Monthly Archives: February 2016

Medical Musing of the Week: Hyperthyroidism


  • Excess Synthesis and secretion of thyroid hormone by the thyroid gland
  • Hyperthyroidism exists as Graves Disease, Toxic Multinodular Goiter, Toxic Adenoma and Subacute Thyroiditis
  • The MCC of hyperthyroidism is Graves Disease  (50-60%)
  • Increased FT4 
  • Increased T3 in Subacute Thyroiditis
  • TSH is suppressed 


  • TRH is produced in the Hypothalamus which then signals the Pituitary Gland to secrete TSH to the Thyroid Gland signaling T3 and T4 to be released to peripheral tissues (see picture below if you are a visual learner.  C/o Medscape)
  • When adequate levels of circulating T3 and T4 have been achieved in the normally functioning thyroid a negative feedback signal is sent to hypothalamus to temporarily halt TRH production (and begin reproducing when T3 and T4 levels are low in periphery) 
  • Iodide binds to thyroglobulin via peroxidase.  This results in monoiodotyrosine (MIT) and Diiodotyrosine–combining to form T3 + T4 which are then stored in the thyroid as preformed hormone (these were terms I haven’t seen since didactic year, hah!)


Etiology & Risk Factors

  • Genetic predisposition
  • Additional Autoimmune diagnosis
  • Pregnancy (Use PTU not MTU)
  • Women > Men
  • 20-40’s
  • Amiodarone toxicity (rare)

Clinical Manifestations


  • Nervousness/Restlessness
  • Increased bowel movements
  • Anxiety
  • Palpitations
  • Weakness
  • Menstrual Irregularities 

Physical Exam

  • Fine resting tremor
  • Warm skin/heat intolerance
  • Thinning hair
  • Increased reflexes
  • Onycholysis
  • Enlarged thyroid
  • Sinus tachycardia/PAC’s/A-Fib
  • Exopthalmos

    Pre-tibial Myxedema
  • Upper eyelid retraction
  • Lid lag w/ downward gaze
  • Pretibial Myxedema


  • The single most important test is TSH (will be decreased)
  • The severity of clinical manifestations does not necessarily correlate with TSH level
  • ELISA for Anti-TPO for Graves Disease
  • Free T4 and Total T3 levels
  • EKG if Sinus Tachycardia (may also want to check electrolytes) 


  • Methimazole
    • Starting dose: 5-20mg Q8h
    • Once euthyroid 5-15mg QD
    • Inhibit coupling of iodotyrosines in thyroglobulin resulting in a gradual decrease in circulating hormone over 2-8 weeks
    • Monitor levels Q4 weeks when first starting treatment
  • Propylthiouracil
    • Starting dose: 300-400mg/day divided Q8h
    • Once euthyroid 100-150mg Q8h
    • Preferred in pregnancy (MTU is safe after first trimester)
    • More potent–also blocks T4 -> T3
    • Inhibit coupling of iodotyrosines in thyroglobulin resulting in a gradual decrease in circulating hormone over 2-8 weeks
    • Monitor levels Q4 weeks when first starting treatment
  • MTU & PTU side effects:
    • Fever, Rash, Agranulocytosis, Aplastic Anemia, Hepatitis
  • Radioactive Iodine Ablation (most common and effective treatment)
Radioactive Iodine Ablation in a patient with Graves Disease
  • Thyroidectomy (not frequently performed due to effectiveness of RAI ablation)
  • Symptom relief (Beta blockers)
    • In addition to treating the symptoms of tachycardia, tremor etc– beta blockers also decrease conversion of T3 to T4 (which I didn’t know before!


  • Patients who go through RAI ablation or thyroidectomy are often left hypothyroid.
  • Thyroid Storm
    • Acute life threatening hypermetabolic state caused by excessive thyroid hormone
    • Fever, tachycardia, hypertension, diaphoresis, AMS
    • Cardiac manifestations and complications can range from sinus tachycardia to high-output cardiac failure and arrhythmias 
    • Treatment
      • Methimazole is first line
        • 20mg Q4-6 hours
      • Propanolol is first line Beta Blocker
        • 60-80mg Q6h or .5-2mg IV Q10 minutes for the first few hours
      • Glucocorticoids
      • Supportive Measures



