March 2017

“Routine, in an intelligent man, is a sign of ambition.”

–WH Auden


TASK AT HAND: This week I’m thinking about routines. Stereotypical movements, rhythmical thoughts, and choreographed actions that we employ without second thought. Sometimes blamed for lacking in creativity for the sake of productivity, routines get an unfair share of criticism. Properly employed, routines can successfully support our strategies and objectives. Below are 3 key benefits of routines.

“Properly employed, routines can successfully support our strategies and objectives.”

1. Routines minimize cognitive burden. I have talked about cognitive burden before (Sunday Surgical Scrub from 12 June 2016, you can find the original post here). 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. You can minimize undue burden by employing routines. For example, email has immense potential to overwhelm our cognitive load; however, by developing a routine to manage your messages, you can efficiently meet priorities without becoming a slave to your inbox.

2. You are what you repeatedly do. Your routines speak volumes about who you are. Routines describe what you commonly do. When looking for change, don’t start with a long shot. Change a routine and build a process to achieve your goal. Are you trying to improve your physical strength? I would forego the goal to bench a new Olympic record. Instead, create a routine where, for example, you incorporate weight training on certain gym days. Simple modifications to routines can transform major behaviors.

“Simple modifications to routines can transform major behaviors.”

3. Routine = Consistency. Having a routine can improve the consistent performance of physical and mental tasks. For example, a basketball player will bounce the ball several times before attempting a free throw. He or she uses this routine as a method of preparation to improve the chances of making the basket. When I’m performing scleral buckle procedures for retinal detachments, I always re-grasp the needle before making a scleral pass. This simple routine reminds me to focus on the exact depth I want to place the needle: too shallow, and the suture will not hold but, too deep, and I will perforate the eye. Both are negative scenarios I need to avoid. This simple routine helps me achieve consistent placement of the suture.

Optimize your routines as a means of process improvement. Life will throw you distractions like travel and sickness with the potential of upending your abilities. Use routines to remain focused on your core ambitions.


MEDICINE & MACULA: Throwback to 2012 when we published our case, Ophthalmic artery occlusion secondary to fat emboli after cosmetic nasal injection of autologous fat. This was published in the journal RETINA (you can find the study here) and is the case of a patient who lost all vision after undergoing cosmetic nasal fat injection. The striking color fundus photograph shows fat emboli that occluded the ophthalmic artery.

A stark reminder that all procedures, even benign elective ones, have the potential for profound complication.


GRATIS: “The secret of your future is hidden in your daily routine.” -Mike Murdock


My best to you,

David Almeida

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“From reading too much, and sleeping too little, his brain dried up on him and he lost his judgment.” -Miguel de Cervantes

TASK AT HAND: This week I’m thinking about sleep. An overlooked and neglected component that is vital to our optimal reasoning and performance. Too often we look to the lack of sleep as a badge of honor indicating exemplary endurance. I look back at my years as a researcher, medical student, and on-call intern and how I would consider 30 or 40 hours without sleep a proud achievement. Now, I realize that, in those instances, I failed to care for myself and operated in suboptimal conditions.

We know that sleep restriction and sleep deprivation is linked with the development of diseases like obesity, diabetes, and hypertension. Researchers have shown that severe sleep loss jolts the immune system just as stress does, impairing our ability to properly tackle mental and physical tasks (check out study here). Sleep loss quadruples the risk of stroke (find the study here). Lack of sleep is not a badge of honor; rather, it is a mark of embarrassment reflecting our myopic self-awareness and unwillingness to be our best.

“Lack of sleep is not a badge of honor; rather, it’s a mark of embarrassment reflecting our myopic self-awareness and unwillingness to be our best.”


Today on the Sunday Surgical Scrub, here are three common questions that I have received on sleep recently. Ponder and enjoy!


1. Once in bed, how long should it take me to fall asleep?

This is known as Sleep Onset Latency or Sleep Latency and defined as the length of time that it takes to accomplish the transition from full wakefulness to sleep. If you take less than 5 minutes to fall asleep, you are sleep deprived! The ideal target is between 10 and 15 minutes, which indicates you’re tired enough to sleep but not exhausted as to show signs of daytime sleepiness.

