“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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“Don’t dwell on what went wrong. Instead, focus on what to do next. Spend your energies on moving forward toward finding the answer.” -Denis Waitley


TASK AT HAND: This week I’m thinking about sunk costs. Also known as retrospective costs or the fallacy of commitment to sunk costs. Do you own an old pair of shoes you don’t wear any more but, because you spent a pretty penny on them, you refuse to throw them away? This is the sunk cost fallacy at work. It is an erroneous approach to strategy focusing on trying to recover your past investment by holding onto something because you cannot accept it is no longer working (Psychology Today, 24 September 2014). By definition, it is a cost that has already been incurred and cannot be recovered. In other words, it’s time to throw away those shoes!

When trapped by the sunk cost fallacy, you become concerned with what you “paid” for something in the past, rather than what you will get out of it in the future. The fundamental problem with commitment to sunken costs owes to it being a backward looking decision. Consequently, it does not offer you any prospects or opportunities for the future. Interestingly, humans are the only animals who honor sunk costs. Other animals will look for new opportunities as soon as previous ones have been exhausted (Psychological Bulletin 125(5):591–600).

The fallacy of honoring sunken costs resides in our old nemesis of insecurity. The insecurity that changing or giving up on a sunk cost will show others we made a mistake. This relates directly to the phenomenon of loss aversion: we all fear loss and we all want to avoid it. However, you need to see beyond this. That submerged boat, let it sink. Feel stagnation in your current job but afraid start over? It is time to consider your options. Is there a void in your relationship but deny it because of the “time you have already invested in it”? Abandon old rationalizations and bring yourself to realization.

The mindset to best eliminate loss aversion and bypass the sunk cost fallacy is to consider only future benefits and costs when pondering a decision. Assess what you need to invest moving forward. Minimize the desire to include resources, capital or emotion that has been previously spent. The latter is baggage which can weigh you down. By letting go of past costs incurred, you can frame your strategy de novo with improved clarity.

MEDICINE & MACULA: I was in Chicago this week for the American Academy of Ophthalmology (AAO) annual meeting!


On Friday I presented a talk on our technique for retinal embolectomy at the AAO Retina Subspecialty Day. Retinal embolectomy involves the removal of emobli from the retinal vasculature in selective cases of arterial occlusions.


Thanks to everyone for their interest in our technique!

GRATIS: For those who know me, a common place to find me is on a squash court. This past week was the Beyond Walls Squash Week in Saint Paul MN. My home club, The Commodore, was the host club.


In addition to playing in the A singles draw, was a proud sponsor of this fantastic event benefiting Beyond Walls.


For more information, check out the MN Squash Week page.

My best to you,

David Almeida

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“Fail early, fail often, but always fail forward.”

John C. Maxwell (Failing Forward)


TASK AT HAND: This week I’m thinking about failure. A word associated with massive negative connotation. Imbedded within insecurity, fear of failure enforces the concept that we need to avoid failure if want to be successful. That failure is for the weak and lazy. That if you are intelligent and industrious, failure can be avoided. This is wrong and ignorant. Failure – and how we cope with it’s force – is of crucial importance to our character development.

Why is failure important? Failure is part of the iterative process of learning. Like trial-and-error, it is a basic process that we master in order to develop higher forms of reasoning and decision making. Thomas A. Edison writes, “I have not failed. I’ve just found 10,000 ways that won’t work.” Failure allows us to improve processes and techniques and is essential to the learning of individuals, growth of organizations, and coherence of cultures. “Ever tried. Ever failed. No matter. Try Again. Fail again. Fail better”; these words by Samuel Beckett see failure as this fundamental process of learning.

Why is fear of failure debilitating? The shame of failure comes from the pervasive negative assumption that failure is an ultimate end. In truth, failure is just another step in the process. I’m a vitreoretinal surgeon and I regularly operate on blinding diseases. I am humbled by the eye and the gravity of complications that may, without notice, occur during surgery. I orchestrate every movement to avoid complications, but I do not fear them. If so, I would be paralyzed with fear and overwhelmed by the weight of possibility. This would dramatically hinder my performance and limit my ability to help patients. Show me a surgeon with no complications, and I’ll show you a surgeon who never operates. Failures are not final but part of evolving solutions and strategies.

How can you erase your fear of failure? If you fail at something, the first step is to give yourself the opportunity to learn from it. There is a twisted irony in the failure to learn from your failures. Don’t do this. Take ownership of your failure. “A man can fail many times, but he isn’t a failure until he begins to blame somebody else” (John Burroughs). Realize your error. Take ownership of the failure. Accept responsibility for the consequences. This provides you with immense learning. See this as a temporary event and in no way a synopsis of your life.

MEDICINE & MACULA: Check out our new feature in the September 2016 issue of Retina Today entitled, Postoperative Infectious Endophthalmitis: Evolving Trends and Techniques.


Infectious endophthalmitis is a vision-threatening condition that involves inflammation of the entire eye. Early vitrectomy for endophthalmitis provides significant benefit in removing infectious material. We describe how vitreoretinal practices have changed with the adoption of small-gauge surgery.


Check out the publication and video here.

GRATIS: If you’re not failing often, you’re not trying hard enough.

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



My best to you,

David Almeida

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