Tag: 19JessicaZ

My last day at Cary Pediatrics was a great close to my work experience. Dr. Villareal’s first three patients were all teenage well checks, so he let me shadow one of the phone nurses, Jenni, instead. I learned that it’s one of the crucial jobs that most people don’t even realize exists (I certainly didn’t before my time at the office). When I thought of “nurse,” I had always pictured someone in scrubs taking measurements of and giving shots to patients, but I discovered that phone nurses are the foundation of support for patients calling in about practically anything. Jenni worked with incredible accuracy, detail, and speed to replay messages left by parents, take notes on their content, peruse the patients’ medical records, call back parents and/or pharmacies, and take further action if needed (whether that was writing a note to the doctor, suggesting a home remedy, or scheduling an appointment). One of the most important parts of her job is telephone triage, which essentially means making a decision on when to see the patient based on calls describing their symptoms. It’s tricky because the nurse can’t physically see the patient but must decide how severe their case is; the procedure is to go down a list of yes-or-no questions decreasing in severity of present symptoms. At the first “yes,” the nurse directs the patient to follow that category of urgency, ranging from home care up to calling emergency services (see attached picture). Jenni told me that she had been doing it for so long that she had basically memorized the questions to ask for common symptoms such as a sore throat, and an online program helped in cases of rarer symptoms. It was eye-opening to see a usually hidden or disregarded side of pediatrics at such a close level.

Additionally, there is at least one interesting story every day; today was no exception. This appointment was actually a Spanish-speaking one, so Dr. Villareal had to explain everything to me afterwards. Long story short, the family had gone to an alternative medicine doctor in Winston-Salem who claimed she could cure autism and was requesting urine and stool samples for their six-year-old boy. This case showed me yet another aspect that doctors have to deal with: false advice or differing views that could turn a patient’s opinion against them. Practicing medicine is so much more than just learning the textbook inside and out; I’ve seen time and again now how flexibility and good communication skills are just as vital to the job.

Ultimately, I’ve really enjoyed my time here at Cary Pediatrics, and I’ve learned so much more than I had anticipated. I’m thankful for the wonderful opportunity I had to shadow Dr. Villareal and the other staff, and I would highly recommend anyone who likes pediatrics, medicine, or kids to try it out as their work experience!

 

The most different thing about today was a lunch meeting. Someone brought pizza for everyone and we all gathered in the lobby for a meeting with Jackie from a program called Reach Out and Read Carolinas. It already has over 300 participating locations in North Carolina, and is currently looking to work with Cary, Apex, and Fuquay-Varina Pediatrics to expand its reach. Reach Out and Read is a program implemented in pediatric centers that provides a free book to patients at every well check from six months to five years old. Dr. Villareal explained to me that providing enough books to all three locations would not be cheap, but that they ultimately decided to implement it for the benefit of their patients. I thought it would be a wonderful opportunity to both emphasize the importance of reading from a young age and provide families with books who may not otherwise have that opportunity. The meeting gave me some insight about expanding the office and its programs that I did not get otherwise in my daily shadowing of the doctor.

Additionally, I got to see a little more of the mother’s side in the newborn story. There was a mother who came in with a five-week-old girl. There were already some complications with the baby — she had had an infection in one of her tear ducts and had to stay in the hospital for a week. They had just been cleared from the hospital a few days ago and the mother was visibly exhausted. Her baby was crying the whole visit, and she explained that she was probably hungry because she hadn’t had a chance to feed her. When Dr. Villareal asked her how much she nursed per day, the mother pulled out an app on her phone and revealed that it was 8-9 hours daily. On top of that, the baby rarely took naps. She told the doctor that she had been going to a lactation support group but that they only found things wrong with every member and that it made her feel worse. Dr. Villareal assured her that her feeding schedule was perfectly normal and that she should continue doing what she was doing. I saw that pediatricians not only have to care for children, but also their parents. I’m excited to see what my last day at Cary Pediatrics has in store!

 

Today was less busy than yesterday, but we still saw our fair share of patients. The first appointment of the day was an 18-year-old well check, so I stayed in the nurses’ lounge/workspace outside the patient rooms while Dr. Villareal went in to examine the patient. The nurse schedule rotates daily, with each nurse in charge of one doctor’s patients, or working as a general nurse, or floating. Dr. Villareal’s nurse today was JJ, and during the first appointment she showed me how to draw up a vaccination shot. She showed me both half- and one-inch needles, explaining that a longer needle is necessary for intramuscular injections (administered to muscle) while shorter ones would suffice for subcutaneous injections (administered to fat). She took the required vaccine (in this case, meningitis B) from a special refrigerator and a one-inch needle, and connected them with a simple twist. The shot then had to be documented by the identification number on its label, type of vaccine, and patient. This same procedure would have to be done to each shot throughout the day.

