The hesitation before shaking a patient’s hand in the hospital

Today, during my psychiatry rotation, a very grateful patient confronted my attending and thanked him profusely for saving him. The patient had been severely depressed and was at his wit’s end before they met. The doctor listened to him, analyzed his situation, and came up with a plan to help which included involving the patient’ family as well as using proper medication. The patient had a great response to this and now wanted to express this to my attending. Thus entered the “hospital handshake.”

After spending enough time in the hospital, I have come to the conclusion that it’s a dirty place. This was not an epiphany that I experienced; rather, it’s just a simple conclusion after seeing/experiencing the dirtiest parts of people throughout the hospital. I’ve even seen a psych patient throw his own feces at his roommate because he “didn’t like the way he was looking at him.”

Therefore, when the grateful patient offered his hand to the doctor to shake as a sign of being thankful, I could sort of understand why the attending hesitated for a second. It was not just the hesitation that tickled me. As we were leaving the floor, the attending walked out of his way to dose his hands in hand cleanser.

A lot of people may have found that action as perfectly reasonable. Especially in this day and age in which around every corner you turn there is a sign about washing hands and stopping infection. And to add to that, I had to complete a form upon starting the rotation that quizzed me on the proper length of time of hand washing (it’s 15 to 20 seconds if you’re curious). However, the attending and I both knew that we were merely heading back to the psych floor where we were going to continue our conversation about his recent trip to India. There would be no spread of infection (there was no reason to believe this patient had an infection anyway) to other patients.

I bring this up not because I have a problem with keeping infection down by hand washing after physical contact with patients. In fact, I think it’s a great habit to get in to. It is because this scene struck me as borderline disrespectful to the patient that I bring it up.

Imagine this, you go to your parents house for Thanksgiving. It’s been months since you’ve seen them and your father has still not thanked you for helping him with a medical problem that he’d been dealing with.  He remembers that he forgot to tell you how grateful he was, thus he elaborates his appreciation as you greet each other. He finishes by giving you a stern, fatherly handshake to demonstrate how strongly he feels. In this particular case, neither your father nor yourself have any signs of an infection. Despite this, you walk past him to the nearest bathroom to wash your hands (for 15 to 20 seconds, of course).

Is this something your father would take offense to? If that was my child, I would feel like he just took my sign of appreciation and smacked me in the face with it. So why is this not the case when a patient wants to shake the hand of the caregiver that had such a profound effect on their life?

In this particular interaction with the attending and patient, I did not perceive the attending as respecting the patient. From the hesitation to shake his hand to cleansing the physical contact from himself once he turned from the patient, the attending came across as cold and uncaring.

My fear is that this lack of respect can be extrapolated to all patients. This would be even more prominent on an inpatient psychiatry floor in which many patients do not have a firm grasp on reality. Will I soon find myself losing respect for patients; declining handshakes and ignoring their displays of gratitude? I hope not.

“Nonmaleficence” is a medical student who blogs at his self-titled site, Nonmaleficence.

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  • Anonymous

    It sounds like this attending  psychiatrist may be suffering from OCD. If he can’t even handle a simple handshake with a patient, he needs help. Intervention please.

    • http://nonmaleficence.wordpress.com Nonmaleficence

      Agreed. I can’t determine if it’s a consequence of being in the job or the idea that psychiatrists specialize in their own fallacies.

    • http://www.facebook.com/perfectlyordinarybunnyofdoom Amber Asaro

      It’s quite a leap to make a diagnosis from one second-hand account.  Perhaps with the patient history of throwing feces he thought it best to be safe and wash his hands. 

  • Anonymous

    I work in OB  and also in the area of Patient satisfaction & Performance improvement;
    I make sure I wash my hand before checking patient and after leaving the room in front of them. It also makes them feel comfortable. If that is a culture of the institute patient will feel good. Patients might not confront you at times but they know you have other patients also.
    I also think it also depands on the area you are working. Psych units have totally different atmosphere, And for sure if I am not there to do assessment. I will not wash my hand in front of them after hand shake to make them feel uncomfortable beacuse I know I will wash, before I check my next patient.
    Thanks for bringing this article. It makes us stop and think. We are in the time of high tech, low touch! Which is very sad!

  • http://twitter.com/JewishPhysician Craig Brenner

    If you are a physician, why don’t you have a pocket hand sanitizer on your armamentum.  Even a psychiatrist who has no white coat at least has pockets on his or her wardrobe.  This makes little sense to me that handshaking is a big issue other than it perhaps distracts your routine in some situations and of course, perhaps you know more about that patient that causes some refrain.  But if you can have a pocket hand sanitizer and especially if you have a fully white coat, why bother worrying about the hand wash station.  Makes sense to me.