Current Medical Diagnosis & Treatment 2015

41 Questions to Prepare For PA School Interviews

Introductory and Experience 

  • Tell me about yourself.
  • What do you like to do for fun?
  • What is your greatest personal accomplishment outside of school to this point in your life?
  • I see that you have spend X amount of years in a <different profession>.  Why do you want to switch careers?
  • What are your strongest attributes that will make you an excellent PA?
  • Talk about what you see for your professional future in the next one, three and five years.
  • What area of medicine do you want to specialize in when you graduate?
  • Who are the two most influential people in your life and why?
  • I see that you withdrew from an accelerated chemistry class, why did you do this and what did you learn?
  • Tell me about your low grades during your freshman year of college.
  • Tell me about the best supervisor you have had.  What made them excellent at their position?

Knowledge of Profession & Healthcare

  • Tell me about why you want to become a Physician Assistant.
  • How was the profession founded?
  • What do you think about “Physician Assistant” being changed to simply “PA”?
  • During your shadowing experiences, tell me about a particularly influential experience you witnessed and how it impacted your decision to become a Physician Assistant.
  • What do you feel is one of the biggest issues currently facing the profession?
  • What is the most difficult aspect of being a Physician Assistant?
  • What is one of the greatest downfalls of healthcare in The United States?
  • What is the difference between a PA and NP?
  • What do you think about the rising cost of health care and do individual providers have a responsibility to help to mitigate this cost?
  • I see on your application that you spent more time shadowing Physician’s than PA’s.  What was the reason for this and what did you learn?
  • I’ve interviewed other students who have told me that they are going to PA school because their parents told them it was a good career.  What do you have to say about this?
  • A nurse is pushing you to give a patient extra narcotics or sedating medication because the patient is “difficult”.  How do you respond to this situation?
  • You are unsure of a course of treatment to take with a hospitalized patient.  What do you do in order to make an effective decision?

Preparedness & Maturity

  • What do you expect a typical week in PA school to entail?
  • How will you manage your time and commitments outside of PA school?
  • What have we not spoken about, that I cannot learn from your resume that makes you an excellent candidate for our program?
  • Talk about a time when you had to deal with a difficult patient.  What did you do and what was the turn out of the situation?
  • If you had to pick one experience in your life that has best prepared you for PA school what would it be and why?
  • What will be the most difficult aspect of being a Physician Assistant for you?
  • It has been brought to our attention that some students are utilizing PA school as a stepping stone to becoming a Physician.  How do you feel about this?
  • Give me one reason why you will pass the PANCE on your first attempt.
  • Tell me about a time that you stepped up to help someone that was struggling with a task or academically.

Behavioral & Ethical 

  • You overhear two of your classmates discussing an answer to an Anatomy exam.  You realize that they got credit for an answer you also wrote down but it was marked wrong.  How do you react?
  • As a licensed PA you notice that your supervising Physician prescribes a treatment that you are certain would harm a patient.  What do you do?
  • On clinical rotation your preceptor is treating patients disrespectfully and making hurtful comments to you about them after they leave.  How do you react and what do you do (if anything)?
  • I see that you are a re-applicant.  What have you done over the past year to better yourself as an applicant and future Physician Assistant?
  • Talk about a time when you recognized a change needed to be made and you demonstrated leadership qualities.
  • An elderly patient who lives independently is admitted for elective surgery for an L4-L5 herniated disc.  The patient is agreeable to the listed neurosurgeon performing her surgery.  However, her sister is telling you that Dr. so-and-so will absolutely not be performing the operation (the patients sister  works in housekeeping and does not like what she has heard)  Is this acceptable and what do you do?
  • You have multiple supervising physicians.  There is one particular Physician who you believe does not respect your time and you are constantly at work 2 hours longer than your scheduled day when he/she is working with you.  What do you do?
  • You’re on your general surgery rotation and the attending surgeon reprimands you in front of everyone for something you did/said that was truthfully an honest mistake.  However, you find yourself being yelled at in front of a room of 8-10 people.  How do you react?


How to Choose an Elective Rotation in PA School

This is probably one of the vital mistakes I made in PA school.  We had to choose within our first six months of didactic year and I was on the clueless train as to what area I wanted to practice.  So, here is the advice I wish I knew when I chose my elective rotation.

 1. Play the Numbers for the PANCE.

Yep this means Cardiology.  Cards makes up 16% of content on the boards.  It’s also a huge part of practice no matter what area you go in to, especially if you are practicing in any type of medicine. Learn everything you need to know about treating STEMI’s, NSTEMI’s, CHF and A-Fib.


