Nearing the End of 2nd Year

Well, in a few short weeks my core classes will be finished and I will be mostly studying for Board Exams (USMLE, COMLEX) and gearing up for rotations. My third year rotations will mostly be taking place around Fairfield and Napa, with two rotations out in Stockton (psychiatry and hospital-internal medicine). That isn't until the end of year 3. My schedule only permits one month of vacation, which I intend to take right at the beginning so I can extend the time that Itake USMLE and COMLEX by a month - an extra month of studying will make a big difference, especially since that is ALL I will be doing. I am leaving a week between the COMLEX and the start of rotations to go on a vacation though - it's my only vacation, I should try to do something!

The unfortunate thing about Touro University is they do not let us finish school very early. We are in actual classes up to April/May, many mandatory, while other schools have already finished second year to give students time to study for boards! No wonder Touro students perform more poorly on boards. It's hard to keep up with boards and classes at the same time. Luckily a lot of the boards review is starting to overlap with what we are currently studying, so hopefully that'll help out a bit.

I also had an interesting extra-clinical experience - we are required to do a visit and then 6 month follow-up with a geriatric patient at a nearby retirement community. When I went to visit, it so happened that my patient had fallen in a parking lot that day and did not feel up to visiting the clinic, so the head nurse told me to make a house call. In a way, it's kind of ironic that my first "house call," once a traditional type of doctor visit, is probably the only one I shall make in my career. It was a little awkward, but kind of cool to examine a patient with an acute injury in the comfort of her home (in case you were concerned, she was barely injured - extremely lucky considering she is an 83 year old female with history of osteoporosis and is on anti-coagulation medications - she could have easily broken her hip, leg, or wrist, or ended up bleeding a ton).

On another "fun" note, we get to do rectal, breast, and vaginal exams on paid "patients" this week...not particularly looking forward to it, but at least I have experienced all three, so it's not an entirely foreign concept. We are getting into the genitourinary and pediatrics sections now so ... time to race to the finish line. I still have some fun stuff planned - next week double date to Sattui Winery for complimentary tastings, thanks to being wine club members. Anyhow, back to boards review...

LASIK Complete!

Well, I got my LASIK done yesterday - and I'm sure everyone is curious about the medical procedure. My first appointment was a while ago where they checked my eyes to determine whether I was a good candidate. Some of the criteria include nearsightedness less than -10.00, sufficient corneal thickness, no severe eye dryness, and little or no astigmatism or other eye problems. My eyes are somewhat dry, both were around -3.00, unnoticeable asigmatism, and a slightly thicker cornea than average, so I was a good candidate.

The second visit, they dilated my eyes and did other tests to get exact readings on my eyes, we discussed payments, methods of going about the laser eye stuff, etc. I went with the laser system for cutting the flap in the eye (instead of a hand held microtome) and LASIK (laser-assisted in situ keratomileusis). After a couple reschedules, my LASIK date was finally set for Dec. 4.

I was instructed to wear glasses (no contacts) for the week prior to the surgery, I had to take a Valium (5mg) 1 hour before the surgery, and have someone drive me to and from the surgery center. When I arrived, they took me into a room to analyze my eyes, I forget what the first test was for, but the second one was to map my iris (similar to iris-recognition for security) so that the laser could lock onto my eye. This was part of the "Custom Vue" LASIK, where they use Wavefront, WaveScan, and WavePrint technology to get a very accurate fingerprint of the eye, so to speak. Supposedly, it can also measure flaws in the eye 25x more precisely than traditional methods. Then they cleaned the area around my eyes, put in numbing drops and antibiotics, and we headed to the first station - the intralase machine (the laser which cuts the corneal flap).

This was the most uncomfortable part - they had to prop my eyes open clockwork orange-style, then attach a plastic fixture to my eyeball with suction, so it was completely fitted to my eye. Then the other end was attached to the intralase machine, and basically my eye saw those gray/white/black patterns you see in your eye when you press on it. Then I had to hold still for a moment and it cut the flap; I couldn't feel it, maybe there was a slight warmth. Then we repeated for the other eye and I went to another room for the LASIK laser procedure. They propped my eyes open again, taped my eyelashes back, added more numbing drops, and had me look up at the laser. The doctor folded back the flap on my eye. The laser itself was a green color, but there were bright dentist-like lights on either side, which were painfully blinding. As they focused the laser's position, there was a grid of red light that I saw pass over my eye. Then I held my focus on the green laser point for a few seconds as it did its work. I could smell flesh burning...not too pleasant. Afterward, the doctor replaced the flap on the eye and smoothed the lines of the incision to make sure it was firmly back in place. Then we repeated with the other eye and I sat aside for a bit while someone else had the same procedure done. Afterwards, my eyes hurt quite a bit - like there was sand in them and some of the chemicals made it difficult to open my lids. The doctor rechecked the eyes, said that the procedure went perfectly and the flap was back in place. About 2 or 3 hours after being back home the pain had gone away and I could open my eyes for brief periods of time.

