A day in the life of a pediatrician

By Dr. Rei Tosu, a CHOC Children’s pediatrician

I’m a board-certified pediatrician at Los Alamitos Pediatrics, part of the CHOC Children’s Primary Care Network. I’ve been a pediatrician for 18 years and chose pediatrics because I love working with children. I feel that I can have the most positive impact on the health and development of my patients when I start taking care of them from day one.

Here is a typical workday for me.

6 a.m. — My alarm goes off. Most days, I’m able to forgo the snooze button and wake up the first time, mostly because I don’t want to be woken up by my alarm twice! I take a shower and make a hearty breakfast. I grew up with the idea ingrained in my head that breakfast was the most important meal of the day and I have continued to enjoy a hearty breakfast through my adult life. My husband usually leaves earlier than I do, but I wait for the kids to come down one by one and we eat breakfast together, going over the day’s schedule and making sure everyone is set for the day.

8:05 a.m. — I get into the office before my first patient is scheduled in order to give myself time to get ready for the day. I look through my email inbox, check my voicemail for messages that need to be returned and handle prescription refill requests that may need to be sent. This morning, I have a voicemail from the parents of a 13-month-old about his diet and transitioning from formula to milk. I notice in his chart that he has not had his 12-month well-check yet. I call the parents back and after addressing their questions, I ask them why they hadn’t brought him in for the 12-month checkup. They share with me their concerns about bringing their baby into the office during the pandemic, and I reassure them that it is safe to bring the baby in, that we have taken extensive safety precautions, and that it is in the baby’s best interest to keep up with their visits and their vaccines. The parents then ask that I transfer them to the front office staff so they can schedule their appointment, and I happily oblige.

8:25 a.m. — One of our nurses lets me know my first patient is ready to be seen. It’s a six-month well check. In the mornings, I tend to see a lot of well-checks, especially the younger ones who are not yet in school. Mom tells me that he has started eating solids and I can see during his exam that he is now sitting well on his own. He seems to be growing and developing well! I talk to the mom about child-proofing the home, since the chances are good that this little boy will be mobile before his next visit. During this visit, he receives his 6-month vaccines plus the flu vaccine. Flu season is upon us and it’s important for everyone to be vaccinated against influenza., Since babies and children who are receiving their first flu vaccine need two doses, they will come in another time for the second dose. I’m looking forward to seeing this baby again during his next well-check. He will have grown so much!

10 a.m. — After seeing a few other patients for their well-checks, I notice a telehealth appointment has been added to my schedule. Our office, just like many other offices around the country, started doing more of these virtual appointments this year in light of the COVID-19 pandemic. Not all medical appointments can be conducted virtually, but for the ones that can, it is a helpful way to promote physical distancing. This particular appointment is a follow-up for a 6-year-old patient with eczema. My patient finds it intriguing to see me on her parent’s laptop screen, and she proceeds to show me her room and tell me about her stuffed animals. After a tour of her room, we eventually talk about her eczema. Her mom points the camera at all the girl’s lesions so I can take a better look and we ultimately decide on a regimen for her eczema.

12:30 p.m. — Time for lunch. Before the pandemic, sometimes I would go out to lunch with co-workers or we would have lunch brought in for meetings or trainings. Most of the time, however, I bring my own lunch and eat in the office. Although current physical distancing guidelines prohibit us from all gathering in the same room and eating lunch together the way we used to, I am eager to get back to those shared meals with my colleagues. It’s a nice time to catch up with everyone and relax a little bit in the middle of hectic workdays. Many of the doctors and staff members have been working in the office for a long time and have become a tight-knit work family.

1 p.m. — I have a little bit of time before my afternoon appointments begin, so I take the opportunity to prep the charts for the following day. I go through the list of patients scheduled for tomorrow and notice I have a 3-year-old new patient. I go into her chart and notice she has had multiple specialist visits. I spend some time reading to find out she was diagnosed with kidney cancer and has been under treatment but is now in remission. One of the advantages of being part of CHOC’s Primary Care Network is that the electronic medical record platform is the same for all CHOC providers and I am able to access notes from her CHOC specialists and studies that have been done. Even though I will be meeting this patient for the first time tomorrow, I already feel well-versed with her medical history and feel comfortable taking care of her.

