynchrony as relationships occuring at different times. These relationships may not be apparent because of their disparate temporal profiles; i.e., they do not occur at predictable times. Like a plant that can fluctuate its uptake of solar energy depending on its external conditions, your ability to act asynchronously with your environment can provide you with a strategic advantage when encountering complications or conflicts.

For example, take a situation where someone submits a work or community proposal and that proposal is met with resistance or outright denial. A synchronous response would entail countering with similar resistance amidst negotiation. This is a reasonable approach and appropriate in some circumstances. However, one could also try responding with an asynchronous strategy such as delayed deliberation. This will create a window of time that may, in turn, change the circumstances of how your proposal is met. Please note that this is not simply procrastination or delay for the sake of delay. Instead, you will alter your plan or proposal over a longer timeline so as to align with changing factors that may improve your chances of succeeding in your ultimate pitch.

Take another example; let us assume you have multiple investments and the market bears significant losses. A synchronous response would be to pull out and sell before you incur further losses. Instead, an asynchronous response would entail diversifying your portfolio to have a more robust defense against further market losses. By diversifying, you are responding with a relationship that will be most relevant to a later time frame when the market changes.

As you consider the varied applications of strategy, be on the lookout for the opportunity to utilize asynchrony. Look for diversity and relationships over courses of time that may appear to be unrelated. This will afford you greater stability towards success in your overall goals.


MEDICINE & MACULA: Many thanks to Don Hutcheson for having me on the fantastic podcast, Discover Your Talent–Do What You Love. I was featured on the episode, More Effective Decision Making, that went live Friday, June 2.

Check out Episode 512, Expert Interview: More Effective Decision Making with David Almeida here.

You can access the podcast, my episode 512, and show notes here.

The website page of Discover Your Talent can be found here.


iTunes (episode 512) is here.

Stitcher (compatible with Android phones and all computers) is here.


GRATIS: This past week, on Tuesday June 6th, I had the privilege of being part of a terrific panel of vitreoretinal surgeons in Dallas-Fort Worth looking at complicated surgical cases. There were terrific videos and discussion and I had a great time seeing outstanding colleagues. I contributed a video on proliferative vitreoretinopathy which, as many of you know, is a serious academic interest of mine.


My best to you,

David Almeida

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“Be aware.

Aware of who you are.

Aware of your surroundings.

Aware so that you may understand how to act.”

TASK AT HAND: This week I’m thinking about awareness. What does it mean to be aware?

Take the simple picture above of an animal and their surroundings. Is there awareness of self, of season, of a hunter in the distance? Or is awareness less complicated and a function of assuming the emotion of the moment?

From my vantage point, awareness is “situational knowledge”; i.e., insight into an instance in time.

“Awareness is situational knowledge.”


There are 3 types of awareness needed for self-realization, understanding and the application of successful strategy.


First and foremost, you must be aware of yourself. What are your core beliefs? What are you in pursuit of? What mores and values do you ascribe to?

This is a non-negotiable aspect of awareness. You absolutely need to know this because this will function as the compass of your life. It will guide your actions through conflict, it will instruct your decisions when pondering questions, it will be your strategic Virgil as you navigate the circles of life.



Second, you must be aware of your surroundings. Without knowledge of the space you occupy, you risk disconnection from your environment. Your environment includes everything from physical objects, to geography, to people. Proper awareness of your surroundings will allow you to be considerate and conscientious of how you move through space. Your impact on relationships are very much a part of your environment. Lacking awareness of this fragments our bonds and hinders our ability to mature our contact with the world around us.



Finally, aware of concept relates to how we apply knowledge. For example, understanding a concept or piece of information and successfully applying it are two very different items. Many times, you will see examples of individuals having correct conceptual understanding but failing in application. These examples occur in personal relationships, business strategies, and political undertakings.

In my opinion, to take a concept, and then successfully apply it requires awareness. You need to be aware of yourself, your environment, and how the knowledge in questions must be applied. This is analogous to working “in context”. If you are out-of-tune or lack situational knowledge – if you lack awareness – I doubt you will be able to successfully apply a concept through application.