As far as post-op care, I cannot use eye makeup, wash my eyes, do any strenuous activities or go swimming, and must put one drop each of Vigamox (Moxifloxacin hydrochloride) and Vexol (Rimexolone) into each eye four times per day, and use Systane (preservative-free) eye drops as needed for dryness. I also cannot rub my eyes and must wear goggles at night and sunglasses outside. I also have to be careful when doing activities that tend to cause less blinking, such as working on the computer, reading, or watching TV - essentially, I have to remember to blink or hold my eyes shut every so often. I have to keep up this post-op care for 1 week, but I have a blackberry app that lets me do as many different alarms as I want, so I have 1 wake-up alarm, 4 eye drop alarms, and 1 birth control pill alarm. I can make it play whatever song I want as the alarm, too, and change it for each alarm - if anyone's curious, this is the app.

The next day (today) I went back in the morning for him to check how my vision had changed, and I am 20/15 in both eyes - so better than 20/20 (standard). I have a followup in a week to make sure things are healing correctly, and other than that it went off without a hitch. It's great being able to see without contacts or glasses! It feels so weird that such a short procedure, which doesn't look or feel like anything changed with my eyes (currently, anyway) could suddenly make it possible to see super-perfectly clear.

As for the breakdown, Dr. Auker's costs for examination and supervision of the procedure were $2,350, use of the LASIK machine was $2,150, and the intralase machine was $600. My mom had originally offered to cover $3,000 as a gift to me, and when it turned out to be more, I covered the excess. So in total, $5,100 dollars for both eyes, $2,100 out of my own pocket, but I got 20/15 vision out of it so I'd say that's money well spent. I should point out that Dr. Auker and the laser center are more pricey than other options out there, and I do not know whether there is a substantial difference in quality - Dr. Auker treated my mom's eyes about 10 years ago when he was still with Kaiser and she is still happy with the results - he now has a private practice. Considering his experience, and the fact that he was performing LASIK successfully when it was brand new with good long-term results, made me feel more confident in his skills/knowledge and more likely to choose him over a cheaper alternative. To see his website, click here.

Faster and Faster

I used to be more on the side of patients when it came to doctor visits, but now I'm feeling a lot worse for the doctors... We have gone through the general screening exam, which includes neuromuscular, cardiac, respiratory, gastrointestinal, HEENT and taking vitals thus far. If we are allowed to do it at our own pace, no rushing, talking sweetly to the patient, etc. it takes us about 30-40 minutes to do it at this point. We are expected to speed it up to 15 minutes. I have been able to do it all in about 15:45 minutes, but it feels so rushed as far as barking orders and telling the patient to jump and sit that I can see even more clearly how a patient would feel like a physician doesn't care about them. Unfortunately, when we're expected to cram exams into a tiny amount of time...it's hard to do it in a way that makes a patient feel happy.

Of course, I'm betting that's where the magic of experience and bedside manner kick in. I'm going to try to practice the exam in 15 minutes but also practice my tone of voice and memorize concise, simple instructions so that I don't feel like I need to cram my words together. That, and I need to get a really good feel for the order and routine, as well as the phrases...ugh! So much to remember! We are required to say specific "lines" when we do examinations, such as "Patient is breathing easily, quietly, and regularly" or "Patient presents with no edema and is not diaphoretic or cyanotic." It really feels like being an actor/actress almost, since they really are lines.

In other news, I got a massage table, which I plan to use for massages, OMM, and exams - so that should help a lot. Also, we're focusing on hemostasis and hematological diseases at the moment - all very interesting and familiar since I worked in the laboratory for 3 years and I've seen all the lab tests before. Goal for this is to memorize the clotting cascade, the diseases, and the treatments, as well as go back over all the stuff I've already learned and try to commit it to memory.