The most important pearl here: once you get to bed, turn off your phone. The never-ending accessibility to the internet and constant messages, notifications, and distractions will disrupt your sleep latency and your subsequent stages of sleep. Your bed should be for sex and sleep. I don’t see the need for a phone here.


2. How much sleep do I actually need?

Most healthy adults need 7 to 9 hours of sleep a night. Although some individuals can function without sleepiness or drowsiness after as little as 6 hours of sleep – known as short sleepers – this represents less than 1% of the population so, chances are, this is not you. Short sleepers are believed to derive this ability from a genetic mutation on the DEC2 gene (check out the study here).

When considering how many hours you need to sleep, I believe there must be a philosophical shift in how you see the objective of sleep. Commonly, we look to how much sleep we need to “get by” or “survive” the next day. Change it up: how much sleep do you need to peak and thrive tomorrow?


3. What’s up with nightmares? What happens when I’m sleeping anyways?

Nightmares are defined as disturbing dreams in which unpleasant visual imagery or emotions wake us up. Contrary to popular belief, fear is not to the main emotion in nightmares; instead, researchers have found that it’s most often feelings of sadness, guilt and confusion (find the study here). Self-reflection, exercise, journaling, meditation are just a few common ways to reconcile the negative emotions that we harbor and can go on to degrade our sleep quality.

This blog post is much too short to describe all the processes and mechanisms that underlie sleep. Further, its unclear exactly why organisms need to sleep. However, it seems that most, if not all, species regularly enter a circadian rest state.


MEDICINE & MACULA: Special mention to an excellent study entitled, Fatigue, Alcohol and Performance Impairment from the journal Nature.


The study looked at sleep loss in terms of equivalent alcohol intoxication. A group of 40 participants were broken up in to two groups: one group was kept awake for 28 hours, simulating pulling an all-nighter, and the other consumed 10-15g of alcohol at 30-minute intervals until their blood alcohol concentration reached 0.10% (legal limit in every state is 0.08%).

Each group was given a performance task that required them to react as quickly as possible to visual cues randomly timed on a computer. After 17 hours of sustained wakefulness, performance was equivalent to a blood alcohol concentration of 0.05%. After 24 hours of sustained wakefulness, performance was equivalent to those with a blood alcohol concentration of 0.10%. According to this study, sleep deprivation is not so much a badge of honor, as an example of public intoxication (study here).


GRATIS: Man is the only mammal that willingly delays sleep. Stop doing it! For your health and engagement, go to sleep!


My best to you,

David Almeida

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“Perspective is Providence.”


What do you see in the picture above?

It is a color photograph of one of my patients, diagnosed with wet macular degeneration, who has suffered a devastating hemorrhage. Her vision is worse than legal blindness and, due to several factors, the prognosis is poor for any vision improvement.

So, what do you see in this picture of pathology?

Do you see a foregone conclusion? A lost cause? A chance for a miracle? Hope in a complicated case? Consequences of a blinding condition?

Do you fight for any gain, at any cost? Or do you accept and move on preferring to first, do no harm?


TASK AT HAND: This week I’m thinking about perspective. Where the painting tells the story, perspective is the frame. Perspective, must be congruent to the painting of houses, to accurately engage the conflict or decision in question. I think of perspective as the ability to see beyond the literal – to read between the lines – and akin to emotional intelligence. Perspective is to see beyond what meets the eyes. Without it, one is tone deaf. Perspective affords you the ability to decipher in real time, rather than in a vacuum.

“Perspective is to see beyond what meets the eyes. Perspective affords you the ability to decipher in real time, rather than in a vacuum.”


As a surgeon, I’m lucky because I get to develop a frank dialogue with my patients so that we can decide, through informed and shared decision making, on a path to purse together. I provide my professional opinion – but ultimately – we decide together. My perspective in these situations combines a mix of the unique patient before me and the knowledge, experience, and instinct within me. I must never disregard this perspective.

For the decisions in our lives, many of the times, we are not so lucky as to have a second vantage point on decision making. This is one of the reasons why fallacies and bias are so troubling and can cause much of misguided strategy. As we bounce possibilities around, they can become extricated from reality and adorned with bias.