2. Increase the Acuity

If you have any interest working in general medicine or in any specialty practicing in a hospital setting think about Critical Care.  I realize that the more rapid responses I’m involved in and forced to handle critical patient situations the more I advance as a provider.


3. Future Job

Preceptors hire previous students, so think about what area of medicine you want to practice and where you might want to live.  Try and get a rotation based on where you want to live, or even just experience in an area of medicine regardless of location. For example rotating in dermatology would give you an edge over an applicant who did not complete a rotation in dermatology.


4. Infectious Disease

Bugs and drugs people.  Everyone needs to know about antibiotic coverage.  I definitely wish I would have dug more into what antibiotics cover what types of bacteria in school. Although you probably don’t need a lot of this information for boards (you likely won’t get questions like what is the best drug to treat gram negative bacteria) it will help you when you graduate.


5. Once in a lifetime

Some people take the opportunity to learn an area of medicine you may never practice or experience again.  For example neonatal medicine, maternal fetal medicine, specific area of oncology, pediatric neurosurgery, etc. You get the idea.


Medical Musing of the Week: Myasthenia Gravis


  • Most common d/o of neuromuscular transmission
  • Autoimmune disorder resulting in weakness of ocular, bulbar, limb & respiratory muscles
  • Ocular and Generalized sub types exist.
  • 50% of individuals presenting with ocular subtype will develop generalized myasthenia within two years


  • Thymic tumor (10%)
  • Decrease in the number available AcH receptors at post synaptic membrane, which leads to inhibition of depolarization, action potential is not propagated.
  • Bimodal age distribution.  Women 30’s-40’s and men later in life 60’s-70’s


Clinical Manifestations

  • History:
    • Fatigue with increased activity
    • Blurry vision
    • Double vision
    • Difficulty chewing foods such as steak,
    • Bulbar weakness (dysarthria, dysphagia, fatigue while chewing)
    • Proximal limb weakness
  • PE:
    • Ptosis (pictured)
    • Fatigue w/ EOEM,
    • May appear expressionless
    • “Dropped head syndrome”inability to hold up head and neck
    • Respiratory symptoms: are the most serious clinical manifestation of MG.  Deemed “Myasthenia Crisis” (see below)
    • image
      Ptosis of the left eye.


Laboratory Values

  • + Anti-AcHR immunoassay 85% sensitive for generalized and 50% sensitive w/ ocular
  • + Anti-MuSK (muscle specific kinase)
    • Bulbar symptoms are increasingly associated with +MuSK
    • + MuSK patients are less responsive to anticholinesterase medications and thymectomy
    • Respond well to Immunosuppresive therapy with Rituximab
  • + lpr4 antibody

Edrophonium (Tensilon) Test:

  • Reversible AcH inhibitor, administered MG patients with improvement in symptoms
  • Reserved for patients who do no demonstrate sero-positive blood results with continued high suspicion for MG
  • Dosing: 2mg at first and if improvement is demonstrated no further dose.  Administer additional 8mg within several minutes if no improvement.  Some sources suggest after the first 2mg wait 60 seconds and give another 2mg, etc until response is seen with a max of 10mg

Edrophonium Test in a child:

Edrophonium Test in a dog.  Because medicine is more fun when you get to watch a dog walk again!


  • Anticholinesterase Inhibitors
    • Pyridostigmine 30-60mg TID-QID
  • Removal avoids spread of malignancy and treats MG
  • Positive prognosis when combined with medication management
Acute Relief
  • Improvement within a week and results lasting approximately 1 month
  • Benefits last weeks-months and usually takes one week for full improvement
  • IVIG
    • 2g/kg; typically administered over 5 days (400mg/kg/day)
  •  Plasmapheresis
    • 5 exchanges; 3-4L/exchange over 10-14 days
    • Provides short term reduction in anti-AcHR antibodies
Intermediate Relief
  • Improvement within 1-3 months
  • Glucocorticoids: 15-25mg/day
  • Cyclosporine: 4-5mg/kg/day
  • Tacrolimus: .07-.1mg/kg/day divided into BID dosing
  • Tacrolimus and Cyclosporine are being used w/ increased frequency as opposed to Azathioprine because of increased effectiveness, less side effets and quicker results.
Long Term:
  • Azanthropine: 50mg/day initially to test for s/e (titrate up to 2-3mg/kg)
  • Mycophenolate: 1-1.5g/day divided into BID dosing
Myasthenia Crisis
  • Respiratory failure due to diaphragm and intercostal muscle fatigue
  • Respiratory therapy will monitor patients inspiratory and expiratory strength
  • Causes: Infection, surgery, medications, ineffective taper of immunosuppresive medications
    • Medications: Aminogylcosides, Quinolones, Macrolides, Beta Blockers, Non-deploarizing muscle relaxants (Paracuronium, Vecuronium, Atracurium), Local anesthetitcs, Botulinum toxin