Radiation, oh my!

In our radiology lecture today, we were discussing how x-ray machines work, from traditional film x-rays to angiograms and radioactive dyes. There was a chart I thought was interesting that compared the chances of getting cancer from a typical dose of radiation to the chances of other life-endangering conditions:

So basically, getting a chest x-ray is about as risky as spending 3 days in the US, or eating several spoonfuls of peanut butter. I definitely did not think peanut butter was so dangerous... Apparently there is a mold that grows on plants such as corn and peanuts, and it produces a toxin that can be highly carcinogenic. The bacterium is named Aspergillus flavus, A. flavus, and thus its toxin was named Aflatoxin. There is another species in the same genus that also produces the toxin, but A. flavus was discovered first so its name was used. I'm not saying we shouldn't eat peanut butter, I'm just surprised that there was such a risk.

Sunday is the white coat ceremony, and in the meantime I'll be hanging out with Kit - he's visiting for the weekend. We have been going over a lot of biochemistry, but most people in class are having some trouble with our professor's lecture style. I imagine it would be very difficult to understand the jumps from one cycle to another and the brevity of his explanations if one had never taken biochemistry. Lucky for me, most of this is old hat. I'll spend most of next week working on those objectives, and hopefully the first exam (August 31) will go well. I also got my approval to take the Medical Spanish elective, which doesn't start until September 31. On Monday I'll be finding the professor who is teaching the advanced nutrition course so I can take that, and also I'll make an appointment to get another tuberculosis test - the physician who did my physical doesn't think the stuff I sent from Kaiser is official enough, and I can't get the records unless I go to San Diego in person, so screw it - I don't mind getting a bubble in my arm if it'll finally end this ordeal. Besides, if I don't have all my immunization stuff in, then my grades won't be disclosed and I'll be left out of clinical activities.

Nose Deep in Clinically Oriented Anatomy

One of our largest, densest texts is Clinically Oriented Anatomy, which our anatomy professor, during his very informal first class, told us we didn't really need to read in much depth. I think that was very misleading (he just wants us to read the easier beginning anatomy text he wrote himself). Also, they put up a lecture powerpoint for the anatomy lab, and even have a section on the schedule which logically is the lecture for the lab, but apparently we are not being lectured on the anatomy lab lecture powerpoints, so we have to go over them in depth beforehand by ourselves if we want to know what's going on in lab. I also know I wasn't the only one - no one else in my group knew what to do either. I don't think they were very clear with us about that, so I feel a little betrayed, but what can I do.

...except go into insane overdrive. Now I'm taking it upon myself to learn all human anatomy without the aid of lectures. Since we're also starting embryology and histology next week, I feel a pressing need to memorize the anatomy stuff before we start those subjects. I wish I had taken physiology or embryology as an undergrad - it would have made things easier for me now, and probably next week. I also dropped my phone in the toilet recently, so I went to Verizon and got a new phone - a PDA since there are some medical apps which are apparently crucial during rotations 3rd year. I ended up getting the Blackberry Storm - 8gb, all touch. I can't stand those little roller balls on the traditional Blackberries. Anyway...back to COA.

White Coat Ceremonies

Well, considering my dream, and the fact that the Touro White Coat Ceremony is drawing closer, I thought I would research a little more about the ceremony. I was surprised to learn that the ceremony was first performed in 1993, and is now practiced in over 100 medical schools. The idea behind the ceremony is that it lends identity and unity to the profession, and reminds physicians to lead their lives and practice medicine honorably and ethically. The ceremony was founded by the Arnold P. Gold Foundation at Colombia University College of Physicians and Surgeons. The foundation sought to focus on medical students and residents so as to positively influence young physicians and instill humanistic principles.

The ceremony itself includes several elements. There is the recitation of a medical oath (Hippocratic, Osteopathic), which represents the public acknowledgment by the students of the responsibilities of the profession and their willingness to assume such obligations in the presence of family, friends, and faculty. Students are cloaked in their first official white coats, there are notable speakers who address ethics and responsibilities in medicine, and after the ceremony there is a reception for the faculty, students, families, and speakers. Some schools also equip students with engraved stethoscopes and White Coat Ceremony pins.