So, the call to action on today’s Sunday Surgical Scrub is seek awareness. Constantly evaluate the multi-dimensional matrix of awareness in the spheres of self, environment, and concept to best guide your actions and strategy.


MEDICINE & MACULA: Many thanks to Michael Brun for showcasing me in the Woodbury Bulletin. You can check out the article entitled, A cure for procrastination: Surgeon combines diverse background in decision-making framework, here.


GRATIS: “That’s the biggest gift I can give anybody: Wake up, be aware of who you are, what you’re doing and what you can do to prevent yourself from becoming ill.” -Maya Angelou


My best to you,

David Almeida

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“The gastrointestinal system has over 100 million neurons. This “second brain” has more neurons than your spinal cord and is similar in number to the brain of a dog.”


TASK AT HAND: This week I’m thinking about “trusting your gut”. Although a cliché statement, there is real basis for its utility. Our gut is the home of our enteric nervous system; a collection of over 100 million neurons that function as an interface with the outside world by carefully interacting with that which enters our alimentary tract.

Humans are complex creatures. Of this, our gut is an incredibly complex component. It needs to be emphasized that such a nervous system goes beyond simply digesting food. The enteric nervous system, also known as the “second brain”, is constantly feeding you information about the outside world. If you are willing to listen, it can serve as a confidant for the interpretation of complex emotions and communications.

“The second brain is constantly feeding you information about the outside world. If you are willing to listen, it can serve as a confidant for the interpretation of complex emotions and communications.”

One can take a deep dive on the enteric nervous system in a myriad of ways. From the digestion of food, to neurotransmitter functions, to the gut bacterial environment that is crucial for homeostasis, to gastrointestinal immunity functions, there are countless books on topics that are beyond the scope of the Sunday Surgical Scrub. What I want to focus on today is your gastrointestinal tract and enteric nervous system as a strategic interpreter for decision making. This may initially seem haphazard, but allow me to explain.

Intuition, which I define as immediate comprehension without reasoning, is an integral part of decision analysis. There will be instances when, despite carefully organized analyses and sound reasoning, the correct decision may remain hidden. The preferred path, in these instances, requires you to remain connected to your second brain as a means of gaining further input. Learn to trust your gut and follow your intuition. We all know what this feels like. The “butterflies” of excitement, the shallow queasiness of apprehension, the disgust at the pit of our stomach from a wrong path taken. These are feelings we have known long before we could reason complex arguments.

How do you hone the ability to focus on what your intuition and gut are trying to tell you?

There are several techniques that one can use to centre on what our gut feelings are telling us such as meditation, sleep, journaling. However, one I really like to use is the act of distraction. At times, we can become entrenched in analyses such that we become susceptible to tunnel vision and bias. At these times, we can rationalize the wrong decision surprisingly easily. If you need to connect with your gut, distract yourself with some physical activity, music, or even a nap. This will serve to refresh the connection between your first and second brains with respect to the conflict in question. There is an essential, evolutionary-tuned survival need to trust our intuition. Trust and follow your gut!


MEDICINE & MACULA: Many thanks to Dr. Jay Sridhar, creator and host of the fantastic podcast, Straight From The Cutter’s Mouth.

I was a recent guest on his show and had a wonderful time discussing retina, work-life balance, social media and my recent book Decision Diagnosis. Check out Episode 44: More Social Media with Dr. David Almeida.

You can find the episode here.

You can also check out the Straight From The Cutter’s Mouth website, blog, other podcast episodes and more here.


GRATIS: “You’ve got a song you’re singing from your gut, you want that audience to feel it in their gut.” Johnny Cash

My best to you,

David Almeida

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“In the pursuit of happiness, the stairway is an illusion and the steps dreams, that convince us that more happiness in just steps away. In reality, it functions more like a treadmill, keeping you in place despite a lifetime of paces.”

TASK AT HAND: This week I’m thinking about the hedonic treadmill theory, which I usually refer to as the hedonic stairway. Simply surmised, the idea is that the pursuit of happiness is akin to a person walking on a treadmill. You keep walking, but stay in the same place. More steps does not equate to more happiness.