Now, what does providence have to do with any of this?

Providence can be defined as protective care from a higher power such as nature, spiritual forces or religious deities. But, I use it here as defining the timely preparation for future eventualities. Providence, to be prepared for the future, can be found in perspective. In other words, to have perspective and insight, provides preparation for what you may encounter in the unknown path in front of you. For all the apparitions of darkness, joy, pain, success, and failure that you may encounter, find providence in perspective. Use perspective for comprehension. Let your execution be guided by providence.

“Providence, to be prepared for the future, can be found in perspective. Use perspective for comprehension. Let your execution be guided by providence.”


MEDICINE & MACULA: If you haven’t had a chance, check out my new book, Decision Diagnosis: Seven Antidotes to Decision Procrastination. For those who have already gotten their copies, sincere thanks for your interest and for making it an Amazon best seller in multiple categories and countries!

Both paperback and Kindle versions are available here.

GRATIS: “The only real voyage of discovery consists not in seeking new landscapes but in having new eyes.” -Marcel Proust


My best to you,

David Almeida

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“Creativity, in an unproductive form, may emit a flash in the pan, but rarely creates enough light to sustain the night.”


TASK AT HAND: This week I’m thinking about productivity versus creativity. Productivity – how we think – can be thought of as the grammar or syntax of a sentence. Creativity – what we think – are the words, concepts and emotions in that sentence. I think of productivity as the order and arrangement of a composition whereas creativity is the unique melody. While productivity tends to have basis in ordered and logical processes, creativity can be borne out of entropy and randomness.

“Productivity is the order and arrangement of a composition.

Creativity is the unique melody.”


Linear thinking; for example, events separated by time, follows a predictable pattern of organization and can be connected without much labor. On the other hand, the connection of multi-dimensional coordinates usually requires creativity to consolidate disparate variables. Creativity can provide wonderful and novel insights into problems and phenomenon but, the crux is that creativity is not enough for successful strategy. At some point, creative findings need to be distilled into elements of capable comprehension for effective decision making. In summary: being creative is not enough! Much talent is wasted and, we all know examples, where lack of work ethic undermines the creative process.

“At some point, creative findings need to be distilled into elements of capable comprehension.”

Why discuss these two concepts here on this week’s Sunday Surgical Scrub? Over the last few weeks, I have received emails and questions on how to enrich one’s creativity. Personally, few wonders are as rewarding as the creative process; however, often, creativity, or a lack thereof, is not the problem. The more commonly encountered issue lies in deficiencies in bringing that original concept – what you thought – into a thesis that can be evoked and understood.

I need to emphasize that the call to action here is not for more productive individuals at a cost of creativity. Rather, seek a state of wholeness where both the synthesis and organization of new thoughts and ideas coexist. Find congruency in their relationship.

“Seek a state of wholeness where both the synthesis and organization of new ideas coexist.”

Next time you are pondering problems or reflecting on ramifications, break down the elements of your decisions into the aspects of productivity (how you think) and creativity (what you think). This will give you valuable insight into the overall process. You will be surprised at your creativity, and you will appreciate the process for decoding it.


MEDICINE & MACULA:  Many thanks to Scott Krzywonos, Editor-in-Chief of New Retina MD and producer of the New Retina Radio podcast.

I was on the latest New Retina Radio Podcast. Check out Episode 4, PhD, MBA, JD, MS: Alphabet Soup where we discuss how multiple degrees, beyond the Medical Doctor, enrich the role of the physician and the subspecialty of vitreoretinal surgery.

You can find the episode here.


GRATIS: Both productivity and creativity are concepts that improve with journaling. Write down 1-3 new ideas each day. Do this at a time of day when you are alert and awake (not as a checklist before bed). Warning: they will be terrible at first, but this is ok. Like working a muscle, you need to build up strength, endurance, and precision in the execution of creative thought. Next, write down one problem or process that hinders your productivity (look out for the repeated theme of procrastination). The latter will allow you to identify areas that bleed productivity from your life. Finally, periodically reflect on your points to strengthen your creativity and intellectual prowess. Not uncommonly, you will be pleasantly surprised to find creative solutions to productivity problems.


My best to you,

David Almeida

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