Medical Musing of the Week: Autoimmune Hepatitis


  • AIH is a chronic disease of unknown etiology marked by hepatocellular damage, inflammation and necrosis
  • 3 Subtypes: AIH 1, AIH 2, AIH 3 (2 is the most common!)



  • Unknown
  • Potential post viral (EBV, Hep A, Hep B or Measles)
  • Toxin exposure (Macrobid, Minocycline, Infliximab


  • Genetic predisposition w/ environmental triggers
  • Cell mediated immunologic attack
  • High serum globulin concentration
  • Potential alterations of T and B cell function


Risk Factors

  • Women 40-50
  • Known Autoimmune disease

Clinical Manifestations

  • History: fatigue, myalgias, pruritus, RUQ pain, amenorrhea
  • PE: jaundice, rash, spider angiomata, hepatomegaly, ascities, encephalopathy
  • Labs: prolonged PT, new coagulopathy
  • Onset is usually insidious
  • Up to 40% of individuals present with acute fulminant hepatitis w/ jaundice + new coagulopathy


  • Liver biopsy is gold standard (mononuclear cell infiltrate & bridging necrosis on histologic examination
  • Elevated IgG, + ANA, +ASMA
  • Elevated AST/ALT AT LEAST 1.5x upper limit of normal



  • Indefinite treatment is liver transplant
  • Prednisone w or wo Azathioprine
  • Prednisone:
    • If patient is symptomatic w/ AST/ALT 10x upper limit
    • AST/ALT 5x upper limit of normal + 2x increase in serum globulins
    • Start 30mg then taper after 1 wk to 20mg, 15mg for 2-3 weeks and then maintain at 10mg
  • End points of treatment:
    • Remission, failure, incomplete response or drug toxcicity
    • Average duration of therapy is 1.5-2 years

Follow up & Considerations

  • CBC weekly x2 if Azathioprine therapy
  • Monitor for osteoporosis with prolonged steroid therapy
  • Repeat liver biopsy after 18 months to confirm histologic improvement to d/c steroids
  • Relapse rate is 60-80%


  • Primary Billiary Cirrhosis
  • Primary Sclerosing Cholangitis
  • Progression to Cirrhosis or Liver Failure
  • Varicies, encephalopathy, coagulopathies

Board Review Product Focus: Physician Assistant Study Guide


Physician Assistant Study Guide

By: National Physician Assistant Education

First, I would like to say that I love ALL of these products and if I were taking the boards I would definitely be purchasing from National Physician Assistant Education. They offer three products which include PANCE/PANRE Study Guide PDF, PANCE/PANRE Study Guide Paperback Book & PANCE/PANRE 2016: Online PA Board Review Program.


This is the most concise resource I’ve seen while still being able to maintain comprehension.  The readability of the product is wonderful, the PDF could not be better organized.  It is put together by organ system just as the PANCE/PANRE so you won’t miss a thing you need to be prepared for your exam.

Helpful Hint: Download to google drive on your iPad to have easy access on-the-go! (or whichever tablet of choice you may own :))

Access PANCE/PANRE Study Guide HERE.  Original price: $14.99.

Use “allthingspa15” for 15% off! 

Example of PDF presentation below:


PANCE/PANRE Study Guide Paper Back Book

If you are old school like me and prefer having a physical book in front of you to jot down notes and make your own, this is a great option. What’s also wonderful about getting the paper back book is that you get a TON of bonus materials!  In addition to a printed version of the PDF, you also get access to the online PDF for quick on-the-go access, full length 300 question practice exam access, and a comprehensive review list.

Access the PANCE/PANRE Study Guide Paper Back Book HERE.