There were a few slightly more memorable cases today. One was a two-year-old boy who was the only patient that Dr. Villareal could remember he had sent to a gastrointestinal specialist because of his weight. I saw that he was quite petite, but fortunately he was gaining weight and doing just fine. (Though he was in the 1st or 2nd percentile for weight, the important thing was that he stayed on his curve without major fluctuations.) Another patient was a 16-year-old boy who was abnormally dependent on his mother. Usually, when the nurse calls teenagers back from the waiting area, she asks their parents to wait outside; this boy insisted that his mother come (and couldn’t accurately say which medications he was taking). When time came for his one shot, it took JJ at least ten minutes of talking to him and soothing him, plus Dr. Villareal going into the room and distracting him, before he would sit still and relax enough to receive his vaccination. Overall, there are so many stories a doctor encounters in just one day, which I think is one of the best parts of the job. I can’t wait to see what the rest of my time here holds!

 

Today was our busiest day yet, since two out of the four doctors were out of the office. In total, we saw over 30 patients (for comparison, we only had 18 on Friday). Because the schedule was so full, we were moving from appointment to appointment with hardly any time in between. There weren’t too many particularly salient cases that stood out to me except for an operation that I watched two nurses perform. A nine-month-old girl had come in for a sick visit, and Dr. Villareal suspected that she might have a urinary tract infection. However, because there was no way to get her to pee into a cup for a urine test, the nurses had to use a catheter. Honestly, it was kind of horrifying to watch — her mother had to pin down her arms while one nurse held her legs and another nurse numbed her and inserted the tube. On top of that, it took multiple tries to properly insert the tube, and the baby was crying and screaming the entire time. The nurses finally succeeded, but overall it was very uncomfortable to watch; however, I’m glad I did so I could experience the procedure. The poor girl also had to get her blood drawn (sample results included in pic).

Other than that, there were just a lot of well and sick checks. I think at least half of the sick visits ended in a strep test, with a couple being positive. We also saw a few newborns — seven days old and four days old — and I learned that babies actually lose weight in the first few days after they’re born because of fluid from the womb.

Lastly, there were a few more cases of troublesome parents/patients (nothing new there). There was one mother who insisted on seeing a neurologist for her son’s panic attacks, even though all the doctors and nurses had tried to tell her that a psychiatrist would be much more appropriate. She tried to call the neurologist herself, and lo and behold, they refused to see her. She then approached the pediatric office again, only to be refused again. There was also a 17-year-old patient who had suddenly requested to switch from pills to liquid after seven years of taking the same medication. (Dr. Villareal was certain it was because he wanted to do something malicious or abuse the drugs.) It showed once again the difficulties that doctors have to deal with on top of the already challenging process of checkup and diagnosis. I’m excited for the rest of my time here!

 

Today was slightly less busy than the first few days of the week, but we still saw a good number of patients. I learned even more about the wide scope of a pediatrician’s job: not only do they have to handle and diagnose uncooperative children, but they also have to deal with their parents — almost another set of patients in and of themselves. In fact, even before we started the day, I was warned about a couple parents we would be seeing on the schedule. One that stood out to me was a mother who had to be absolutely certain that her daughter’s father would not be able to find out certain information in case he were to call the office asking for details of her appointment (because he would “punish” her). Dr. Villareal had to explain that he did have legal parental rights to his daughter but that she could put certain comments in a “confidential” section that he would not be able to see. Another mom asked the doctor about her son’s rash, when he wasn’t even present at the appointment (it was his sister’s checkup). There was also a boy coming in for medication management who had already been prescribed three different medicines, none of which were working. Dr. Villareal explained to me that he suspected that the patient hadn’t actually been taking them as directed and that he might have been faking his side effects, but that there was no way to be sure. Out of options, he had to refer the patient to a psychiatrist instead. (Complete referrals were rare; the doctor had only had about three in the six years he had been working at the office.) In yet another case, Dr. Villareal recounted something that had happened to the patient’s sister weeks ago — showing his incredible memory and attention to detail. In all, I learned that the job requires many social and communication skills in addition to just medicinal knowledge.

I also got to see a bit more of what the nurses do around the office. Two additional tasks that I observed today were the weighing and measuring of a four-month-old baby and a strep test. The nurses always call the patient in from the waiting room and take their measurements, but it’s a little harder for children who are too young to stand up. They have to use a scale to lay them down and weigh them, and they do their best to lay the baby flat and make marks using a pen on a large sheet of paper to measure their length. The strep test included two samples from cotton swabs that the doctor took from a patient’s throat. One was tested immediately and if it was negative, the other would be plated and cultured overnight for a reading 24 hours later. The nurses are also responsible for running and reading other tests such as urine and blood. I had a fantastic first week at Cary Pediatrics, and I can’t wait for next week!

 

Today, I got to see two specialists in addition to shadowing Dr. Villareal. The first was Janice, the developmental screening specialist. She typically has fewer appointments but each one is longer than a traditional checkup due to all the skills she has to test. I had the opportunity to watch a screening of a three-year-old boy whose mother was worried about his speech and fine motor skills. The boy turned out to be on the higher end of Janice’s spectrum of patients – they are carefully tested for specific skills and scored on a scale of 100, with 45 being the passing mark. (This patient received a score well into the 80s.) The meeting consisted of Janice asking the boy’s mother about how he behaved at home, then using toys and pictures to stimulate responses from him. He was a very bright kid; the only thing he had some trouble with was pronouncing certain consonants such as c’s, g’s, and r’s, as well as gripping a crayon. As he answered questions, Janice would take notes on a sheet of paper and at the end she scored his responses to report.