  • http://handsintheworld.wordpress.com/ DramaDoc

    As an EMT, I am an AVID hand-washer and user of CalStat. From seeing patients’ homes, I’ve learned that appearances can be very deceiving. A well-dressed upper class woman can live like a slob. You should NEVER let outer appearances sway you from OccHealth guidelines for patient contact. I remind you of all the common surfaces in a hospital. Psych patients may not enter the hospital with infections, certainly (though many do- trust me- I bring them in).  But hospital staff is not confined to the ward, and they are the carriers of all kinds of pathogens that they pick up in their tour of the hospital. A discrete use of sanitizer or a brief stop in to the restroom to wash your hands really does make a difference in the overall health of hospital staff, patients, and visitors.  It took me a while to get over it, too, but whenever anyone mentions it, I explain that it’s for everyone’s health, including their own. 99% of patients understand that.

  • Anonymous

    Uh, more like the doctor doesn’t want to shake hands until he’s seen the chart and knows the patient is insured, right doc? 

    • http://nonmaleficence.wordpress.com Nonmaleficence

      I don’t think this is necessarily true. Of course, every human being is worried about being compensated in some form (monetary, ego, resume) before they perform a task. In this case, accepting the respect and gratitude of the patient would be the compensation, therefore in theory the attending would be willing to accept.

  • http://www.facebook.com/perfectlyordinarybunnyofdoom Amber Asaro

    The hesitation to shake hands certainly could be perceived by the patient and be taken as disrespectful.  However, washing his hands elsewhere, out of view of the patient, could not be perceived as disrespectful since it can’t be perceived at all (by the alleged victim of the disrespect).  Perhaps this person is in the habit of washing his hands after contact with individuals with whom he is not familiar. 

    Your comparison with shaking hands with your father is not analogous; shaking hands may be a sign of respect in public, but not washing your hands after touching people and before eating or resuming your daily activities is a sign of particular trust that the individual is not exposing you to infection.  Also, if my father thanked me with a handshake, I would feel slighted, because that relationship and hypothetical situation seems that a hug is more appropriate.  Unless my father has his own boundary and closeness issues, since each person has their own quirks in that area.  This may be at play for the attending as well.

    I worked at a bank for a few years.  I touched money and shook hands all day.  Anytime I was going to take a break or leave, I washed my hands.  I just felt like I couldn’t touch my face or food until I washed away all of the various germs I might have contacted.  In family situations or even with close friends, I am in a different mode.  The beginning of the clinking of drinking glasses for “cheers” is not certain, but some scholars speculate that it originally involved actually sloshing a bit of the drink between glasses to show trust that no one was poisoning the other.  Not washing your hands with family and friends seems like a modern day extension of that concept of demonstrating trust.

  • http://www.facebook.com/anirudh.shukla Anirudh Shukla

    I guess thats why Indians dont shake hands, they simply fold their hands and say “Namaste” which is akin to saying Hello. Thats better I guess.. :)

  • http://twitter.com/Rudywg Rudy Wilson Galdonik

    After my second open-heart surgery for a congential heart defect, I was in the SICU about 24 hours after my surgery. Three docs talked nearby. The youngest doc, a resident, I suspect, sneezed into his hand during the discussion. I then watched him wipe his hand on his white coat, not wanting to break the conversation.  Moments after the conversation ended he turned toward me.  I asked him what he was doing. He said, “I’m going to examine you.” You could say I blasted the poor guy about what I had just observed. Fortunately, my respirator had been removed, so I could speak. If the same thing happened today, I would have insisted he change his lab coat as well and I probably would have had the nurse find the other 2 docs who did not even notice what had just happened.
    Later that day my surgeon suggested my “blasting” was probably one of the most powerful lessons in his new career as a doc.We all need to be vigilant of the spread of germs. Since handwashing (15 to 20 seconds) is one of the best ways to reduce deadly infections, no one should appologize for this.

    • http://nonmaleficence.wordpress.com Nonmaleficence

      He definitely needed to be talked to. It should be like a reflex to always wash BEFORE and AFTER any patient encounter. I’m sure your ‘blasting’ him helped to reinforce this reflex for his subsequent encounters. Thank you for that.
      Also, I don’t want you to think that I am against hand washing before and after touching (or sneezing in this case), it’s just that in this particular scenario I don’t think it was as warranted. The Psychiatrist was not immediately going to see another patient and it could have waited a few moments before sterilizing the human contact.