Surprisingly, there is some debate about the benefit of this contemporary tradition - most notably a sense of elitism, premature recitation of the oath and celebration, and encourages antiquated notions such as paternalism. There is a really interesting article by the BMJ Journal of Medical Ethics about it. Personally I think sure, it might be a tad elitist, welcoming a select few into the secret doctor world that lay people don't understand, but it'll be fun and is a nice way to encourage camaraderie within the profession. Plus, it's a big deal, starting medical school - I don't see much wrong with celebrating the path we are about to take.

By the way, the Journal of Medical Ethics is FREE and viewable after registering with the website. It has a lot of nice reading material.

Something to Remember...

Sometimes, in my line of work as a low-level hospital worker, I learn things that disappoint or shock. The latest discovery is related to time-dependent blood tests. I would say that at least 75% of the people who work in the laboratory drawing blood do not have education beyond high school and vocational training - those who do have more education are usually working toward getting into a nursing program. For those who stay in the lab, sometimes the vocational training is not thorough enough and common sense just does not exist. The following case demonstrates how important it is for all people in the medical field to have a basic understanding of medicine; they need to understand why they have to do the things a certain way and the consequences if they do not follow instructions.

Some phlebotomists, particularly on the graveyard and night shifts when it is not very busy, do not want to waste time going up to get multiple samples of blood from the same patient. This is understandable if the person is a hard stick and there will be no difference if the blood is drawn at that time, or at two different times. However, some tests are measuring a person's metabolism of certain medications, and are supposed to be drawn right on time, sometimes as often as every two hours. Vancomycin is one of the common antibiotics which requires blood tests to determine the trough and peak levels of the medication. Learning that some lab assistants draw all the tubes at the same time and then write fake times (as in, they draw a tube at midnight but write that they drew it at 2:00 am) is rather alarming. If I were a patient's doctor and I thought their trough and peak levels were lower than in actuality, I would have to increase their medication and possibly cause harmful side effects. The ramifications of giving doctors incorrect information can be fatal - hearing this almost makes me want to draw all of my future patients' blood samples myself! Alas, it is not feasible, but it will at least make me think twice when I get back unexpected drug level reports.

Relishing the News

I have gradually grown to oppose dietary supplements, culminating in my history of medicine paper documenting the history of the industry (which is quite interesting). I rarely do double posts on the medical blog, but felt compelled to share a recent article. In this article, it has been found that those who take vitamin C and E supplements do not receive some of the benefits of exercise, such as increased resistance to oxidation and better control of insulin production. To spare the nitty gritty, it stems from vitamin C and E neutralizing the oxygen radicals produced from muscles respiring. As a result, the body does not receive damage from the radicals and therefore does not launch a response to the oxidation - the vitamins took care of the problem. This is not to say that antioxidants are bad, but just that megadoses of vitamins C and E is not a good option.

This is just one of many recent studies disproving the long-term health benefits of vitamins C and E in preventing heart attacks and cancer, as well as the lack of long-term benefits from taking a daily multivitamin. Like with weight loss, people always want fast, easy solutions to difficult problems, and the artificial solutions are almost always worse than the natural solution. Want to lose weight? Take ephedrine or hydroxy-cut and get a heart attack. Want to eat what you want without gaining weight? Binge and purge, while your teeth rot out. Want to eat more junk food and less fruits and vegetables? Pop a multivitamin and lose money and the benefits conferred from actual food. When it comes to one's long-term health, there is no magic solution, and people seem to refuse to acknowledge that. In an age of instant-gratification, perfect health is still unattainable at the click of a button.

The Hospital

So, I get to work tomorrow at the main hospital. I tend to avoid shifts at the main hospital, as there are more supervisors, there is stress because it is a very busy place, there are more doctors, and more complicated procedures since they have the equipment to deal with more than clinics. For example, at clinics one cannot do a blood test for deep-vein thrombosis or lactic acid. Also, the hospital is a very clique-y place. I am not sure whether it is like this outside the United States, but at most hospitals we have a large proportion of Filipino nurses and laboratory workers. I have no problem with Filipinos, but they do tend to group together and establish a hierarchy within themselves. Also, they are very communal and every lunch/dinner break becomes a potluck, which can make a person feel awkward if he only brought a meal for himself.

