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Why don’t you have separate sick and well waiting rooms?

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Written by Suzanne Berman MD. Dr. Berman is a practicing general pediatrician in rural Tennessee.

We’re occasionally asked by families why we don’t have separate waiting rooms for sick and well patients.  It’s a good question, especially given that many pediatric offices are designed this way.  There are several reasons why we chose not to do this.

 What ‘s a “sick” visit vs. a “well” visit?  

The first problem is one of definition.   While some kids are very clearly sick and other kids are clearly well, many of the visits we do don’t fit nearly into one category or another.  Is a depressed teenager “sick” or “well” ?

What about a 4 year old with a possible urinary tract infection?   An infant who’s not gaining weight?  An 8-year-old with belly pain?   A better way to separate the waiting rooms would be a “contagious” waiting room and a “noncontagious” waiting room.

However…

Parents often don’t know whether a child is contagious or not when they check in.  

We don’t expect them to be – that’s our job.   If a child comes in with a new rash, it might be eczema (not contagious at all), chickenpox (very contagious), or ringworm (only very mildly contagious, and certainly not enough to keep them out of school or sports.)   Fifth disease is contagious and causes a rash – but once the rash appears, the child is no longer contagious.

Knowing whether the child is contagious (and how contagious, and for how long) first requires a medical evaluation – and that happens after the child has been brought back, not in the waiting room.

What about siblings? 

We often see double or triple appointments in a family.   If Dad brings in a 6-month-old baby for a checkup (a well visit) and his two year old sister for a cough (a sick visit), what side of the waiting room should the whole family sit on?

We could put the well baby on the sick side (since he’s already been exposed to the two year old’s illness, presumably), or we could put the sick child on the well side (to keep the well baby well.)   There’s no good answer.

And I can’t put a number on the times I’ve seen a well child who was accompanied by a parent who was coughing and sneezing uncontrollably.

It actually can make crowding in the waiting room worse.

Our office’s single large waiting area measures about 20 x 30 feet.   Let’s say we divided it in half, to create separate sick and well waiting areas, each about 20 x 15 feet.

In the summer, when 70 percent or more of our visits are “well,” our patients would be crammed in a much smaller room while our “sick room” would be underutilized.

The exact opposite would be true in the winter months –a crowded waiting room of sick children half as big as it could be.   When we have a single large area, we can make the most of our space; families can sit wherever they wish, near or far away from anyone else in the waiting room.

Parents are sometimes not honest about their child’s contagious condition.

I once reviewed a malpractice case in which the plaintiff contended that the defendant pediatrician didn’t recognize a baby’s sickness. The defendant’s attorney asked the plaintiff’s grandmother (who had brought the baby to the office) whether the grandmother chose the sick or well side.

The grandmother said, “We sat on the well side.”  The defendant’s attorney asked, “If the baby was sick, as you say, why did you sit on the well side?”   The grandmother replied, “Well, she wasn’t very sick at the time – just a little sneezing and cough.  And I didn’t want her catching something from the sick side.”

Honest parents will admit that they’re usually more concerned about keeping their own child away from other sick children, rather than worried that other well children will catch their child’s illness.

Our receptionists don’t want to police the waiting rooms.

Colleagues with separate sick and well waiting rooms tell me that their receptionists spend at least part of each day helping parents decide which waiting room to sit in, moving patients from one waiting room to another, or settling angry squabbles between two families who are convinced the other’s child is in the “wrong” area.

Our receptionists would rather check in patients quickly – validating insurance information, updating phone numbers, and processing questionnaires — rather than serving as “waiting room police.”

There’s no evidence separate sick and well waiting rooms make a difference in controlling the spread of infection.

The American Academy of Pediatrics’ statement on controlling infection in pediatric offices states, “No studies document the need for, or benefit of, separate waiting areas for well and ill children.”

We believe that other commonsense precautions are more effective – like making masks, tissues, and hand sanitizer available in the waiting room; bringing children suspected of having an extremely contagious disease in through the back door; bringing extremely fragile/susceptible children back as soon as they enter the office.

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Is Providing Food Snacks To Children Contributing To Obesity?

Written by Dr. Jesse Hackell

I recently had a call from a local child psychologist, one to whom I regularly refer patients. After the usual pleasantries, and her report on her findings about, and treatment plan for, the most recent patient, she hit me with a question that I had never been asked before. “Why,” she inquired, “do so many patients seem to think that my waiting room is a picnic area?” When I inquired about what she meant, she went on to describe a recent family who brought a child in for an appointment, and while sitting in the waiting room, proceeded to spread out a cloth on the floor, and actually start giving the three year old child a variety of snacks. This was not, she was careful to inform me, at a normal lunch hour.

I had no good answer, but it did set me to observing my own office. I quickly came to realize that not a day goes by that the exam rooms and waiting area are not littered with candy wrappers, discarded juice boxes, raisins and crumbs of all descriptions. And while I have not found chewing gum stuck to the underside of the exam tables (yet!), many surfaces in the office end the day with unidentifiable sticky patches on them. But maybe worst of all is asking a child to open his or her mouth and finding the mushy remains of a chocolate cookie, pretzel or bagel coating the tissues one is trying to assess.

We do a pretty good job of running on time most days, getting patients out of the office within a half-hour or so of their arrival (see Dr. Lessin’s recent post), so most of the time patients are not sitting around waiting for more than a few minutes, either in the waiting room or the exam room. Are our children so nutritionally deprived that they cannot go thirty or even sixty minutes without some sort of food or drink, lest they starve?

But it goes further than the crumbs underfoot in the exam rooms (where we do expect our patients to be barefoot during some examinations) or the sticky patches on the waiting room chairs. Children in pre-school and all the way through elementary school seem to have snack time, sometimes twice a day, with cookies and juice provided two hours after breakfast and two hours after lunch.

With the national alarm increasing about the rate of obesity in our children (and adults as well), what message are we giving our children about eating when we provide them with a continuous stream of things entering their mouth throughout the day? We know that eating habits and relationships with food which are developed and reinforced in childhood will persist readily into adolescence and adult life. I fear that we may be creating problems for a whole new generation of people when we make food and snacks available at every waking moment of a young child’s day.

Signs in the office requesting patients and family members to refrain from eating and drinking have some effect, at least on our office cleaning bills. But I think we need to carefully think about the messages we give to parents about feeding their children. Breast feeding, even on demand, is fine, but even feeding an infant too frequently can develop a “snacking” habit, where the baby never learns to take a full feeding which will last a few hours until the next feeding time. But once the child moves on to beikost (German for foods other than milk or formula), we need to help parents develop a schedule where times for meals are separate and distinct from times where food and drink is not offered.

There are a whole host of potential benefits to this pattern, not the least of which might be less of a focus on food and drink as a continuous feast, and, just possibly, a reduction in a child’s total daily calorie intake. But teaching our children that the times when we eat are discreet and separate moments might also go some way to returning eating to a social, and not just refueling, activity.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.