1:30 p.m. — I get ready for another telehealth appointment on Zoom, this time with a pregnant mom for her prenatal consult. She is expecting a baby boy next month, and I answer some questions she has about newborn care and circumcision. It’s nice for both sides to put faces to names before we meet for the first time when the baby is delivered.

2 p.m. — My first in-person patient of the afternoon is a 15-year-old healthy girl here for a sports physical. I know many teens come just because they need their forms filled out, but these appointments are nice opportunities to make sure not only that they are healthy enough to participate in sports, but also to find out how they’re doing in school, how they’re coping emotionally during the well-known turbulent adolescent years, and to make sure they’re up-to-date on their vaccines. This particular teen I have seen since day one of her life in the hospital when she weighed just under 5 pounds. Today, she towers over me and is a competitive rower. This is one of the most enjoyable and rewarding parts of what I do, getting to know the patients and their families, watching them grow from an infant to a young adult, and being able to take part in their journey.

4 p.m. — My last patient of the day is a 13-year-old boy with anxiety. Unfortunately, we’re seeing increasing numbers of patients, at younger and younger ages, with mental health issues. While we may refer some of these patients to our mental health colleagues, our job as the pediatricians is to be the first landing spot and a gateway for the specialists. We share a few tears, but I am glad that he has taken the first step to come see me and to talk about his issues.

5:30 p.m. — I finish updating my patients’ charts from today and head home.

6 p.m. — As I walk into my house, I can hear the familiar sound of a bouncing basketball. My 12-year-old daughter must be out in the backyard practicing again. I start cooking, my husband gets home, and we all sit to eat together. I believe it is important to eat together as a family and am grateful that we get to do that almost every night. After dinner, we are treated to a viewing of the latest production by my 14-year-old son who is a budding video editor.

7:30 p.m. — As my kids have gotten older, I have more of my own time in the evenings and have gotten better about self-care. Tonight will be a yoga night for me.

9:00 p.m. — Before bed, I get some reading in. More often than not these days, I’m reading books recommended to me by my 17-year-old son who is an avid reader.

Find a CHOC pediatrician near you

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An innovative internship approach during COVID-19

A year ago, Jenae Vancura joined an elite group of college and high school students for a unique and innovative summer internship program at CHOC Children’s. The interns shadowed physicians, joined doctors on their rounds and attended meetings with a wide range of professionals in the medical field.

The days were long. The work was challenging.

And Jenae, a 21-year-old biology major from UC Santa Barbara, is back again this year, now serving as a lead intern for the Sharon Disney Lund Medical Intelligence and Innovation Institute  (MI3) summer internship program. She now helps guide a new group of students through the rigorous program.

“But this year is a little different,” Jenae says.

Now in its eighth year, the internship has been effectively reimagined as a virtual program, a pivot quickly executed at the onset of the global coronavirus pandemic.

virtual MI3 internship meeting
Jenae participates in a virtual meeting as part of the MI3 internship.

The COVID-19 crisis emerged just as CHOC leaders and physicians were gearing up for this year’s internship program. That meant that the 63 participating students would not be able to work directly with hospital staff or go on rounds to interact with patients as in years past.

Cancelling not an option

While many internship programs have been halted worldwide due to COVID-19, canceling the MI3 internship was simply not an option, organizers say. The experience was much too valuable and too many young had worked too hard to get this far.

“Many of our interns look to our program to affirm and motivate their decision to apply to medical school,” says Debra Beauregard, director of MI3. “Nearly all of the interns aspire to become physicians.”

So, with just weeks to go, the decision was made to recalibrate the program and put the whole curriculum online.

“The easy thing would have been to postpone or cancel,” says Dr. Anthony Chang, CHOC’s chief intelligence and innovation officer who launched the program eight years ago. “We wanted to give the students the same level of opportunity. To their credit, the team stepped up and made the internship rotation on par with previous years.”

Dr. Chang started the internship because he wanted to give young people an in-depth experience of the medical field.

“I felt like no one was really doing something like this,” he says. “The students were staying with one mentor doing one assignment. That sounds like a research assignment, not an internship. I wanted to give them access to something that gave them access to a hundred mentors.”

A rigorous pace remains

Even though the pandemic has restricted access to the hospital, it hasn’t slowed the  interns’ pace. Their work schedule starts early and, with a few breaks between, doesn’t end until the evening.