Use “allthingspa15” for 15% off

PANCE/PANRE 2016: Online PA Board Review Program

The whole she-bang. The online review program is honestly awesome.  It has everything you need to prepare and excel for the PANCE or PANRE. The whole program was developed through a website and App called Schoology so you can conveniently study whenever and wherever you want! The website, program and app are incredibly user friendly and well organized.  The content is beyond comprehensive.  Organized by organ system and the NCCPA blueprint. With each organ system you get the PDF, Audio review, several matching quizzes.

In total you get 2000+ practice questions, 10 hours of audio review, 100+ flash cards, 109 page PDF review, 13 progress quizzes and 5 full-length exams.  

For $199 this is an awesome deal.  I paid $400 for my Kaplan review course and ended up not even using it because I didn’t think it was worthwhile.  I would have much preferred the PANCE/PANRE Online PA Board Review Program.  

Access PANCE/PANRE Online PA Board Review Program HERE.

Use “allthingspa15” for 15% off


5 EKG Resources for PA Students

EKG’s are a part of my daily life at work and also one aspect of clinical medicine I struggled with the most.  Below I’ve handpicked 5 EKG resources I wish I would have watched both before I started my first EKG lecture and throughout learning EKG’s. Disclaimer: By “BEFORE” I mean a few days prior to your first lecture when you have reviewed your classroom materials and want to have a deeper understanding before class.  Again, I also recommend using these tools throughout school to continue to learn!

1.How to Read an EKG: Khan-Academy Style Tutorial

If you let this continue to play to the next video it is actually a series of 10 videos that through your journey of learning EKG’s will be extremely helpful!  I recommend only watching until you don’t feel overwhelmed.  This may vary for individuals based on their background.  For instance I may have watched the first three videos; but, for someone with a paramedic background this would probably be too simple or they may watch all of them for a refresher!


 2. ECG Zone: Tutorials & Cases

These are case studies that help you learn how to interpret EKG’s. This may be too much for someone before in class lectures.  Definitely a great resource to have as you go along and learn!


3. The Rapid Interpretation of EKG’s

This is a comprehensive book of all the rhythms you need to know in PA school and clinical practice.  At times it is a bit slow and basic; but, I’m sure a review never hurt anyone.  I think I paid around $14.99 and I think you can get it cheaper on kindle/ibooks. Contains everything from physiology explanations, the different pacemakers of the heart, pictures of EKG strips, explanations of arrhythmias, etc. This is the resource that I used in PA school.  Click here to buy.  DISCLAIMER: The link is to the 5th edition.  There is now a 6th edition out; however, it costs about $50 dollars more.  If you want to purchase the 6th edition click here.


4. EKG Interpretation: 24 Hours or Less to Easily Pass the ECG Portion of NCLEX


Made for nursing boards but also great for the PA student.  Again, if you were a paramedic to fulfill your health care experience hours this will probably be too simple for you (you could probably teach the EKG portion in PA school). Contains links to videos, explains basics of conduction and how it relates to the physiology of the heart.  Explains all of the arrhythmias and gives good picture examples.  The BEST part about this book is that if you have kindle unlimited with amazon ($9.99/month) it is FREE!.  If you don’t have a subscription you can buy for about $2.99.  Definitely a great buy for the dollar value.  Click here to buy!


5. ECG Interpretation & Rhythm Recognition

Another great Amazon Kindle Unlimited find! This is a bit more in depth that the above option with more pictures and nitty gritty information on arrhythmias and how the are represented on EKG. I would read one of the more simple/basic resources such as #3 or #4 first before delving in to this book. Click here to buy!


Top 5 Ways to Get PA Shadowing Hours

1. PA Shadow Online

This is a website (click here to visit) where you create your own username and password.  After you can search an entire database of PA’s who are willing to have students shadow. I have not personally used this; however, from my understanding you search the location you want to shadow and use the site to contact PA’s.


2. Teaching Institutions

Most major teaching institutions have a designated individual in the education department (title may vary by site) who you can contact in order to ask about shadowing opportunities.  For instance if you go onto UPMC’s website and search “physician assistant shadow” results return for their job shadow program and contact information is available.


3. Friend of a friend of a friend.

Squeaky wheel gets the grease.  I got a lot of my shadowing hours by asking everyone I knew if they knew a PA and if I could shadow them.  Then if I shadowed that PA I would ask kindly if they knew anyone in other specialties who would be willing to have me for a day.  If you don’t ask the answer is always no.