The “Hedonic Treadmill” was coined by Brickman and Campbell in their article “Hedonic Relativism and Planning the Good Society” (Brickman; Campbell, 1971, Hedonic relativism and planning the good society. New York: Academic Press. pp. 287–302. in M. H. Apley, ed., Adaptation Level Theory: A Symposium, New York: Academic Press).

In this seminal paper, the authors describe the tendency of people to keep a stable baseline level of happiness despite positive or negative external events. From the work of Brickman and Campbell, they interviewed 22 lottery winners and 29 paraplegics with the aim of assessing change in happiness levels after the life changing events of winning the lottery or becoming paralyzed. The authors found that the group of lottery winners reported being similarly happy before and after the event, and expected to have a similar level of happiness in a couple of years. They found that the paraplegics reported having a higher level of happiness in the past, a lower level of happiness at the time of the study but – surprisingly – they also expected to have similar levels of happiness in a couple of years.

What can we take away from these results?

For the most part, individuals can expect to have the same baseline level of happiness irrespective of quite drastic, dramatic and different life events. The effect of a large monetary gain had no effect on baseline level of happiness for both the present and the future. In the paraplegic group, although there was an initial decrease in happiness, they too expected to maintain or return to the same baseline level of happiness for the future.

How can we use this for our development and strategies?

Awareness that, at least with respect to the pursuit of happiness, more steps you take on the hedonic stairway, will not grant you any additional happiness. Striving for that next promotion, a new car, or even great personal gain or loss, does not seem to alter your baseline level of happiness. Does this mean we should avoid these or strive for less? No, but it does call for awareness for why we pursue certain stations in life. More steps does not equal more happiness so be cognizant of your pace, journey and destination.


MEDICINE & MACULA: For those who know me, you are aware of my squash enthusiasm (although obsession might be a better descriptor…). This week, the WHOOP Performance Optimization System featured me in their The Locker feature.

Thanks very much to WHOOP and Mark Van Deusen for their interest! I don’t have any financial ties to the WHOOP system but believe, wholeheartedly, it is the best fitness tracker available for the serious sports enthusiast.

You can read the story here.

Stay active!


GRATIS: “Yes, there are two paths you can go by. But in the long run, there’s still time to change the road you’re on.” Jimmy Page & Robert Plant


My best to you,

David Almeida

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Think about the last thing you did that made you feel really good?

What was special about it?

Most people I ask this question answer with the resultant accomplishment or achievement related to whatever event they are thinking about. Let’s take a fictitious example; someone might say, “I enjoyed my last run. It was special because I completed 10 miles.”

There is nothing wrong with this answer and I believe it’s important to celebrate accomplishment. However, now, go back to that event or action, and describe it without using some sort of productivity or accomplishment associated with it. You cannot use an outcome as a means of ascribing value to it.

Get’s difficult right?

What am I getting at? We tend to value productivity over presence. We want to extract takeaways from actions and events like: “I had…”, “I did…”, “I got…”. Instead of the desire to immerse in moments and experiences, we are all too ready to define our life in basic terms.

To continue with our example from above, maybe the significance of that last run was it allowed connection with nature or moments of mental clarity. Only if you are present, can you catch these wonderful experiences.

TASK AT HAND: This week I’m thinking about presence. One of my favorite quotes is from Walt Whitman: “We convince by our presence.” The ability to be present and engaged with the turbulent twists of life – rather than a mere passenger of happenstance – is not trivial!

The title of this blog, the Sunday Surgical Scrub, is dedicated to a ceremonious time of clarity. From the blog introduction above, “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.” The scrub is a moment of reflection to remind the surgeon to be present in the moments that lie ahead.

Unfortunately, too many times, we lose the connection to presence. A common example I see is simple conversations. You will notice that people will speak and, as soon as they stop speaking, they focus on what they will say next rather than listening. The other person does it as well. Is the point of the conversation to conduct some sort of business (productivity) or an opportunity for engagement (presence)?