“We set up a lot of Zoom meetings,” Debra says. “Our interns have a full schedule. They participated in rounds and shadowed our physicians virtually. They were even able to remotely view multiple surgeries. This was a challenge, but everyone pulled together to provide what turned out to be a great summer program.”

a virtual session as part of the MI3 internship program
MI3 interns participate in a Zoom meeting as part of their virtual internship.

Dr. Chang says that while the interns are receiving the same level of instruction, what’s missing are some of the personal interactions that come with face-to-face contact.

“Not having one-on-one time in person and not having more intimate moments in small groups is difficult for us,” he says. “For instance, in past years they’ve had one-day retreats where they come to my house for breakfast and lunch. I wasn’t able to do that this year.”

But that doesn’t mean there isn’t room for a little fun.

“Our directors and lead interns made sure that all interns felt connected,” Debra says. “We included team-building exercises, interactive small group sessions, and even a virtual graduation ceremony. The leads even organized a virtual talent show and Zoomie Awards, in addition to a competitive team competition. Our leads have gone above and beyond to ensure that our interns had a meaningful and memorable experience.“

Dr. Sharief Taraman, internship co-director and pediatric neurologist at CHOC, has been part of the program almost since it started. He’s confident that this year’s group is better off than students anywhere else.

“They’re way ahead of their peers in terms of experience and what they can get out of the summer,” he says. “We have a lot of moving parts, so we had to pivot very quickly.”

And to ensure the interns get all the experience they can, they are being invited back next year when they are hopefully able to receive hands-on work.

“We have offered guaranteed spots for our interns next year, so they can have an in-person experience,” Debra says. “We are confident that most will be coming back.”

Student gratitude abounds

The interns themselves are grateful for the chance to continue their internships during these difficult times.

“When I thought it wouldn’t happen, I got very upset,” says 20-year-old Julia Keating from the Massachusetts College of Pharmacy and Health Sciences University. “It’s such a competitive internship.”

For Jessica Octavio, a 20-year old San Diego State student majoring in microbiology, going online was positive experience.

‘’We’re lucky,” she says. “They’ve been more than flexible. The biggest thing was learning this online interface, but as far as programming goes, it’s almost advantageous for us.”

While working on site would have been ideal, Luke Arnold says he appreciates all the work the health system staff have put into making this year’s program a success.

“It’s not ideal and obviously we’d like to have this in person,” says the 21-year-old biology major from Chapman University. “But being in quarantine has given us opportunities to work in group settings. We’re all in this together.”

For intern Nicole Fraga, working from home has had some surprising benefits.

“It can be a very rigorous process,” says the 22-year-old recent graduate from Brown University. “But ironically, I think they’re getting closer to the interns online because we are meeting in small groups. We are able to communicate on Slack and share memes. We have a smaller community.”

Dr. Chang calls the internship a “circular experience.” The health system staff, he says, learn as much from the students as the students do from the physicians.

“We’re grateful that the interns are even more inspired to go into medicine despite the pandemic,” he says. “It’s very heartwarming to hear. The future of medicine is in good hands. I see the interns push back against the temptation to give up. They have the idealism and no fear of failure.”

Learn more about CHOC's MI3 internship

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How being an athlete prepared me to be a nurse

elyse-shelger-rn-choc-childrens

By Elyse Shelger, registered nurse at CHOC Children’s

In my life before nursing, I was a soccer player. I started playing the game when I was 4 years old. It shaped my childhood and taught me more than I realized at the time. In high school, I learned from incredible coaches and teammates, and then had the honor of playing for one of the top college programs in the country, Santa Clara University. When you practice something day after day, those movements, patterns, principles and lessons eventually become ingrained in your mind, body and soul. You don’t always notice they are there since they become part of you gradually, until you are forever changed.

As an adult, I often am reminded of certain guidance my coaches imparted and recognize why I do certain things the way I do. A large part of my mentality, behavior and beliefs have been shaped by the game of soccer, my life-long teammates and my undeniably great coaches. These are a few lessons that have shaped me as a person and as a nurse, and how I apply them in my world today.

