th-2Bioethicist Arthur Caplan presents a dilemma:

If a doctor, dentist or nurse reaches out to shake your hand, should you: (a) reciprocate and extend your hand, (b) shake at least once or twice but don’t pump or hold hands for more than five seconds, (c) make eye contact and smile while shaking or (d) recoil in horror, shove your hands deep into any available pocket and report the perpetrator to the nearest infection control specialist?

If you answered ‘d,’ then high five me. You understand the sorry state of hand hygiene in American health care and the toll it takes in spreading disease.


Pediatric cardiologist Mark Sklansky and colleagues acknowledge in this week’s JAMA the cultural importance of the handshake, from the ancient Greeks to modern day health care workers:

In the health care setting, where patient encounters commonly begin and end with a handshake, the handshake has been shown to have the capability of improving the perception of the physician’s empathy and compassion. Handshakes between health care practitioners and their patients have the potential to comfort and to calm.


But the transmission of infectious diseases through handshakes in these same health care settings continues despite great efforts to improve hand washing by increasing awareness, education, technology, and availability of hand sanitizing liquid/gel stations. The emergence of antimicrobial resistance and the urgency to prevent hospital-acquired infections have prompted the authors to go beyond current efforts to improve hand hygiene and call for an end to this cultural practice.  They propose the following signage in hospitals and clinics:

“Handshake-free zone: to protect your health and the health of those around you, please refrain from shaking hands while on these premises.”


Dr. Sklansky offers other appropriate alternatives:

Some well-established gestures include the familiar hand wave (using an open palm, and practiced widely as an informal greeting/departure gesture) and placement of the right palm over the heart (as practiced in the United States while facing the American flag). Practiced predominantly in the Far East, the bow symbolizes reverence and respect but can also have a variety of secular/religious meanings and may signify greeting/departure, humility, obedience, submission, apology, or congratulations. The Namaste gesture, practiced for centuries throughout South Asia, has become increasingly prevalent in yoga practice throughout the world. By placing the hands, palms together, against the face or chest, and tilting the head forward, the gesture symbolizes respect and may carry religious significance among Hindus and Buddhists. In Thailand, the wai gesture functions similarly. The salaam (peace) gesture—wherein the right palm is placed over the heart, sometimes with subtle bowing—has been practiced among some Muslims and generally represents a symbol of greeting/departure and respect.


Or maybe a fist bump.  That’ll work!

More PediaBlog on hand hygiene here and antimicrobial resistance here.