Look out for all too easy trap of productivity. Efficiency and productivity are cornerstones of success but make sure you are producing relevant outcomes. Pause and ask yourself what it is that you want out of an action or interaction. More often than not, you will find that presence in a simple conversation, a parenting action, a commitment to a cause has great worth and impact than a trivial takeaway.


MEDICINE & MACULA: Thank you Tina and The Morning Blend for having me as a guest this past week! I had a wonderful time on the show and continue to be humbled and excited about all the interest in Decision Diagnosis.

You can watch the interview here.


GRATIS: Happy Mother’s Day! Resiliency I learned from my grandmother. Kindness and unyielding support I absorbed from my mother. Every day, I am lucky to witness the virtues of patience and grace in the mother of my children


My best to you,

David Almeida

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“To broker innovation is to facilitate the cross-pollination of ideas. To take concepts out of their silos, synthesize novel viewpoints, and paint new pictures where once lay empty space.”

TASK AT HAND: This week I’m thinking about brokering innovation. This is a relatively new term but the practice is longstanding. The idea is to support growth via the unique mixing of ideas from different fields or backgrounds. The cross-pollination of thought – whether it be geographically-, culturally-, or specialty-based – is a fundamental strategy for creative thought.

For example, you may work in a typical corporate culture but this does not mean you can’t incorporate strategies from a performer and team-building from sports culture. Similarly, approach you pain points with different vantage points. If all I have is a hammer, sooner or later, everything starts to look like a nail. Alternatively, if I see someone else using a different tool – even if it is for a much different task – maybe I can create a hybrid to address my need.

Personally, I have long been interested in the process of brokering innovation and this is one of the reasons for my diverse background. I find that, when we can forcefully take ideas out of their nascent environments, and join them with other disparate ideas, then creativity flourishes. Sometimes, this creativity may be hypothetical and lack practical use. Sometimes, a sort of Frankenstein is born that is difficult to categorize. However, when it comes off right, there is potential for the genesis of truly transformational thought.

“When we can forcefully take ideas out of their nascent environments, and join them with other disparate ideas, creativity flourishes. At these crossroads, there is potential for the genesis of truly transformational thought.”

The desire to work in a physical or figurative cubicle enforces constraints. Instead, much how the modern workplace has morphed into non-traditional settings and processes, how you approach challenges and conflicts must evolve. Staying fixated on strategies that exist in a vacuum risks failure in global applications.

The call to action here is to facilitate the brokering of innovation! Break down silos! One of the simplest strategies is to work with as many individuals with different backgrounds as possible. Akin to a musician who jams with someone with a different style or from a different genre, join others in the pursuit of unique thought. Support the sharing of ideas between different groups. Look to build connections between heterogeneous cohorts. Look to guide cross-functional conversation, exchange and communication. Your horizons will expand, and the accompanying understanding will lead you to ask better questions and seek better answers.


MEDICINE & MACULA: Check out one of our recent publications, Myelinated retinal nerve fibre, myopia, and amblyopia syndrome (Kunyong Xu & David RP Almeida) published in the Canadian Journal of Ophthalmology (April 2017).

You can find the study here.

We describe the complex relationship among myelinated nerve fibre, myopia, and amblyopia. We present the case of a 6-year-old boy who presented with blurry vision of the right eye over 2 months. The visual prognosis in these cases is variable.


GRATIS: “For good ideas and true innovation, you need human interaction, conflict, argument, debate.” -Margaret Heffernan


My best to you,

David Almeida

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“Refuse to be average. Let your heart soar as high as it will.”

Aiden Wilson Tozer

TASK AT HAND: This week I’m thinking about “regressing to the mean”. You hear this a lot in sports, economics, and human performance. In statistics, regression to the mean describes that over time, extreme measurements will be closer to the average for the group (because measurements cluster about the average). In other words, outliers will tend to be closer to the average as more measurements are made.

For example, a baseball player may hit 2 home runs in one game but, over the season, they will perform closer to their overall batting average. In another example, the stock market may have a positive or negative run in the short term but, over any appreciable time frame, it will perform closer to the average lifetime behavior. Basically, “regression to the mean” describes that things tend to even out over time.

“Regression to the mean describes that things tend to even out over time.”

How can we use regression to the mean to improve our decision making and strategy?