The second specialist I had the opportunity to briefly shadow was Zana, the nutritionist. The particular appointment I observed was a bit different in that only the mother of the patient was present, with the nine-year-old boy himself absent. The boy was on the spectrum as well as a supertaster, and was very picky about foods but seemed to be gaining weight. His mother had brought in a sheet of paper with a list of all the foods he could eat, as well as a slightly shorter list of foods he used to eat but now refused. In the end, Zana helped her create an eating schedule for the patient to make sure he wasn’t just eating out of boredom (the next step would be to try to change his food combinations).

There were also a few interesting cases during my time with Dr. Villareal, notably an ADHD consultation and a medication modification checkup. I can’t disclose any information that might identify the patient, but I will say that the latter meeting became quite tense and lasted over half an hour, much longer than the typical appointment. It didn’t seem to be within the scope of Dr. Villareal’s job (and he told me afterward that it was a rare occurrence), but he dealt with it with surprising calmness and poise. It just went to show how flexible and prepared a doctor has to be. I’m looking forward to the rest of my work experience!

 

Today was equally busy and eventful. We started the schedule off with a newborn baby, just five days old and here for the first checkup of his life. I was not expecting him to be so tiny — he was almost like a doll in his mother’s hands! His two four-year-old brothers had also accompanied him to his appointment, and there was not a single moment of quiet during the checkup. While they fought over who was to hold their mother’s phone, blasting an episode of Daniel Tiger, their baby brother cried as Dr. Villareal tried to talk to the mother. Eventually the nurse came in, having heard the commotion and trying to alleviate the situation with crayons and paper, but by then one of the older brothers was in time-out. I learned that being a pediatrician is so much more than being a doctor for smaller humans — it’s also being a teacher, communicator, babysitter, and so much more.

Another case that stood out today was a two-month-old girl who had come in for both a checkup and ear piercing. Dr. Villareal told me that he pierced ears for children from two to six months old and age seven and older; I thought it was interesting that those middle years were actually the hardest to get the kid to sit still. Of course, the two-month-old was far from easy, either. She began squirming and crying even when the doctor drew dots on her ears with just a normal pen (to ensure the right placement of the piercings). I couldn’t even imagine clicking the piercing gun, inserting the earrings for life, into such a wriggling child. I probably would’ve missed her ear entirely, but Dr. Villareal skillfully and efficiently deposited the studs — just another part of his job.

I also got some experience with Dr. Villareal’s nurse, JJ. Whenever he had an annual checkup for a teenager, I was free since we agreed that it would be awkward for me to watch one of my peers (sick visits were different), so I took the opportunity to shadow JJ instead. Her job was to call the patient in from the lobby/waiting area, do a quick height/weight/blood pressure/hearing test, ask about any questions or concerns, and let the patient know the doctor would be with them shortly. She also gave the shots after the doctor left. I was able to watch her give three shots to a four-year-old girl, who was definitely one of the better cases. The shots were quick, and she was brave; she didn’t cry a single tear. I’m excited to see what the rest of my experience holds!

 

I had a great first day shadowing Dr. Mike Villareal at Cary Pediatrics. I was able to see a plethora of patients, ranging in age from a few months old to a couple years older than me, and both sick and well checks provided a wide variety of cases. Something that surprised me was the number of ADHD checkups. Kids coming in to change or replace medication was almost just as common as an annual checkup or a minor sickness. It wasn’t anything complicated, either: Dr. Villareal would ask about recent symptoms and suggest medication in chewable or liquid form, the patient and their family would make a decision, and the prescription was sent to the pharmacy. Aside from these cases, we also saw a wide range of minor sick visits, spanning rashes to breathing problems to ear infections to sleep training. It was difficult for the smaller children to sit still and remain calm through all the probing required of the checkup, but Dr. Villareal did a fantastic job both placating and efficiently evaluating them. Being a Spanish-speaking doctor, he also treated several patients in Spanish only (I picked up bits and pieces of the conversation and he explained the main points afterward). Overall, I loved seeing so many different children who were either healthy and strong or on their way to being healthy and strong.

I also had the opportunity to briefly shadow the other staff at the office. One of the highlights of the day was being able to watch Dr. Hope Seidel perform a Nexplanon (a contraceptive implant) operation, where a small tube was cut and removed from a patient’s arm and replaced with a new one. I had never seen an operation up close before, and it was incredibly kind of the patient to allow us to watch. What surprised me the most was when Dr. Seidel pulled out what looked like an exacto knife and inserted the blade straight into the patient’s arm to start cutting out the tube. We weren’t allowed to have phones in patient areas so unfortunately I couldn’t take pictures, but it was truly a unique experience I won’t forget. I’m looking forward to the rest of my time here!