Politics aside, I prefer not to work within sight of my manager - since the hospital is more stressful, she is always more stressed. Even though I have a very strong union and know it takes a lot to be fired from Kaiser, I can't help but feel nervous for my job any time she brings up a single negative about my performance. Honestly, you can only be fired for something close to criminal, like compromising patient confidentiality or misidentifying a blood donor and potentially killing someone. Nothing like the good 'ol depression days where if a man doesn't work fast enough he is fired and one of the 100s of people waiting outside runs in to take his place for a penny less per hour. At any rate, it is a small comfort knowing I will be leaving in 2 months and not have to work in the laboratory again.

Magic Blue Pills

After seeing the movie "Taken" for the second time, I was reminded indirectly of those magic blue pills - Viagra. Example of indirect train of thought: girls get sold to powerful people such as sheiks, sheik in the movie was overweight, overweight leads to erectile dysfunction (ED) which is funny considering that he was buying women for sex - hopefully he had some on hand.

First, some statistics. I do not have access to the lists of data from Pfizer, Inc. but Wall Street Journal quoted the following from Pfizer's data: Viagra use results in sex 66% of the time. Men with ED who use Viagra, when compared to the placebo group, experience an increase in erection duration from 3.6 seconds to 1 minute. 50% of men do not refill their Viagra prescriptions, even though it is supposedly effective for ~75% of the population. 48% of users suffer at least one side effect, yet the percentage of men who discontinue due to side effects is 1%.

Side effects, for those who are interested: 23% experience headaches, 17% experience flushed faces, 12% have upset stomachs, and a more obscure side effect (3%) experience vision with blue-green tinges.

Some additional statistics about erections: With every increase in age by one decade there is a decline in erectile function of 12%, and for every 20 pounds of weight gain (beyond optimal, obviously) there is a 3% decline in function.

Now, how to tell whether you have physiological ED or psychological ED. During REM sleep, men and women experience physical arousal, so if a man does not experience erections during REM sleep, it indicates that the ED is a physiological problem treatable by Viagra or similar medications. However, if a man does have erections during REM, then it is psychological ED and Viagra just ignores the real problem. A cheaper method than going to a sleep lab that my cognitive science textbook recommended was wrapping a line of stamps around the penis and checking the perforations in the morning - if they're broken, then there were erections during REM.

On a final note, I thought this article was fascinating. Apparently, the CIA has begun using Viagra as one of the many less conspicuous methods of gaining favor with foreign warlords, particularly tribal chiefs in Afghanistan. It is a very logical move since supplying them with guns or money is dangerous and obvious. However, offering an elderly tribal chief medical treatments for his family, cosmetic treatments, or Viagra for help with his four young wives is more subtle and even more successful. Check out the article if you have a chance - it shows that the CIA does have a few intelligent creative thinkers on staff.

Difficult Patients

I was able to access the study from work, but now that I am home I cannot access it. It has been written about in newspapers, blogs, and magazines across the country. The main gist: doctors who see more "difficult" patients are also more burned out, more stressed, and tend to be younger-than-average female physicians. The article does not make any attempts to establish causality, though the relationship between seeing difficult patients and stress levels would seem directly proportional to common sense.

What I found more interesting were the most common attributes of patients that made them qualify as "difficult." Over 1/3 of the difficult patients were so categorized for insisting on an unnecessary medication. Another ~10% were difficult for having unrealistic expectations for their care, and ~10% were unsatisfied with the care they were receiving. I have complained before, but the US is only one of two countries (the other is either Australia or New Zealand) which advertises prescription-only drugs in the media. It is creating a culture in which people who know nothing about medications and physiology of the body to demand new, expensive name brand drugs despite their doctors' medical opinions. When a physician has a full waiting and exam rooms, he is pressed for time and often does not feel he has the time to explain why the advertised drug is not as good as the currently prescribed medication, or why the drug is not needed at all. It has gotten to the point that dangerous surgical procedures like gastric bypasses are being advertised on television!

I admit that if a patient has a physician who has not kept up-to-date with the ever growing field of medicine, then bringing new medications to his attention could do some good. However, over half of the "new" drugs released each year qualify as "Incrementally Modified Drugs", in which a different but equally potent version of the same chemical is being advertised as a new drug. Honestly, I think pharmaceuticals should not be advertised through any media PERIOD.

Put Down Those iPods!