In my new life, I am a nurse. I am not just a nurse when I am working a shift at the hospital. I am a nurse every day, always, at all times. I grew up learning that success comes when you commit yourself fully, on and off the field. I was also taught a great deal about accountability and personal responsibility. Why blame teammates or others when things get tough? We all must do what we can to make a difference. We each have to do our part. When I began working at CHOC Children’s Hospital, I took an oath to defend childhood. As an athlete, the word defense runs deep. Every team needs goal scorers— we need people to take action and move things forward, innovate, be creative, solve problems and think outside the box. This is what medical professionals do every shift, and some say a good offense is the best defense.

“Off the field,” I am still a nurse.

In team sports, you learn about selflessness. It becomes second nature to do what’s best for the team as a whole, to give 100% for each other, to have each other’s backs, and to fight selflessly until the last whistle. As a nurse, when I clock out after a long shift and I’m driving home, I relive each play in my mind, whether I won or lost that game, knowing I gave it my all. Sometimes no matter how well the team prepares, and how well you perform together, you can be defeated by a really strong opponent.

Currently we are in the middle of a big game. Our opponent is COVID-19. In our communities, some people are so terrified of losing that they are paralyzed with fear. Others have heard the opponent isn’t as formidable as people claim, so they grossly underestimate it as a threat. This is where risk lies. We must prepare properly. We must come to the game ready to play hard. We must give 100%. We must not lose focus.

What we do off the field matters. I will wear my mask to do my part to contribute to our team’s defense. I will speak responsibly and not spread misconceptions. I will encourage those around me to be safe as well because we are all in this together. If some team members decide they don’t really need to train for this game because it will be an easy one that can hurt all of us.

We don’t yet know what the rest of the COVID-19 pandemic will bring. Maybe this is half-time, or maybe we’re at another point in the game. But we know the game is not over yet. Do not let up now — not if you feel tired, and not if you feel like we are already winning. The game isn’t over.

Please don’t confuse my care for fear. I believe and have confidence we can win the game if we all come out to play our best, with and for each other.

Get more information on Coronavirus (COVID-19)

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One nurse’s thank you letter to a former patient

By Amanda Paragas, registered nurse, CHOC Children’s cardiovascular intensive care unit

The CHOC Children’s RN Residency Program is a 17-week program that is specifically customized to meet the requirements of the new nursing graduate to be successfully transitioned to becoming a professional pediatric nurse. Here, a recent RN Residency Program graduate pens a thank you letter to a patient she had the privilege of caring for during the RN Residency Program — one who impacted her as a nurse.

To you, my sweet girl, I owe many thanks.

Thank you for showing me humility and grace.

Thank you for showing me what compassion and love looks like from your perspective. Thank you for letting me watch you grow and develop your wonderful personality.

Thank you for showing me, and everyone else, that you are capable of so much more than anyone ever gave you credit for.

Thank you for showing me how strong and resilient such a young patient can be, without even knowing it.

Thank you for always being mighty and always fighting for what you wanted.

Thank you for never giving up despite being faced with unthinkable circumstances.

Thank you for reminding me that life should not be taken for granted and that all of our time is limited here on Earth.

Thank you for challenging me to be a better nurse and to always strive for excellence when caring for others.

And most importantly, thank you for letting me defend your childhood.

The August RN Residency/Fellowship Program is scheduled to begin on August 17, 2020. Applications will be accepted: May 15, 2020 through May 19, 2020.

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How one surgery inspired a career in nursing

By Lisa Turni, surgical unit nurse manager, CHOC Children’s

lisa-turni-rn-choc-childrens

I’ve been a nurse for 18 years, but the seeds of my career were planted long before I put on my first pair of scrubs. Although I didn’t know it at the time, having surgery as a teenager would ultimately inspire my career path.

Growing up, I was an athlete and especially loved playing basketball. Although I was in good shape, I was always out of breath and would hyperventilate often. I felt insecure because I thought I was giving my best at practice.

When I was 14 years old, my mom took me to the pediatrician who initially assumed I had asthma. But when my doctor lifted my shirt to listen to my breathing, she noticed a depression in my chest. I had always known it was there, but I thought that’s just how my chest looked. He diagnosed me with pectus excavatum, commonly referred to as “sunken chest.” This is when the breastbone, or sternum, and some of the ribs grow abnormally and cause a depression in the middle of the chest. Pectus excavatum is the most common congenital chest wall abnormality in children. Many cases of pectus excavatum are found in the early teenage years because growth spurts during puberty can exacerbate the chest depression.