What can we learn from this statistical phenomenon to illuminate our performance?

First, we need to identify that, on average, we are all average for most of our skills. Everyone cannot be the top 1% or 10% – statistically this is impossible. I find it a callous fallacy when we endow the belief that we can all be the best or fastest at all tasks. This is not possible because, over time, we will gravitate towards the average for that task in question.

But, this need not be a self-fulfilling prophecy because statistical regression toward the mean is not a causal phenomenon. Regression to the mean does not describe cause and effect. Instead, regression to the mean is based on random error about an average. The next bit is important: your performance is not destined to be average. Your performance can be an outlier. It can be bold and a superlative extension of the objective you are trying to achieve.

I have found that, self-awareness into how we are performing, can bring to light where “our average” lies for certain tasks and proficiencies. As we learn our “average”, we can work to incrementally improve them. Realizing that regression to the mean is not an eventuality opens the door to reflection and progress. Ultimately, it starts to differentiate our performance on tasks from ourselves as individuals. Our performance may sometimes be average, but our ability to learn from it will never just be average.


MEDICINE & MACULA: Check out one of our recent publications, Proliferative Vitreoretinopathy (PVR) Update: Current Surgical Techniques and Emerging Medical Management (Robin K Kuriakose, Kunyong Xu, Eric K Chin & David RP Almeida) published in the Journal of VitreoRetinal Diseases (April 2017).

You can find the study here.

In this detailed review, we provide an update on current surgical techniques and emerging medical management in proliferative vitreoretinopathy (PVR). PVR is the number one cause of failed retinal detachment repair and still a relatively unexplained phenomenon. We, along with Citrus Therapeutics, are working hard to find treatments for this challenging disease.


GRATIS: “The average adult laughs 15 times a day; the average child, more than 400 times.” Martha Beck


My best to you,

David Almeida

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“Cogito ergo sum.”

“I think, therefore I am.”

This is the proposition most commonly quoted for the French philosopher Rene Descartes.

However, when you look at his text, Discourse on the Method, it actually reads:


“Dubito, ergo cogito, ergo sum.”

“I doubt, therefore I think, therefore I am.”


TASK AT HAND: This week I’m thinking about doubt and apathy. Doubt, in my opinion, is a vital force in the quest for understanding. Without doubt, the search for knowledge can become complacent and dull.

“Without doubt, the search for knowledge can become complacent and dull.”

For Descartes, the act of doubting one’s own existence served as a basic proof of the reality of one’s own mind. This doubt, allowed for thinking beasts to realize fundamentals. Today’s Sunday Surgical Scrub is not about Descartes but it serves our discussion on doubt well.

Doubt is an extension of the existence of the individual. It is this ability – the ability to doubt – that can affirm one’s existence and their associated system of beliefs and ethics. In modern living, with all its virtual connections and influences, it is necessary to doubt regularly so that one can arrive at key aspects of character in multiple scenarios.

In the modern context, there exists an endless sea of statements, many of which are derived neither from data or fact. This is where doubt can save you! Doubt what you see on social media, doubt what you hear on television, doubt what you read in the news; doubt your teacher and preacher alike. Doubt so that you may come to understand.

“Doubt so that you may come to understand.”

What role does apathy play? Apathy is defined as a lack of interest, enthusiasm, or concern. In medicine, it can be a diagnostic clue to psychiatric disease. However, I believe the strength to be apathetic – to garner little concern for trivialities can be a boon of strength. Consider the human of today as an over-connected organism and you realize that – to effectively think for yourself – doubt and apathy are cornerstones to living comfortably in your own skin.


MEDICINE & MACULA: Many thanks to Mpls.St.Paul Magazine for selecting me as one of their Top Doctors Rising Stars in the April 2017 issue. This is awarded to physicians selected through a peer-nomination process. You can find the list here.

GRATIS: Descartes published The Discourse on the Method in 1637. It was originally titled: Discourse on the Method of Rightly Conducting One’s Reason and of Seeking Truth in the Sciences. I like the long title!


My best to you,

David Almeida

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“Learn about others and the world around you but, most of all, be a lifelong learner of who you are and how you are changing.”