I always objected to the bud earpieces on a comfort level - I just could not get those little things in my ears comfortably. Looks like I dodged a bullet. Most people listen to those buds with the volume so loud I can hear them from a few feet away. In my youth, I always sprang for the huge DJ headsets, which felt like they made sound easier on the ear. I used to listen to music pretty loudly, despite my parents telling me I was killing my ears. Somehow, those warnings never felt very finite - I might have a slight buzzing in my ears after an hour or two of listening, but it always went away. Even though I have since stopped pounding the music into my ears, most of the damage is probably done - at least I never stuck those buds in my ears. I always thought those smoker's lung vs. healthy lung ads were particularly convincing, so perhaps these images will be convincing to a few (c/o my CogSci class):

The first image is pristine, healthy cochlear cilia, or in simple terms, "the hairs in your inner ear that interpret sound for your brain." The second image is cochlear cilia with mild-moderate damage, and the third image is cochlear cilia with a lot of damage. Unlike lungs, which take a long time to recover but do to a certain degree, damage to cochlear cilia is PERMANENT. I seriously expect half the people in my generation to have significant hearing loss by the time they are 40 years old on account of the mp3 player/bud headset craze. Do your ears a favor - if you want to listen to music for more than half of your lifespan, turn down the volume.

Dietary Supplements

To preface this entry, a new study came out disclaiming the medical benefits of taking multivitamins, adding to the message from the November studies disclaiming the benefits of Vitamin C and Vitamin E. I have never been a big fan of dietary supplements, in fact I wrote a paper explaining why the industry is so unregulated and able to make such fantastic health claims, but many people are self-medicating with vitamins, minerals, etc. This is one of my favorite clips summing up my view on the subject:

Yes, indeed, they really are no better than placebos. Unless a person has an actual vitamin deficiency, there is no real reason to take dietary supplements. You may think you are taking steps to prevent cancer by popping that Vitamin C every day, or that your memory will improve by downing Gingko Biloba, but the odds are good that you're just producing expensive urine. As a side note, make sure you're not also taking birth control pills, since Gingko Biloba affects liver enzyme activity and you may end up getting pregnant or extremely hormonal. I am very glad that these decade-long studies are finally coming to their conclusion and proving that there are no long-term health benefits to taking dietary supplements. Maybe the hubbub will die down by the time I am practicing, and I won't have to listen to a speech by a patient enlightened by Wikipedia about the benefits of taking Selenium or Echinacea each day.

Not Just A Doctor's Visit

Working in a hospital laboratory, one can see the complexity behind a simple doctor's visit. There are many steps, and many points at which a critical error could be made. For example, say an elderly person comes in and has a suspected vitamin B-12 deficiency and a couple sores on the arm which resemble community acquired methicillin-resistant staphylococcus aureus (MRSA). So the doctor talks to the patient, swabs the wound to be cultured, suggests using multi-antibiotic ointment on the sores, and recommends eating supplements or food rich in B-12, while scheduling a follow-up appointment. At this point, the patient feels he has been treated and leaves the office, goes downstairs for a B-12 blood test and is feeling pretty good.

What the patient doesn't see is the many steps of labeling the culture tube and blood sample, tracking the sample on multiple packing lists, how long the blood sample is sitting around unspun and unaliquoted (B-12 is sensitive to light and temperature - must be put in a light-protected tube and frozen). Any one of these steps could lead to a wrong diagnosis - the B-12 could break down, the patient's medical record number could be typed in incorrectly when labels are printed, an incomplete order could result in the sample sitting around for a day or two, while aliquoting the tech could put the wrong label on the new light-resistant tube, etc. There are so many variables involved in laboratory science, it's a wonder that there are not more misdiagnoses. Maybe there are. Something has to be said for the work these people do - there is a huge volume of samples and patients to process in a given day compared to what doctors see, and they often put in extra hours or forego breaks to make sure everything is processed and sent out on time. However, most of these people, from couriers to lab assistants to receptionists, do not have more than a high school education, are overloaded with information about hospital protocol, and are constantly rushed, so mistakes inevitably happen.

After working in the lab, there are a few things I will take with me to medical school: always be courteous to hospital personnel, regardless of their position; take sensitive lab tests with unexpected results with a grain of salt - do a retest to be certain; make my instructions, particularly written instructions, as simple and clear as possible; always pick up my phone in case the lab or other department is calling for a clarification; and keep up-to-date on hospital protocols, in case test names/codes have changed or if certain tests can only be performed at specific locations.