I was referred to a surgeon, who explained that the depression in my chest was pushing down on my heart and lungs, which make it harder for them to work properly, and harder for me to breathe properly. He told me that I would need surgery to correct the deformity in my chest wall. I hadn’t realized there was anything I could do to fix it. He explained that during surgery, he would make an incision across my chest and reshape my rib cartilage which would keep my breastbone in the correct position.

As my surgery date got closer, I became more aware of the depression in my chest, and the way I thought about and saw myself started to change.

At that age, kids at school can be harsh. Sometimes they would unknowingly ask hurtful questions like, “Oh, why does your chest look like that?”

I started to realize I was different. Not necessarily all of the kids and comments were mean, but I was aware that I stood out. I changed the types of bathing suits and clothing I wore to hide the depression in my chest, a behavior I now know is common among pectus excavatum patients.

A physical abnormality is an emotional thing to shoulder as a child. It can be hard for others to understand how much it can affect a child emotionally. When I became a nurse, I used that understanding to inform the care I provided to my patients.

My surgery went well, and although that occurred in the days before the minimally-invasive Nuss procedure was invented, my surgeon was able to “hide” my scar near my bra line so it wouldn’t show in bathing suits or other clothing. The scar became a badge of honor. It was a sign of my courage.

My hospital stay after surgery is what led me to pursue nursing. I knew from that hospital stay that I wanted to help other kids. Some of my providers during that time got frustrated with me because I couldn’t take a deep breath or cough due to pain. Even though pain management has improved tenfold in the years since, the way my care team acted toward me has made me want to always treat patients better than they did.

After eventually getting my bachelor’s degree in nursing, I came to CHOC Children’s Hospital as a travel nurse. As soon as I stepped foot inside CHOC, I knew it was my forever home because of the people and culture.

I worked my way up to nurse manager of the combined medical/surgical unit. Later, when we created separate medical and surgical units, I chose to stay in the surgical unit. Giving back and taking care of patients undergoing surgery is my way of making a difference. I have a special connection with patients undergoing pectus excavatum surgery.

Even though my surgery was over 20 years ago, I’ve found that many pectus patients have similar journeys. When I share my story with my patients, I let them know they are not alone. When I was younger, I didn’t know anyone else who had this condition or understood what my surgery felt like.

Now, I do my best to connect my pectus excavatum patients with one another for peer-to-peer support. In fact, at CHOC, we’re developing a mentor program where former pectus excavatum patients, along with scoliosis patients, are trained to meet with new patients prior to surgery, and help answer their questions and be part of their support system alongside clinical staff.

I also make sure to be there for my patients’ parents as well. Parents often feel guilty for not noticing how deep the chest depression had gotten – but how could they have known? By the time their kids are becoming teenagers, the period during which pectus excavatum becomes most pronounced, they’re no longer in charge of bathing them and they’re not often seeing them without a shirt. I can comfort them in a unique way because my mom had similar feelings.

They are also understandably worried about their child’s surgery and recovery, and they seem grateful to talk to someone who is so many years post-surgery without any major complications. Parents usually have a lot more questions for someone who has been through it, and I spend as much time with them as they need. Thanks to our new mentor program, it has been amazing to see connections made between our parents and patients, and what a huge support that has been for them.

I’m grateful that I had pectus excavatum because it shaped who I am as a person. When I was younger, I didn’t realize how powerful nursing could be. I’m grateful this has been my journey because it feels right to be able to give back and to help patients and their families.

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    By Dr. Rei Tosu, a CHOC Children’s pediatrician I’m a board-certified pediatrician at Los Alamitos Pediatrics, part of the CHOC Children’s Primary Care Network. I’ve been a pediatrician for 18 ...
  • An innovative internship approach during COVID-19
    A year ago, Jenae Vancura joined an elite group of college and high school students for a unique and innovative summer internship program at CHOC Children’s. The interns shadowed physicians, ...
  • How being an athlete prepared me to be a nurse
    By Elyse Shelger, registered nurse at CHOC Children’s In my life before nursing, I was a soccer player. I started playing the game when I was 4 years old. It shaped ...