TASK AT HAND: This week I’m thinking about what it means to be a lifelong learner. Traditionally, we consider this in the context of learning new skills or the increased proficiency of our current skill set. This is beneficial for the objectives of improving productivity and efficiency.

But, more importantly – and often neglected – is the commitment to the evolution of learning about who we are and how we are changing. Study after study shows that people generally underestimate the extent of future personality growth. Researchers call this phenomenon “the end of history illusion” in that we tend to assume that our growth ends as we get older. (You can find a nice summary of recent studies here.)

“More importantly – and often neglected – is the commitment to the evolution of learning about who we are and how we are changing.”

This “end of history” illusion creates a possible hurdle in that we stop learning of who we are and how we are changing. This occurs because we think we have stopped changing, not realizing that, like the empty pages of a book yet to be written, our personalities have ongoing potential for growth. This potential for growth is often materialized with or without our knowledge or consent.

“The ‘end of history’ illusion occurs when people underestimate the extent of future personality growth.”

In this sentiment, today’s Sunday Surgical Scrub has a simple call to action: be a lifelong learner of you! Dedicate time and resources to the reflection of who are now and who you are becoming tomorrow. This will strengthen you, support your future strategies and goals, and be a boon to the ones around you.


MEDICINE & MACULA: A very sincere thanks for making The Ophthalmologist 2017 Power List! I am humbled to be considered one of the top 50 rising stars in ophthalmology. Moreover, I am grateful to be in the company of such wonderful and gifted colleagues!

You can find the list here.


My profile is here.


GRATIS: “ ‘Thank you’ is the best prayer that anyone could say. I say that one a lot.” -Alice Walker


My best to you,

David Almeida

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“Begin the work. Forget the phantom of failure. Just start!”


TASK AT HAND: This week I’m thinking about the power of starting something. For those that visit here often, you know of my contempt for procrastination. My distaste for the paralysis of inaction. The inability to overcome inertia limits positive movement and meaningful strategy.

How do you keep this from holding you or your firm back?


Begin the work. Forget the phantom of failure. Simply start. Don’t worry about how hard you will have to strive. Don’t catalogue the reasons why it won’t work. Don’t fret over details and dire straits. Don’t ingratiate with impotence and ineptitude. Be it a moment or movement, start something. Whether a decision or an affirmation, by simply starting, you have overcome dread, delay and procrastination.

“By simply starting, you have overcome dread, delay and procrastination.”

When success finds you, the wave is easy to ride. When strategic moves are clicking, the puzzle fills in an orderly fashion and it seems all too easy. But, when you hit walls, when the pieces don’t fit, when your plans fail to crystallize; this when the ability to start something must be called upon.

Pandora, the online music streaming site, was rejected by over 300 venture capitalists and spent over two years of its early life broke, without cash. Nonetheless, Pandora utilized the resources available to create a basic platform. It started a tangible access point towards the goal of its creators. Online music streaming, like other competitive spaces, ensures multitudes of roadblocks and challenges and it will require the continual call of this skill.

Let’s take a job seeker as another example. How many rejections will you take? How many “No” and “I’ll pass” will you accept before you give up? How many times will you fail before you will do not risk failure again?

There is no number to contemplate, just start! Not in the fashion of Sisyphus, where the task was stereotyped and repeated in an endless loop. Instead, start anew, be willing, be flexible to learn from previous examples. This willingness to start anew, to pivot, to find a path of positive movement serves individuals and companies alike with the vector of acceleration where many seem content to circle at some average speed. The only requirement is that you start.


MEDICINE & MACULA: Fantastic to be part of the faculty at the Vit-Buckle Society V meeting in Las Vegas this past weekend (6-8 April 2017). Grateful for the discussion, learning new techniques that can best help our patients, and catching up with friends and colleagues!

I presented a talk on proliferative vitreoretinopathy (PVR), including pearls and techniques, for this challenging group of patients. Patients who are current or former smokers are significantly more likely to have PVR formation after retinal detachment repair.


GRATIS: Go ahead, start something!


My best to you,

David Almeida

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