4. Cold calling or e-mailing

As lame as it sounds it works. It’s quick and simple. Google search your area and call away.


5. Show up

Walk in to offices and speak with the receptionist.  Don’t show up empty handed! Bring your resume with a cover letter stating your intentions.  I know personally now, if a student showed up where I was working, professionally dressed resume and cover letter in tow to shadow me I would never say no.  If you dress professionally there is a good chance the secretary will comment about it when handing your information to the PA!


Top 7 Ways to Avoid Burnout in PA School

Let’s be honest, we all go in guns blazing thinking we can study 24/7 and survive on coffee alone. This could not be further from the truth, let me help you get a jump start on everyone in your class with some quick advise!

1. Exercise.

We do a lot of sitting in PA school, finding a way to blow off physical steam helps break up the study process and give yourself a mental break from the books!


2. Go have fun.

See your friends, boyfriend, girlfriend and do whatever it is you do for fun.  Movies, drinks, dinner, etc. Make time for balance in your PA school career.  I promise a few hours a week will not make or break your GPA (btw as long as you are passing no one really cares about your GPA when you graduate unless you’re applying for a residency)



3. Rest Days.

They aren’t just for your workout schedule anymore.  Just like muscle needs time to rest in order to re-build, so does your brain! Friday nights became my “rest days” from studying.  It gave me time to relax, see my friends and spend time away from my books! Let your brain recover and come back strong Saturday morning.



4. A little bit goes a long way.

Chip away at your work each night.  Review the days lectures when you get home.  This prevents the need to cram which is stressful and stress contributes to burn out.



5. One bad grade won’t kill you.

Listen, I hear you–we are all type A people and want to perform well in school. However, let me be real with you…in 5 years this will not matter.  No one will care that you bombed one of you Anatomy practicals.  In fact no one will likely even find out.  I am in no way advocating failing exams.  I’m just suggesting perspective.  Work hard and learn, but likely you will have one test that “gets you” in PA school and I’m here to tell you it will be ok.  In athletics I was always told: “The best athletes have the shortest memories”.  You had a bad performance.  Shake it off and kill it on the next exam 🙂



6. Take one week at a time.

Concentrate on the week ahead of you, it gives you small goals to work towards and at the end of each week you can feel good about crossing part of the semester off your list!


7. Enjoy the Journey

Not always the easiest thing to do I realize.  However, go back and read your personal statement.  Remember why you are doing this.  Remember how many people wanted to be in your shoes and you got lucky enough to be chosen!  Time flies so learn lots and have fun with it!




How Working In Medicine Gives Me Perspective On My Health

For those of you who do not know, I practice medicine as a Hospitalist Physician Assistant. Well, technically I am a traveling PA, but I don’t think I will ever leave general medicine (for now).

I see ALOT of very sick patients.  So many people are so sick that I think at times I lose perspective that healthy people actually exist.  I see people everyday who can’t walk because they are so short of breath, who are sick all of the time because they are immunocompromised, have severe heart failiure, complications of Diabetes, have suffered a Stroke, etc.

Just last week I took care of a patient who previously survived Adenocarcinoma Gastric CA status post partial gastrectomy. He had been symptom free for several years and now as a complication of treatment requires biliary duct stenting every 3 months in order for their intestinal tract to function properly.  Prior to admission this patient could not tolerate any food or liquid by mouth and was experiencing severe nausea and vomiting for several days.

I walked away from this room and was first of all humbled because he was the nicest person ever.  Didn’t complain, was soft spoken.  Second of all I thought how damn lucky am I? No matter how bad a day at work might seem on some days I get to leave.  I use my legs that function properly to walk out of the hospital and go home to my dog.  I have the ability to lift heavy weights, run, drive and function on a daily basis without assistance.  I don’t require any life sustaining medications or surgeries.

I am lucky.  Sometimes when I am tired on my weeks on service (12 hour shifts for 7 days) and think I am too tired to go workout or walk my dog I think about stories of the people I treat. Not because I like to think of sad things but because it is a reminder to myself not to take my health for granted.

I know we all have bad days and can moan about policies, co-workers, bosses, whatever the case—- bad days happen (this is not me saying anything bad about my job).  But don’t forget how lucky we are to be able to get ourselves to work and provide ourselves with a decent living.  Most importantly pay that thankfulness forward in kindness to patients 🙂